Ipm Intro.pdf

interventional pain management

an introduction Dr Hema datar MBBS D Ortho Fellow Interventional pain management Fellow closed chain biomechanics and theratogs application

pain -definition ● In 1994, the international association for study of

pain defined pain as “An unpleasant emotional and sensory experience associated with actual or potential tissue damage or described in terms of such damage”

Types of pain ● Acute pain is one of the basic adaptations that

most species have to warn the organism of internal or external stimuli potentially harmful to the well-being of that organism.

● Chronic pain exists when pain symptoms are

prolonged well passed the natural course of disease processor a disease process of protracted over the course of many months to years

Pathophysiology of chronic pain ● Acute pain is a protective phenomenon ● But when left untreated develops into chronic pain

Physiological theories proposed to explain why chronic pain develops ✓ Sensitization in peripheral and central nervous system ✓ Spontaneous activity and discharges from the injured axons ✓ Demyelination and abnormal connections between them ✓ Influence on the deep brain structures like reticular formation influencing emotional response to pain

Fibromyalgia

Feature

MPS

FMS

Pain pattern

Localized/regional

Generalized

Least distribution

Single muscle

11 tender points

Muscle spasm

+++

++

Trigger points

Local/regional

Not a feature

Tender points

Not a feature

Common/widespread

Taut band

++

__

Referred pain

+++

__

Gender disposition

Common in males

Common in females

Genetic predisposition

Present

Not seen

Systemic symptoms

Usually not seen

Present

Prognosis

Curable

Seldom curable

Associated findings

Mobility restriction, Abnormal posture

Fatigue ,sleep disturbances , IBS, psychological disturbances

Documented findings ● Fibromyalgia may develop after a major trauma. ● Substance P in CSF is three times higher in FMS. ● Low serotonin levels in platelets & CNS. ● Low levels of ATP in RBC and trigger points. ● Dysfunction of the HPA axis. ● Low growth hormone. ● Nerve growth factor was 4 times higher in CSF. ● Strong familial pattern with females more affected. ● Non-restorative deep sleep.

No single explanation We can easily understand that there is no single clear patho-physiological explanation, which can explain all clinical, & biochemical abnormality.

Frozen shoulder

Frozen shoulder (adhesive capsulitis)

Adhesive capsulitis ● Painful progressive loss of

shoulder movement

● It affects both active and

passive movements of the shoulder

tendinopathies

Tendinopathies (enthesitis)

Definition- tendinopathy Tendinopathy is a general descriptor that includes any painful condition occurring within or around a tendon ● Overuse

(athletes and /or sports personnel) ● Overloading (sedentary lifestyle)

Common Tendinopathies

Common Tendinopathies

Tendinopathy- s/s ● Focal tenderness on

palpation pain

● Activity related pain ● Decreased strength in

the affected area Swelling

Decreased load bearing

Pathophysiology of tendinopathy ● Micro injury in and around the tendon and their

insertion points ● No e/o inflammation at the tender site ● Pain is produced due to neo neuralization ARE WE JUSTIFIED IN GIVING STEROIDS FOR THIS PATHOLOGY?

Low Back Pain and Sciatica

Prolapsed Intervertebral Disc

MRI LS Spine

Internal Disc Disruption

Differential diagnosis of LBP ● PIVD ● Facetal arthropathy ● Sacro-iliac arthritis ● Pyriformis syndrome ● Myofascial pain syndrome

Incidence Low back pain and sciatica ● Facet – 15 to 45 % ● SIJ – 2 to 30% ● Piriformis -5 to 6 %

Predominant back pain

Axial

DDD B/L Facet Comp #

paraxial

Facet SIJ Myofascial pain

Predominant leg pain

Low back pain & sciatica Evaluation CRPS

Global

Dermatomal distribution

Disc pathology with Root irritation Root pathology

Segmental

Non dermatomal distribution Facet pathology Sacro iliac joint pathology Piriformis pathology

Pain originating above L 5 Pain originating below L 5

Facet pathology

S I joint Piriformis

X
 knee

Osteoarthritis knee Osteoarthritis is a degenerative joint disease affecting both cartilage and bone.

Aetiology of oa (knee) ● Aging ● Joint injury ● Being overweight ● Stresses on the joints from work and/or sports ● Joints that are not properly formed ● An abnormal defect in the joint cartilage ● Hormones (lack of estrogen in postmenopausal women) ● Repetitive joint movements/ occupational injuries ● Genetics ● Nutrition (lack of vit D)

Risk factors for oa knee ● Age ● Female ● Obesity ● Previous knee surgery ● Lower limb malalignment ● Repetitive knee bending ● Weak muscles ● High impact activities

Stages of oa knee ● Acute osteoarthritis—people in denial ● Subacute osteoarthritis— no denial here ● Chronic osteoarthritis—constant pain in multiple

joints ● Degenerative Osteoarthritis—bone on bone and

unbearable pain

Anatomy of knee

Pathologic changes in knee

sYmptoms ● Pain ● Stiffness ● Crepitus

Diagnosis of oa knee

Treatments that help arthritis pain
 ● ● ● ● ● ● ● ● ● ● ●

Exercise General activity and sports Managing your weight Changing the way you do daily activities Knee braces Heat and cold Capsaicin cream Walking stick Knee injections Pain medication Arthroscopy

Treatment modalities ● Pharmacotherapy ● Physiotherapy ● Interventional pain management ● Lifestyle changes ● Surgeries

Arthroscopic surgery High tibial osteotomy Joint replacement surgery

Interventional pain management What is interventional pain management? Interventional pain management is a discipline of medicine (allopathy) devoted to the diagnosis and treatment of pain and related disorders by the application of interventional techniques in managing subacute and chronic, persistent and intractable pain independently or in conjunction with other modalities of treatment

Interventional Pain Management

What is it?

Treatment of Pain Recovery Operation Strong opioids Weak opioids +/non-opioids Non- +/- adjuvant opioids Non-pharmacological methods

Treatment of Pain Recovery Operation Strong opioids

Nonopioids

Weak opioids +/non-opioids

Non-pharmacological methods

World of Misery

Treatment of Pain Recovery Operation Strong opioids

Nonopioids

Weak opioids +/non-opioids

Non-pharmacological methods

IPM

What are interventional pain procedures? Minimally invasive procedures include percutaneous precision needle placement, with placement of drugs in targeted areas or ablation of targeted nerves.

How does it work? 1. Targeted delivery of drugs. 2. Aims to correct the pathology 3. Blocking of nerve signals corrects

neuropathy.

What is the scope of IPM? ● Fibromyalgia and myofascial pain syndrome ● Osteoarthritis knee ● Frozen shoulder ● CRPS ● Tendinopathy ● Low back pain ● Neuropathy and neuralgias ● Failed back surgery syndrome ● head and neck pain ● cancer pain

OA KNEE

Interventional Treatment modalities ● Intraarticular corticosteroids – aggravates the degenerative

process in the joint

● Intraarticular hyaluronic acid ● Intraarticular pulsed radiofrequency(PRF) ● prolotherapy ● Dolorclast therapy ● Laser chondroplasty ● prolotherapy (PRP)

pain around knee

intra articular pulsed radiofrequency

Knee Arthritis – Genicular Nerve Radio frequency ablation

treatment options for low back pain

Medial Branch Block (MBB) Which nerve to block?

To block L4-5 facet

Block the L3 &L4 branches

as they cross

the transverse process of

L4 & L5 vertebrae

Respectively

Medial Branch Block (MBB) Oblique view : Showing position of the needle at the junction of the SAP and transverse process

Facet intra-articular block

Dye injected into the facet joint

Procedure Positioning of patient and fluoroscopy

Posterior oblique view

Procedure

Management ● Dye injected into the

piriformis muscle to confirm needle position

SNRB V/S LRB

Prolotherapy

Prolotherapy

Prolotherapy ● R – rest ● I - ice ● C – compression ● E – elevation

RICE (conventional method)

● M – movement ● E – exercise ● A – analgesics ● T – treatment

MEAT (prolotherapy)

RICE v/s MEAT RICE ● Decreases immune ● ● ● ● ●

system response Decreases blood flow to injured area Hindered collagen formation Delays recovery Decreased ROM Decreased complete healing

MEAT ● Increased immune ● ● ● ●

response Increased blood flow to injured area Encourages collagen formation Increased ROM Increased complete healing

PRP PREPARATION

layers after centrifuge

occipital neuralgia

Botox Injections for migraine headaches

causes of sympathetically mediated pain

• ischaemia • pressure on adjacent bone or nerve • surgical pain • tumor necrosis

sympathetic overactivity in CRPS

anatomic supply of sympatheti c plexus

Common Sympathetic blocks • Stellate Ganglion • Celiac Plexus / Splanchnic plexus • Lumbar Sympathetic Plexus • Superior Hypogastric Plexus

trigeminal neuralgia

Stellate ganglion block

Splanchnic Plexus / Celiac Plexus Blockade

coeliac ganglion supply

coeliac ganglion anatomy

superior hypogastric block

superior hypo-

gastric ganglion anatomy

superior hypogastric block

Lumbar Sympathetic blockade

lumbar sympathetic ganglion

lumbar sympathetic ganglion block

ganglion impar

ganglion impara anatomy

ganglion impar block

overview of cancer pain management area or organ involved

sympathetic block

head and neck

stellate ganglion

thoracic

T2-T3 or thoracic sympathetic

foregut

splanchnic or coeliac ganglion

distal to transverse colon

lumbar sympathetic

pelvis

superior hypogastric

perineal / anal

ganglion impar

……thank you!

thank you!