Lumbar Injections For Diagnosis and Treatmentneurosurgerylnh.com/uploads/Lumbar Radicular Pain...
Transcript of Lumbar Injections For Diagnosis and Treatmentneurosurgerylnh.com/uploads/Lumbar Radicular Pain...
1/10/2018
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Lumbar Injections ForDiagnosis and Treatment
Ovidiu Nicolae PaleaCentrul de Diagnostic si Tratament ProVita
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Pain Management
Anesthesiology and Intensive Care
2009 decided to focus on Pain Management
2010 started the first Multidisciplinary Minimal Invasive Pain Center in Romania –Centrul de Diagnostic si Tratament Provita
Full time Pain Management
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Pain Management
Medicine has evolved into 30 specialties and OVER 140 Subspecialties!!!!!
Anesthesiologists were first, but now ….
Neurosurgeons
Physical Medicine and Rehab docs
Rheumatologists
Orthopedic Surgeons
Neurologists
Interventional Radiologists
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Pain Management
Patient Population – sub acute and chronic:
Lower back 50%
Upper back 20%
Peripheral joints – hip, knees etc – 20%
Head and Facial Pain 10%
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The Goal Today:
Functional Diagnosis
Radiological Landmarks
Technique for Infiltrations
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Definition and Etiology
Radicular pain is a type of pain that radiates into the lower extremity directly along the course of a spinal nerve root
It needs a good differential to Pseudoradicular Pain
Radicular pain is caused by inflammation rather than compression, and/or injury to a spinal nerve root
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Definition and Etiology
Inflammation of the nerve root can be caused by:
‐ herniated disc
‐ facet hypertrophy
‐osteophytes
‐epidural fibrosis
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Definition and Etiology
Inflammation of the nerve root can be caused by:
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Definition and Etiology
Inflammation of the nerve root:
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Clinical Diagnosis
History of Present Illness
‐ how did the pain start?
‐ where is the pain? Back or leg pain?
Physical exam:
‐ neurological deficits
‐ straight leg raising, SI and Hip
‐ reflexes
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Differential Diagnosis
Facet pain
Sacroiliac pain
Coxarthritis
Tendinopathy
Peripheral nerve Entrapments
Bursitis, Psoas Impingement
Internal pathology
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Radiological Diagnosis
X ray AP and Lateral
‐ mainly bone landmarks BUT also critical alignment information
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Radiological Diagnosis
CT scan
‐ more soft tissue anatomy
‐ great for osteophytes
‐ used mainly when MRI is contraindicated
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Radiological Diagnosis
MRI
‐ soft tissue detailed anatomy
‐ very limited for osteophytes
‐ BIGGEST pitfall: NO CLINICAL CORELLATION!!!
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Clinical Diagnosis is Critical
Do we treat the actual hernia?
Do we treat the cause? Is Hernia the cause?
Do we treat the SYMPTOMS?
Symptoms caused by what? Hernia?
Nerve Inflammation?
Fibroses of the nerve root?
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Electromiography
Great Sensitivity
Poor Specificity
Poor clinical correlation
Lesion has to be over 4 weeks old to see any changes
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Functional Diagnosis is Critical
Guided Anesthetic infiltrations are the only available functional diagnosis at the present time ‐
In multilevel pathology there is no other test that has a better correlation!!!!!
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Functional Diagnosis is Critical
Guided Anesthetic infiltrations are the only available functional diagnosis at the present time – X ray guided or Ultrasound guided
Ultrasound guided injections are growing as indications more and more – axial as well as articular or peripheral nerve entrapments
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Indications for minimal invasive
Symptoms severity VAS >4‐5/10
Duration of pain – usually > 2 weeks
Failed conservative treatments – kinetotherapy, NSAIDS
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NOT AN INDICATION FOR ANYTHING!!
Numbness, hypoesthesia
Old moderate motor deficits
Presence of a hernia on the MRI but no symptoms
Clinical picture improving!!!
Free fragments
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Epidural Injections
There 3 types:
‐ Interlaminar Epidural
‐ Caudal Epidural
‐ Transforaminal Epidural
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Interlaminar Epidural Steroid injection
34% Success rate
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Interlaminar Epidural Steroid injection
Nonspecific block
No diagnostic value
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Caudal Epidural
60% success
Nonspecific
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Caudal Epidural
60% success
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Transforaminal Steroid Injections
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Transforaminal Infiltrations
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Transforaminal Infiltrations
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Transforaminal Infiltrations
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Transforaminal Injections
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Transforaminal Infiltrations
Transforaminal Steroid Injections
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Often first step
Risk of:
Bleeding
Infection
Nerve damage
Wet tap
Paralysis
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Often first step
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Treatment Algorythm
First step is always GUIDED periradicular injections!
‐ success rate of 70‐80% for radicular pain that isunder 8 weeks old!!
‐ response is due to the long acting depo steroidinjection and is based on the assumption that most ofthe pain is due to inflammation
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Treatment Algorythm
First step is always GUIDED periradicular injections!
‐ response is MAINLY in the second week after the injection NOT at the time of the infiltration
‐ it can be repeated x3 at 2‐4 weeks interval if RESPONSE is achieved
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Technique – we love our Scotty Dog
Discography
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Technique – we love our Scotty Dog
Discography
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Technique – we love our Scotty Dog
Discography
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Technique – we love our Scotty Dog
Facet Injections
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Technique – we love our Scotty Dog
Facet Injections
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Technique – we love our Scotty Dog
Facet Injections
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Treatment Algorythm
Epiduroscopy with laser ablation of scar tissue
small hernias
multilevel degenerative spine
moderate spinal stenosis
failed back surgery
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Treatment Algorythm
Epiduroscopy with laser ablation of scar tissue
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Treatment Algorythm
Epiduroscopy with laser ablation of scar tissue
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Cadaver Workshops for guided infiltrations
‐ Pick up initially easy cases –lumbar single hernia‐ Pair up with a radiologist ‐ Start with Caudal Ultrasound guided
‐ do CT guided infiltrationsAsk for help any time!!!
How to start my practice?
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‐ Anesthesiologists can DIAGNOSE the cause of pain!!!
‐ We can treat the cause of pain
‐ You could be the third opinion
TAKE HOME MESSAGE
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www.centrul-provita.roMy email: [email protected]
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