Dr.
RIDA ALKAABI
CABA+IC,FRCA,GMC,FIPP
Consultant in Anesthesia , ICU & Pain
Medicine
Supervisor & Trainer in Anesthesia Iraqi Board
and Surgical Specialties
Interventiona
l Pain
Management
Pain Management
• It is a new specialty
• It is recognized as 34th
specialty in USA
Pain management:
What is new?
• Newer developments in
understanding the
pathophysiology of pain
• Newer concepts of analgesic
therapy
• Newer drugs to manage pain
• Interventional Pain Management to
diagnose & treat pain
Interventional
Pain Management
What is it?
Case history-1
B D 42 yrs. Low back pain, had undergone surgery 2 times before (laminectomy &
discectomy). Pain is increasing day by day. Repeated investigations & visit to 16
consultants for last 4 years has taken away all faith from any form of medical
treatment.
What next????
Case history-2
A S 48 yrs age suffering from L4-L5 disc herniation. He has excruciating pain at Low
Back for 6 weeks with radiation to left leg. He is diabetic, hypertensive, and H/O MI
6 month back with ejection fraction 28%. Considering the risk involved he denied
operation and continued to suffer. BP & Bl. Sugar shooting up.
What next????
Case history-3
MS 63 yrs. Complaining of severe low back pain without any radiation. There was
local tenderness over L2 spinous process. X-ray & CT reveals osteoporotic
compression fracture of L2 Vertebral body. Most of the analgesics were of little
value.
What next????
Case history-4
B D, 55 yrs. Suffering from low back pain with radiation towards rt. buttock & thigh. It
does not follow any dermatomal pattern. Pain increases on extension & rotation of
lumber spine. There was local tenderness over lower paraspinal area (on rt. side).
MRI findings were inconclusive. NSAIDs gives short term pain relief.
What next????
Treatment of Pain
Recovery
Operation
Strong
opioids
Weak
opioids +/-
non-
Non- opioids +/-
opioids adjuvant
Non-pharmacological
methods
Treatment of Pain
Recovery
Operation
Strong
opioids
Weak
opioids +/-
non-
Non- opioids
opioids World of Misery
Non-pharmacological
methods
Treatment of Pain
Recovery
Operation
Strong
opioids
Weak
opioids +/-
non-
Non- opioids
opioids
Non-pharmacological
methods
•Interventional Pain Management are some
minimally invasive procedures which gives
permanent/long term pain relief.
•It fills the gap between pharmacologic
management of pain & more invasive
operative procedure.
Interventional Pain
Management
The discipline of medicine devoted to the
diagnosis and treatment of pain and
related disorders by the application of
interventional techniques in managing
sub-acute, chronic, persistent, and
intractable pain, independently or in
conjunction with other modalities of
treatments.
National Uniform Claims Committee
Interventional Pain
Management
Minimally invasive procedures including
percutaneous precision needle
placement, with placement of drugs in
targeted areas or ablation of targeted
nerves.
Medicare Payment Advisory Commission
How it acts?
IPM are group of
procedures with
different
mechanism of
actions
1. Targeted delivery of drugs.
2. Aims to correct the pathology
3. Blocking of nerve signals corrects
neuropathy.
Diagnostic
Interventiona
l Pain
Management
Procedures
Etiology of low back
pain
• Despite a large differential diagnosis, the precise
etiology is rarely identified, although musculo-
ligamentous processes are usually suspected. For most
patients, back symptoms are nonspecific….an exact
etiology is identifiable in only about 15%.
• In the majority of cases the exact cause of low back
pain is not identified. If an underlying source of pain is
not identified then a diagnosis of idiopathic back pain
or myofascial back pain is often given.
104 patients low back pain
without any identifiable cause
Facet joint(s) disease in 24%
Lumbar nerve root and facet disease in 24%
Facet(s) and sacroiliac joint(s) in 4%
Lumbar nerve root irritation in 20%
Disc disorder in 7%
Sacroiliac joint in 6%
Sympathetic dystrophy in 2%
No cause was identified in 13%
Ref: Pang WW et al. Application of spinal pain mapping in
the diagnosis of low back pain—analysis of 104 cases. Acta
Anaesthesiol Sin 1998; 36:71-74.
120 patients low back pain
without any identifiable
cause
Facet joint pain in 40%,
Discogenic pain in 26%,
Sacroiliac joint pain in 2%,
Segmental dural/ nerve root pain in 13%
No cause was identified in 19%
Ref: Manchikanti L et al. Evaluation of the relative contributions
of various structures in chronic low back pain. Pain Physician
2001; 4:308-316.
Diagnostic IPM
procedures
Diagnostic nerve block
Facet joint block
Provocative discography
Epidurogram, epiduroscopy
Selective nerve root block
SI joint block
Sympathetic Nv. Block
Therapeutic
Interventional
Pain
Management
Procedures
Therapeutic IPM
procedures
Trigeminal nv. Block at ganglion or branch
Spheno-palatine ganglion block
Glosso-pharyngeal nerve block
Stellate ganglion block
Thoracic sympathetic block
Celiac Plexus block
Superior Hypogastric plexus block
Ganglion Impar block
Therapeutic IPM
procedures
for Spinal pain
Epidural steroid inj
Selective nerve root Block
Stellate ganglion block
Lumber sympathetic block (RF),
Medial br. Block (RF) & Facet joint inj.
Trigger point inj.
SI Joint inj./Radiofrequency Rhizotomy
Therapeutic IPM
procedures
for Spinal
Prolotherapy pain
& Prolozone therapy
Epidurolysis & Epiduroscopy
Ozone nucleolysis
Percutaneous Discectomy/
Decompression
Percutaneous Vertebroplasty
Implantable drug delivery system
Spinal cord stimulator
Trigger point
injection
Done with local anaesthetic, depo-steroid, ozone gas, or even dry needling
Myofascial Pain Syndrome and Fibromyalgia.
Repeated in a course of 3-7 injections
Epidural steroid
injection
It reduces inflammation, blocks transmission of nociceptive C-fibre input and
prevents ectopic discharge from axon & dorsal root ganglion.
Cervical, Thoracic, Lumber, Caudal
75-85% short term relief
50% (approx) long term relief
Selective nerve root/
Transforaminal epidural
block
Diagnostic as well as therapeutic purpose.
Sensitivity ranges from 45% to 100%.
Therapeutically it is more effective than ESI as we are installing the drug more
anteriorly right at the target.
10-20mg vs. 40-80 mg in lumber epidural.
If there is epidural scar as in FBSS it is the only root.
Transforaminal epidural block
Epidurogram
Normal Epidurogram looks like an inverted Christmas tree where dye
enters into the dural extension of each nerve root.
Filling defect in epidural spread of dye indicate Epidural fibrosis.
Epidurogram
Normal
Filling defect in
FBSS
Epidurogram
Normal
Filling defect in
FBSS
Epidurolysis
Epidurolysis/ epidural adhesiolysis/ neuroplasty is done in epidural fibrosis
with normal saline/hypertonic saline with/without hyaluronidase.
It may be done with Racz catheter after performing an Epidurogram.
Provocative
discography
Sterile needle is placed into the center of the IVD, radio-opaque contrast is instilled
To provoke pain
To assess radiological disc morphology
To assess intensity and concordancy of evoked pain in relation to baseline pain.
Discogenic pain may contribute up to 26% of spinal pain.
Provocati
ve
Percutaneous Disc
Decompression/Discectomy
It is done for contained disc prolapse & discogenic pain.
Here a 17G needle introduced into the diseased disc under C-arm guidance.
Then a special motorized probe is introduced through this needle & operated.
It breaks the nucleus pulposus into fine particles and sucks it out.
PDD: advantages
Success rate 80%,
No cut, scar,
No epidural fibrosis,
Stability of normal anatomical structure is maintained.
Hospital stay is less and less costly.
Ozone Nucleolysis
It is done for both contained & non-contained disc prolapse & discogenic pain.
Here also a needle introduced into the diseased disc & ozone gas (2-10ml. at a conc.
29-30micgm./ml.) is injected.
It causes some chemical changes so that the nucleus pulposus is dehydrated & it
shrinks in size.
Ozone has powerful anti-inflammatory actionreduces edema.
Inferior end plate
Disc space between of L4 Vertebra
L4-L5 disc
Superior end plate
Facet joint
of L5 Vertebra
C-arm should be rotated such a way so that
facet joint is opened up maximally & end
plate of two adjacent vertebrae are in line.
Entry point of needle
should be just lateral to
Superior articular
process of facet joint.
Picture showing entry of 22 G spinal needle
into the L4-5 disc. Needle should be in end-
on view showing whole needle as a point.
Facet joint block/ RF
neurotomy of medial
branch
Mostly remains undiagnosed with CT/MRI
Facet joints responsible for spinal pain in 15% to 45% of patients with low back pain
54% to 67% of patients with neck pain, and 42% to 48% of patients with thoracic
pain
Therapeutic facet joint injection with steroid/ RF ablation of medial branch of dorsal
rami gives long-term relief
SI joint Block/ Radio-
Frequency Rhizotomy
SI joint is responsible for at least 13% and perhaps as high as 30% of Low Back
Pain.
Percutaneous radiofrequency neurotomy of sacroiliac joints or steroid
injection into SI joint provide long-term relief
Percutaneous
Vertebroplasty
Done for vertebral compression fracture with severe pain (osteoporosis, cancer
metastasis, haemangioma etc.)
11G needle is introduced through pedicle under C-armThen low viscosity bone
cement is injected.
Caution taken so that bone cement does not come in contact with nerves in the
epidural space/foramen.
It stabilizes the spine and gives immediate ……………..pain relief.
W
Lumber sympathetic
block
Sympathetic dystrophy may be the cause of pain in a significant number of
cases.
Neurolysis of Lumber sympathetic chain using alcohol/ phenol or RF
ablation gives relief.
Spinal Cord Stimulation
• It delivers low-
voltage electrical
stimulation to the
spinal cord to inhibit
or block the
sensation of pain.
Spinal Cord Stimulator
implantation
Steps of SCS
implantation
Case history-1
(Failed Back Surgery Syndrome)
• B D 42 yrs. Low back pain Had
undergone surgery 2 times before
(laminectomy , discectomy). Pain is
increasing day by day. Repeated
investigations & visit to 16 consultants
for last 4 years has taken away all faith
from any form of medical treatment.
Spinal Cord Stimulator (Spinal pace maker)
gave permanent relief.
Case history-2
(L4-L5 disc herniation)
A S 48 yrs age suffering from L5-S1 disc
herniation. He has excruciating pain at
Low Back for 6 weeks with radiation to
left leg. He is diabetic, hypertensive, and
H/O MI 6 month back with ejection
fraction 28%. Considering the risk
involved he denied operation and
continued to suffer. BP & Bl. Sugar
shooting up.
Percutaneous Discectomy cured him.
Case history-3
(compression fracture of L2)
MS 63 yrs. Complaining of severe low
back pain without any radiation. There
was local tenderness over L2 spinous
process. X-ray & CT reveals osteoporotic
compression fracture of L2 Vertebral
body. Most of the analgesics were of
little value.
Percutaneous Vertebroplasty relieved
her.
Case history-4
(Facet Joint Arthropathy)
B M, 55 yrs. Suffering from low back pain
with radiation towards rt. buttock &
thigh. It does not follow any dermatomal
pattern. Pain increases on extension &
rotation of lumber spine. There was
local tenderness over lower paraspinal
area (on rt. side). MRI findings were
inconclusive. NSAIDs gives short term
Radio-Frequency Rhizotomy of
pain relief.
Medial Br. of dorsal rami relieved the
pain.
Interventional Pain
Summary Management are some
minimally invasive procedures
which gives permanent/long
term pain relief.
It fills gap between
pharmacologic pain
management & more invasive
operative management.
Interventional Pain
Management may work in
situations where all other
options have failed.
Thank
you
