7persantine

(dipyridamole) Aggrenox

(dipyridamole/aspirin)

7days Aspirin or aspirin

containing medications:

(i.e., Excedrin, Equagesic,

synalogos-DC, BC Powder)

7Herbals containing

ginger, ginko biloba, or feverfew 7

3Non-steroidal anti-

inflammatory drugs: (i.e.,

ibuprofen, Naproxen,

Mobic, Arthrotec,

Relafen, Daypro and Celebrex)

5Orgaran (damaparoid) 6Coumadin (warfarin)

12 houresHeparin, Lovenox

(enoxaparin), Innohep

(tinzaparin), Fragmin

(dalteparin), Normiflo

(ardaparin)

14Ticlid (ticlopidine)

7daysVitamin E (greater than 400 IU)

10Plavix (clopidogrel)

2Pletal (cilostazol) and Trental (pentoxifylline)

Facet joint

Facet joints (zygapophyseal joints) are paired synovial joints formed by articulation of the inferior

articular process of one vertebra with the superior articular process of the subjacent one. They

allow the spine to move in flexion, extension, and rotation.

Innervated by the medial branch originating from the dorsal ramus of the spinal nerve

usually the pain of facet joint created in the upper back and thigh regions. Pain

frequently is also referred into the groin, buttocks, hip, or lateral and posterior thigh regions

(or a combination of these sites). Pain is often described as a “deep, dull ache” and may

be either unilateral or bilateral. On physical examination, there may frequently be

increased pain with extension, tenderness to palpation over the affected joints, and

normal findings on neurologic examination. Electrical stimulation of the medial branch nerves has also assisted in identifying referral pain patterns

Epidural steroid injection ESI

ILESILumbar interlaminar epidural steroid injections can be helpful in the

management of lumbar radicular symptoms. Lumbar interlaminar

epidural injections instill medication into the posterior epidural space

with variable spread into the anterior epidural space

Lumbar interlaminar epidural steroid injections can be performed for

lower extremity radicular symptoms recalcitrant to conservative

interventions including medications and physical therapy. With

severe limitation of function

injections should be limited to 3 in a 6-month period or 4 in a year.

These should ideally be spaced by at least 14 days to assess full response and minimize adrenal suppression.

TFESITransforaminal epidural steroid injections (TFESI’s) can be very helpful

in the management of lumbar radicular symptoms. Transforaminal

epidural injections instill medication along the affected nerve root

and into the anterior epidural space at the site of inflammation.

Lumbar spinal stenosis (central or foraminal) and herniated nucleus

pulposus can induce nerve root inflammation

Inflammation of the nerve root induces neurophysiologic and

histologic change ,that can result in radicular symptoms

Corticosteroid reduces morphologic and functional nerve root

changes, and lidocaine decreases nerve root inflammation, while increasing intraradicular blood flow

Causes of Pain after Failed Back Surgery

improper preoperative patient selection before back surgery. This is the most common cause of

failed back surgery syndrome. Surgeons look for an anatomic lesion in the spine that they can

correlate with a patients pain pattern. Some lesions are more reliable than others. For example,

degenerative disc disease is less commonly correlated with patients back pain than leg pain

from a disc herniation pinching a nerve root. There are other sources of pain that can mimic back

pathology such as piriformis syndrome,sacroiliac joint dysfunction and hip pathology (such as hip

osteoarthritis).

Recurrent disc herniation after spine surgery. This is another common cause of recurrent pain

Technical error during spine surgery. a fragment of herniated disc material missed, or a piece of

bone left adjacent to the nerve, incorrect operative levels chosen during surgical planning

preoperative nerve damage that does not heal after a decompressive surgery, or nerve damage that occurs during the surgery)

Scar tissue considerations

Scar Tissue and Pain After Back Surgeryperidural adhesiolysis

The formation of scar tissue near the nerve root (also called epidural fibrosis) is a common occurrence after back surgery

Typically, symptoms associated with epidural fibrosis (scar tissue around the nerve

root) appear at 6 to 12 weeks after back surgery. This is often preceded by an

initial period of pain relief, after which the patient slowly develops recurrent leg

pain or back pain

Adhesiolysis was developed as a means of removing epidural scarring leading

directly or indirectly to compression, inflammation, swelling, or a decreased

nutritional supply of nerve roots. Adhesiolysis utilizes a number of modalities in the

effort to break up epidural scarring, including the use of a wire-bound catheter

for mechanical adhesiolysis, placement of the catheter in the ventro-lateral

aspect of the epidural space at the site of the exiting nerve root, and the use of

high volumes of injectate, including local anesthetics and saline, either hypertonic or isotonic, along with steroids.

Sacroiliac joint

Contraindication

Absolute

Bacterial infection: systemic or localized at injection site

Bleeding diathesis: due to anticoagulants or hematological disease

Relative

Allergy to injectants; steroid psychosis

Pregnancy

NSAIDs, aspirin, or other antiplatelet agents (e.g. Ticlid, Plavix, Coumadin,

Trental, Pletal, Heparin, Lovenox, Innohep, Fragmin, Normiflo, Persantine,

Aggrenox, Ginko Biloba, Orgaran, and Damaparoid)

Hyperglycemia, adrenal suppression, immune compromise, or congestive heart failure

COMPLICATION OF INTERVENTIONAL PROCEDUREPotential complications

• Infection (cellulitis, osteomyelitis with potential spread to include epidural abscess, discitis, meningitis, arachnoiditis, sepsis)

• Bleeding

• Cardiovascular (dysrhythmias, congestive heart failure, hypotension, bradycardia, vasovagal reaction)

• Respiratory (oversedation, central nervous system trauma)

• Urologic (urinary retention, incontinence)

• Neurologic injury (direct neural trauma, compression from hematoma or abscess, radicular or vertebral artery trauma, arterial particulate injection, seizure)

• Adverse local anesthetic drug reaction (CNS and cardiovascular toxicity, restlessness, anxiety, incoherent speech, light-headedness, perioral parethesias, blurred vision, tremors, drowsiness, seizures, cardiac arrest, excessive intrathecalor epidural local anesthetic injection resulting in spinal block or leg weakness)

• Adverse steroid reaction (facial flushing, injection site hypopigmentation, subcutaneous fat atrophy, increased appetite, fluid retention, gastritis, malaise, euphoria, insomnia, headache, immunosupression, aseptic meningitis, arachnoiditis, congestive heart failure, increased intraocular pressures, adrenal insufficiency, steroid myopathy, mania, hyperglycemia, hypertension, epidural lipomatosis, menstrual irregularity)

• Allergic reaction (to non-ionic contrast agent allergy, local anesthetic, corticosteroid, or latex causing urticaria, laryngeal edema, bronchospasm, anaphylaxis)

Potential post-procedural complaints

• Vasovagal reaction (hypotension, bradycardia, nausea, pallor, diaphoresis, syncope)

• Pain (injection site, radicular, corticosteroid flare) • Headache (corticosteroids)

Management of Side effects

We generally advise the patients to use

diphenhydramine or other allergy medications at

night for flushing and insomnia. We also

recommend acetaminophen 500 mg every 6

hours as needed for headache and pain and

prochlorperazine orally 5 mg every 6 hours if needed .

References

Bogduk N. Diagnostic nerve locks in chronic pain. Best Pract Res Clin

Anaesthesiol 2002;16:56578.

Hansen HC. McKenzie-Brown AM. Cohen SP. Swicegood JR. Colson JD. Manchikanti L. Sacroiliac joint interventions: a systematic review.

[Review] [132 refs] [Journal Article. Review] Pain Physician. 10(1):165-84,

2007 Jan.

Botwin KP, Natalicchio J, Hanna A. Fluorscopic guided lumbar

interlaminar epidural injections: A prospective evaluation of

epidurography contrast patterns and anatomical review of the epidural space. Pain Physician 2004;7:77-80.