Eye of the Needle Interventional Management of the Degenerative Spine Brian A. Rosenberg, MD Interventional Pain Management Bone & Joint - Wausau, WI

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1 Eye of the Needle Interventional Management of the Degenerative Spine Brian A. Rosenberg, MD Interventional Pain Management Bone & Joint - Wausau, WI

2 No conflicts to disclose Disclosure

3 Agenda Introduction/Tools of the Trade Definitions Conservative Care Interventional Techniques Advanced Decision Making Conclusion

4 Introduction/Disclosures and no relevant financial or nonfinancial relationships exist.

5 Tools of the Trade

6 ools of the Trade C-Arm (DSA) Fluoroscopy Table Monitoring (Vitals) Contrast (Tubing) Shielding (Apron/Thyroid)

7 Tools of the Trade

8 Tools of the Trade

9 Tools of the Trade

10 Tools of the Trade

11 Definitions Spon-Dy-Lo-Lis-The-Sis

12 Definitions Degenerative Spondylolisthesis Spondylosis Stenosis Spondylolysis Radiculopathy/Radiculitis/Ra dicular

13 Definitions Degenerative - de gen er a tive [dəˈjenərədiv] ADJECTIVE (of a disease or symptom) characterized by progressive, often irreversible deterioration, and loss of function in the organs or tissues: "degenerative diseases of or tending to decline and deterioration: "the young generation had fallen into a degenerative backslide"

14 Degenerate

15 Spondylosis Definitions

$Definitions Spondylolysis Spondylolysis is the name given to a stress fracture of the lumbar$

16 Definitions Spondylolysis Spondylolysis is the name given to a stress fracture of the lumbar spine (lower back) and specifically affects a region of bone known as the pars interarticularis

Definitions Spondylolisthesis The word spondylolisthesis is derived from the Greek words spondylo, meaning spine, and listhesis, meaning to slip or

17 Definitions Spondylolisthesis The word spondylolisthesis is derived from the Greek words spondylo, meaning spine, and listhesis, meaning to slip or slide. Spondylolisthesis is a descriptive term referring to slippage (usually forward) of a vertebra and the spine above it relative to the vertebra below it.

18 Definitions Stenosis ste no sis [stəˈnōsis] the abnormal narrowing of a passage in the body.

19 Definitions Radiculitis/Radicul opathy/radicular Pain

20 Radiating/Referred pain Definitions

21 Definitions

22 Conservative Measures

23 Therapeutic Exercise Physical Therapy Weight Bearing Aquatherapy Chiropractic Care Home Exercise Regimen Modalities Traction TENS Electrophoresis Iontophoresis Ultrasound Contrast Baths Fluidotherapy

24 NSAIDS OTC Ibuprofen, Naproxen Rx Etodolac, Diclofenac, Nabumetone, Meloxicam, Piroxicam, Celecoxib, Naproxen, Ibuprofen, Sulindac, Fenoprofen, Ketorolac, Indomethacin, Oxaprozin, Ketoprofen, Meclofenamate, Tolmetin, Salsalate Aspirin

25 Neuropathic Agents Gabapentin Pregabalin Duloxetine TCA s Amitriptyline, Nortriptyline Methadone

26 Muscle Relaxers Rx Cyclobenzaprine, Baclofen, Tizanidine, Dantrolene, Metaxalone, Methocarbamol Work centrally (except Dantrolene) producing somnolence Dantrolene affects sarcoplasmic reticulum. Less sedating, but may be hepatotoxic.

27 Topicals Ice Heat Menthol (Stinks!) Capsaicin (Burns!) Diclofenac (With or without DMSO) TENS/Electro/Iontophoresis

28 Interventional Techniques

29 Interventional Techniques Sacroiliac Joint Injection Lumbar Epidural Steroid Injection Facet Injection/Intervention Discography Neuromodulation

30 Sacroiliac Joint Injection Indications Need/desire to know if SI joint is pain source (20% incidence, 30% of new pain after fusion) History/exam lack reliability Contraindications Bacterial infection, systemic or localized in the region of the blocks to be performed Possible Pregnancy

31 Sacroiliac Joint Injection

32 Sacroiliac Joint Injection Efficacy At least 70% relief at 6 months in more than half of subjects with inflammatory SI pain. Brit J Rheumatol 1996; 35: of 22 patients with SI pain related to AS had relief at 1 month. Acta Radiol 2002; 43: One study showing sustained > 50% relief of pain for avg. 9.3 months in 118 out of 155 patients (Non-Inflammatory SI pain) Pain Med 2009; 10:

33 Lumbar Epidural Interlaminar Transforaminal Caudal

34 Lumbar Epidural Indications Treatment of lumbar radicular pain Contraindications Patient unable/unwilling to consent Contrast medium cannot be used Untreated localized infection in procedural field Patient unable to cooperate

35 Interlaminar

36 Interlaminar

37 Transforaminal

38 Transforaminal

39 Caudal

40 Caudal

41 Caudal with Catheter

42 Lumbar ESI: But Does It WORK?!

43 Lumbar Epidural Steroid Injection Efficacy Transforaminal ESI reduced surgery by 56% in LDH Can J Surg Feb 1;56(1): For axial LBP in SS, Bilat TFESI > ILESI Clin J Pain Mar-Apr;25(3): Excellent results with ESI for lumbar radic when performed earlier (3 months vs. 8 months) AJNR Am J Neuroradiol May;27(5):

44 Lumbar Epidural Steroid Injection Efficacy TFESI for LDH provided better early improvement, fewer long term surgical interventions than ILESI Pain Physician Oct;9(4): % with LBP and discogenic abnormalities on MRI had >50% pain relief 1 year after TFESI Pain Physician Jul;5(3): Degenerative lumbar scoliotic stenosis and radiculopathy: 55.8% at 1 month, 37.2% at 1 year, 27.3% at 2 years after TFESI Pain Physician Jul;7(3):

45 Lumbar Epidural Steroid Injection Efficacy L5/S1 TFESI for S1 radiculopathy: 60% day 8, 60-67% day 30, 67% day 90. J Radiol Nov;85(11): TFESI for lumbosacral radic at 1.4 years with 84% success vs 48% from NaCl TPI (Mock ESI) Spine (Phia Pa 1976) Jan 1;27(1):11-6. SNRB provided resolution of pain in 60% at 16 months, avoiding surgery. (87% had rapid relief). Swiss Med Wkly Feb 10;131(5-6):75-80.

46 Facet Intervention Indications To diagnose or treat pain emanating from the facet joints Contraindications Bacterial infection, systemic or localized in the region of the intervention to be performed Possible Pregnancy

47 Facet Intervention Intraarticular injection Medial Branch Block Radiofrequency Ablation

48 Intraarticular Facet Injection

49 Intraarticular Facet Injection

50 Medial Branch Block

51 Medial Branch Block

52 Radiofrequency Ablation

53 Radiofrequency Ablation Efficacy 71% of 324 with marked improvement of pain, no complications. 29 with previous surgery. Stereotact Funct Neurosurg. 1997;68(1-4 Pt 1): Significantly greater relief following RFA vs. Sham for low back pain > 1 year. Spine Sep 15;24(18): Facet loading did NOT correlate with better results, repeated procedure was successful. Can J Neurol Sci May;27(2):

54 Radiofrequency Ablation Efficacy Following controlled diagnostic blocks, 60% of patients with 90% relief at 12 months. Spine May 15;25(10): RF more effective than placebo in systematic review of randomized clinical trials. Reg Anesth Pain Med Sep-Oct;26(5): Repeated RFA successful >85% of the time (up to 4 in this study) with mean duration 10.5 months. Spine Nov 1;29(21):

55 Discography Indications Diagnose (and maybe treat) discogenic pain Absolute Contraindications Patient unable or unwilling to consent Inability to asses patient response Evidence of untreated localized infection in the field Pregnancy Systemic or local infection Relative Contraindications Allergy to contrast/anesthetic/abx Bleeding d/o or anticoagulants Anatomical derangements preventing safe performance

56 Provocative Discography

57 Provocative Discography

58 Post-Disco CT

59 Neuromodulation Spinal Cord Stimulator Trial Permanent Spinal Cord Stimulator Implant

60 Trial Spinal Cord Stimulator

61 Trial Spinal Cord Stimulator

62 Spinal Cord Stimulator Trial

63 Permanent Spinal Cord Stimulator Implant

64 Advanced Decision Making

65 Conclusion Consider Conservative Care

66 Conclusion Many Hammers

67 Conclusion Time s a Factor

68 Questions?

Treatments for Common Pain Disorders. Matthew R. Kohler, MD Hudson Spine and Pain Medicine 03/01/2017

Treatments for Common Pain Disorders Matthew R. Kohler, MD Hudson Spine and Pain Medicine 03/01/2017 Acute Disc Herniation Conservative Approach (Four to Six Weeks) Physical Therapy, exercise and gentle