1/10/2018 1 www.centrul-provita.ro Lumbar Injections For Diagnosis and Treatment Ovidiu Nicolae Palea Centrul de Diagnostic si Tratament ProVita www.centrul-provita.ro Pain Management Anesthesiology and Intensive Care 2009 decided to focus on Pain Management 2010 started the first Multidisciplinary Minimal Invasive Pain Center in Romania – Centrul de Diagnostic si Tratament Provita Full time Pain Management Karachi Spine - Pain and Minimally Invasive Spine Surgery Workshop
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1/10/2018
1
www.centrul-provita.ro
Lumbar Injections ForDiagnosis and Treatment
Ovidiu Nicolae PaleaCentrul de Diagnostic si Tratament ProVita
www.centrul-provita.ro
Pain Management
Anesthesiology and Intensive Care
2009 decided to focus on Pain Management
2010 started the first Multidisciplinary Minimal Invasive Pain Center in Romania –Centrul de Diagnostic si Tratament Provita
Full time Pain Management
Karach
i Spin
e - Pain
and M
inimall
y Inv
asive
Spine S
urgery
Work
shop
1/10/2018
2
www.centrul-provita.ro
Pain Management
Medicine has evolved into 30 specialties and OVER 140 Subspecialties!!!!!
Anesthesiologists were first, but now ….
Neurosurgeons
Physical Medicine and Rehab docs
Rheumatologists
Orthopedic Surgeons
Neurologists
Interventional Radiologists
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Pain Management
Patient Population – sub acute and chronic:
Lower back 50%
Upper back 20%
Peripheral joints – hip, knees etc – 20%
Head and Facial Pain 10%
Karach
i Spin
e - Pain
and M
inimall
y Inv
asive
Spine S
urgery
Work
shop
1/10/2018
3
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The Goal Today:
Functional Diagnosis
Radiological Landmarks
Technique for Infiltrations
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Definition and Etiology
Radicular pain is a type of pain that radiates into the lower extremity directly along the course of a spinal nerve root
It needs a good differential to Pseudoradicular Pain
Radicular pain is caused by inflammation rather than compression, and/or injury to a spinal nerve root
Karach
i Spin
e - Pain
and M
inimall
y Inv
asive
Spine S
urgery
Work
shop
1/10/2018
4
www.centrul-provita.ro
Definition and Etiology
Inflammation of the nerve root can be caused by:
‐ herniated disc
‐ facet hypertrophy
‐osteophytes
‐epidural fibrosis
www.centrul-provita.ro
Definition and Etiology
Inflammation of the nerve root can be caused by:
Karach
i Spin
e - Pain
and M
inimall
y Inv
asive
Spine S
urgery
Work
shop
1/10/2018
5
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Definition and Etiology
Inflammation of the nerve root:
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Clinical Diagnosis
History of Present Illness
‐ how did the pain start?
‐ where is the pain? Back or leg pain?
Physical exam:
‐ neurological deficits
‐ straight leg raising, SI and Hip
‐ reflexes
Karach
i Spin
e - Pain
and M
inimall
y Inv
asive
Spine S
urgery
Work
shop
1/10/2018
6
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Differential Diagnosis
Facet pain
Sacroiliac pain
Coxarthritis
Tendinopathy
Peripheral nerve Entrapments
Bursitis, Psoas Impingement
Internal pathology
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Radiological Diagnosis
X ray AP and Lateral
‐ mainly bone landmarks BUT also critical alignment information
Karach
i Spin
e - Pain
and M
inimall
y Inv
asive
Spine S
urgery
Work
shop
1/10/2018
7
www.centrul-provita.ro
Radiological Diagnosis
CT scan
‐ more soft tissue anatomy
‐ great for osteophytes
‐ used mainly when MRI is contraindicated
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Radiological Diagnosis
MRI
‐ soft tissue detailed anatomy
‐ very limited for osteophytes
‐ BIGGEST pitfall: NO CLINICAL CORELLATION!!!
Karach
i Spin
e - Pain
and M
inimall
y Inv
asive
Spine S
urgery
Work
shop
1/10/2018
8
www.centrul-provita.ro
Clinical Diagnosis is Critical
Do we treat the actual hernia?
Do we treat the cause? Is Hernia the cause?
Do we treat the SYMPTOMS?
Symptoms caused by what? Hernia?
Nerve Inflammation?
Fibroses of the nerve root?
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Electromiography
Great Sensitivity
Poor Specificity
Poor clinical correlation
Lesion has to be over 4 weeks old to see any changes
Karach
i Spin
e - Pain
and M
inimall
y Inv
asive
Spine S
urgery
Work
shop
1/10/2018
9
www.centrul-provita.ro
Functional Diagnosis is Critical
Guided Anesthetic infiltrations are the only available functional diagnosis at the present time ‐
In multilevel pathology there is no other test that has a better correlation!!!!!
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Functional Diagnosis is Critical
Guided Anesthetic infiltrations are the only available functional diagnosis at the present time – X ray guided or Ultrasound guided
Ultrasound guided injections are growing as indications more and more – axial as well as articular or peripheral nerve entrapments