10/8/2015. Consultant for Boston Scientific-no conflicts with this presentation

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1 Consultant for Boston Scientific-no conflicts with this presentation Mehul Sekhadia, DO Medical Director Advocate Lutheran General Hospital Park Ridge, IL Identify when to consider interventional pain treatments. Explain the rationale for interventional pain treatments. Discuss how to use interventional pain procedures to find the pain generator. In the United States, the lifetime prevalence of back pain is approximately 80%, One-year prevalence rate of 15% to 20%, the highest prevalence is in the 45 to 64 age group. Acute and chronic pain affects large numbers of Americans, with approximately 100 million 2 U.S. adults burdened by chronic pain alone The annual national economic cost associated with chronic pain is estimated to be $ billion. Is there ever 100% success with any medical treatment? 95% of these patients return to their previous employment within 3 months of symptom onset.(fischgrund JS. Orthop Rev 22: , 1993) Failure to return to work within 3 months may be considered a poor prognostic sign. In patients who experience total disability after 1 year, the likelihood of returning to work is less than 20%. After 2 years of disability, the probability of returning to work is less than 2%.(Andersson GB. Spine 8: , 1983) Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research ( 2011 ) 1

2 Where does it hurt and how long has it been hurting? Associated manifestations? Functional limitations? Exacerbating/Alleviating Factors Past treatments? Were they successful? And. Everything else. Past Med/Surg/Fam/Sochistory ROS Meds/Allergies The Pain Physician Exam Spine ROM Gait Neuromuscular Sensory Reflexes Provocative testing 2

3 10/8/2015 Lumbar x-ray MRI Sagittal MRI T2 weighted image Axial T2 weighted image CT Bone Scan Acute vs Chronic Axial vs Radicular Muscular/ligamentous Discogenic Facetogenic Sacroiliac Cancer Associated Traumatic Congenital Deformity 3

4 Vague, diffuse back pain Worse with flexion, transfers Worse with rapid weight transfers Associated spasm Radicular pattern? Not mechanically reproducible Epidural Steroid Injections Facet joint Injections Nerve ablations Sympathetic Blocks Intrathecal Drug Delivery Systems Neuromodulation(spinal cord stimulation) Intradiscal Procedures Vertebro/kyphoplasty and more. Epidural Steroid Injections 4

5 Patient Selection Patient Selection Patient Selection 1 or 2-sided paravertebral LBP Mild to moderate deep, dull ache Morning stiffness Can radiate into buttocks, flanks and thighs Exacerbated by sit-to-stand transfers Exacerbated by prolonged activity and joint loading Exacerbated by golf swing, baseball swing, etc. Relieved by standing, walking, activity Usually responds to NSAIDS, opiates Tender to palpation of joint (paravertebral) Limited extension Pain exacerbated by rotational maneuvers Pain exacerbated by lateral flexion Osteoarthritic degenerative condition Loss of cartilage Erosions of adjacent bone margins Bony overgrowths Late stage instability and subluxation 5

6 Prospective (unblinded, unrandomized) 454 pts. with LBP, neuro intact, no radicular sx Pts. had facet joint injections of LA + steroid Initial mean reduction in VAS = 29% No significant lasting benefit Better relief in following subsets: Elderly, isolated sx, nlmuscle tone, absence of leg pain, pain on E & LR Jackson, RP. Facet joint injection in low-back pain. A prospective statistical study, Spine Sep;13Jackson, RP. Facet joint injection in low-back pain. A prospective statistical study, Spine Sep;13(9): Overall Results: Good short term benefit in responders Only a small subgroup achieves long-term relief So Can we achieve long-term relief by anesthetizing or ablating the facet joint Strong evidence that RF offers short term relief of LBP Moderate evidence of long term relief Good outcomes 41-75% in long term f/u Very low complication rate Datta Pain Physician (2): Van Boxem et al Pain Practice 8 (5) Cetas J Neurosurgery 109(3) Sept 2008 Dreyfuss& Dreyer Spine 20002;5;

7 MRI study found that there was degeneration or bulging of a disc at at least one lumbar level in 35% of the subjects between 20 and 39 years old none of the subjects had anyhistory of low back pain Boden SD,. J Bone Joint Surg Am Mar;72(3): Deyo RA. N Engl J Med, Vol. 344, No. 5. February 1, ] Loss of water content (dehydration) 2.] Pathological changes in the structure and function of the extracellular matrix (ECM) 3.] Enzymatic/biochemical imbalance 4.] Abnormal biomechanical forces 5.] Failure of nutrient supply 6.] Genetics 7.] Aging Three Main Anatomical Features: Nucleus pulposus (NP), Annulus fibrosus (AF), Vertebral endplates (EP) Raj PP. Intervertebral Disc: Anatomy-Physiology-Pathophysiology-Treatment 7

8 Whats a discogram? Invasive study Disc injected with contrast Pressure is measured Pattern of contrast is observed Amount of pain provoked is recorded Infection <1% Nerve injury <1% Lumbar discography in asymptomatic volunteers- Positive pain response and pain-related behavior with discography were found in 10% of the healthy subjects, in 40% of patients with neck pain, and in 83% of the somatization disorder (Carragee EJ SPINE 2000;25:1373) 50% of patients with no LBP but with disc degeneration/annular tear on MRI had a positive discogram (Carragee EJ SPINE 1999;24:2542) 8

9 Sacroiliac joint (SIJ) pain affect between 15 and 30% of individuals with chronic, nonradicular pain. Predisposing factors for SIJ pain include true and apparent leg length discrepancy, older age, inflammatory arthritis, previous spine surgery, pregnancy and trauma. Compared with facet-mediated and discogenic low back pain, individuals with SIJ pain are more likely to report a specific inciting event, and experience unilateral pain below L5. Cohen et al., Sacroiliac joint pain: a comprehensive review of epidemiology, diagnosis and treatment, Expert Review of Neurotherapeutics, :1, pp The pain referral patterns of the SIJ are extremely variable. Three or more provocation tests can predict response to diagnostic blocks. Evidence supports both intra- and extra-articular causes for SIJ pain, with clinical studies demonstrating intermediate-term benefit for both intra- and extraarticular steroid injections. In those who fail to experience sustained relief from SIJ injections, radiofrequency denervation may provide significant relief lasting up to 1 year. 9

10 From: Novel 10-kHz High-frequency Therapy (HF10 Therapy) Is Superior to Traditional Low-frequency Spinal Cord Stimulation for the Treatment of Chronic Back and Leg Pain:The SENZA-RCT Randomized Controlled Trial Anesthesiology. 2015;123(4): doi: /aln Figure Legend: Study subject flow. HF10 = 10-kHz high-frequency; SCS = spinal cord stimulation. Kapurelet al., Anesthesiology , Vol.123, doi: /aln Date of download: 9/27/2015 Copyright 2015 American Society of Anesthesiologists. All rights reserved. From: Novel 10-kHz High-frequency Therapy (HF10 Therapy) Is Superior to Traditional Low-frequency Spinal Cord Stimulation for the Treatment of Chronic Back and Leg Pain:The SENZA-RCT Randomized Controlled Trial Anesthesiology. 2015;123(4): doi: /aln Table Title: Baseline Demographics and Clinical Characteristics Date of download: 9/27/2015 Copyright 2015 American Society of Anesthesiologists. All rights reserved. Opioid Oral IV Epidural Spinal Morphine Dilaudid Fentanyl Meperidine

11 Hamza et al., Pain Medicine, 2012; 13: Epidural corticosteroid injections for radiculopathy are associated with immediate improvements in pain and might be associated with immediate improvements in function, but benefits are small and not sustained, and there is no effect on the long-term risk of surgery. Evidence did not suggest that effectiveness varies based on injection technique, corticosteroid, dose, or comparator. Limited evidence suggested that epidural corticosteroid injections are not effective for spinal stenosis or nonradicularback pain, and that facet joint corticosteroid injections are not effective for presumed facet joint pain. There was insufficient evidence to evaluate the effectiveness of sacroiliac joint corticosteroid Chou injections. R, Hashimoto R, Friedly J, Fu Rochelle, Dana T, Sullivan S, Bougatsos C, Jarvik J. Pain Management Injection Therapies for Low Back Pain. Technology Assessment Report ESIB0813. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. HHSA I.) Rockville, MD: Agency for Healthcare Research and Quality; March

12 Interventional pain treatments are optional. Interventional pain treatments CAN provide relief of back pain Function and disability is a probably a better measure of response to treatment than subjective improvement in pain. Multi-disciplinary works better than any individual treatment alone. 12