ADVANCE PAIN TREATMENT INTERVENTIONAL TECHNIQUES

ADVANCE PAIN TREATMENT INTERVENTIONAL TECHNIQUES

Dr. Neeraj Jain   MD, FIMSA, FIPP (USA)

09810033800.     [email protected]

Senior Consultant Spine & Pain Specialist,

Spine & Pain Clinics,

Sri Balaji Action Medical Institute & Action Cancer Hospital

In-charge Spine & Pain Clinic, Max Hospital, Shalimar Bagh, New Delhi.

In-charge Spine & Pain Clinic, Max Hospital, Pitampura, New Delhi.

www.spinenpain.com , www.spine-disc-pain.com

 “The neurosignature of pain experience is determined by the neuromodulating chemical & synaptic architecture of the neuromatrix”

There have been many advances in the understanding & usefulness of an intervention at right time in selective patients producing excellent results. Interventional pain procedures scores over both medicine and surgery, as they do not have side effects like medicines. Surgeries for pain now have limited indications & usually as a last resort.

The interventional pain procedures produce immediate pain relief, can be performed with ease by pain physicians without anesthesia as outpatient or daycare and adequate duration of pain relief is obtained and they are suitable for surgically unfit, unwilling & debilitated patients, procedures can be repeated safely if required.

With the advancement of technology and science, we have unveiled many aspects of the pain and its treatment. We have to work hard to spread the knowledge of interventional pain techniques. Our goal is to help people suffering from pain, make them productive human being for the society and increase their self esteem so that they can live life as normal individuals.

PERCUTANEOUS  LEAST INVASIVE  INTERVENTIONAL  PAIN  MANAGEMENT  OF  BACK  PAIN:     

It has both diagnostic & therapeutic relevance( as there are significant false positive & negative imaging studies not correlating to symptoms)

Better results are obtained if treatment is started early.

? LESI-lumbar epidural steroid injections::

§ interlamminar or transforaminal or caudal approach (Fig 2,3)

? SNRB- selective nerve root block

? Epidural adenolysis or percutaneous decompressive neuroplasty (Fig 4)

? Trigger point injection

? Botox paraspinal muscle injection

? Facet joint or pericapsular injection

? Spine Prolotherapy & manipulation

? Facet RF thermal neurolysis

? SI joint injection or denervation

? Piriformis muscle block

? Diagnostic provocative discography

? Intradiscal procedures:-Ozone Discolysis/ Chemonucleolysis 

                                               - Dekompressor disc debulking                                                         

                                                 - IDET-intradiscal electrothermal therapy

                                                 - Biacuplasty/RF Annuloplasty

                                                 - Coblation nucleoplasty

                                                 - SELD/Laser percutaneous discectomy

                                                 - Disc-FX / Endoscopic Discectomy                                             

? Vertebroplasty & kyphoplasty         

? Intrathecal pump neuraxial implants

? Augmentation or neuromodulation spinal cord stimulation

? Lumbar/cervicothoracic sympathetic blocks / neurolysis

? Stellate /splanchnic/ celiac plexus/ hypogastric/ impar neurolysis

? Paravertebral / psoas compartment blocks

? Intrathecal/ Epidural neurolysis

? Cranial nerves blocks / neuroablations

? Trigeminal gangliolysis

? Pituitary chemoadenolysis

? Botox chemodenervation

? Laser lessioning / radiofrequency (RF) neuroablations

ONCE THE CONSERVATIVE TREATMENT FAILS:

Early aggressive treatment plan of back & leg pain has to be implemented to prevent peripherally induced CNS changes that may intensify or prolong pain making it a complex pain syndrome. Only approx 5% of total LBP patients would need surgery & approx 20% of discal rupture or herniation (Fig 1) with Neurologically impending damage like cauda equina syndrome would need surgery. Nonoperative treatment is sufficient in most of the patients, although patient selection is important even then. Depending upon the diagnosis one can perform & combine properly selected percutaneous fluoroscopic guided procedures (Fig 5) with time spacing depending upon patient`s pathology & response to treatment. 

Using precision diagnostic & therapeutic blocks in chronic LBP , isolated facet joint pain in 40%, discogenic pain in 25% (95% in L4-5&L5-S1), segmental dural or nerve root pain in 14% & sacroiliac joint pain in 15% of the patients. This article describes successful interventions of these common causes of  LBP after conservative treatment has failed.

NEED FOR NON-SURGICAL OPTIONS:

Outcome studies of lumber disc surgeries documents, a success rate between 49% to 95% and re-operation after lumber disc surgeries ranging from 4% to 15%, have been noted. “In case of surgery, the chance of recurrence of pain is nearly 15%. In FBSS or failed back surgery the subsequent open surgeries are unlikely to succeed.

Reasons for the failures of conventional surgeries are:

1. Dural fibrosis

2. Arachnoidal adhesions

3. Muscles and fascial fibrosis

4. Mechanical instability resulting from the partial removal of bony & ligamentous structures required for surgical exposure & decompression

5. Presence of Neuropathy.

6. Multifactorial aetiologies of back & leg pain , some left unaddressed surgically.

FIGURES 1:Prolapsed Disc  2:Lateral Interlaminar Epidural  3:Caudal Epidural      4:Racz Neuroplas 5:Interventional Pain Procedures 6:FBSS: SNRB      7:SELD:Epiduroscopy     8:Bartilotti Syndrome           

EPIDURAL ADENOLYSIS OR PERCUTANEOUS DECOMPRESSIVE NEUROPLASTY is done for epidural fibrosis or adhesions in failed back surgery syndromes (FBSS) (Fig 6). A catheter is inserted in epidural space via caudal/ interlaminar/ transforaminal approach. After epidurography testing volumetric irrigation with normal saline/ L.A./ hyalase/ steroids/ hypertonic saline in different combinations is then performed along with mechanical adenolysis with spring loaded or stellated catheters or under direct vision with EPIDUROSCOPE (Fig 7)

FIGURES 9,10: NJ Balloon Neuroplasty & Epiduroplasty                  11, 12: Biacuplasty with Epidural Balloon           

Sciatica gets complicated by PIVD with disco-radicular conflict causing radicular pain sometimes disabling. In this era of minimally invasive surgery lot many interventional techniques have evolved to address the disc pathology. We are still working for the ideal, safe & effective technique to tackle disco- radicular interphase. Here now we have devised a mechanical neuroplasty or foraminoplasty technique using an inflatable balloon tip catheter with guide wire via targeted transforaminal (Fig 9,10) or interlaminar route aided by drugs instillation.

Selected patients are procedured fluoroscopic guided with local anesthesia under prescribed sedation aseptically via preselected route depending upon location & type of PIVD causing root insult (Fig 13). First a suitable size needle is placed at desired site confirming with radiolucent dye through which hyaluronidase with saline or LA was injected. A flexible guide wire is passed at selected location & direction on which the inflatable balloon is threaded to the area of interest. Adhesiolysis is achieved mechanically with inflating balloon for 10 seconds at a time & location. We inflated the balloon with contrast agent to have visualization of adhesiolysis & opening up of adhesions or root route. Here the balloon pressure & time has to be kept in minimum to avoid neurological damage, for which we inflate balloon for 10 seconds at a time. Close observation is made to balloon shape, pressure & patient`s response. Once dilatation is done the drug mixture of steroid with LA & or hynidase/ hypertonic saline is instilled over nerve in epidural space.

We have logically used same approach for our Balloon Neuroplasty & foraminoplasty as it is safe & targets exactly the area of disco-radicular interphase or conflict. We can manage to address both the exiting and traversing nerve roots with single entry just by manipulating our guide wire to the place of offence (Fig 27). The procedure can be done via transforaminal (Fig 9,10) route at level or level above or below, especially via S1 foramen (Fig 11, 12). Now we are employing this technique for fresh cases coupling with Intradiscal decompression aided by instant disc retrieval by epidural balloon inflation with good results. The IDD is done by Coblation/ Laser/ DeKompressor or RF Biacuplasty. There is scope of coupling this technique with endoscopic spine surgery.

By adding “Balloon Neuroplasty” to the armamentarium of the interventional pain management many patients can be benefited & relieved of previously interventionally unmanageable disco-radicular pain including FBSS sufferers.

INTRADISCAL PROCEDURES::PROVOCATIVE DISCOGRAPHY: coupled with CT

A diagnostic procedure (Fig 16) & prognostic indicator for surgical outcome is necessary in the evaluation of patients with suspected discogenic pain, its ability to reproduce pain(even with normal radiological finding), to determine type of disc herniation /tear, finding surgical options & in assessing previously operated spines.

PERCUTANEOUS DISC DECOMPRESSION (PDD): After diagnosing the level of painful offending disc various percutaneous intradiscal procedures can be employed.

OZONE-CHEMONEUCLEOPLASTY: Ozone Discectomy (Fig 14) a least invasive safe & effective alternative to spine surgery is the treatment of choice for prolapsed disc (PIVD) done under local anaesthesia in a day care setting. This procedure is ideally suited for cervical & lumbar disc herniation with radiculopathy. Total cost of the procedure is much less than that of surgical discectomy. All these facts have made this procedure very popular at European countries. It is also gaining popularity in our country due to high success rate, less invasiveness, fewer chances of recurrences, remarkably fewer side effects meaning high safety profile, short hospital stay, no post operative discomfort or morbidity and low cost.

If despite the ozone therapy the symptoms persist, Percutaneous intradiscal decompression can be done via Transforaminal route (Fig 17) with Drill Discectomy/ Laser or Coblation Nucleoplasty/ Biacuplasty/ Disc-FX (Fig 20)/ Endoscopic Discectomy are good alternatives before opting for open surgerical Discectomy; which has to be contemplated in those true emergencies, as mentioned above as the first choice. In Biacuplasty (Fig 12) radiofrequency energy is used in bipolar manner heating & shrinking the disc & making it harder as well for weight bearing. It also seals the annular defect & ablates annular nerves relieving back pain. In Laser or Coblation Nucleoplasty (Fig 19) energy is used to evaporate the disc thereby debulking it to create space for disc to remodel itself assisted by exercises.

DEKOMPRESSOR: A mechanical percutaneous nucleotome (Fig15,16) cuts & drills out the disc material somewhat like morcirator debulking the disc reducing nerve compression. A mechanical device cuts & drills out the disc material debulking the disc reducing nerve compression curing Sciatica & Brachialgia. It comes in needle size of 17G for lumbar discs & 19 G for cervical discs. In lumbar region postero-lateral approach is used & in cervical discs anterolateral approach is used.

DISC-FX & ENDOSCOPIC DISCECTOMY: In this novel technique A wide bore needle is inserted & placed sub-annular in post disc just under the disc protrusion. Disc is then mechanically extracted with biopsy forceps to empty the annular defect. This painful & sensitive annular defect supplied be sinuvertebral nerve is thermo-ablated with radiofrequency which also seals the defect to prevent & decrease recurrences.

Next Higher procedure, Endoscopic Discectomy  is done with endoscope (Fig 18) put through sheath inserted via posterolateral transforaminal or posterior interlaminar approach. Mostly done under local anaesthesia its fast becoming standard of care for disc protrusion & extrusions causing spinal canal stenosis with root or cord compression with leg pain.

 LASER DISCECTOMY done for closed bulging discs is an outpatient procedure with one-step insertion of a needle into the disc space. Disc material is not removed; instead, nucleus pulposus is debulked by evaporating it by the laser energy. Laser discectomy (Fig 19)  is minimally invasive, cost-effective, and free of postoperative pain syndromes, and it is starting to be more widely used at various centers.

SELD: Epiduroscopic laser neural decompression (Fig 7) is considered an effective treatment alternative for chronic refractory low back and/or lower extremity pain, including lumbar disc herniation, lumbar spinal stenosis, failed back surgery syndrome with morbid adhesion neuritis that cannot be alleviated with existing noninvasive conservative treatment. This Procedure is done under vision via an epiduroscope inserted via Caudal canal or Transforaminally employing front or side firing Laser fibers &/or fine instruments.

FIGURES 13:Radicular Pain 14:Ozone Chemoneucleolysis 15:Disc Needle decompression 16:DeKompressor drilling 17:Transforaminal IDD    18:Lumbar Endoscopic Discectomy   19:Cervical Needle Discectomy         20:Cervical Disc-FX

INTRATHECAL (SPINAL) PUMP IMPLANTS: 

Implanted when oral narcotics provide insufficient pain relief or side effects are troublesome in intractable cancer & chronic pain patients. It delivers drug via an implanted catheter (Fig 23, 24) directly into CSF needing a very small dose (1/300 of oral dose). This tunneled catheter can be attached either to external flexometric drug delivery pump for short term need or to the programmable pump which is implanted in anterior lower abdomen for long term needs. It can be programmed to delivers the drugs as per the patients needs. The drugs can be mixed in different concentration & combinations as per patient pain type factors like nociceptive or Neuropathic / Intensity /regular or episodic/presence spasticity. The drug can be delivered regular flow or bolus as PCA pump or a combination of them as per patient requirement. The drugs commonly used are Morphine, Hydromorphone, Fentanyl, Ziconotide, Baclofen, Clonidine & Sensorcaine. More powerful analgesia is achieved using lower doses, constant relief & fewer side effects as compared with oral doses like Somnolence, mental clouding, constipation, euphoria with decreased chances of drug addiction or misuse. It is also used very effectively as Baclofen spinal pump in spasticity patients relieving their spasm further aided by physiotherapy & rehabilitation improving their QOL.

NEUROMODULATION TECHNIQUES: SPINAL CORD STIMULATION (SCS) IMPLANTS :

Effectively done for FBSS( failed back surgery syndrome) (Fig 21) & CRPS(complex regional pain syndromes) in USA; In Europe it is done more for chronic intractable angina & pain of peripheral vascular diseases (PVD). The indications are ever expanding further in chronic pain & neuralgic states. A set of electrodes is placed in epidural space at dorsal columns or lately at DRG of the root involved (Fig 22) & connected to a pulse generator (like a cardiac pacing device) that is implanted in upper buttock. Low level of electric impulses replace pain signals to the brain with mild tingling sensation. This is based on gate control theory as pain transmitting C & Adelta nerve fibers signals are overridden by Abeta fiber signals artificially produced by stimulator battery implant device. Newer high frequency stimulators don't have this side effect of bothersome tingling & dynamic Multi-stim adjusts to postural changes of patient spine keeping stimulation constantly at required spot only. A trial stimulation is done to have an acceptable pain relief  before planning permanent SCS lead implant. In newer developments the stimulation leads are also placed perineural in peripheral neuropathies like in Trigeminal Neuralgia or in Occipital Neuralgia & subcutaneously in dysthesic patch like one in herpetic pain.

FIGURES 21:Vertebroplasty gone Wrong 22:SCS Lead Lat. view 23, 24:Spinal Catheter with implanted & External Pump

PERCUTANEOUS VERTEBROPLASTY / KYPHOPLASTY: A newer approach to management of vertebral body fractures (Fig 24) 

Percutaneous Vertebroplasty (PVP) is an established interventional techniques in which PMMA bone cement is injected (Fig 25) under local anaesthesia via a needle into a fracture VB with imaging guidance providing increased bone strength, stability, pain relief, decreased analgesics, increased mobility with improved QOL and early return to work.

As life expectancy is increasing so is the incidence of vertebral body (VB) fracture now being the commonest fracture of the body; its incidence >the fracture hip, it becomes imperative to take it more seriously. With increasing life span there is more of aged osteoporotic population, more so due to sedentary indoor lifestyle and post menopausal osteoporosis. Diabetics, smokers & alcoholics are at higher risk of developing osteoporosis. I have seen such alcoholic patient developing six spine fractures in just three months time from a single fracture being on complete bed rest. Quick fix of fracture spine (Fig 26) makes patient walk back same day instead of bed rest of months together avoiding morbidity & mortality of prolonged bed rest, making bedridden patient walk, in a way bringing patient back to normal life.

In this era of MAS replacing open surgeries, PVP is a novel procedure & should be in the first line of management in place of conservatism or major spine surgery for painful uncomplicated compression fracture.

KYPHOPLASTY OR BALLOON  VERTEBROPLASTY: is cementing the fractured vertebra after creating cavity, is ideal for collapse osteoporotic # with height loss & can be employed in selected traumatic wedge collapse VB# with height loss.

Balloon kyphoplasty (Fig 27,28,29)

? Restores vertebral body height

? High pressure ballooning (150-400 psi) followed by cement injection into cavity created by balloon

? fewer complications resulting from cement extravasation

? reduction in morbidity of kyphosis

Started in 1984 by Galibert PVP is done in host of INDICATIONS:

·      Senile osteoporotic compression fracture remains the commonest Indication.

·      Metastatic VB fracture 

·      Multiple myeloma VB fracture

·      VB haemangioma (Fig 30)

·      Vertebral osteonecrosis &

·      for strengthening VB before major spinal surgery.

·      The benefit has been extended to the traumatic stable uncomplicated VB compression fracture (VCF) which is commoner in younger age group with active life profile and prime of their career where strict bed rest and acute or chronic pain are unacceptable and they are more demanding for proactive treatment approach so as to be back to work ASAP.

CONTRAINDICATIONS:

? Pre-existing neurological deficit

? Burst fractures (relative C/I)

? Fracture related spinal canal stenosis

? Uncorrectable coagulation disorders

? Allergy against bone cement or contrast media

? Unable to lie prone          

FIGURES 25:Fracture Spine     26:Fracture Augmented & cemented    27:Kyphon with Epidural Balloon 28:Balloon Kyphoplasty with PVP     29:Balloon Kyphoplasty          30:Cementing Sacrum

Pain relief is by virtue of different mechanisms postulated :

·        Cementing of fracture fragments.

·        Thermal neurolysis of VB nerve ending due to heat of polymerization.

·        Washing away of nociceptor chemicals.

·        Neurolytic action of liquid monomer.

·        By allowing early ambulation decreasing pains of immobility & bed rest.

COMPLICATIONS:

·        PVP is generally safe with low risk.

·        Ectopic cement leak is frequent but generally inconsequential.

OUTCOME:

·           PVP is a novel procedure with high benefit to risk ratio, which is highly underutilized in relation to the 

        high prevalence of the vertebral fracture

·          Different studies show an immediate pain relief in (85 – 90)% of patients with low complication rate ranging from (1-5)% depending upon the type of lesion.

·          PVP does augment height of VB but ideal would be kyphoplasty.

·          Patient is either off medicine or on reduced doses.

·          Patient feels so well that he almost forgets if he had VB fracture