2. Contact Information Denis G. Patterson, DO Nevada Advanced Pain Specialists www.nvadvancedpain.com patterson@nvadvancedpain.com

3. Education and Training DO –Michigan State University College of Osteopathic Medicine (1998 – 2002) Pain Fellowship –Emory University (2006 – 2007) Residency –Mayo Clinic (2003 – 2006)

4. Certifications Board Certified, Pain Medicine (2007) Board Certified, Physical Medicine and Rehabilitation (2007)

6. Mechanical Low Back Pain Denis G. Patterson, DO Echo Project 11/18/2015

7. Introduction

8. Life expectancy continues to increase in the US > 65 year old age group grew by 30% between 1994 – 1999

9. Introduction Fear of the aging population is “having pain” Chances of having pain increase with each decade of life Pain leads to negative consequences for health, decreased function, and quality of life

10. Introduction Pain is one of the most common complaints for the > 65 year old age group when they visit the doctor The lumbar spine (low back) is a common area for pain

11. Basic Lumbar Spine Anatomy

15. Lumbar Arthritis AKA “Facet Joint Syndrome”

16. Facet Joint Syndrome It is a general term for age-related wear and tear affecting the facet joints Also known as lumbar osteoarthritis

17. Facet Joint Syndrome The condition usually appears in men and women older than 40 and progresses with age

18. Facet Joint Syndrome Causes: - Drying and loss of elasticity in the lumbar disks - Stiffening of the ligaments connecting bones and muscles

19. Facet Joint Syndrome Symptoms: - Low back, hip or buttock pain - Cramping lower extremity pain (usually not past the knee)

20. Facet Joint Syndrome Symptoms - Low back stiffness, especially in the morning - Pain with prolonged sitting or standing

21. Conservative Treatment Measures

22. Modalities Medications Physical Therapy Injections

23. Modalities Ice Heat TENS Massage Traction

24. Medications Tylenol NSAIDS Ultram Nerve pain medications Narcotics

25. Physical Therapy Goals: - Pain relief - Improve posture/biomechanics - Improve motion - Improve strength - Improve function - Resume regular activities

26. Facet Injections Gold standard for diagnosis of facet mediated spine pain Radiographic findings - joint space narrowing, hypertrophy, sclerosis, tropism Pain is not always related to radiographic findings

27. Facet Injections Two types of injections – Intra-articular joint injections –Medial branch blocks and radiofrequency ablation

28. How Do We Do These Procedures? Contrast-enhanced with fluoroscopic guidance. –May pre-medicate with prednisone and Benadryl if allergic. Used to ensure needle placement and proper medication flow. Safety. Question non-response in blind injections.

29. Facet Intra-Articular Injections Fluoroscopic localization. Use of contrast confirms intraarticular needle placement. Most common levels L4-L5, L5-S1. Inject anesthetic and steroid.

30. Medial Branch Block Similar results to intra-articular facet injection without entering the joint. Targets the medial branch of the dorsal primary ramus. Diagnoses pain originating from facet joint. Identifies patients who will benefit from radiofrequency ablation.

31. Medial Branch Block Performed as a series of 2 blocks. 1 st set of blocks are performed with 1 ml 1% preservative free lidocaine injected at each medial branch. –Provides 2-3 hours of relief 2 nd set of blocks performed with 1 ml 0.5% preservative free bupivacaine at each medial branch. –Relief lasts 4-6 hours. Positive response defined as 50% pain reduction.

32. Medial Branch Block

34. Radiofrequency Ablation (RF) Electrical current produced by a radio wave is used to to heat tip of needle and destroy medial branch and eliminate painful signal from facet joint. Procedure is similar to medial branch block except wire is placed through needle at target point instead of anesthetic. Medial branch is then lesioned for 120 seconds at 80 degrees. Provides 9-12 months of relief. –Nerve grows back with time.

35. Questions

36. Discussion