Invasive Management for Spinal Conditions

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Invasive Management for Spinal Conditions
2014-02-12 14:42:50
Invasive Management Spinal Conditions
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  1. Epidural Steroid Injection (ESI)
    • Combines steroid medication w/ local anesthetic to provide immediate pain relief
    • Injected into epidural space, does not penetrate theca sac
    • May provide short-term relief from extremity pain w/ spinal stenosis
    • Most research suggests max of 3 injections per year/per site
  2. Epidural Steroid Injection (ESI): Side Effects
    • 2-4 days of soreness
    • Nausea/vomiting
    • Dizziness
    • Headache
  3. Epidural Steroid Injection (ESI): Complications
    • Infection
    • Dural puncture w/ or w/o headache
    • Aseptic meningitis
    • Arachnoiditis
    • Epidural abscess/cyst
  4. Trigger Point Injection
    Jump sign confirms needle has entered TrP
  5. Facet Joint Injection/Medial Branch Block
    • (Medial branch innervates facet joints)
    • Injected 1st w/ anesthesia, if pain relieved --> cortisone is injected
    • Used as gold standard to diagnose segmental involvement
  6. SI Joint Injection
    • Injected w/ anesthesia, if pain relieved --> cortisone is injected
    • Should be pain free immediately due to anesthesia
  7. Glucocorticoid Injections (Steroid Injections)
    • Epidural Steroid Injections
    • Trigger Point Injection
    • Facet Joint Injection/Medial Branch Block
    • SI Joint Injection
  8. Discography
    • Diagnosis by pain provocation
    • Multiple discs injected w/ contrast medium
    • Study: resulted in accelerated disc degeneration, disc herniation, loss of disc height and signal and development of reactive endplate changes
  9. Botulinum Toxin A (Botox)
    • Stops/reduces spasm when injected into muscle in small amounts
    • Not permanent - 3-4 months of pain relief has been reported
  10. Electrothermal & Radiofrequency Therapies
    • Intradiscal Electrothermal Therapy (IDET)
    • Percutaneous Intradiscal Radiofrequency Thermocoagulation (PIRFT)
  11. Intradiscal Electrothermal Therapy (IDET)
    • Flexible catheter inserted into disc in ring-like fashion
    • Slowly heated to 194 degrees F (kills nerve fibers, toughens disc tissue, and seals small tears)
  12. Percutaneous Intradiscal Radiofrequency Thermocoagulation (PIRFT)
    • Radiofrequency probe placed into center of disc, activated for 90s at 70 degrees C
    • Minimal research performed on this technique, some studies suggest no better than placebo
  13. Selective Dorsal Rhizotomy (Radiofrequency Nerve Ablation)
    • Ventral and dorsal roots separated from each other
    • Electrical current produced by radio waves to ablate the dorsal (sensory) nerve roots --> kills proprioceptive contra of segment
    • Nerve roots regenerate within 5-8 months
  14. Prolotherapy
    • Dextrose solution injected into ligament/tendon @ enthesis --> causes local inflammation
    • Increase blood flow and nutrient supply to area
    • Rationale: strengthens damaged tissue by sclerosing the area
  15. Spinal Stimulators
    • Leads are inserted over SC in epidural space
    • Pulse generator implanted into abdomen or gluteal region
    • Pulsed current may provide analgesic effect
    • Used predominantly for FBSS (Failed Back Surgery Syndrome) and CRPS (Chronic Regional Pain Syndrome)
  16. Opiods
    • Only intended for pain that is constant and acute
    • Hindrance to MMI (maximum medical improvement)
    • Substance abuse common
    • Frequently prescribed despite contraindications
    • Narcotics reliably cause an abnormally severe sensitivity to pain (termed "hyperalgesia")
  17. Opiods: Side Effects
    • Immune system compromise
    • Cognitive impairment
    • Sleep abnormalities
    • Generalized ill health and disability¬†
    • Erectile dysfunction
  18. "Iatrogenic Vortex"
    Pattern of increasing over-medicalization throughout a patient's care