Download Free Medical Chronic Low Back Pain & Interventional Spine Procedures PowerPoint Presentation

Chronic Low Back Pain & Interventional Spine Procedures PowerPoint Presentation

DOWNLOAD MEDICAL POWERPOINT PRESENTATION

About This Presentation

Description : This medical presentation titled "Chronic Low Back Pain & Interventional Spine Procedures" provides us information on chronic low back pain and various interventional spine procedures.

Tags : Chronic, Low Back Pain, Interventional Spine Procedures, Pain, muscle tension, stiffness, Lumbar spinal pain, Sacral spinal pain, Lumbosacral pain, Gluteal and Loin pain

Published on : Apr 27, 2021 | Views : 2590 | Downloads : 25

Shareable Url :

Embed Code :

Comment

Transcript

Slide 1-

Chronic Low Back Pain & Interventional Spine Procedures Henry Kim, MD Pain Medicine
Slide 2-

Epidemiology 80% lifetime prevalence Common reason for physician visits in the United States (2nd or 3rd leading cause) Most common cause of disability in patients < 45 years old
Slide 3-

Definition Pain, muscle tension or stiffness localized below the costal margin and above the inferior gluteal folds, with or without leg pain International Association for the study of pain (IASP) Low Back Pain Lumbar spinal pain Sacral spinal pain Lumbosacral pain Gluteal and Loin pain (not considered LBP)
Slide 4-

ppt slide no 4 content not found
Slide 5-

Classification Mechanical (HNP, OA, spinal stenosis, spondylolisthesis, compression fracture) Nonmechanical Tumor (metastases, MM, lymphoma) Infection (osteomyelitis, diskitis) Inflammatory arthritis (RA, AS) Visceral disease (AAA, nephrolithiasis, pancreatitis, prostatitis, PID)
Slide 6-

Classification Complicated (“Red Flag” conditions) Specific Diagnosis Lumbar Radiculopathy Lumbar Spinal Stenosis Others such as Ankylosing Spondylitis Uncomplicated (Non-Specific) A diagnosis of exclusion
Slide 7-

“Red Flags” Metastatic CA (History of cancer*, Unexplained weight loss, Rest pain, Age >50) Infection (Unexplained fever*, Recent bacterial infection, Immunosuppression, IVDA) Fracture (Steroids*, Osteoporosis, Recent trauma, Age >70) Cauda Equina Syndrome (Urinary retention or incontinence, Saddle anesthesia, Decreased rectal tone, Bilateral lower extremity weakness/numbness) Severe or progressive focal neurologic deficit Failure to improve with therapy Pain > 4 weeks (* Most important in the condition)
Slide 8-

“Red Flags” Compression Fracture (4%) Metastatic CA (0.7%) Cauda Equina Syndrome (0.04%) Infection (0.01%)
Slide 9-

Compression Fracture Osteoporosis Location Thoracolumbar junction Midthoracic spine Pain may not be localized to the level of fracture, as thoracolumbar fractures may present with low back or lumbosacral pain.
Slide 10-

Cancer Past history of cancer is by far the single strongest indicator of cancer related low back pain. Metastatic (Prostate, Lung, Breast) Multiple myeloma Lymphoma Increases post test probability from 0.7% to 9% Not including nonmelanoma skin CA
Slide 11-

Cauda Equina Syndrome Large central disc herniation (L4-5) Urinary retention (Retention develops initially and leads to overflow incontinence later.) Normal post-void residual essentially rules it out. Surgical emergency
Slide 12-

Nonspinal LBP AAA Nephrolithiasis Pancreatitis Prostatitis PID * Most spinal cause of low back pain will be aggravated by spinal movement.
Slide 13-

Lumbar Radiculopathy L4-5 or L5-S1 levels (90%) Inflammation > Mechanical compression Phospholipase A2, TNF-α Pain with sitting, bending and coughing Pain radiates below the knee in a narrow band.
Slide 14-

ppt slide no 14 content not found
Slide 15-

ppt slide no 15 content not found
Slide 16-

ppt slide no 16 content not found
Slide 17-

ppt slide no 17 content not found
Slide 18-

Lumbar Radiculopathy
Slide 19-

Not all leg pain is from sciatica. Uncomplicated low back pain is often referred to lower leg. (somatic referred pain) Ask “Where is the pain worst?” “Where do you feel the pain most consistently?”
Slide 20-

Radicular vs. Referred Pain
Slide 21-

Lumbar Radiculopathy Listing away from the side of disc herniation (paracentral herniation) Straight-leg-raise (SLR) for L5 or S1 root. Reproduction of radicular pain between 30-70˚ High sensitivity but low specificity Crossed SLR is more specific but less sensitive.
Slide 22-

Natural History Favorable Conservative and surgical treatments are both successful. Large extruded discs are more likely to decrease in size.
Slide 23-

Surgery vs. Prolonged Conservative Treatment for Sciatica – NEJM 2007 Prospective randomized 283 patients with severe sciatica for 6 to 12 weeks 141 → Early Microdiskectomy (2.2 weeks) 142 → Conservative treatments Faster pain relief in surgery Same 1 year outcomes
Slide 24-

ppt slide no 24 content not found
Slide 25-

Lumbar Spinal Stenosis Congenital - Onset in 30s Degenerative Most common Onset in late 50s or early 60s Most commonly involves L4-5 level followed by L3-4 Mechanical Compression Compression of microvasculature Nerve root ischemia Increased microvascular permeability and edema
Slide 26-

ppt slide no 26 content not found
Slide 27-

Lumbar Spinal Stenosis Insidious onset Chronic low back pain that progresses to buttock, thigh and leg pain. Fatigue, heaviness or pain in the legs with ambulation (Neurogenic claudication)
Slide 28-

Neurogenic vs. Vascular Claudication
Slide 29-

Lumbar Spinal Stenosis Most common exam findings Loss of lumbar lordosis with limited extension Trunk is flexed forward in standing and walking. (“Simian Posture”) No significant tenderness to palpation Negative SLR Normal motor exam despite the report of weakness
Slide 30-

Natural History At 4 years 70% No change 15% Improved 15% Worsened 5-15% may have coexisting cervical spinal stenosis.
Slide 31-

Ankylosing Spondylitis The earliest clinical features Gradual onset in males < 30 years old Morning stiffness Improvement with exercise Not relieved by bed rest Schober test Chest expansion < 2.5 cm (late stage) Plain films typically normal in early stages
Slide 32-

Classification Complicated (“Red Flag” conditions) Specific Diagnosis Lumbar Radiculopathy Lumbar Spinal Stenosis Others such as Ankylosing Spondylitis Uncomplicated (Non-Specific) A diagnosis of exclusion
Slide 33-

Uncomplicated Low Back Pain A diagnosis based on exclusion of specific pathology Generally classified by the duration of the pain Acute: < 1 month Subacute: 1-3 months Chronic: > 3 months
Slide 34-

Uncomplicated Low Back Pain Majority (> 85%) of low back pain in primary care Acute low back pain Rapid improvement in the first month in most patients High recurrence rate up to 1/3 Chronic low back pain (7-10%)
Slide 35-

What is the anatomic source of LBP? Controversial Possible sources Discs Facet (Zygapophysial) Joints Sacroiliac Joints Ligaments Muscles
Slide 36-

ppt slide no 36 content not found
Slide 37-

Uncomplicated Low Back Pain Cannot determine specific anatomic source based on history and exam alone. “Lumbar spinal pain of uncertain origin?” X ray? MRI ? Diagnostic Injections ?
Slide 38-

X ray Asymptomatic degenerative changes Finding of degenerative disc disease, spondylolisthesis or pars defect does not establish the cause of low back pain.
Slide 39-

MRI Recommended initial imaging study of choice in complicated low back pain Cancer Infection Cauda equina syndrome Severe or progressive neurologic deficit Lumbar disc herniation Lumbar spinal stenosis
Slide 40-

MRI MRI often shows abnormal findings in asymptomatic patients. At age 42, disc bulges in 52% and protrusion in 27% of asymptomatic adults After age 60, these findings are even more common. Spinal stenosis in 25% of asymptomatic adults over 60 years.
Slide 41-

MRI Indicated for complicated low back pain and specific diagnosis How about in uncomplicated LBP? Controversial Auto mechanic analogy? Opening up the hood?
Slide 42-

Diagnostic Injections Lumbar Transforaminal ESI (Selective Nerve Root Block) Lumbar Medial Branch Blocks Sacroiliac Joint Injections Lateral Branch Blocks
Slide 43-

Diagnostic Injections Identify the pain generator Plan long term treatment
Slide 44-

Treatment of Uncomplicated LBP Life Style Changes Diet Exercise Weight control No smoking Physical Therapy Medications? Opioids? Spinal Injections? Surgery?
Slide 45-

“Yellow Flags” Previous history of disability Inconsistent findings Abnormal pain behavior Litigation Work dissatisfaction Attention seeking Preference for prolonged bed rest Depression Chemical dependency History of abuse Family history of chronic pain
Slide 46-

Waddell’s Signs Superficial tenderness: Pain elicited from light touch on the skin Simulation: Back pain is produced by maneuvers that should not be painful such as axial loading of the head (1-2 lb) or passive rotation of shoulders and pelvis in the same plane. Distraction: A symptomatic response to a test, such as straight- leg-raise, changes when the test is repeated while the patient is distracted. Regionalization: Ratchet like “givingway” weakness or non-neuroanatomic numbness Overreaction: Disproportionate response to routine examination such as collapsing, grimacing, guarding, groans, tremors or any other type of overreaction. (Behavioral response to examination, Not a proof of malingering, > 3 signs suggest the presence of non-organic factors)
Slide 47-

Prognosis Psychosocial Risk Factors “Yellow Flags” and Waddell’s signs are psychosocial risk factors of delayed recovery. More predictive of outcome than severity of pain or any exam findings. Duration of Symptoms The status of patients at 2 months may help predictor the outcome at 12 months.
Slide 48-

Summary – Low Back Pain Be aware of “Red Flags.” Identify specific diagnosis. (LR, LSS, AS) Uncomplicated LBP is a diagnosis of exclusion. MRI for complicated and specific diagnosis. MRI for uncomplicated? Diagnostic Injections Don’t forget the “Yellow Flags.”
Slide 49-

Interventional Spine Procedures Epidural Steroid Injections Facet Interventions Sacroiliac Joint Interventions Sympathetic blocks (Stellate ganglion and lumbar paravertebral) Discography (Intradiscal Procedures) Spinal Cord Stimulation(Neuromodulation) Intrathecal Pain Pump
Slide 50-

Epidural Steroid Injections Anatomy Clinical Indications Complications Medical Evidence
Slide 51-

ppt slide no 51 content not found
Slide 52-

Epidural Steroid Injection Interlaminar Transforaminal Caudal
Slide 53-

ppt slide no 53 content not found
Slide 54-

ppt slide no 54 content not found
Slide 55-

ppt slide no 55 content not found
Slide 56-

ppt slide no 56 content not found
Slide 57-

ppt slide no 57 content not found
Slide 58-

ppt slide no 58 content not found
Slide 59-

ppt slide no 59 content not found
Slide 60-

ppt slide no 60 content not found
Slide 61-

ppt slide no 61 content not found
Slide 62-

Patient selection for ESI Positive Factors Radicular pain Radicular numbness Short duration of pain No significant psychological factors Negative Factors Axial pain primarily Work-related injury Unemployed due to pain High number of past treatments and drugs taken Previous back surgeries Smoking Very high pain rating Litigation
Slide 63-

Why not ESI for axial LBP? Different anatomical origin of pain– Facet arthropathy, Internal Disc Disruption (Annular tear), or Sacroiliac joint pain Epidural route of administration of steroid does not reach the target area any better than systemic administration.
Slide 64-

Complications Infection Bleeding Spinal Cord Infarct Increased vertebral fracture?
Slide 65-

Multistate Outbreak of Fungal Meningitis and Other Infections CDC investigation in September 2012 Contaminated steroid (methylprednisolone) New England Compounding Center in Framingham, MA Fungal meningitis and spinal abscess 751 cases across 20 states – 64 deaths Don’t use contaminated steroids!
Slide 66-

Lumbar ESI Complications Multi-institutional study 16,638 consecutive procedures 14,956 TF ESIs and 1,682 IL ESIs Minor complications Vasovagal reactions – 1.2% Dural puncture – 0.04% No neurologic, bleeding or infectious complications EI-Yahchouchi CA. Complication rates of transforaminal and interlaminar epidural steroid injections: a multi-institutional study
Slide 67-

Spinal Cord Infarct
Slide 68-

ppt slide no 68 content not found
Slide 69-

Extremely rare but devastating complication of lumbar transforaminal ESI Injection of particulate steroids into radicular artery Paraplegia Using non-particulate steroid and digital subtraction angiography mitigate the risk. Spinal Cord Infarct
Slide 70-

Lumbar ESI Meta-analysis 39 publications on lumbar TF ESIs Disc herniation 60% achieved at least 50% relief at between 1 and 2 months 40% maintained this outcome for 12 months Effective in reducing pain, restoring function and avoiding surgery The Effectiveness of Lumbar Transforaminal Injection of Steroids: A Comprehensive Review with Systemic Analysis of the Published Data. Pain Medicine 2013;14:14-28
Slide 71-

Lumbar ESI Lumbar spinal stenosis 50% achieved 50% relief of pain for 6 months but rigorous studies are lacking and no controlled studies have corroborated this outcome. Failed back surgery syndrome or Epidural lipomatosis The literature on TF ESI is sorely limited. The Effectiveness of Lumbar Transforaminal Injection of Steroids: A Comprehensive Review with Systemic Analysis of the Published Data. Pain Medicine 2013;14:14-28
Slide 72-

Lumbar Spinal Stenosis Multisite (16) randomized trial 400 patients Central lumbar spinal stenosis Buttock and/or leg pain > back pain Glucocorticoids + Lidocaine vs. Lidocaine alone No control group with sham injections A Randomized Trial of Epidural Glucocorticoid Injections for Spinal Stenosis. NEJM 2014:371(1):11-21
Slide 73-

Lumbar Spinal Stenosis Primary outcomes: Roland-Morris Disability Questionnaire (0-24) and the intensity of leg pain (0-10) Secondary outcomes: >30% relief at 6 weeks >50% relief at 6 weeks A Randomized Trial of Epidural Glucocorticoid Injections for Spinal Stenosis. NEJM 2014:371(1):11-21
Slide 74-

Lumbar Spinal Stenosis Steroid + Lidocaine (200) RMDQ – 14.4 to 12 Intensity of 1week avg pain – 7.0 to 4.9 >30% relief at 6wks – 49.2% >50% relief at 6wks – 38.3% Lidocaine only (200) RMDQ – 14.8 to 12.1 Intensity of 1 week avg pain – 7.0 to 4.9 >30% relief at 6 wk – 49.7% >50% relief at 6 wks – 38.3%
Slide 75-

Lumbar Spinal Stenosis Both groups improved Subgroup analyses: Glucocorticoids-Lidocaine group reported better physical function on RMDQ (-2.5)and less leg pain (-0.9) at 3 weeks No statistically significant difference between the two groups at 6 weeks Negative Study?
Slide 76-

Medical Evidence for ESIs Lumbosacral radiculopathy secondary to disc herniation Literature support – Yes Lumbar Spinal Stenosis with leg pain Literature support – limited FBSS with leg pain Literature support - Don’t know Other causes of axial back pain Literature support – No
Slide 77-

Summary Lumbar ESI ESIs may be an option for relief of severe radicular pain unresponsive to conservative treatments. Not for axial low back pain Safe procedure Good support for disc herniation Controversial support for lumbar spinal stenosis
Slide 78-

Lumbar Facet Pain Clinical Symptoms Predominantly axial pain May have somatic referred pain to legs Generally older patients Exam Lumbar paraspinal tenderness Positive facet loading Negative nerve tension tests No focal neurologic deficit
Slide 79-

Anatomy Synovial joint Medial branches from dorsal rami innervate the facet joints. L4-5 and L5-S1 levels are most commonly affected.
Slide 80-

Anatomy
Slide 81-

Anatomy
Slide 82-

ppt slide no 82 content not found
Slide 83-

Lumbar Facet Procedures Intra-articular Steroid Injection Medial Branch Block Percutaneous Radiofrequency Medial Branch Neurotomy
Slide 84-

Intraarticular Injection
Slide 85-

Lumbar Medial Branch Block Diagnostic Test – No therapeutic benefit Placebo Injection of Normal Saline Most rigorous control block Impractical in most clinical settings Comparative Block Lidocaine Bupivacaine
Slide 86-

Medial Branch Blocks
Slide 87-

Radiofrequency Ablation Therapeutic procedure for lumbar and cervical facet pain Teflon-coated electrode with an exposed tip is inserted onto the target nerve. High frequency electrical current is concentrated around the exposed tip. The nerve is heated and coagulated.
Slide 88-

ppt slide no 88 content not found
Slide 89-

ppt slide no 89 content not found
Slide 90-

ppt slide no 90 content not found
Slide 91-

ppt slide no 91 content not found
Slide 92-

Gofeld – Pain Physician 2007 209 patients 10 year period 70% relief to diagnostic blocks 35% had 50% relief 22% had 100% relief Mean duration of relief 12 months
Slide 93-

MacVicar – Pain Medicine 2012 106 patients 100% relief to diagnostic blocks 56% achieved complete relief Mean duration of relief 13 months Restoration of normal activities
Slide 94-

Summary -Lumbar Facet Procedures Predominantly axial low back pain Intra-articular Facet Injection Primarily diagnostic Long term relief? Radiofrequency Ablation Select patients with diagnostic MBBs Only helpful if facet mediated pain About 50% chance of relief for about 12 months
Slide 95-

Sacroiliac Joint Pain Sacroilitis (Inflammatory Arthritis) AS RA Sacroiliac Joint Dysfunction Abnormal gait pattern Leg length discrepancy Lumbar fusion Trauma Scoliosis Pregnancy
Slide 96-

Anatomy Diathrodial Synovial Joint Anterior: true synovial Posterior: syndesmosis (ligaments and muscles – gluteal and piriformis) Innervation Anterior: lumbosacral plexus Posterior: primarily dorsal ramus L5 and lateral branches S1 to S4
Slide 97-

Sacroiliac Joint Dysfunction Clinical Symptoms Pain near PSIS in gluteal area Unilateral Pain when rising from sitting May have somatic referred pain down the leg Does not pass above L4-5 level (iliac crest) Exam Multiple clinical exams Fortin Finger Test – simplest
Slide 98-

Sacroiliac Joint Interventions Intraarticular Injections Primarily diagnostic Long term relief? Radiofrequency Ablations Select patients with LBBs Designed for long term relief Improving techniques Emerging evidence
Slide 99-

Intraarticular SI Joint Injection
Slide 100-

Radiofrequency Neurotomy
Slide 101-

ppt slide no 101 content not found
Slide 102-

Summary – SI Joint Procedures SI Joint Dysfunction Intra-Articular Injection Radiofrequency Ablation Diagnostic LBBs for patient selection Long term relief Developing techniques