Chronic pain management , Chronic pain assessment

1. Modrator - Dr. NIMISHA VERMA
Presenter-Dr. SHEKHAR ANAND(MD JR2)
Department of Anesthesiology
METHODS OF
CHRONIC PAIN
MANAGEMENT

2. Pain
• Pain is not just a sensory modality but is an experience.
• The International Association for the Study of Pain defines pain as
"an unpleasant sensory and emotional experience associated with
actual or potential tissue damage, or described in terms of such
damage.“
• response to pain can be highly variable among persons as well as in
the same person at different times.

3. (1) acute pain, which is primarily due to nociception, and
(2) chronic pain, which may be due to nociception but in which psychological
and behavioral factors often play a major role.
• Pain can also be classified according to pathophysiology (eg, nociceptive or
neuropathic pain), etiology (eg, postoperative or cancer pain), or the
affected area (eg, headache or low back pain). Such classifications are
useful in the selection of treatment modalities and drug therapy.

4. Chronic Pain
• Chronic pain is defined as pain that persists beyond the usual course
of an acute disease or after a reasonable time for healing to occur;
this period can vary from 1 to 6 months.
• Chronic pain may be nociceptive, neuropathic, or mixed.
• Patients with chronic pain often have an attenuated or absent
neuroendocrine stress response and have prominent sleep and
affective (mood) disturbances, differentiate from acute pain
• A distinguishing feature is that psychological mechanisms or
environmental factors frequently play a major role.

5. Nociceptive Pain
• VisceralPain: Associatedwith internal
organs.
•Nature: Crampy,pressure, deep,
dullto sharp,diffuse,referred.
• Somaticpain: Soft tissues/myalgic.
•Nature: Dull to sharp, throbbing,
achy, localized
TYPES

6. Neuropathic Pain
• Abnormal neural processing by the peripheral or central
nervoussystem
• Signals are amplified or distorted; Synapsereceptor
numbers are altered pathways not originally involved
becomeinvolved
• Patient Description of Neuropathic Pain:
• Burning, electric, shearing, tingling, and migrating or
traveling.

8. most common forms of chronic pain include those associated with –
• musculoskeletal disorders,
• chronic visceral disorders,
• lesions of peripheral nerves, nerve roots, or dorsal root ganglia
(including diabetic neuropathy, causalgia, phantom limb pain, and
postherpetic neuralgia),
• lesions of the central nervous system (stroke, spinal cord injury, and
multiple sclerosis), and
• cancer pain.
The pain of most musculoskeletal disorders (eg, rheumatoid arthritis
and osteoarthritis) is primarily nociceptive, whereas pain associated
with peripheral or central neural disorders is primarily neuropathic.

9. Mechanisms of Pain: Neuroplasticity
How does a Chronic Pain State Develop?
• Peripheral Sensitization
- Injury causes release of
“sensitizing soup”
- Reduction in threshold and
increase response of
nocioceptors
• Central Sensitization
- Membrane excitability, synaptic
recruitment and decreased
inhibition
- Uncoupling of pain from
peripheral stimuli

10. CHRONIC PAIN IS…
MULTI-FACTORIAL
Psychological factors – depression, anxiety, somatization
Socioeconomic factors – cultural differences, urban, poor,gender
Spiritual factors – spiritual suffering, meaning ofpain
Physical factors – VERY complex neuroanatomy creating the pain
sensation, from pain receptors to afferent nerves to spino-thalamic
tract, to thalamus to cortex with modulators all along the way.
Treating only one aspect of this complex syndrome is insufficient.
Therefore best approach isMulti-disciplinary.

11. Pain Consultation Team
Multidisciplinary group
• It results in increased physical and psychosocial function,
reduced health care use and vocational rehabilitation.
• Ameta-analysis found such programs offer the most efficacious
and cost effective, evidence based treatment of chronic non
malignantpain.
Referral
Recommendation
ConsultationTeam
Anesthesiology Psychologist
Physical therapist Occupationaltherapist
Nursing
Bio-psycho-social concept of Chronic Pain

12. EVALUATION OF CHRONIC PAIN
GOALS:
Determine Etiology tobetter treat this pain
Determine if correctable, intractable, or potentially
dangerous causes
Determine impact on patient’s life
Takeadetailed pain history to aid in controlling thispain

13. Evaluating the Patient with Pain
• Physician must first distinguish between acute and chronic pain.
• Management of acute pain is primarily therapeutic, whereas that of chronic pain
additionally involves investigative measures.
• Physical examination should emphasize the musculoskeletal and neurological
systems.
• Imaging studies are often necessary and may include plain radiographs, computed
tomography (CT), magnetic resonance imaging (MRI), or bone scans.
• These studies can often detect unsuspected trauma, tumors, or metabolic bone
disease. MRI is particularly useful for soft tissue analysis and can show nerve
compression.

14. Pain Measurement
• Numerical rating scale, faces rating scale, visual analog scale (VAS), and the
McGill Pain Questionnaire (MPQ) are most commonly used.
• Because chronic pain is so complex, there are often multiple treatment
goals

15. Psychometric testing:
a. Minnesota Multiphasic Pain Inventory(MMPI)
b. Symptom check list-90.
c. Million behavioral pain inventory.
d. The beck depression inventory.
e. The spielberger state-trait anxiety scale.

16. • Chronic pain often is best managed using what is called a “multimodality”
approach. A multimodality approach to chronic pain includes a
combination of therapies selected from eight broad categories:
 Drug therapies
 Psychological therapies
 Rehabilitative therapies
 Anesthesiological therapies
 Neurostimulatory therapies
 Surgical therapies
 Lifestyle changes
 Complementary and Alternative medicine therapies

17. THERAPEUTIC MODALITIES

18. • Improvements in nociception, notcuring.
• There is no magic bullet, no single cure
• Decrease pain and suffering
• Rehabilitation: Reconditioning & Prevention
• Coping: Management of Residual Pain
Chronic Pain Management
Goals

19. Modified WHO AnalgesicLadder for
Cancer pain
Proposed
4th Step
Pain
Step 1
Nonopioid
Adjuvant
Pain persisting orincreasing
Step 2
Opioid for mild to moderatepain
Nonopioid  Adjuvant
Pain persisting or increasing
Pain persisting or increasing
Step 3
Opioid for moderate to severepain
Nonopioid Adjuvant
Invasive treatments
Opioid Delivery
Quality of Life
• TheWorld HealthOrganization(WHO)in 1986
developedastepwiseapproachto analgesic
dosing.

20. Moving toward a “flexible approach” to pain
management
• The previously described three- and four-step ladders are widely employed for
managing malignancy related and other terminal pain states; however, the time
has cometo re think andpossiblydiscardthese traditionalstepwise approaches.
• Application of flexible and more individualized treatment plans would be
particularly beneficial for patientssuffering benignchronicpain.
• For certain individuals, care plans that include non-opioid-based multimodal
analgesia and early application of interventional pain management may be
superior to progressive increasesin opioiddosing.
• Instead of being considered as a “last resort”, interventional pain management
can beemployed at anearly stageofcare
• Suchtherapy, while invasive and expensive, would be encouraged in setting where
patients might benefit from improved pain relief and significant opioid-sparing
effects.

22. Drug options...
• NSAIDS,{COXINHIBITORS} AND ACETAMINOPHEN
• OPIOIDS
• NEUROLEPTIC AGENTS
• ANTICONVULSANTS
• ANTIDEPRESSANTS
• CORTICOSTEROIDS
• LOCAL ANAESTHETICS– Systemicadministration.
Pharmacological Interventions

24. Nonsteroidal Anti-inflammatory Drugs and
Antipyretic Analgesics
• The acidic NSAIDs and the nonacidic antipyretic analgesics (e.g., acetaminophen,
phenazones) inhibit COXs, enzymes that catalyze the transformation of
arachidonic acid (a ubiquitous cell component generated from phospholipids) to
prostaglandins and thromboxanes.
• Less severe pain states (e.g., early arthritis, headache) are commonly treated
with nonselective NSAIDs (e.g., aspirin, ibuprofen, indomethacin, diclofenac) or
antipyretic analgesics (e.g., acetaminophen), mostly used orally.
• Some agents are available for parenteral, rectal, or topical application

25. Antidepressants- These agents demonstrate an analgesic effect that occurs at a
dose lower than needed for their antidepressant action. Both actions are due to
blockade of presynaptic reuptake of serotonin, norepinephrine, or both.
• Older tricyclic agents appear to be more effective analgesics than selective
serotonin reuptake inhibitors (SSRIs).
• Most useful in patients with neuropathic pain, eg, from postherpetic neuralgia
and diabetic neuropathy. They potentiate the action of opioids and frequently
normalize sleep patterns

26. Anticonvulsants
• Anticonvulsants have been found to be extremely useful in patients with
neuropathic pain, particularly trigeminal neuralgia and diabetic neuropathy.
• These agents block voltage-gated sodium channels and can suppress the
spontaneous neural discharges that play a major role in these disorders.
• Gabapentin may offer additional unique beneficial effects. It has also been shown
to be an effective adjuvant for postoperative pain.
Neuroleptics
• Neuroleptics useful in patients with refractory neuropathic pain.
• The most commonly used agents are fluphenazine, haloperidol, chlorpromazine,
and perphenazine
• Their therapeutic action appears to be due to blockade of dopaminergic receptors
in mesolimbic sites.

27. Corticosteroids
• Glucocorticoids are extensively used in pain management for their
antiinflammatory and possibly analgesic actions.
• They may be given topically, orally, or parenterally (intravenously, subcutaneously,
intrabursally, intraarticularly, epidurally).
• Large doses or prolonged administration result in significant side effects.
• Excess glucocorticoid activity can produce hypertension, hyperglycemia, increased
susceptibility to infection, peptic ulcers, osteoporosis, aseptic necrosis of the
femoral head, proximal myopathy, cataracts, and, rarely, psychosis.
• Patients can also develop the physical features characteristic of Cushing's syndrome
• Excess mineralocorticoid activity causes sodium retention and hypokalemia, and
can precipitate congestive heart failure.

28. Systemic Local Anesthetics
• Local anesthetics are occasionally used systemically in patients with neuropathic
pain.
• They produce sedation and central analgesia; the analgesia frequently outlasts
the pharmacokinetic profile of the local anesthetic and breaks the "pain cycle
" Lidocaine, procaine, and chloroprocaine are the most commonly used agents.
• They are given either as a slow bolus or by continuous infusion. Lidocaine is given
by infusion over 5–30 min for a total of 1–5 mg/kg.
• Monitoring should include the electrocardiogram (ECG), blood pressure,
respirations, and mental status; full resuscitation equipment should also be
immediately available. Signs of toxicity such as tinnitus, slurring, excessive
sedation, or nystagmus necessitate slowing or discontinuing the infusion.

29. Alfha2
Adrenergic Agonists
• The primary effect of alfa 2-adrenergic agonists is activation of descending
inhibitory pathways in the dorsal horn. Epidural and intrathecal 2-adrenergic
agonists are particularly effective in neuropathic pain and opioid tolerance.
• Clonidine is most commonly used drug in this group.
Botulinum Toxin
• Botulinum toxin injections have been increasingly utilized in the treatment of
painful conditions associated with skeletal muscle.
• Use in the treatment of conditions associated with involuntary muscle contraction
(eg, focal dystonia and spasticity) it is FDA approved T/t for chronic migraine
headache.
• Some clinicians have used the drug in the management of headaches and
myofascial syndromes.

30. Topical Analgesics
• The topical application of various analgesics is an area of considerable interest because
many chronic pain syndromes depend to some degree on the peripheral activation of
primary afferent neurons.
• Localized administration can potentially optimize drug concentrations at the site of pain
generation while avoiding high plasma levels, systemic side effects, drug interactions,
and the need to titrate doses into a therapeutic range.
• topical NSAIDs, tricyclic antidepressants, capsaicin, local anesthetics, and opioids are
used .
topical tricyclic antidepressant (doxepin) has shown efficacy in a mixed group of patients
with neuropathic pain and, as a mouthwash, in patients with chemotherapy-induced
oral mucositis.
Capsaicin is the active pungent ingredient in chili peppers.
• Capsaicin is available as 0.025% and 0.075% cream. It was shown to achieve pain relief
in patients with postherpetic neuralgia, postmastectomy syndrome, osteoarthritis, and
a variety of neuropathic syndromes.
Topical formulations of local anesthetics block Na+ channels in primary afferent neurons
• lidocaine patches and gels showed pain reduction in patients with postherpetic
neuralgia and allodynia.

31. Topically applied or locally injected opioids produce analgesia by activating opioid
receptors on primary afferent neurons.
• Intra-articular morphine also produces analgesia in chronic rheumatoid and
osteoarthritis, where its potency was shown to be similar to standard intra-
articular steroids and long lasting (up to 7 days), possibly because of morphine's
anti-inflammatory activity.
• opioids have been applied locally (e.g., in gels) to treat pain from skin ulcers,
cystitis, cancer-related oral mucositis, corneal abrasion, and bone injury
Topical Opioids Provide Temporary Relief in Central Intractable Pain.

32. Opioids
1. Parentral opioid Administration: In patients with cancer
adjunctive treatment such as surgery , radiation , chemotherapy ,
hormonal therapy , neurolysis may be helpful.
2. Spinal Opioid Therapy
3. Transdermal Fentanyl: Alternative for oral, major obstacle to
frntanyl absorption through skin is stratum corneum,
as dermis acts as reservoir so absorption continues for several
hours after the removal of patch.

33. CAUTIONS IN OPIOID USE
 80% of the time dose needs to be increased because the
disease is advancing; 20%because of tolerance.
 Mixed or partial agonists have a ceiling, neurotoxicity, and
can induce withdrawal if on otheropioids.
 Methadone – drug, may be better with neuropathies &
addiction because inhibits the NMDA receptor in the brain,
though half-life 6-100hrs so watch for accumulation.
 Meperidine – neurotoxic metabolite can build up in 1 wk; in
1 day with renal failure
 Oral, sublingual, rectal short acting,= peak within 1 hr.,
IV/SC peak within 10 minutes. Choose oral if
they can do it.
 Totaper drug, decrease by 25%aday.

34. OPIOID SIDE EFFECTS
Constipation ,
Nausea/vomiting – tolerance can occur in
2-5 days, Prochlorperazine/ metoclopramide can help.
Sedation – tolerance can occur in 2-3 days, changing drug can
help if persists.
Clonic jerks – usually high doses; change drug or
benzodiazepam canhelp
Respiratory suppression in toxic doses.

35. PHYSICAL vs. PSYCHOLOGIC
DEPENDENCE
PHYSICALDEPENDENCE:
Tolerance (20-40%) – up-regulate opioid receptors to need
higher dose for sustained effect
Withdrawal (20-40%) – after 2 wks, withdrawing drug leads
to adrenaline response (sweating, tachycardia, tachypnea,
cramps, diarrhea, hypertension); avoid by decreasing drug
25%a day.
PSYCHOLOGICDEPENDENCE:
Addiction (0.1% in CApain) – a need to get “high” where drug
controls your life, compulsive uncontrolled behavior to get the
drug; lie, cheat, steal.

36. Opioid
Dosing
regimen

37. Pain management by rehabilitative
approaches
Physical therapy (PT)-useful in teaching patients to control pain, to move in
safe and structurally correct ways, to improve range of motion, and to increase
flexibility, strength and endurance.
• “Active” and “Passive” modalities can both be used, but active modalities, such as
therapeutic exercise,are particularly important when the goal is to improve both
comfort and function.
Bed rest - use of prolonged bed rest in the treatment of patients with neck and
low back pain.
Bracing- acute neck pain secondary to whiplash injury,
Manipulation & mobilisation- treatment of patients with acute low
back pain.

38. Transcutaneous electrical nerve stimulation-
has been used to treat patients with various pain conditions,including neck
and low back pain
• TENS is generally used in chronic pain conditions and not indicated in the
initial management of acute cervical or lumbar spine pain.
Thermal modalities- Thermal modalities include a variety of methods that
produce heating and cooling of the tissues to manage acute and chronic
musculoskeletal pain.
• Superficial heat, such as moist hot packs, increases skin and joint
temperature and blood flow, and may decrease joint stiffness and muscle
spasms.
Diathermy- Diathermy involves the use of high-frequency oscillating current
and ultrasound (inaudible sound wave vibrations) to create deep heating.
• The deep heating may reduce the perception of pain.

39. Ultrasound- Ultrasound is a deep-heating modality that is most effective in
heating structures such as the hip joint, which superficial heat cannot reach
• It is perhaps best used in the region of the upper trapezius or lumbar paraspinals to
facilitate active stretching and strengthening.
Cryotherapy - Cryotherapy can be achieved through the use of ice, ice packs, or
continuously via adjustable cuffs attached to cold water dispensers Intramuscular
temperatures can be reduced by between 3 °C and 7 °C, which functions to reduce
local metabolism, inflammation, and pain.
• Cryotherapy works by decreasing nerve conduction velocity, termed cold-induced
neuropraxia, along pain fibers with a reduction of the muscle spindle activity
responsible for mediating local muscle tone.

40. Psychological/Mind-Body therapies for chronic pain
management
• Psychological factors are important contributors to the intensity of pain and to
the disability associated with chronic pain.
• Pain and stress are intimately related. There may be a vicious cycle in which pain
causes stress, and stress, in turn, causes more pain
• Mind/body approaches address these issues and provide a variety of benefits,
including a greater sense of control, improved coping skills, decreased pain
intensity and distress, changes in the way.
Cognitive-Behavioral therapy - CBT has proven to be effective in reducing pain
and disability when it is used as part of a therapeutic strategy for chronic pain.
• CBT may include training in various types of relaxation approaches, which can
help people in chronic pain lower their overall level of arousal, decrease muscle
tension, control distress, and decrease pain, depression and disability.

41. Biofeedback- Biofeedback is the use of electronic monitoring instruments to provide
patients with immediate feedback on heart rate, blood pressure, muscle tension, or
brain wave activity.
• This allows the patient to learn how to influence these bodily responses through
conscious control and regulation.
• Biofeedback has been shown to be effective in the management of migraine
headaches, fibromyalgia, temporomandibular disorders, and rheumatoid arthritis,
Raynaud’s disease, tension headaches, headaches in children and the pain
associated with irritable bowel syndrome.

42. Interventional Methods Used for Chronic Pain
• Interventional pain management or interventional pain medicine is a subspecialty
of the medical specialty - pain management, devoted to diagnosis & treatment of
pain & related disorders by application of interventional techniques in managing
subacute , chronic, persistent & intractable pain independently or in conjuction with
other modalities of treatment.
• It fills the gap between pharmacological management of pain and more invasive
operative procedures.
1) Diagnostic & Therapeutic Neural Blockade- Neural blockade with
local anesthetics can be useful in delineating pain mechanisms, but, more
importantly, it plays a major role in the management of patients with acute or
chronic pain .
• Selection of the type of block depends on the location of pain, its presumed
mechanism, and the skills of the treating physician.

43. A )Somatic Blocks-
 Trigeminal Nerve Blocks- The two principal indications are trigeminal neuralgia
and intractable cancer pain in the face
• these blocks may be performed on the gasserian ganglion
 Facial Nerve Block- Blockade of the facial nerve is occasionally indicated
to relieve spastic contraction of the facial muscles and to treat herpes zoster
affecting this nerve.
 Glossopharyngeal Block- Glossopharyngeal nerve block may be used for
patients with pain due to malignant growths at the base of the tongue, the
epiglottis, and palatine tonsils. It can also be used to distinguish glossopharyngeal
neuralgia from trigeminal and geniculate neuralgia
 Occipital Nerve Block- Occipital nerve block is useful diagnostically and
therapeutically in patients with occipital headaches and neuralgias.
 Phrenic Nerve Block- Blockade of the phrenic nerve may occasionally provide
relief for pain arising from the central portion of the diaphragm. It can also be
useful in patients with refractory hiccups (singultation

44.  Suprascapular Nerve Block -This block is useful for painful conditions arising
from the shoulder (most commonly arthritis and bursitis.
 Cervical Paravertebral Nerve Block- Selective paravertebral blockade at the
cervical level can be useful diagnostically and therapeutically for cancer patients
with pain originating from the cervical spine or the shoulder.
 Lumbar Paravertebral Somatic Nerve Block- Paravertebral block at this
level is useful in evaluating pain due to disorders involving the lumbar spine or
spinal nerves,
 Lumbar Medial Branch & Facet Blocks- These blocks may establish the
contribution of lumbar facet (zygapophyseal) joint disease in back pain.
Corticosteroids are commonly injected with the local anesthetic when the
intraarticular technique is chosen.

45.  StellateBlock- used in patients with head, neck, arm, and upper chest pain.
 Thoracic Sympathetic Chain Block –
 Celiac Plexus Block- indicated in patients with pain arising from the abdominal
viscera, particularly abdominal malignant growths.
 Splanchnic Nerve Block-
B)Sympathetic Blocks- Sympathetic blockade can be accomplished by a
variety of techniques including subarachnoid, epidural, as well as
paravertebral blocks.
• Unfortunately, these approaches usually block both somatic and
sympathetic fibers.
• most common indications include reflex sympathetic dystrophy, visceral
pain, acute herpetic neuralgia, postherpetic pain, and peripheral vascular
disease.

46. Neurolytics- Neurolytics employ injection of chemical agents such as alcohol,
phenol, or glycerol to block pain messages.
– It is indicated for patients with limited life expectancy and patients who have
recurrent or intractable pain after a series of analgesic blocks.
– Potential side effects of neurolytic agents include neuritis and deafferentation
pain, motor deficit and unintentional damage to non-targeted tissue.

47. • Radiofrequency ablation
– High frequencies of 300–500 KHz are used
– A modern RF lesion generator has the following functions:
■ Continuous on-line impedance measurement
■ A nerve stimulator
■ Monitoring of voltage, current, and wattage during the RF procedure
■ Temperature monitoring
■ Pulsed current delivery mode

48. Contd…
– Continuous Radio Frequency Lesioning
• The voltage of the generator is set up between the electrode and the
ground plate. The body tissues complete the circuit and RF-current flows
through the tissue, resulting in an electric field.
• Frictional dissipation of the ionic current within the fluid medium causes
tissue heating. RF heat is therefore generated in the tissue, and the
electrode is heated by the tissue.
• The size of the lesion depends on the tip temperature and the tip
temperature depends on the power deposition.
• But there are other factors involved as well. Heat is also removed from
the lesion area by conductive heat loss and blood circulation. This is
referred to as heat “washout.”
• Maximum “volume” of a lesion is effectively obtained after 40 seconds,
and that the lesion size strongly depends on tip temperature and on
probe diameter.

49. Indications of RF neuroablation
Radiofrequency neuroablation is frequently carried out for
following conditions :
• - Lumbar RF sympathectomy for peripheral vascular disorders and
complex regional pain syndrome (CRPS) of lower extremity
• - RF ablation of Gasserian Ganglion or of individual branches for
trigeminal neuralgia
• - Cervical, thoracic, lumbar facet joint RF denervation
• - Stellate ganglion lesioning for CRPS of upper extremity
• - Cervical thoracic lumbar, sacral rhizolysis
• - Sacroiliac joint denervation
• - Intervertebral disc annuloplasty in intervertebral disc
• prolapse

50. • Cryoneurolysis
– A technique in which the application of low temperatures produced by
cryosurgical equipment achieves anesthesia or analgesia by blocking
peripheral nerves or destroying nerve endings.
– Expansion of gas enclosed in the cryoprobe results in Kelvin effects; that is,
gas under pressure escaping through a small orifice expands and cools,
achieving temperatures between -500C & -700C at the tip, and returns
through an inner tube.

51. Contd…
– For myelinated fibers, a direct lesion 3 mm in diameter with a freeze time of
1 minute produces a conduction block.
– Where the nerve is frozen amid other tissues, the duration of exposure
should be approximately 90 to 120 seconds.
– A prolonged conduction block occurs when the nerve is frozen at
temperatures between -5 C and -20 C. This causes axonal disintegration and
breakdown of myelin sheaths.

52. • Intrathecal Drug Delivery Systems
– In general, chronic intraspinal infusion therapy using implantable drug
administration systems has been reserved for patients whose condition is
considered chronic, and have failed more conservative therapies.
– Patients must have either inadequate pain control or intolerable side effects
on systemic opiates and adjuvant therapy.
– General guidelines for considering intrathecal therapy include an expected
3-month survival.
– Although percutaneous externalized epidural or even intrathecal catheter
placement is feasible for short-term treatment, vulnerability to infection and
economic considerations preclude serious considerations for long-term use
(>3 months).

53. • Vertebroplasty
– It is a minimally invasive procedure that is effective in the treatment of pain
resulting from pathologic compression fractures, osteolytic bone lesions,
myelomas, hemangiomas and osteoporosis.
– The main indication is the symptomatic (painful) osteoporotic compression
fracture of the thoracolumbar spine.
– It is essential to discriminate an acute event with sudden onset of pain and
plain x-rays showing radiological signs of an acute fracture from chronic
painful disorders of the spine.
• Balloon Kyphoplasty
– The indications for balloon kyphoplasty are the same as in vertebroplasty.
– It is especially indicated in the presence of vertebral body deformity.
• General contraindications include uncorrectable coagulation disorders,
infectious processes of the spine, and allergies against PMMA or contrast
medium. Poor pulmonary status and difficulty lying prone are relative
contraindications.