Interventional Pain Management Treatment Options

Transcription

1 Interventional Pain Management Treatment Options PATRICK W. HOGAN, D.O. PRESIDENT & CEO ARIZONA SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS FELLOWSHIP-TRAINED PAIN PHYSICIAN ARIZONA PAIN SPECIALISTS

2 Patrick W. Hogan, D.O. My Background D.O. Degree Arizona College of Osteopathic Medicine at MWU in Glendale, AZ. Anesthesiology Residency The Cleveland Clinic ACGME Pain Fellowship The Cleveland Clinic Diplomate of the American Board of Anesthesiology Subspecialty ABA Board-Certified in Pain Medicine I currently practice full-time pain management in a multi-disciplinary pain clinic in Glendale, Arizona.

3 Who are these Pain Docs? How are they Trained? Pain Medicine is a young specialty. We didn t have our own ABMS certification until 1993 via the ABA. Training starts with medical school, residency, and finally a pain medicine fellowship. Complete a residency in 1 of these four primary specialities: Anesthesiology (roughly 80% of pain fellowships) Physical Medicine and Rehabilitation Neurology Psychiatry

4 ACGME moves to broaden training background of Pain Physicians After completing residency training Apply for a fellowship in Pain Medicine. In 2007 ACGME established NEW curriculum guidelines which required multidisciplinary education in all pain management fellowships. Typically these are all 1 year in duration. There is talk of this being expanded to 2 years in future. All fellowships are now multi-disciplinary and include training/rotations in PM&R, Anesthesiology, Psychiatry, and Neurology.

5 Which Boards within ABMS can certify Pain Specialists? A subspecialty certification examination is administered by each of the following American Board of Medical Specialty (ABMS) Boards: American Board of Anesthesiology American Board of Physical Medicine and Rehabilitation American Board of Psychiatry and Neurology

6 What Type of Treatments can an Interventional Pain Doctor Offer to Patients?

7 Types of Interventional Pain Procedures Epidural Injections (cervical/thoracic/lumbar/caudal) Medial Branch Blocks/Facet Joint Interventions and Radiofrequency Ablation (cervcial/thoracic/lumbar) Spinal Cord Stimulators ( Pacemaker for Pain ) Joint and Bursa injections Peripheral Nerve Blocks Sympathetic Blocks (RSD/CRPS, Neuropathic Pain) Vertebroplasty/Kyphoplasty Facial Blocks Botox Injections for Migraine The Future: Stem Cells, Platelet-Rich Plasma, etc.

8 Procedures for Low Back and/or Leg Pain Chronic low back pain #2 reason that patients visit a doctor 85% of population will have it at some point Usually lasts 2-4 weeks and over 80% resolve within 6 months Diagnosis History Physical Examination Imaging studies

9 Determine the Etiology-- Back vs. Legs or Both Radicular Pain Often herniated discs or bulging discs Frequently caused by postsurgical changes Axial spine pain Typically doesn t radiate distal to elbow or knee, but can! Facet joint-related pain Mechanical low back pain Compression Fractures

10 Lumbar Radiculopathy

11 Acute & Chronic Lumbar Radiculitis Epidural Steroid Injections Fluoroscopically-guided placement of steroid and local anesthetic at the site of the herniated disc Lutz et al. demonstrated an outcome success rate of 75.4% in patients with a lumbar HNP/radiculitis in whom conservative therapy failed. Most clinicians agree that image-guided transforaminal epidural injections are preferred to an interlaminar or caudal approach. This technique routinely delivers medication to the anterior epidural space. Long-term success is 71-84%. When to consider referrals for injections? Current trend is towards EARLY intervention (lost productivity). As soon as 3-6 months post-onset but earlier if patient is in severe pain

12 Transforaminal Lumbar Epidural

13 Transforaminal Lumbar Epidural Contrast Outline of Left L5 Nerve Root

14 Cervical Radiculopathy Caused by any condition that can compress or irritate a cervical nerve root Cervical Stenosis Cervical Herniated Disc Cervical DDD

15 Interlaminar approach is the most commonly utilized. Deposit steroid and local anesthetic or normal saline into the cervical epidural space. Always performed at the C7-T1 interspace for maximum safety. Cervical epidural space is widest here but still only 3-4mm wide. Cervical Epidurals

16 Facet Joint Pain Patterns

17 Procedures for Axial Back Pain Facet Joints Facilitate extension, flexion, and rotational movements of the spine Facet joints are innervated by the medial branches of the dorsal ramus at the same level and the level above Lumbar facet pain pattern is typically axial with referred pain into hips and posterior thighs above the knee Cervical facet pain pattern is typically referred to neck and upper back and into the back of the head.

18 Facet Joint Pain and Procedures Diagnosis: -H & P, Imaging (CT, MRI) Best dx: Provocative Testing Medial Branch Blocks Treatment: 1. Low-Dose Steroid Injections (into the joint directly or preferably blocking medial branches then RFA) 2. Radiofrequency Ablation (6mos-2yrs of relief)

19 Medial Branch Nerves Innervate the Joints

20 Lumbar Facet Joint Procedures

21 Cervical Facet Joint Procedures Preferred over intra-articular blocks as they have similar efficacy but fewer complications

22 Radiofrequency Ablation If patient obtains >80% temporary pain relief with diagnostic/ therapeutic block, then allowed to proceed with RFA of those nerves. Lesions conducted at degrees Celsius for seconds x2 (160 to 176 degrees Fahrenheit).

23 Failure of Facet and Disc Treatments When the patient does not get relief with epidurals, MBBs, RFA, etc. can consider a Spinal Cord Stimulator (SCS) Many insurances require other interventions prior to considering SCS and it is more invasive so generally smart to exhaust other options first.

24 Spinal Cord Stimulation First stimulator was in late 1960 s New technology readily available since 1990 s FDA-approved for intractable pain of the trunk and limbs Melzack and Wall s Gate-Control Theory -more commonly Neuromodulation Place neurostimulator leads within in the epidural space to block/modulate pain transmission in the dorsal column of the spinal cord

25 Spinal Cord Stimulation #1 indication in the United States is failed back or neck surgery syndrome Other indications: Causalgia RSD Postherpetic neuralgia Phantom limb pain Radiculopathies

26 SCS Effectively Reduces Pain Randomized, Controlled Trial in 54 pts. SCS + Physical Therapy Group had a statistically significant Reduction in Pain measured by Visual Analogue Scale (p <. 001) Improvement in Global Perceived Effect (p <.01) Kemler et al. New England Journal of Medicine. Volume 343, Number 9, August 31, 2000:

27 Overview of Trial Procedure A percutaneous lead is positioned in the epidural space on the dorsal aspect of the spinal cord at the appropriate nerve root level(s). Electrical current from the lead generates paresthesias that can be adjusted in intensity and location to achieve the best pain coverage. Leads are attached to an external pulse generator (screener) which supplies the current. Patients can use the screener to adjust stimulation to meet pain management needs.

28 Spinal Cord Stimulation

29 Bursa and Joint Injections

30 The Glenohumeral joint Frozen shoulder Trauma, Osteoarthritis or Rheumatoid arthritis Pain in the Deltoid area, could radiate to the hand in severe cases, worse with arm movements and laying on that shoulder. Loss of lateral rotation Loss of abduction The less the radiation and the earlier the joint treated the more dramatic the relief of symptoms. May need 4-6 injections over 2 months

31 Hip joint OA, RA, traumatic capsulitis Buttock, groin and or anterior thigh pain Loss of medial rotation Hip capsule attaches to base of neck of femur Lateral approach is safe and easy Avoid injecting the hip joint within 6 weeks of surgery

32 Trochanteric bursa Direct blow or fall on the hip Patient says I can t lie on that side especially thin patient Very common lesion to inject

33 Knee joint Knee joint has a potential capacity of approx.120 ml Multiple approaches to the knee joint The suprapatellar approach Lateral at the mid-point of the patella Medially at the mid-point of the patella NO Posterior approach since there is the neurovascular bundle Synvisc injection is a common practice Avoid injection 6 weeks prior to total knee replacement.

34 Peripheral Nerve blocks

35 Occipital Nerve Block Occipital neuralgia is one type of cervicogenic headache described as pain in the distribution of the greater and lesser occipital nerves Associated with posterior scalp dysesthesia or hyperalgesia The pain is described as a lancinating, sharp, throbbing, electric shock like pain

36 Occipital Nerve Block Patient is usually placed in the sitting position with the cervical spine flexed and the forehead on a padded bedside table Draw up about 8 cc of local anesthetic (I use bupivicaine 0.25%) in a 12-mL sterile syringe. I use 10 mg of decadron (nonparticulate) but you can use 40mg of Kenalog as well. For subsequent nerve blocks decrease the steroid by 50%. Smaller needle like 22 or 25-guage with 1.5 inch length is ideal. Less chance of hematoma or bleeding.

37 ONB Duration of Relief Pain relief can vary from hours to months Generally, at least 50% of patients will experience more than 1 week of relief after one injection Isolated pain relief for more than 17 months has been reported after a series of five blocks.

38 Intercostal Nerve Block Indications: Diagnostic Zoster Cancer Surgical pain Rib fracture Post-thoracotomy

39 Suprascapular Nerve Block Indications: Diagnostic Acute pain Post-op pain Cancer pain Adjunct to physical therapy Suprascapular nerve entrapment syndrome shoulder-hand variant of reflex sympathetic dystrophy

40 Genicular Nerves Refractory Knee Pain 53% of patients continue to have pain after TKR and 12% of general population suffers from chronic knee pain Three genicular nerves can be blocked near the knee joint. These nerves are distal branches of the femoral/saphenous, obturator, common peroneal and tibial nerves. Principle is that a successful diagnostic G block (improved pain and/or function) then leads to genicular neurotomy/radiofrequency ablation. 59% patients had relief 3 months after the procedure. Safe and effective minimally invasive technique to control pain from the knee joint (post TKR patients, severe OA but not surgical candidate, refuses surgery, etc.).

41 Genicular Nerve Radiofrequency Ablation Left Knee

42 Sympathetic Nervous System Blocks Stellate Ganglion Block Thoracic Sympathetic Ganglion Block Celiac Plexus Block Lumbar Sympathetic Block Superior Hypogastric Block Ganglion Impar Block

43

44 Celiac Plexus Block Indications: To determine whether flank, retroperitoneal, or upper abdominal pain is sympathetically mediated. Palliation of pain acute pancreatitis/other acute pain syndromes subserved by the plexus Arterial embolization of the liver for cancer therapy Abdominal angina- visceral arterial insufficiency Prognostic value prior to celiac plexus neurolysis - malignancies of the retroperitoneum and upper abdomen

45

46 Lumbar Sympathetic block (LSB) Indications: Sympathetically maintained pain of the kidneys, ureters, genitalia and lower extremities Phantom limb pain, CRPS Palliation of pain - vascular insufficiency of the lower extremity Pain secondary to frostbite, atherosclerosis, Buerger s disease, arteritis secondary to collagen vascular disease Maximize blood flow after vascular procedures on the lower extremities

47 Lumbar Sympathetic Block

48 Fluoroscopy of LSB in A/P View

49 Lumbar Sympathetic Block Local Anesthetic and Steroid with Contrast Dye

50 Lateral View of Lumbar Sympathetic Block

51 Superior Hypogastric Plexus Block Location: The plexus is located bilaterally along the lower 1/3 of the L5 vertebral level and upper 1/3 of the S1 vertebral body level. Indicated for managing sympathetically-mediated pain of the pelvic viscera (neuropathic pain burning, electrical) Malignancy Endometriosis CRPS Proctalgia fugax

52 Hypogastric Plexus Block Single-needle technique

53 Ganglion of Walther (Impar) Block Indications: Sympathetically mediated pain of the perineum, rectum and genitalia (afferent fibers) Unpaired ganglion located 2-3cm anterior to the sacroccygeal junction, although in some patients can be found closer to anterior tip of the coccyx. Treatment of pain secondary to malignancy Other pain syndromes which failed to respond to conservative therapies Endometriosis CRPS Proctalgia fugax Radiation enteritis

54 Ganglion of Impar (the Old-Fashioned Way)

55 Vertebroplasty/Kyphoplasty Used to treat primarily osteoporosis-related compression fractures in the vertebral bodies Placement of cement, either with or without inflation of a balloon (kyphoplasty), inside the vertebral body to stabilize the fracture and reduce pain. Prior to this procedure the standard of care was a back brace (rigid TLSO type) for up to 6 months. Still an acceptable option. Two poorly designed studies in NEJM questioned efficacy of the procedures, however, procedure was vindicated in Lancet article recently. Best candidates have a newer fracture (2-3 months) old. MRI generally must show acute of subacute marrow changes for insurance to cover the procedure and for outcomes to be the best. Must be tender over the spinous process on physical examination.

56 Vertebroplasty

57 The End Any Questions/Discussion? Thank you to Austin Horrocks, MS-IV for his assistance in putting together this presentation. Also thank you to Waldman s Book of Interventional Pain Medicine and other sources for some of the illustrations. Patrick W. Hogan D.O.