1. 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

2. Case 1

3. 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

4. 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

5. Case 1
MRI of the cervical spine was ordered

6. Case 1

7. Case 1

8. Case 1

9. Case 1

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

11. 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

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

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

14. Case 1
Happy camper 
No PCP > Spine Surgeon > Surgery > More problems down the road
No High Dose Narcotics > Dependence > Addiction > Impact of life/ Job

15. Case 1
What if Patient’s left arm pain improved but she continued to have neck Pain?

16. Case 1

17. Case 1

18. Cervical Facet Radiofrequency Neurotomy

19. Case 2

20. 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

21. 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

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

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

24. Case 2

25. Case 2

26. Case 2

27. Case 2

28. Case 2

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

30. Interlaminar Epidural Steroid Injection

31. Transforaminal Epidural Steroid Injection

32. 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

33. Disc Herniations Unresponsive to Injections

34. Old Approach: Open Laminectomy & Discectomy

35. New Approach: Minimally Invasive

36. New Approach: Ultra Minimally Invasive

37. 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

38. Laminectomy > Instability

39. Instrumentation for Stability

40. Adjacent level disease

41. Down the Road…

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

43. Thermal Annuloplasty Endoscopic

44. 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”

45. 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.

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

47. Thank you!
Questions?