Dr Asafu-Adjaye Frimpong Consultant Interventional Radiologist Interventional radiologic spinal pain management-A 7 year experience in Ghana Dr Asafu-Adjaye Frimpong Consultant Interventional Radiologist

introduction Chronic back pain is in the spectrum of neuropathic pain Affects a significant proportion of our aged population Affects productivity Financial implications Psychosocial effects

Categories of chronic backpain Non specific back pain Back pain associated with radiculopathy and stenosis Back pain referred from a non spinal source Back pain associated with another spinal cause

Mechanical from Spinal Degenerative disk disease and facet Herniated disk Spinal stenosis Traumatic fracture Osteoporotic fracture Congenital disease-scoliosis/kyphosis Spondylosis

Non Mechanical Spinal Neoplasia Metastatic carcinoma Primary vertebral tumours Multiple myeloma Infection Septic Diskitis with abscesses Osteomyelitis Osteochondrosis Pagets Disease of bone Inflammatory arthritis Ankylosisng spondylitis Reiter syndrome Psoriatic spondyloarthritis

Clinical Presentation Focal back pain-whole spine Radiculopathy Claudication Numbness and tingling Burning sensation

Evaluation History Physical Examination Labortory assessment Imaging Psychosocial issues

Management Pharmacological Non pharmacological Interventional Surgery

Therapeutic interventions CT guided nerve blocks CT guided Vertebroplasty CT guided tumor ablation CT guided percutaneous laser disc decompression (PLDD)

Interventional Pain management Intrathecal drug delivery Anesthetic nerve blocks Neurolysis Laser Disc Decompression Ozone therapy

Successes with thoracic and cervical in pain control is >90% over a 2 year period Less in lumbar region @ 70% Recurrence of pain related to age of patient, duration and severity of disease Generally a very safe and effective treatment for small and moderate prolapses without severe neurologic deficits Not done for patients with weakness in limbs or atrophy. Not very effective for treatment for numbness.

Discogenic Radiculopathy Common in the lumbar and Cervical Region Less common in the thoracic and Sacral regions Access usually epidural in the lumbar region as well as selective periradicular Cervical region usually extraforaminal periradicular Thoracic periradicular and transforaminal with epidural extension 3 dose regimen of 40mg triamcinolone and 1% bupivacaine with a weekly interval

Management Pharmacological Non pharmacological Interventional Surgery

Nerve Blocks Undertaken predominantly for pain resulting from discogenic radiculopathies For cancer related Pain For

Our 7 year experience in GH Interventional pain clinic Clinical evaluation Imaging Post treatment management and follow up

CT guided nerve blocks- 7 year experience CT guided percutaneous laser disc decompression- about 3years

CT guided nerve blocks About 4200 procedures involving about 1400 patients in 7 years were undertaken. Categories Age range 16-91yrs Comprises 55% Females and 45% males

Referral Pattern 80%-patient to patient referral 15% from clinicians 5% from health education and promotion

Clinical History Low back pain with or without radiculopathy Parathesias Numbness and tingling Claudication Spinalis Pain with weakness

locations Cervical-20% Thoracic-< 5% Lumbar 75% Sacrococygeal < 1%

procedure Planning scan Determination of trajectory Duration-10mins averagely Needle placement Confirmation of drug location and path with iodinated contrast or air Injection of kenalog

protocol CT guidance 3 X procedure seperated by 1 week interval Combination of macaine (bupivacaine) 0.25% and kenalog (triamcinolone) 40mg

Access Transforaminal cervical Epidural Periradicular Facettal Sacroiliac

Trajectory

Needle/contrast outline

Right periradicular transforaminal T 9 block with epidural extension

Efficacy and successes Defined as significant reduction of pain and symptoms more than 70% Cessation of oral medication. Short term up to 6 months Medium term . Up to 2 years Long term. More than 2 years

Short term- Almost 90% success rate Failure considered if symptoms remain the same 3 months after treatment Seen in patients with emotional and psychosocial issues severe or absolute stenosis Grade 2+ listhesis

Medium Term 70% Middle Age Moderate stenosis History – usually up to 12 months prior to treatment

Long term- > 50% Younger age Shorter duration of symptoms prior to onset of treatment Mild to moderate prolapsed disc sizes and stenosis

complications < 0.3% Procedural Medication induced

procedural Contrast Allergy Severe numbness Post dural puncture headache-blood patch employed for unresolving cases Acute back pain

Steroid Induced Poor glycaemic control Discoloration of the hands and sometimes skin Menstrual irregularities Weight gain Increased libido and performance

limitations Patients with severe or absolute stenosis Poorly treated diabets Patients with grade 2 + listhesis

Post intervention management Review 2 weeks, 6weeks 5months Physiotherapy Medication Bed rest for those presenting with acute pain

Conclusion CT guided nerve block is a very safe, very effective therapeutic intervention for patients suffering from discogenic radiculopathy. Limited efficacy in patients with very severe or absolute canal stenosis or grade 2+ listhesis Complications are very minimal and usully related to general effects of steroid