Spinal pain: Interventional treatment and evidence

Interventional treatment chronic pain
ZOL 24/3/16
Koen Van Boxem, MD, PhD, FIPP
Sint-Jozefkliniek, Bornem en Willebroek
Content
I.
II.
•
•
Interventions
Spinal pain
Lumbosacral radicular pain
Lumbar facet pain
III. Non- Spinal pain
• Trigeminal neuralgia
• Cervicogenic headache
• Occipital neuralgia
Content
I.
II.
•
•
Interventions
Spinal pain
Lumbosacral radicular pain
Lumbar facet pain
III. Non- Spinal pain
• Trigeminal neuralgia
• Cervicogenic headache
• Occipital neuralgia
Outline
• When ?
– conventional treatment failed
– pharmacologic untolerable side effects
– balance possible benefits against potential complications
Outline
• When ?
– conventional treatment failed
– pharmacologic untolerable side effects
– balance possible benefits against potential complications
• Interventional options ?
1.
2.
3.
Injection therapy
(Pulsed) radiofrequency treatment
Neurostimulation
1.
Injection therapy
Targets nerve(s) involved in pain condition
– local anesthetic
» immediate pain reduction
» potential anti-inflammatory action
– corticosteroid
» anti-inflammatory action
– biological agents e.g. botulism toxin, anti-NGF, anti-TNF
» Value ?
2.
Radiofrequency treatment
• High frequency electrical current adjacent to a nerve
– change in structure  changed pain conduction
Chronic radicular pain - PRF
After positive diagnostic block :
Pulsed RadioFrequency (PRF) treatment adjacent to DRG:
Burst of RF
No RF
Geurts, Lancet 2003
Van Boxem et al. In press
• High frequency electrical current adjacent to a nerve
– change in structure  changed pain conduction
Continuous radiofrequency
Pulsed radiofrequency
Pulsed radiofrequency treatment
• High frequency electrical current adjacent to a nerve
– change in structure  changed pain conduction
Continuous radiofrequency
Pulsed radiofrequency
Continuous administration of
high frequency electrical current
Production of heat
Nerve damage
Sluijter et al. The Pain Clinic 1998; 11 (2): 109-117
Pulsed radiofrequency treatment
• High frequency electrical current adjacent to a nerve
– change in structure  changed pain conduction
Continuous radiofrequency
Continuous administration of
high frequency electrical current
Production of heat
Nerve damage
Pulsed radiofrequency
Short electrical pulses with higher
voltage followed by a silent period:
heat is washed
out
Less nerve damage
Sluijter et al. The Pain Clinic 1998; 11 (2): 109-117
3.
Neurostimulation
Mechanism SCS for Neuropathic Pain
From Smits H. et al (2012)
Summary SCS NeuP
RVM & LC
Linderoth & Meyerson, Anesthesiology 2010
Content
I. Interventions
II. Spinal pain
• pathofysiology
Ontstaan rugpijn
Wervel :
•
•
Geniaal qua architectuur
200 miljoen jaar evolutie tot mens
Maar … we zijn
rechtop gaan lopen :
•
•
Evolutie : grote stap voorwaarts
Maar voor rug … een vergissing
Facetgewrichten
Tussenwervelschijf
2.Verschuiving wervel
facetarthrose
1.Discus smaller
3.Vernauwing uitgang
zenuwwortel
Content
I. Interventions
II. Spinal pain
• Lumbosacral radicular pain
• Radiculaire pijn:
– Ontstekingsreactie zenuwwortel (hernia)
– Lage rug : Lumbo-sacraal
– Uitstralingspijn bv. L5 of S1
• Radiculaire pijn:
– Ontstekingsreactie zenuwwortel (hernia)
– Lage rug : Lumbo-sacraal
– Uitstralingspijn bv. L5 of S1
• Frequent:
1/20 van de mensen ouder dan 30 jaar
→ Meest voorkomende vorm van zenuwpijn
• Lage levenskwaliteit
Doth 2010, Bala 2011
• Spontaan verloop : 75 % herstel 3 maanden maar …
– resterende 25 % : ongunstig, vrouwen
– Hoge hervalkans
– 2 jaren, 2e lijns :
• 40 % niet succesvol
• ¼ werkonbekwaam
• Conservatieve behandelingen : juiste waarde ?
Balague 1999, Vroomen 2002, Pinto 2012
Dworkin 2007 Suri 2012, Haugen 2012, Grovle 2013
• Hernia :
Hernia
Cellichamen zenuwen
in ganglion spinale
Van Boxem RAPM 2014
Van Boxem RAPM 2014
Interventional pain management
I.
(Sub)acute radicular pain: epidural corticosteroids
II.
Chronic radicular pain:
–
–
pulsed radiofrequency treatment
Neurostimulation
Interventional pain management
I.
(Sub)acute radicular pain: epidural corticosteroids
Subacute
• Epidural corticosteroids : close to the inflammation
• Interlaminar
• Transforaminal
AVU sept 2009
Evidence
All epidural approaches :
• 23 RCT : high quality (GRADE)
- short term: + over placebo leg pain, disability
- long term: -
Pinto Ann. Int. Medic. 2012
Interventional pain management
I.
(Sub)acute radicular pain: epidural corticosteroids
II.
Chronic radicular pain:
–
–
pulsed radiofrequency treatment
Neurostimulation
5HT en NA
PRF biological effects
↗ C-Fos
↗ Met-enkephalinen
↘ OX-42 (microglia)
↘ glutamate – aspartate
Spinale ganglion :
Δ myeline, mitochondrien,
microfilamenten, microtubuli
↗ ATF-3
Van Boxem Van
VanZundert
Boxem RAPM 2014
Chronic radicular pain - radiofrequency
• Pulsed RadioFrequency (PRF) treatment adjacent to DRG:
– PRF improves pain in patients with chronic lumbosacral radicular
pain
Van Boxem Pain Medicine 2014
Interventional pain management
I.
(Sub)acute radicular pain: epidural corticosteroids
II.
Chronic radicular pain:
–
–
pulsed radiofrequency treatment
Spinal Cord Stimulation
Spinal cord stimulation: evidence
• Pts with FBSS: SCS vs reoperation
– SCS more effective, less cross over to surgery
• Pts with FBSS: SCS vs CMM
– Less cross over in SCS group to CMM, more pts satisfied.
North et al. Neurosurgery 2005
Kumar et al. Pain 2007
Conclusion radicular pain
• Interventions :
•
subacute radicular pain: epidural steroids efficient but short-term
•
Chronic radicular pain:
pulsed radiofrequency treatment
Spinal cord stimulation: FBSS
Content
I.
II.
•
•
Interventions
Spinal pain
Lumbosacral radicular pain
Lumbar facet pain
Facet pain
• Innervation : medial branch
Goldthwaite J.Boston Med Surg J. 1911
Ghormley R. JAMA. 1933
Cohen SP, Anesthesiology. 2007
Diagnosis
• History: axial low back pain potentially with referral pattern
• Clinical examination: lumbar paravertebral tenderness
• Diagnostic Medial Branch Block
Van Kleef et al. Pain Practice 2010
Treatment facetpain
• Radiofrequency of medial branch for lumbar facet joint pain
Content
I.
II.
•
•
Interventions
Spinal pain
Lumbosacral radicular pain
Lumbar facet pain
III. Non- Spinal pain
• Trigeminal neuralgia
• Cervicogenic headache
• Occipital neuralgia
Indications interventional pain therapy
I.
Head and face
– Trigeminal neuralgia
– Cervicogenic headache
– Occipital neuralgia
Trigeminal neuralgia
Trigeminal neuralgia
•
•
•
•
Description :
recurrent unilateral brief electric
shock-like pains
abrupt in onset and termination
limited to the distribution of one or
more divisions of the trigeminal
nerve
triggered by innocuous stimuli.
International Headache Society, Cephalalgia 2013
Pathofysiology
Classical :
Neurovasculair compression : superior cerebellar artery
Painful trigeminal neuropathy
neural damage
(post)herpetic
MS (7%)
space-occupying lesion
IHS, Cephalalgia 2013
Imaging
• MRI
– For exclusion of the symptomatic variant
– Support for the decision of surgical decompression
– 30% has also compression of the asymptomatic side.
Trigeminal neuralgia
Trigeminal neuralgia : Gasserian ganglion
ganglion
pterygopalatinum
Gasserian
ganglion
RCT’s on Trigeminal neuralgia
• Comparison of pulsed radiofrequency with conventional
radiofrequency in the treatment of idiopathic trigeminal
neuralgia.
→ RF > PRF
Erdine, S., et al. Eur J Pain 2007
Overview
I. Head and face
– Trigeminal neuralgia
– Cervicogenic headache
Anamnesis
• Pain begins in the neck  radiates outward to frontotemporal and possibly to the supra-orbital area.
• Nagging and nonpulsating
• Occurs in attacks of unpredictable duration (hours to days)
• Pattern of attacks can change into a chronic fluctuating
headache.
Physical examination
Interventional treatment
• Local injections :
– occipital nerve – intra-articular facet
• Radiofrequency treatment
– Facet : ramus medialis (medial branch) dorsal ramus of the segmental
nerve
– DRG : ganglion spinale
RF Medial branch of dorsal ramus
• RCTs
– RF facet vs sham  no difference 3, 12 and 24 months (no
examination of facet joints!)
– RF facet ± RF DRG C2-C3 vs injection of n. occipitalis ± TENS
• At 1 year FU significant pain reduction in 53% RF patients and in
46% of injection/TENS patients
Hildebrandt. Man Med 1986; 2: 48-52
Van Suijlenkom et al. Funct. Neurol. 1998; 13 : 297- 303
Stovner et al. Cephalgia 2004; 24: 821-830
Haspeslagh et al. BMC Anesthesiol. 2006; 16: 1
Overview
I. Head and face
– Trigeminal neuralgia
– Cervicogenic headache
– Occipital neuralgia
Local injections
Steroid or PRF Occipital nerve ?
• RCT LA/saline + PRF vs LA/steroid + sham PRF
• N= 81
• Outcome : PRF > steroid
– Average occipital pain : 6weeks- 6 months
– Worst occipital pain
: 3 months
– Average overall headache : 6 weeks
Cohen Pain 2015
Stimulation n. occipitalis
• Systematic review : 9 studies (level III)
Stimulation is a treatment option after failure
approach
conservative
Sweet Neurosurg 2015