Chiropractic & Pain Case Studies Advances In Interventional Pain Management Omid Ghalambor, MD, DABA, FIPP, DABIPP, DABPM Chiropractic & Pain Case Studies 2/16/17 Brett Stephens, DC Omid Ghalambor, MD
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Case 1 28 year Supervisor Auto body repair shop Initial consultation 10/27/16 Found us by “Google search” Chief Complaint “Low Back Pain”
Case 1 Reported pain being there on and off for about a year Started without any known trigger event Worsened since 3-4 months prior Saw Dr. K in Allen for three months to get Airrosti treatments
Case 1 Pain was reported as Sharp in the low back, constant, occasionally radiating to both legs Worse with sitting, driving, standing up holding his daughter. Had tried Ibuprofen and Massage in addition to Airrosti treatments.
Case 1 Upon Exam he was unable to sit comfortably. Rated the pain as 9/10. Pain upon percussion of the low lumbar region. Normal neurological exam.
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Case 1 Prescribed muscle relaxant (Flexeril) 10 mg po qhs and hydrocodone 7.5-325 mg po tid prn.
Interlaminar Epidural Steroid Injection
Transforaminal Epidural Steroid Injection
Case 1 First Lumbar Bilateral L5-S1 Transforaminal Epidural Steroid Injection 11/01/2016 > 30% Relief Second Lumbar Bilateral L5-S1 Transforaminal Epidural Steroid Injection 11/29/2016 > 50% Relief Third Lumbar Bilateral L5-S1 Transforaminal Epidural Steroid Injection 12/27/2016 > 70% Relief
Case 1 Pain is now “Tolerable” Patient referred to Dr. Mills Chiropractor to start chiropractic therapy with adjustments and physical therapy.
Case 1 Emphasized importance of ongoing adjustments and physical therapy No follow up with Pain needed
Case 1 Happy camper No PCP > Spine Surgeon > Surgery > More problems down the road No High Dose Narcotics > Dependence > Addiction > Impact of life/ Job
Case 1 What if Patient’s symptoms continue?
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Case 1 Lumbar Facet blocks (Diagnostic)
Facet Joint Injection
Case 1 Discography
Case 1 Discography
Case 1 Discography
Case 1 Discography
Surgical Options
Adjacent level disease
Down the Road…
Case 1 What are the options for Disc related (Discogenic) pain other than fusion surgery?
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Thermal Annuloplasty Endoscopic
Case 1 Intradiscal Plasma Rich Protein (PRP) Injection
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Case 1 Annular injection of Fibrin Sealant
Case 1 Evidence?
Case 2
Case 2 65 year old female Referred by Dr. Morgan Spine Surgeon for a “Cortisone Injection” Complaining of severe Neck Pain on the left Max 8/10 VAS
Case 2 Past Medical History positive for low back pain under care of local Chiropractor in McKinney with great response. Depression, GERD, Migraines, High Cholesterol
Case 2 After patient’s back pain responded well to chiropractic care, she started getting adjustments on her neck. After two sessions of adjustments, patient’s neck pain worsened to the point that she needed to go to the ED.
Case 2 At the ED, X-ray of the cervical spine was performed and was negative for any “Red Flags” Patient was discharged with NSAIDs, flexeril and hydrocodone. She was then referred to Dr. Morgan spine surgeon and MRI of the Cervical Spine was ordered.
Case 2
Case 2 No indication for surgery based on imaging and normal neurological exam Surgeon suggested a Cervical epidural steroid injection
Case 2 Upon exam, cervical facet loading on the left was extremely painful. Palpation of the cervical facet joints was also uncomfortable.
Case 2 Patient was scheduled for fluoroscopic guided cervical facet joint injection both for diagnostic and therapeutic purposes
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Case 2 Patient was recommended to return back to her chiropractor for continued adjustments, keep working on her alignment as well as therapy for best long term outcome.
Case 2 What if patient’s “Migraine” headaches go away after cervical facet injections?
Cervicogenic headaches Case 2 Cervicogenic headaches
Cervicogenic headaches C2-3 Update Case 2 Cervicogenic headaches C2-3 Update
Cervicogenic headaches Case 2 Cervicogenic headaches
Case 2 What if the patient continues to have pain from the facet joints despite series of injections and chiropractic care?
Cervical Facet Radiofrequency Neurotomy
Thank you! Questions?