Interventional radiologic spinal pain management-A 7 year experience in Ghana

1. Interventional radiologic spinal pain management-A 7 year experience in Ghana DrAsafu-Adjaye Frimpong Consultant Interventional Radiologist

2. introduction • Chronic back pain is in the spectrum of neuropathic pain • Affects a significant proportion of our aged population • Affects productivity • Financial implications • Psychosocial effects

3. Categories of chronic backpain • Non specific back pain • Back pain associated with radiculopathy and stenosis • Back pain referred from a non spinal source • Back pain associated with another spinal cause

4. Mechanical from Spinal • Degenerative disk disease and facet • Herniated disk • Spinal stenosis • Traumatic fracture • Osteoporotic fracture • Congenital disease-scoliosis/kyphosis • Spondylosis

5. Non Mechanical Spinal • Neoplasia Metastatic carcinoma Primary vertebral tumours Multiple myeloma • Infection Septic Diskitis with abscesses Osteomyelitis • Osteochondrosis • Pagets Disease of bone • Inflammatory arthritis Ankylosisng spondylitis Reiter syndrome Psoriatic spondyloarthritis

6. Clinical Presentation • Focal back pain-whole spine • Radiculopathy • Claudication • Numbness and tingling • Burning sensation

7. Evaluation • History • Physical Examination • Labortory assessment • Imaging • Psychosocial issues

8. Management • Pharmacological • Non pharmacological • Interventional • Surgery

9. Therapeutic interventions • CT guided nerve blocks • CT guided Vertebroplasty • CT guided tumor ablation • CT guided percutaneous laser disc decompression (PLDD)

10. Interventional Pain management • Intrathecal drug delivery • Anesthetic nerve blocks • Neurolysis • Laser Disc Decompression • Ozone therapy

11. Successes with thoracic and cervical in pain control is >90% over a 2 year period • Less in lumbar region @ 70% • Recurrence of pain related to age of patient, duration and severity of disease • Generally a very safe and effective treatment for small and moderate prolapses without severe neurologic deficits • Not done for patients with weakness in limbs or atrophy. • Not very effective for treatment for numbness.

12. Discogenic Radiculopathy • Common in the lumbar and Cervical Region • Less common in the thoracic and Sacral regions • Access usually epidural in the lumbar region as well as selective periradicular • Cervical region usually extraforaminalperiradicular • Thoracic periradicular and transforaminal with epidural extension • 3 dose regimen of 40mg triamcinolone and 1% bupivacaine with a weekly interval

13. Management • Pharmacological • Non pharmacological • Interventional • Surgery

14. Nerve Blocks • Undertaken predominantly for pain resulting from discogenic radiculopathies • For cancer related Pain • For

15. Our 7 year experience in GH • Interventional pain clinic • Clinical evaluation • Imaging • Post treatment management and follow up

16. CT guided nerve blocks- 7 year experience • CT guided percutaneous laser disc decompression- about 3years

17. CT guided nerve blocks • About 4200 procedures involving about 1400 patients in 7 years were undertaken. • Categories • Age range 16-91yrs • Comprises 55% Females and 45% males

18. Referral Pattern • 80%-patient to patient referral • 15% from clinicians • 5% from health education and promotion

19. Clinical History • Low back pain with or without radiculopathy • Parathesias • Numbness and tingling • Claudication Spinalis • Pain with weakness

20. locations • Cervical-20% • Thoracic-< 5% • Lumbar 75% • Sacrococygeal < 1%

21. procedure • Planning scan • Determination of trajectory • Duration-10mins averagely • Needle placement • Confirmation of drug location and path with iodinated contrast or air • Injection of kenalog

22. protocol • CT guidance • 3 X procedure seperated by 1 week interval • Combination of macaine(bupivacaine) 0.25% and kenalog (triamcinolone) 40mg

23. Access • Transforaminal cervical • Epidural • Periradicular • Facettal • Sacroiliac

25. Trajectory

26. Needle/contrast outline

27. Right periradicular transforaminal T 9 block with epidural extension

28. Efficacy and successes • Defined as significant reduction of pain and symptoms more than 70% • Cessation of oral medication. • Short term up to 6 months • Medium term . Up to 2 years • Long term. More than 2 years

29. Short term- • Almost 90% success rate • Failure considered if symptoms remain the same 3 months after treatment • Seen in patients with emotional and psychosocial issues severe or absolute stenosis Grade 2+ listhesis

30. Medium Term • 70% • Middle Age • Moderate stenosis • History – usually up to 12 months prior to treatment

31. Long term- • > 50% • Younger age • Shorter duration of symptoms prior to onset of treatment • Mild to moderate prolapsed disc sizes and stenosis

32. complications • < 0.3% • Procedural • Medication induced

33. procedural • Contrast Allergy • Severe numbness • Post dural puncture headache-blood patch employed for unresolving cases • Acute back pain

34. Steroid Induced • Poor glycaemic control • Discoloration of the hands and sometimes skin • Menstrual irregularities • Weight gain • Increased libido and performance

35. limitations • Patients with severe or absolute stenosis • Poorly treated diabets • Patients with grade 2 + listhesis

36. Post intervention management • Review 2 weeks, 6weeks 5months • Physiotherapy • Medication • Bed rest for those presenting with acute pain

37. Conclusion • CT guided nerve block is a very safe, very effective therapeutic intervention for patients suffering from discogenic radiculopathy. • Limited efficacy in patients with very severe or absolute canal stenosis or grade 2+ listhesis • Complications are very minimal and usully related to general effects of steroid