Karachi Spine - Pain and Minimally Invasive Spine Surgery Workshop. Lumbar Injections For Diagnosis and Treatment. Pain Management

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1 Lumbar Injections For Diagnosis and Treatment Pain Management Ovidiu Nicolae Palea Centrul de Diagnostic si Tratament ProVita Anesthesiology and Intensive Care 2009 decided to focus on Pain Management 2010 started the first Multidisciplinary Minimal Invasive Pain Center in Romania Centrul de Diagnostic si Tratament Provita Full time Pain Management 1

2 Pain Management Medicine has evolved into 30 specialties and OVER 140 Subspecialties!!!!! Anesthesiologists were first, but now. Neurosurgeons Physical Medicine and Rehab docs Rheumatologists Orthopedic Surgeons Neurologists Interventional Radiologists Pain Management Patient Population sub acute and chronic: Lower back 50% Upper back 20% Peripheral joints hip, knees etc 20% Head and Facial Pain 10% 2

3 The Goal Today: Functional Diagnosis Radiological Landmarks Technique for Infiltrations Definition and Etiology Radicular pain is a type of pain that radiates into the lower extremity directly along the course of a spinal nerve root It needs a good differential to Pseudoradicular Pain Radicular pain is caused by inflammation rather than compression, and/or injury to a spinal nerve root 3

4 Definition and Etiology Inflammation of the nerve root can be caused by: herniated disc facet hypertrophy osteophytes epidural fibrosis Definition and Etiology Inflammation of the nerve root can be caused by: 4

5 Definition and Etiology Inflammation of the nerve root: History of Present Illness Physical exam: how did the pain start? Clinical Diagnosis where is the pain? Back or leg pain? neurological deficits straight leg raising, SI and Hip reflexes 5

6 Facet pain Sacroiliac pain Coxarthritis Tendinopathy Peripheral nerve Entrapments Bursitis, Psoas Impingement Internal pathology X ray AP and Lateral Differential Diagnosis Radiological Diagnosis mainly bone landmarks BUT also critical alignment information 6

7 CT scan Radiological Diagnosis more soft tissue anatomy great for osteophytes used mainly when MRI is contraindicated Radiological Diagnosis MRI soft tissue detailed anatomy very limited for osteophytes BIGGEST pitfall: NO CLINICAL CORELLATION!!! 7

8 Do we treat the actual hernia? Clinical Diagnosis is Critical Do we treat the cause? Is Hernia the cause? Do we treat the SYMPTOMS? Symptoms caused by what? Hernia? Nerve Inflammation? Fibroses of the nerve root? Great Sensitivity Poor Specificity Poor clinical correlation Electromiography Lesion has to be over 4 weeks old to see any changes 8

9 Functional Diagnosis is Critical Guided Anesthetic infiltrations are the only available functional diagnosis at the present time In multilevel pathology there is no other test that has a better correlation!!!!! Functional Diagnosis is Critical Guided Anesthetic infiltrations are the only available functional diagnosis at the present time X ray guided or Ultrasound guided Ultrasound guided injections are growing as indications more and more axial as well as articular or peripheral nerve entrapments 9

10 Indications for minimal invasive Symptoms severity VAS >4 5/10 Duration of pain usually > 2 weeks Failed conservative treatments kinetotherapy, NSAIDS Numbness, hypoesthesia NOT AN INDICATION FOR ANYTHING!! Old moderate motor deficits Presence of a hernia on the MRI but no symptoms Clinical picture improving!!! Free fragments 10

11 There 3 types: Interlaminar Epidural Caudal Epidural Transforaminal Epidural Epidural Injections Interlaminar Epidural Steroid injection 34% Success rate 11

12 Interlaminar Epidural Steroid injection Nonspecific block No diagnostic value 60% success Nonspecific Caudal Epidural 12

13 60% success Caudal Epidural Transforaminal Steroid Injections 13

14 Transforaminal Infiltrations Transforaminal Infiltrations 14

15 Transforaminal Infiltrations Transforaminal Injections 15

16 Transforaminal Infiltrations Transforaminal Steroid Injections Risk of: Bleeding Infection Nerve damage Wet tap Paralysis Often first step 16

17 Often first step Treatment Algorythm First step is always GUIDED periradicular injections! success rate of 70 80% for radicular pain that is under 8 weeks old!! response is due to the long acting depo steroid injection and is based on the assumption that most of the pain is due to inflammation 17

18 Treatment Algorythm First step is always GUIDED periradicular injections! response is MAINLY in the second week after the injection NOT at the time of the infiltration it can be repeated x3 at 2 4 weeks interval if RESPONSE is achieved Technique we love our Scotty Dog Discography 18

19 Technique we love our Scotty Dog Discography Technique we love our Scotty Dog Discography 19

20 Technique we love our Scotty Dog Facet Injections Technique we love our Scotty Dog Facet Injections 20

21 Technique we love our Scotty Dog Facet Injections Treatment Algorythm Epiduroscopy with laser ablation of scar tissue small hernias multilevel degenerative spine moderate spinal stenosis failed back surgery 21

22 Treatment Algorythm Epiduroscopy with laser ablation of scar tissue Treatment Algorythm Epiduroscopy with laser ablation of scar tissue 22

23 How to start my practice? Cadaver Workshops for guided infiltrations Pick up initially easy cases lumbar single hernia Pair up with a radiologist Start with Caudal Ultrasound guided do CT guided infiltrations Ask for help any time!!! TAKE HOME MESSAGE Anesthesiologists can DIAGNOSE the cause of pain!!! We can treat the cause of pain You could be the third opinion 23

24 My 24