1. INTERVENTIONAL PAIN MANAGEMENT
DOMINICK LAGO JR., M.D.
Michigan Pain Management Consultants

2. INTERVENTIONAL PAIN MANAGEMENT
Definition: The use of invasive techniques to decrease or eliminate pain
This can be accomplished in three ways:
Interrupting the pain signal along a neural pathway
Neuroaugmentation (SCS, PNS)
Implantable drug delivery system

3. INJECTION THERAPY Trigger Point Injections Epidural
Facet Joint/Medial Branch Block
Sympathetic Chain Block

4. INJECTION THERAPY Usually performed utilizing fluoroscopy
No sedation vs conscious sedation
Can be therapeutic or diagnostic

5. TRIGGER POINT INJECTION
Trigger points are discrete, focal, hyper- irritable spots located in a taut band of skeletal muscle
The pain will be localized and or referred
Palpation of a hypersensitive bundle or nodule of muscle fiber of harder than normal consistency is the physical finding typically associated with a trigger point. Palpation of the trigger point will elicit pain directly over the affected area and/or cause radiation of pain toward a zone of reference.

6. TRIGGER POINTS
Treatment consists of release of the affected muscle or muscle groups
Stretching, physical therapy and ice have been utilized

7. TRIGGER POINTS
Injection therapy is also effective in both the acute and chronic presentations
“Dry” technique
Injection of local anesthetic with or without steroids

8. TRIGGER POINTS Injection Technique Identify the muscle via palpation
Using a 25 gauge needle and 0.5% Xylocaine
The needle is advance to the affected muscle
A twitch response is noted and then the local is injected (3-5 cc).

9. EPIDURAL
Injection performed to deposit medication into the epidural space in proximity to the spinal nerves
Can be utilized in the cervical, thoracic or lumbar region
Most effective for radicular pain into the arm or leg
Should be performed with fluoroscopy

10. EPIDURAL There are three approaches to the epidural space Interlaminar
Transforaminal
Sacral Hiatus (caudal)

11. SPINE ANATOMY

12. EPIDURAL Interlaminar injection
Performed in the midline, between the spinous processes at the affected level of pathology
Medication will spread cephalad, caudad and bilaterally

13. SPINE ANATOMY

14. EPIDURAL Transforaminal Injection
Performed lateral to the midline with a goal of depositing the medication near a specific nerve root in the neuroforamen
Has a higher complication rate due to the artery of Adamkiewicz
More effective for one sided, one level pathology

15. SPINE ANATOMY

16. EPIDURAL Caudal The epidural space is entered via the sacral hiatus
Most commonly utilized if there has been a previous spine surgery

17. SPINE ANATOMY

18. EPIDURAL
Pain conditions that may respond to epidural steroid injections
Herniated disc
Spinal stenosis
Post laminectomy syndrome
Spondylosis
Complex r

19. EPIDURAL
Pain conditions that may respond to epidural injections with local anesthetic
Diabetic Neuropathy
Complex Regional Pain Syndrome (RSD)
Post Herpetic Neuralgia

20. EPIDURAL ESI, how does it work?
When the spinal nerve is inflamed it becomes edematous. As it travels through the neuroforamen it becomes “pinched” which maintains the inflammation. After the steroids are injected, they reduce the inflammation, decreasing the diameter of the nerve, giving it more room in the foramen.

21. EPIDURAL
These injections may be repeated, but limited to three within six months.
Long term success is based on a multi- disciplinary approach, not just injection therapy

22. EPIDURAL
Sympathetic epidural injection is utilized for neuropathic pain syndromes (PHN, CRPS, etc)
These are local anesthetic injections that may be repeated many times in a series over a short period of time
The mechanism of action is to disrupt the pain transmission and allow the nerve impulse to revert to it’s usual state

23. MEDIAL BRANCH NERVE BLOCK AND RADIO FREQUENCY LESIONING
It is a synovial joint between the superior articular process and inferior articular process of two vertebra
The medial branch nerve derives from the corresponding spinal nerve transmitting sensory information from each joint
Disease of the facet joints is seen with aging
In simplest form, these changes are arthritic and degenerative
It produces axial pain, usually with activity

24. SPINE ANATOMY

25. MEDIAL BRANCH NERVE BLOCK AND RADIO FREQUENCY LESIONING
Facet joint injections used to be the treatment of choice for this condition
With new technologies and advanced imaging joint injections are rarely performed

26. MEDIAL BRANCH NERVE BLOCK AND RADIO FREQUENCY LESIONING
Prior to RF, the patient should undergo one or two diagnostic MBNBs with local anesthetic
They should have significant relief of their symptoms( 50% or greater), however, it will not be long lasting
Subsequent diagnostic blocks may be necessary as there is a contribution from the levels above and below

27. MEDIAL BRANCH NERVE BLOCK AND RADIO FREQUENCY LESIONING
Radio frequency lesioning or neurotomy is performed using a specialized machine to produce a radio wave to “burn” a specific nerve blocking the transmission of the painful impulse
The lesion should provide relief for 6-9 months
There is regeneration of the neural pathway which allows the pain to return
This procedure can be repeated

28. MEDIAL BRANCH NERVE BLOCK AND RADIO FREQUENCY LESIONING
Symptoms or conditions that may have a facet component
Headaches
Neck, mid or lower back pain
Post fusion neck or back pain

29. SYMPATHETIC BLOCKS
These blocks are performed when pain is neuropathic with a sympathetic component
The blocks interrupt the nerve transmission in a large area of the body
They are performed at the ganglion

30. SYMPATHETIC BLOCKS Stellate Ganglion Block
Performed by injecting 10 cc of local anesthetic in proximity to the stellate ganglion
Used to treat upper extremity pathology CRPS, PHN

31. SYMPATHETIC BLOCKS Celiac Plexus Block
Performed by injecting local anesthetic in proximity of the celiac plexus
Used to treat pathology of the abdomen
Should always be performed with imaging (CT Scan or fluoroscopy)

32. SYMPATHETIC BLOCKS Lumbar Paravertebral Sympathetic Block
Performed to treat neuropathic pain of the lower extremity

33. Post Operative Pain
Nerve blocks can be performed to manage post operative pain
Best used for extremity procedures
Shoulder - Interscalene
Hand - Supraclavicular/Axillary
Ankle - Sciatic (Popliteal)
Single shot~12-18 hours
Peripheral catheters may be used for several days with Ambit/On Q pump

34. Post Operative Pain Single shot nerve blocks (18 Hrs)
Peripheral nerve catheters (3 Days)
Epidural

35. Post Operative Pain Epidural Thoracic - Thoracotomy
Abdominal - Exploratory laparotomy

36. NEUROAUGMENTATION
Spinal Cord Stimulation (SCS) and Peripheral Nerve Stimulation (PNS) are technologies that are available for patients that have not responded to the previous modalities
They require the implantation of lead(s) and a battery generator
SCS lead(s) are placed into the epidural space
PNS lead(s) are placed in the subcutaneous tissue

37. NEUROAUGMENTATION
SCS works by having a low voltage electrical stimulation to block the pain transmission via the dorsal column tracts of the spinal cord
It can be utilized for cervical, thoracic or lumbar symptoms
More effective for extremity than truncal symptoms

38. NEUROAUGMENTATION
PNS is utilized to provide pain relief over a peripheral nerve distribution
The lead(s) are place along the course of peripheral nerves
May be effective for occipital headaches, inguinal neuralgia, intercostal neuralgia

39. INTRATHECAL THERAPY
An implanted infusion delivery system that delivers a precise amount of medication into the spinal fluid via an infusion pump and catheter
Baclofen (spasticity) and Morphine (pain) are the two most common medications delivered through this modality

40. INTRATHECAL THERAPY Who is a candidate for this therapy?
Failed all previous modalities
Medication requirements have produced intolerable side effects
Patients who cannot achieve adequate pain control even with high doses of opioids

41. CONCLUSION
Interventional pain management should be considered with any pain condition
Pain is most effectively treated with a multi-disciplinary approach
We should utilize all resources that are available

42. SPINE ANATOMY

43. SPINE ANATOMY