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Interventional spine & pain management dr manish raj
This document provides an overview of chronic pain and interventional pain management techniques. It defines chronic pain as pain that lasts more than 3 months and outlines its prevalence and impact, noting it affects more Americans than diabetes, heart disease, and cancer combined. Interventional pain management aims to decrease or eliminate pain through minimally invasive techniques like injections, radiofrequency ablation, and spinal cord or peripheral nerve stimulation. The document reviews common causes of back pain and neck pain, as well as conditions treated by interventional techniques. It also discusses evidence-based guidelines for interventional pain management and the multidisciplinary approach needed for successful chronic pain treatment.
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Introduction to pain, acute vs chronic pain, and chronic pain facts. Highlighting chronic pain as a significant health issue with millions affected.
Chronic pain is costly and difficult to manage. Interventional pain management methods are introduced.
Diverse conditions treated in pain management and their classification. Approach to chronic pain treatment.
Lumbar spine structure and pathologies, risk factors for chronic back pain, and assessment considerations.
Focus on cervical pain, treatment strategies, and various interventional therapies for spine pain.
Minimally invasive procedures and advanced techniques like ozone nucleolysis and spinal stimulation.
Focus on nerve pain conditions and evidence-based interdisciplinary guidelines for effective management.
Final summary emphasizing the complexity of chronic pain and the need for a comprehensive approach.
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Interventional spine & pain management dr manish raj
- 1. INTERVENTIONAL SPINE & PAINMANAGEMENT Dr Manish Raj MD, DA(gold medal), FISP, FMIS, FESSA Brief review by
- 2. Pain ?? “Pain isan unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”
- 3. Acute vs chronicpain pain that extends beyond the expected period of healing“ or more than 2 months acute pain is a normal sensation triggered in the nervous system to alert you to possible injury and the need to take care of yourself or caused by occurrences such as traumatic injury, surgical proc edures, or medical disorders
- 4. Chronic pain –A Disease Chronic pain often out lives its original causes, worsens over time, and takes on a puzzling life of its own… there is increasing evidence that over time, untreated pain eventually rewrites the central nervous system, causing pathological changes to the brain and spinal cord, and that these in turn cause greater pain. Even more disturbingly, recent evidence suggests that prolonged pain actually damages parts of the brain, including those involved in cognition.
- 5. Chronic pain facts… Condition Number of Sufferers Source Chronic Pain 100 million Americans Institute of Medicine of The National Academies (1) Diabetes 25.8 million Americans (diagnosed and estimated undiagnosed) American Diabetes Association Coronary Heart Disease (heart attack and chest pain) Stroke 16.3 million Americans 7.0 million Americans American Heart Association (2) Cancer 11.9 million Americans American Cancer Society 1. Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011 2. 2. Heart Disease and Stroke Statistics—2011 Update: A Report From the American Heart Association. Circulation 2011, 123:e18-e209, page 20. 3. http://www.painmed.org/patientcenter/facts_on_pain.aspx
- 6. Chronic pain facts… The total annual incremental cost of health care due to pain ranges from $560 billion to $635 billion (in 2010 dollars) in the United States, which combines the medical costs of pain care and the economic costs related to disability days and lost wages and productivity. More than half of all hospitalized patients experienced pain in the last days of their lives and although therapies are present to alleviate most pain for those dying of cancer, research shows that 50-75% of patients die in moderate to severe pain. An estimated 20% of American adults (42 million people) report that pain or physical discomfort disrupts their sleep a few nights a week or more.
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- 8. What is interventionalpain management ? Interventional pain management or interventional pain medicine is a super-specialty of the medical specialty pain medicine, devoted to decrease or eliminate pain with use of invasive & non invasive techniques This can be accomplished in following ways: Interrupting the pain signal along a neural pathway Remodeling anatomical source of pain Neuroaugmentation (SCS, PNS) Implantable drug delivery system
- 9. Conditions treated … Back Pain : Slip disc /Sciatica /Lumbar Radiculopathy, Spinal stenosis Disc herniation - protrusion/extrusion/sequestration/DDD Facet Arthritis, Sacroilitis, Vertebral compression fracture, Failed Back surgery syndrome, Spondylolysis, spondylolisthesis Neck Pain : Cervical Radiculopathy,Cervical disc bulge,Cervical Facetal Arthritis, Trapezitis Nerve Pain : Reflex Sympathetic Dystrophy/ Complex Regional Pain Syndrome, Post Herpetic & Intercostal Neuralgia, Diabetic neuropathy, Phantom limb pain Musckuloskeletal Pain : Fibromyalgia, Scapulocoastal, Shoulder/Arm/Elbow/ Leg /Knee & foot chronic pain Facial pain & headache: Trigeminal Neuralgia, Intractable Headaches (Migraine, Cluster, Chronic Daily , cervicogenic , occipital neuralgia, Tension) Cancer & other pain : Cancer (Abdominal,pelvic,thoracic), Post chemotherapy pain, Ischemic leg pain, Any pain more than 3 months
- 10. Treating Chronic pain- conservative
- 11. Interventions Injections: ImageGuided ( Fluroscopy/ USG Guided) - Epidural( Transforaminal/ Interlaminar at cervical spine) - Diagnostic block ( Pain Mapping) at nerve ,ganglion, muscles - Neurolysis, joints proliferation - Discography Radiofrequency ablation: High frequency alternating current - Trigeminal/celiac/splanchnic/hypogastric/stellate /DRG ganglion Minimally invasive spine & pain procedures: - Percutaneous disc modulation ( Nucleoplasty, Dekompressor, Hydrodiscectomy, Disc-Fx, Nucleotomy, Ozone nucleolysis) - Endoscopic discectomy ( Band- Aid surgery) - Spinal cord & peripheral nerve stimulator , Intrathecal pump, - Vertebroplasty, Kyphoplasty
- 12. Back pain -Causes Disc : Disc herniation of all types Bulge, Protrusion, Extrusion, Sequestration Degenerative disc disease, Spinal stenosis Bone – Verebral compression fracture, Trauma Joints – facetal arthritis, sacroilitis Muscles – Quadratus lumborum, Psoas, Piriformis
- 13. Another cause ofback problems… Trauma It is also possible to injure your back due to accidents.
- 14. Natural History ofLBP Acute LBP inflammatory or neuropathic injury resolves spontaneously with minimal treatment Intermittent, relapsing LBP more challenging diagnostic and treatment dilemma precipitates symptomatic care and more aggressive interventions aimed at specific underlying pathology Unremitting, recurring chronic LBP structural, neurophysiological, and biopsychosocial pathology requires management at all these levels major public health problem
- 15. LBP Patient TreatmentPrototypes Chronic axial LBP pain does not extend beyond mid-buttock absence of radicular pain or sensory symptoms below the knee Chronic axial LBP with radiation pain with radiation beyond mid-buttock absence of radicular pain or sensory symptoms below the knee Chronic axial LBP with radicular component radicular pain or sensory symptoms below the knee
- 16. Structure of LumbarSpine Basic functional units of spine— motion segments—consist of two posterior zygapophyseal (facet) joints and an intervertebral disc, forming a tri-joint complex Zygapophyseal joint
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- 18. Lumbar Structural Pathologyand Degenerative Cascade In all individuals, there is natural, progressive degeneration of the motion segments over time This results in anatomic, biochemical, and clinical sequelae Although lumbar motion segment degeneration is not a normal process, it may not be painful Three phases of degeneration Dysfunction Instability Stabilization
- 19. Risk Factors Pregnancy Poor physical conditioning Poor movement techniques Poor posture Occupation Previous back injuries Others – spinal disorders (e.g. scoliosis, osteoporosis, spondylosis)
- 20. Considerations in theClinical Assessment and Diagnosis of Chronic LBP Medical History General Neurologic Psychosocial Pain Scales/Questionnaires Factors in the Elderly Physical Examination Neurologic Diagnostic Studies Evaluation of the Elderly Goals of Clinical Assessment
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- 23. Treatment ladder (Modified….) Diagnosticblocks Epidural steroids Radiofrequency technigues Neurostimulation techniques Neuroaxial medication Interventional Therapies ADJUVANT ANALGESICS + PATIENTS EDUCATION
- 24. Spine Pain Treatment Neural blockade selective nerve root blocks facet joint blocks, medial branch blocks Neurolytic techniques radiofrequency neurotomies pulse radio frequency Stimulatory techniques spinal cord stimulation peripheral nerve stimulation Intrathecal medication pumps delivery into spinal cord and brain via CSF Minimally invasive Percutaneous disc modulation ( Nucleoplasty, Dekompressor, Disc-Fx, Hydrodiscectomy, Nucleotomy, Ozone nucleolysis, IDET, Disctrode) Endoscopic discectomy (Band- Aid surgery) Vertebroplasty, Kyphoplasty , Open spine surgery
- 25. STEP UP ALGORITHM North american spine society guidelines 2014 Minimally Invasive spine techniques “Daniel Kim”
- 26. Epidural Lumbar &cervical o Usually performed utilizing fluoroscopy o No sedation vs conscious sedation o Can be therapeutic or diagnostic Selective root sleeve tranforaminal epidural Cervical Epidural
- 27. Joints Interventions Facet JointRF Ablation Sacroiliac joint injection ( Arthrogram) Cervical Facet Injection (RFA)
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- 41. Nerve pain( Neuropathy) TrigeminalNeuralgia CRPS Post Herpetic Neuralgia Diabetic neuropathy Neuropathic pain
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- 44. EVIDENCE BASED GUIDELINESFOR INTERVENTIONAL PAIN MEDICINE EFNS guidelines on neurostimulation therapy for neuropathic pain. Cruccu et all. Eur J Neurology 2007;14:952-70. Polyanalgesic consensus conference 2007: recommendations for the management of pain by intathecal (intraspinal) drug delivery: Report of an interdisciplinary expert panel. Deer et al. neuromodulation 2007;10:300-328 Evidence-based guidelines for interventional pain medicine according to clinical diagnoses. Van Kleef et al. Pain Practice 2009;9:247-51. Evidence based medicine. Trigeminal neuralgia. Van Kleef et al. Pain Practice 2009;9:252-9. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic pain. Manchikanti et al. Pain Physician 2009;12: 699 (in press).
- 45. summary Chronic Painis a very complex disease, not a symptom Progress is focused on targeting treatment at the mechanisms that produce pain rather than ameliorating the symptoms Biopsychosocial & multispeciality approach is critical for the successful management of chronic Pain Current standards & future in chronic Pain treatment include Uses of new & multimodal agents Early Interventions to reduce incidence of chronic pain uses of Modern techniques Constant research for better understanding of brain imprint & objectifying pain
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