Jessica Jameson MD Post Falls, ID

Jessica Jameson MD Post Falls, ID

Discuss the history of interventiona l pain Discuss previous tools to manage chronic pain Discuss current novel therapies to manage chronic pain and indications

HISTORY OF INTERVENTIONAL PAIN Nerve blocks date back to the 1800s Transition from acute pain treatment to chronic pain treatment began in the early 1950s Initially just nerve block clinics 1974 groups of pain physicians came together to create societies and long term clinics

HISTORY OF INTERVENTIONAL PAIN Development of injection techniques to treat ongoing pain began in the 1980s and has progressed As time moves on we realize the potential effects of long term exposure to steroid Shift toward diagnostic utilization of steroid and local KNOWING THE PAIN GENERATOR IS A BIG PART OF THE BATTLE

NSAIDs Adjuvant medications Opioids PT Chiro Steroid injection Ablation Spinal Cord Stimulation Intrathecal pain pump

NSAIDs- kidneys and bleeding and stomach Adjuvant medications- side effects Opioids?- no evidence for long term use, addiction, dependence PT- lack of patient follow through Chiro- lack of patient follow through Steroid injection- osteoporosis, adrenal suppression Ablation- only for sensory nerves Spinal Cord Stimulation- previous systems hard to capture back and neck Intrathecal pain pump- still opioids

Spinal Cord Stimulation Indirect Spinal Decompression Peripheral Nerve Stimulation Regenerative Medicine

SPINAL CORD STIMULATOR Neurosurgeon C. Norman Shealy has been credited with the first implantable neuromodulator device for the relief of intractable pain in 1967. His spinal cord stimulators, which he called dorsal column stimulators, were intended exclusively for pain relief. Publication of the Gate Theory in 1965 helps move pain treatments towards reversible, modulatory treatments: neuromodulation for the treatment of refractory chronic pain. Spinal cord stimulator therapy is the commonest indication, particularly neuropathic pain The implantable devices used for neuromodulation have steadily improved over the last four decades and recently have taken a leap forward with the introduction of rechargeable systems, smaller devices, and systems with greater but useable complexity.

Candidates for SCS implantation: Failed back surgery syndrome Radicular pain Postlaminectomy pain Degenerative disc disease Complex Regional Pain Syndrome (CRPS) Arachnoiditis Refractory angina

85% in patients who are implanted within 2 years of receiving a chronic pain diagnosis 8% when implanted in those who have had chronic pain more than 15 years

Kapural L, Yu C, Doust MW, et al. 24-Month Results From a Multicenter, Randomized, Controlled Pivotal Trial. Neurosurgery. 2016;79(5):667-677. doi:10.1227/neu.0000000000001418.

Spinal cord stimulation therapy is effective for patients at any level of opioid usage prior to implantation. Opioid use declined or stabilized in 70% of patients who received a spinal cord stimulation system. Among patients who had their spinal cord stimulation system explanted, opioid use was higher at one year compared to those who continued with the therapy.

Nonsurgical back Diabetic peripheral neuropathy Pelvic pain Abdominal pain

152 subjects with chronic, intractable pain of the lower limbs were randomized to a DRG stimulation group or a control group (commercially available SCS device) across 22 investigational sites. Primary endpoint success provided the subjects met the following three criteria: 50% pain relief in their primary area of pain at the end of the trial phase 50% pain relief in their primary area of pain at three months post implant Freedom from stimulation-induced neurological deficit through three months

Persistent pain, numbness and/or cramping in the legs (neurogenic intermittent claudication) relieved in flexion Diagnosis of lumbar spinal stenosis, with or without Grade 1 spondylolisthesis Presenting with impaired physical function Subjects who have been symptomatic and unresponsive to conservative care treatment for at least six months Operative treatment is indicated at no more than two adjacent levels

470 patients were enrolled in a Superion U.S. IDE trial at 29 sites with a 24-month follow-up and annually thereafter through 60 months. T The data suggest significant relief from the symptoms of spinal stenosis is achievable, along with very high patient satisfaction with the surgery.

Allergy to titanium or titanium alloy Spinal anatomy or disease that would prevent implantation of the device or cause the device to be unstable in situ Instability of the lumbar spine (spondylolisthesis greater than grade 1) Ankylosed segment at the affected level(s); Fracture of the spinous process, pars interarticularis, or laminae (unilateral or bilateral); Scoliosis (Cobb angle >10 degrees) Cauda equina syndrome defined as neural compression causing neurogenic bladder or bowel dysfunction Severe osteoporosis, defined as bone mineral density (from DEXA scan or equivalent method) in the spine or hip that is more than 2.5 S.D. below the mean of adult normals; Active systemic infection, or infection localized to the site of implantation; Prior fusion or decompression procedure at the index level; Body mass index (BMI) greater than 40.

PERIPHERAL NERVE STIMULATOR Electrodes placed along the course of a peripheral nerve The electrical stimulation of a peripheral nerve to either induce activation or modulation of the activity of the nerve. Stimulation can be induced by either monopolar or bipolar stimulation. Clinically, PNS is used for neuropathic pain that follows a single nerve distribution.

INDICATIONS Ilioinguinal Neuralgia Intercostal Neuralgia Lateral Femoral Cutaneous Neuropathy (Meralgia Paresthetica) Occipital Neuralgia Pain Following Hernia Surgery Painful Nerve Injuries Pain after total joint

MRI compatible 5 day trial of the device before permanent implantation Small incision and one suture

REGENERATIVE MEDICINE RESPONSIBLE REGENERATIVE MEDICINE KEYS: Source of the cells Number of cells

Bone marrow stromal cells are mesenchymal stem cells In the proper environment, they can differentiate into cells that are part of the musculoskeletal system. They can help to form bone, tendon, cartilage, ligaments and part of the bone marrow.

Knee Hip Shoulder Spine and Cervical Conditions Elbow Hand/Wrist Foot/Ankle Non-union fractures

International Orthopaedics showed that 21 out of 26 patients who received an autologous bone marrow concentrate stem cell injection to treat 1 to 2 level degenerating discs were stable and had lower pain scores past 2 years. (Pettine et al, 2015) International Orthopaedics, Hernigou et al showed that bone marrow-derived stem cell injection added to a rotator cuff repair enhanced the healing rate and improved the quality of life of the repaired surface (Hernigou et al, 2014)

Rich in growth factors and regenerative proteins that provide the necessary healing messages to the injured area.

Platelet Rich Plasma (PRP) comes from a patient s own blood. PRP is a concentrated source of growth factors and cellular signaling factors that play a significant role in the biology of healing. Basic science studies show that PRP treatment may improve healing in many tissues. Anti-inflammatory medicines should be stopped before and after PRP treatment is given. Some new evidence supports combining PRP with an inject-able joint lubricant called hyaluronic acid for knee osteoarthritis.

Current evidence supports platelet-rich plasma to be more effective than cortisone for treatment of joint and connective tissue issues, especially long term. A well-designed, two-year, randomized, controlled, blind trial, with a significant test group of 100 patients investigated cortisone versus PRP injections for elbow tendon problems. The researchers concluded that PRP reduced pain and increased function significantly, exceeding the effect of corticosteroid injection even after two years. A similar study in 2017 agreed. 11 These two treatments were also compared for use in chronic, severe plantar fasciitis and concluded: PRP was more effective and longer lasting than cortisone injection." Platelet-rich plasma has also been found to be a superior treatment option versus cortisone for lumbar facet (low back joint) injections, with longer lasting effectiveness. https://www.practicalpainmanagement.com/treatments/c omplementary/prolotherapy/platelet-rich-plasma-stemcell-rich-prolotherapy

Many new and improved tools to treat chronic pain Many patients who are otherwise relegated to opioids may be helped by these therapies