Should I order an injection or let the specialist do it? – Part 1
- 1. Pain Management of the Spine Image Guided Procedures Dr Brendan Moore Dr Greg Cowderoy
- 2. IMAGING GUIDANCE FOR BACK PAIN MANAGEMENT • CT (CT fluoroscopy) – Nerve sheath block – Epidural injections – Facet joint injection – Medial branch block • RF ablation – SI joint injection • Fluoroscopy – Discography – Vertebroplasty
- 3. BACK PAIN AND THE RADIOLOGIST • IMAGING GUIDANCE FOR PAIN MANAGEMENT • BACK PAIN MANAGEMENT PROCEDURES – Diagnostic test – Pre-operative control of symptoms – Palliation of non-surgical cases – Definitive treatment
- 4. MR LUMBAR SPINE Clinical details: 54M. Left leg pain, paresthesia and weakness. Sequences: T1, T2 transverse and sagittal Findings: Conclusion: Multilevel disc degeneration. Spondylolisthesis at L5/S1 with associated degenerative changes. The most significant lesion is a large left central disc extrusion at the L4/5 level displacing the left L5 and S1 nerve roots. A left L5 nerve root block should be considered. Facet joint injections could also be performed
- 5. BACK PAIN MANAGEMENT PROCEDURES • Selective nerve sleeve block • Facet joint block • Medial branch block + RF ablation • Sacroiliac joint block • Discography • Vertebroplasty
- 6. SELECTIVE NERVE ROOT BLOCK INDICATIONS • No definite imaging findings • Multilevel imaging findings • Equivocal neurological examination • Temporary pain relief • Not suitable for surgery
- 7. SELECTIVE NERVE ROOT BLOCK • Marcaine (1-3ml) • Dexamethasone 1 ml • Needle tip in/on nerve root sleeve NOT in the nerve • Concordant pain • Sensory block +/- motor weakness • Diagnostic and therapeutic
- 8. L5 NERVE SLEEVE INJECTION
- 9. S1 NERVE SLEEVE INJECTION
- 10. C6 NRB
- 11. BACK PAIN MANAGEMENT PROCEDURES • Pharmacology • Selective nerve sleeve block • Facet joint block • Medial branch block + RF ablation • Sacroiliac joint block • Discography • Intradiscal electrotherapy • Vertebroplasty
- 12. FACET JOINT SYNDROME • Uni/ bilateral lower back pain – Buttock, hip, not past knee – ↑ twisting, rotation – ↑ extension – ↓ standing, walking • Morning stiffness • Local tenderness • Normal CNS; -ve SLR
- 16. BACK PAIN MANAGEMENT PROCEDURES • Selective nerve sleeve block • Facet joint block • Medial branch block + RF ablation • Sacroiliac joint block • Discography • Vertebroplasty
- 19. RADIOFREQUENCY ABLATION • Successful facet joint block • 2 x MBBB • ‘Permanent’ relief
- 20. BACK PAIN MANAGEMENT PROCEDURES • Pharmacology • Selective nerve sleeve block • Facet joint block • Medial branch block + RF ablation • Sacroiliac joint block • Discography • Vertebroplasty
- 21. SACROILIAC JOINT PAIN • Unilateral low back pain • Groin pain • Sitting intolerance • Numbness, burning, tingling buttock and upper leg • No radiculopathy • Underlying arthropathy eg ank spond
- 23. BACK PAIN AND THE RADIOLOGIST • Radiologists may be helpful in pain management due to accurate needle placement • Most back pain will get better • General practice referral reasonable if diagnosis is definite and the treatment plan is clear. • If the diagnosis and treatment is unclear following investigation, specialist referral is appropriate.