Interventional Pain Management:

Not All Injections are Created Equal

Craig W. Davis, MDGranger Pain & Spine

President UTSIPP

Vice-President UAPM

Disclosures

Conultant/Faculty with Stryker

Interventional Spine

Consultant/Faculty with St. Jude/Abbott

Neuromodulation

Objectives

1) Identify and evaluate the options for interventional

treatment as they pertain to the low back

2) Identify and evaluate the options for interventional

treatment as they pertain to the neck

3) Identify the basic tenets of advanced interventional pain

procedures

4) Identify when a referral is warranted

Common Types of Low Back Pathology

1)Myofascial Pain

2)Facet mediated pain

3)Disc Mediated pain: herniations, annular tears, discogenic

4)Sacroiliac Dysfunction

Myofascial pain

Pain localized to paraspinal

musculature & PSIS

Spasm probable

Limited flex. & ext. (pain)

No radiating pain

May not correlate to specific

mechanism

--Treatment options, PT, NSAIDs,

muscle relaxants, TPIs, CBT

Facet Mediated Low Back Pain

~40% of all LBP

Vague symptoms that mimic

other pathologies

Localized pain

Often improves with activity

Nerve entrapment may result

from compensatory posturing

Worsened by:

Repeated spine-loading activities (ext,

side bending, rotation)

Poor LE flexibility

Poor Trunk strength

Tenderness over facet joint

Facet Mediated Referral Patterns

Facet Mediated Pain Treatment

1) Exhaust Conservative care: NSAIDs, MRs, SNRI/SSRI,

PT, acupuncture, CBT, etc

2) Interventional treatment:

1) Facet Injection

2) MBB/RFA

1) Potential for longer duration of relief

Lumbar Disc Lesion

Crack in annulus fibrosus herniation of

nucleus pulposus

Pressure on nerve rootpain/burning

sensation

“Bulge” pathology

Radiating pain into buttocks and down leg

MRI for best diagnosis

Altered standing posture

Symptoms with activity

Bilateral or unilateral symptoms

Usually acute onset

Lumbar Disc Lesion, cont.

herniated disc

radiating leg pain > back pain

pain ↑ sitting & leaning forward, coughing,

sneezing, & straining

neurologic deficits are usually present

+ ipsilateral straight leg raising test

annular tears

back pain > leg pain

pain ↑ sitting & leaning forward, coughing, sneezing, & straining

may have muscle spasm and loss of lordosis

+ ipsilateral straight leg raising test

Dermatome Map

Epidural Steroid Injection

Injection of the corticosteroids as close to the nerve as

possible – TO REDUCE SYPTOMS DUE TO

INFLAMMATION / OR SENSITIVITY

Multiple studies – suggest that surgery can be avoided in

upto 75% cases

Compression of the disc may continue in spite of resolution

of symptoms following ESI

Steroid – How it helps???

• Anti inflammatory

• Reverses effect of inflammatory mediators, Stops

inflammation cascade, Helps in healing annular

tear

• Reduces edema – improves micro circulation

• Reduce ischemia – reduce hypersensitivity of

dorsal horn cells

Steroid – How it helps???

• Direct inhibition of C-fibers neuromembrane excitation

• Stabilizes cell membrane

• Interact with 5HT & NE at Substantia Gelatinosa in dorsal horn – modulate

the pain inputs from peripheral nociceptors

• Delays pain impulse conduction

• Gives pain/ inflammation free time for disc herniation to settle down by natural

process (Natural history of disc disease)

Sacroiliac Dysfunction

unilateral, dull pain that extends into buttock & posterior thigh

ASIS or PSIS may appear asymmetric bilaterally

leg-length discrepancy

↑ pain w/ standing on one leg & stair climbing

↑ pain w/ lateral flexion toward injured side

↑ pain w/ straight leg raises beyond 45º

--common after MVAs, pregnancy, fusion

Treatment: PT, Brace, NSAIDs, yoga, etc…interventional options: inject, ablate, fuse

Common Types of Neck Pathology

1)Myofascial Pain

2)Facet mediated pain

3)Disc Mediated pain: herniations, annular tears

Neck Myofascial Pain

Definition: regional muscle pain disorder accompanied by

trigger points(discrete point of tenderness, palpable in a

taut band of muscle)

Treatment: PT, NSAIDs, MRs, behavioral tx, TPIs, Botox,

dry needling, etc

Cervical Facet Mediated Pain

1) Similar to lumbar facetogenic pathology

2) Common after whiplash injury

3) Often includes radiating occipital headache

4) 50% of population over 50y/o and 75% over 65 y/o have

radiologic evidence of cervical spondylosis

1) Treatment: similar to lumbar

1) NSAIDs, TCAs, PT, TENS

2) Interventional options: facet joint steroid injections vs MBB/RFA

Cervical Disc Pathology

Similar to Lumbar; ie radicular component, however,

radiculopathy does not always mean radiation to the hand

MRI with spinal cord edema, would recommend surgical

consult

Treatments include: PT, NSAIDs, MRs, rest, ice, heat; anti-

convulsents, etc;

Interventional options: epidural steroid injection

Piriformis syndrome

Radiating pain in the buttock,

posterior thigh and lower leg)

and the physical exam finding of

tenderness in the area of the

sciatic notch.

The pain is exacerbated with

activity, prolonged sitting, or

walking.

The diagnosis is largely clinical

and is one of exclusion.

In physical examination, attempts

Advanced Interventional Pain Procedures

1) Sympathetic Nerve Blocks

2) Head and Facial Blocks

3) Spinal Cord Stimulation

4) Intrathecal Drug Delivery

5) Vertebral Augmentation

Sympathetic Nerve Blocks

1)Helpful for a multitude of sympathetically mediated pain

syndromes including(but not limited to) CRPS I and II;

abdominal pain; pelvic pain; perineal pain;

1)Stellate Ganglion

2)Celaic/Splanchnic

3)Superior Hypogastric Plexus

4)Ganglion Impar

Head and Facial Blocks

1)Helpful for a multitude of headache and or facial pain

syndromes; including migraine, Trigeminal neuralgia, etc

1)GONB, SONB, ATNBs, etc

2)Trigeminal nerve block

3)Botulinum toxin

Spinal Cord Stimulation

Indications: CRPS I and II; Radiculopathy; Failed Back

Surgery Syndrome; Arachnoiditis; PHN; Phantom Limb;

Ischemia secondary to PVD; Intractable Angina

**Patients able to “try before buy” with temporary implant

Evolving therapy: Improved technologies over past 5 years

including wave-form technologies; Battery technology;

MRI compatibility; and specific DRG therapy

Intrathecal Drug Delivery

Indications:

1)Severe pain from: Failed back surgery syndrome;

Cancer pain, CRPS I and II; Arachnoiditis; Chronic

pancreatitis

2)Severe Spasticity from: stroke, brain injury, cerebral

palsy, MS, spinal cord injury

Vertebral Augmentation

1)Diagnosis: Often under diagnosed; ultimately need MRI to

eval STIR image; or bone scan if MR contraindicated

2) Pain worse with standing, sitting; rolling out of bed

excruciating; LE symptoms may indicate another etiology

or concurrent one, ie spinal stenosis, radiculopathy

3) High success rate; complications minimal; ONLY “FIX”

for IPM Physicians

4)NEJM- Kalmes/Buchbinder studies both downgraded in

2013 after meta-anlaysis

Thank You!

Questions:

Craig W. Davis, MD

cdavis@grangermedical.com

www.grangerpain.com