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