Phillip Weidner, DO, DABA, BCPM May 20th, 2014

Transcription

1 Phillip Weidner, DO, DABA, BCPM May 20th, 2014

2 Introduction Comprehensive Pain Management Center Interventional therapies Epidural steroid injections Sacroiliac interventions Facet joint disease Who to refer Referral process

3 Who is the Comprehensive Pain Management Center?

4 Phillip Weidner Born and raised in Anchorage, Alaska BA in neuroscience, Colorado College Neuroscience research, UCSB University of New England Doctor of Osteopathy, ΣΣΦ, ΨΣΑ Oregon Health and Sciences University Board Certified in Anesthesiology Oregon Health and Sciences University Board Certified in Pain Management

5 Lifelong outdoorsman Travelled from Canadian border to Kiana by foot/raft Backpacked throughout Alaska Alaska is my home Respect for Alaska Native culture

6 Other members of CPMC Bibs Carantes, RN Kathy LeBeau, RN Cindy Wilson, RN

7 Vision for ANTHC CPMC Comprehensive Pain Management Center (CPMC) Address the entire patient Not simply Chronic and/or Interventional Pain Clinic Addresses physical, behavioral and environmental forces contributing to a patients perception of pain Multidisciplinary approach Interventional therapy Medication suggestions Appropriate referrals

8 What is pain? An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life. International Association for the Study of Pain pain.org

9 Introduction Comprehensive Pain Management Center Interventional therapies Epidural steroid injections Sacroiliac interventions Facet joint disease Who to refer Referral process

10 Interven?onal Pain Management Diagnostic nerve block Peripheral nerve ablation Intralaminar epidural steroid injections Transforaminal epidural steroid injection Lumbar/Cervical Medial branch block Lumbar/Cervical Medial branch denervation Peripheral nerve and plexus blocks Occipital nerve block Sacroiliac joint injection Sacroiliac joint denervation Lumbar sympathetic nerve block Stellate ganglion nerve block Trigger point injection Intrathecal pump placement Spinal cord stimulation Botox therapy for spasticity and migraines Intercostal nerve block

11 Interven?onal Pain Management Diagnostic nerve block Peripheral nerve ablation Intralaminar epidural steroid injections Transforaminal epidural steroid injection Lumbar/Cervical Medial branch block Lumbar/Cervical Medial branch denervation Peripheral nerve and plexus blocks Occipital nerve block Sacroiliac joint injection Sacroiliac joint denervation Lumbar sympathetic nerve block Stellate ganglion nerve block Trigger point injection Intrathecal pump placement Spinal cord stimulation Botox therapy for spasticity and migraines Intercostal nerve block

12 Interven?onal Pain Management Diagnostic nerve block Peripheral nerve ablation Intralaminar epidural steroid injections Transforaminal epidural steroid injection Lumbar/Cervical Medial branch block Lumbar/Cervical Medial branch denervation Peripheral nerve and plexus blocks Occipital nerve block Sacroiliac joint injection Sacroiliac joint denervation Lumbar sympathetic nerve block Stellate ganglion nerve block Trigger point injection Intrathecal pump placement Spinal cord stimulation Botox therapy for spasticity and migraines Intercostal nerve block

13 EPIDURAL STEROID INJECTIONS (ESI s) Two kinds Intralaminar Transforaminal Both introduce steroid into the epidural space Premise is that these injections decrease the local inflammation/swelling which causes pain.

14 Pa?ents likely to benefit Depends on what trials you look at American Pain Society Low Back Pain Guideline,2009 Recommend ESI s for radicular pain, insufficient evidence to evaluate benefits/harm for spinal stenosis 1B level evidence 1 (strong recommendation, moderate quality evidence) Best evidence in Acute lumbar disc herniation with radiculopathy Low back pain with radicular symptoms 1 Rathmell, J. Atlas of Image Guided Intervention in Regional Anesthesia and Pain Medicine

15 Introduction Comprehensive Pain Management Center Who to refer Interventional therapies Epidural steroid injections Sacroiliac interventions Facet joint disease Referral process

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17 Introduction Comprehensive Pain Management Center Who to refer Interventional therapies Epidural steroid injections Sacroiliac interventions Facet joint disease Referral process

18 Lumbar Facet Syndrome

19 Pathophysiology Degeneration of the joint itself from repetitive injury Hyperextension injuries

20 Increased wear on joint secondary to desiccated disk Pathophysiology

21 Facet syndrome Defined as any pain that arises from the facet joints Fibrous capsule, synovial membrane, bone, cartilage Prevalence is somewhere between 4-75% How do we actually define the presence of something not readily observed? Approximately 27% prevalence rate of patients with LBP in a 2004 paper by Manchikanti using diagnostic blocks. Manchikanti L, Boswell MV, Singh V, et al. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord. May ;5:15.

22 Who to refer for facets? Patients without lumbosacral radicular pain who have failed conservative treatment Medications Physical therapy Weight loss Lack of concerning neurological symptoms Cauda equina Progressive loss of motor control

23 Radiofrequency Abla?on Indicated by a positive response to diagnostic test(s) First controlled study in Numerous double blind studies show improvement 2 1 Gallagher et al. Radiofrequency facet joint denervation in the treatment of low back pain- a prospective controlled double blind study to assess its efficacy. Pain Clinic Nath et al. Percutaneous lumbar zygapophysial joint neurotomy using radiofrequency current, in the management of chronic low back pain: a randomized double- blind trial. Spine. 2008; 33:

24 RFA (cont) Considered the gold standard for facet arthropathy When compared with sham procedure after 6 months 1 Significant improvement of pain Global perception of pain improved Improved quality of life Note: In some cases, the procedure needs repeating. Repeat procedures have a very high success rate Repeat procedures last as long, if not longer than the original procedure. 1 Nath, S et at. Percutaneous lumbar zygapophysial joint neurotomy using RF current, in the management of chronic low back pain: a randomized double- blind trial. Spine. 2008; 33:

25 Introduction Comprehensive Pain Management Center Interventional therapies Epidural steroid injections Sacroiliac interventions Facet joint disease Who to refer Referral process

26 Who to refer?

27 In general Same basic principles of other referrals Reliable, reasonable, follows instructions Please ask a specific question Specific to pain referrals, best case scenario Patients with localized pain Patients with an acute injury Decision about whether a patient is more appropriate for addiction medicine Patients who do not need to be anti- coagulated

28 Introduction Comprehensive Pain Management Center Interventional therapies Epidural steroid injections Sacroiliac interventions Facet joint disease Who to refer Referral process

29 Referring Patients to the Pain Management Center REFERRING PROVIDER PATIENT PAIN MANAGEMENT

30 Referring Patients to the Pain Management Center REFERRING PROVIDER PATIENT PAIN MANAGEMENT

31 Referring Patients to the Pain Management Center REFERRING PROVIDER PATIENT PAIN MANAGEMENT

32 Referring Patients to the Pain Management Center REFERRING PROVIDER PATIENT Patient not felt to be a good candidate for pain management. PAIN MANAGEMENT Patient is a good candidate, called to schedule. Recs made. After the questionnaire and the referral request have been received, either the provider will be contacted, or the patient will be called to schedule an appointment.

33 Referring Patients to the Pain Management Center REFERRING PROVIDER Questionnaire PATIENT PAIN MANAGEMENT

34 Referring Patients to the Pain Management Center REFERRING PROVIDER PATIENT PAIN MANAGEMENT

35 Referring Patients to the Pain Management Center REFERRING PROVIDER PATIENT PAIN MANAGEMENT

36 Referring Patients to the Pain Management Center REFERRING PROVIDER PATIENT PAIN MANAGEMENT

37 Referring Patients to the Pain Management Center REFERRING PROVIDER PATIENT PAIN MANAGEMENT Pain management able to provide therapeutic procedure and recommendations for non- opioid analgesics and therapies.

38 Ques?ons? Thank you! Questions? Phillip Weidner Ext 2522, pager 2522