Discussion Points 10/17/16. Spine Pain is Ubiquitous. Interventional Pain Management

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1 Interventional Pain Management Blake Christensen, D.O. Fellowship Trained Interventional Pain Management Board Eligible in Anesthesiology and Interventional Pain Management Oklahoma Interventional Pain Specialists Affiliated with Oklahoma Spine, Mercy, OCOM and Deaconess Hospital Systems Discussion Points What is Interventional Pain Management Localizing the Pain Generator (Columns) Multimodal Approach to Chronic Pain and Medication Management Spine Pain is Ubiquitous Spine pain is one of the leading causes of medical disability in the U.S. Lifetime incidence is as high as 84% for back pain and 67% for neck pain. 2nd leading cause of physician visits Pain of various types is responsible for a half million lost workdays Costs more than $150 billion annually in health care, disability, and related expenses 1

2 Why is back pain so difficult to treat Etiology is multifactorial Localize the Pain Generator via a combination of: - History - Clinical symptoms - Physical Exam - Image findings - Diagnostic testing Response to Injections is VERY important to determine the source of pain or to treat the pain. Treatment of Acute Low Back Pain Assess for rare, but serious causes of back pain red flag conditions Imaging indications are specific and explicit Thorough medical assessment - explore pt s beliefs and fears about the pain, chance of recurrence, and fear of making condition worse Pharmacologic Agents Affect Pain Differently 2

3 Nociceptive vs Neuropathic Pain Origins of Low Back Pain Anterior Column Anterior Column - Vertebral Compression Fractures - Disk Herniation (40%) Posterior Column - Facet Jt (15-40%) - SI Jt (13-30%) Middle Column - Stenosis, Radicular, Discogenic pain VCF- Options for Percutaneous Treatment Vertebroplasty Balloon Kyphoplasty Mechanical Device Augmentation Vertebral Body Implants 3

4 Origins of Low Back Pain Posterior Column Anterior Column - Vertebral Compression Fractures - Disk Herniation (40%) Posterior Column - Facet Jt (15-40%) - SI Jt (13-30%) Middle Column - Stenosis, Radicular, Discogenic pain Radiofrequency Ablation - Workup Treatment of Choice for Painful Facet Joints or SI joint pain Criteria used for pt selection - History & Physical exam - Imaging studies - Single intra articular blocks - Single MBB s (>50% relief) Double diagnostic blocks are recommended due to the high false positive rate PT and rehabilitation post procedure are very important to increase ROM 4

5 Radiofrequency Ablation Each facet joint is innervated by the MB from above and the MB from below RFA needles are placed at the corresponding medial branches of the targeted joint 6 months several years of relief that is dependent on nerve regeneration Origins of Low Back Pain Middle Column Anterior Column - Vertebral Compression Fractures - Disk Herniation (40%) Posterior Column - Facet Jt (15-40%) - SI Jt (13-30%) Middle Column - Stenosis, Radicular, Discogenic pain Sacroiliac Joint Pain SIJ s affected by osteoarthritis & Spondylitis - Can also be seen post partum or with instability Pain below L-S junction & medial to PSIS (sacral sulcus) Difficult to Dx confused with Disk or Facet Jt Pain Injection of Jt often difficult RF ablation of nerve supply can consistently decrease pain 5

6 Classification and relationship of simple analgesics 6

7 Mechanism of action of Opioids Exert their effects by: decreasing camp production close voltage gated calcium channels and open potassium channels inhibit GABA transmission in the brainstem decrease the pain evoked release of tachykinins from primary afferent nociceptors. Initial tx of choice for pts with radiculopathy Four Approaches: - Caudal - Interlaminar - Transforaminal - Selective nerve root blocks Epidural Steroid Injections 7

8 Spinal Cord Stimulators Cost benefit analysis of neuro-stimulation from 222 patients from Cleveland clinic showed a net savings of $93,000 per patient compared to oral opiates and traditional methods Failed Back Syndrome (FBS) or low back syndrome or failed back Radicular pain syndrome or radiculopathies resulting in pain secondary to FBS or herniated disk Postlaminectomy pain Degenerative Disk Disease (DDD)/herniated disk pain refractory to conservative and surgical interventions Epidural fibrosis Arachnoiditis or lumbar adhesive arachnoiditis Complex Regional Pain Syndrome (CRPS), Reflex Sympathetic Dystrophy (RSD), or causalgia Technology has continued to improve via new stimulator programming, batteries, and MRI capability of percutaneous leads and paddles Antidepressants Released in the 1950 s Started being used for pain in the 1970 s Pharmacology Side effect profiles 8

9 Number needed to treat calculated for various drug classes in the treatment of painful diabetic neuropathy Continued Treatment Multidisciplinary PT/OT, Psychological and behavioral therapy, disability management and retraining, acupuncture, TENS, dry needling, medication management Medication management should be specific to each individual patient. Monitor 4 A s on each visit when narcotics are prescribed 1. Analgesia 2. Activity levels 3. Adverse effects 4. Aberrant behaviors Summary Back pain is ubiquitous Tx involves localizing the Pain Generator Educate and assure the patient Combination therapy via medications and interventional techniques Thank you, Blake Christensen, D.O. (405) Blakedc20@yahoo.com 9