Interventional Procedures & Epidural Steroid Injections

Interventional Procedures in Pain Management

• Definition: the use of invasive techniques to decrease or eliminate pain.
• Invasive techniques can accomplish pain management in three ways:
  • Interrupting the pain signal along a neural pathway.
  • Neuroaugmentation (SCS, PNS).
  • Implantable drug delivery system.
• Interventional pain management techniques can be performed for diagnostic or therapeutic purposes.
• Ideally, before the procedure, a complete patient history and physical examination will be performed and a specific diagnosis has been made.
• Procedures should be target specific and performed in a technically sound way using proper technique.

Epidural Steroid Injections

• Epidural steroid injections involve injecting steroid into the epidural space in order to reduce inflammation and pain.
• Epidural Steroid Injection Techniques:
  • Interlaminar Epidural Steroid Injection
  • Transforaminal Lumbar Epidural Steroid Injection
  • Caudal Epidural Steroid Injection
• The epidural space sits outside the dura mater inside the surrounding vertebrae.
• This space can be accessed to provide access to nerve roots and provide pain relief
• The superior limit of the epidural space is the foramen magnum.
• The inferior limit of the epidural space is the sacrum.
• Multiple approaches can be used in this space as well as different medications.
• A catheter may be introduced into the epidural space to deliver a continuous infusion of local anesthetic such as for an expectant mother.
• After delivery, the infusion is stopped and the catheter can be removed

Vertebral Discs

• A vertebral disc is built like a jelly doughnut: annulus fibrosus (outer layer) and nucleus pulposus (inner jelly part).
• Anulus fibrosis can weaken, enabling the nucleus pulposus to herniate into or through it
• The herniation causes compression and irritation onto adjacent nerve roots.
• This compression and irritation is known as radicular pain or radiculopathy.
• 90% of disc herniations happen in the lumbar spine at the L4–L5 and L5–S1 levels.
• The greatest range of motion in the spine is at the L4–L5 and L5–S1 levels making these discs most vulnerable to herniation.
• When a nerve root is irritated, it sends an aberrant signal to the brain, which interprets this as pain along that entire nerve.
• Nucleus pulposus contains inflammatory factors that can leak out through the anulus fibrosus and bathe the nerve root in an inflammatory matrix.
• Steroids suppress the autoimmune response triggered by glycoproteins from the nucleus pulposus.
• Steroids also exert membrane-stabilizing effects on injured nerve segments, reducing ectopic discharges from the affected nerve roots.
• Disc herniation can compress the epidural venous plexus potentially leading to venous obstruction.
• If the venous side is backed up, it can result in decreased perfusion of the nerve root from the arterial side.
• Hypersensitive nerve roots and prolonged radicular pain are a product of Prolonged irritation and poor blood circulation.
• This phenomenon can occur in the cervical spine which occurs most often at the C5-C6 and C6-C7 levels.
• Cervical discs can herniate, causing cervical radiculopathy with paresthesia ("pins and needles") radiating down the arm.

Uses of Epidural Steroids

• Lumbar and cervical radiculopathy are the most common indications for epidural steroid injections.
• Spinal stenosis.
• Postlaminectomy syndrome
• Vertebral compression fractures.
• Sacral fractures
• Degenerative disc disease
• Postherpetic neuralgia
• Epidural steroid injections can prevent chronic fibrosis and adhesions around the nerve root, and serve as a conservative alternative to surgery
• They are more effective in the first three months of radiculopathy and results in reduced steroid doses when compared oral or IV administration
• Pain from disc herniations typically dissolves independently in about a year but an ESI can shorten this time frame.

Epidural Steroid Injection Techniques

• Interlaminar Epidural Steroid Injection, which is the most common type.
• Transforaminal Lumbar Epidural Steroid Injection
• Caudal Epidural Steroid Injection

Interlaminar Epidural Steroid Injection

• It is essential that the procedure be completely explained to the patient, that all questions are answered, and that informed consent is obtained.
• The patient is placed face down on the fluoroscopic table.
• Noninvasive hemodynamic monitors and pulse oximetry are placed.
• The skin over the lower back is prepped with Betadine and drapes are placed over the area in standard sterile fashion.
• To begin, the fluoroscope is placed in the anteroposterior (AP) position

Transforaminal Lumbar Epidural Steroid Injection

• Nerve roots leave the epidural space via neural foramen on either side of the spine.
• Vertebral discs lie on the anterior side of the epidural space (towards stomach) and can herniate posteriorly into neuroforamenae.
• In this case, the disc makes contact with the nerve e.g. L4 nerve root on the right.
• A needle can be pushed to the epidural space at the neuroforamen.
• The foraminal approach delivers medication directing to the anterior epidural space where the disc is affecting that particular nerve root

Comparison of Intralaminar and Transforaminal Approaches

• The interlaminar approach uses the posterior epidural space to flow medication to the affected area.
• The transforaminal approach delivers medication directly to the area of interest

Caudal Epidural Steroid Injection

• A caudal approach is necessary for certain cases requiring access to the epidural space through the sacral hiatus.
• These injections treat sacral neuropathy, sacral fractures, and coccygodynia.
• In people with extensive posterior fusion, the interlaminar approach to the epidural is obstructed, so a caudal approach is necessary.
• Systemic or local skin infection for needle insertion, blood thinners are contraindications
• Pregnancy is a contraindication because of fluoroscopy use
• Possible complications: infection, bleeding, nerve damage, and lumbar puncture headache

Facet Joint Procedures

• Facet Joint Injections.
• Medial Branch Blocks.
• Radiofrequency Ablation of the Medial Branches of the Spinal Nerve Roots.

Facet Joints

• Synovial-lined joints that link two vertebral bodies posteriorly
• It is formed by the articulation of the inferior articulating process of one lumbar vertebra with the superior articular process of the next vertebra.
• They allow the spine to flex, extend, and rotate.
• With wear and tear over time, these joints can become arthritic and painful
• Up to 70% of the compressive force is transferred to the facet joints following intervertebral disc height loss
• Most commonly affected are the lower cervical (C4/C5 and C5/C6) and the lower lumbar (L3/L4, L4/L5, and L5/S1) facet joints.
• Axial weight distribution along the spine is greatest at vulnerable lumbar facet joints.
• This is where the greatest range of motion in the spine.

Facet Joint Pain

• Pain from a facet joint is transmitted to the brain through the medial branch of the posterior division of the spinal nerve roots.
• Each facet joint has medial branch that innervates the superior aspect and one that innervates the inferior aspect.
• Facet joint pain is axial in nature, not radicular.
• It is described as deep and achy and the pain is localized to source of an arthropathy.

Facet Joint Injections

• Diagnostic injections determine if a facet joint or joints are the pain generator, through use of a local anesthetic
• If pain is relieved post-injection, the pain generator was targeted
• Next is commonly radiofrequency (RF) ablation for permanent block

Facet and Medial Branch Blocks

• Intra-articular facet joint injections or medial branch blocks can be used

Facet Joint Injection Intended Target

• The inferior aspect of the facet joint.

Medial Branch Blocks

• Lumbar Spine:
  • Each facet joint is innervated by the medial branch of two consecutive spinal nerve roots.
  • A medial branch from the superior aspect of the joint and one from the inferior aspect of the joint.
  • Medial branch covers superior articulating process - runs from the facet joint - covered by the mamillo-accessory ligament, and tracks to intervertebral foramen where it enters the dorsal rami of its respective spinal nerve root on its way up to the brain.

Radiofrequency Ablation

• An electric field is established around the needle tip
• The field oscillates with alternating RF current to move ions, which cause friction.
• The friction in surrounding tissue produces heat.
• Ablation is achieved on the medial branch of the spinal nerve root.
• Cell damage commences a 45°C
• Protein coagulation commences between 60-100°C leading to cell death
• Standard ablation runs at 80°C for 60 seconds
• RF Machines are programmed with preferred sensory/motor testing parameters

RF Ablation and Pain

• A process using heat to destroy the medial branches, thus innervating a facet joint.
• This eliminates pathologic pain
• Painful facet joint may remain unchanged unless surgery performed
• Structural integrity of the joint is not changed
• Fluoroscopy is performed.
• RF Needle(s) are positioned then a RF probe into the needle.
• Electrical stimulation is used by the RF machine to the tip of the needle.
• The RF machine set to ablation and the ablation process begins
• The needle is then removed and a bandage placed

Contraindications and Complications of Facet Joint Procedures

• For Contraindications includes infection (systemic or where the needle is inserted) and pregnancy.
• Blood thinners should be withheld before the procedure
• For diagnostic blocks ensure the patient comprehends, and has the ability to tolerate the block
• Risking motor weakness and sensory loss for the RF procedure

Sacroiliac Joint (SI) Injections

• This can be therapeutic and diagnostic
• Diagnostic Sacroiliac Joint Injections
• Therapeutic Sacroiliac Joint Injection
• Sacroiliac Joint Radiofrequency

SI Joints

• Weight-bearing, and connects the sacrum (base of the spine) to the ileum (pelvis)
• Visible at the gluteal dimples
• Origin of pain in 13–19% of patients with chronic low back pain
• Pain is aching, sharp, and worsen when climbing stairs
• The injection is performed under fluoroscopic guidance and a similar way with previous protocols.

SI Joint Injections vs Diagnostic block

• For SI joint injections: history and analysis are insufficient for analysis
• A diagnostic block determines If relief occurred post anesthesia, this confirms the diagnosis

Performing a SI Joint: Therapeutic Injection

• Follow the exact steps for the diagnostic SI joint but a steroid is administered.
• Kenalog at 40 mg or Methylprednisolone acetate at 40 mg in SI joint/s

SI Joint Radiofrequency

• Radiofrequency ablates the SI joint and engages the posterior nerves.

Trigger Point Injections

• Actin and Myosin slide over one another, during muscle contraction. After, they both slide back to the starting position
• A taut muscle band prevents muscle filaments from releasing
• A trigger point forms a painful taut muscle band
• Abnormal neuromuscular junctions may lead to this.
• Muscle tissue gets information on when to contract and the junction is a highly excitable region
• Contractions remains if the region becomes overexcited

Trigger Points

• Result in regional, persistent pain with decreasing ROM
• Develop along weight-bearing axial skeleton used to maintain body posture such as the neck, shoulder, or back
• Diagnosis through palpating the pain w/ finger pad + verbal confirmation.
• No specific lab test
• Imaging/Interventional modalities (EMG or Biopsy) will not help in diagnosis
• PTs may have either several, or one PT injection

Trigger Point Injection Contents

• It is thought, to diffuse abnormal electrical charge + restore normal muscle contractions.
• A variety of fluids may be injected: saline * local anesthetic
  • Corticosteroids, vitamin B solution, ketorolac (a non Steroidal Anti-inflammatory Drug; NSAID), or Butolinum Toxin
• Lidocaine 2%/bupivacaine 0.5% may be used, either separately or combined.

Appropriate Uses and Procedure for a Trigger Point Injection

• relatively safe, and reduces symptoms of myofascial pain
• PTs can be I.D.’d clearly to ensure the effectiveness of the injection.
• Palpate region ask PT to identify painful spots to be injected
• Insert/Redirect the needle into spots (superior, inferior, medially and laterally)
  • Administer an anesthetic following needle insertion

Contraindications and Potential Complication for a Trigger Point Injection

• TP injections = safe, does not require fluro guidance
• However is contraindicated in: systemic and skin infections, bleeding disorders.
• To prevent cervical regions’ arterial/intrathecal injections, remain in the muscle
• Be cautious of lungs/cervical region

Joint and Associated Bursa Injections

• Including Shoulders, Elbows, Hips and Knees.

Injections and Bursea

• Steroids and anesthesia can lessen pain and inflammation
• These injections ^ ROM in painful joints
• Injection locations include (intra-articular) for arthritis/ (para-articular) for bursitis. Bursitis is an inflammation of bursa in friction sites
• These injections can be done for frozen shoulders, Bursitis, tendinitis, and osteoarthritis.

Joint Injections

• Local anesthetics combined with steroids commonly used.
• Anesthetics provide short term relief
• One syringe is used to administer solution

Corticosteroid Function

• Corticosteroids act to impede bone/ cartilage destruction as they reduce :
  • inflammation/ excess blood flow. • Lidocaine + bupivacaine are types of local anesthetics : block VG Na+ channels

Types of Corticosteroids/ Levels

• Kenalog- 40mg
• Trimacinolone- 40 mg
• (Depo-Medrol) Methylprednisolone acetate - 40mg
• Celestone- 6mg
• Betamethasone Acetate- 6mg
• Decadron- 8mg
• Dexamethasone Acetate- 8mg

Soulder Region Joint injections

• Shoulder (Glenohumeral) Joint Injection
• Shoulder (Acromioclavicular) Joint Injection
• Shoulder (Subacromial Bursa) Injection

SHOULDER (GLENOHUMERAL) JOINT INJECTION

• Inject 2cm lateral to edge of the inferior coracoid

SHOULDER (ACROMIOCLAVICULAR) JOINT INJECTION

• Find the depressions laterally near the clavicle- which can be tender
• The AC joint is there.

SHOULDER (SUBACROMIAL BURSA) INJECTION

• Palpated lateral posterior edge of the acromion is necessary
• Elbow Joint

Elbow Region Joints

• Lateral Epicondylitis (Tennis Elbow) Injection
• Olecranon Bursa injection
• Medial Epicondylitis (Golfer's Elbow) Injection
• Elbow Joint Injection

Elbow Injections vs tennis/golfer

• Tennis Elbow injections should be preformed to relieve lateral epicondyle pain exacerbated by wrist extensions
• Golfers Elbow injections are for medial epicondyle to rx the pain by resisted wrist flexions

Elbow Joint Injection

• To perform the injections, it must happen between 3 surfaces. Humerus/radius meeting, Humerus meets with Ulna, or Radius/Ulna
• Groove head injection is preformed in the lateral elbow + landmarking with the humerus.

Elecranon Bursa Injection

• Inject fluid into the extensor aspect of the ulna (fluid-filled sac-olecranon bursa is targeted)
• Aspiration/ injection are 2 aspects of injection with area palpation for sensitivity is req

Hip Injections Regions

• fluoroscopy + US= req
• Hip Regions include
  • Intra-articular Hip Injection :
  • Greater Trochanteric Bursa Injection

Intra-articular injection info

• left hip needs to be in frog-leg position
• Target: middle/lateral femur

InterTrochanteric

• trochan busitis friction from the grater trochanteric muscle on the femur
• Target Skin Point : pt injected with NO fluro

Knee

• injections enter above, below, laterally or medially aspect.
• The Inf. Lateral is the easiest spot for most practitioners*
• **

Sympathetic Block

• Sympathetic Ganglia include Stellate, Celiac, Lumbar, as well as superior Hypogastric +Ganglion Impar,

Nervous Chain Compositions & Actions

• A nervous bundle from skull down the spine
• Nerves band tgt. for the sympathetic chain (in parasympathetic fashion) (A Paravertebral chain with autonomic actions that work inconspicuously w/ blood vessels, sphincters and the heart

Sympathetic VS Somatic Division

• Ganglia centers that relay impulses- compared w/ Somatic chains, which require flexing and feeling w/ sensory/motor input
• Spinal location is affected by sympathetic chain’s location/ body part, - as gangi control a body part
• Cervical Stellate location is where the upper ext, head, neck is controlled
• Pancreas location is where the celiac’s plexus/ the pancreas is affected
• Lumbar, a region of lower extremity control

Appropriate Sympathetic Uses

• symp. blocks are used to treat
  • maintained pain or RSD (Sympathetic Reflex Dystrophy), as its ganglionic blocks act on upper/ lower ext.
  • pancreatic or peritoneal pain- used during pancreatic plexus -Ischemic Syndrome- due to relief offered by vasoconstriction; decreasing overall pain

How to preform Nervous Chain Procedure

• Fluro Guidance (Live X-Ray) Req,

Ganglions + Stellate

• Stellate ganglia is formed by merging the thoracic/ inferior- cervical ganglia ( @ Cervical 7)

• C7 = lvl for it and to the transverse access of C7 (typically)

Celiac Plexia Blocks

• at the bodies’ front of the vertebra

Neurolytic

• reduce pain during cancer

Lumbar Blocks

• paravertebal blocks is an alternative

Plevic Blocks

• super hypogastric + performed for pain

Ganglion

• impar blocks in inferior regions performed to treat pain in the perneal pelvic

Contraindications

• contraindications (preggo, infections, needle use)
• hypotension due its functions
• prevent bilateral use

INJECTIONS FOR HEADACHES

(Occipital NErve B/c/ BOT Injections)

• Procedures treat the condition and neuralgia

Nerves

• GO Nerve =sensory fibers/C2( Med.)
• Lesser Nerve = C2/3 in pinna/side

Occyptal

• deep buring & the burning w/ nerve + injury = anyhwere that spine travels
• Cluster, Migarines treated as head ache, & injury

BTX / INJECTION

M

• minimize
• helpful with pt. w headache
• a trial with open label to treat headaches and migraine
• BTX:
• ACh is inhibited -> prevent the transfer on neuromusclar jnx -> paralysis -the pain can be relieved too with medication for patients in acute migraine + headache

ONBS

used

• block where 2x fingers over point + side
• inject therapeautric at a fly motion

· Vertebroplasty and kyphoplasty · Vertebral compression fractures. · Both procedures involve injecting a cement-like substance,Polymethymethyacrylate, into a fractured vertebral body under fluoroscopy(x-ray guidance). · Significantly reduces pain and improve mobility in patients with VCFs.

• Vertebroplasty and kyphoplasty* are used for stability,pain relief,and to improve mobility in patients with vcf's because of a variety of reasons, such as: · Benign Tumors · Metastatic Tumors. · Multiple myeloma · Osteoporosis · Trauma.

COMMON NERVE BLOCKS.

• Trigeminal Nerve block includes-Ophthalmic (V1). Maxillary (V2). and Mandibular(V3)Branches.

• median Nerve Block

• Suprascapular Nerve Block

• INTERCOSTAL Nerve Block

• pelivic Nerve block includes ilioinguinal. iliohypogastric. and genitofemoral nerves

• Lateral Femoral Nerves

• Posterior Tibial Nerve.

• Many people mistakenly think oft the term nerve block as a permanent block of a nerve's function

• The trigeminal Nerve is the fifth cranial nerve responsible for sensory in pulses orinating from the face above the jaw to the forearm.

• Sharp, electric pain radiates deep into the cheek,lips and tongue,typically on one side of the face, with often come in clusters with complete.

Trigeminal Nerve branches consist Of:

·opthalmic,maxillary,and mandibular
· rather than blocking the trigeminal galglion usually the branches  of the trigeminal nerves that correlate to the patient are blocked.
· Pain is most common in the maxillary and mandibular distributions. 

• Pelvic Nerve Blocks* The pelvis is thought of as a source of chronic lower abdominal pain:and
• In a small number of patients after tranverse,lower abdominal procedures hernia repairs, or hystrerectomies.An electric.burning groin pain may evelop believed to occur resulting fron Entrapment
• Lateral Femoral Cutaneous Nerve Block*·
• The Lateral femoral Cutaneous nerve is purely sensory, derived from the L2 and L3 nerve roots.
• Its passes just medial and inferior to ASIS,
• Supplies the anterolateral aspect of he thigh starting just below.

Posterior Tibial Nerve.

·Is a Nueropathy of the posterior Tibia

• Posterior Tibial nerve Block. · Patients often describe the pain as shooting,electric pain radiating from the medial malleous into the big toe and adjacent toes

PerQcutaneous Lumbar Disc Decompression .

• A vertebral disc is built Like a jelly doughnut, with its. innuer Nucleus pulposus and the outer Annulus fibrosus,
• It becomes weak and a herniation of disc material occurs from the Compression and iffitatilom of the adjacent nerve root. known ass radicular pain.
• Goals : decrease the amount of imternal disc pressure allowing the disc to implode or return to it´s original form.
• Pressure transducers placed have recorded a significant drop in intradiscal after nucleus pulposus Extraction.
• Needle with the requency is placed in the center of the N.P using freq Enrgy the NP tissue is lated and the decreases significantly in the iussue
• A .Tip of needle placed in the N.p that degrades the material , But if the N.P Is rekeased the enzyme . It can and might cause Neurolic Damge
• Per cutaneous Lasers Use the samé material or procedure use heat and lase to Vap a portion of the N.p tissue.

Programmable Intrathecal Pain Pump

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Spinal Cord Stimulation

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