Procedures  in  Chronic  Pain      Dr  Brendan  Moore  Pain  Medicine  Specialist  Physician  Adjunct  Associate  Professor  

 University  of  Queensland  

Identifying appropriate procedures for your

patient  

Degenera(ve  Lumbar  Back  Pain  

Degenera(on  of  Lumbar  Spine  

•  Disc  degenera(on  +  narrowing  

•  Osteoporosis    •  Facet  Joint  Arthri(s  •  Spinal  and  Foraminal  stenosis  

•  Loss  of  Lumbar  concavity    

Posterior  Elements  

•  Facet  Joints  frequently  implicated  in  pain  •  Mechanical  back  pain  with  upper  leg  and  buFock  radia(on  

Origins  of  lumbar  pain  

•  Degenera(ve  Discs  •  Vertebral  fractures  •  Spinal  /  Foraminal  Stenosis  

•  Disc  Bulge  /  Prolapse  •  Facet  Joint    •  Muscle  /  SoI  (ssue    

Invasive  Treatment  Op(ons  

•  Surgery  •  Facet  Joint  Injec(on  •  Radiofrequency  medial  branch  abla(on  •  Epidural  /  Caudal  steroid  •  Vertebroplasty  •  Coeliac  /  Lumbar  Sympathe(c  Plexus  Blocks  •  Sacro-­‐iliac  Joint  injec(on  

Identifying appropriate procedures for your patient Identifying appropriate procedures for your patient

•  Who  should  order  the  Pain  procedure  ?  

How persistent pain can become a problem

Adapted from: Nicholas, 2008.

•  Who  should  order  the  Pain  procedure  ?  

•  Who  should  order  the  Pain  procedure  ?  

•  Mul(disciplinary  considera(on  in  assessment  •  Part  of  a  comprehensive  management  plan  •  Pa(ent  fully  informed  

– Poten(al  benefits  – Limita(ons  – Expecta(ons  – What  happens  next  

•  Clear  follow  up  plan  

Facet  Joint  Injec(on  

•  Primarily  diagnos(c  •  25G  Spinal  needle    •  LA  +  Steroid  •  Steroid  confers  possible  longer  term  benefit  

Sacro-­‐iliac  Joint  Injec(on  

Medial  Branch  Nerve  Abla(on  

•  Denerva(on  of  Medial  Branch  via  Radiofrequency  Neurotomy  

Radiofrequency  Neurotomy  

•  AP  and  oblique  views  to  confirm  posi(on  •  Test  s(mula(on;  2.0  Hertz,  0  to  2.0  v  to  test  for  motor  nerve  

contact  •  Lesion  85oC  x  90sec    

Cervical  Radiofrequency  Neurotomy  

Cervical  Radiofrequency  Neurotomy  

Lumbar  Epidural  Injec(on  

•  18  or  16  G  Toohey  needle  

•  LOR  to  air  (or  saline)  •  Radio-­‐opaque  contrast  to  confirm  posi(on  

•  Px  for  nerve  root  irrita(on  and  assoc.  radicular  pain  

Lumbar  Epidural  Injec(on  

Caudal  Epidural  Injec(on  

Coeliac  Plexus  Block  

Coeliac  Plexus  Block  

Procedures available at a pain clinic

•  Epidural injections •  Facet joint injections •  Sacroiliac joint injections •  Medial branch blocks •  Radiofrequency nerve ablation

Appropriate conditions for interventional pain procedures

•  Aseptic conditions

•  Appropriate analgesia

•  Monitored sedation with anaesthetist in attendance

•  Image intensifying X-ray or CT guidance

Epidural injections

•  Most effective in the presence of nerve root compression and spinal stenosis

•  Increased efficacy if given in the first weeks of the onset of pain

•  Effects of the injection tend to be temporary (1 week to 1 year)

•  Can be beneficial in providing relief for patients during an episode of severe back pain

•  Allows patients to progress in their rehabilitation

Lumbar epidural injection

•  18G or 16G Toohey needle

•  Radio-opaque contrast to confirm position

•  Injection and distribution of local anaesthetic and steroid to nerve root

Facet joint injections

•  Back pain originating from facet joints

•  Low back pain (unilateral or bilateral) and no root tension signs or neurological deficits

•  Pain usually being aggravated by extension of the spine

•  Facet joint injection may reduce inflammation and provide pain relief

•  Therapeutic goal and potential benefit –  Temporary relief from pain –  Patient may proceed into an appropriate exercise program

Facet joint injection

•  Diagnostic

•  25G spinal needle

•  Local anaesthetic + steroid

•  Steroid indicative of possible long-term benefit

Sacroiliac joint injection

•  Indicated with referred pain

•  Pain referral pattern – area around and just caudal to the posterior superior iliac spine

•  Referred pain in the low back, buttocks, abdomen, groin or legs

•  In some patients, S-1 joint injections can provide significant pain relief

Sacroiliac joint injection

•  Diagnostic

•  25G spinal needle

•  Local anaesthetic + steroid

•  Steroid indicative of possible long-term benefit

Medial branch blocks

•  Medial branch nerves are the very small nerve branches that controls sensation of the facet joint

•  Indicated in low back pain (unilateral or bilateral)

•  Pain usually aggravated by extension of the spine

•  Medial branch blocks are a diagnostic procedure

•  Can provide temporary pain relief

Medial branch nerve ablation

•  Diagnostic medial branch blocks

•  Local anaesthetic + steroid

•  Progress to radiofrequency ablation if diagnostic block indicative of long-term benefit

Radiofrequency neurotomy

X-ray to confirm needle position – AP and oblique views Test stimulation – 2.0 Hz 0–2 volt to test for motor nerve contact Lesion 85°C for 90 seconds

Cervical radiofrequency neurotomy

Position for C2/3 and C3/4 facet joint radiofrequency

Cervical  radiofrequency  neurotomy    -­‐  lateral  view  

 Marker  shows  needle  at  C2/3  facet  joint

QUEENSLAND

Queensland Rural and regional health services

•  Department of Health website has a comprehensive list of Statewide Community Health Services

•  www.health.qld.gov.au

Health Contact Centre •  13-HEALTH telephone triage and referral service •  24 hours, 7 days per week •  Based on a partnership model with Smart Service Queensland and the

Queensland Government •  Responsible for the development and integration of existing or future health

care services which are / can be delivered through contact centre management practices

Accessing allied health services in your local area

Australian Psychological Society (APS) •  Find a psychologist in your local area – internet search •  APS homepage>Community Information>Find a Psychologist

Australian Physiotherapy Association •  Find a physiotherapist in your local area •  http://apa.advsol.com.au/

The Australian Pain Society has a comprehensive directory of Pain Specialists, Multidisciplinary Pain Clinics and Pain Management Centres •  www.apsoc.org.au/facility_directory.php

Cervical radiofrequency neurotomy – lateral view

Marker shows needle at C2/3 facet joint