Pain-Relieving Procedures: The Illustrated Guide

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Wave velocity is the tomical approach. This capacity depends not only on the char- Ultrasonography or echography is the result of technologi- acteristics of the ultrasound waves but also on the properties cal developments in the application of ultrasound to imaging of the medium through which the sound travels. When an ultrasound beam pene- frequency above the human auditory threshold over trates a given structure, the beam intensity decreases as a 20, Hz.

Attenuation represents the loss of wave amplitude effect is based on the capacity of certain crystals piezoelec- energy on traveling through a medium, and depends on tric crystals to generate mechanical energy in the form of the wavelength, the density of the medium or tissue, and ultrasound waves in response to the application of electric the heterogeneity number and type of the interface present energy, and vice versa.

In turn, images , or on the separation zones between tissues contour hypoechogenic structures may appear anechogenic ane- images. Methods of ultrasonography Linear array transducer ultrasonography. This method uses a probe containing multiple acoustic transducers to send pulses of sound into body tissue. The time it takes for the echo to travel back to the probe is measured and used Figure The greater the difference between acoustic imped- beyond which echoes are no longer generated. Acoustic ances, the larger the echo is.

If the pulse hits gases or solids, shadowing occurs when ultrasound crosses interfaces with the density difference is so great that most of the acoustic great differences in acoustic impedance e. Water is the body element that best The frequencies used for medical imaging are generally in transmits ultrasound waves, generating a black anechoic the range of 1—18 MHz. Higher frequencies have a corre- image.

Thus highly cellular tissues containing abundant spondingly smaller wavelength, and can be used to make water can be expected to be hypoechoic, whereas more sonograms with smaller details. The speed of sound varies as it travels lution, the lower the working depth tissue penetration. The common indications, focused and image resolution is reduced. A transducer may be swept mechanically by rotating or swinging; or a one-dimensional phased array Equipment for ultrasonography transducer may be used to sweep the beam electronically.

There are seven ultrasonographic models in clinical use for The received data are processed and used to construct the medical imaging. They are enumerated in Table The image is then a two-dimensional representation et al. Box plots summarize the 8 distribution of points at each factor level. The ends of the box are the 25th and 75th 7 quartiles, and the difference between the g 6 quartiles is the interquartile range.

The sound waves travel into the body and hit a boundary Disadvantages of transverse technique between tissues e.

Visualization of nerves and surrounding structures: The image is highly dependent on the angle to ultrasound beam. Some nerves are more anisotropic than others. Ninety degrees gives the best picture. Ultrasound beams will not pass through air. Be generous with Table A C-mode image is formed in a plane normal to a B-mode image. M stands for motion.

Pain-Relieving Procedures: The Illustrated Guide

Ultrasound pulses are Lumbar spine emitted in quick succession each time, and either an A-mode Facet joints or B-mode image is taken. Over time, this is analogous to Medial branch of posterior ramus recording a video in ultrasound. Quadratus lumborum Psoas Doppler mode. Piriformis muscle Color Doppler. Velocity information is presented as a Pudendal nerve color-coded overlay on top of a B-mode image. Possible applications Knee are nerve blocks of the cervical and lumbar zygoapophysial joints, stellate ganglion block, intercostal nerve blocks, peripheral nerve blocks of the extremities, blocks of painful stump neuromas, caudal epidural injections, and injections of tender points.

Ultrasound can be used for local anesthetic Three-dimensional images can be generated by acquir- injection procedures, and for destructive procedures, such ing a series of adjacent two-dimensional images. Commonly as cryoanalgesia, RF lesions, or chemical neurolysis Figs a specialized probe that mechanically scans a conventional two- Lee used a curved array dimensional images of moving tissues. Accuracy of ultrasound-guided T12—L4 oped. This procedure has limitations, because and muscle motion.

In the obese patient, color. Colors may alternatively be used to represent the poor ultrasound image quality is obtained, considering a amplitudes of the received echoes.

They are as follows. In the treatment of patients suffering from vascular dis- A-mode. A-mode is the simplest type of ultrasound. A eases, sympathetically maintained pain of the head or the single transducer scans a line through the body with the upper extremity, ultrasound allows the visualization of all echoes plotted on screen as a function of depth.

In B-mode ultrasound, a linear array of trans- thetic to 5 ml was achieved, and no hematoma in the ducers simultaneously scans a plane through the body that ultrasound group was recorded. There are no published data can be viewed as a two-dimensional image on screen. The geni- or recovered by the caudal edge of the rib. Eichenberger tofemoral nerve, probably because of its deep course, is et al. Using ultrasound can help during the injection. These authors add the concept of to identify the anatomical source of pain in these patients. The be a useful tool for appropriate caudal needle placement ilioinguinal and the iliohypogastric nerves are often blocked Figs Ultrasound offers a perspective of muscle.

According to Eichenberger et al. With some anatomical variations on the sound visualization, it is possible to see a muscle twitch location, they lie between the external and internal oblique when the needle is entering the trigger point in the target or the internal oblique and transverse abdominal muscles, muscle. Montero Matamala et al. Note the local anesthetic image shown in red. Since this publi- Further reading cation, the usefulness of sonographically guided percutane- ous neurolysis of the celiac plexus in patients with abdominal Cahana, A.

Pain-Relieving Procedures - The Illustrated Guide (Hardcover)

The ultrasonic-guided anterior approach was used target position pulsed and continuous radiofrequency energy. The aorta and discharge of the truncus celiacus Chen, C. Radionics Procedure Technique observed around the origin of the celiac trunk and superior Series Monographs. Journal of Neuroscience 17, interventional pain management.

Techniques in Regional Anesthesia — Regional Anesthesia and Pain Medicine 29, glion morphology. European Journal of Pain 9 3 , — There is no compressive effect on the corresponding grade 3 tear has leaked contrast completely through all three nerve root. Many of these patients with grade 2 IDD com- zones of the annulus. This tear is believed to be painful plain of lower back pain, which may travel into the lower because the outer one-third of the disc has many tiny nerve limb and even past the knee into the lower leg and foot.

The grade 4 tear is a more serious Grade 3. During discography, tear with a concentric annular tear. The grade 5 tear includes contrast material leaks out of the back of the disc into the either a grade 3 or grade 4 radial tear that has completely epidural space. This condition is material from the disc into the epidural space.

In some having sciatica as the grade 2 IDD patients. There are two components to provocation discography. The second is a painless discogram in the adjacent discs. Lumbar discography disc stimulation or provocative discog- 6. Drugs and equipment for discography genic pain is suspected. The type of analgesia or sedation needs to be ascertained before performance of the invasive procedure. Patient response should be tify the midpoint of the intervertebral space at the target monitored and the dosage titrated to establish a level of level. Adjust the lower endplate of the target vertebral body sedation allowing the patient to be conversant and respon- to be aligned by moving the C-arm in a cephalocaudal direc- sive after needle placements.

Because the disc is avascular, tion Fig. Rotate the C-arm in the oblique projection so that the discographers use prophylactic antibiotics. Prophylactic superior articular process is positioned at the junction of the intravenous antibiotics 20 minutes before the procedure are posterior and middle thirds of the cephalad vertebral body recommended.

Usual prophylaxis consists of intravenous Fig. For patients Step 5. Position and monitor the patient symptoms, to prevent the confusion of pain, i. Place from the procedure or the pathology Figs Fix the head on the table with a strip of adhesive tape. Insert an intravenous cannula for injecting medication. A 10 cm, 22 gauge spinal needle is advanced in tunneled 4.

Provide oxygen by nasal cannula. As a b Figure The C-arm should the C-arm laterally and advance the needle toward the be rotated obliquely in the cephalad direction until the iliac center of the intervertebral disc Fig. The needle tip should be in Note: If the needle tip is cen- tered on the anteroposterior view but posterior on the lateral image, the needle entered the disc too medially. Injection into the disc can be performed using a pressure- controlled injection discomanometry.

This is performed using a specially designed injection device and a pressure monitoring system. The opening pressure of the disc and the pressure at which the concordant pain is elicited can be accurately monitored using this method. After discography, 50— mg of cefazoline is injected in and back pain after lumbar discography. After a satisfactory the disc.

Written instructions are Step 8. Postprocedure care preferable for emergencies and are helpful to the patient and After completing the procedure, observe the patient for at least their family. Complications of discography are shown in Table The patient should be followed up for any evidence of subcutaneous bleed- Complications of discography Table In addition, objectively document the pain relief. These comprise the following. Discs that are not painful despite pressure above 50 p.

Reproduced The normal lumbar disc in the lateral decubitus position from Pino et al. No signs of degeneration. The incidence of discitis is around 0. It may be due 2. Correlates with grade 0 Dallas Discogram microorganisms are Staphylococcus aureus and Staphylococcus criteria. It may also develop owing to Gram-negative 3. The patient complains of increasing pain.

To prevent nucleus and inner annulus. Correlates with grade 1 or 2 discitis, intradiscal antibiotics are recommended. Correlates with grade 3 or 4 considered. Correlates with grade 5 Dallas procedure. In Thomas This may be due to dural puncture or an irritation of the discovered the chemical structure of this material. However, one should credit Repeated puncture of the disc may cause disc hernia.

Thus Menno Sluijter when, in , he described intradiscal RF the physician should try to enter the disc in one attempt. In Changes in the disc due to aging Finch described a discTRODE procedure and recently biacu- During growth and skeletal maturation, the boundary plasty has been popularized Figs With age and degeneration, the disc The anatomy of the lumbar intervertebral disc is described changes in morphology, becoming increasingly disorganized.

Only some special points will be Often the annular lamellae become irregular, bifurcating, described here. In addition, the aggrecan molecules ticularly in the nucleus. Cell proliferation occurs, smaller, more degraded fragments in the disc than in articu- leading to cluster formation, particularly in the nucleus.

It has been reported that more from the matrix with increasing age. Discs from individuals as young as 2 years of age have some very mild Pathophysiology cleft formation and granular changes to the nucleus. It is degeneration is loss of proteoglycan. This results in loss of glycosaminogly- Biochemistry of the normal disc can; this loss is responsible for a fall in the osmotic pressure The mechanical functions of the disc are served by the extra- of the disc matrix and therefore a loss of hydration.

The main mechanical role is retain the ability to synthesize large aggrecan molecules with provided by two major macromolecular components. The absolute quantity Aggrecan, the major proteoglycan of the disc, is responsible of collagen changes little but the types and distribution of for maintaining tissue hydration through the osmotic pres- collagens can be altered. For example, there may be a shift sure provided by its constituent chondroitin and keratin in proportions of types of collagen found and in their appar- sulfate chains. The proteoglycan and water content of the ent distribution within the matrix.

However, collagen cross-link studies indicate that, as with proteogly- Matrix cans, new collagen molecules may be synthesized, at least The matrix is a dynamic structure. Its molecules are continu- early in disc degeneration, possibly in an attempt at repair. The balance between synthe- Other components can change in disc degeneration and sis, breakdown, and accumulation of matrix macromole- disease in either quantity or distribution. The integrity and it becomes more fragmented. Disc aggrecan is more highly substituted in in-vitro systems.

A past and populations. Several families of enzymes are capable of current hypothesis is that, in symptomatic individuals, the breaking down the various matrix molecules of disc, includ- nerves are somehow sensitized to the pressure, possibly by ing cathepsins, MMPs, and aggrecanases. These molecules can be produced by cells of herniated discs and because of the close physical contact Functional changes of the disc owing to degeneration between the nerve root and disc following herniation they The loss of proteoglycan in degenerate discs has a major may be able to sensitize the nerve root.

Loss of proteoglycan to be failure of the nutrient supply to the disc cells. Like all and matrix disorganization has other important mechanical cell types, the cells of the disc require nutrients such as effects; because of the subsequent loss of hydration, degen- glucose and oxygen to remain alive and active. In vitro, the erated discs no longer behave hydrostatically under load. The disc is large discs, apophyseal joints adjacent to such a disc may be and avascular and the cells depend on blood vessels at their subject to abnormal loads and eventually develop osteoar- margins to supply nutrients and remove metabolic waste.

Loss of disc height can also affect other The pathway from the blood supply to the nucleus cells is structures. Nutrients must then diffuse from the increasing problem as the population ages. Aggrecan, because of its be as far as 8 mm from the capillary bed high concentration and charge in the normal disc, prevents The nutrient supply to the nucleus cells can be disturbed movement of large uncharged molecules such as serum pro- at several points. Factors that affect the blood supply to the teins and cytokines into and through the matrix.

Long-term exer- from the disc, possibly accelerating a degenerative cascade. The increased vascular that exercise affects the architecture of the capillary bed at and neural ingrowth seen in degenerate discs and associated the disc—bone interface. For many decades, it was suggested that a major cause of back problems is injury, often work-related, that causes structural damage.

It is Step 1.

Pain-Relieving Procedures: The Illustrated Guide - P. Prithvi Raj, Serdar Erdine - Google Книги

Prepare the patient before the procedure believed that such an injury initiates a pathway that leads 1. Plain radiography will clarify the disc back pain. Ascertain the type of analgesia or sedation before per- forming the invasive procedure. If a local anesthetic or Genetic factors in disc degeneration neurolytic block is planned, mild sedation is all that is More recent work suggests that the factors that lead to disc necessary.

If pulsed RF is planned, the patient needs to be degeneration may have important genetic components. Findings from two comfort.

MRI in identical effects, and complications should be thoroughly explained twins was very similar with respect to the spinal columns to the patient and their family. The patient should be aware and the patterns of disc degeneration.

Individuals with a polymorphism in the aggrecan gene explained in detail, before the procedure. Valid written were found to be at risk for early disc degeneration. Studies consent should be obtained. Position and monitor the patient and collagen IX can lead to disc degeneration.

Options for treatment of discogenic pain 4. Monitor vital signs mandatory. The approach towards the disc is similar for all procedures. Rotate the C-arm laterally and advance the needle until 1.

Adjust the lower endplate of the target vertebral body disc and the direction of the needle should be parallel to to be aligned by moving the C-arm in a cephalocaudal direc- the upper and lower endplates of the vertebral bodies tion Fig. Oblique the C-arm in the coronal plane approximately 3. Advance the needle into the disc. The entry point is at the midpoint of the superior articular 5.

For the L5—S1 level, the angle of the C-arm should be process, at the lateral edge. Direction of the needle Inject 2 ml of contrast material into the disc: Impedance monitoring is crucial to verify that the tip of the electrode is within the disc. The impedance should be around — ohms, otherwise one should check the position of the needle.

Description

Motor stimulation at 2 Hz up to 1—2 V. If there are strong motor contractions at the lower extremities, change the site of the electrode. Intradiscal injections a Chemonucleolysis Chymopapain works by depolymerizing the proteoglycan and glycoprotein molecules in the nucleus pulposus. These large molecules are responsible for water retention and tur- gidity. When exposed to chymopapain, the water content within the disc plummets; shrinkage follows and causes a reduction in disc height and girth. The bulging disc, there- fore, shrinks Fig. Intradiscal procedures mopapain test should be performed one day before the pro- cedure, and H1 and H2 receptor blockers should be a Intradiscal electrothermal therapy: The annulus will provide sedation.

This will be followed by a sudden loss of resistance. Some authors prefer to inject units. When To prevent muscle spasms and low back pain after chy- using the spine-CATH system, the curve at the tip of the mopapain injection, some authors recommend injection of catheter and the white line on the catheter handle should local anesthetics to the paradiscal region.

This indicates the tip of the catheter has reached the Low back pain may occur for several days. Bed rest for tip of the introducer needle. It became clear that good patient the annulus and the nucleus and curl inside the disc at selection, proper surgical training and technique, preopera- the interface of the nucleus and the interior annular wall tive hypersensitivity testing, and antihistamine administra- Fig. Note that the catheter must not be outside of the disc b Ozone chemonucleolysis wall. The catheter from the top of the disc. This should be observed injection itself, except for a slight sense of localized pain of as radiopaque markers of the resistive coil being outside of short duration, is generally painless and well tolerated.

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After inserting the introducer; the navigable, semi- should be immediately removed together. As the temperature increases, the patient is con- introducer placement. These local temperatures register on tinuously evaluated for back pain and any other signs of the external temperature monitor attached to the RFG-3C nerve root irritation such as extremity pain. It is expected Plus Lesion Generator. This range should be maintained throughout the thermo- coagulation and is an indicator of a functioning power circuit.

This may require some rotation. The introducer is advanced through the disc. The treatment temperature is manually increased Fig. RF cobla- The new annuloplasty procedure termed intradiscal biacu- tion combines disc removal and thermal coagulation to plasty Baylis Medical, Montreal, Canada uses a bipolar decompress a contained herniated disc.

Two 17 gauge herniated disc, and failed conservative therapy. Patients who transdiscal introducers are placed in the posterior annulus should be excluded from receiving this procedure include using a posterolateral, oblique approach. YAG laser; the others are potassium—titanyl— mally treating the channel, which leads to a denaturing of phosphate, and the neodymium Nd: YAG laser is most commonly paired with an endoscope pulposus.

A ruptured annulus and lateral recess stenosis are not contraindications. The outer cal pressure decreases, allowing the disc to return to its cannula measures 1. Irrigation with saline allows for automated technique are limited. Newer neous lumbar discectomy: Pain Practice to provide more control of laser placement, better observa- 4, 19— British Journal tion, and can help reduce the risk of injury to several areas, of Radiology 65, — Journal of Bone and Joint Surgery America 23, ablated, the laser and dilators are removed. The incision can — The patient is Benedetti, E. Techniques in Regional Anesthesia and Pain Management 13 4 , up to 2 hours.

After a satis- Benzon, H. A review of the relative neurotoxicities and adequate instructions given to their escort. Written of the steroids. Anesthesiology 2 , — International Spinal Intervention Society. Postprocedural care Bonica, J. In the second month, most niques: Pain Physician 10 1 , 7— In the third month, the intensity of Brodsky, A. Athletic activities such as Brown, D. Wiener Klinische Wochenschrift 37, Pain Physician 10, — Techniques in Regional Anesthesia and Pain Management 8 1 , 35— Pain Physician 12 1 , — New York Medical Journal 42, — Medical Journal of Australia 1, — Techniques in Regional Anesthesia and Pain Management 13 4 , — Pain blocking procedures for localizing spinal pain.

The lumbar Physician 10 1 , — Pain Digest 3, — Techniques in Regional Anesthesia and Pain Management in the lumbar region. Acta Radiologica 25, — Pain Practice 2 4 , — Techniques in Regional Anesthesia and Pain pathectomy. Techniques in and radiculopathy. Techniques in Regional Anesthesia injections: Tech- and Pain Management 13 2 , 85— Pain Practice 8 1 , 18— Journal of Bone and Joint Surgery, British Volume 90 10 , segmental nerves in the treatment of the intervertebral disk syn- — Annals of General Practice 16, Evidence from a nationwide sympathetic chain.

British Journal of Surgery 57, Annals of Medicine 21, — Minerva Medica 98, during labor and delivery. Anesthesia and Analgesia 21, — Acta Orthopaedica Scandinavica 18, — Archives of Neurology and Psychiatry 44, Hirsch, C. Acta Orthopaedica Scandinavica 33, 1. Journal of Biological Chemistry , report. Spine 25 3 , — Bulletin of the Academy of Medicine low-back disorders.

Multidisciplinary information is required if you intend to practice pain management at a high level of effectiveness.

This includes anatomy and physiology, pain syndromes, diagnosis and management, and the correct use of interventional techniques. The Illustrated Guide provides you with a step-by-step guide to interventional techniques underpinned by a solid multidisciplinary knowledge base. The text is enhanced by the wide use of illustrations, including amazing color 3D-CT images that enable you to easily visualize anatomy. The first part of the book gives the fundamentals you need for modern pain practice. The second part describes all commonly used procedures, using a head-to-toe organization.

Each procedure is described using a template that includes anatomy, indications, contraindications, technique and complications.

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