BACK PAIN
BACK PAIN
A Pain Specialist's Perspective
INTERVENTIONAL PAIN MANAGEMENT
DR J KURIAN MD MRCP FRCA FFPM
CONSULTANT
ANAESTHESIA AND PAIN MEDICINE
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
Pain
An unpleasant sensory and emotional
experience which we primarily associate
with tissue damage or describe in terms of
such damage, or both
Pain Pathophysiology
• Nociceptive pain
• Neuropathic pain
Nociception
The detection of tissue damage by specialized
transducers connected to
A-delta and C-fibers
Classification of Pain
Nociception
• Proportionate to the stimulation of the
nociceptor
• When acute
– Physiologic pain
– Serves a protective function
– Normal pain
• Pathologic when chronic
Classification of Pain:
Neuropathic Pain
• Sustained by aberrant processes in
PNS or CNS
• Disproportionate to the stimulation of
nociceptor
• Serves no protective function
• Pathologic pain
Peripheral and Central Pathways for Pain
Ascending Tracts
Descending Tracts
Cortex
Thalamus
Midbrain
Pons
Medulla
Spinal Cord
Nociceptive Pain
Neuropathic Pain
PNS
peripheral
nervous
system
Peripheral
PNS
sensitization
“Healthy”
Abnormal
nociceptors
nociceptors
CNS Normal
central
nervous
system
Central
CNS
transmission sensitization
Central
reorganization
Physiologic
state
Pappagallo M. 2001.
Pathologic
state
Overview
Chronic Pain Syndrome
• End result of a variety of pathological and
psychological mechanisms that may have
included, at some stage tissue or nerve
damage.
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.
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
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
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)
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
Trigger Point Injection
• Myofascial pain syndrome
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•
•
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
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•
•
•
Dry needling
Local anaesthetic only
Local anaesthetic and steroid
Botulinum toxin
Epidural Injection (I)
• Employed for decades using various techniques
materials and patients
• Limited RCT evidence of efficacy
• Cervical, Thoracic, Lumbar , Caudal
• Trans laminar
• Transforaminal
Epidural Injection(II)
• Applied for symptomatic relief in
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•
•
•
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
Steroid Injections
• Interlaminar Epidural
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
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
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
Sacroiliac joint injection
Symapthetic Blocks
• Diagnostic
• Stellate ganglion
• Lumbar
• Therapeutic
• CRPS of upper and lower extremity
• Vascular insufficiency
• Refractory angina
• Technique
• Local anaesthetic, Neurolytic
MISCELLANEOUS
• Trigeminal ganglion
• Glossopharyngeal nerve
• Sphenopalatine ganglion
NEWER DEVELOPMENTS
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PULSED RADIOFREQUENCY
VERTEBROPLASTY
IDET, DISCTRODE
DORSAL COLUMN STIMULATORS
PERIPHERAL NERVE STIMULATORS
DEEP BRAIN STIMULATORS
IMPLANTABLE PUMPS
Managing Pain
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