BACK PAIN

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BACK PAIN

• BACK PAIN
• A Pain Specialist's Perspective

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INTERVENTIONAL PAIN MANAGEMENT

• DR J KURIAN MD MRCP FRCA FFPM
• CONSULTANT
• ANAESTHESIA AND PAIN MEDICINE

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Background

• Neurosurgical ablative treatments for pain since
  19th century but now infrequently used
• Ablation eclipsed by percutaneous injections or
  therapies that target central or peripheral
  pathways

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Pain

• An unpleasant sensory and emotional experience
  which we primarily associate with tissue damage
  or describe in terms of such damage, or both

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Pain Pathophysiology

• Nociceptive pain
• Neuropathic pain

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Nociception

• The detection of tissue damage by specialized
  transducers connected to A-delta and C-fibers

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Classification of Pain Nociception

• Proportionate to the stimulation of the
  nociceptor
• When acute
• Physiologic pain
• Serves a protective function
• Normal pain
• Pathologic when chronic

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Classification of PainNeuropathic Pain

• Sustained by aberrant processes in PNS or CNS
• Disproportionate to the stimulation of nociceptor
• Serves no protective function
• Pathologic pain

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Peripheral and Central Pathways for Pain
Ascending Tracts
Descending Tracts
Cortex
Thalamus
Midbrain
Pons
Medulla
Spinal Cord
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Nociceptive Pain
Neuropathic Pain
PNS peripheral nervous system
PNS
Peripheral sensitization

Healthy nociceptors
Abnormal nociceptors
CNS
CNS central nervous system
Central sensitization
Normal transmission
Central reorganization
Physiologic state
Pathologic state
Pappagallo M. 2001.
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Overview
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Chronic Pain Syndrome

• End result of a variety of pathological and
  psychological mechanisms that may have included,
  at some stage tissue or nerve damage.

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Pain Interventions

• Nerve blocks and injections should be seen as
  part of a process of education and
  rehabilitation, allowing an opportunity for
  mobilization and return to normal activity.

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Nerve Blocks (1)

• Diagnostic local anaesthetic only, to clarify
  mechanism or simulate effects of therapy
• Therapeutic anaesthetise a site or pathway
  temporarily(local anaesthetic) or
  permanently(lytic agent, cryo, radiofrequency)
  or reduce inflammation (corticosteroids)
• A block may be diagnostic and therapeutic eg.
  Symapthetic block or trigger point injection

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Nerve Blocks (1)

• Diagnostic local anaesthetic only, to clarify
  mechanism or simulate effects of therapy
• Therapeutic anaesthetise a site or pathway
  temporarily(local anaesthetic) or
  permanently(lytic agent, cryo, radiofrequency)
  or reduce inflammation (corticosteroids)
• A block may be diagnostic and therapeutic eg.
  Symapthetic block or trigger point injection

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Nerve Blocks (II)

• Common blocks for chronic pain include
• -Trigger-point injection
• -Bier block
• -Peripheral nerve injection (eg.
  Ilioinguinal,lateral femoral cutaenous, greater
  occipital)
• -Epidural injection
• -Intra-articular(eg.facet, SI joint)
• Sympathetic block(cervical, lumbar)
• Plexus block (coeliac, hypogastric)

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Nerve Blocks (III)

• Case reports, preclinical data support long
  lasting effects of local anaesthetic blockade -
  RCTs support lytic coeliac block
• However, unclear how much clinical improvement
  reflects placebo effects, irrevelant cues,
  systematic absorption of local anaesthetic,
  expectations
• Side effects possible
• Rarely successful as a stand alone strategy for
  chronic pain

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Trigger Point Injection

• Myofascial pain syndrome
• Taut band palpable (if muscle is accessible)
• Exquisite spot tenderness of a nodule in a taut
  band
• Pressure on tender nodule reproduces pain
• Range of motion with stretch limited by pain
• Techniques
• Dry needling
• Local anaesthetic only
• Local anaesthetic and steroid
• Botulinum toxin

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Epidural Injection (I)

• Employed for decades using various techniques
  materials and patients
• Limited RCT evidence of efficacy
• Cervical, Thoracic, Lumbar , Caudal
• Trans laminar
• Transforaminal

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Epidural Injection(II)

• Applied for symptomatic relief in
• Disc protrusion with radiculopathy
• Spinal stenosis(circumferential or
  transforaminal)
• Acute pain, local inflammation of vertebral
  fracture
• Acute herpes Zoster
• May facilitate rehabilitation, avert surgery when
  applied within multidisciplinary frame work

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Steroid Injections

• Interlaminar Epidural

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Nerve Root Injection

• Diagnostic Establish or confirm mechanism of pain
• Therapeutic Local anaesthetic plus corticosteroid
• Technique Fluroscopy or CT essential for needle
  placement with contrast confirmation

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INTRA ARTICULAR INJECTIONS

• Facet and Sacroiliac joints most common
• Diagnostic facet syndrome or SI joint pain
• Simulate results of potential spinal fusion or
  denervation of medial branch of dorsal ramus
• Therapeutic (local anaesthetic corticosteroid)
• Reduce inflammation, pain
• Increase mobility, facilitate rehabilitation

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Specific anatomic syndromes

• Facet syndrome

Continuous pain worsened by rotation and
extension Radiation into the leg or gluteal area,
in a non-dermatomal distribution Tenderness over
the joints and paravertebral muscle spasm
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Sacroiliac joint injection
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Symapthetic Blocks

• Diagnostic
• Stellate ganglion
• Lumbar
• Therapeutic
• CRPS of upper and lower extremity
• Vascular insufficiency
• Refractory angina
• Technique
• Local anaesthetic, Neurolytic

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MISCELLANEOUS

• Trigeminal ganglion
• Glossopharyngeal nerve
• Sphenopalatine ganglion

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NEWER DEVELOPMENTS

• PULSED RADIOFREQUENCY
• VERTEBROPLASTY
• IDET, DISCTRODE
• DORSAL COLUMN STIMULATORS
• PERIPHERAL NERVE STIMULATORS
• DEEP BRAIN STIMULATORS
• IMPLANTABLE PUMPS

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Managing Pain
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CONCLUSION

• Interventional approaches are often reserved for
  patients with well established problems, failure
  of other treatments and pronounced disability.
• Do we miss an opportunity for early cost
  effective preventive treatment by reserving
  interventions for those least likely to benefit?
• Doctors think a lot of patients are cured who
  have simply quit in disgust
• DON HEROLD 1889