HELPING THE OLDER ADULT PATIENT MANAGE CHRONIC PAIN: INTERVENTIONAL HIGH TECH INJECTIONS

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1 HELPING THE OLDER ADULT PATIENT MANAGE CHRONIC PAIN: INTERVENTIONAL HIGH TECH INJECTIONS Lawrence M. Kutz, DO The CORE Institute Learning Objectives: Explain to patients different potential treatment options to treat spinal pain/pathology. Determine which patients are candidates for interventional pain management. Formulate full treatment plans utilizing all options. DISCLOSURE OF COMMERCIAL SUPPORT Lawrence M. Kutz, DO does not have a significant financial interest or other relationship with manufacturer(s) of commercial product(s) and /or provider(s) of commercial services discussed in this presentation. 1

2 Lawrence Kutz, D.O. CORE Institute Spine Division Board Certified, Fellowship Trained Pain Management Physician Lumbar Spinal Stenosis Low back pain #2 reason patients seek medical care More health care $$ spent on back pain than any other condition 4 6 million Americans with chronic LBP 13 14% who seek specialist have LSS 1.2 million back & leg pain related to LSS Leading cause work related disability Classic Neurogenic Claudication Back and buttock pain radiating into thighs or legs with numbness, tingling or cramping Exacerbating factors: excessive standing, walking (uphill) Relieving factors: leaning forward, sitting, crouching May present with radiculopathy Age no race predilection Men > Women under 55 Women > Men over 55 2

3 Stenosis Greek for choke Defined as: a condition involving any narrowing of the spinal canal, nerve root canals or intervertebral foramen leading to compression or pressure of neural elements Purpose of Interventional Spine Techniques Diagnostic Identify the pain generator Therapeutic Decrease acute inflammation and pain Facilitate patient participation in therapy Delay/prevent surgical intervention Interventional Spine Techniques Epidural Steroid Injections Caudal Interlaminar Transforaminal Selective Nerve Root Block Facet Joint Injection Medial Branch Blocks Radiofrequency denervation Sacroiliac joint injections 3

4 Epidural Steroid Injections Route Caudal Interlaminar Transforaminal Epidural Steroid Injections Perform under fluoroscopic guidance Ensure proper 40% caudal and 30% intelaminar not properly placed CAUDAL APPROACH Thought to be least technically demanding <0.6% risk of dural puncture Medication likely to reach only the L4 L5 level More volume of injectate needed, resulting in dilution of the steroid 4

5 Caudal Epidural Usually post surgical when transforaminal technique not possible or appropriate, rather than as first line technique Consider in patients with coccydynia Severe stenosis at L5/S1 Caudal Injection Patient prone wedge shaped pillow under hips Sacral hiatus into prominence A/P view for approach, Lateral view for depth 10 ml soln. reaches L4 5 80% of the time Intravacular 10.9% 5

6 L5 INTERLAMINAR APPROACH Not translaminar Allows for administration of medication to higher lumbar levels Highest rate of dural puncture (<5%) 6

7 Interlaminar Injection Midline or paramedian approach Patient prone use A/P view Through supraspinous, interspinous ligaments to ligamentum flavum loss of resistance 3 5 ml 1% Lidocaine (Lumbar) 1 2 ml corticosteroid 2 6 ml saline Intravascular 1.9% 7

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9 TRANSFORAMINAL INJECTION Indication Radicular pain Rationale Drug is delivered in maximum concentrations, closer, if not directly to, the site of pathology 9

10 Supplied by Prof Nik Bogduk dural sleeve dorsal root ganglion Pedicle safe triangle spinal nerve ventral ramus dorsal ramus P L4 P L5 A B Provided by Ray Baker 10

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13 A Provided by Paul Dreyfuss B Provided by Paul Dreyfuss 13

14 Controversies 1 or 2 or 3? Practice audits found that if there is no response to first fluoroscopically guided ESI, then the second will not help. Controversies 1 or 2 or 3? Three ESIs should not be the routine Evaluate response after each ESI before deciding need for another Wait at least 2 weeks between ESIs, due to suppression of hypothalamic pituitary axis (2 3 wks) and duration of epidural C/S effects (2 3 weeks) Rationale for Anesthetics Local anesthetics alone can, on occasion, provide long term pain relief as observed in Nerve blocks, MBBs and ESIs (Postulated mechanisms; interrupt painspasm cycle and reverberating nociceptive transmission, and hydrostatic (mechanical) effects 14

15 Corticosteroid Effects Stabilize NR membranes by suppressing ectopic discharges Inhibit release of cytokines by immune cells Diminish migration and accumulation of lymphocytes Partially block passage of immune complexes across the basement membrane Corticosteroids Corticosteroid Effects Inhibit prostaglandin synthesis Suppress superoxide radicals Stabilize lysosomal enzymes at supraphysiologic concentrations Block C fiber transmission Reduce capillary permeability 15

16 Contrast must be used for all spine injections to assure the validity of the procedure Selective Nerve Root Blocks Largely, a pre surgical tool Blocks the spinal nerve and associated neural elements (spinal nerve, DRG,, SVN, and origin of the DR &VR) Similar to transforaminal epidural technique except less volume, higher strength anesthetic with flow at and lateral to the DRG (outside pedicle) attempted Cervical Epidural Techniques Posterior approach (interlaminar); non diagnostic Transforaminal (selective) approach: diagnostic 16

17 C7-T1 Epidural Epidural Veins DISC SPACE cord DRG SAP Big Red DRG SAP 17

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19 27th Annual Fall Symposium Arizona Geriatrics Society C6 Transforaminal Vertebral artery sheath injection Courtesy David Schultz, MD C6 Transforaminal Needle repositioned Nerve root outlined Courtesy David Schultz, MD 19

20 Spinal injections Comparative, local anesthetic, medial branch blocks under fluoroscopic guidance are the gold standard for diagnosing Z joint pain. Intra articular Z joint injections with local anesthetic and steroid can be both diagnostic and therapeutic. The goal of Z joint steroid injections is to provide temporary pain relief and facilitate a physical therapy program. Imaging No imaging modality can definitively diagnose z joint based pain X ray and MRI can help rule out other causes of LBP. MRI is good for patient education and peace of mind. Z joint Innervation Medial branch nerves are the branches off the dorsal rami of spinal nerves. Each segmental medial branch of the dorsal ramus supplies at least 2 z joints. 20

21 Z joint Innervation In the lumbar spine, each z joint is innervated by the medial branch of the level of the IAP and the level above. Example: The L4 5 z joint is innervated by the L3 and L4 medial branches off the L3 and 4 spinal nerves. From Sluijter 21

22 Making the diagnosis Mooney 1976 Making the diagnosis Anesthetizing the joint is the only reliable way of assessing the facet joint as a pain generator Intra articular articular injection OR Medial branch block 22

23 Medial Branch Block (From Dreyfuss) 23

24 Z joint Innervation In the cervical spine, each z joint is innervated by the medial branches correlating with the IAP and SAP of that joint. Example: The C4 5 z joint is innervated by the C4 and C5 medial branches off the C4/5 spinal nerves C2 3 C2-3 24

25 C2 3 C2-3 C3-4 C3 4 C2-3 C6 7 C4-5 C3-4 C5-6 25

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27 Treatment The least invasive, most definitive treatment for chronic Z joint pain is a radiofrequency neurotomy. Treatment RF neurotomy Radiofrequency neurotomy denervates the facet joint by coagulating the medial branch of the dorsal ramus, which denatures the proteins in the nerve. The treatment consisted of heating the nerve to 80 C for 90 seconds. However, the nerve is not destroyed since the medial branch cell bodies in the DRG are not affected. RF Neurotomy The nerve may grow back to its target facet joint after 6 9 months (depending on the radiofrequency lesion site) at which time the painful messages may again pass through the nerve to the brain if the joint remains painful. Repeating the neurotomy is an option since the medial branch appears to regrow in its anatomical path. The procedure should not be performed bilaterally at multiple segments at the same time because of increased risk of cervical muscular fatigue with activities of daily living 27

28 RF Neurotomy Radiofrequency neurotomy is highly effective and validated for the treatment of chronic neck pain and cervicogenic headaches. Lau 2004 SIJ arthrogram 28

29 Lateral View Discussion Did this patient get too many injections in one year? 6 epidural steroid injections 1 facet joint injections Lumbar radiofrequency ablation 1 sacroiliac joint injection 1 kyphoplasty Spinal Cord Stimulator GATE CONTROL THEORY Published in 1965 by Ronald Melzack and Patrick Wall proposed a mechanism in which the nervous system interprets and regulates pain signals three main components of the gate : the substantia gelatinosa the dorsal column afferents the central transmission cells 29

30 Gate Control Theory of Pain spinal cord is continually bombarded by incoming nerve impulses even in the absence of obvious stimulation. from small diameter A delta and C fibers typically inhibited by the larger A beta fibers in the resting state set the gate in a more closed position The Spinal Cord Stimulator system consists of three components: the lead(s) the extension wiring the pulse generator/ power source Trial Procedure potential candidates typically undergo a trial prior to permanent implantation Percutaneous leads, temporarily secured to the patient s body External pulse generator and power source Evaluates the effectiveness of different stimulation settings and programs Typically 5 to 7 days 30

31 Neurostimulation Applications multitude of applications, ever expanding: prostadynia headaches back pain vulvodynia limb pain phantom pain CRPS coccydynia epididymo-orchalgia orchalgia interstitial cystitis mesenteric ischemia angina pectoris Limb Pain: Diabetic Neuropathy Daousi C et al. Electrical spinal cord stimulation in the long-term treatment of chronic painful diabetic neuropathy. Diabetic Med 2005 Apr; 22(4): Visual Analog Scale (mm) mean follow-up 3.3 years follow-up at 7.5 years (6 patients) (4 Patients) 31

32 Did this patient get too many injections in one year? 2 knee steroid injections 20 supartz injections 4 shoulder subacromial bursa steroid injections 1 left CMC joint steroid injection 1 lateral epicondyle steroid injection 2 epidural steroid injections 1 ankle joint steroid injection 1 plantar fascia steroid injection Patient RB: 79 year old male with a history of severe L4 5 steonsis without spondylolisthesis Low back, buttock, thigh and leg pain exacerbated with standing and walking and relieved with sitting that became debilitating 1 month ago. Patient can walk to the mailbox, but the pain begins on the way back. No neurologic deficits on exam First epidural: Bilateral L4 5 TFESI with 30% relief in overall standing and walking pain What if patient wants surgery at this point? 32

33 Second Epidural: Bilateral L4 5 TFESI with 70% overall pain relief with standing and walking pain Patient wants to try one more injection. Third epidural Bilateral L4 5 TFESI with 95% overall relief Patient is very happy Pain returns 6 months later Patient MW is an 84 year old female with L4 5 Grade I spondylolisthesis without significant stenosis and worsening axial low back pain for the past year. No radicular pain or neurologic deficit No segmental instability Low back pain is exacerbated with standing and walking and alleviated with sitting. 33

34 Patient compliant with P.T. and home exercise program, but the pain is still bothersome and affecting her quality of life. Would you consider a fusion? Facet injections vs. RFA The patient undergoes an L4 5 fusion surgery and subsequent physical therapy. Initially, she felt she was doing better, but returns to the office 12 months after surgery with persistent pain over the lower lumbar and sacral regions. Repeat imaging unremarkable. Further treatment? Consider a spinal cord stimulator? 34

35 TS is a 73 year old male with new onset radicular left leg pain exacerbated with standing and walking and improved with sitting. No neurologic deficit other than subjective paresthesias in the lateral leg and the dorsum of the left foot. MRI shows multilevel facet arthropathy, mild L4 5 central canal stenosis and severe bilateral L5 S1 foraminal stenosis. Know when To quit Not all patients are needle responsive 35