Category: Blog

Dr Shantanu Mallick

Recently I have attended the workshop organised by dr neeraj jain in action medical institute in paschim vihar, delhi.
I want to share my experience:
Dr Neeraj Jain is tremendously knowledgeable, caring to the patients, skilled in interventions and a great teacher. Even after clearing FIPP Exam, I have learned lot more things in different way which are so much innovative, only a research fellow can think of. He has no hesitation to distribute his knowledge and tricks which is really exceptional. I think his skill and knowledge beside vertebraplasty was never explored by anybody before this workshop. I feel every upcoming pain physician should attend his workshop.
Many many thanks
regards
Dr Shantanu Mallick
MBBS (Kol), DA (Mum), FIPP (USA)
Pain Physician

Pain Relieving tips for Blackberry Thumb

The following article has been provided by Dr. Neeraj Jain, Senior Consultant, Pain Clinic, Sri Balaji Action Medical Institute

All you teenagers, young guns and cell phone addicts out there! Next time you are exchanging any text message with your friends or colleagues, beware! You may end up suffering from sore wrists & thumbs and repetitive strain injury. Every year, more than 3 million people across the globe complain of injuries resulting from text messaging. People tend to hold the device in their fingers and press the tiny keys with their thumbs which results in numb fingers, painful thumb and aching wrists. It is a signal to stop.

Blackberry Thumb and iPhone finger are few of the hand ailments caused by this method of typing or pressing your phone keys. At first, you will feel a slight discomfort in your thumb and ignoring it would soon lead to its painful swelling. Following are some tips that would help you get some relief from this condition before you consult a pain specialist:

  1. Outward thumb bending: Bend your thumb towards the outward direction applying resistance until you feel the stretch or pull.
  2. Thumb Rotation: Rotate your thumb in both clockwise and anti-clockwise movement to loosen the stiffened joints and relieve pain.
  3. Hot Fermentation: Treat your aching thumb with hot water fomentation to increase blood circulation and help the joint muscles to relax. Add 1 teaspoon Epsom salt in a small vessel of hot water. Soak a towel in the saline water. Squeeze out excess water and place the towel on affected area. Repeat this 5 times.
  4. Wrap your thumb safely: To avoid any pressure on your paining thumb, keep it safe and padded at night by wrapping it in a soft bed of cotton.

Rest: Stop doing what makes your thumb hurt. Put a halt to your daily routine of texting. It won’t do any harm. This important pause will in fact allow the thumb to start healing otherwise surgery may be required which also doesn’t guarantee cure.

Vertebroplasty: for Fracture Spine

Percutaneous Vertebroplasty (PVP) is an emerging interventional technique in which surgical polymethyl methacrylate bone cement is injected under local anaesthesia via a large bore needle into a vertebral body (VB) under imaging guidance providing increased bone strength, stability, pain relief, decreased analgesics, increased mobility with improved QOL and early return to work.

Started in 1984 by Galibert PVP is done in host of INDICATIONS:

Senile osteoporotic compression # remains the commonest Indication. Other indications are  Metastatic VB #,  Multiple myeloma VB #, VB haemangioma,  Vertebral osteonecrosis & for strengthening VB before major spinal surgery. The benefit has been extended to the traumatic stable uncomplicated VB compression # (VCF)   which is commoner in younger age group with active life profile and prime of their career where strict bed rest and acute or chronic pain are unacceptable and they are more demanding for proactive treatment approach so as to be back to work ASAP.

Discovering the fact that # VB is the commonest # of body, its incidence >the # hip, it becomes imperative to take it more seriously. With increasing life span there is more of aged osteoporotic population, more so due to sedentary indoor lifestyle and post menopausal osteoporosis.  Diabetics, smokers & alcoholics are at higher risk of developing osteoporosis. I have seen such alcoholic patient developing six spine fractures in just three months time from a single fracture being on complete bed rest.

Quick fix of fracture spine makes patient walk back same day instead of bed rest of months together avoiding morbidity & mortality of prolonged bed rest, making bedridden patient walk, in a way bringing patient  back to normal life.

In this era of MAS replacing open surgeries, PVP is a novel procedure & should be in the first line of management in place of conservatism or major spine surgery for painful uncomplicated compression #.

MORBIDITY & CONSEQUENSES OF SPINAL #:

  • Traumatic VB # is painful condition requiring bed rest restricting daily activities markedly.
  • Left untreated it can cause DVT, increase osteoporosis, loss of VB height, respiratory &

GI disturbances, emotional & social problems secondary to unremitting pain, loss of independence with high cost of rehabilitation.

  • High risk of primary or consequential damage to neural, bony or disc elements.
  • Increased wedging, deformity & increase incidence of adjacent VB #.
  • Chronic pain of altered spine mechanics.
  • Uncomfortable braces & sleep disturbance because of pain & discomfort with its sequels.

MORBIDITY & COMPLICATIONS OF SPINAL SURGERY:

  • Cost of surgery and hospital treatment
  • Cost of implants
  • Phobia of surgery
  • Prolonged recovery period & Extensive rehabilitation
  • Changed spinal mechanics & transition syndrome
  • Major surgery & anesthesia with its own complications

Preparation & Procedure:
X-ray spine in a/p & lat view. CT is more informative of bone & # morphology. MRI is good for soft tissue injuries. Ask for pedicle size in all dimensions and construct a 3D image aiming needle placement and cement filling in scan room itself as rehearsal of PVP. This reduces operative time & gives better results.

Conventionally PVP is done by hammering the vertebroplasty needle through the bone. Here we use light weight drill to bore through the vertebra. It is important to set the needle at exact entry site & side with right trajectory aiming the # defects. In lateral view needle should go through middle of the pedicle going up to anterior 1/3 of VB. In P/A view the needle can be in midline or paramedian depending upon # & if uni/bipedicular approach is planned. Approach varies as per location of vertebra, anterolateral in cervical, costotransverse/parapedicular in thoracic & transpedicular in lumbar vertebra.

Do bone biopsy if there is any doubt about # lession. Do dye test (vertebral venography). Make cement more radiopaque by adding barium /or tungsten. Inject cement with 1or2 ml luerlock syringes strictly under fluoroscope in lateral view & cross checking in P/A view. Stop injecting either there is adequate filling or at the first sight of ectopic cement leak. Keep sample cement to see for hardening. Remove needle with rotational movement before cement hardens.

Pain relief is by virtue of different mechanisms postulated :

  • Cementing of # fragments.
  • Thermal neurolysis of VB nerve ending due to heat of polymerization.
  • Washing away of nociceptor chemicals.
  • Neurolytic action of liquid monomer.
  • By allowing early ambulation decreasing pains of immobility & bed rest.

COMPLICATIONS:

  •   PVP is generally safe with low risk.
  • Ectopic cement leak is frequent but generally inconsequential.
OUTCOME:
  • PVP is a novel procedure with high benefit to risk ratio, which is highly underutilized in relation to the high prevalence of the vertebral #.
    • Different studies show an immediate pain relief in (85 – 90)% of patients with low complication rate ranging from (1-5)% depending upon the type of lesion.
    • PVP does augment height of VB but ideal would be kyphoplasty.
    •  Patient is either off medicine or on reduced doses.

Patient feels so well that he almost forgets if he had VB #.

Low Back Pain And Slip Disc With Sciatica: A Nascent Treatment

A young lady came to me with disabling back pain for last 5 years which made her leave the job. She is not marrying due to same problem.

A schoolgirl of 10th class is not able to focus on studies since past 6 months because of back pain which she relates to dance competition preparation 7 months back. She has her board exams coming making her & family all the more worried.

“Because of my back pain I can’t play with my children or sleep comfortably.” Said  a patient.

A patient had to change his job because he could not commute distances for same reason.

I keep getting this neck pain as & when I have to spend extra hour on my computer at duty in the bank.

A patient requested me to get rid of her back pain as her daughter is getting married in two months.

“Help me doctor as my married life is getting ruined” said a young back pain patient.

For all these and many like them Dr. Neeraj Jain`s massage is pain is real and treatable- there is no merit in suffering” “No one needs to suffer as so many good and effective treatments are now available at specialty pain clinics”. You must see a pain specialist if you still suffer from pain after a month of conservative treatment. Sooner your pain is managed better are the overall results.

It’s a pandemic disease having 80% of lifetime prevalence, affecting 15-20% population at any point of time, as such pain (the 5th vital sign as per W.H.O.) is the commonest symptom to consult a doctor. It is the commonest cause of young age disability (3-4% annually with 1% permanently disabled). 30-60% of all acute LBP relapse & develop chronic LBP. It has significant financial, socioeconomic, emotional & physical morbidity. It needs an integrated multidisciplinary proactive treatment approach

“Do not take your back for guaranteed” says Dr. Jain who is heading pain clinic at Sri Balaji Action Medical Institute inNew Delhi. One can avoid back pain with spine care and avoiding risk factors like osteoporosis, obesity, smoking, prolonged driving, sedentary lifestyle, too heavy or too little exercise, bad spine postures and wrong way of pushing or lifting heavy objects.

While spinal arthritis is the common reason of young age back pain at prime of their carriers including some bollywood celebrities, disc diseases including slip disc is prevalent in all age groups, in young age due to trauma & in old age due to degeneration.

With interventional pain management patients are getting back to life. It has both diagnostic and treatment values, as sometimes all investigations put together do not give the exact diagnosis.

Newer technologies like ozone injection cures most of the patients of slip disc & sciatica, as ozone’s nascent oxygen atom shrinks the disc so taking away pressure from pain sensitive nerves. It is a non surgical, outpatient procedure done under local anesthesia not requiring bed rest for more than day or two & prolonged absence from work realizing the importance of time, at much lower cost with almost no complications. This procedure is done under radiological guidance for precise needle targeting and best results. There after patient is given advice for spine care & healthy habits. This technology is latest & many people including medical caregivers don’t know about it. It has benefited millions in developed world and is now available inIndiaalso.

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CHRONIC PAIN: A MENACE

Pain is one of the most common reasons for patients to seek medical attention and one of the most prevalent medical complaints in today’s world. Chronic pain has many causes and can affect any part of the body. Conditions most associated with pain include arthritis, headache, neck and back problems, cancer, neuropathies eg. Diabetic, chronic regional pain syndromes (CRPS), pelvic pain disorders, fibromyalgia, myofacial pains, herpes and trigeminal neuralgias.

Chronic pain can lead to depression, anxiety, marital & interpersonal problems, decreased productivity, unemployment, compromised social roles, isolation, financial burden, dependence, prolonged analgesics usage, decreased self esteem with behavioral changes adversely affecting mental and physical abilities, activities of daily living  & ruining quality of life

Pain still remains inappropriate & inadequately treated. Although tremendous scientific & technological advances have been made, the knowledge & techniques are highly underutilized. Untreated pain destroys people’s lives. I have had patients come in who couldn’t work or sleep or play with their children. Good pain management gave them their lives back. It is cruel to deny people in pain access to effective pain treatment. People should not be suffering needlessly.

Thus, pain clinics are specialized areas that are now assuming the role of an essential service as they meet a need unmet by any previously existing medical facility. They help by simultaneously treating the physical, emotional, cognitive, behavioral, vocational and social aspects of chronic pain cost-effectively.

Our ultimate goal is to cure & care people suffering from pain, make them productive human beings for the society and increase their self esteem so that they can live life as normal individuals.

Interventional pain procedures scores over both medicine and surgery, as they do not have side effects like medicines. Surgeries for pain, have now limited indications, usually as a last resort.

The interventional pain procedures produce immediate pain relief, can be performed with ease by pain physicians without anesthesia as outpatient or daycare and adequate duration of pain relief obtained and suitable for surgically unfit & debilitated patients, procedure can be repeated safely if required.

In the absence of proper education among health care professionals and lack of awareness in the public mind inIndia, there is misuse of painkillers resulting in high incidence of complications like gastritis, kidney failure, bone marrow depression and bleeding from gut which can be catastrophic.

The Indian health care scene has a curious mix of paradoxes. Advances in cardiovascular surgery or high-tech investigative facilities inIndiaare on par with any advanced country, at least in some cities. Though skills, advanced equipments are available, still pain relief is not available to majority of its population. At least a million people inIndiasuffer unrelieved cancer pain. The number of people suffering other chronic pain conditions is anyone’s guess. Paradoxically,Indiastands high chance to become the health destination for pain management for the world, by using interventional pain therapies and very effective traditional therapies unique toIndia.

“Stop pain from managing you.”

“No one dies of pain but many people die in pain and even many more live with pain”

“Enjoy a pain free life”

“Pain relief is a human right.”

W.H.O. has assigned pain as 5th vital sign.

“Don’t let pain control your life. Be proactive to manage pain.

Intractable pain ruins patient’s life. It robs the patient of his life.

“Pain has the thousand teeth”.

“The pain of mind is worse than the pain of body”

“Chronic pain is something you wear on inside, not on the outside”

We work with the patient to identify the root cause of the problem and create a treatment plan to alleviate the pain.

We offer the full range of advanced treatment for chronic pain.

A good treatment improves patient’s quality of life.

State of the art pain clinic is benefiting many patients with intractable pains..

Under treatment of pain is a major public health concern.

Pain is the 1st reason for work abstinence.

Because of increase in age expectancy pain is becoming more prevalent.

Pain should be managed promptly before it gets complexed & centralized to brain.

One in every four persons suffers from pain of which 50% have serious pain issues so as to affect them physically, mentally, socially and financially.

Chronic pain is a disease in and of itself. It not only affects the patient, but also impacts the lives of family and friends.

Pain is one of the most neglected problem of the patient and has very serious and lasting consequences.

Ozone Discectomy (Ozonucleolysis) For Disc Prolapse (Cervical & Lumbar)

Ozone Discectomy is the injection of Ozone inside the intervertebral disc in trouble. This is done as an outpatient under local anaesthesia with strict real time radiological control, which ensures the proper placement of Ozone in the center of the disc making it shrink.

LOW BACK PAIN, SCIATICA & PIVD:

Among working age people, as many as 20 percent experience back symptoms at least

every year. spinal diseases are the most common cause of disability in persons under the age of 45. Spine care results in expenditures two to three time greater than cardiac services for many health plans. While there is no specific data related toIndia, spine surgeons estimate that roughly 5% of the general population is affected by serious disc problems.

Some of the main causes of back pain include facet arthropathy, sciatica, muscle strain, sacroilitis, bulging or herniated discs and degenerative disc disease. Prolapsed intervertebral discs (PIVD) are the most common cause of low back pain associated with a defined structural Abnormality.

Patients who are not helped by weeks of conservative therapy are often referred for

surgery on the premise that further non-operative care is unlikely to help. Ideally, a patient with low back pain that has persisted beyond a four-week period should be referred to a multidisciplinary pain centre.

Different Non Surgical Interventions Employed Successfully:

  • Epidural Steroid Inj.
  • Epidurogram & Epidurolysis.
  • Nerve root sleeve/ transforaminal Inj.
  • Intra-discal steroid inj.
  • Nucleoplasty- Laser, Thermal & Mechanical
  • Ozone Discolysis

Conventional treatment methods for back pain comprise lamminectomy/ discectomy microsurgery, endoscopic disectomy and percutaneous arthoscopic disectomy, among others. These are invasive methods and their goal is to remove or contain the protruding disc. However, these methods have occasionally demonstrated a discrete incidence of failure and/or recurrence. Outcome studies of lumber disc surgeries documents, a success rate between 49% to 95% and re-operation after lumber disc surgeries ranging from 4% to 15%, have been noted. “In case of surgery, the chance of recurrence of pain is nearly 15 per cent as against less than three percent in Ozone treatment.

 Reasons for the failures  of conventional surgeries are:

  1. Dural fibrosis
  2. Arachnoidal adhesions
  3. Muscels and fascial fibrosis
  4. Mechanical instability resulting from the partial removal of boney & ligamentous structures required for surgical exposure & decompression
  5. Presence of Neuropathy.
  6. Multifactorial etiologies of back & leg pain , some left unaddressed surgically.

 

THE NEED FOR NEOTECHNOLOGY:

  • The various treatment options has confused clinicians and investigators due to high failure rate and complications associated with different kinds of surgeries and interventions. There has been surge of interest in search of safer alternative method of decompressing the nerve roots maintaining the structural stability.
  •  Another safe least invasive alternative therapy that has been receiving exposure inEuropeis the use of medical Ozone (02/03 mixture) in the treatment of  PIVD.  Epidural steroid injection, transforaminal epidural decompressions has a high success rate (up to 85%), but chances of recurrences are there specially if these interventions are done at later stage. Chemonucleolysis using chymopapain has also high success rate (80%) with low recurrences but not popular owing to the chances of anaphylaxis following intradiscal chymopapain injection. Injection of Ozone for discogenic radiculopathy (low back pain with radiation to legs) has developed as revolutionary alternative to chemonucleolysis and disc surgery .

 

THE OZONE REVOLUTION IN DISC DISEASES:

Muto suggested intradiscal injection of Ozone for disc hernia in 1998 under CT guidance. Leonardi popularized fluoroscopy guided Ozone injection into the intervertebral disc. After that successful outcome has been reported from various European centers. It is very important to note from those reports that complications are remarkably few. Not a serious single life threatening complication was found even after 120,000 cases of Ozone nucleolysis, which stresses the safety of these procedures.

The most critical portion of performing any of the minimally invasive procedures is accurate and safe positioning of the needle (or terminal device) in the centre of the disc space. The risk in ozonucleolysis is particularly minimised, with the use of a very thin 22/25-gauge needle. It may take anywhere from 5 to 30 minutes to position a needle in the centre of the disc space under radiological guidance. Once the needle is safely placed in position, ozonucleolysis is completed in only another 2 to 3 minutes.

HOW DOES OZONE WORK ?

There are four main biochemical actions on the intervertebral disc and its surrounding tissues. The various proposed mechanisms of action are:

 BY  “MUMMIFICATION” OF THE DISC.

  • Intra/intermolecular Bonds and collapse of the three dimensional Structure of the disc.

The plausible mechanism of action is the direct effect of the ozone on the Herniation. It is well established that the nucleus pulposus (the actual part of the disc that herniates through annulus) is 70-90% water contained within the domain of proteoglycans. The water binding capacity of the proteoglycan molecule is partially a property of its size and physical shape, but the main force that holds water to the molecule stems from the ionic, carboxyl (COOH) and sulphate (SO4) radicals of the glycosaminoglycan chains. The ozone can have a direct effect on these carboxyl and sulphate groups, breaking down some of these glycosaminoglycan chains which make up the proteoglycans. The destruction of these cross-linked structures reduces their ability to hold water therefore diminishing the size of the herniation by dehydration of the fibrillary matrix of the nucleus pulposus, revealing collagen fibers and signs of regression (vacuole formation and fragmentation)- a sort of disk “mummification.”

BY INHIBITING INFLAMMATORY NOCICEPTORS.

  • Synthesis of Prostaglandines & Secretion of Proteinases
  • Liberation of Bradykinines and Pain Inducing Products
  • Several studies suggest disc inflammation as a mechanism of sciatica due to disc herniation. Ozone has been shown to have an effect on the inflammatory cascade by inhibiting synthesis of proinflammatory prostaglandins or release of bradykinin or release of algogenic compounds; increased release of antagonists or soluble receptors able to neutralize proinflammatory cytokines like interleukin (IL)-1, IL-2, IL-8, IL-12, IL-15, interferon, and tumor necrosis factor. Therefore, by reducing the inflammatory components there is a corresponding reduction in pain.

BY STIMULATING FIBROBLASTS & IMMUNOSUPPRESSOR CYTOKINES

  • Local production of Antioxidant Enzymes
  • Release of immunosuppressor cytokines like transforming growth factor, and IL-10
  • Another action which may prove to be one of the most important is the stimulation of

fibroblastic activity by ozone. Fibroblasts initiate the repair process by stimulating the

deposition of collagen. Although yet to be validated, this mode of action could

explain the resolution of PIVD on CT scans and the small percentage of patients who

have relapses after the completion of treatment plan.

  • “Ozone may have a reflex therapy effect called ‘chemical acupuncture’, breaking            the     chain of chronic pain stimulating anti-nociceptor analgesic mechanism. As pain is multi-factorial, ozone may also have a multi-factorial pharmacological effect alleviating disc compression by shrinkage of the herniated disc.”
  • BY IMPROVING MICROCIRCULATION & OXYGENATION.
    • The direct effect is the oxygen directly diffusing into the area.
  • The indirect action is the Ozone causing an increase in 2,3-DPG (diphosphoglycerate) which has a direct effect in the release of O2 from hemoglobin.. The end result is an increase in the amount of oxygen and a reduction in anoxia.
    • Disk shrinkage may also help to reduce venous stasis caused by disk compression of

vessels, thereby improving local microcirculation and increasing the supply of oxygen.

This effect has a positive effect on pain as the nerve roots are sensitive to hypoxia.

RESULTS & SAFETY:

In a multi-centre, retrospective 3 year follow-up study of lumber disc herniation treated with European Neurosurgical Institute protocol of ozone therapy in 917 patients showed 78.9% good & excellent results with only one case of disc infection which healed with antibiotic.

In fact, over 120,000 patients have been treated successfully worldwide using injection of medical ozone with a success rate of 80-90% and with a near nil rate of procedure-related complications. “The procedure is a safe and effective alternative to open surgical procedure. Patients get the advantage of going home after a short recovery on the same day. They generally go to work within a week and are spared prolonged absence from work and disability,” The treatment relieves pain substantially and, after two sittings, people “can go back to work under medical guidance”.

COMPARISON:    SPINAL SURGERY              OZONE DISCOLYSIS

1 More Hospital Stay.                                            One day/Day Care.

2    Complications of prolonged surgery& anaesthesia            GA is not required

3   “failed back surgery syndrome”                              No “failed back surgery syndrome”

4    High Cost                                                      Total cost is 1/5th to 1/10th

5    Failure rate 10-51%                                            Comparable 10-21%

6    Safety profile comparatively not so high.                      Very high safety profile

7    Repeat surgeries are more complicated.                 May be safely repeated many times

8    Cervical  PIVD poses a surgical challenge                 Ideal procedure in cervical PIVD

9    Highly invasive very demanding surgery            Least invasive much easier procedure

10  High postoperative morbidity                                    Negligible morbidity

11  In-patient major surgery                                        Mostly OPD procedure

CONCLUSION:
Ozone Discectomy a revolutionary least invasive safe & effective alternative to spine surgery is the treatment of choice for prolapsed disc (PIVD) done under local anaesthesia in a day care setting. This procedure is ideally suited for cervical & lumbar disc herniation with radiculopathy. Total cost of the procedure is much less than that of surgical discectomy. All these facts have made this procedure very popular at European countries. It is also gaining popularity in our country due to high success rate, less invasiveness, fewer chances of recurrences, remarkably fewer side effects meaning high safety profile, short hospital stay, no post operative discomfort or morbidity and low cost.

Intractable cancer pain

Pain is a major symptom of cancer and occurs at all stages of the disease. In addition, pain is usually a hallmark of progression or metastatic spread, and 65 to 85 percent of people with cancer have pain when they develop advanced disease. In 10 to 20 percent of cancer cases, pain is difficult to treat, frustrating, and poorly controlled. Currently, opioid pharmacotherapy is the principal weapon in the fight against cancer pain; but when less invasive treatments are unsuccessful, invasive interventions should be added to optimize pain relief. Interventional pain procedures target neural and non-neural pain generators and neural blockade techniques provide excellent pain relief for neuropathic, sympathetic, nociceptive somatic, or visceral pain. Neural blockade techniques are broadly categorized into non-neurolytic and neurolytic blocks.

Non-Neurolytic Blocks
Local anesthetic and corticosteriod blocks are used to treat a variety of pain syndromes. They can also predict how a patient will respond to neurolytic blocks. A good response to non-neurolytic interventions usually means the patient will benefit from neurolytic procedures as well. Fluoroscopic guidance improves the accuracy of these blocks and minimizes complications. Somatic, sympathetic, and neuropathic pain respond to local anesthetic injections or the continuous administration of anesthetic drugs through a catheter. Intercostal nerve blocks or interpleural analgesia are indicated in post-thoracotomy chest wall pain/intercostal neuralgia, and radiculopathy requires selective nerve root blocks or transforaminal epidural injections when non-invasive treatments fail. Sympathetic blocks and other regional anesthetic techniques are employed in sympathetically maintained pain states, ischemic pain, postherpetic neuralgia, and radiation plexopathy

Neurolytic Blocks
Alcohol and phenol are the preferred agents for neurolytic procedures because they cause axonal degeneration within minutes and effectively interrupt the central transmission of pain impulses. Chemical neurolysis can result in immediate and total pain relief in selected patients with localized or regional pain. Opioid requirements decrease sharply, and patients on high doses of opioids will require careful tapering to avoid respiratory depression. Other indications for neurolysis are costopleural syndrome and sympathetically maintained pain in Pancoast’s syndrome. Unfortunately, potentially unacceptable side effects limit the utility of neurolytic blocks; but neurolytic blocks are still preferred over standard opioid analgesia to control intractable abdominal, pelvic, and perineal pain. The following four criteria must be met before a nerve block is considered appropriate: –Limited lifespan of three to six months –A favorable risk to benefit ratio (i.e., the block will not impair bladder or bowel function or cause limb paralysis) — A poor response to primary antitumor treatment, which has not been able to reduce the tumor burden — A good analgesic response and acceptable side effects with prognostic blocks.
Advantages: The neurolytic blocks have the following advantages in home care by relatives of patients particularly in rural area of India: 1). Neurolytic blocks provide longer duration of pain relief. 2).Drugs and inexpensive equipment required are readily available.Elaborate equipment is not mandatory. 3). Long-term indoor ward treatment is avoided, repeated visits to the urban pain center are not required. 4). Patient can remain at home pain free even in rural areas where medical help is scarce.

Table 1. AUTONOMIC NERVE BLOCKS

Neurolytic Block Site/Condition Treated
Stellate ganglion Head Neck or arm pain
Gasserian ganglion Trigeminal neuralgia and facial pain
Interpleural (thoracic sympathetic chain) Upper—head, arms

Middle—thorax, heart, lung

Lower— abdominal organs, uterus, bladder

Celiac plexus (splanchnic nerves) Pancreatitis, Hepatobiliary Cancer pain, visceral/GIT cancer pain upto trans.Colon.
Lumbar sympathetic Lower limb pain, retroperitoneal pain
Hypogastric plexus Pelvic,  Perineal, urogenital pain
Sacrococcygeal ganglion (impar, Walther) Rectal, uretheral, perineal, vaginal pain

Neurolytic Celiac Plexus Blocks (NCPB) And Splanchnic Nerve Blocks (SNB) are routinely performed (and are preferred over standard analgesic therapies) for patients with intractable pain from pancreatic and upper gastrointestinal cancer. NCPBs provide immediate and substantial pain relief in 70 to 90 percent of cases, improve the patient’s quality of life, and significantly reduce opioid intake. The procedure can be repeated in three to six months if the effect of the initial block wears off. NCPBs are performed percutaneously or intraoperatively. Under radiologic guidance, 50 to 100 percent alcohol is instilled anterior to the aorta at the level of the L1 vertebral body. Injection site pain, diarrhea, and temporary hypotension are transient adverse effects. A low complication rate is observed, since the risk of the neurolytic agent spreading to the somatic nerves supplying the lower limbs, bladder, and bowel is minimal
Superior Hypogastric Plexus Blocks (SHPB) are indicated for unrelenting pain from cancer of the pelvic viscera. This plexus lies in front of the L5 and S1 vertebrae in the prevertebral space. A spinal needle is placed percutaneously in this space from the back under radiologic guidance. Excellent analgesia is reported by 70 percent of patients after a SHPB. Reductions in pain scores and opioid consumption are reported to be significant, even in patients with advanced disease. No major complications have been reported following SHPBs, although a potential risk exists for the spread of neurolytic agents to the nerve fibers controlling micturition, bowel motility, and sexual function. The SHPB block can be repeated if pain recurs. Patients who fail two consecutive attempts are candidates for intraspinal opioid analgesia.

Ganglion Impar Neurolytic Blocks relieve perineal pain from cancer of the cervix, endometrium, bladder, and rectum. The ganglion is a single, midline structure ventral to the sacrococcygeal junction and can be accessed by a midline trans-sacral approach.
Painful input from somatic and visceral structures can produce sympathetically maintained pain (SMP) that may be visceral or neuropathic in nature. Sympathetic Ganglion Neurolysis relieves SMP and improves blood flow and is used to treat pain from radiation plexopathy, phantom pain, herpes zoster, vascular insufficiency secondary to malignancy, and complex regional pain syndromes (reflex sympathetic dystrophy and causalgia), with little risk of motor or sensory loss or deafferentation pain.
The trigeminal nerve receives sensory input from the skin of the face, anterior two-thirds of the tongue, and oronasal mucosa. Anesthetic Blockade Or Chemical Rhizolysis of the trigeminal ganglion or its individual branches is indicated in orofacial malignancies with intractable head and face pain.

Neurolytic Spinal Blockade can produce profound segmental analgesia. Nociceptive input is interrupted by selectively destroying the dorsal roots and rootlets between the spinal cord and the dorsal root ganglia. The procedure is reserved for terminally ill patients with cancer who have a short life expectancy and unilateral somatic pain localized to a few adjacent dermatomes, ideally in the trunk and distant from sphincter or limb innervation. Combined with a unilateral cordotomy, subarachnoid phenol blocks effectively control pain in costopleural syndrome, which is caused by invasion of the pleural cavity and thoracic wall. Adverse effects include PDPH, meningitis (rarely), persistent numbness and paresthesia, loss of motor function due to the unintended neurolysis of ventral rootlets, and sphincter and limb weakness.

Trans-sphenoid Pituitary Neuroablation: Chemical Hypophysectomy
Very useful simple intervention with 70-80% success rate in diffuse cancers of advanced stage with multiple bony & spinal metastasis especially hormone dependent cancers not responding to all other measures.

3) Intraspinal Opioid Therapy

continued administration of opioids intrathecally or epidurally with or without dilute concentration of local anesthetic& adjuvant drugs is an important option for patients with thoracic, abdominal or pelvic cancer pain that is refractory to conventional pharmacologic management. Advantages include profound analgesia, often at a much lower opioid dose without the motor, sensory, or sympathetic block. However combinations of low-dose opioids given epidurally with a local anesthetic act synergistically to produce effective analgesia while decreasing the side effects. Administration can be carried out using a variety of drug-delivery systems ranging from a temporary percutaneous epidural catheter to a totally implanted system. The effectiveness of preimplantation procedure and reversibility of effect makes this an attractive treatment option.

Conclusion
The management of patients with cancer pain can be a challenging task, even for physicians trained in cancer pain management Effectively relieving pain in cancer patients requires a range of treatment alternatives, including neural blockade when the patient’s pain no longer responds to opioid analgesia. The type of neural block selected is determined by the location and mechanism of the pain, the physical status of the patient, the extent of tumor spread, and the technical skill and experience of the person performing the intervention. Non-neurolytic blocks can provide safe and effective analgesia for the less serious conditions indicated above. Neurolytic blocks, with their potential for complications, are reserved for select patients who are unresponsive to standard analgesic pharmacotherapy and/or are at a more advanced stage of disease. However, few would question that aggressive intervention is often appropriate. Neurolytic nerve blocks offer an excellent option for the physician in the fight to control cancer pain. Such blocks can be easily utilized to help provide cancer pain relief in most of patients at the utmost needed times.

Cancer Pain :Effective Pain Management

Pain is a major symptom of cancer and occurs at all stages of the disease. In addition, pain is usually a hallmark of progression or metastatic spread, and 65 to 85 percent of people with cancer have pain when they develop advanced disease. In 10 to 20 percent of cancer cases, pain is difficult to treat, frustrating, and poorly controlled. Currently, opioid pharmacotherapy is the principal weapon in the fight against cancer pain; but when less invasive treatments are unsuccessful, invasive interventions should be added to optimize pain relief. Interventional pain procedures target neural and non-neural pain generators and neural blockade techniques provide excellent pain relief for neuropathic, sympathetic, nociceptive somatic, or visceral pain. Neural blockade techniques are broadly categorized into non-neurolytic and neurolytic blocks.

The management of patients with cancer pain can be a challenging task, even for physicians trained in cancer pain management Effectively relieving pain in cancer patients requires a range of treatment alternatives, including neural blockade when the patient’s pain no longer responds to opioid analgesia. The type of neural block selected is determined by the location and mechanism of the pain, the physical status of the patient, the extent of tumor spread, and the technical skill and experience of the person performing the intervention. Non-neurolytic blocks can provide safe and effective analgesia for the less serious conditions indicated above. Neurolytic blocks, with their potential for complications, are reserved for select patients who are unresponsive to standard analgesic pharmacotherapy and/or are at a more advanced stage of disease. However, few would question that aggressive intervention is often appropriate. Neurolytic nerve blocks offer an excellent option for the physician in the fight to control cancer pain. Such blocks can be easily utilized to help provide cancer pain relief in most of patients at the utmost needed times.

For all these and many like them Dr. Neeraj Jain`s massage is “pain is real and treatable- there is no merit in suffering” “No one needs to suffer as so many good and effective treatments are now available at specialty pain clinics”. You must see a pain specialist if you still suffer from pain after a month of conservative treatment. Sooner your pain is managed better are the overall results.

The interventional pain procedures produce immediate pain relief, can be performed with ease by pain physicians without anesthesia as outpatient or daycare and adequate duration of pain relief obtained and suitable for surgically unfit & debilitated patients, procedure can be repeated safely if required.
In the absence of proper education among health care professionals and lack of awareness in the public mind in India, there is misuse of painkillers resulting in high incidence of complications like gastritis, kidney failure, bone marrow depression and bleeding from gut which can be catastrophic.

Though skills, advanced equipments are available, still pain relief is not available to majority of its population. At least a million people in India suffer unrelieved cancer pain. The number of people suffering other chronic pain conditions is anyone’s guess. Paradoxically, India stands high chance to become the health destination for pain management for the world, by using interventional pain therapies and very effective traditional therapies unique to India.
Pain is 5th vital sign as per W.H.O. Pain is now understood as primary medical condition.

Pain Medicine, a super-specialty, deals with the management of these difficult chronic painful disease states including treatment of cancer pain. A majority of complex chronic painful states, unresponsive to conventional treatment are being successfully treated at Pain Clinics. The very concept of a Pain Clinic is based on the conviction that the effective management of difficult pain conditions is possible only through well-coordinated efforts of a specialist possessing knowledge and skills to diagnose and treat pain.

Thus, Pain Clinics are specialized areas that are now assuming the role of an essential service as they meet a need unmet by any previously existing medical facility.

Despite these startling statistics pain still remains inappropriate & inadequately treated. Although tremendous scientific & technological advances have been made, the knowledge & techniques are highly underutilized. This is due to lack of dissemination of information to clinicians. “It’s easy to be paranoid when you hurt like hell and you are on the mercy of healthcare system”.
The interventional pain procedures produce immediate pain relief, can be performed with ease by pain physicians without anesthesia as outpatient or daycare and adequate duration of pain relief obtained and suitable for surgically unfit & debilitated patients, procedure can be repeated safely if required.
In the absence of proper education among health care professionals and lack of awareness in the public mind in India, there is misuse of painkillers resulting in high incidence of complications like gastritis, kidney failure, and bone marrow depression.

Unfortunately awareness about pain management among medical professionals is very limited. In contrast to USA and other developed countries Indian medical community is not aware of interventional pain management techniques which can be helpful for many patients suffering from intractable cancer & chronic pain.
It is cruel to deny people in pain access to effective pain treatment. People should not be suffering needlessly.

“Pain is real & treatable – There is no merit in suffering!”

Pain Management: A Superspeciality

“It is easier to find a man who will volunteer to die, than to find those who are willing to endure pain with patience” Julius Caesar

 Remember:-“No one dies of pain but many die in pain and many more live with pain”

 “Control pain before it controls you” as “Pain begets pain”

 “Sweet is death that takes away pain” is true for cancer pain.

 “Pain is more terrible master than death itself”

  “For all the happiness man can gain, is not in pleasure but freedom from pain”. Remember “Freedom from pain is patient’s right”

 Pain is 5th vital sign as per W.H.O.  Pain is now understood as primary medical condition.

“The neurosignature of pain experience is determined by the synaptic architecture of the neuromatrix”

Pain Medicine, a super-specialty, deals with the management of these difficult chronic painful disease states including treatment of cancer pain. A majority of complex chronic painful states, unresponsive to conventional treatment are being successfully treated at Pain Clinics. The very concept of a Pain Clinic is based on the conviction that the effective management of difficult pain conditions is possible only through well-coordinated efforts of a specialist possessing knowledge and skills to diagnose and treat pain.

A Pain Clinic uses services of specialties such as neurology, psychology, physical therapy, orthopedics, anaesthesiology and neurosurgery. “Comprehensive multidisciplinary pain management centre” is the highest pain management facility/ centre of excellence, which is equivalent to super specialty cardiac / neuro / nephrology centre.

Thus, Pain Clinics are specialized areas that are now assuming the role of an essential service as they meet a need unmet by any previously existing medical facility. They help by simultaneously treating the physical, emotional, cognitive, behavioral, vocational and social aspects of chronic pain cost-effectively.

Chronic pain is a disease, a syndrome not just a symptom.

Chronic pain can lead to depression, anxiety, marital & interpersonal problems, decreased productivity, unemployment, compromised social roles, isolation, financial burden, dependence, prolonged analgesics usage, decreased self esteem with behavioral changes adversely affecting quality of life (QOL) & activities of daily living (ADL).

“Pain has the thousand teeth”.

“The pain of mind is worse than the pain of body”

“Chronic pain is something you wear on inside, not on the outside”

“Not tonight, dear. I have a backache.” Backache is second only to headaches as the most common location of pain.

Pain is one of the most common reasons for patients to seek medical attention and one of the most prevalent medical complaints in today’s world.

Some 75 million Americans experience persistent pain and at least nine per cent of the USA adult population is estimated to suffer from moderate to severe non-malignant pain. Patients with chronic (or “persistent”) pain can be especially difficult to treat. In one survey conducted for the American pain society, 47 per cent of those with moderate, severe or very severe pain had challenged physicians at least once since their initial visit for pain relief. When asked why, they cited continued suffering (42 per cent), the physician’s lack of knowledge (31 per cent), not taking the pain seriously enough (29 per cent), and unwillingness to treat it aggressively (27 per cent) as reasons for the change. Situation in India is not very different from this one.

Despite these startling statistics pain still remains inappropriate & inadequately treated. Although tremendous scientific & technological advances have been made, the knowledge & techniques are highly underutilized. This is due to lack of dissemination of information to clinicians. “It’s easy to be paranoid when you hurt like hell and you are on the mercy of healthcare system”.

The clinicians must learn to make distinction between acute and chronic pain before embarking upon treatment. The skill of proper pain management lies in not in ability to perform difficult advanced blocks but in the determination of appropriate diagnosis & therapeutic modalities

 The treatment of the acute, chronic & cancer pain is demanding & challenging. Effective pain management presents a significant challenge for physicians, other healthcare professionals, and their patients.

A problem arises when chronic pain feels like acute pain, is described to (and is accepted by) physicians and therapists as acute pain, and is then treated as acute pain. When this happens results are apt to be disappointing to both the patient and the physician and both may end up feeling quite frustrated. To both recover from, and to treat, chronic pain requires taking a different approach.

“Take two aspirins & go to bed” dictum of old days is over “What can’t be cured has to be endured” has changed with the role of the interventional pain specialist.  It’s a “medical necessity”

There have been many advances in the understanding & usefulness of an intervention at right time in selective patients producing excellent results.

Our ultimate goal is to cure & care people suffering from pain, make them productive human beings for the society and increase their self esteem so that they can live life as normal individuals.

Interventional pain procedures scores over both medicine and surgery, as they do not have side effects like medicines. Surgeries for pain, have now limited indications, usually as a last resort.

The interventional pain procedures produce immediate pain relief, can be performed with ease by pain physicians without anesthesia as outpatient or daycare and adequate duration of pain relief obtained and suitable for surgically unfit & debilitated patients, procedure can be repeated safely if required.

In the absence of proper education among health care professionals and lack of awareness in the public mind in India, there is misuse of painkillers resulting in high incidence of complications like gastritis, kidney failure, and bone marrow depression.

The Indian health care scene has a curious mix of paradoxes. Advances in cardiovascular surgery or high-tech investigative facilities in India are on par with any advanced country, at least in some cities. Though skills, advanced equipments are available, still pain relief is not available to majority of its population. At least a million people in India suffer unrelieved cancer pain. The number of people suffering other chronic pain conditions is anyone’s guess. Paradoxically, India stands high chance to become the health destination for pain management for the world, by using interventional pain therapies and very effective traditional therapies unique to India.

With the advancement of technology and science, we have unveiled many aspects of the pain and its treatment. We have to work hard to spread the knowledge of interventional pain techniques. Our goal is to help people suffering from pain, make them productive human being for the society and increase their self esteem so that they can live life as normal individuals.

Unfortunately awareness about pain management among medical professionals is very limited. In contrast to USA and other developed countries Indian medical community is not aware of interventional pain management techniques which can be helpful for many patients suffering from intractable chronic pain.

“You purchase pain with faulty lifestyle” “All pain is a punishment”

Pain treatment is tailor-made & no single treatment fits all.

Under treatment of pain is a major public health concern. It is a silent epidemic, don’t let this happen to someone you love.

Untreated pain destroys people’s lives. I have had patients come in who couldn’t work or sleep or play with their children. Good pain management gave them their lives back.

It is cruel to deny people in pain access to effective pain treatment. People should not be suffering needlessly.

“Pain is real & treatable —        There is no merit in suffering!”

 CONTROL PAIN BEFORE IT CONTROLS YOU!

FOR ADVANCED PAIN MANAGEMENT OF:-

 CHRONIC INTRACTABLE PAIN SYNDROMES

BACK PAIN / LEG PAIN (DISCOGENIC/SPINAL CANAL STENOSIS)

FACET JOINT SYNDROME/SPINAL ARTHRITIS

SPINE (AXIAL) PAIN (CERVICAL/LUMBOSACRAL/THORACIC)

SACROILITIS / STRAIN & COCCYDYNIA

DISC DISEASES (HERNIA/PROLAPSE/RUPTURE/SLIPPED)

REDICULOPATHY / SCIATICA

NEURALGIC PAINS / PLEXOPATHIES

HERPES ZOSTER PAIN /NEURALGIA (PHN)

TRIGEMINAL / CRANIAL NEURALGIAS

SPASTIC CEREBRAL/SPINAL PALSY

FRACTURE SPINE (COMPRESSION # OF VERTEBRA)

REFLEX SYMPATHETIC DYSTROPHIES (RSD)

COMPLEX REGIONAL PAIN SYNDROMES (CRPS 1 & 2)

FAILED BACK SURGERY SYNDROMES (FBSS)

MUSCULOSKELETAL / MYOFASCIAL PAIN SYNDROMES

VASOSPASTIC ISCHEMIC PAINS

NEUROGENIC CLAUDICATION

CERVICOGENIC / TENSION/CLUSTER HEADACHES

POST SURGICAL / POST TRAUMATIC / SPORTS INJURY PAINS

CENTRAL PAIN STATES

FIBROMYALGIA

CANCER PAIN/ END OF LIFE PAIN / AIDS PAINS

CHRONIC VISCERAL / PELVIC PAIN SYNDROMES

OSTEOPOROSIS / METASTATIC / PAGET`S DISEASE BONE PAINS

HYPERHIDROSIS (WET HANDS/UNDERARMS/FEET)

 

REMEMBER: NO ONE DIES OF PAIN BUT MANY DIE IN PAIN  

                    AND EVEN MORE LIVE WITH PAIN!

   

              “HELP THEM”

NON SURGICAL TECHNIQUES OF SPECIALISED

FLUOROSCOPIC/ULTRASOUND/NERVE STIMULATOR/CT GUIDED

 PERCUTANEOUS INTERVENTIONAL PROCEDURES

FOR DIAGNOSTIC/THERAPEUTIC/NEUROLYSIS OF:

 

DIAGNOSTIC EPIDUROGRAPHY FOLLOWED BY

TRANSFORAMINAL / INTERLAMMINAR EPIDURAL MEDICATION AT

CERVICAL / THORACIC / LUMBAR / SACRAL / CAUDAL LEVELS

SELECTIVE NERVE ROOT SHEATH BLOCK (SNRB)

PROVOCATIVE DISCOGRAPHY & INTRADISCAL INTERVENTIONS

LUMBAR/CERVICOTHORACIC SYMPATHETIC BLOCKS / NEUROLYSIS

PERCUTANEOUS VERTEBROPLASTY (PVP)

FACET JOINT/ SACROILIAC JOINT / PIRIFORMIS BLOCKS

DECOMPRESSIVE NEUROPLASTY / EPIDURAL ADENOLYSIS

INTRATHECAL OPIATE/BACLOFEN PUMP IMPLANTS

SPINAL CORD STIMULATOR/NEUROMODULATION IMPLANTS

CRANIAL NERVES BLOCKS / NEUROABLATIONS

TRIGEMINAL GANGLIOLYSIS

SOMATIC NERVE / MYOFASCIAL / MYONEURAL BLOCKS

TRIGGER POINT INJECTIONS WITH STEROIDS/BOTOX/NEUROLYTICS

STELLATE/CELIAC PLEXUS/HYPOGASTRIC/IMPAR NEUROLYSIS

BOTOX CHEMODENERVATION

PROLOTHERAPY/MESOTHERAPY/INTRAMUSCULAR STIMULATION

INTERPLEURAL CATHETER /SPLANCHNIC BLOCKS

PARAVERTEBRAL / PSOAS COMPARTMENT BLOCKS

VERTEBROPLASTY, KYPHOPLASTY,

SHOULDER & KNEE JOINTS BLOCKS

NERVE SHEATH & PLEXUS CATHETERISATION & MEDICATION

LASER LESSIONING / RADIOFREQUENCY (RF) NEUROABLATIONS

Low Back Pain

LOW BACK PAIN (LBP) is a pandemic disease having 80% of lifetime prevalence, affecting 15-20% population at any point of time, being one of the commonest reason for visit to a doctor & young age morbidity/disability/work absenteeism.

AETIOLOGY OF LBP:
LBP is not just a disease but a symptom, a syndrome with combination of multiple possible abnormalities of anterior & posterior longitudinal ligaments, vertebral body, synovia / chondropathy/ osteoarthritis of articulating facets joints, sacroiliac joint, nerve roots & foramen, paraspinal muscles, related connective tissues eg.- ligamentum flavum , spinal canal, intervetebral disc at annulus ring. It may be due to mechanical, nonmechanical, referred pain, psychological & failed back surgery (FBSS).

PERCUTANEOUS LEAST INVASIVE INTERVENTIONAL PAIN MANAGEMENT OF LBP:-
It has both diagnostic & therapeutic relevance( as there are significant false positive & negative imaging studies not correlating to symptoms)

  • Better results are obtained if treatment is started early.
  • LESI-lumbar epidural steroid injections::
    • interlamminar or transforaminal or caudal approach
  • SNRB- selective nerve root block
  • Epidural adenolysis or percutaneous decompressive neuroplasty
  • Trigger point injection
  • Botox paraspinal muscle injection
  • Facet joint or pericapsular injection
  • Spine Prolotherapy & manipulation
  • Facet RF thermal neurolysis
  • SI joint injection or denervation
  • Piriformis muscle block
  • Diagnostic provocative discography
  • Intradiscal procedures:-Ozone Discolysis/ Chemonucleolysis

– Dekompressor disc debulking
– IDET-intradiscal electrothermal therapy
– Coblation nucleoplasty
– Laser percutaneous discectomy

  • Vertebroplasty & kyphoplasty
  • Intrathecal pump neuraxial implants
  • Augmentation or neuromodulation spinal cord stimulation

ONCE THE CONSERVATIVE TREATMENT FAILS:-
Early aggressive treatment plan of pain has to be implemented to prevent peripherally induced CNS changes that may intensify or prolong pain making it a complex pain syndrome. Only 5% of total LBP patients would need surgery & 20% of discal rupture or herniation would need surgery. Nonoperative treatment is sufficient in most of the patients, although patient selection is important even then.

Depending upon the diagnosis one can perform & combine properly selected percutaneous fluoroscopic guided procedures with time spacing depending upon pt`s pathology & response to treatment.

Using precision diagnostic & therapeutic blocks in chronic LBP , isolated facet joint pain in 40%, discogenic pain in 25%(95% in L4-5&L5S1) ,segmental dural or nerve root pain in 14% & sacroiliac joint pain in 15% of the patients. This article describes successful interventions of these common causes of LBP after conservative treatment has failed.

LESI : LUMBAR EPIDURAL STEROID INJECTION
Indicated in – Acute radicular pain due to irritation or inflammation.

– Symptomatic herniated disc with failed conservative therapy
– Acute exerbation of discogenic pain or pain of spinal stenosis
– Neoplastic infiteration of roots
– Epidural fibrosis
– Chronic LBP with acute radicular symptoms

ESI TREATMENT PLAN:
Compared to interlaminar approach better results are found with transforaminal approach where drugs (steroid+ LA/saline +/- hyalase) are injected into anterior epidural space & neural foramen area where herniated disc or offending nociceptors are located. Whereas in interlaminar approach most of drug is deposited in posterior epidural space.Drugs are injected total 6-10 ml at lumbar, 3-6 ml at cervical & 20+ ml if caudal approach is selected. Lumbar ESI is performed close to the level of radiculopathy, often using paramedian approach to target the lateral aspect of the epidural space on involved side. Cervical epidural is performed at C7-T1 level .
SNRB- SELECTIVE NERVE ROOT BLOCK.

Fluoroscopically performed it is a good diagnostic & therapeutic procedure for radiculopathy pain if

  • There is minimal or no radiological finding.
  • Multilevel imaging abnormalities
  • Equivocal neurological examination finding or discrepancy between clinical & radiological signs
  • Postop patient with unexplainable or recurrent pain
  • Combined canal & lateral recess stenosis.
  • To find out the pathological dermatome for more invasive procedures , if needed

EPIDURAL ADENOLYSIS OR PERCUTANEOUS DECOMPRESSIVE NEUROPLASTY for EPIDURAL FIBROSIS OR ADHESIONS IN FAILED BACK SURGERY SYNDROMES (FBSS)
A catheter is inserted in epidural space via caudal/ interlaminar/ transforaminal approach
After epidurography testing volumetric irrigation with normal saline/ L.A./ hyalase/ steroids/ hypertonic saline in different combinations is then performed along with mechanical adenolysis with spring loaded or stellated catheters or under direct vision with EPIDUROSCOPE.

FACET SYNDROME:- FACET JOINT INJECTION OR RF MEDIAL BRANCH NEUROTOMY
It is due to mechanical stress on the Zygapophysial joints or traumatic/anatomical derangement & degenerative facet arthropathy. It is commoner in male of younger age group during active careers . CT/ MRI/ Bone scan show structural pathology, but diagnosis is confirmed by relief of pain with joint injection (1ml of LA+ 20 mg triamcinolone) which has therapeutic value also.After effective facet joint block, fluoroscopic percutaneous radiofrequency(RF) thermal rhizotomy of two level medial branches of dorsal ramus is a safe, effective & long term treatment.

SACROILIAC JOINT INJECTION & DENERVATION:
The only way to make a definitive diagnosis is pain relief with image guided joint injection of depo-steroid with L.A..This can be followed by joint denervation of L4-5 S1-3 branches to this joint providing long term pain relief.

INTRADISCAL PROCEDURES::
PROVOCATIVE DISCOGRAPHY: coupled with CT
A diagnostic procedure & prognostic indicator for surgical outcome is necessary in the evaluation of patients with suspected discogenic pain, its ability to reproduce pain(even with normal radiological finding), to determine type of disc herniation /tear, finding surgical options & in assessing previously operated spines

PERCUTANEOUS DISC DECOMPRESSION (PDD)
After diagnosing the level of painful offending disc various percutaneous intradiscal procedures can be employed:–
OZONE-DISCOLYSIS: Ozone Discectomy a revolutionary least invasive safe & effective alternative to spine surgery is the treatment of choice for prolapsed disc (PIVD) done under local anaesthesia in a day care setting. This procedure is ideally suited for cervical & lumbar disc herniation with radiculopathy. Total cost of the procedure is much less than that of surgical discectomy. All these facts have made this procedure very popular at European countries. It is also gaining popularity in our country due to high success rate, less invasiveness, fewer chances of recurrences, remarkably fewer side effects meaning high safety profile, short hospital stay, no post operative discomfort or morbidity and low cost.

DEKOMPRESSOR: A mechanical percutaneous nucleotome cuts & drills out the disc material somewhat like morcirator debulking the disc reducing nerve compression.

INTRATHECAL (SPINAL) PUMP IMPLANTS:
Opted when oral narcotics provide insufficient pain relief or side effects are troublesome in intractable cancer & chronic pain patients. It delivers drug via an implanted catheter directly into CSF needing a very small dose (1/300 of oral dose). The programmable pump is implanted in ant. lower abdomen. It delivers the drug as per the patients needs. More powerful analgesia & spasticity control is achieved using lower doses, constant relief & fewer side effects as with oral doses eg. Somnolence, mental clouding, constipation, euphoria with decreased chances of drug addiction or misuse.

NEUROMODULATION TECHNIQUES:
SPINAL CORD STIMULATION (SCS) IMPLANTS :

Done for FBSS( failed back surgery syndrome) & CRPS(comlex regional pain syndromes) inUSA. In Europe it is done for chronic intractable angina & pain of peripheral vascular diseases (PVD). The indications are expanding further in chronic pain states. A set of electrodes is placed in epidural space & connected to a pulse generator ( like a cardiac pacing device) that is implanted in upper buttock. Low level of electric impulses replace pain signals to the brain with mild tingling sensation. A trial stimulation is done before permanent SCS lead implant.

PERCUTANEOUS VERTEBROPLASTY / KYPHOPLASTY:
A NEWER APPROACH TO MANAGEMENT OF VERTEBRAL BODY FRACTURES
As life expectancy is increasing so is the incidence of vertebral body (VB) # now being the commonest # of the body. PVP is an established interventional techniques in which PMMA bone cement is injected under L.A. via a needle into a # VB with imaging guidance providing increased bone strength, stability, pain relief, decreased analgesics, increased mobility with improved QOL and early return to work.