Should I order an injection or let the specialist do it? – Part 2
- 1. Procedures in Chronic Pain Dr Brendan Moore Pain Medicine Specialist Physician Adjunct Associate Professor University of Queensland
- 3. Identifying appropriate procedures for your patient
- 4. Degenera(ve Lumbar Back Pain
- 5. Degenera(on of Lumbar Spine • Disc degenera(on + narrowing • Osteoporosis • Facet Joint Arthri(s • Spinal and Foraminal stenosis • Loss of Lumbar concavity
- 6. Posterior Elements • Facet Joints frequently implicated in pain • Mechanical back pain with upper leg and buFock radia(on
- 7. Origins of lumbar pain • Degenera(ve Discs • Vertebral fractures • Spinal / Foraminal Stenosis • Disc Bulge / Prolapse • Facet Joint • Muscle / SoI (ssue
- 8. Invasive Treatment Op(ons • Surgery • Facet Joint Injec(on • Radiofrequency medial branch abla(on • Epidural / Caudal steroid • Vertebroplasty • Coeliac / Lumbar Sympathe(c Plexus Blocks • Sacro-‐iliac Joint injec(on
- 10. Identifying appropriate procedures for your patient Identifying appropriate procedures for your patient
- 11. • Who should order the Pain procedure ?
- 12. How persistent pain can become a problem Adapted from: Nicholas, 2008.
- 13. • Who should order the Pain procedure ?
- 14. • Who should order the Pain procedure ? • Mul(disciplinary considera(on in assessment • Part of a comprehensive management plan • Pa(ent fully informed – Poten(al benefits – Limita(ons – Expecta(ons – What happens next • Clear follow up plan
- 16. Facet Joint Injec(on • Primarily diagnos(c • 25G Spinal needle • LA + Steroid • Steroid confers possible longer term benefit
- 18. Medial Branch Nerve Abla(on • Denerva(on of Medial Branch via Radiofrequency Neurotomy
- 19. Radiofrequency Neurotomy • AP and oblique views to confirm posi(on • Test s(mula(on; 2.0 Hertz, 0 to 2.0 v to test for motor nerve contact • Lesion 85oC x 90sec
- 22. Lumbar Epidural Injec(on • 18 or 16 G Toohey needle • LOR to air (or saline) • Radio-‐opaque contrast to confirm posi(on • Px for nerve root irrita(on and assoc. radicular pain
- 27. Procedures available at a pain clinic • Epidural injections • Facet joint injections • Sacroiliac joint injections • Medial branch blocks • Radiofrequency nerve ablation
- 28. Appropriate conditions for interventional pain procedures • Aseptic conditions • Appropriate analgesia • Monitored sedation with anaesthetist in attendance • Image intensifying X-ray or CT guidance
- 29. Epidural injections • Most effective in the presence of nerve root compression and spinal stenosis • Increased efficacy if given in the first weeks of the onset of pain • Effects of the injection tend to be temporary (1 week to 1 year) • Can be beneficial in providing relief for patients during an episode of severe back pain • Allows patients to progress in their rehabilitation
- 30. Lumbar epidural injection • 18G or 16G Toohey needle • Radio-opaque contrast to confirm position • Injection and distribution of local anaesthetic and steroid to nerve root
- 31. Facet joint injections • Back pain originating from facet joints • Low back pain (unilateral or bilateral) and no root tension signs or neurological deficits • Pain usually being aggravated by extension of the spine • Facet joint injection may reduce inflammation and provide pain relief • Therapeutic goal and potential benefit – Temporary relief from pain – Patient may proceed into an appropriate exercise program
- 32. Facet joint injection • Diagnostic • 25G spinal needle • Local anaesthetic + steroid • Steroid indicative of possible long-term benefit
- 33. Sacroiliac joint injection • Indicated with referred pain • Pain referral pattern – area around and just caudal to the posterior superior iliac spine • Referred pain in the low back, buttocks, abdomen, groin or legs • In some patients, S-1 joint injections can provide significant pain relief
- 34. Sacroiliac joint injection • Diagnostic • 25G spinal needle • Local anaesthetic + steroid • Steroid indicative of possible long-term benefit
- 35. Medial branch blocks • Medial branch nerves are the very small nerve branches that controls sensation of the facet joint • Indicated in low back pain (unilateral or bilateral) • Pain usually aggravated by extension of the spine • Medial branch blocks are a diagnostic procedure • Can provide temporary pain relief
- 36. Medial branch nerve ablation • Diagnostic medial branch blocks • Local anaesthetic + steroid • Progress to radiofrequency ablation if diagnostic block indicative of long-term benefit
- 37. Radiofrequency neurotomy X-ray to confirm needle position – AP and oblique views Test stimulation – 2.0 Hz 0–2 volt to test for motor nerve contact Lesion 85°C for 90 seconds
- 38. Cervical radiofrequency neurotomy Position for C2/3 and C3/4 facet joint radiofrequency
- 39. Cervical radiofrequency neurotomy -‐ lateral view Marker shows needle at C2/3 facet joint
- 40. QUEENSLAND
- 41. Queensland Rural and regional health services • Department of Health website has a comprehensive list of Statewide Community Health Services • www.health.qld.gov.au Health Contact Centre • 13-HEALTH telephone triage and referral service • 24 hours, 7 days per week • Based on a partnership model with Smart Service Queensland and the Queensland Government • Responsible for the development and integration of existing or future health care services which are / can be delivered through contact centre management practices
- 42. Accessing allied health services in your local area Australian Psychological Society (APS) • Find a psychologist in your local area – internet search • APS homepage>Community Information>Find a Psychologist Australian Physiotherapy Association • Find a physiotherapist in your local area • http://apa.advsol.com.au/ The Australian Pain Society has a comprehensive directory of Pain Specialists, Multidisciplinary Pain Clinics and Pain Management Centres • www.apsoc.org.au/facility_directory.php
- 43. Cervical radiofrequency neurotomy – lateral view Marker shows needle at C2/3 facet joint