chronic pain management by interventional pain techniques

1. MY WORKING PLACE

2. CHRONIC PAIN ALGORITHM
HOW TO MANAGE CHRONIC PAIN ?
DR DIPAK DESAI
MD, DA . (ANAESTHESIOLOGIST)
PAIN CONSULTANT
CIMS HOSPITAL

3. INTERVENTIONAL PAIN
MANAGEMENT
• Definition: The use of invasive techniques to
decrease or eliminate pain
• This can be accomplished in three ways:
• Interrupting the pain signal along a neural pathway
• Neuro augmentation (SCS, PNS)
• Implantable drug delivery system

4. INJECTION THERAPY
• Usually performed utilizing fluoroscopy
• No sedation vs conscious sedation
• Can be therapeutic or diagnostic

5. TRIGGER POINT INJECTION
Trigger points are discrete, focal, hyper-irritable spots located in a taut band of
skeletal muscle
• The pain will be localized and or referred
• Palpation of a hypersensitive bundle or nodule of muscle fiber of harder
than normal consistency is the physical finding typically associated with a
trigger point. Palpation of the trigger point will elicit pain directly over the
affected area and/or cause radiation of pain toward a zone of reference.

6. EPIDURAL
• Injection performed to deposit medication
into the epidural space in proximity to the
spinal nerves
• Can be utilized in the cervical, thoracic or
lumbar region
• Most effective for radicular pain into the arm
or leg
• Should be performed with fluoroscopy

7. EPIDURAL
• There are three approaches to the
epidural space
• Inter laminar
• Trans foraminal
• Sacral Hiatus (caudal)

8. Thoracic epidural blockfor chronic chest pain

9. EPIDURAL
• Trans foraminal Injection
• Performed lateral to the midline with a goal of
depositing the medication near a specific nerve
root in the neuroforamen
• Has a higher complication rate due to the artery
of Adamkiewicz
• More effective for one sided, one level

10. L5-S1 transforaminal injection

11. L5 L5 –S1 nerve root block

12. AP view with RF lesion L5-S1

13. EPIDURAL
• Caudal epidural
• The epidural space is entered via the sacral hiatus
• Most commonly utilized if there has been a previous spine
surgery

14. Caudal
Epidural
dye sprea
d

15. Caudal epidural dye spread

16. EPIDURAL
• Pain conditions that may respond to epidural steroid injections +
LA
• Herniated disc
• Spinal stenosis
• Post laminectomy syndrome
• Spondylosis
• Diabetic neuropathy
• Complex regional pain syndrome ( RSD)
• Post Herpetic neuralgia

17. MEDIAL BRANCH NERVE BLOCK AND RADIO FREQUENCY
LESIONING FOR FACET JOINT PAIN
• It is a synovial joint between the superior articular process and
inferior articular process of two vertebra
• The medial branch nerve derives from the corresponding spinal
nerve transmitting sensory information from each joint
• Disease of the facet joints is seen with aging
• In simplest form, these changes are arthritic and degenerative
• It produces axial pain, usually with activity

19. MEDIAL BRANCH NERVE BLOCK AND
RADIO FREQUENCY LESIONING
• Radio frequency lesioning or neurotomy is
performed using a specialized machine to
produce a radio wave to “burn” a specific nerve
blocking the transmission of the painful impulse
• The lesion should provide relief for 6-9 months
• There is regeneration of the neural pathway
which allows the pain to return
• This procedure can be repeated

20. SYMPATHETIC BLOCKS
• These blocks are performed when pain is
neuropathic with a sympathetic component
• The blocks interrupt the nerve transmission in a
large area of the body
• They are performed at the ganglion

21. SYMPATHETIC BLOCKS
• Stellate Ganglion Block
• Performed by injecting 10 cc of local anesthetic in proximity to the stellate
ganglion
• Used to treat upper extremity pathology CRPS, PHN

22. Celiac plexus CT guidance

23. SYMPATHETIC BLOCKS
• Celiac Plexus Block
• Performed by injecting local anesthetic in proximity of the celiac
plexus
• Used to treat pathology of the abdomen
• Should always be performed with imaging (CT Scan or fluoroscopy)

24. DOSES
• For diagnostic and prognostic block by Retrocrural
method : 12-15 ml of 1% lidocaine OR 0.25%
sensorcaine through each needle. LA should be
administered in incremental dose to avoid toxicity.
• For Rx of Acute pancreatitis : 80 mg methylprednisolone
for initial block and 40 mg for subsequent blocks.
• Neurolytic block : 10-12 ml 50% alcohol OR 6% phenol
through each needle.
• After neurolytic block each needle should be flushed
with sterile saline solution.
• CT guided celiac plexus block provide added margin of
safety to pain specialist so it is recommended.

25. SUPERIOR HYPOGASTRIC PLEXUS BLOCK
25
1) Needles advanced anterior to L5/S1
– Bilateral
– Unilateral Transdiscal
2) Radio contrast dye is used to confirm
placement of needle
3) Diagnostic block with local anesthetic
or
Neurolytic block with alcohol or phenol

26. Superior hypogastric
plexus block

27. CT guided Needle placement + Dye spread

28. Superior hypogastric plexus block

29. Superior hypogastric plexus block dye spread

30. 30
GANGLION IMPAR
• Aka “Ganglion of Walther”
• Sits just anterior to sacrococcygeal junction
• Provides Innervation to:
• Perineum*
• Distal Rectum/Anus
• Distal Urethra
• Distal 1/3 Vagina
• Vulva

31. SYMPATHETIC BLOCKS
• Lumbar Paravertebral Sympathetic Block
• Performed to treat neuropathic pain of the lower
extremity

32. RF lesionin
g

33. Needle with dye injection

34. Needle at L2-3-4 sympathetic chain

35. NEUROAUGMENTATION
• Spinal Cord Stimulation (SCS) and Peripheral Nerve
Stimulation (PNS) are technologies that are available for
patients that have not responded to the previous
modalities
• They require the implantation of lead(s) and a battery
generator
• SCS lead(s) are placed into the epidural space
• PNS lead(s) are placed in the subcutaneous tissue

36. NEUROAUGMENTATION
• SCS works by having a low voltage electrical stimulation to
block the pain transmission via the dorsal column tracts of
the spinal cord
• It can be utilized for cervical, thoracic or lumbar symptoms
• More effective for extremity than truncal symptoms

37. BACKGROUND
• SCS has been used for decades in the treatment of various syndromes
• Used mainly for CRPS
• Used in the treatment of vascular diseases chronic pain
• Has been successfully used for the treatment of intractable angina
• Studied extensively for its use in non-reconstructible critical limb ischemia (NR-
CLI)
• Used successfully in the treatment of Reynaud’s as well as Buerger’s diseases

38. SPINAL CORD STIMULATION
– Patients can trial the therapy
• Temporary system
• Only component implanted is lead
• Patient uses system 3-10 days
– Successful trial can be followed
by implant
• Implantation of neurostimulator, lead(s), and
extensions(s) if
trial effective
38

40. THE PROCEDURE
• Types Of Leads

42. CHRONIC - NON-CANCER PAIN
INTRASPINAL THERAPIES
• Spinal Cord Stimulation
• Relies on the “Gate theory” principle –
continuous non-noxious stimuli via A beta
fibres inhibit nociceptive traffic in dorsal horn &
cord.

47. NEUROAUGMENTATION
• PNS is utilized to provide pain relief over
a peripheral nerve distribution
• The lead(s) are place along the course of
peripheral nerves
• May be effective for occipital headaches,
inguinal neuralgia, intercostal neuralgia

48. CHRONIC - NON-CANCER PAIN
INTRASPINAL THERAPIES
• Discovery of receptors in Spinal cord for
• Opioids
• Adrenergic alpha agonists
• Alpha 2 agonists ( Clonidine)
• Serotonergic
• GABA

49. CHRONIC - NON-CANCER PAIN
INTRASPINAL THERAPIES
•Portals
• Epidural and Intrathecal catheters.
•Implanted Pumps & Intrathecal
catheter
Allows 10- 100 times decrease in dose
c.f. systemic delivery with increased efficacy and marked decrease
in side effects.

50. INTRATHECAL THERAPY
• An implanted infusion delivery system
that delivers a precise amount of
medication into the spinal fluid via an
infusion pump and catheter
• Baclofen (spasticity) and Morphine
(pain) are the two most common
medications delivered through this
modality

51. SPINAL COLUMN STIMULATION/
INTRATHECAL PUMPS
• SCS potentially good in CAREFULLY
SELECTED patients for Neuropathic pain problems.
( Failed Back , CRPS Type 1 & 2,)
• Intrathecal pumps potentially useful for - nociceptive
pain states
lower body spasticity
cancer pain with reasonable prognosis

52. INTRATHECAL THERAPY
• Who is a candidate for this therapy?
• Failed all previous modalities
• Medication requirements have produced intolerable side effects
• Patients who cannot achieve adequate pain control even with high
doses of opioids

53. CONCLUSION
• Interventional pain management should
be considered with any pain condition
• Pain is most effectively treated with a
multi-disciplinary approach
• We should utilize all resources that are
available

55. SPINAL DRUG DELIVERY FOR
REFRACTORY PAIN IN CANCER
PATIENTS

59. IMPLANTABLE PUMPS VS EXTERNAL CATHETERS
Advantages
 ↓ risk of infection
 Fully independent of
external devices
 Little maintenance
Infrequent refill
Disadvantages
High initial cost

60. • Opioid conversion by route is
• Intrathecal Morphine 3mg/day – Opioid equivalence?
• On about 12.5mg IV Morphine per hour or about 2.5mg per hour of IV Dilaudid (if we use 5:1
M:HM)
Morphine
PO 300mg
IV 100mg
Epidural 10mg
Intrathecal 1 mg

61. ZICONITIDE (PRIALT):
GOOD POTENTIAL, BUT SIDE EFFECTS LIMIT USE
• Synthetic peptide derived from the venom of the
marine snail Conus magus.
• IT Nonopioid blocks Ca channels in spinal cord to
inhibit afferent pain signal
• FDA approved for refractory chronic pain
• Staats et al RCT vs Placebo for Refractory
Cancer/AIDS Pain in JAMA 2004*
• High rate of cognitive impairment and psychiatric
changes with dose escalation limit use
Zuurmond et al. New aspects in performing interventional techniques for chronic pain. Current Opinion in Supportive and Palliative Care 2007; 1:132–
136.Christo, P and Mazloomdoost, D. Interventional Treatments for Cancer Pain. Ann. NY Acad. Sci. 2008; 1138:299-328.