Interventional Pain Management
for Chronic Spinal Pain
1
MANONMANI ANTONY, M.D.
SUSSEX PAIN RELIEF CENTER
GEORGETOWN, DELAWARE
WESTERN SUSSEX COUNTY
CONFERENCE
SATURDAY, JULY 20, 2013
7/20/2013
www.sussexpainrelief.com
Bio & Disclaimer
2
 Manonmani Antony, MD
 Board Certified: ABA, ABA subspecialty Pain Medicine
 ASA’s 2009 Certificate in Business Administration(CBA)
 CEDIR/AMA Guides 6th ed.
 AAAP Certified - Buprenorphine in Rx of Opioid Dependence
 Founder: Sussex Pain Relief Center LLC – “The Preferred Pain Relief Center for
Patients and Their Providers in Southern Delaware.”
 Pain Management Consultant, Nanticoke Health Services since 2005
 Delaware Today’s Top Doctors for 2012
 No outside funding, no grants, no support from industry
7/20/2013
www.sussexpainrelief.com
Objectives
3
 Recognize interventional pain management as the discipline of medicine
devoted to the diagnosis and treatment of pain
 Recognize interventional techniques as minimally invasive procedures and
some surgical techniques
 Recognize management of back pain using interventional pain procedures
7/20/2013
www.sussexpainrelief.com
Objectives
4
 Recognize management of thoracic pain using interventional pain procedures
 Recognize management of neck pain using interventional pain procedures
 Recognize management of pain with implantables and MILD procedure
 Recognize procedure-related complications and new technologies
7/20/2013
www.sussexpainrelief.com
7/20/2013
5
www.sussexpainrelief.com
Chronic Pain-Definition
6
 An unpleasant sensory & emotional experience associated with actual tissue
damage or described in terms of such damage. (IASP)
 Pain that persists 6 months after an injury, and beyond the usual course of
acute disease, that is associated with chronic pathological process and may
not be amenable for routine pain control methods, and healing may never occur
(ASIPP)
7/20/2013
www.sussexpainrelief.com
Interventional Pain Management-Definition
7
 The discipline of medicine devoted to the diagnosis and treatment of pain and
related disorders by the application of interventional techniques in managing
sub-acute, chronic, persistent, and intractable pain, independently or in
conjunction with other modalities of treatments.(NUCC)
(National Uniform Claims Committee)
7/20/2013
www.sussexpainrelief.com
Interventional Techniques- Definition
8
 Minimally invasive procedures, such as needle placement of drugs in targeted
areas, ablation of targeted nerves, and some surgical techniques, such as
discectomy and the implantation of intrathecal infusion pumps and spinal cord
stimulators. (MedPAC)
(Medicare Payment Advisory Commission)
7/20/2013
www.sussexpainrelief.com
Evidence-based Medicine
9
 EBM is defined as a conscientious, explicit, and judicious use of current best
evidence in making decisions about the care of individual patients.
 The following lecture is prepared based on Evidence-Based Guidelines for
Interventional Techniques in Chronic Spinal Pain by ASIPP
Pain Physician 2013, (16), S1-S48. ISBN 1533-31
7/20/2013
www.sussexpainrelief.com
Spinal Interventional Techniques Guidelines by
ASIPP 2013
10
Pain Physician 2013, (16), S1-S48. ISBN 1533-31
7/20/2013
www.sussexpainrelief.com
IPM –Indications: part of Multimodal
Therapeutic Strategies for managing CSP
11
7/20/2013
www.sussexpainrelief.com
Introduction
12
 MANAGEMENT OF LOW BACK PAIN
 MANAGEMENT OF NECK PAIN
 MANAGEMENT OF THORACIC PAIN
 IMPLANTABLES
 MILD
 IPM PHARMACOLOGY-STEROIDS
 IPM NEW TECHNOLOGY
7/20/2013
www.sussexpainrelief.com
Spinal Interventional Techniques
13
Controlled Diagnostic
Interventional
Therapeutic
Interventional Techniques
 Used to identify the pain generator
 Prolonged pain relief
 Facet Joint nerve blocks (MBB)
 Epidural Injections,
 Sacroiliac joint injections
 Adhesionolysis
 Provocative discography
 Facet joint Interventions
 Intradiscal therapies
 Implantable therapies
7/20/2013
www.sussexpainrelief.com
Spine Anatomy
14
7/20/2013
www.sussexpainrelief.com
MANAGEMENT OF LOW BACK PAIN
15
 Disc-related pathology: Spinal
Stenosis, and Radiculitis (Radicular
Pain)
 Lumbar Facet/Zygapophysial Joint
Pain
 Sacroiliac joint pain
7/20/2013
www.sussexpainrelief.com
Disc-related pathology: Spinal Stenosis, and
Radiculitis
16
Diagnostic I T
Therapeutic IT
 Diagnostic Selective Nerve Root
 Epidural Injections: Interlaminar,
Blocks
 Lumbar Discography
Transforaminal and Caudal.
 Lumbar Epidural Adhesiolysis:
 Thermal Annular Procedures IDB,
IDET
 Percutaneous Disc Decompression
(APLD), (PLDD
7/20/2013
www.sussexpainrelief.com
Disc-related pathology: Lumbar Radicular Pain
17
Deramatomes
7/20/2013
Illustrative Fluorscopic
Anatomy
www.sussexpainrelief.com
Lumbar Radicular Pain
18
 Predominant leg or radicular pain in a
dermatomal distribution
 Nerve root tension signs with SLRT
30 - 70 degrees or a positive crossleg straight leg raising
 Corroboration of neurologic signs with
muscle weakness and wasting,
sensory impairment, and reflex
suppression
7/20/2013
www.sussexpainrelief.com
Lumbar Radicular Pain
19
 Epidural Injections: 1) Interlaminar, 2) Transforaminal and




3) Caudal
Indication: Radicular pain due to disk herniation, spinal stenosis, Post–lumbar
laminectomy syndrome, CRPS, PHN, Phantom Limb pain
Technique: 1) Interlaminar, 2) Transforaminal and 3) Caudal approaches, Loss of
resistance technique, soap bubble appearance, 30% miss rate without fluoro, blind
technique
Complications: 1) Interlaminar: spinal headache, spinal block, 2) Transforaminal:
spinal cord injury by intravascular injection of steroids into the artery of Adamkiewicz
3) Caudal
Outcome: moderate evidence for interlaminar ESI for short term pain relief, and
limited evidence for long-term relief. Moderate evidence for Transforaminal-ESI for
short and long-term pain relief.
7/20/2013
www.sussexpainrelief.com
Lumbar Radicular Pain - Interlaminar ESI
20
LOR Technique AP
7/20/2013
Epidurography AP View
www.sussexpainrelief.com
Lumbar Radicular Pain - Interlaminar ESI
21
Lateral Position
7/20/2013
Lumbar EpidurographyLateral view
www.sussexpainrelief.com
Lumbar Radicular Pain - Transforaminal ESI
(LTESI)
22
Nerve root filling after
contrast injection
7/20/2013
Nerve root filling with
partially into epidural space
www.sussexpainrelief.com
Digital subtraction image-Live fluoroscopy
(LTESI)
23
Contrast injection for left
L5-S1 Transforaminal
7/20/2013
Digital substraction view:
epidural & vascular
contrast pattern
www.sussexpainrelief.com
LTESI: Artery of Adamkiewicz Injury
24
 Clinical Significance: Artery of
Adamkiewicz
 79% arise from Left T8 and L1, 30%
from Right
 Anterior spinal artery syndrome
 Loss of urinary and fecal
continence and impaired motor
function of the legs; sensory function
is often preserved to a degree
7/20/2013
www.sussexpainrelief.com
Lumbar Radicular Pain - Caudal ESI
25
Needle position for caudal
7/20/2013
AP View with contrast
Injection
www.sussexpainrelief.com
Disc-related pathology: Percutaneous Epidural
Adhesiolysis
26
Racz Epidural catheter
Removal of epidural
Fibrosis
 Indication: epidural Fibrosis (Scar tissue) causing
Low back pain with radiculopathy
 Technique: Inject dye caudally, demonstrate filling
defects, insert Epimed Racz catheter, steer and
twist tip in circles, inject Hyaluronidase (1500 U in
10ml NS), inject local anesthetic and steroid.
Followed by neural flossing exercises.
 Complications: spinal cord compression from
loculation of the injected fluid
 Outcome: FBSS pts showed a reduction in pain
and improvement in functional status in 73% of the
epidural adhesiolysis gp compared to 12% in the
control gp.
Manchikanti et al. Pain Phys 2009; 12(6):E355-E368
7/20/2013
www.sussexpainrelief.com
Disc-related pathology: Percutaneous Epidural
Adhesiolysis
27
Pre-procedure Filling
defect in left L5 nerve root
7/20/2013
Post-procedure excellent
filling of left L5 nerve root
www.sussexpainrelief.com
Disc-related pathology: Discogenic Pain
(diagnostic)
28
Pressure controlled
Discography
Disc pathology
 Indications: Other pain generators
have been ruled, considering surgery
or p/c interventions. Surgery is
planned, and the surgeon desires an
assessment of the adjacent disc
levels.
 Technique: pressure controlled
discography with manometer
(Discpoint) syringe and contrast
medium.
7/20/2013
www.sussexpainrelief.com
Discogenic Pain – Diagnostic-Provocation
Discography
29
Positive Response
 Positive response is: pain ≥ 7/10 at
pressure <50 psi , concordant pain,
grade 3 or greater annular tear, ≤ 3.5 mL
volume, and at least one negative control
disc.
 Complications: Discitis, < 0.15% per
patient, diminished with the double- vs.
single-needle technique, screening for
infection, aseptic skin preparation,
styleted needles, and IV and antibiotics
7/20/2013
www.sussexpainrelief.com
Discogenic Pain - Provocation DiscographyFluoroscopice images
30
AP post-discography view
7/20/2013
Lateral post-discography view
www.sussexpainrelief.com
Discogenic Pain - Provocation Discography-Post
Discography CT Scan images
31
Modified Dallas
discogram scale Grade 0-5
Grade 0, Grade 5
Outcome: Strong evidence as imaging tool,
Strong evidence that intradiscal distention can
produce pain, Strong evidence to identify chronic
lumbar discogenic pain,
Wolfer. et al. Pain Physician 2008, (11), 513-538.
7/20/2013
www.sussexpainrelief.com
Discogenic Pain-Therapeutic-IDET & Diskit ll
32
IDET: Intradiscal Electro
Thermal Annuloplasty
7/20/2013
Diskit ll (NT 1100 and
pulsed RF mode
www.sussexpainrelief.com
Discogenic Pain-Therapeutic- Intradiscal
Biacuplasty (IDB)
33
 Technique: minimally invasive
procedure
 Two Transdiscal RF probes (Kimberly
Clark) are positioned on the
postereolateral sides of annulus
fibrosus. The internally cooled RF
probes were attached to the RF
generator, and RF energy is delivered
(45°C in bipolar configuration for 15
min).
 Complications: Discitis
7/20/2013
www.sussexpainrelief.com
The Cooled RF System
34
Cooled RF
RF
Standard
RF
 RF energy heats the tissue
while circulating water
moderates the temperature
in close proximity to the
electrode or active tip. This
combination creates large
volume lesions without
excessive heating at the
electrode
A Randomized, Placebo-Controlled Trial of Transdiscal
Radiofrequency, Biacuplasty for Rx of Discogenic Lower
Back Pain, Pain Medicine 2013; 14: 362–373
7/20/2013
www.sussexpainrelief.com
7/20/2013
35
www.sussexpainrelief.com
Lumbar Facet Joint Pain
36
Diagnostic IT
Therapeutic IT
 Diagnostic Lumbar Facet Joint
 Radiofrequency Neurotomy
Blocks
 Diagnostic MBB
 Intra-articular Injections
7/20/2013
www.sussexpainrelief.com
Lumbar facet Joint pain
37
7/20/2013
www.sussexpainrelief.com
Lumbar facet Joint Pain- Diagnostic- MBB
38
 Technique: Diagnostic block
is done by using local
anesthetics only w or w/o
steroids, pain diary is given to
patient. If >50% pain relief,
f//u with RFN
 Outcome: strong evidence in
the diagnosis of lumbar facet
joint pain.
Anatomy: One facet Joint (L4-5) is innervated by 2
medal branch nerves from L3 and L4 nerve roots
7/20/2013
Boswell et al, Pain Physician 2007; 10:7-111 • ISSN
1533-3159
www.sussexpainrelief.com
Lumbar facet Joint pain –Therapeutic- Intraarticular joint injections
39
 Technique: After confirmation of intra-
articular needle tip placement, w or
without contrast, the joint is injected
with an local anesthetic agent to
complete a diagnostic block or in
combination with a steroid for
therapeutic injection.
 Outcome: moderate evidence for
short term and long term pain relief,
Boswell et al, Pain Physician 2007; 10:7-111 • ISSN 1533-3159
7/20/2013
www.sussexpainrelief.com
Lumbar Facet Joint Pain-TherapeuticRadiofrequency Neurotomy
 Technique: A 22-gauge RFL 100mm
40
needle with a 10mm active tip is inserted,
Sensory stimulation at 50 Hz up to 1v and
motor stimulation at 2 Hz up to 2.5v,
Lesioning at 80 deg C for 60 sec at each
level
 Outcome: strong evidence for short term
pain relief, and moderate -strong
evidence for long-term relief. Boswell et
al, Pain Physician 2007; 10:7-111 • ISSN
1533-3159
 Repeat RFN for chronic back pain 10
months relief; 4 – 6 successful repeats
Rambaransingh B, et al. Pain Med 2010
7/20/2013
www.sussexpainrelief.com
Lumbar Facet Joint Pain-TherapeuticRadiofrequency Neurotomy
41
7/20/2013
www.sussexpainrelief.com
Sacroiliac Joint Pain
42
Diagnostic IT
 Diagnosis of Sacroiliac Joint Pain
Therapeutic IT
 Therapeutic Sacroiliac Joint
Interventions
 Radiofrequency Neurotomy
 Cooled Radiofrequency Neurotomy
7/20/2013
www.sussexpainrelief.com
Sacroiliac Joint Pain
43
Needle position
7/20/2013
Pain distribution
www.sussexpainrelief.com
Sacroiliac Joint Pain-Interventions
44
 Diagnostic
 Intra-articular sacroiliac joint injections
with local anesthetics
 Therapeutic SIJ interventions
 Intra-articular steroid injections; periarticular injections with Steroid,
evidence: fair
 Pulsed radiofrequency and
conventional radiofrequency
neurotomy, evidence: limited
7/20/2013
www.sussexpainrelief.com
SIJ pain -Therapeutic
45
Pulsed RF
Cooled Probe RF
Cooled radiofrequency neurotomy, evidence: fair
Pain Physician: April 2013; 16:S49-S283
7/20/2013
www.sussexpainrelief.com
MANAGEMENT OF NECK PAIN
46
 Cervical facet Pain
 Diagnostic Cervical Facet Joint Nerve Blocks, Evidence: good
 Therapeutic Cervical Facet Joint Interventions: Evidence: Intra-articular injection: Limited, RFN:
Fair
 Cervical radicular Pain
 Therapeutic Cervical Interlaminar ESI, Evidence: Good
 Cervical Discogenic Pain
 Cervical Provocation Discography, Evidence: Limited
7/20/2013
www.sussexpainrelief.com
Cervical Facet Pain
47
7/20/2013
www.sussexpainrelief.com
Cervical facet Pain: Therapeutic- Intra-articuar
inj and RFN of Medial Branch nerves
48
Intra-articular Jt inj
7/20/2013
RFN of Medial Branch N
www.sussexpainrelief.com
Cervical RadicularPain: Therapeutic- Cervical
Interlaminar ESI
49
7/20/2013
www.sussexpainrelief.com
Cervical Discogenic Pain-Diagnostic- Provocation
Discography
50
AP view
7/20/2013
Lateral View
www.sussexpainrelief.com
MANAGEMENT OF THORACIC PAIN
51
 Thoracic Facet Pain
 Diagnostic Thoracic Facet Joint Nerve Blocks, Evidence: good
 Therapeutic Thoracic Facet Joint Interventions: Evidence: Intra-articular injection: None, RFN:
Limited
 Thoracic Radicular Pain
 Therapeutic Thoraic Interlaminar Epidural Injections, Evidence: Fair
 Thoracic Discogenic Pain
 Thoracic Provocation Discography, Evidence: Limited
7/20/2013
www.sussexpainrelief.com
Thoracic Facet Pain
52
7/20/2013
www.sussexpainrelief.com
Thoracic Radicular Pain- Therapeutic Thoraic
Interlaminar ESI
53
7/20/2013
www.sussexpainrelief.com
7/20/2013
54
www.sussexpainrelief.com
IMPLANTABLES
55
 Spinal Cord Stimulation: evidence for SCS is fair in managing patients with
FBBS.
 Peripheral Nerve Stimulation
 Implantable Intrathecal Pump: evidence for intrathecal infusion systems is
limited in managing chronic non-cancer pain
7/20/2013
www.sussexpainrelief.com
Spinal Cord Stimulation
56
Implanted medical
device that delivers
electrical impulses to
nerves in the dorsal
aspect of the spinal cord
that can interfere with
the transmission of pain
signals to the brain and
replace them with a
more pleasant sensation
(paresthesias)
7/20/2013
www.sussexpainrelief.com
Spinal Cord Stimulation
57
Electrode
Remote
control
Pulse Generator(IPG)
7/20/2013
www.sussexpainrelief.com
Spinal Cord Stimulation-Indications
58
 Failed back surgery syndrome (FBSS)
 Complex regional pain syndrome (CRPS) I and ll
 Peripheral neuropathic pain
 Phantom limb/post-amputation syndrome
 Post-herpetic neuralgia
 Spinal cord injury
7/20/2013
www.sussexpainrelief.com
Spinal Cord Stimulation
59
Permanent Implant
Screening Trial
 Outpatient/office 3-7 days
 Percutaneous electrode placed under
fluoroscopy
 Local Anesthesia/conscious sedation
 Important for efficacy, localization,
cost-effective
 Pain relief>50%, increased physical
activity and decrease analgesic
consumption
7/20/2013
 Dorsal column stimulator (SCS)
 Local anesthesia/sedation vs.






GETA/neuromonitoring
ASC/HOPD
Sublaminar and/or Percutaneous
electrode
Pulse generator
Programmer
Psychologic testing is recommended
Peripheral nerve stimulator(PNS)
www.sussexpainrelief.com
Spinal Cord Stimulation
60
7/20/2013
www.sussexpainrelief.com
Spinal cord Stimulation-Cost effectiveness
61
 SCS therapy consistently showed higher initial costs, but overall long-term cost
efficacy was greater than conventional medical management.
 SCS therapy showed lower medical costs by reducing the demand for medical
care by patients with FBSS
 SCS to be more effective and less expensive when compared with the standard
treatment protocol for chronic RSD.
Kumar K., Malik S., Demeria D.: Treatment of chronic pain with spinal cord stimulation versus alternative therapies: cost-effectiveness
analysis. Neurosurgery 2002; 51:106
7/20/2013
www.sussexpainrelief.com
Spinal cord Stimulation-Complications
62
 Infection
 Lead migration
 Loss of coverage
 Coverage over non-painful area
 Painful coverage
 Depletion of battery
 Pain around the IPG site
 Pain around the anchor site
7/20/2013
www.sussexpainrelief.com
Intrathecal Drug delivery System (Pain Pump)
63
7/20/2013
www.sussexpainrelief.com
Intrathecal Drug delivery System (Pain Pump)
64
7/20/2013
www.sussexpainrelief.com
Intrathecal Drug delivery System (Pain Pump)
65
7/20/2013
www.sussexpainrelief.com
Intrathecal Drug delivery System
(Pain Pump)
66
Trial
Medications
 Opiates: Morphine,




Hydromorphone, Fentanyl and
Sufentanyl (mu)
Bupivacaine (LA)
Clonidine (Alpha 2)
Baclofen (GABA)
Ziconotide) (VDCC)
 Pre-implantation Trial: 24 hrs,





(Polyanalgesic Consensus Conference—2012)
7/20/2013
spinal or epidural opioid
Components
Spinal infusion Pump,
Spinal catheter
Programmer
“Patient Therapy Manager”
Medtronic
www.sussexpainrelief.com
Spinal Stenosis - Minimally Invasive Lumbar
Decompression (MILD)
67
MILD - provides relief for some patients whose
stenosis is due to thickening of a particular
ligament called the ligamentum flavum. MILD
allows for paring down the thickened
ligament, taking pressure off the nerves and
relieving pain
7/20/2013
www.sussexpainrelief.com
Spinal Stenosis - Minimally Invasive Lumbar
Decompression (MILD)
68
7/20/2013
www.sussexpainrelief.com
Spinal Stenosis - Minimally Invasive Lumbar
Decompression (MILD)
69
 Minimally invasive procedure through





a tiny incision, requiring no stitches.
Local anesthetic and light sedation is
typical.
Fast procedure time, usually
performed in 1 hour.
Generally return home the same day.
Often return to work and resume light
daily tasks within a few days.
No implants left behind.
7/20/2013
www.sussexpainrelief.com
Spinal Stenosis - Minimally Invasive Lumbar
Decompression (MILD)
70
7/20/2013
www.sussexpainrelief.com
Vertebroplasty & Kyphoplasty
71
7/20/2013
www.sussexpainrelief.com
Vertebroplasty & Kyphoplasty
72
7/20/2013
www.sussexpainrelief.com
Vertebroplasty & Kyphoplasty
73
Lateral view pre & post
procedure
7/20/2013
AP view
www.sussexpainrelief.com
Multistate Outbreak of Fungal Infections among Persons Who
Received Injections with Contaminated Medication
74
 Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #05212012@68,
 Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #06292012@26
 Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #08102012@51
 SPRC remains unaffected by the recent nationwide recall on compounding
pharmacy medical products, as SPRC does not use Methylprenisolone or the
compounding Pharmacies.
7/20/2013
www.sussexpainrelief.com
New technology: Epiducer lead delivery system
St Jude’s medical: allows introduction of multiple neurostimulation leads
through a single entry point
75
7/20/2013
www.sussexpainrelief.com
New Technology: Position Adaptive Stimulation
Medtronic : Restore Sensor adopts positional changes
76
7/20/2013
www.sussexpainrelief.com
New Technology: Position Adaptive Stimulation
Medtronic : MRI compatible
77
7/20/2013
www.sussexpainrelief.com
Reference
78
 Spinal Interventional Techniques for Chronic Spinal Pain by ASIPP: Pain Physician 2013;






16:S1-S48 • ISSN 1533-3159 Pain Physician 2013; 16:S49-S283 • ISSN 1533-3159
Percutaneous Epidural Adhesiolysis: Pain Physician 2009; 12:361-378 • ISSN 1533-3159
Kapural et al, R P-CT Biacuplasty for discogenic LBP , Pain Medicine 2013; 14: 362–373
Rambaransingh B, et al, Repeat RFN for chronic back pain effect on pain, disability, Pain
Medicine 2010; 11: 1343–1347
Kapural et al, R P-CT Biacuplasty for discogenic LBP , Pain Medicine 2013; 14: 362–373
Kumar K., Malik S., Demeria D.: Treatment of chronic pain with spinal cord stimulation versus
alternative therapies: cost-effectiveness analysis. Neurosurgery 2002; 51:106
Wang et al, Decrease in healthcare resource utilization with MILD , Pain Medicine 2013; 14:
657-661
7/20/2013
www.sussexpainrelief.com
7/20/2013
79
www.sussexpainrelief.com
Sussex Pain Relief Center: State-of-the-Art Pain
Care Center
80
7/20/2013
www.sussexpainrelief.com