dr. dr. yusak m.t. siahaan, sp.s, fipp siloam hospital lippo village/ medical faculty pelita harapan...

Dr. dr. Yusak M.T. Siahaan, Sp.S, FIPPSiloam Hospital Lippo Village/ Medical Faculty Pelita Harapan University

What is Pain?

Pain is an unpleasant sensory and/or

emotional experience associated with

actual or potential tissue damage, or

described in terms of such damage. (International Association for the Study of Pain)

“Traditional” Biological model of pain

Injury

- Nociception

- Neuropathy Pain

Impact on activity, mood

Treatment implications?

Pain-freeNocicepti

onor

neuropathy

Normal activity & mood restored

(e.g. Bogduk N. Management of chronic low back pain. Med J Aust 2004; 180 (2): 79-83)

Pharmacologic Control of Pain WHO Pain Ladder

http://erlewinedesign.com/end-of-life-care/gfx/who_ladder.gif

Non-opioids

Weak opioids +/- non-opioids

Strong opioids

Recovery

Operation

Treatment of Pain

World of Misery Non-pharmacological methods

Non-opioids

Weak opioids +/- non-opioids

Strong opioids

Recovery

Operation

Treatment of Pain

Non-pharmacological methods

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.

Interventional Pain Management

Interventional Pain Management

Minimally invasive procedures including percutaneous

precision needle placement, with placement of drugs in

targeted areas or ablation of targeted nerves.

IPM are group of procedures with different mechanism of

actions

1. Targeted delivery of drugs

2. Blocking of nerve signals corrects neuropathy.

Therapeutic IPM procedures

Trigeminal nv. Block at ganglion or branch

Spheno-palatine ganglion block Glosso-pharyngeal nerve block Stellate ganglion block Thoracic sympathetic block Celiac Plexus block Superior Hypogastric plexus

block Ganglion Impar block

104 patients low back pain without any identifiable cause

Facet joint(s) disease in 24% Lumbar nerve root and facet disease

in 24% Facet(s) and sacroiliac joint(s) in 4% Lumbar nerve root irritation in 20% Disc disorder in 7% Sacroiliac joint in 6% Sympathetic dystrophy in 2% No cause was identified in 13%

Ref: Pang WW et al. Application of spinal pain mapping in the diagnosis of low back pain—analysis of 104 cases. Acta Anaesthesiol Sin 1998; 36:71-74.

Area of pain : Low Back

120 patients low back pain without any identifiable cause

Facet joint pain in 40%, Discogenic pain in 26%, Sacroiliac joint pain in 2%, Segmental dural/ nerve root pain in

13% No cause was identified in 19%

Ref: Manchikanti L et al. Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician 2001; 4:308-316.

Diagnostic IPM procedures

Diagnostic nerve block Facet joint block Provocative discography Epidurogram, epiduroscopy Selective nerve root block SI joint block Sympathetic Nv. Block

Discogenic Pain :

Young and Aprill 2000, Young et al 2003

Characteristics associated with disc pain:

Pain at or above L5 Obstruction to movement Change in loss of movement with

repeated movements Centralisation / peripheralisation Pain rising from sitting

MRI : High Intensity Zone

Carragee 2005, Carragee 2005, NEJMNEJM

Discogenic pain : management Treatment

Medication Functional restoration Intradiscal Electrothermal Therapy

(IDET) Lumbar fusion

Management : Medication

Analgesics NSAIDS (mechanism of pain relief

unclear) Tylenol, Tramadol Opioids (time contingent use most

effective) Anti-inflammatories

NSAID’s (consider side effects) Corticosteroids (consider side effects)

Muscle relaxants

Discography

Provocative test

Injection of contrast

directly into disc

Localizes source of back

pain

Positive Test: A concordant

pain pattern (reproduction

of “usual” typical pain)

Very controversial

Lumbar Discography

Fluoroscopic placement of needles

Discography : Interpretation

Sacroiliac Joint Pain

The typical pain of the SIJ is deep, intense, variable low back and buttock pain, which may refer pain, numbness, and tingling in various patterns down the leg. It may be constant, or vary with position and movement

SI Joint : Anatomy

The sacroiliac articulation is an amphiarthrodial joint, formed between the auricular surfaces of the sacrum and the ilium. The articular surface of each bone is covered with a thin plate of cartilage. They are separated by a space containing a synovial-like fluid; hence, the joint presents the characteristics of a diarthrosis. The ligaments surrounding the joint are the interosseous ligament and the anterior and posterior SI ligaments.

SI Joint Anatomy Injection USG-Guided

SI Joint Anatomy USG Injection

Sacroiliac Joint Injection Carm Guided

Sacroiliac Joint Injection Carm Guided

Sacroiliac Joint Injection Carm Guided

needle

Piriformis Syndrome Pain

Piriformis Syndrome : Introduction• Approximately 6%-8% of low

back pain can be attributed to the piriformis syndrome, which remains a diagnosis of exclusion,

• Piriformis syndrome is considered by many clinicians as a condition in which muscle physically irritates the sciatic nerve because of muscle strain, overuse, or anatomic anomaly.

• Persons with this syndrome often present with ipsilateral numbness, tingling, and pain in the buttocks, thigh, and leg, resembling features of sciatica.

Piriformis Syndrome: Anatomy

The piriformis muscle lies deep in the gluteus maximus.1 Originating from the anterior aspect of the sacrum and inserting into the upper border of the greater trochanter, its contraction causes an abduction and lateral rotation of the thigh.

Piriformis Muscle: Anatomy

Ultrasound-Guided Piriformis Muscle : Scanning

Transverse ultrasound view of the sciatic nerve.

Longitudinal ultrasound view of the piriformis muscle

Ultrasound-Guided Piriformis Muscle Injection Technique

A curvilinear transducer is placed in a transverse orientation to first identify the sacral cornuae and is then moved toward the greater trochanter until the lateral edge of the sacrum is observed. The transducer is moved further laterally until the greater trochanter and ilium are both observed .

The piriformis muscle will appear as a hyperechoic band lying between the lateral edge of the sacrum and the greater trochanter and deep in the gluteus maximus muscle. The sciatic nerve appears as an oval-shaped hypoechoic structure lying deep in the piriformis muscle

Fishman LM, Dombi GW, Michaelsen C, et al: Piriformis syndrome: Diagnosis, treatment, and outcome-a 10-year study. Arch Phys Med Rehabil 2002;83:295-301

Ultrasound-Guided Piriformis Muscle : Scanning

Ultrasound-Guided Piriformis Muscle Injection

Piriformis Injection C Arm Guided

The piriformis muscle lies deep in the gluteus maximus.1 Originating from the anterior aspect of the sacrum and inserting into the upper border of the greater trochanter, its contraction causes an abduction and lateral rotation of the thigh.

Herniated Disc pain

A herniated lumbar disc can press on the nerves in the spine and may cause pain, numbness, tingling or weakness of the leg called "sciatica." Sciatica affects about 1-2% of all people, usually between the ages of 30 and 50.

A herniated lumbar disc may also cause back pain, although back pain alone (without leg pain) can have many causes other than a herniated disc.

Herniated Disc pain : symptoms Low Back to lower leg Sharp, shooting or burning pain Decreased with standing : increased

with bending or sitting Positive straight leg raise test

Herniated Disc pain : symptoms

Herniated Disc : Transforaminal Epidural Steroid Injection

• Consists of a mixture of saline,

local anesthetic and the long

acting steroid

• The long acting steroid reduces

the inflammation and swelling of

spinal nerve roots and other

tissues surrounding the spinal

nerve root

Transforaminal Epidural Steroid

Transforaminal Epidural Steroid

45

Intralaminal Epidural Steroid Injection

46

Intralaminal Epidural Steroid Injection

47

Intralaminal Epidural Steroid Injection

Epidural Caudal Injection

Epidural administration of

corticosteroids is one of the commonly

used interventions in managing

chronic low backpain . The lumbar

epidural space is accessible eitherby

caudal, interlaminar, or transforaminal

routes . Reports of the effectiveness of

all types of epidural corticosteroids

irrespective of route of administration

have varied from 18% to 90%

Epidural Caudal Injection : Anatomy The philosophy of epidural

steroid injections is based on

the premise that the

corticosteroid delivered into

the epidural space attains

higher local concentrations

over an inflamed nerve root

and will be more effective than

a steroid administered either

orally or by intramuscular pain relief outlasting by hours,

days, and sometimes

Caudal epidurals have been

described as very effective,

with easy entry without dural

puncture.

Epidural Caudal Injection USG-Guided

Epidural Caudal Injection USG-Guided

The transducer was placed transversely on the sacral hiatus and checked intercornual distance, thickness of sacrococcygeal membrane, depth of caudal space. (A) Photo, (B) Ultrasound finding.

Heunguyn Jung, M.D., Dae Hee Kim, M.D., Seong Hun Jeon, M.D., The Effectiveness of Ultrasound Guidance in Caudal Epidural Block J Korean Soc Spine Surg. 2013 Dec;20(4):178-183

Epidural Caudal USG-Guided Injection

The transducer was rotated 90 degrees to obtain the longitudinal view of sacral hiatus. (A) Photo, (B) Ultrasound finding.

Epidural Caudal Injection USG-Guided

Epidural Caudal Injection USG-Guided

Needle was inserted to caudal epidural space under ultrasound guidance. (A) Photo, (B) Ultrasound finding.

Epidural Caudal Injection USG-Guided

57

Epidural Caudal Injection C Arm Guided

58

Epidural Caudal Injection C Arm Guided

Epidural Caudal Injection C Arm Guided

Facet Joint Pain : Background

Facet joints responsible for spinal

pain in 15% to 45% of patients

with low back pain ,

Manchikanti L, et al (2004) : 54%

to 67% of patients with neck pain,

and 42% to 48% of patients with

thoracic pain

Mostly remains undiagnosed with

CT/MRI

Facet Joint Pain Pattern

• Most patients will have a persisting

point tenderness overlying the

inflamed facet joints and some

degree of loss in the spinal muscle

flexibility

• Low back pain from the facet joints

often radiates down into the buttocks

and down the back of the upper leg.

The pain is rarely present in the front

of the leg, or rarely radiates below

the knee or into the foot, as pain

from a disc herniation often does.

Facet Joint pain : treatment

Postural Rehabilitation

Anti-inflamatory drugs

Intervetebral Differential Dynamics (IDD)

Therapeutic injections

Facet joint injection

Medial Branch block

Ultrasound-Guided Lumbar Facet Nerve Blocks

Longitudinal facet views were obtained by curved tranducer to identify the different spinal segments (A), longitudial facet view by ultrasound showed L3-4, L4-5, and L5-S1 facet joints (B).

Facet Joint Pain: Anatomy

Ultrasound-Guided Lumbar Facet Nerve Blocks

Needle insertion between the superior articular process and on the upper edge of the transverse process.SP: Spinous process, FJ: Facet joint, TP: Transverse process.

Facet Joint Injection C Arm Guided

Radiofrequency Ablation