Chiropractic & Pain Case Studies Advances In Interventional Pain Management Omid Ghalambor, MD, DABA, FIPP, DABIPP, DABPM Chiropractic & Pain Case Studies 1/19/17 Brett Stephens, DC Omid Ghalambor, MD

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Case 1 42 year old psychologist Started Chiropractic care 03/03/16 Complaining of on going neck, upper thoracic pain of about a month duration Pain increased by sitting and computer use Initial Pain resolved by 03/28/16 after 6 visits and then started monthly treatments with good results and minimal reported pain

Case 1 On 10/21/2016 (7 months after first visit) patient reported new increased pain in the cervical spine. Pain was reported as severe, shooting, sharp and stabbing rated 9/10 Reported recent cold with lots of coughing and sneezing a week prior Patient further reported new pain shooting down to the left shoulder and left arm Worse with sitting for long period of time Better with Ice, laying down

Case 1 MRI of the cervical spine was ordered

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Case 1 Prescribed muscle relaxant (Flexeril) 10 mg po qhs and hydrocodone 5-325 mg po tid prn.

Case 1 First Cervical Epidural Steroid Injection 11/15/2016 combined with continued chiropractic therapy > 70% to 80% relief of neck and left arm pain

Case 1 Second Cervical Epidural Steroid Injection 12/13/2016 combined with continued chiropractic therapy > 99% relief of neck and left arm pain

Case 1 Emphasized importance of ongoing adjustments and physical therapy No follow up with Pain needed Keeps seeing Dr. Stephens

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 left arm pain improved but she continued to have neck Pain?

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Cervical Facet Radiofrequency Neurotomy

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Case 2 57 year old Male originally from NJ currently resident of McKinney 5 year history of Low back, Left buttock and occasional Left leg pain

Case 2 Patient had tried: Chiropractic care on and off for about 5 years > Short term relief NSAIDs, Tylenol, Low Dose Narcotics > Minimal Relief Massage therapy >Minimal Relief Physical Therapy > Minimal Relief Series of three Epidural Steroid Injection by another provider in Allen > Minimal Relief

Case 2 Patient saw a spine surgeon in Allen who did not recommend surgery as the MRI “did not look that bad”

Case 2 First visit 10/28/2016 Normal neurological exam Positive straight leg raise test at 15 degrees on the left side.

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Case 2 Left L5-S1 Annular tear as shown on the T2 sequence by a High Intensity Zone (HIZ)

Interlaminar Epidural Steroid Injection

Transforaminal Epidural Steroid Injection

Case 2 Patient reported 70% relief only for a day relief of pain from Left L5-S1 transforaminal epidural steroid injection 11/01/2016 He reported No improvement upon follow up on 11/17/2016

Disc Herniations Unresponsive to Injections

Old Approach: Open Laminectomy & Discectomy

New Approach: Minimally Invasive

New Approach: Ultra Minimally Invasive

Advantages Less: Trauma to muscles, ligaments Bone resection>Iatrogenic Instability>Need for instrumented fusion Epidural fibrosis Bleeding Faster recovery/ Less Postop Pain Doesn’t “burn any bridges” for future revision Could be done without GA in high risk patients Elderly Morbidly Obese

Laminectomy > Instability

Instrumentation for Stability

Adjacent level disease

Down the Road…

New Approach: Ultra Minimally Invasive The size of a #2 pencil

Thermal Annuloplasty Endoscopic

Case 2 Patient underwent Left L5-S1 endoscopic discectomy and annuloplasty on 11/29/2016. Upon follow up on 01/06/2017 patient reported 70% relief of his pain. “The best he has felt in 5 years”

Case 2 Patient was released back to follow up with his Chiropractor to continue adjustments and therapy. Would like us to now focus on his shoulder.

Case 2 What if he wants the remaining back pain gone?

Thank you! Questions?