Interventional Pain Management
Oliver Ghalambor, MD, DABA, FIPP, DABIPP, DABPM
Frequency of Pain
Raising Pain Awareness
Why do we have back pain?
One theory as to why humans have so many spine and especially low back problems hypothesizes that vertebrates were never meant to be upright. Humans for the most part are the only vertebrates that constantly load their spinal structures vertically and hence they experience more troubles with their spine than their non-upright vertebrate counterparts. But this is just a theory!
A quick review of the spinal structures will help one understand what can go wrong with the spine. The discs can get in trouble by the jelly of the disc (nucleus) coming out (herniation) or by the disc simply getting worn out (degeneration). The joints of the spine (facet) joints can also get worn out and get arthritis. The bones (vertebrae) can break, especially if they are fragile (osteoporosis) and finally the surrounding tissues such as muscles, tendons, and ligaments can get damaged (usually short term) which we call sprain/ strain.
Xray of the Lumbar Spine
Left: Normal Disc Height
Right: Disk Degeneration
Disk Herniation (Different types)
Disk Degeneration (Different Phases)
Athritis (of the facet joints)
Risk Factors/ Preventions
The main question here is what can one do to avoid having spine problems. Otherwise said, what are the “risk factors” and how can we avoid getting in trouble with our back or neck.
Based on what research has found, the most frequent reason why one has back or neck problems is determined by their genetic. So watch out if your father and mother have spine related issues. Also, we have found that excessive body weight, smoking, excessive drinking, poor body posture, jobs that are too hard on the body such as Truck driving or Jack Hammer operation call all lead to accelerated wear and tear of the spine.
Prevention therefore, should focus of smoking cessation, being cautious with duties that overload the spine, keep the muscles especially core body muscles in good shape to support the spine while keeping an eye on your calories.
Being conscientious about your posture, especially if you are in front of the computer, or using electronics in your hands with you head bent down “Tech Neck” are good preventative advises.
Lastly, supplementation with Calcium and Vit D. especially in post menopausal periods has been shown to help prevent osteoporosis and therefore compression fractures.
Since the disc does not have any vascular supply, the anti-inflammatory medications (steroids) need to be delivered close to the area of inflammation which is the epidural space.
Interlaminar Epidural Steroid Injection
The oldest and easiest way to inject steroids in the epidural space is via the interlaminar approach. This could be done without Xray.
However, most of the medication will remain in the posterior epidural space or will travel to the path of least resistance which is the normal side; and therefore can be less efficacious.
Summary of Pain Management Interventions
While the best way to deal with spine and joint related problems is to avoid them (prevention); unfortunately most of the time we see patients after the problem has already started and therefore needs to be treated before we can talk about prevention.
The good news is, over the course of last 20-30 years we have made tremendous amount of improvement for the spine and joint related problems. It is no longer “get it some rest”, “do some physical therapy” and then straight to the surgeon’s office.
At this point in time, the Interventional Pain Management has become a specialty requiring most physician to do a fellowship and get board certification in order to be able to offer most advanced non surgical treatments for back, neck and joint problems.
I have done my best to summarize some of the most frequently offered treatment for each problem we described above. The list is by no means comprehensive. To learn more about some of the available treatments, you can click on the “Treatments” tab of this website.
Transforaminal Epidural Steroid Injection
The injection of steroids in the epidural space via transforminal approach is more precise and results in better delivery of the medication at the site of inflammation. This needs to be done under fluoroscopy and with use of contrast and requires more training and skills.
Disc Herniations Unresponsive to Injections
Not all disc herniations will respond favorably to conservative management including epidural steroid injection.
Old Approach: Big Surgery
Ultra Mimimally Invasive Endoscopic Discectomy
Facet Joint Injection
Facet joint injections are the “arthritis shots” in the neck (cervical spine) or the back (thoracic and lumbar spine).
This is done under fluoroscopy and is done both to help the pain as well as to diagnose/ confirm that the pain is coming from the joints.
Facet Joint Medial Branches
Lumbar Radiofrequency Neurotomy (Rhizotomy)
Cervical Epidural Steroid Injection
Cervical Facet Radiofrequency Neurotomy
Joint Radiofrequency Neurotomy
Spinal Cord Stimulation
The idea behind spinal cord stimulation is that if we can no longer treat the painful area; we can modify the signals at the spinal cord level from pain (unpleasant) to massage and tingling (pleasant).
This treatment modality is widely used in cases of failed back surgery syndrome as well as complex regional pain syndrome (RSD).
The advantage of this treatment is that it is first “tested” during trail period by placing the temporary leads via a needle. Only is the trial phase results in significant relief of the symptoms, then the leads and the battery are implanted with a small incision.