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

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 anesthesia 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.

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.

Slip Disc with Sciatica – Newer Non-Surgical Treatment

Neeraj Jain
Senior Consultant Spine & Pain Specialist, Spine & Pain Clinics & Sri Balaji Action Medical Institute,
Max Hospital, Pitampura, New Delhi & Sant Parmanand Hospital, New Delhi, India

Abstract: 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. 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. 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 patient‘s pathology & response to treatment

INTRODUCTION

The inter-vertebral discs are made-up of two concentric layers, the inner gel like Nucleus Pulposus and the outer Annulus fibrosus. As a result of advancing age, the nucleus looses fluid, volume and resiliency and the entire disc structure becomes more susceptible to trauma and compression. This condition is called as degeneration of the disc. The disc then is highly vulnerable to tears and as these occur, the inner nucleus pulposus protrudes through the fibrous layer, producing a bulge in the inter-vertebral disc. This condition is named as herniated disc. This can then cause compression to the spinal cord or the emerging nerve roots and lead to associated problems of Sciatica radiating pain from back to legs in the distribution

of the nerve. Other symptoms could be weakness, tingling or numbness on the areas corresponding to the affected nerve. Sometimes bowel or bladder sphincter compromise is also present, which is made evident for urine retention and this need to be taken care as an emergency.

“Do not take your back for guaranteed” says Dr. Jain who is heading Spine & Pain Clinic, New Delhi. One can prevent back pain with spine care and avoiding risk factors like bad postures like slouch & couch, 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 sports & film celebrities, disc diseases including slip disc is prevalent in all age groups, in young age due to trauma & in old age due to degeneration. Also, it has to be known that those who had a herniated disc have 10 times more chances of having another herniation than the rest of the population.

The first steps to deal with a herniated or prolapsed lumbar disc are conservative. These include rest, analgesic and anti-inflammatory medication and in some cases physical therapy. At this point it is convenient to have some plain X-rays done, in search of some indirect evidence of the disc problem, as well as of degenerative changes on the spine. If in a few days these measures have failed, the diagnosis has to be confirmed by means of examinations that give better detail over the troubled area, as the MRI, CT which will show the disc, the space behind it and in the first case, the nerves. In some instances the EMG (electromyography) is also of great value, as this will show the functionality of the nerves and muscles

Provocative Discography: coupled with CT: A diagnostic procedure

Correspondence: Dr Neeraj Jain, Senior Consultant Spine & Pain Specialist, Spine & Pain Clinics & Sri Balaji Action Medical Institute, Max Hospital, Pitampura, New Delhi & Sant Parmanand Hospital, New Delhi. e-mail: managepain@yahoo.com www.spinenpain.com

& 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

NEED FOR NON-SURGICAL OPTIONS

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%. In FBSS or failed back surgery the subsequent open surgeries are unlikely to succeed.

Reasons for the failures of conventional surgeries are:

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

NON-SURGICAL TREATMENTS

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. 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.

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. Different non surgical interventions can be employed successfully:

• Epidural Steroid Inj. Via interlamminar/ transforaminal or caudal route.
• Nerve root sleeve block.
• Epidurogram & Epidurolysis.
• Nucleoplasty- Laser, Coblation, Drill, RF Biacuplasty decompressions.
• Ozone Discolysis
• Facet Joint Block & RF Denervation
• SI Joint Block

Once the diagnosis has been confirmed, one of the best alternatives existing

Sciatica- Back pain radiating to Leg

today is the Ozone Discolysis as the results obtained are excellent and practically has no complications. In most patients left with pain killers as the only treatment, the symptoms eventually disappear, only that this could take weeks to months. Ozone speeds up these developments, seen the same result in a few weeks. The problem has to be seen and approached integrally and frequently the combination of therapies has to be used, most frequently physiotherapy

OZONE DISC TREATMENT

Ozone Disc Treatment a revolutionary newer technology cures many of the patients of slip disc & sciatica, as ozone’s nascent oxygen atom shrinks the disc, taking away pressure from pain sensitive nerves. It is non surgical, safe & effective alternative to open spine surgery, now the treatment of

choice for prolapsed disc (PIVD) done under local anaesthesia in a day care setting with success rate of 80% in early degenerative disc disease. This procedure is ideally suited for cervical & lumbar disc herniation with nerve compression. Total cost of the needle procedure is much less than that of surgical discectomy. Patient does not require bed rest for more than a 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 placement and best results. Then 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 in India also. Only 5% of total low back pain patients would need surgery & 20% of

Lumbar Ozone Injection Drill decompression- Disc jelly on drill

discs rupture or hernia patient would need surgery. Non-operative treatment is sufficient in most of the patients, although patient selection is important even then. If despite the ozone therapy the symptoms persist, Percutaneous intradiscal decompression can be done with Drill Discectomy/ Laser or Coblation Nucleoplasty/ Biacuplasty are good alternatives before open surgerical Discectomy which has to be contemplated in those true emergencies, as mentioned above as the first choice.

DEKOMPRESSOR DRILL DISCECTOMY

A mechanical device cuts & drills out the disc material debulking the disc reducing nerve compression curing Sciatica & Brachialgia. It comes in needle size of 17G for lumbar discs & 19 G for cervical discs. In lumbar region postero-lateral approach is used & in cervical discs anterolateral approach is used. In Biacuplasty radiofrequency energy is used in bipolar manner heating & shrinking the disc & making it harder as well for weight bearing. In Laser or Coblation Nucleoplasty energy is used to evaporate the disc thereby debulking to create space for disc to remodel itself. 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. With interventional pain management patients are getting back to normal life.

BIBLIOGRAPHY

• Olmarker K, Rydevik B. Pathophysiology of sciatica. Orthop Clin North Am 1991; 22:223-234.
• McCarron RF, Wimpee MW, Hudkins PG, Laros GS. The inflammatory effect of nucleus pulposus: a possible element in the pathogenesis of low-back pain. Spine 1987; 12:760-764
• Bogduk N, Aprill C, Derby R. Epidural steroid injections. In: White AH, eds. Spine care. Vol 1. St Louis, Mo: Mosby, 1995; 322-343.
• Dussault RG, Kaplan PA, Anderson MW. Fluoroscopy-guided sacroiliac joint injections. Radiology 2000; 214:273-277.
• Kinard RE. Diagnostic spinal injection procedures. Neurosurg Clin N Am 1996; 7:151-165
• Deer T, et al.. Initial experience with a new rechargeable generator: A report of twenty systems at 3 months status postimplant in patients with lumbar postlaminectomy syndrome. Abstracts of the 9th Annual Meeting of the North American Neuromodulation Society, Nov 10-12, 2005, Washington,D.C.
• Dr. Neeraj Jain. Balloon neuroplasty: expanding the scope and effectiveness of interventional techniques for management of pivd with disco-radicular conflict in new and previously failed interventions or surgeries. 1st WIPF 2013, 911939 _ WIPF_DEF.indd 67, 8/11/13 17:27

Vertebroplasty/Kyphoplasty: A Novel Approach for Treatment of Spine Fractures

Neeraj Jain
Senior Consultant Spine & Pain Specialist, Spine & Pain Clinics, Sri Balaji Action Medical Institute,
Max Hospital, Pitampura, New Delhi & Sant Parmanand Hospital, New Delhi, India

Abstract: As life expectancy is increasing so is the incidence of vertebral body (VB) fractures now being the commonest fracture of the body.Percutaneous Vertebroplasty/ Kyphoplasty (PVP) is an established interventional technique in which bone cement is injected under local anaesthesia via a needle into a fractured VB with imaging guidance providing instant pain relief, increased bone strength, stability, decreasing analgesic medicines, increased mobility with improved quality of life and early return to work in days. In this era of minimally access surgery 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 compressionfracture spine. PVP is a novel procedure with high benefit to risk ratio, which is highly underutilized in relation to the high prevalence of the vertebral fractures. Vertebroplasty is a palliative procedure and does not correct the underlying cause of the vertebral fracture. Medical management of osteoporosis or malignancy must therefore be initiated and continued.

INTRODUCTION

Discovering the fact that fracture /# vertebrae 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.

Stable VB # are normally treated conservatively with bed rest, strong analgesics, removable braces, a programmed progressive ambulation and physiotherapy. Fractures with > 50% of anterior VB collapse or > 20%of sagital angulations are potentially unstable and may require posterior instrumentation and fusion if not cemented in time. For burst # pedicle

instrumentation with extension segmental constructs are required. PVP is not ideal for # dislocations or # distractions. Spine surgeon has to be consulted if patient needs operative spine stabilization. Quick fix of fracture spine makes patient walk back same day instead of bed rest of months together avoiding morbidity & mortality of prolonged

Correspondence: Dr Neeraj Jain, Senior Consultant Spine & Pain Specialist, Spine & Pain Clinics & Sri Balaji Action Medical Institute, Max Hospital, Pitampura, New Delhi & Sant Parmanand Hospital, New Delhi. e-mail: managepain@yahoo.com www.spinenpain.com

bed rest, making bedridden patient walk, in a way bringing patient back

to normal life.

VERTEBROPLASTY: AN OVERVIEW

Percutaneous Vertebroplasty (PVP) is an established interventional technique in which rapidly hardening surgical polymethyl methacrylate bone cement is injected under local anesthesia 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. Kyphoplasty has the added advantage of addressing fracture with spinal deformity and appears to be associated with fewer instances of bone cement extravasations As per Greek mythology pain was thought to be due to intrusion of particles into soul, now pain relief is done by intrusion of particles into bone. The bone of content is to fill bone with content. In this era of MAS replacing open surgeries, PVP is a novel procedure & should be in the first line of management in place of painful conservatism or major spinal surgery with a list of complications in polytrauma settings for painful uncomplicated VB #; especially when the spine surgery is relatively complicated or patient refuses due to surgery phobia or cost involved or there may be comorbid conditions /injuries deterrent for surgery. PVP is a big help in polytrauma setting when stabilizing spine does lot of good to the patient’s overall management.