Date post: | 11-Apr-2017 |
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Health & Medicine |
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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