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Max Wirjo,MD,FRCPC,DABA.Director, Integrated Pain Medicine.
The Permanente Medical Group,Kaiser Fresno Medical Center, California, USA
Systematic approach based on pain generators of the spine :
Posterior compartment : all structures innervated by dorsal ramus of the spinal nerve, i.e. Facet joint / Z joint
Neuraxial compartment : all structures within the epidural space and neural pathways
Anterior compartment : vertebral bodies and intervertebral disc
-Intra-articular Facet injection-Medial Branch block-Radiofrequency Ablation of the medial branch.
-Translaminar Epidural Steroid injection-Transforaminal Epidural Steroid injection-Selective Nerve Root block-Pulse RFA of nerve root/DRG
Anterior CompartmentDiscogenic pain: - Discography (Provocative) - IDET (Intradiscal Electrothermal Therapy) - Transdiscal Biacuplasty
Vertebral body compression fracture; - Vertebroplasty - Kyphoplasty
IDET
Kyphoplasty (or Vertebroplasty)
Kyphoplasty
Kyphoplasty
Spinal StenosisBulging discFacet hypertrophy:Ligamentum flavum hypertrophy
Treatment: - Lumbar Epidural Steroid - RFA of the medial branch - MILD (Minimally Invasive Lumbar
Decompression)
MILD - Epidurogram
MILD – portal
MILD – bone sculpture
MILD – tissue sculpture
Failed Back Surgery SyndromeNeuromodulation/Implantable
device/Advanced Pain TherapySpinal Cord/Peripheral/field Nerve
StimulatorIntraspinal Drug Delivery /Morphine
pump
Pain Management ProceduresAdvanced Pain Therapy
RFA: Heat Pulse
Spinal Cord Stimulator Trial Permanent All done as outpatient surgery
Morphine/Baclofen pump Trial (as outpatient, baclofen needs 8 hr monitoring Permanent, done as inpatient
Sacroiliac injection
Spinal Cord Stimulator
Spinal Cord Stimulator
Intraspinal Drug Delivery system/ Morphine pump
Intrathecal Drug Delivery Pump1.Narcotic : Morphine, Dilaudid, Ziconotide , Fentanyl. with Clonidine/ Baclofen/ Bupivacaine added.2.Baclofen ( Liorisal ) for Spastic Disorder i.e. CP, MS, Spinal Cord Injury, Stroke
Recommended