Download Ultrasound Guided Pain Management

INTERVENTIONAL PAIN
MANAGEMENT FOR LBP
Dr. dr. Yusak M.T. Siahaan, Sp.S, FIPP
Siloam Hospital Lippo Village/ Medical Faculty Pelita Harapan University
What is Pain?
Pain is an unpleasant sensory and/or
emotional experience associated with
actual or potential tissue damage, or
described in terms of such damage.
(International Association for the Study of Pain)
“Traditional” Biological model
of pain
Injury
- Nociception
- Neuropathy
Pain
Impact on activity, mood
Treatment implications?
Nociception
or
neuropathy
Pain-free
Normal activity & mood restored
(e.g. Bogduk N. Management of chronic low back pain. Med J Aust 2004; 180 (2): 79-83)
Pharmacologic Control of Pain
WHO Pain Ladder
http://erlewinedesign.com/end-of-life-care/gfx/who_ladder.gif
Treatment of Pain
Recovery
Operation
Strong
opioids
Weak
opioids +/non-opioids
Nonopioids
Non-pharmacological
methods
World of Misery
Treatment of Pain
Recovery
Operation
Strong
opioids
Weak
opioids +/non-opioids
Nonopioids
Non-pharmacological
methods
Interventional Pain Management
 The discipline of medicine devoted to the diagnosis and
treatment of pain and related disorders by the
application of interventional techniques in managing
sub-acute, chronic, persistent, and intractable pain,
independently or in conjunction with other modalities of
treatments.
Interventional Pain Management
 Minimally invasive procedures including percutaneous
precision needle placement, with placement of drugs in
targeted areas or ablation of targeted nerves.
IPM are group of procedures
with different mechanism of
actions
1. Targeted delivery of drugs
2. Blocking of nerve signals corrects
neuropathy.
Therapeutic IPM procedures
 Trigeminal nv. Block at ganglion or
branch
 Spheno-palatine ganglion block
 Glosso-pharyngeal nerve block
 Stellate ganglion block
 Thoracic sympathetic block
 Celiac Plexus block
 Superior Hypogastric plexus block
 Ganglion Impar block
104 patients low back pain without any identifiable cause
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Facet joint(s) disease in 24%
Lumbar nerve root and facet disease in 24%
Facet(s) and sacroiliac joint(s) in 4%
Lumbar nerve root irritation in 20%
Disc disorder in 7%
Sacroiliac joint in 6%
Sympathetic dystrophy in 2%
No cause was identified in 13%
Ref: Pang WW et al. Application of spinal pain mapping in the diagnosis
of low back pain—analysis of 104 cases. Acta Anaesthesiol Sin 1998;
36:71-74.
Area of pain : Low Back
120 patients low back pain without any identifiable
cause
 Facet joint pain in 40%,
 Discogenic pain in 26%,
 Sacroiliac joint pain in 2%,
 Segmental dural/ nerve root pain in 13%
 No cause was identified in 19%
Ref: Manchikanti L et al. Evaluation of the relative contributions of various
structures in chronic low back pain. Pain Physician 2001; 4:308-316.
Diagnostic IPM procedures
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Diagnostic nerve block
Facet joint block
Provocative discography
Epidurogram, epiduroscopy
Selective nerve root block
SI joint block
Sympathetic Nv. Block
Discogenic

Pain :
Young and Aprill 2000, Young et al 2003
 Characteristics associated with disc
pain:
 Pain at or above L5
 Obstruction to movement
 Change in loss of movement with
repeated movements
 Centralisation / peripheralisation
 Pain rising from sitting
MRI : High Intensity
Zone
Carragee 2005, NEJM
Discogenic pain : management
 Treatment
 Medication
 Functional restoration
 Intradiscal Electrothermal Therapy (IDET)
 Lumbar fusion
Management : Medication
 Analgesics
 NSAIDS (mechanism of pain relief unclear)
 Tylenol, Tramadol
 Opioids (time contingent use most effective)
 Anti-inflammatories
 NSAID’s (consider side effects)
 Corticosteroids (consider side effects)
 Muscle relaxants
Discography
 Provocative test
 Injection of contrast directly
into disc
 Localizes source of back pain
 Positive Test: A concordant
pain pattern (reproduction of
“usual” typical pain)
 Very controversial
Lumbar Discography
Fluoroscopic placement of needles
Discography : Interpretation
Sacroiliac Joint Pain
The typical pain of the SIJ is deep, intense, variable low back and buttock pain, which may refer pain, numbness, and
tingling in various patterns down the leg. It may be constant, or vary with position and movement
SI Joint :
Anatomy
The sacroiliac articulation is an amphiarthrodial joint, formed between the auricular surfaces of the sacrum and the
ilium. The articular surface of each bone is covered with a thin plate of cartilage. They are separated by a space
containing a synovial-like fluid; hence, the joint presents the characteristics of a diarthrosis. The ligaments
surrounding the joint are the interosseous ligament and the anterior and posterior SI ligaments.
SI Joint Anatomy Injection USGGuided
SI Joint Anatomy USG
Injection
Sacroiliac Joint Injection Carm
Guided
Sacroiliac Joint Injection Carm
Guided
Sacroiliac Joint Injection Carm
Guided
needle
Piriformis Syndrome Pain
Piriformis Syndrome :
Introduction
• Approximately 6%-8% of low back
pain can be attributed to the
piriformis syndrome, which remains
a diagnosis of exclusion,
• Piriformis syndrome is considered
by many clinicians as a condition in
which muscle physically irritates the
sciatic nerve because of muscle
strain, overuse, or
anatomic
anomaly.
• Persons with this syndrome often
present with ipsilateral numbness,
tingling, and pain in the buttocks,
thigh, and leg, resembling features of
sciatica.
Piriformis Syndrome: Anatomy
The piriformis muscle lies deep in the gluteus maximus.1 Originating from the anterior aspect of
the sacrum and inserting into the upper border of the greater trochanter, its contraction causes an
abduction and lateral rotation of the thigh.
Piriformis Muscle:
Anatomy
Ultrasound-Guided Piriformis Muscle
: Scanning
Transverse ultrasound view of the sciatic nerve.
Longitudinal ultrasound view of the piriformis muscle
Ultrasound-Guided Piriformis Muscle
Injection Technique
A curvilinear transducer is placed in a transverse
orientation to first identify the sacral cornuae and is then
moved toward the greater trochanter until the lateral edge
of the sacrum is observed. The transducer is moved
further laterally until the greater trochanter and ilium are
both observed .
The piriformis muscle will appear as a hyperechoic band lying
between the lateral edge of the sacrum and the greater trochanter
and deep in the gluteus maximus muscle. The sciatic nerve appears as
an oval-shaped hypoechoic structure lying deep in the piriformis
muscle
Fishman LM, Dombi GW, Michaelsen C, et al: Piriformis syndrome: Diagnosis, treatment, and outcome-a 10-year study. Arch Phys Med
Rehabil 2002;83:295-301
Ultrasound-Guided Piriformis Muscle
: Scanning
Ultrasound-Guided Piriformis
Muscle Injection
Piriformis Injection C Arm
Guided
The piriformis muscle lies deep in the gluteus maximus.1 Originating from the anterior aspect of
the sacrum and inserting into the upper border of the greater trochanter, its contraction causes
an abduction and lateral rotation of the thigh.
Herniated Disc pain
 A herniated lumbar disc can press on the nerves in the
spine and may cause pain, numbness, tingling or
weakness of the leg called "sciatica." Sciatica affects
about 1-2% of all people, usually between the ages of 30
and 50.
 A herniated lumbar disc may also cause back pain,
although back pain alone (without leg pain) can have
many causes other than a herniated disc.
Herniated Disc pain :
symptoms
 Low Back to lower leg
 Sharp, shooting or burning pain
 Decreased with standing : increased with
bending or sitting
 Positive straight leg raise test
Herniated Disc pain :
symptoms
Herniated Disc : Transforaminal Epidural
Steroid Injection
• Consists of a mixture of saline,
local anesthetic and the long
acting steroid
• The long acting steroid reduces
the inflammation and swelling of
spinal nerve roots and other
tissues surrounding the spinal
nerve root
Transforaminal Epidural Steroid
Transforaminal Epidural
Steroid
Intralaminal Epidural Steroid
Injection
45
Intralaminal Epidural Steroid Injection
46
Intralaminal Epidural Steroid Injection
47
EPIDURAL CAUDAL INJECTION
Epidural Caudal Injection

Epidural administration of corticosteroids is one
of the commonly used interventions in
managing chronic low backpain . The lumbar
epidural space is accessible eitherby caudal,
interlaminar, or transforaminal routes . Reports
of the effectiveness of all types of epidural
corticosteroids
irrespective
of
route
administration have varied from 18% to 90%
of
Epidural Caudal Injection :
Anatomy
 The philosophy of epidural steroid
injections is based on the premise
that the corticosteroid delivered
into the epidural space attains
higher local concentrations over
an inflamed nerve root and will be
more effective than a steroid
administered either orally or by
intramuscular
 pain relief outlasting by hours,
days, and sometimes
 Caudal
epidurals
have
been
described as very effective, with
easy entry without dural puncture.
Epidural Caudal Injection USGGuided
Epidural Caudal Injection USGGuided
The transducer was placed transversely on the sacral hiatus and checked intercornual distance, thickness of sacrococcygeal
membrane, depth of caudal space. (A) Photo, (B) Ultrasound finding.
Heunguyn Jung, M.D., Dae Hee Kim, M.D., Seong Hun Jeon, M.D., The Effectiveness of Ultrasound Guidance in Caudal Epidural Block J
Korean Soc Spine Surg. 2013 Dec;20(4):178-183
Epidural Caudal USG-Guided
Injection
The transducer was rotated 90 degrees to obtain the longitudinal view of sacral hiatus. (A) Photo, (B) Ultrasound
finding.
Epidural Caudal Injection USGGuided
Epidural Caudal Injection
USG-Guided
Needle was inserted to caudal epidural space under ultrasound guidance. (A) Photo, (B) Ultrasound
finding.
Epidural Caudal Injection USGGuided
Epidural Caudal Injection C Arm Guided
57
Epidural Caudal Injection C Arm Guided
Epidural Caudal Injection C Arm Guided
58
Facet Joint Pain : Background

Facet joints responsible for spinal pain
in 15% to 45% of patients with low
back pain ,

Manchikanti L, et al (2004) : 54% to
67% of patients with neck pain, and
42% to 48% of patients with thoracic
pain

Mostly remains undiagnosed with
CT/MRI
Facet Joint Pain Pattern
• Most patients will have a persisting
point
tenderness
overlying
the
inflamed facet joints and some
degree of loss in the spinal muscle
flexibility
• Low back pain from the facet joints
often
radiates
down
into
the
buttocks and down the back of the
upper leg. The pain is rarely present
in the front of the leg, or rarely
radiates below the knee or into the
foot, as pain from a disc herniation
often does.
Facet Joint pain : treatment
 Postural Rehabilitation
 Anti-inflamatory drugs
 Intervetebral Differential Dynamics (IDD)
 Therapeutic injections
 Facet joint injection
 Medial Branch block
Ultrasound-Guided Lumbar Facet
Nerve Blocks
Longitudinal facet views were obtained by curved tranducer to identify the different
spinal segments (A), longitudial facet view by ultrasound showed L3-4, L4-5, and L5S1 facet joints (B).
Facet Joint Pain:
Anatomy
Ultrasound-Guided Lumbar Facet
Nerve Blocks
Needle insertion between the superior articular process and on the upper edge of
the transverse process.SP: Spinous process, FJ: Facet joint, TP: Transverse process.
Facet Joint Injection C Arm
Guided
Radiofrequency Ablation