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Advancement in back pain treatment
1. Dr. Manish Raj MD,DA,FISP,FPM
Minimally Invasive Spine & Pain consultant
Fellow of Interventional spine & pain(Pci-Mumbai)
Fellow of Pain manganement (FPM-Aesculap Germany)
Member- North american spine society(NASS)
-Society of minimally invasive spine surgery(SMISS)
2. • About 85% of Indians experience back trouble by age 50.
• Back problems are the most frequent cause of activity
limitations in working-age adults
• In the long run, surgery, chiropractic care, etc., are
considered no more effective than no treatment in
reducing low back pain…so, prevention is key!
Back facts in general…
4. BACK & NECK PAIN
One of the most common chronic conditions in India
Frequency in men & women are equal
4 out of 5 Indians will experience LBP or Neck Pain
Acute: 6 weeks
Chronic: > 6 weeks
8. MUSCLES & Connective Tissues
Spine is supported by bones, muscles and connective
tissues
9. Injury to any structures previously
mentioned in the Spine
region
How do you get low back pain?
10. • Poor body mechanics
• Stressful living & work habits
• General physical fitness decline
• Loss of flexibility
• Loss of strength
Leading Causes of Back
Problems
11. General joint stiffness
Acute strains and sprains
Muscle guarding or spasm
Disc bulge herniation
Degenerative disk disease
Osteoarthritis
Common Back Disorders
12. A other ause of a k pro le s…
accidents
It is also possible to injure
your back due to accidents.
14. Disc Injury
Discs have sensory pain receptors
Discs can:
Degenerate
Bulge/ herniate
Most easily injured with flexion
& rotational forces
15. Fractures
Less common
Usually occurs with major trauma or as a result of a
pathology
Fall from a tall height
Osteoporosis
Cancer in the bone
Infection of the bone
32. Optimal Patient Selection
Radicular pattern with or without Axial Pain
Leg pain > back pain
MRI evidence of contained disc protrusion
Discography positive, if indicated
Failed selective nerve root block x 1
Failed conservative therapy X 3 months
Axial Back Pain
Failed conservative therapy X 3 months
MRI evidence of contained disc protrusion
Discography positive for concordant pain
Failed diagnostic injections (facet, nerve, epidural etc)
Disc height > 75%
33. Exclusion Criteria
50 % loss of disc height
Extruded or sequestered disc
Spinal fracture or tumour
Moderate to severe spinal stenosis
Complete annular disruption
Degenerative instability
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34. Clinical Outcomes After Lumbar Discectomy for Sciatica:
The Effects of Fragment Type and Annular Competence
EJ Carragee et al., Stanford University , The Journal of Bone and Joint Surgery. Jan 2003
Are Nucleoplasty and Microdiscectomy patients the same?
Study of microdiscectomy outcomes based on
herniation type
Classified herniations into 4 types
Results: contained herniation with no sub-annular
fragment performed poorly with microdiscectomy
Conclusion: The ideal Nucleoplasty patient is not a
good candidate for microdiscectomy
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39. Lumbar Nucleoplasty Technique
1. Using fluoroscopy, introduce
the needle to the
nucleus/annulus junction of
the disk (Confirm position
using fluoroscopy).
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40. Lumbar Nucleoplasty Technique
2. Insert the wand through
the needle, and advance
the Wand until the
Reference Mark is at the
needle hub.
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41. Lumbar Nucleoplasty Technique
3. Using blunt dissection,
advance the tip of the DLR
into the nucleus, and
STOP when the distal
annulus is reached.
This determines the Distal
channel limit.
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42. Lumbar Nucleoplasty Technique
4. Position Depth Gauge at
the needle hub
It will reference the Distal
channel limit within the
nucleus (this should be
confirmed using fluoroscopy).
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43. Lumbar Nucleoplasty Technique - Final Result
Create additional
channels at the 4, 6,
8, and o’clock
positions.
Approximately 1/2 cc
of tissue removed
causing
decompression.
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44. The Procedure-Cervical Nplasty
The surgeon uses the fingers to detect the vertebral space holding the SCM
muscle laterally and the trachea medially.
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45. Under fluoroscopic control, the introducer needle is inserted using an anterior
lateral approach, medially to the SCM and vessels.
The Procedure
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46. Needle Placement
Check needle placement in A/P projection
Needle should be in line with the midline (spinous process)
A/P Lateral
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47. Cervical Nucleoplasty Technique
Position needle tip in the posterior 1/3 of the
nucleus
Anterior-lateral approach
Fluoroscopic guidance
If desired, move the green
marker down to skin level.
Unscrew and remove the
stylet
Insert the Perc DC SpineWand
Only as far as tip remains within end of needle
Do not allow device to protrude from needle
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48. Cervical Nucleoplasty Technique
Once the device is inserted,
withdraw the needle from
over the tip of the device
monitor deployment of device
beyond end of needle
Lock Perc DC into Needle
Hub
Confirm with fluoroscopy
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49. Cervical Nucleoplasty Technique
In ablation mode, rotate device
through 360
o
for approximately
2 - 3 seconds
Withdraw device 1-2 mm and
repeat to make a series of 2-3 voids.
Never maneuver or advance the
needle with the device inserted
Unlock SpineWand from needle
hub and withdraw into introducer
needle before removing.
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3 2 1
50. 3 2 1
The Procedure
Ablation mode is performed for three cycles in
withdrawal, rotating the wand 180 in each cycle (8
seconds ablation each)
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