Evidence for Spinal Interventions 2012

8/17/2019 Evidence for Spinal Interventions 2012

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Evidence for Precision Diagnosis

and Management of Spinal Painand Radicular Pain

Dr Sanjeeva GuptaMD; DNB; FRC; F!PP; FFPMRC

Consultant in Pain Management and naest"esia

Bradford #eac"ing $ospitals N$S #rust


2/100

%utline of t"e #al&

• '"at is Precision Diagnosis ( Management)

• *um+ar Facet ,oint Pain

• Sacroiliac ,oint Pain• *o-er *im+ Radicular Pain

• Failed Bac& Surger. S.ndrome

• Cervical /ial Pain• Cervicogenic $eadac"e

• 0pper *im+ Radicular Pain


3/100


4/100

Location Location Location

Diagnosis

Diagnosis

Diagnosis


5/100

Current diagnostic methods

1. History

2. Physical examination

3. Imaging

4. Blood tests

5. er!e conduction studies

"lide #rom Dr $ %ichardson


6/100

&'( o# )atients *ith )ersistent lo*

+ac, )ain cannot +e diagnosed

using the con!entional model



7/100

Precision diagnostic methods

Principle:

1. Inner!ated

2. Bloc,ade - %elie#

3. "timulation Pain



8/100

euroanatomy o# the ")ine

• /acet 0oints su))lied +y edian Branches o# Dorsal %ami

• uter third o# nnulus /i+rosis richly inner!ated – Branches o# the "inu!erte+ral er!es

– he rey %ami Communicantes

– Lum+ar 6entral %ami

Bogdu, 7 et al. $ nat 18&19 132: 385;

Bogdu, 7 ")ine 18&39 &:2&;283.


9/100

svn

ST

direct

branches

**1 disc1

verte+ra

ALL nerve plexus

svn

r. comm.

ST

PLL nerve plexus

P**1 dura1

disc1 verte+ra

#ter roen $ et al. m , nat 2334; 2556 757839


10/100

?here does +ac, )ain come #rom@

1. /acet $oints

2. Discs

3. "acroiliac 0oint

4. er!e root > dura

5. 6erte+ral Body

;. Ligaments

A. uscles


11/100

?here does +ac, )ain come #rom@

/acet $oint Pain

21( 4'( in general

)o)ulation

1;( in )ost lum+ar

surgery )atients /B""

"ch*ar=er et al. Spine 1884 Ann

Rheum Dis 1885

Datta "7 et al. Pain Physician 2''89

12: 43A4;'


12/100

/acet $oint Pain E!aluation

• /acet $oint In0ections

• edial Branch Bloc,

• /alse )ositi!e rate 3'( – Datta "7 et al. Pain Physician 2''89 12: 43A4;'

High on the FeyeG o# the F"cotty dogG


13/100

edian Branch Bloc, Diagnostic

• Lum+ar medial +ranch +loc,s ha!e +een

sho*n to ha!e +oth diagnostic and thera)eutic

utility – Datta "7 et al. Pain Physician 2''89 12:43A4;'.A4;'. – "ehgal 7 et al. Pain Physician 2''A9 1':21322&.

– Hancoc, $7 et al. Eur ")ine $. 2''A ct91;1':15385'.

– %u+instein "7et al. Best Pract %es Clin %heumatol 2''&9 22:4A14&2.

– I"I". Lum+ar BB. In: Bogdu, 7 ed. Practice uidelines #or ")inal Diagnostic and reatment

Procedures. "an/rancisco7 C: I"I"9 2''4:4A-;5.

– Cohen "P7et al. nesthesiology. 2'1' ug91132:3854'5. – Cohen "P7 et al. ")ine $. 2''& ay$un9&3:48&5'4

– Bogdu, : he inner!ation o# the lum+ar s)ine. ")ine 18&39 &:2&;283

– "ch*ar=er C7 et al. ")ine 18849 18:1132113A

– "ch*ar=er C7 et al. nn %heum Dis 18859 54:1''1';

– Drey#uss P7 et al. ")ine 188A9 22:&858'2

– a)lan 7 et al. ")ine 188&9 23:1&4A1&52


14/100

hera)eutic E##ecti!eness o# Lum+ar7 horacic

and Cer!ical edian Branch Bloc,s

L": L 2''1 1 - 3 in0 - LJ"ara)in> LJ sara)in J steroid: L 2''& 3 - 4 in0

C": L 2''& L> LJ "teroid


15/100

/acet $oint - %adio#reKuency Dener!ation


16/100

"ummary o# In!alid "tudies o# /acet $oint

Dener!ation due to echnical /la*s


17/100

Laclaire et al "tudy


18/100

"ummary and utcomes o# 6alid

"tudies o# /acet $oint Dener!ation

• omBerme0o /7 et al. $ ")inal Disord ech. 2'11 )r9242:;8A5.• Do+rogo*s,i $7 et al. Pharmacol %e). 2''595A4:4A5&'.• "cho##erman $7 et al. E##ecti!eness o# re)eated %/D #or lum+ar #acet )ain.

2''4 o! 192821:24A13.

• ornic, C7 et al. Com)lications o# lum+ar #acet %/D. ")ine Phila Pa 18A;.

2''4 $un 1592812:13524.

LEE% HE EDI% P i Ph i i


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LEE% HE EDI% Pain Physician

itle: I %E"P"E

CritiKuing the critiKues: the merican Pain "ociety guideline and

the merican "ociety o#

Inter!entional Pain Physicians res)onse to it

• "hort itle: CritiKuing the critiKue

• Corres)onding uthor: "herdil ath

• "ir7

In the a+o!e letter to the editor7 %oger Chou im)lies that the results could +e +iased and concludes that7 I Kuote7

“It is difficult to see how the Nath et al trial could be taken as reliable evidence that radiofrequenc denervation iseffective!"

he reason #or this7 as Kuoted in the letter *as“because the sham control #roup $which had hi#her baseline scores% had #reater potential to e&perienceimprovement from baseline! here is a mista,e here as it *as the acti!e treatment grou) that had higher+aseline scores o# )ain7 ot the sham grou) as stated


20/100

eneralised Pain



21/100

lo+al Im)ro!ement



22/100

here are se!en systematic re!ie*s o#

radio#reKuency dener!ation #or chronic LBP

uthor conclusions:

• Bos*ell 2''A: Me!idence #or )ain relie# *ith radio#reKuency neurotomy o# medial

+ranch ner!es *as moderate to strong in cer!ical and lum+ar s)ine.N

•Datta 2''8: Mle!el II2 e!idence #or radio#reKuency neurotomyN

•uerts 2''1 Mmoderate e!idence that radio#reKuency lum+ar #acet dener!ation *as more

e##ecti!e #or chronic lo* +ac, )ain than )lace+oN

•anchi,anti 2''2 Mmoderate to strong e!idence #or radio#reKuency neurotomyN

•iemisto 2''3 Mcon#licting shortterm e##ect on chronic lo* +ac, )ainN

•Bos*ell 2''5 Mmoderate to strong e!idence #or radio#reKuency neurotomyN

•"li)man 2''3 M the e!idence #or radio#reKuency dener!ation is Le!el III or moderate.N


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International Lo* Bac, Pain uidelines

• ICE C&&: htt):>>***.nice.org.u,>C&&

Do not re#er #or radio#reKuency dener!ation

• merican Pain "ociety Lo* +ac, )ain guideline

• htt):>>***.am)ainsoc.org>li+rary>)d#>LBPE!id%e!.)d#

E!idence on e##icacy o# %/ dener!ation o# the B o# the

)rimary dorsal ramus is di##icult to inter)ret

•Euro)ean Lo* Bac, Pain uideline

htt):>>***.+ac,)aineuro)e.org>*e+>#iles>?2Ouidelines.)d#

?e cannot recommend %/ #acet dener!ation #or )atients

*ith nons)eci#ic chronic lo* +ac, )ain

http://www.nice.org.uk/CG88http://www.ampainsoc.org/library/pdf/LBPEvidRev.pdfhttp://www.backpaineurope.org/web/files/WG2_Guidelines.pdfhttp://www.backpaineurope.org/web/files/WG2_Guidelines.pdfhttp://www.backpaineurope.org/web/files/WG2_Guidelines.pdfhttp://www.backpaineurope.org/web/files/WG2_Guidelines.pdfhttp://www.backpaineurope.org/web/files/WG2_Guidelines.pdfhttp://www.ampainsoc.org/library/pdf/LBPEvidRev.pdfhttp://www.ampainsoc.org/library/pdf/LBPEvidRev.pdfhttp://www.nice.org.uk/CG88http://www.nice.org.uk/CG88http://www.nice.org.uk/CG88


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International Lo* Bac, Pain uidelines• "IPP uideline Com)rehensi!e E!idenceBased uidelines #or

Inter!entional echniKues in the anagement o# Chronic

")inalPain:

htt):>>***.)ain)hysician0ournal.com>2''8>0uly>2''89129;88&'2.)d#

%ecommendation: Based on uyatt et alNs criteria7 #or lum+ar

radio#reKuency neurotomy the recommendation is 1C>strong

• merican "ociety o# naesthesiologists Practice uidelines #or

Chronic Pain anagement

htt):>>0ournals.l**.com>anesthesiology>/ulltext>2'1'>'4'''>Pract

iceOuidelinesO#orOChronicOPainOanagementO.13.as)x• %/ o# the B ner!es to the /$ should +e )er#ormed #or LBP *hen

)re!ious diagnostic or thera)eutic in0ections o# the 0oint or B ner!e

ha!e )ro!ided tem)orary relie# Category 1 e!idence

http://www.painphysicianjournal.com/2009/july/2009;12;699-802.pdfhttp://journals.lww.com/anesthesiology/Fulltext/2010/04000/Practice_Guidelines_for_Chronic_Pain_Management_.13.aspxhttp://journals.lww.com/anesthesiology/Fulltext/2010/04000/Practice_Guidelines_for_Chronic_Pain_Management_.13.aspxhttp://journals.lww.com/anesthesiology/Fulltext/2010/04000/Practice_Guidelines_for_Chronic_Pain_Management_.13.aspxhttp://journals.lww.com/anesthesiology/Fulltext/2010/04000/Practice_Guidelines_for_Chronic_Pain_Management_.13.aspxhttp://www.painphysicianjournal.com/2009/july/2009;12;699-802.pdf


25/100

Precision Diagnosis andanagement

o# "acroiliac $oint "I$ Pain


26/100


27/100

?here does +ac, )ain come #rom@"I$ Pain Pre!alence

21A )atients *ith maximal

)ain +elo* L5 e!aluated

– natomic controlled neg =0t +loc,s and>ordual )ositi!e A5( relie# "I$ +loc,s)er#ormed

– Pre!alence o# "I$ )ain *as 1'2'(

• "ch*ar=er7 ")ine7 2':317 18857 aigne7 ")ine 2171&&87 188;


28/100

"I$ )ain +elo* a L>" #usion

Pre!alence

• In A4 com+ined )atients *ith lo* +ac, )aina#ter lum+osacral #usion7 the "I$ *as the )ainsource in 32( as esta+lished +y single I "I$in0ections – at=. $ ")inal Disorders 1;98;887 2''37 aigne. Euro

")ine $ 149;54;5&7 2''5

• "I$ *as #ound to +e a source o# )ost#usion )ain in 32( o# )atients +y singleI +loc,


29/100

"I$ %e#erral Qones

• aximal "I$ )ain is +elo* L5 +ut can re#er

into the entire lo*er extremity *ith 84(

ha!ing +uttoc,7 4&( *ith thigh )ain and 2&(

*ith lo*er leg )ain• "ch*ar=er. ")ine 18857 aigne. ")ine 188;7 Drey#uss. ")ine 188;7 "li)man. rch Phys

ed %eha+il 2'''9&1:33433&

• Based on dual +loc,s7 maximal )ain is +elo*

L5 and in the +uttoc,


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"I$ Inter!entions


31/100


32/100

he medial 0oint lines are the margins o# the )osterior

"I 0oint line arro*

C t t di d


33/100

Contrast medium s)read

along the "I 0oint line

Dou+le eedle echniKue: n lternati!e ethod #or Per#orming


34/100


Di##icult "I$ In0ections." u)ta. Pain Physician 2'119 14: 2&12&4



35/100


Di##icult "I$ In0ections.

" u)ta. Pain Physician 2'119 14: 2&12&4n Dynamic /luorosco)y the needle is not in the "I$ line

Dou+le eedle echniKue #or "acroiliac $oint In0ection


36/100

Dou+le eedle echniKue #or "acroiliac $oint In0ection" u)ta. Pain Physician 2'119 14: 2&12&4

"econd eedle in Inserted into the e*ly Identi#ied $oint Line on

Dynamic /luorosco)y


37/100


Contrast In0ected hrough the "econd eedle Identi#ies the "I$

Dou+le eedle echniKue #or "acroiliac $oint In0ection


38/100


Contrast In0ected rough the /irst eedle @ 6ascular ")read


39/100

"I$ Inter!entions E!idence

• ost ex)erts maintain lo*!olume intraarticular local anaesthetic in0ections to +e the

only relia+le diagnostic modality to diagnose "I$

)ain – Cohen "P. "acroiliac 0oint )ain: a com)rehensi!e re!ie* o# anatomy7

diagnosis7 and treatment. nesth nalg. 2''591'1:144' - 1453

– Drey#uss P7 Dreyer "$7 Cole 7 et al. "acroiliac 0oint )ain. $ m cad

rtho) "urg. 2''4912:255 2;5

– Hansen HC7 cen=ieBro*n 7 Cohen "P7 et al. "acroiliac 0ointinter!entions: a systematic re!ie*. Pain Physician. 2''A91':1;5< &4.

"I$ I t ti E id


40/100

"I$ Inter!entions E!idence

• here is one dou+le +lind and & )ros)ecti!e o+ser!ational studies

*hich conclude that /luorosco)y > C > %I guided "I$ in0ectiono# steroid )ro!ides good short to intermediate term )ain relie# 3

to ; months – augars


41/100

"I$ %adio#reKuency E!idence

• 2 %C and 3 Pros)ecti!e o+ser!ational studies in#orm

that 5'( )atients o+tain 5'( )ain relie# *ith

im)ro!ed #unction #or ; months #ollo*ing "I$ %/D in

care#ully selected )atients #ollo*ing diagnostic in0ection

o# local anaesthetic into the "I$

– " P. Cohen7 et .al. %andomi=ed Place+ocontrolled "tudy E!aluating Lateral Branch %/D #or

"I$ Pain. nesthesiology 2''&9 1'8:2A8-&&

– Patel7 et al. %andomi=ed7 Place+o Controlled "tudy to ssess the E##icacy o# Lateral

Branch Dener!ation #or Chronic "I$ Pain. Presented at the "IPP nnual eeting $une 2'11 – " P. Cohen7 et al. utcome Predictors #or "acroiliac $oint Lateral Branch%adio#reKuency

Dener!ation. %eg nesth Pain ed 2''89 34: 2'; - 214

– H araman7 et al. cta eurochir 2'11. Pu+lished online )ril 2'113

– Bui0s E$7 et al. Pain Clinic 2''49 1;: 13814;.

– e!arge= 7 et al. Eur %adiol 2''29 12: 13;'13;5


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lancinating1 s"ooting1 or

:electric pain; traveling

do-n t"e lim+ in a

narro- +and<

RD!C0*R P!N

Presentation can

alter if treated

Bogdu& N1 Govind ,< Medical Management of cute *um+ar Radicular Pain< n Evidence8Basedpproac"< Ne-castle6 Ne-castle Bone and ,oint !nstitute1 2333


43/100

echanism - I/LI


44/100

spinal nerve

dorsal root

ganglion

RD!C0*R P!N

N%

P*7 P*E7

#NF

interleu&ins 51 27

metalloproteinases

!g M1 !g G

!NF*MM#!%N

leu&otriene B=

t"rom+a/ane

interferon

macrop"ages

l.mp"oc.tes

fi+ro+lasts


45/100

spinal nerve

dorsal root

ganglion

RD!C0*R P!N

N%

P*7 P*E7

#NF

interleu&ins 51 27

metalloproteinases

!g M1 !g G

!NF*MM#!%N

leu&otriene B=

t"rom+a/ane

interferon

macrop"ages

l.mp"oc.tes

fi+ro+lasts

S#ER%!DS


46/100

%adicular Pain

• E)idurals - Caudal7 Interlaminar7

rans#oramenal

• Catheter euro)lasty

• ")inal endosco)y

• ")inal cord stimulator


47/100

Caudal E)idural "teroid In0ection #or


48/100

Caudal E)idural "teroid In0ection #or

Lum+ar disc herniation>radiculitis

Dash#ield - "ingle )rocedure

L - L>LJ"teroid9 !erage )rocedure 3 to 4>year *ith 5'( )ain relie# and 4'( im)ro!ement o# DI o# 3;>5"igni#icant decrease in o)ioid inta,e and em)loyment status 12>52 )er )rocedure


49/100

Caudal E)idural "teroid In0ection

LBP o# Post "urgery "yndrome

L and %e!el - Post lum+ar laminectomy syndrome9 L DB eKui!alence trial9 L or L J Betamethasone9

!erage )rocedure 3 to 4>year9 5'( )ain relie# and 4'( im)ro!ement o# DI o# 3544>52

"igni#icant decrease in o)ioid inta,e 1'14>52 )er )rocedure

Hesla - herniated disc o)erated

L + I t l i E id l "t id I 0 ti


50/100

Lum+ar Interlaminar E)idural "teroid In0ection


51/100

"ummary - Lum+ar E"I

•15 %CNs: & )ositi!e and A negati!e

– %adicular )ain relie# +et*een ; *,s 3 mths• o #luorosco)y• In the )osterior e)idural s)ace

• @dhesions


52/100

rans#oraminal E)idural

%andomised rials o# E##ecti!eness o#


53/100

%andomised rials o# E##ecti!eness o#

rans#oramenal E)idural In0ection

hahreman 7 /erch %7 Bogdu, . Pain edicne 2'1'9 11: 114811;&

hahreman 7 Bogdu, . Pain ed. 2'11 $un912;:&A18.

Le#t L4>5 rans#oraminal In0ection


54/100

Le#t L4>5 rans#oraminal In0ection


55/100


56/100


57/100


58/100

i $ t l " i 2''1 23 25&A


59/100

ar))inen $7 et al. ")ine 2''19 23: 25&A

85

• Cost e##ecti!eness o# /E"I #or sciatica

• /or contained herniations

– "teroid +etter #or leg )ain7 disa+ility7 "L% in the short

term

– By 1 year steroid )re!ented o)erations costing

R127;;; less )er res)onder

• /or extrusions – "teroid seemed to increase the o). rate and *as more

ex)ensi!e

%ie* D7 et al: Pros)ecti!e %C Dou+le Blind rial


60/100

7 )he main outcome measure *as a!oidance o# surgery

Bu)i!acaine and

Betamethasone

Bu)a!acaine only

otal Patients 2& 2A

Patients notha!ing surgery 2' A1(

P S '.'''4

8 33(

Normall. all -ould "ave +een treated operativel.

#reatment algorit"m no- includes > to = #FES! +efore considering surger.


61/100

# i l L l th ti I 0 ti


62/100

rans#oraminal Local naesthetic In0ection

# i l "t id I 0 ti


63/100

rans#oraminal "teroid In0ection

Change in Tse o# Health Care #rom +e#ore to a#ter treatment


64/100

Change in Tse o# Health Care #rom +e#ore to a#ter treatment

Degree o# Pain %elie# in the 5 di##erent rou)s


65/100

Degree o# Pain %elie# in the 5 di##erent rou)s


66/100

/E"I "ystematic %e!ie*s

• DePalma $7 et al. rch Phys ed %eha+il. 2''59&;A:14AA&3 – he e!idence #or /E"Is re!eals le!el III moderate e!idence in su))ort o#

these minimally in!asi!e and sa#e )rocedures in treating )ain#ul lum+ar

radicular sym)toms. Current studies su))ort use o# /E"Is as a sa#e and

minimally in!asi!e ad0unct treatment #or lum+ar radicular sym)toms.

• +di "7 et al. Pain Physician. 2''A $an91'1:1&5212.

– he e!idence #or cer!ical and lum+ar /E"I is moderate #or longterm

im)ro!ement in managing ner!e root )ain.

• %o+erts "7 et al. P %. 2''8 $ul91A:;5A;&.

– here is #air e!idence su))orting /E"Is as su)erior to )lace+o #or treatingradicular sym)toms.

– here is good e!idence that /E"Is should +e used as a surgerys)aring

inter!ention

– /E"Is are su)erior to interlaminar E"Is ILE"Is and caudal E"Is #or

radicular )ain in )atients *ith su+acute or chronic radicular sym)toms.



67/100


• Buena!entura %7 et al. Pain Physician. 2''8 $an/e+9121:23351

– he indicated e!idence #or /E"I is Le!el II1 #or shortterm relie# and

Le!el II2 #or longterm im)ro!ement in the management o# lum+ar ner!e

root and lo* +ac, )ain

• anchi,anti L7 et al. Pain Physician. 2''89124:E1238&. – Based on uyatt et alNs criteria7 the recommendation #or lum+ar /E"I is

1C>strong in managing chronic lo* +ac, and lo*er extremity )ain

• Benny B7 et al. $ Bac, usculos,elet %eha+il. 2'11 $an

19242:;AA; – here *as strong e!idence #or /E"I in the treatment o# lum+osacral

radicular )ain #or +oth short term and long term relie#


68/100


69/100


70/100


71/100

ur %es)onse

Care#ul )atient selection7 #luorosco)y and contrast

in0ection are needed #or e##ecti!e s)inal in0ections.

on7 2'11'82; 11:58

htt):>>***.+m0.com>content>343>+m0.d52A&@ta+res)onses

http://www.bmj.com/content/343/bmj.d5278?tab=responseshttp://www.bmj.com/content/343/bmj.d5278?tab=responseshttp://www.bmj.com/content/343/bmj.d5278?tab=responses


72/100

euromodulation

– ICE echnology a))raisal guidance 158

• %ecommended #or chronic )ain o# neuro)athic

origin

• /ailed Bac, "urgery "yndrome

• Com)lex %egional Pain "yndrome


73/100

Cervical Spinal Pain and 0pper

*im+ Radicular Pain Spinal

• Diagnosis anagement o# ec, Pain

• Diagnosis and anagement o# %adicular Pain

?here does the Pain Come /rom@


74/100

?here does the Pain Come /rom@

• /acet $oints

• Inter!erte+ral Discs

•Ligaments

• Dura mater

• er!e %oot7 D%

• Bone – In#ection7 rauma7 umour

• uscles

Discs: roen. m $ nat 188'9 &&:2&28;

Bogdu,. ")ine 18&&913:2&

endal. ")ine 18829 1A:13235

/acet $oints: Bogdu,. ")ine 18&29 A:3183'

C i > i i


75/100

Cer!ical > ec, Pain Incidence

• Lo*er Cer!ical /acet $oint PainC4>5 to C;>A

– +out 5'( *ith nec, )ain• Spine )11,2 ).:.--3-.2 Spine )1142 ,):).5.3-+2 Spine )11+2 ,*: ,*3,4

– High s)eed 6 - &&( 6 of 7usculoskeletal Pain ,***2 0: 0.31+

• T))er Cer!ical /$ Pain Cer!icogenic Headache C'>1 to C3>4

– 53( #rom C23 0oint 6 Neurol Neurosur# Pschiatr )11-2 +.: ))0.31*

$istor. and Clinical E/amination6 Cervical Somatic Referred Pain

•Facet ,oint Pain


76/100

C?89

C>8=

C78>

C=8?

C98@

•Facet ,oint Pain

•Discogenic Pain

D-.er et al< Spine 2334; 2?6=?>8=?@ Gru++ and Aell.< Spine 7444; 7?62>5782>53

C5; #acet 0oint most commonly

in!ol!ed #ollo*ed +y C;A

ne can localise to *ithin

J> one 0oint on the +asis

o# re#erral ma)s


77/100

C>

C=

C?

C9

ap

/luorosco)ic natomy

Centroid o# the articular )illar

C2 C2

C4

C5

/alse Positi!e Bloc,s


78/100

/alse Positi!e Bloc,s

• !erage #alse )ositi!e rate o# single +loc,

*as 48( range 2A to ;3( – Barnsley et al. he Clinical $ournal o# Pain 18839 8:12413'

– anchi,anti et al. Pain Pract 2''&9 &:51'

– anchu,onda %7 et al. $ ")inal Disord ech 2''A9 2': 53845

edian Branch eurotomy E!idence


79/100


Lord "7 Bogdu, 7 et al. %adio#reKuency eurotomy #or ChronicQyga)o)hyseal

$oint Pain. he e* England $ournal o# edicine 188;9 335:1A211A2;

• %andomised dou+le+lind trail

• 24 )atients #ollo*ing 6• "ource o# )ain identi#ied +y dou+le+lind )lace+o

controlled L +loc,s "aline7 lignocaine7 Bu)i!acaine

• 12 )atients recei!ed %/ neurotomy C3>4 to C;>A• edian time +e#ore )ain returned to 5'( o# the

)reo)erati!e le!el *as 2;3 days in the acti!e

treatment grou) and & days in the control grou)



80/100


cDonald $7 Lord "7 Bogdu, . Long term #ollo*u) o# )atients treated *ith

cer!ical radio#reKuency neurotomy #or chronic nec, )ain. eurosurgery 1888945: ;1;&

• 2& )atients treated - 1& ;4( had com)lete )ain

relie# #or a median )eriod o# 421 days

• I# )ain recurred com)lete )ain relie# reinstated

+y re)eat %/ neurotomy *ith some )atients

ha!ing 4 to ; success#ul re)etitions

"a)ir D et al. %/ B neurotomy in litigant and nonlitigant

)atients *ith cer!ical *hi)lash. ")ine 2''19 2;: E2;&E2A3


81/100


Cer!icogenic Headache


82/100

hird cci)ital er!e

• C23 $oint is the source o# Cer!icogenic Headache in

54( o# )atients

• C3: three )oints reKuired7 to co!er !ariants in

location• longitudinal +isector C23 =yga)o)hysial 0oint

– High o))osite a)ex o# C3 "P

– Lo* o))osite +ase o# C23 #oramen – mid mid*ay +et*een


83/100

B

longitudinal bisector longitudinal bisector high, mid, and low pointshigh, mid, and low points

TARGT P!"#TS $!R T%"R& !''"P"TAL #R(TARGT P!"#TS $!R T%"R& !''"P"TAL #R(

- E!idence


84/100

o!ind $7 Bogdu, 7 et al. %adio#reKuency neurotomy #or the

treatment o# third occi)ital headache. $ eurol eurosurg Psychiat

2''39 A4: &&83

• &;( o# 48 )atients o+tained com)lete )ain

relie#7 the median duration o# )ain relie# *as28A days

• 14 )atients had re)eat %/ neurotomy *hen

their )ain recurred and 12 &;( regained

com)lete )ain relie#


85/100

Cer!ical Pain lgorithm

Cer!ical > ec, Pain


86/100

Cer!ical > ec, Pain/acet 0oints

• Headache Dominant "ym)tom- T))er cer!ical #acets

• Headache ot Dominant - iddle and Lo*er Cer!ical

/acets

D-.er et al< Spine 2334; 2?6=?>8=?@

C78>

C=8?

C98@

C>8=

C?89

Cer!ical > ec, Pain lgorithm


87/100

Cer!ical > ec, Pain lgorithm

Cer!ical Pain

@T))er Lim+ Pain Cer!ical xial Pain

o T))er Lim+ %adicular Pain

@Cer!ical %adicular Pain

5'&'( ha!e nec, )ain


88/100

Cer!ical /acet $oint Pain lgorithm

"elect ost Li,ely $oint /rom Pain a)s Per#orm /irst Bloc, C5; common

8'( Pain %elie# C;A7 C457 CA1


89/100

Cer!icogenic Headache lgorithm

Per#orm C23 $oint Bloc, 54(

ood Pain %elie# o Pain %elie#-C34 +loc,

echnically deKuate@

Can C12 +loc, +e done sa#ely

Per#orm Con#irmatory Bloc, echnically deKuate@


90/100

Does the )ain satis#y the de#inition o# Cer!ical %adicular Pain

o


91/100

Cer!ical Interlaminar E)idural "teroid In0ections

l*ays +elo* C; le!el

Ideally CA1 le!el or +elo*

T))er Lim+ %adicular Pain

C i l E id l "t id I 0 ti


92/100

Cer!ical E)idural "teroid In0ection

Cer!ical rans#oramenal E)idural In0ection


93/100

%ight nterior +liKue


94/100

B

Le#t CA ./.E.


95/100

nterior ")inal rtery

• I# )articulate material li,e

de)ot steroid )re)aration is

in0ected into the radicular

!essels it could reach the "

and s)inal cord and act as an

em+olus

• eedle trauma or air em+olus

8untoon 7A" Pain ,**+2 )).: )*-3))

9heshire P' et al" Neurolo# )1142 -.:5,)35*

P !ie* o# an angiogram


96/100

g g

o+tained a#ter in0ection

o# contrast medium

Digital "u+traction 6ie*

Con!entional #luorosco)ic

ex)osure

"ummary - Cer!ical E"I


97/100

y• Cer!ical E"I

– Pros)ecti!e study *ith good results• Pain 18849 5&2: 23843.

• Cer!ical /E"I – 3 Pros)ecti!e "tudy

• Eur ")ine $ 188;9 5:318325

• %adiology 2''19 21&:&&;&82• $% 2''49 253: 44145

– 1 %C• P Drey#uss. Pain edicine 2'';9 A: 23A42

– 3'( o+tain com)lete relie#

– 3'( o+tain )artial7 lasting relie#

– o +e tried +e#ore surgery

– In the a+sence o# controlled studies7 it cannot +e ,no*n *hetherthese outcomes are due to natural history7 /E"I or nons)eci#ictreatment e##ects

Pulsed %adio#reKuency reatment


98/100

Pulsed %adio#reKuency reatment

#or %adicular euro)athic Pain

• Dou+le +lind sham %C

• P%/ ad0acent to the cer!ical D% com)ared to "ham

• P%/ grou) com)ared to sham at 3 months sho*ed a signi#icantly

+etter outcome *ith regards to the glo+al )ercei!ed e##ect 5'(im)ro!ement and 6" 2')oint )ain reduction

• his translated to a o# 1.1 in the P%/ grou) com)ared *ith

o# 3 in the sham grou)

• "ix months a#ter the )rocedures7 the o# P%/ *as 1.; and ;

#or the sham inter!ention. – Van Zundert J, Patijn J, Kessels A, Lamé I, van Suijlekom H, van Kleef ! Pulsed radiofre"uen#$

adja#ent to t%e #ervi#al dorsal root &an&lion in #%roni# #ervi#al radi#ular 'ain( a dou)le )lind s%am

#ontrolled randomi*ed #lini#al trial! Pain +-./+-0/1+2(/-314+!


99/100

"ummary

• ost )atients *ith LBP7 nec, )ain and u))er and lo*er

lim+ radicular )ain *ill reco!er *ith conser!ati!e

management

• Precision diagnostic techniKues allo*s us to identi#y the

source o# )ersistent )ain guides #urther management

• +taining a diagnosis sto)s #urther #utile in!estigations

and )re!ent surgery


100/100

han,

Documents

Evidence for Spinal Interventions 2012