Interventional Procedures for Lower Back Pain Patients With and

Epidemiology
Lumbar Spine Anatomy
!  Major medical problem: > 5 million people affected
!  Major economic problem: >$25 billion per year
!  Zygopophyseal joint
!  Synovial
!  FBSS:
Interventional Procedures for
Spine Pain
!  Facet joint
!  200,000 patients undergo back surgery every year
!  20-40% persistent pain or recurrent pain:
Moises lustgarten, md
Medical director
Center for Pain management at Baptist Hospital
!  Erroneous diagnosis
!  Column instability
!  Erroneous location
Radiculitis
Recurrent herniation
Arachoiditis
!  Epidural fibrosis
Lumbar Spine Anatomy
Financial Relationship disclosure
LBP
!  Nothing to disclose
!  Bone / Vertebrae
!  Sacroiliac Joint
!  Disc
!  Tight, Synovial
!  Annulus
!  Ligaments
!  Nucleus Pulposus
!  “SI Dysfunction”
!  Muscles / Ligaments
!  Spinal Nerve Roots
Learning objectives
Lumbar Spine Anatomy
cross-section
Interventional Pain Procedures
!  Interventional modalities to identify and
interrupt pain pathways
!  Be able to identify those patients most likely to benefit
from interventional modalities
!  Understand the differences between the various
procedures used to diagnose and treat LBP
!  Nerve stimulation
!  Nerve ablation
!  Dorsal column stimulation
!  Selective epidural injection
!  Recognize limitations to each procedure
!  Develop strategies to maximize treatment outcomes
!  Selective nerve root isolation
!  Percutaneous decompression
Common Procedures
!  Selective nerve root
blocks
!  Joint injections
!  Ganglion injections
!  Local anesthetic
infusions
!  Implantable intrathecal
Trigger Point Injections
!  Most basic intervention known to help with
myofascial pain syndrome
!  Different types of medications and/or
combination of different pharmacologic
agents: local anesthetics +/- steroids +/opioids, botulinum toxin
pumps
!  Spinal Cord Stimulation
Anatomy
!  Contains fatty
tissue, venous
plexus,
lymphatics and
dural
projections of
spinal nerve
roots
!  Radiofrequency
Neurolysis
Common Procedures
Center for Pain Management of South Florida
Epidural Steroid Injection
Epidural Injection
!  The Epidural injection
!  Epidural steroid
injections
!  Permanent epidurals
!  Facet Joint Injections
!  Epidural blood patch
!  Trigger point injections
Interventional Failures
!  While interventional treatments may provide
excellent relief there is a subset of patients
that will require pharmacological
management
or catheter is a
versatile technique
than can be utilized for
types of acute or
chronic pain.
!  They are most well
known for labor and
delivery
!  They can also be
utilized to deposit antiinflammatory
medication around the
spinal nerves
Epidural Steroid Injection
!  E p i d u r a l s t e ro i d
injections are used
for a number of
chronic pain states.
!  T h e y
are most
effective for
b u l g i n g o r
herniated disks,
and nerve root
irritation
Epidural Steroid Injection
Thoracic epidural Injection
Cervical Epidural Injection
Selective Nerve Root Block
Facet JOINT ANATOMY
Selective Nerve Root Block
Facet Block
Facet Joint blockade
!  Local anesthetic
blockade of the joint or
innervating nerves helps
make the diagnosis
!  Intrarticular or
periarticular steroid
injections may provide
prolonged relief
!  Cryo or radiofrequncy
dennervation of the
medial branch nerves is
an option if local
anesthetic blockade gives
good but temporary relief
Facet Block
Sacroiliac Joint Injection
Cervical Facet Block
Discography
Radiofrequency Denervation
Lumbar Facet joints
Sacroiliac Joint Injection
INTRADISKAL
PROCEDURES
!  PERCUTANEOUS DISK DECOMPRESSION:
LASER, NUCLEOPLASTY
!  THERMAL ANNULAR DISRUPTIONS (IDET)
Radiofrequency Denervation
Cervical Facet Joints
Lumbar Discography
Dorsal Column Stimulation or
Spinal Cord Stimulation
Electrodes placed
w i t h i n t h e
epidural space
can alleviate pain
in a wide variety of
locations.
They substitute pain
wit h a mor e
p l e a s a n t
vibration.
Spinal Cord Stimulation
Intrathecal Pumps
Questions
!  Moises Lustgarten, MD
!  E-mail:
!  New advances in pump technology have led
to design applications which have resulted
in smaller pump sizes
!  However pump capacity has increased
!  Center for Pain Management at Baptist
Hospital
!  Increasing patient comfort and allowing
for less frequent need for refilling in
certain cases
Conclusion
!  Proper diagnoses is required for appropriate intervention to
provide optimal relief.
!  From simple trigger point injections to a highly complex
spinal cord stimulation are very effective if chosen properly
!  Low back pain treatment is multifocal, can be managed, but
very difficult to treat and cure.
Intrathecal Pumps
References
!  Proximal end is in the CSF
!  Allows for smaller doses
!  Catheter is Tunneled under the
Skin
!  Distal ends attached to the Pump,
which is subcutaneous
!  No external pump
!  Rescues are not given via the
Pump, usually, oral
!  Refilled approximately every 4-6
weeks
!  Interventional Therapies for Chronic Low Back Pain: A
Focused Review (Efficacy and Outcomes), Vikram B.
Patel, Ronald Wasserman and Farnad Imani.
Anesth Pain Med. 2015 Aug; 5(4): e29716
An Update of Comprehensive Evidence-Based Guidelines for
Interventional Techniques in Chronic Spinal Pain. Part II:
Guidance and Recommendations, Laxmaiah Manchikanti et al.
Pain Physician 2013, 16:S49-S283
!  305 279-3223