1. 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

2. 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

3. 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

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

5. 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

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

7. Evaluation History Physical Examination Labortory assessment Imaging
Psychosocial issues

8. Management
Pharmacological
Non pharmacological
Interventional
Surgery

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

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

11. Successes with thoracic and cervical in pain control is >90% over a 2 year period
Less in lumbar 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.

12. 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

13. Management
Pharmacological
Non pharmacological
Interventional
Surgery

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

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

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

17. 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

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

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

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

21. 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

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

23. Access Transforaminal cervical Epidural Periradicular Facettal
Sacroiliac

25. Trajectory

26. Needle/contrast outline

27. Right periradicular transforaminal T 9 block with epidural extension

28. 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

29. 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

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

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

32. complications
< 0.3%
Procedural
Medication induced

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

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

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

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

37. 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