INTERVENTIONAL PAIN INTERVENTIONAL PAIN MANAGEMENT UPDATEMANAGEMENT UPDATE

Orlando G. Florete Jr.,M.D.Orlando G. Florete Jr.,M.D.

Director, Institute of Pain ManagementDirector, Institute of Pain Management

Director, Florida Institute of Medical Director, Florida Institute of Medical ResearchResearch

Jacksonville, FLJacksonville, FL

HIPPOCRATIC OATHHIPPOCRATIC OATH

““I will prescribe a regimen for the good I will prescribe a regimen for the good of my patients according to my of my patients according to my ability and my judgment and never ability and my judgment and never do no harm to anyonedo no harm to anyone””

PRIMUM NO NOCEREPRIMUM NO NOCERE

BACK PAINBACK PAIN 65 million sufferer in US Back pain is the #1 reason for health care

expenditure US back pain costs are 3 times greater than

cardiac services costs each yeareach year 20% of US working population20% of US working population experiences

back pain every year By age of 50, 97% of people have

degenerated lumbar discs

Lower Back Pain

ROLE OF SURGERYROLE OF SURGERY No role in self limited, episodic back pain, No role in self limited, episodic back pain,

mild to moderate back pain that does not mild to moderate back pain that does not impair function, or in global, nonimpair function, or in global, non--specific specific pain associated with inactivity and pain associated with inactivity and deconditioningdeconditioning

There is a clear and widely accepted role There is a clear and widely accepted role in progressive deformity, neural in progressive deformity, neural compression, intractable pain associated compression, intractable pain associated with instabilitywith instability

MEDICATION PRECAUTION For neuraxial injectionsFor neuraxial injections

AnticoagulantsAnticoagulants

-- Warfarin INR<1.2; 5 daysWarfarin INR<1.2; 5 days

-- Low molecular weight heparin >12 Low molecular weight heparin >12 hourshours

Thrombin Inhibitors Thrombin Inhibitors ––no data, no data, monitor PTTmonitor PTT

Antiplatelet: Plavix 7 daysAntiplatelet: Plavix 7 days

Triclid 14 daysTriclid 14 days

ASA and NSAIDS ASA and NSAIDS –– no no contraindicationcontraindication

BEWARE COMBINATION THERAPIESBEWARE COMBINATION THERAPIES

PATIENT FACTORSPATIENT FACTORS Diabetes mellitusDiabetes mellitus

-- Steroids can cause increase blood glucoseSteroids can cause increase blood glucose

-- Blood sugar check in the morning of the Blood sugar check in the morning of the procedureprocedure

-- Glucophage Glucophage –– renal problems with renal problems with iodinated contrast = stop glucophage iodinated contrast = stop glucophage for 48 hours following procedurefor 48 hours following procedure

Communicate with managing physicians PRNCommunicate with managing physicians PRN

Multidisciplinary approach

Psychiatric evaluationPsychiatric evaluation

Conventional treatment methodsConventional treatment methods

Interventional proceduresInterventional procedures

Aggressive physical therapyAggressive physical therapy

Pharmacological managementPharmacological management

Selecting the right procedure

(Racz GB, Eval. and Treatment of Chronic Pain, Ch.36 1998)

PAIN MANAGEMENT PAIN MANAGEMENT MODALITIESMODALITIES

PHARMACOTHERAPYPHARMACOTHERAPY

NERVE BLOCKSNERVE BLOCKS

NEUROLYSIS NEUROLYSIS -- CHEMICAL, CRYOABLATION, RFL, CHEMICAL, CRYOABLATION, RFL, SURGICALSURGICAL

ENDOSCOPY ENDOSCOPY -- EPIDUROSCOPYEPIDUROSCOPY

IMPLANTATION TECHNOLOGY IMPLANTATION TECHNOLOGY -- SPINAL CORD SPINAL CORD STIMULATOR, IMPLANTABLE INFUSION THERAPYSTIMULATOR, IMPLANTABLE INFUSION THERAPY

NEWER TECHNOLOGY NEWER TECHNOLOGY -- IDET, NUCLEOPLASTY, IDET, NUCLEOPLASTY, VERTEBROPLASTY, MICRODISCECTOMY, ETCVERTEBROPLASTY, MICRODISCECTOMY, ETC

SURGERYSURGERY

PHYSICAL MEDICINE AND REHABILITATIONPHYSICAL MEDICINE AND REHABILITATION

PSYCHOLOGICAL AND BEHAVIORAL MANAGEMENTPSYCHOLOGICAL AND BEHAVIORAL MANAGEMENT

INTEGRATIVE MEDICINE INTEGRATIVE MEDICINE -- ACUPUNCTURE, MASSAGE, ACUPUNCTURE, MASSAGE, BIOFEEDBACK, HERBALS, MANIPULATION, ETCBIOFEEDBACK, HERBALS, MANIPULATION, ETC

PAIN MANAGEMENT PAIN MANAGEMENT MODALITIESMODALITIES

THERE IS NO SINGLE TREATMENT THERE IS NO SINGLE TREATMENT MODALITY THAT GUARANTEES MODALITY THAT GUARANTEES COMPLETE PAIN RELIEFCOMPLETE PAIN RELIEF

INTERDISCIPLINARY APPROACH IS INTERDISCIPLINARY APPROACH IS MOST SUCCESSFULMOST SUCCESSFUL

A 50 % OR MORE REDUCTION IN A 50 % OR MORE REDUCTION IN TOTAL BODY PAIN IS CONSIDERED A TOTAL BODY PAIN IS CONSIDERED A POSITIVE RESPONSE TO THERAPYPOSITIVE RESPONSE TO THERAPY

PHARMACOTHERAPYPHARMACOTHERAPY CORNERSTONE OF CORNERSTONE OF

THERAPYTHERAPY

WHO ANALGESIC WHO ANALGESIC LADDERLADDER

CLASSES OF CLASSES OF ANALGESICSANALGESICS NONNON--OPIOIDSOPIOIDS

OPIOIDSOPIOIDS

ANALGESIC ADJUVANTSANALGESIC ADJUVANTS

TYPES OF NERVE BLOCKSTYPES OF NERVE BLOCKS

DIAGNOSTICDIAGNOSTIC -- ASCERTAIN PAIN TYPE, ASCERTAIN PAIN TYPE, POSSIBLE MECHANISMS AND ORIGIN POSSIBLE MECHANISMS AND ORIGIN OF THE PAIN, LOCALIZE PAIN SITEOF THE PAIN, LOCALIZE PAIN SITE

PROGNOSTICPROGNOSTIC –– PREDICTS PREDICTS SUBSEQUENT RESPONSE TO THERAPYSUBSEQUENT RESPONSE TO THERAPY

THERAPEUTICTHERAPEUTIC –– PATIENTPATIENT’’S SUBJECTIVE S SUBJECTIVE RESPONSE AND PHYSICIANRESPONSE AND PHYSICIAN’’S S OBJECTIVE OBSERVATIONOBJECTIVE OBSERVATION

NERVE BLOCKS: NERVE BLOCKS: TECHNIQUESTECHNIQUES LOCAL INFILTRATION, TRIGGER POINT LOCAL INFILTRATION, TRIGGER POINT

INJECTION, PROLOTHERAPY, BOTOXINJECTION, PROLOTHERAPY, BOTOX SOMATIC NERVE BLOCKSSOMATIC NERVE BLOCKS SYMPATHETIC NERVE BLOCKSSYMPATHETIC NERVE BLOCKS EPIDURAL STEROID INJECTIONSEPIDURAL STEROID INJECTIONS FACET JOINT INJECTIONFACET JOINT INJECTION JOINT INJECTIONSJOINT INJECTIONS-- HIPS, KNEES, HIPS, KNEES,

SHOULDERS, SACROILIAC, ETCSHOULDERS, SACROILIAC, ETC INTRATHECAL BLOCKINTRATHECAL BLOCK

NERVE BLOCKS NERVE BLOCKS -- BASIC BASIC CONSIDERATIONSCONSIDERATIONS

REQUIRES ANATOMIC REQUIRES ANATOMIC KNOWLEDGE AND EXPERIENCEKNOWLEDGE AND EXPERIENCE

ACCURATE PAIN DIAGNOSISACCURATE PAIN DIAGNOSIS

MEDICAL HISTORY AND MEDICAL HISTORY AND PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

LABORATORY EXAMINATION LABORATORY EXAMINATION WHEN APPROPRIATEWHEN APPROPRIATE

NERVE BLOCK: NERVE BLOCK: MECHANISMS OF ANALGESIAMECHANISMS OF ANALGESIA

INTERRUPTION OF NOCICEPTIVE INTERRUPTION OF NOCICEPTIVE OR PAIN SENSORY PATHWAYS OR PAIN SENSORY PATHWAYS

INDUCTION OF SYMPATHETIC INDUCTION OF SYMPATHETIC BLOCKADE BLOCKADE -- REDUCE REDUCE VASOMOTOR, VISCEROMOTOR, VASOMOTOR, VISCEROMOTOR, AND SUDOMOTOR OVERACTIVITYAND SUDOMOTOR OVERACTIVITY

SOMATOSENSORY BLOCKADESOMATOSENSORY BLOCKADE

INTRAVENOUS INTRAVENOUS SYMPATHETIC BLOCKSYMPATHETIC BLOCK

ALTERNATIVE METHODALTERNATIVE METHOD

IF PATIENTS ARE IF PATIENTS ARE ANTICOAGULATED, HAVE ANTICOAGULATED, HAVE DECREASED PLATELETS OR DECREASED PLATELETS OR POSTSURGICAL CHANGES AT POSTSURGICAL CHANGES AT SITE OF SYMPATHETIC SITE OF SYMPATHETIC BLOCKBLOCK

IV GUANITHEDINE, IV GUANITHEDINE, PHENTOLAMINE, BRETYLIUMPHENTOLAMINE, BRETYLIUM

BIER BLOCK (REGIONAL IV BIER BLOCK (REGIONAL IV BLOCK)BLOCK)

NEUROLYSIS TECHNIQUESNEUROLYSIS TECHNIQUES

CHEMICAL NEUROLYSISCHEMICAL NEUROLYSIS

CRYOABLATIONCRYOABLATION

RADIOFREQUENCY LESIONINGRADIOFREQUENCY LESIONING

SURGICAL DISRUPTIONSURGICAL DISRUPTION

CHEMICAL NEUROLYSISCHEMICAL NEUROLYSIS DESTRUCTION OF NERVES TO DESTRUCTION OF NERVES TO

PROMOTE ANALGESIAPROMOTE ANALGESIA NEUROLYTIC AGENTS CAN BE USED IN NEUROLYTIC AGENTS CAN BE USED IN

THE EPIDURAL AND SUBARACHNOID THE EPIDURAL AND SUBARACHNOID SPACES, PERIPHERAL NERVES, AND SPACES, PERIPHERAL NERVES, AND CELIAC PLEXUS.CELIAC PLEXUS.

USE IS LIMITED DUE TO NONUSE IS LIMITED DUE TO NON--SPECIFIC SPECIFIC DESTRUCTION OF NERVES AND DESTRUCTION OF NERVES AND SURROUNDING TISSUESSURROUNDING TISSUES

PRIMARILY USE IN MALIGNANT PAIN PRIMARILY USE IN MALIGNANT PAIN AND RARELY, IN INTRACTABLE AND RARELY, IN INTRACTABLE CHRONIC PAINCHRONIC PAIN

NERVE DAMAGE CATEGORY NERVE DAMAGE CATEGORY DURING NEUROLYSISDURING NEUROLYSIS

FIRST DEGREE OR NEUROPRAXIA FIRST DEGREE OR NEUROPRAXIA --REVERSIBLE NERVE INJURYREVERSIBLE NERVE INJURY

SECOND DEGREE OR AXONOTMESIS SECOND DEGREE OR AXONOTMESIS --DESTRUCTION OF AXONAL FIBERS DESTRUCTION OF AXONAL FIBERS BUT NEURAL SHEATH IS INTACTBUT NEURAL SHEATH IS INTACT

THIRD DEGREE OR NEUROTMESIS THIRD DEGREE OR NEUROTMESIS --COMPLETE NERVE DESTRUCTIONCOMPLETE NERVE DESTRUCTION

NEUROLYSISNEUROLYSISAGENT ADVANTAGES DISADVANTAGESALCOHOL HYPOBARICITYALCOHOL HYPOBARICITY NEURITIS; SLOUGHINGNEURITIS; SLOUGHING

(50(50--100%)100%) MAYBE USEFULMAYBE USEFUL OF SUPERFICIAL AREASOF SUPERFICIAL AREAS

PHENOLPHENOL HYPERBARICITY OFHYPERBARICITY OF <PROFOUND & SHORTER<PROFOUND & SHORTER

66--12% IN NS,12% IN NS, GLYCERIN MAYBEGLYCERIN MAYBE DURATION THAN ALCOHOL;DURATION THAN ALCOHOL;

GLYCERIN,GLYCERIN, USEFULUSEFUL NEURITIS; SLOUGHINGNEURITIS; SLOUGHING

CONTRASTCONTRAST

CRYOPROBECRYOPROBE REVERSIBLE, NOREVERSIBLE, NO VERY EXACT PROBE VERY EXACT PROBE

NEURITIS, SMALLNEURITIS, SMALL LOCATION, LARGE PROBELOCATION, LARGE PROBE

DESTROYED AREADESTROYED AREA

RFLRFL SMALL AREA OFSMALL AREA OF NEURITIS, ACCURATE PROBENEURITIS, ACCURATE PROBE

DESTRUCTIONDESTRUCTION PLACEMENTPLACEMENT

What is RF?A high frequency electrical current,

transmitted from an active electrode (lesion electrode) through the body and to the passive electrode (dispersive electrode, grounding electrode). Tissue around the electrode is modulated or ablated.

What is RF?

Which types of paincan be treated with RF?

Chronic/Benign and Chronic/Malignant

Cranial Pain

Spinal Pain

Peripheral Pain

EPIDUROSCOPYEPIDUROSCOPYFLEXIBLE FIBEROPTIC ENDOSCOPYFLEXIBLE FIBEROPTIC ENDOSCOPY

3 DIMENSIONAL REAL3 DIMENSIONAL REAL--TIME VIDEO TIME VIDEO COLOR IMAGINGCOLOR IMAGING

PROVIDES A NEW MEDIUM FOR PROVIDES A NEW MEDIUM FOR VIEWING THE CNSVIEWING THE CNS

DIAGNOSTIC AND THERAPEUTIC DIAGNOSTIC AND THERAPEUTIC TOOLTOOL

Epidural Lysis of Adhesions

Also known as:Also known as:

NeurolysisNeurolysis

EpidurolysisEpidurolysis

NeuroplastyNeuroplasty

RACZ ProcedureRACZ Procedure

INDICATIONS FOR ENDOSCOPY

PROVIDES SPECIFIC ETIOLOGY OF PROVIDES SPECIFIC ETIOLOGY OF LOW BACK PAINLOW BACK PAIN

TREAT EPIDURAL ADHESIONS TREAT EPIDURAL ADHESIONS AND INFLAMMATORY REACTION IN AND INFLAMMATORY REACTION IN THE EPIDURAL SPACE IN THE EPIDURAL SPACE IN PATIENTS WHO FAIL TO RESPOND PATIENTS WHO FAIL TO RESPOND TO CONSERVATIVE TREATMENT TO CONSERVATIVE TREATMENT OR FAILURE TO IMPROVE OR FAILURE TO IMPROVE FOLLOWING SURGERYFOLLOWING SURGERY

CONTRAINDICATIONS OF CONTRAINDICATIONS OF ENDOSCOPYENDOSCOPY

PATIENT REFUSALPATIENT REFUSAL

BLEEDING DISORDERSBLEEDING DISORDERS

PREGNANCYPREGNANCY

INFECTION AT INSERTION SITE / INFECTION AT INSERTION SITE / SEPSISSEPSIS

HISTORY OF DRUG REACTION TO HISTORY OF DRUG REACTION TO ANY OF THE INJECTED DRUGS ( ANY OF THE INJECTED DRUGS ( STEROID, HYALURONIDASE, STEROID, HYALURONIDASE, OPIOID, LOCAL ANESTHETICS)OPIOID, LOCAL ANESTHETICS)

Principles of neurolysis

Breaking up of scar formationBreaking up of scar formation

Lesion specific injection Lesion specific injection

Saturation of medication to swollen nerve Saturation of medication to swollen nerve rootsroots

Delivery of medication to painful nerve root Delivery of medication to painful nerve root and decompressionand decompression

Decompressed nerve root has better blood Decompressed nerve root has better blood supply and chance for improved functionssupply and chance for improved functions

COMPLICATIONS OF ENDOSCOPYCOMPLICATIONS OF ENDOSCOPY

NERVE TISSUE IRRITATIONNERVE TISSUE IRRITATION

INTRAVASCULAR DRUG INJECTIONINTRAVASCULAR DRUG INJECTION

POSTDURAL PUNCTURE HEADACHEPOSTDURAL PUNCTURE HEADACHE

TOTAL SPINAL BLOCKTOTAL SPINAL BLOCK

ALLERGY/ ADVERSE DRUG REACTIONALLERGY/ ADVERSE DRUG REACTION

RETINAL HEMORRHAGERETINAL HEMORRHAGE

BLEEDINGBLEEDING

INFECTIONINFECTION

Extended efficacy of neurolysis

(Racz GB, P.E. Neuroplasty, Pain Digest 1999)

IMPLANTATION TECHNOLOGYIMPLANTATION TECHNOLOGY

DRUG INFUSION THERAPY DRUG INFUSION THERAPY --OPIOIDS, LOCAL ANESTHETIC, OPIOIDS, LOCAL ANESTHETIC, CLONIDINE, BACLOFENCLONIDINE, BACLOFEN

SPINAL CORD STIMULATOR SPINAL CORD STIMULATOR IMPLANTATIONIMPLANTATION

IMPLANTATION TECHNOLOGYIMPLANTATION TECHNOLOGY

END OF THE LINE END OF THE LINE THERAPYTHERAPY

INDICATIONSINDICATIONS::

INCOMPLETE PAIN RELIEF INCOMPLETE PAIN RELIEF FROM CONSERVATIVE FROM CONSERVATIVE MANAGEMENTMANAGEMENT

NEUROSURGICAL/NEURODESNEUROSURGICAL/NEURODES--TRUCTIVE PROCEDURES TRUCTIVE PROCEDURES ARE NOT INDICATEDARE NOT INDICATED

IMPLANTATION TECHNOLOGYIMPLANTATION TECHNOLOGY

BASIC PREBASIC PRE--REQUISITESREQUISITES

NO ACTIVE DRUG ADDICTION.NO ACTIVE DRUG ADDICTION.PATIENT IS NOT A SURGICAL PATIENT IS NOT A SURGICAL

CANDIDATE.CANDIDATE.PSYCHOLOGIC CLEARANCE IS OBTAINED.PSYCHOLOGIC CLEARANCE IS OBTAINED.PATIENT FAILED CONSERVATIVE PAIN PATIENT FAILED CONSERVATIVE PAIN

MANAGEMENT.MANAGEMENT.TRIALS HAVE BEEN SUCCESSFUL.TRIALS HAVE BEEN SUCCESSFUL.NO CONTRAINDICATION EXISTS.NO CONTRAINDICATION EXISTS.

DRUG INFUSION THERAPYDRUG INFUSION THERAPY

BASED ON THE CONCEPT OF BASED ON THE CONCEPT OF ““FOCUSED DRUG DELIVERYFOCUSED DRUG DELIVERY””

DRUGS ARE DELIVERED EITHER DRUGS ARE DELIVERED EITHER INTO THE EPIDURAL SPACE OR INTO THE EPIDURAL SPACE OR THE SUBARACHNOID SPACETHE SUBARACHNOID SPACE

INVOLVES CATHETER INSERTIONINVOLVES CATHETER INSERTION

DRUG INFUSION DELIVERY SYSTEMDRUG INFUSION DELIVERY SYSTEM

TEMPORARY EPIDURAL CATHETER TEMPORARY EPIDURAL CATHETER SYSTEMSYSTEM

TUNNELED PERCUTANEOUS TUNNELED PERCUTANEOUS ““SEMISEMI--PERMANENTPERMANENT”” EPIDURAL / INTRATHECAL EPIDURAL / INTRATHECAL SYSTEMSYSTEM

FULLY IMPLANTED EPIDURAL / FULLY IMPLANTED EPIDURAL / INTRATHECAL PORT SYSTEMINTRATHECAL PORT SYSTEM

FULLY IMPLANTED CONTINUOUS FULLY IMPLANTED CONTINUOUS INFUSION PUMPSINFUSION PUMPS

FULLY IMPLANTED INTRATHECAL FULLY IMPLANTED INTRATHECAL PATIENT CONTROLLED PUMPSPATIENT CONTROLLED PUMPS

DRUG INFUSION THERAPY: DRUG INFUSION THERAPY: COMPLICATIONSCOMPLICATIONS

SKIN AND SUBCUTANEOUS INFECTION SKIN AND SUBCUTANEOUS INFECTION AROUND CATHETER EXIT SITEAROUND CATHETER EXIT SITE

EPIDURAL HEMATOMAEPIDURAL HEMATOMA

ABSCESSABSCESS

MENINGITISMENINGITIS

DRUG SIDE EFFECTS DRUG SIDE EFFECTS -- ITCHING, ITCHING, NAUSEA, CONSTIPATION, URINARY NAUSEA, CONSTIPATION, URINARY RETENTION LESS COMMONRETENTION LESS COMMON

TOLERANCE TO DRUG EFFECTTOLERANCE TO DRUG EFFECT

DRUG INFUSION THERAPY DRUG INFUSION THERAPY FAILUREFAILURE

NEUROPATHIC OR INCIDENT PAINNEUROPATHIC OR INCIDENT PAINFAILURE OF THE DELIVERY FAILURE OF THE DELIVERY

SYSTEMSYSTEM INADEQUATE DOSINGINADEQUATE DOSING INCORRECT PRESCRIPTIONINCORRECT PRESCRIPTIONOBSTRUCTED CSF MECHANICSOBSTRUCTED CSF MECHANICSPSYCHOPSYCHO--EMOTIONAL EMOTIONAL

DECOMPENSATIONDECOMPENSATIONDEVELOPMENT OF DRUG DEVELOPMENT OF DRUG

TOLERANCETOLERANCE

SPINAL CORD STIMULATOR SPINAL CORD STIMULATOR IMPLANTATIONIMPLANTATION

REQUIRES INSERTION OF EPIDURAL REQUIRES INSERTION OF EPIDURAL ELECTRODES OVER THE SPINAL ELECTRODES OVER THE SPINAL CORD AREA NEEDED TO BE CORD AREA NEEDED TO BE STIMULATED.STIMULATED.

A PERMANENT NEUROA PERMANENT NEURO--PULSE PULSE GENERATOR IS SUBCUTANEOUSLY GENERATOR IS SUBCUTANEOUSLY IMPLANTEDIMPLANTED.

““ PAIN PACEMAKER PAIN PACEMAKER ““

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Current Indications(and growing)

Failed Back Surgery Syndrome. Ischemic Peripheral Vascular

Disease. Atypical Trigeminal Neuralgia. Refractory Angina Pectoris. Phantom Limb Pain. Post Thoracotomy Pain. Multiple Plexopathies.

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Preparing the Patient for Test Stimulation

Position and Position and sedate the sedate the patientpatient

Mark Mark interspinous interspinous intervals with intervals with fluoroscopyfluoroscopy

Mark desired Mark desired entry levelentry level

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Important Information on Implanted Devices for Pain Therapy

Possible complications Infections

Lead dislodgment

Loss of functionality

Surgical revision for reduction or loss of pain relief

Interference may be caused by MRIs and other radio frequency devices

Lead fracture

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MISCELLANEOUS TECHNIQUESMISCELLANEOUS TECHNIQUES

VERTEBROPLASTYVERTEBROPLASTY

INTRADISCAL ELECTROTHERMY INTRADISCAL ELECTROTHERMY (IDET)(IDET)

NUCLEOPLASTYNUCLEOPLASTY

MINIMALLY INVASIVE MINIMALLY INVASIVE MICRODISCECTOMYMICRODISCECTOMY

DISC IMPLANTDISC IMPLANT----CHARITECHARITE

VERTEBROPLASTY

an effective, minimally invasive procedure in which acrylic bone cement is injected into a pathologically compressed vertebral body

Indications

Pain related to vertebral compression fracture associated with:

Osteoporosis

Tumor infiltration

OSTEOPOROSIS

Pathologic Vertebral Body Compression Fracture

Primary osteoporosis

Elderly patient

Female>male

Secondary osteoporosis

Young patient

Steroid use

Asthma, vasculitis, transplant, inflammatory bowel disease

Contraindications:

Moderate or severe retropulsion of the posterior vertebral body cortex into the spinal canal

Height loss >70%

Infection

Coagulopathy

Complications

Spinal cord or nerve root injury

<1%

Direct

Puncture

Indirect

Compression

Hematoma

Ischemia

Complications

Hemorrhage

Rare

Infection

Rare

Pulmonary embolism

Fracture

Lamina

Pedicle

Increased pain

1-2%

Death

Complications

Symptomatic cement extravasation

Incidence: depends upon etiology of fracture

Osteoporosis 1-2%

Neoplasm 5-10%

Complications: Cement Extravasation

Location

Epidural

Foraminal

Paravertebral

Disc