This document discusses various interventional pain procedures for chronic pain management, including their indications and how they are performed. It describes epidural injections, facet joint injections, sacroiliac joint injections, medial branch blocks, and radiofrequency nerve ablation. Epidural injections are most effective for nerve root compression and spinal stenosis. Facet joint injections target back pain from facet joints, while sacroiliac joint injections are for referred pain in the low back or lower extremities. Medial branch blocks and radiofrequency ablation can provide diagnostic information and long-term pain relief by denervating facet joints. Proper patient selection, aseptic technique, imaging guidance, and monitored sedation are important for safety. The document also reviews
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Pain management
1. Interven'onal
Â
Procedures
 in
 Chronic
Â
Pain
Â
Â
Â
Dr
 Brendan
 Moore
Â
Specialist
 Pain
 Medicine
 Physician
Â
Adjunct
 Associate
 Professor
Â
 University
 of
 Queensland
Â
4. Origins
 of
 lumbar
 pain
Â
â˘âŻ Degenera've
 Discs
Â
â˘âŻ Vertebral
 fractures
Â
â˘âŻ Spinal
 /
 Foraminal
Â
Stenosis
Â
â˘âŻ Disc
 Bulge
 /
 Prolapse
Â
â˘âŻ Facet
 Joint
Â
Â
â˘âŻ Muscle
 /
 So@
 'ssue
Â
Â
5. Invasive
 Treatment
 Op'ons
Â
â˘âŻ Surgery
Â
â˘âŻ Facet
 Joint
 Injec'on
Â
â˘âŻ Radiofrequency
 medial
 branch
 abla'on
Â
â˘âŻ Epidural
 /
 Caudal
 steroid
Â
â˘âŻ Vertebroplasty
Â
â˘âŻ Coeliac
 /
 Lumbar
 Sympathe'c
 Plexus
 Blocks
Â
â˘âŻ Sacro-Ââiliac
 Joint
 injec'on
Â
6. Posterior
 Elements
Â
â˘âŻ Facet
 Joints
 frequently
 implicated
 in
 pain
Â
â˘âŻ Mechanical
 back
 pain
 with
 upper
 leg
 and
 buNock
Â
radia'on
Â
7. Appropriate conditions for
interventional pain procedures
â˘âŻ Aseptic conditions
â˘âŻ Monitored sedation
with anaesthetist in
attendance
â˘âŻ Image intensifying X-
ray or CT guidance
â˘âŻ Appropriate analgesia
11. Epidural injections
â˘âŻ Most effective in the presence of nerve root
compression and spinal stenosis
â˘âŻ Increased efficacy if given in the first weeks of
the onset of pain
â˘âŻ Effects of the injection tend to be temporary (1
week to 1 year)
â˘âŻ Can be beneficial in providing relief for patients
during an episode of severe back pain
â˘âŻ Allows patients to progress in their rehabilitation
12. Lumbar epidural injection
â˘âŻ 18G or 16G Toohey
needle
â˘âŻ Radio-opaque contrast
to confirm position
â˘âŻ Injection and
distribution of local
anaesthetic and
steroid to nerve root
15. Facet joint injections
â˘âŻ Back pain originating from facet joints
â˘âŻ Low back pain (unilateral or bilateral) and no
root tension signs or neurological deficits
â˘âŻ Pain usually being aggravated by extension of
the spine
â˘âŻ Facet joint injection may reduce inflammation
and provide pain relief
â˘âŻ Therapeutic goal and potential benefit
â⯠Temporary relief from pain
â⯠Patient may proceed into an appropriate exercise program"
16. Facet
 Joint
 Injec'on
Â
â˘âŻ Primarily
 diagnos'c
Â
â˘âŻ 25G
 Spinal
 needle
Â
Â
â˘âŻ LA
 +
 Steroid
Â
â˘âŻ Steroid
 confers
 possible
Â
longer
 term
 beneďŹt
Â
17. Sacroiliac joint injection
â˘âŻ Indicated with referred pain
â˘âŻ Pain referral pattern â area around and just
caudal to the posterior superior iliac spine
â˘âŻ Referred pain in the low back, buttocks,
abdomen, groin or legs
â˘âŻ In some patients, S-1 joint injections can
provide significant pain relief"
18. Sacroiliac joint injection
â˘âŻ Diagnostic
â˘âŻ 25G spinal needle
â˘âŻ Local anaesthetic +
steroid
â˘âŻ Steroid indicative of
possible long-term
benefit
20. Medial branch blocks
â˘âŻ Medial branch nerves are the very small nerve
branches that controls sensation of the facet joint
â˘âŻ Indicated in low back pain (unilateral or bilateral)
â˘âŻ Pain usually aggravated by extension of the spine
â˘âŻ Medial branch blocks are a diagnostic procedure
â˘âŻ Can provide temporary pain relief
21. Medial branch nerve ablation
â˘âŻ Diagnostic medial
branch blocks
â˘âŻ Local anaesthetic +
steroid
â˘âŻ Progress to
radiofrequency
ablation if diagnostic
block indicative of
long-term benefit
22. Medial
 Branch
 Nerve
 Abla'on
Â
â˘âŻ Denerva'on
 of
 Medial
Â
Branch
 via
Â
Radiofrequency
Â
Neurotomy
Â
23. Radiofrequency neurotomy
X-ray to confirm needle position â AP and oblique
views
Test stimulation â 2.0 Hz 0â2 volt to test for motor
nerve contact
Lesion 85°C for 90 seconds
28. Facet joint injection
â˘âŻ Diagnostic
â˘âŻ 25G spinal needle
â˘âŻ Local anaesthetic +
steroid
â˘âŻ Steroid indicative of
possible long-term
benefit
29.
30.
31. Elena Yusim â Pain Psychologist
The Psychology of Pain
Management
32. Strategy
Psychosocial
 Assessment
Â
Â
§ď§âŻ
 medical
 history
 â
 any
 ďŹags/concerns/drug
 seeking
Â
§ď§âŻ Thinking
 paNerns
 â
 helpful
 or
 unhelpful
Â
§ď§âŻ Social
 interac'ons
 -Ââ
 family,
 friends,
 spouse
Â
§ď§âŻ Behaviours
 -Ââ
Â
 ac'vity
 levels,
 avoidance,
 anything
 harmful
Â
§ď§âŻ Sleep
 paNerns
 â
 any
 changes
Â
Â
Â
33. Testing
§ď§âŻ Beck
 Depression
 Inventory
 â
 BDI
Â
§ď§âŻ Depression,
 Anxiety
 and
 Stress
 Scale
 â
 DASS
Â
§ď§âŻ Personality
 Assessment
 Inventory
 -Ââ
 PAI
Â
34. Reality Check
§ď§âŻ Why
 is
 the
 pa'ent
 here?
Â
§ď§âŻ Mo'va'on
 to
 RTW?
Â
§ď§âŻ Any
 secondary
 gain
 from
 sick
 role?
Â
§ď§âŻ Are
 they
 prepared
 to
 do
 the
 hard
 work?
Â
§ď§âŻ Do
 they
 expect
 to
 be
 ďŹxed?
Â
§ď§âŻ What
 do
 they
 agree
 to,
 if
 they
 donât
 comply?
Â
35. Invisible Tool Kit
§ď§âŻ Goal
 seng
Â
§ď§âŻ Pacing
Â
§ď§âŻ Journaling
Â
§ď§âŻ Thought
 Management
 â
 CBT,
 ACT
Â
§ď§âŻ Relaxa'on
Â
 and
 self
 regula'on
 strategies
Â
§ď§âŻ Relapse
 preven'on
 planning
Â
Â
36. Opioids
 in
 Chronic
 Pain
Â
Â
Â
Dr
 Brendan
 Moore
Â
Pain
 Medicine
 Specialist
 Physician
Â
Adjunct
 Associate
 Professor
Â
 University
 of
 Queensland
Â
38. Suggested maximum opioid dose
â˘âŻ Consult a Pain Medicine Specialist if higher doses
considered necessary
1. Hunter Integrated Pain Service. Opioid use in persistent pain. November 2010
Drug Maximum dose for GP
prescription
Morphine 120mg daily
Oxycodone 80mg daily
Hydromorphone 24 mg daily
Methadone 40mg daily
Fentanyl transdermal patch 25 mcg/hr applied every 3 days
Buprenorphine transdermal patch 40 mcg/hr applied weekly
Tramadol 400 mg daily
40. Opioid trial guidelines
â˘âŻ Commence trial with low dose sustained-release
opioid
Use a lower dose and titrate slowly in patients
who are:
â˘âŻ Elderly
â˘âŻ Taking other CNS depressants
â˘âŻ Opioid naĂŻve
â˘âŻ Have severe hepatic or renal dysfunction
1.⯠Graziotti & Goucke, 1997.
41. Review of opioid trial
â˘âŻ Discuss progress and outcomes
â˘âŻ Functional goals achieved?
â˘âŻ Medication used responsibly?
â˘âŻ Discuss risks / benefits of continued therapy
â˘âŻ Assess 4 âAâs1
â⯠Analgesia
â⯠Activity
â⯠Adverse effects
â⯠Aberrant drug behaviours
1. Gourlay & Heit, 2005.
42. Federal requirements
PBS prescription
Restricted benefit
â˘âŻ Chronic severe disabling pain not responding to non-
narcotic analgesics (treatment <12 months)
â˘âŻ If treatment required beyond 12 months, patient must be
reviewed by a second medical practitioner
â˘âŻ Authority required when prescribing increased quantities
of opioid and/or repeats
â⯠By phone â 1 monthâs supply with no repeats
â⯠In writing â 1 monthâs supply with 2 repeats
â˘âŻ Short term supply can be prescribed without an authority
Department of Health and Ageing, 2008.
43. State requirements - QLD
â˘âŻ If intend to prescribe S8 drugs for longer than 8 weeks,
forward a âReport to the Chief Executiveâ through the
Drugs of Dependence Unit (DDU)
â˘âŻ A treatment approval from the Chief Executive is required
prior to treating, for any controlled drug for a patient
considered to be drug dependent
â˘âŻ For approvals and âReports to the Chief Executiveâ contact
the Drugs of Dependence Unit
â⯠Phone 3328 9890
â⯠Fax 3328 9821
44. Preventing doctor-shopping
Medicare Australia
Prescription Shopping Information Service
â˘âŻ If patient suspected of getting medicine in excess
of medical need, contact the Prescription
Shopping Information Service:
â⯠Complete and sign the registration form available at
www.medicareaustralia.gov.au
â˘âŻ Registration confirmed within 2 business days (fax) or by
mail
â⯠Information Service available 24/7 for registered GPs to:
â˘âŻ Find out if patient has been identified under the
Prescription Shopping Program
â˘âŻ Receive information on the amount and type of PBS
medicine recently supplied to that patient
(ď¨
 1800
 631
 181
Â
Â
45. Summary â opioid pathway
Multidimensional assessment
GP +/â practice nurse +/â others
Opioid trial
Maintenance therapy
Authority to Prescribe
Review
Exit from pathway:
i.⯠Goals of therapy not
achieved in trial or
maintenance phase
ii.⯠Predominance of
psychosocial issues
iii.⯠Evidence of aberrant
drug related
behaviour
Integrated Pain Service, 2008.
Is the patient suitable for opioid therapy?
46. State / territory health departments
State /
territory
Department Contact
ACT Pharmaceutical Services Section, ACT Health (ď¨ 02 6207 3974
NSW Pharmaceutical Services Branch, NSW Health (ď¨ 02 9879 3214
8ď¸ www.health.nsw.gov.au/publichealth/
pharmaceutical
NT Poisons Control Unit, Department of Health &
Community Services
(ď¨ 08 8922 7341
8ď¸ www.health.nt.gov.au
QLD Drugs of Dependency Unit, Queensland Health (ď¨ 07 3896 3900
SA Drugs of Dependence Unit, Drug & Alcohol Services,
Department of Health
(ď¨ 1300 652 584
8ď¸ www.health.sa.gov.au
TAS Pharmaceutical Services Branch, Department of
Health & Human Services
(ď¨ 03 6233 2064
VIC Drugs & Poisons Unit, Department of Human
Services
(ď¨ 1300 364 545
8ď¸ www.health.vic.gov.au/dpu
WA Drugs of Dependency Unit, Department of Health (ď¨ 08 9388 4985