The Role of Interventional Procedures in Sports Medicine

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Edmund Gilbert
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1 The Role of Interventional Procedures in Sports Medicine Zacharia Isaac M.D. Director, Interventional Physical Medicine and Rehabilitation Spaulding Rehabilitation Hospital Spinal Injections Localize Diagnosis Reduce Pain/Inflammation Complement/Facilitate an Exercise Regimen Provide Non-Surgical Pain Management Options Overall, a Limited Role in Athletic Populations, Limited to no literature in this subset Overview Mechanisms/ Physiology Evaluation History Examination Diagnostic Testing Interventional Diagnoses and Procedures 1

2 PAIN A time-based definition Acute Pain/ Subacute Time limited, <4 to 12 weeks Results from injury to tissue Resolves with healing Example: hnp versus Chronic Pain 3 months Continues after initial injury heals Example: postherpetic neuralgia, chronic low back pain, fibromyalgia Less likely to improve Mechanisms of pain Nociceptive Pain Involves somatic structures An appropriate physiologic response to painful stimuli Neuropathic Pain Involves nervous system structures An inappropriate response caused by a primary lesion or dysfunction in the nervous system Neuropathic Pain Peripheral Mechanisms Bradykinins, PG, histamine, i cytokines, nerve growth factors Membrane hyperexcitability Ectopic discharges Peripheral sensitization Central Mechanism Wind up Central sensitization Central reorganization of A fibers Loss of inhibitory controls Emotions/ context 2

3 Predisposing factors to degenerative disc disease Aging (L1-2,L2 2,L2-3,L3-4,L4-5) Lifting related occupations (L1-2) Sports Activities (L5-S1) High BMI (all lumbar discs) High LDL (L4-5)/ aortic atherosclerosis Genetics Tobacco Infectious propionobacterium acnes, coag neg staph, cornyebacterium Biochemistry and Disc Degeneration Painful structures Intervertebral disc Dorsal Ganglia of spinal nerve Facet Joint Ligaments Muscles Vascular perineural phenomenon Osseous Pain from fracture/ stress reaction 3

4 Dysfunction History Need to define the nature of the inciting event, and time relationship to onset of symptoms axial or extremity symptoms? Axial is lumbosacral junction Extremity is the thigh and beyond The buttock is a subjective clinical judgement but usually gets lumped with the predominating complaint Assess Pain Intensity History VAS, PI-NRS Assess function Work status Basic activities of daily living Instrumental activities of daily living Assess psychological function Symptom exaggeration Anxiety/ Depression Job satisfaction 4

5 Physical Examination Physical Examination Manual Muscle Testing Sensory Testing Reflex Testing Provocative Maneuvers Spinal Nerve Root Tension Psychological Pain Behavior Test Hip, knee, shoulder and for upper motor neuron signs Dermatomes Not fully explanatory of clinical presentation Autonomic Disturbances Sensory changes discordant 5

6 Cervical Radiculitis Pain Pattern Summary C4 C5 Upper Trapezius and Deltoid: C4-C8 C8 Scapula: C6-C8 moreso than C4 and C5 Upper Arm: C5-C8 Forearm Pain: C6-8 moreso than C5 Chest Pain: C7,C8,C6 C6 C7 Slipman Et al. Spine Oct 15;23(20): Pain referral pattern L5 Radiculopathy 6

Spinal Nerve Root Tension Herniated discs

of spinal nerve root and dura Stretching

recreates pain Straight Leg Raise L5 and

7 Pain referral pattern S1 Radiculopathy Pain referral pattern L4 radiculopathy Spinal Nerve Root Tension Herniated discs generate inflammatory cascade Tethering of spinal nerve root and dura Stretching leg stretches spinal nerve root and recreates pain Straight Leg Raise L5 and S1 spinal nerves Femoral Stretch L2,L3,L4 spinal nerves 7

$Blocks Sacroiliac joint Intervertebral Disc Xrays Useful for fractures,$ $Reaction Evaluate for tumor, infection, fracture CT radiation exposure, $$ MRI$

8 Xrays Diagnostic Testing MRI/ CT/ Myelography Electromyography Diagnostic anesthetization or provocation Spinal Nerve Root Hip Facet joint/ Medial Branch Blocks Sacroiliac joint Intervertebral Disc Xrays Useful for fractures, spondylolisthesis, segmental instability CT and MRI Identify herniated disc, spinal stenosis, degenerative disc disease, Pars Fracture/ Osseous Stress Reaction Evaluate for tumor, infection, fracture CT radiation exposure, $$ MRI no radiation exposure, $$$ 8

9 Asymptomatic Findings on MRI - boden 1990 Electromyography Electromyography Needle exam identifies spinal nerve root motor involvement Does not identify sensory involvement Insensitive to clinical syndrome of radicular pain Can continue to show chronic changes in asymptomatic patients Herniated Disc 9

10 Disc Herniations The larger the disc herniation, the more resorption The farther beyond the PLL, the more resorption Overall 69% herniations decrease in size Subligamentous 56% Transligamentous 79% Sequestered 100% Mechanisms of Nociception Local inflammatory mediators and intradiscal neuropathic pain Nucleus pulposus is remnant of embryonic notochord herniation may result in antigen presentation ti to immune system PLA2, TNF-alpha, Interleukin B1,IL-6, MMP, PGF2, bradykinins, C-Fos, Nerve growth factor, Substance P and CGRP and GAP-43 immunoreactive nerve fibers, etc. Surgical Treatment The Professional Athlete Spine Initiative: outcomes after lumbar disc herniation in 342 elite professional athletes. Hsu, Wellington K. et al. Spine Journal; Mar 2011, Vol. 11 Issue 3, p , 7p professional athletes successfully returned to sport 82% of the time, with an average career length of 3.4 years 226 patients who underwent surgical treatment, 184 successfully returned to play (81%), on average, for 3.3 years after surgery. There were no statistically significant differences in outcome in the surgical and nonoperative cohorts MLB more likely to return to sport, but discectomy associated with shorter careers compared with nonoperative cohort NFL less likely to return to sport, but had best benefit from surgery 10

Mechanical Low Back Pain Discogenic Pain Facet Joint Myofascial Pain Sacroiliac Joint Syndrome Discogenic Pain Typically exacerbated with prolonged sitting Younger

lesion (HIZ), herniations may be present but not required.

11 Mechanical Low Back Pain Discogenic Pain Facet Joint Myofascial Pain Sacroiliac Joint Syndrome Discogenic Pain Typically exacerbated with prolonged sitting Younger age group (20-50) MRI demonstrates nonspecific findings of degenerative disc disease: disc dessication, loss of disc height, anular tears/high intensity zone lesion (HIZ), herniations may be present but not required. nonsedated provocative lumbar discogram (controversial) Mechanisms of Nociception Mechanical insufficiency of disc Pain typically increased with prolonged sitting, stand, bending forward Pain from anulus, vertebral endplate, dura, spinal nerve root, or other mechanisms 11

Discogenic Pain Discogenic Pain Disc receives innervation from:

from sympathetic nervous system) and collateralize with ventral rami

Discography Limitations Pain Referral Patterns Reproducible and follow

Spine 1988; 13(1):2-8 Slipman et al, The Spine Journal 2005; 5:381-388

referred pain to extremity without neural compression MRI findings can

12 Discogenic Pain Discogenic Pain Disc receives innervation from: Sinuvertebral nerve (ventral Ramus), Vertebral Nerve (autonomic root from sympathetic nervous system) and collateralize with ventral rami (somatic afferent) Based on Discography? Discography Limitations Pain Referral Patterns Reproducible and follow an anatomic trend Bogduk et al. Spine 1988; 13(1):2-8 Slipman et al, The Spine Journal 2005; 5: Facet Syndrome back pain, exacerbated with standing and walking referred pain to extremity without neural compression MRI findings can demonstrate nonspecific findings of facet arthropathy diagnosis made with controlled diagnostic anesthetization of the facet joint or its innervation 12

Facet osteoarthropathy Facet Pain Referral

and Atlantoaxial (AA) joints are innervated

known as the Third Occipital Nerve) C3-4 to

of dorsal rami one level cephalad and one

13 Facet osteoarthropathy Facet Pain Referral Cervical Z-Joint Pain Occipitoatlantal (OA) and Atlantoaxial (AA) joints are innervated by ventral rami of first and second cervical spinal nerves C2-3 joint innervated by two branches of the Dorsal Rami of the third Cervical Spinal Nerve (communicating branch and Medial branch known as the Third Occipital Nerve) C3-4 to C7-T1 joints innervated by medial branches of dorsal rami one level cephalad and one level caudal to joint Bogduk N. Spine. Jul-Aug 1982;7(4):

I: A study in normal volunteers. Spine. Jun 1990;15(6):453-7.

Jun 1990;15(6):458-61. Dreyfuss P, Michaelsen M, Fletcher D.

Ablation for Facet Syndrome Slipman, Bhat, Gilchrist, Isaac,

14 Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain patterns. I: A study in normal volunteers. Spine. Jun 1990;15(6): Aprill C, Dwyer A, Bogduk N. Cervical zygapophyseal joint pain patterns. II: A clinical evaluation. Spine. Jun 1990;15(6): Dreyfuss P, Michaelsen M, Fletcher D. Atlanto-occipital and lateral atlanto-axial joint pain patterns. Spine. May ;19(10): Facet Pain Facet injections/ radiofrequency ablation RF Ablation for Facet Syndrome Slipman, Bhat, Gilchrist, Isaac, Chou, Lenrow - Spine Journal 2003 Literature review Moderate evidence for long term benefit with RF denervation 14

SI Joint Syndrome Back and buttock pain which can refer to the extremity Often seen post trauma, intra or post partum, or without inciting etiology Not associated with specific radiographic features

15 SI Joint Syndrome Back and buttock pain which can refer to the extremity Often seen post trauma, intra or post partum, or without inciting etiology Not associated with specific radiographic features Gold standard of diagnosis is controlled diagnostic anesthetization Sacroiliac Joint Syndrome Not sacroilitis Need to consider radicular pain, discogenic pain, facet pain first Double block to define diagnosis Intra-articular articular steroid and physical therapy Role of Denervation? SI Joint Syndrome More than 2 provocative exam maneuvers correlates with positive diagnostic block (Broadhurst, Laslett, Slipman) Symptoms in back, buttock, groin, thigh If symptoms above the L5 transverse process, less likely 15

16 Treatment of Back Pain Reassure Vs restrict Patients Borenstein 2001 Asymptomatic patients with MRI abnormalities followed for 7 years 58% did not develop back pain No correlation between severity of abnormality and symptoms However, athletic population much more active and may have unrealistic expectation for age Targets of treatment Biomechanics Treatment Core strength, Activity level, Surgical Local inflammation Injections, Oral anti-inflammatory, inflammatory, Motion Centrally Mediated Pain Desensitize: meds, exercise, behavioral Comorbidities Mood, Sleep 16

Treatment of Spine Disorders Injections Fluoroscopic

Blocks/Facet injections, radiofrequency ablation selective

Injections More helpful for radicular pain Reasonable to

relief is indicated Fluoroscopic guidance important 3 main

17 Treatment of Spine Disorders Injections Fluoroscopic guidance Diagnosis specific injections Medical Branch Blocks/Facet injections, radiofrequency ablation selective nerve root blocks/ transforamenal epidurals Epidural Steroid Injections More helpful for radicular pain Reasonable to consider if less invasive means are unhelpful or more rapid relief is indicated Fluoroscopic guidance important 3 main routes Interlaminar (Translaminar) Caudal Transforamenal Transforamenal Injection 17

18 Spine Pre-Surgical Planning Exclusion of significant nonspinal pain generator Evaluate patient expectations of surgery Evaluate comorbid diagnoses that may affect outcome Diabetic, tobacco, psych, secondary gain, obesity, spinal anatomy Medical Stability and operative risk Pre-Surgical Planning Establish as best possible the pain generator History, Exam, Imaging selective nerve root blocks discography Hip, sacroiliac joint, facet joint anesthetization Communication between Medical Spine Specialist, Spine Surgeon and Patient 18

Degenerative Disease of the Spine

Degenerative Disease of the Spine Introduction: I. Anatomy Talk Overview II. Overview of Disease Processes: A. Spondylosis B. Intervertebral Disc Disease III. Diagnosis IV. Therapy Introduction: Myelopathy