Interventional Pain Management Low Back Pain
Interventional Pain Management Low Back Pain
Interventional Pain Management Low Back Pain
Low back pain is defined as acute/ sub acute or chronic discomfort localized
to anatomic area below the posterior ribs and above the lower margin of the
buttock line.
Back pain is most expensive health care problem because it affects 20
to 50 years age group which is the most productive age. Eighty-five percent
of our population suffers at least one episode of back pain a year. Most of
them (Between 75% and 90%) resolve with in 2-4 weeks time and, about 5%
to 10% of LBP patients required Interventional management however,
degree of invasiveness and costs of different treatment modalities varies.
• Possible fracture,
• Signs of tumor or infection.
• Bladder or Bowel dysfunction.
• Severe or progressive neurological dysfunction in the legs.
• Major motor weakness in quadriceps, plantar flexors, evertors, and
dorsiflexors.
Low Back Pain Management
Algorithmic approach*
Nucleus
Pulposus
Annulus
Fibrosus
To get longer pain relief due to facet joint involvement, medial branch
supplying the facet joint is treated with radio waves and procedure is known
as radiofrequency ablation. With the help of thermocouple radio waves are
focused on affected nerves. Due to heat generated and inherent properties of
radio waves Neuromodulation occurs in the nerves and pain signals are
blocked for 12-16months. A precaution is taken while radio-ablating the
sensory nerves that motor fibers should not be affected.
Lumber Selective Nerve Root Block and Root Adhesinolysis
Lumber dorsal and ventral root arise from the spinal cord and join together
to form spinal nerve in intervertebral foramen. The cause of radicular pain is
stretch and ischemia of nerve root because nerve root is surrounded by
inflammatory deposits or adhesions which prevent the movement of that root
during movement of body. Interventional procedures are used to reduce the
edema around the nerve root and make it free to move in and out of foramen
when nerve movement is required. The affected nerve root is targeted in
upper and outer quadrant of foramen. This procedure is diagnostic as well as
therapeutic in lumber radicular pain. Local anaesthetics are injected in
affected nerve root; if pain is relieved than steroid (Depomaderol 20mg for
each root) mixed with 1-2ml local anaesthetic is injected near the nerve root
through intervertebral foramen under fluoroscopic guidance. Needle position
is repeatedly checked in AP, Oblique and Lateral position to confirm the
needle position to avoid nerve root injury. If nerve root is entrapped by
adhesion due to scar of previous surgery, a catheter can be passes along the
exiting root and adhesinolysis can be done by catheter movement or by
injection of hypertonic saline/ infusion of normal saline. Catheter is left for
three days and removed after giving steroid plus local anaesthetic mixture to
prevent further inflammation and edema. This procedure requires high
degree of precision to insert the catheter at desired level and it is helped by
radiopaque contrast and fluoroscopy.
Before the popularity of IPM, epidural steroid was most common
procedure to treat radicular pain due to nerve root compression by disc or
root inflammation. Large volume of local anaesthetic and higher dosage of
steroid were used to reach the targeted roots. With transforaminal approach a
small amount of drug is required and results are superior to epidurals.
Trans Foraminal Selective Nerve Root Block;
(L4 nerve root is seen) (S1 nerve root is seen)
Caudal Decompressive Neuroplasty
When lumber and sacral roots are entrapped in fibrous tissue either due to
previous surgery or chronic disc protrusion resulting in inflammation and
edema, a special steel catheter coated with polymer (Racz catheter) is
inserted through sacral hiatus and negotiated through adhesions with the
help of contrast and fluoroscopy. A mixture of local anaesthetic, steroid,
hyaluronidase and hypertonic saline is injected every day for three days. The
effect on adhesion can be immediately confirmed by injecting contrast
through catheter and compared with previous contrast study which showed
various filling defects around nerves.
Black Arrow Showing Filling Defects Filling Defects Removed
Epiduroscopy
• givemmediate pain
A x i a l P a i n P a r a - m e d i a n P a i Gn l o b a l S e g m e n t a l / P a t
D D D C o m p r e s F s a i co e n t # J t S I J t M P S C R P S D e r m a N t o o m n a- dl e r m a
2 5 - 4 0 % 3 - 5 % 1 5 - 4 5 % 1 5 - 3 0 % 2 - 8 % 2 - 8 %
I D E T V e r t e b r R o pF l r a h s i t zy Ro tF o rm h y i z o T t o P m i ny j .R F L u m b e r
P D D S y m p a t h e t i c P l
D i s c p r o F l a a c p e s t e/ S I J t
2 - 5 % 4 0 - 7 0 %
O z o n e N P uy rc i l f e o o r l m y s i is s
P e r C u t D B i os c t eo cx t oi n m j . y
Acknowledgements:
Dr. Gautam Das MD, FIPP
(Director Daradia-The Pain Clinic, Kolkata)
Dr. Vikram B Patel MD, FIPP
(Director ACMI Pain Clinic Chicago USA
References:
Dr Ashok Jadon,
MD DipNB, MNAMS,
Fellowship Interventional Pain Management
Sr Consultant & HOD
Dept. of Anaesthesia & Pain Clinic
Tata Motors Hospital, Jamshedpur-831004, India
Address for correspondence: Duplex 63, Vijaya heritage phase 6, Uliyan Kadma,
Jamshedpur-831005, India
Mob: +91 9234554341