INTERVENTIONAL PAIN
MANAGEMENT
DOMINICK LAGO JR., M.D.
Michigan Pain Management Consultants
INTERVENTIONAL PAIN
MANAGEMENT
• Definition: The use of invasive
techniques to decrease or eliminate
pain
• This can be accomplished in three
ways:
• Interrupting the pain signal along a
neural pathway
• Neuroaugmentation (SCS, PNS)
• Implantable drug delivery system
INJECTION THERAPY
• Trigger Point Injections
• Epidural
• Facet Joint/Medial Branch Block
• Sympathetic Chain Block
INJECTION THERAPY
• Usually performed utilizing fluoroscopy
• No sedation vs conscious sedation
• Can be therapeutic or diagnostic
TRIGGER
INJECTION
• Trigger
pointsPOINT
are discrete,
focal, hyperirritable spots located in a taut band of
skeletal muscle
• The pain will be localized and or
referred
• Palpation of a hypersensitive bundle or
nodule of muscle fiber of harder than
normal consistency is the physical
finding typically associated with a
trigger point. Palpation of the trigger
point will elicit pain directly over the
affected area and/or cause radiation of
TRIGGER POINTS
• Treatment consists of release of the
affected muscle or muscle groups
• Stretching, physical therapy and ice
have been utilized
TRIGGER POINTS
• Injection therapy is also effective in both
the acute and chronic presentations
• “Dry” technique
• Injection of local anesthetic with or
without steroids
TRIGGER POINTS
• Injection Technique
• Identify the muscle via palpation
• Using a 25 gauge needle and 0.5%
Xylocaine
• The needle is advance to the affected
muscle
• A twitch response is noted and then the
local is injected (3-5 cc).
EPIDURAL
• Injection performed to deposit
medication into the epidural space in
proximity to the spinal nerves
• Can be utilized in the cervical, thoracic
or lumbar region
• Most effective for radicular pain into the
arm or leg
• Should be performed with fluoroscopy
EPIDURAL
• There are three approaches to the
epidural space
• Interlaminar
• Transforaminal
• Sacral Hiatus (caudal)
SPINE ANATOMY
EPIDURAL
• Interlaminar injection
• Performed in the midline, between the
spinous processes at the affected
level of pathology
• Medication will spread cephalad,
caudad and bilaterally
SPINE ANATOMY
EPIDURAL
• Transforaminal Injection
• Performed lateral to the midline with a
goal of depositing the medication near
a specific nerve root in the
neuroforamen
• Has a higher complication rate due to
the artery of Adamkiewicz
• More effective for one sided, one level
pathology
SPINE ANATOMY
EPIDURAL
• Caudal
• The epidural space is entered via the
sacral hiatus
• Most commonly utilized if there has
been a previous spine surgery
SPINE ANATOMY
EPIDURAL
• Pain conditions that may respond to
epidural steroid injections
• Herniated disc
• Spinal stenosis
• Post laminectomy syndrome
• Spondylosis
• Complex r
EPIDURAL
• Pain conditions that may respond to
epidural injections with local anesthetic
• Diabetic Neuropathy
• Complex Regional Pain
Syndrome (RSD)
• Post Herpetic Neuralgia
EPIDURAL
• ESI, how does it work?
• When the spinal nerve is inflamed it
becomes edematous. As it travels
through the neuroforamen it becomes
“pinched” which maintains the
inflammation. After the steroids are
injected, they reduce the inflammation,
decreasing the diameter of the nerve,
giving it more room in the foramen.
EPIDURAL
• These injections may be repeated, but
limited to three within six months.
• Long term success is based on a multidisciplinary approach, not just injection
therapy
EPIDURAL
• Sympathetic epidural injection is utilized
for neuropathic pain syndromes (PHN,
CRPS, etc)
• These are local anesthetic injections
that may be repeated many times in a
series over a short period of time
• The mechanism of action is to disrupt
the pain transmission and allow the
nerve impulse to revert to it’s usual
state
MEDIAL BRANCH NERVE BLOCK
AND
RADIO
FREQUENCY
• It is a synovial joint between the
LESIONING
superior articular
process and inferior
articular process of two vertebra
• The medial branch nerve derives from
the corresponding spinal nerve
transmitting sensory information from
each joint
• Disease of the facet joints is seen with
aging
• In simplest form, these changes are
arthritic and degenerative
SPINE ANATOMY
MEDIAL BRANCH NERVE BLOCK
AND RADIO FREQUENCY
LESIONING
• Facet joint injections used to be the
treatment of choice for this condition
• With new technologies and advanced
imaging joint injections are rarely
performed
MEDIAL BRANCH NERVE BLOCK
AND RADIO FREQUENCY
LESIONING
• Prior to RF, the patient should undergo
one or two diagnostic MBNBs with local
anesthetic
• They should have significant relief of
their symptoms( 50% or greater),
however, it will not be long lasting
• Subsequent diagnostic blocks may be
necessary as there is a contribution
from the levels above and below
MEDIAL BRANCH NERVE BLOCK
AND RADIO FREQUENCY
LESIONING
• Radio frequency
lesioning or neurotomy
is performed using a specialized
machine to produce a radio wave to
“burn” a specific nerve blocking the
transmission of the painful impulse
• The lesion should provide relief for 6-9
months
• There is regeneration of the neural
pathway which allows the pain to return
• This procedure can be repeated
MEDIAL BRANCH NERVE BLOCK
AND RADIO FREQUENCY
LESIONING
• Symptoms or conditions that may have
a facet component
• Headaches
• Neck, mid or lower back pain
• Post fusion neck or back pain
SYMPATHETIC BLOCKS
• These blocks are performed when pain
is neuropathic with a sympathetic
component
• The blocks interrupt the nerve
transmission in a large area of the body
• They are performed at the ganglion
SYMPATHETIC BLOCKS
• Stellate Ganglion Block
• Performed by injecting 10 cc of local
anesthetic in proximity to the stellate
ganglion
• Used to treat upper extremity
pathology CRPS, PHN
SYMPATHETIC BLOCKS
• Celiac Plexus Block
• Performed by injecting local
anesthetic in proximity of the celiac
plexus
• Used to treat pathology of the
abdomen
• Should always be performed with
imaging (CT Scan or fluoroscopy)
SYMPATHETIC BLOCKS
• Lumbar Paravertebral Sympathetic
Block
• Performed to treat neuropathic pain of
the lower extremity
Post Operative
• Nerve blocks Pain
can be performed to
manage post operative pain
• Best used for extremity procedures
• Shoulder - Interscalene
• Hand - Supraclavicular/Axillary
• Ankle - Sciatic (Popliteal)
• Single shot~12-18 hours
• Peripheral catheters may be used for
several days with Ambit/On Q pump
Post Operative
Pain
• Single shot nerve blocks (18 Hrs)
• Peripheral nerve catheters (3 Days)
• Epidural
Post Operative
Pain
• Epidural
• Thoracic - Thoracotomy
• Abdominal - Exploratory laparotomy
NEUROAUGMENTATION
• Spinal Cord Stimulation (SCS) and
Peripheral Nerve Stimulation (PNS) are
technologies that are available for
patients that have not responded to the
previous modalities
• They require the implantation of lead(s)
and a battery generator
• SCS lead(s) are placed into the epidural
space
• PNS lead(s) are placed in the
subcutaneous tissue
NEUROAUGMENTATION
• SCS works by having a low voltage
electrical stimulation to block the pain
transmission via the dorsal column
tracts of the spinal cord
• It can be utilized for cervical, thoracic or
lumbar symptoms
• More effective for extremity than truncal
symptoms
NEUROAUGMENTATION
• PNS is utilized to provide pain relief
over a peripheral nerve distribution
• The lead(s) are place along the course
of peripheral nerves
• May be effective for occipital
headaches, inguinal neuralgia,
intercostal neuralgia
INTRATHECAL THERAPY
• An implanted infusion delivery system
that delivers a precise amount of
medication into the spinal fluid via an
infusion pump and catheter
• Baclofen (spasticity) and Morphine
(pain) are the two most common
medications delivered through this
modality
INTRATHECAL THERAPY
• Who is a candidate for this therapy?
• Failed all previous modalities
• Medication requirements have
produced intolerable side effects
• Patients who cannot achieve
adequate pain control even with high
doses of opioids
CONCLUSION
• Interventional pain management should
be considered with any pain condition
• Pain is most effectively treated with a
multi-disciplinary approach
• We should utilize all resources that are
available
SPINE ANATOMY
SPINE ANATOMY