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