Max Wirjo,MD,FRCPC,DABA. Director, Integrated Pain Medicine. The Permanente Medical Group, Kaiser Fresno Medical Center, California, USA
Max Wirjo,MD,FRCPC,DABA.Director, Integrated Pain Medicine.
The Permanente Medical Group,Kaiser Fresno Medical Center, California, USA
Systematic approach based on pain generators of the spine :
Posterior compartment : all structures innervated by dorsal ramus of the spinal nerve, i.e. Facet joint / Z joint
Neuraxial compartment : all structures within the epidural space and neural pathways
Anterior compartment : vertebral bodies and intervertebral disc
-Intra-articular Facet injection-Medial Branch block-Radiofrequency Ablation of the medial branch.
-Translaminar Epidural Steroid injection-Transforaminal Epidural Steroid injection-Selective Nerve Root block-Pulse RFA of nerve root/DRG
Anterior CompartmentDiscogenic pain: - Discography (Provocative) - IDET (Intradiscal Electrothermal Therapy) - Transdiscal Biacuplasty
Vertebral body compression fracture; - Vertebroplasty - Kyphoplasty
IDET
Kyphoplasty (or Vertebroplasty)
Kyphoplasty
Kyphoplasty
Spinal StenosisBulging discFacet hypertrophy:Ligamentum flavum hypertrophy
Treatment: - Lumbar Epidural Steroid - RFA of the medial branch - MILD (Minimally Invasive Lumbar
Decompression)
MILD - Epidurogram
MILD – portal
MILD – bone sculpture
MILD – tissue sculpture
Failed Back Surgery SyndromeNeuromodulation/Implantable
device/Advanced Pain TherapySpinal Cord/Peripheral/field Nerve
StimulatorIntraspinal Drug Delivery /Morphine
pump
Pain Management ProceduresAdvanced Pain Therapy
RFA: Heat Pulse
Spinal Cord Stimulator Trial Permanent All done as outpatient surgery
Morphine/Baclofen pump Trial (as outpatient, baclofen needs 8 hr monitoring Permanent, done as inpatient
Sacroiliac injection
Spinal Cord Stimulator
Spinal Cord Stimulator
Intraspinal Drug Delivery system/ Morphine pump
Intrathecal Drug Delivery Pump1.Narcotic : Morphine, Dilaudid, Ziconotide , Fentanyl. with Clonidine/ Baclofen/ Bupivacaine added.2.Baclofen ( Liorisal ) for Spastic Disorder i.e. CP, MS, Spinal Cord Injury, Stroke