INTERVENTIONAL PAIN MANAGEMENT IN LOW BACK PAIN

Introduction: 
Interventional Pain Management (IPM) is defined as the discipline of medicine devoted to the diagnosis and treatment of pain and related disorders by the application of interventional techniques in managing subacute, chronic, persistent, and intractable pain, independently or in conjunction with other modalities of treatments.(1) Low back pain with or without leg pain and knee pain is a common; complex problem affecting about 40% to 80% of general population in life time and point prevalence being 14 to 20% (2-6) About one fourth of U.S. adults report low back pain in the past 3 months. (7) Back pain is associated with significant economic, societal, and health impact (8-10). Estimates and patterns of direct healthcare expenditures among individuals with back pain in the United States have reached $90.7 billion for the year 1998 (9). Before availability of diagnostic IPM procedures etiology remained unclear in most situations (85-90%) even with CT/MRI. In one prospective evaluation (11), consecutive adult patients with intractable low back pain (who had failed conservative therapy) of undetermined etiology (by medical history, physical examination, x-ray, CT, MRI, EMG/NCV) had pain from facet joint(s) in 24%, combined lumbar nerve root and facet disease in 24%, combined facet(s) and sacroiliac joint(s) in 4%, lumbar nerve root irritation in 20%, internal disc disorder in 7%, sacroiliac joint in 6%, and sympathetic dystrophy in 2%. No cause was identified in 13% of patients. In another similar study, 40% of the patients were shown to have facet joint pain, 26% discogenic pain, 2% sacroiliac joint pain, 13% segmental dural/ nerve root pain and no cause was identified in 19% of the patients (12). Thus diagnostic IPM procedures like diagnostic facet joint block, provocative discography, epidurogram, selective nerve root block, SI joint block etc. can unmask diagnosis in most situations. Similarly therapeutic IPM procedures which include facet joint interventions encompassing intra-articular injections, medial branch blocks, and medial branch neurotomy; sacroiliac joint interventions, including sacroiliac joint blocks, and radiofrequency neurotomy; epidural injections including caudal epidural injections, interlaminar epidural injections, and transforaminal epidural injections; epidural adhesiolysis including percutaneous adhesiolysis, and spinal endoscopic adhesiolysis; intradiscal therapies including percutaneous micro-discectomy/ disc decompression, nucleolysis and implantable therapies, which include spinal cord stimulation and intrathecal drug administration systems give permanent/long-term relief. Many of these procedures are done in Kolkata; are discussed briefly below.

Trigger point injection Trigger point injection with local anaesthetic, depo-steroid, ozone gas, or even dry needling gives pain relief in Myofascial Pain Syndrome and Fibromyalgia. These are very simple procedures, repeated in a course of 3-7 injections and gives permanent/ long-term relief in properly selected cases. (13-14)

Epidural steroid injection It reduces inflammation, blocks transmission of nociceptive C-fibre input and prevents ectopic discharge from axon & dorsal root ganglion. Immediate relief is more than 85% but long-term relief is nearly 50%. Earlier it is done long-term relief is more. It may be done through Lumber or Caudal approach, later being slightly more effective. (15-19) Most of the studies showed positive results for short-term and long-term pain relief. Best results are obtained in disc herniation with poor outcome in non-specific neck/back pain.

Selective nerve root/ Transforaminal epidural block Transforaminal epidural injection (modern nomenclature) or a selective nerve root block (old nomenclature) consists of injection of contrast, local anesthetic, or other substances around spinal nerves under fluoroscopy (20-21). These are used for diagnostic as well as therapeutic purpose. The reported sensitivity of a diagnostic selective nerve root block ranges from 45% to 100% (22-23). Therapeutically it is more effective than simple Lumber or Caudal epidural steroid injection as we are installing the drug more anteriorly right at the target. Drug dose is also much less. (10-20mg vs. 40-80 mg in lumber/caudal epidural.) (24-26) If there is epidural scar like in failed back surgery syndrome it is the only root to inject epidural steroids.

Epidurogram Here non-ionic water-soluble radio-opaque dye is injected in the epidural space under fluoroscopy and distribution of dye is noted. Normal Epidurogram looks like an inverted Christmas tree where dye enters into the dural extension of each nerve root. In cases of nerve root oedema/inflammation or epidural fibrosis the dye does not enter into the root / filling defect in epidural spread of dye. Epidural fibrosis is better diagnosed with Epidurogram than CT/MRI. Epidural fibrosis may account for as much as 20% to 36% of all cases of failed back surgery syndrome (FBSS) (27-29).

Epidurolysis Epidurolysis/ epidural adhesiolysis/ neuroplasty is done in epidural fibrosis with normal saline/hypertonic saline with/without hyaluronidase. It may be done with Racz catheter after performing an Epidurogram. Epidural fibrosis is seen in failed back surgery syndrome or in post-inflammatory adhesion following extrusion/ sequestration of nucleus pulposus. (30-32)

Provocative discography Discography literally means the opacification of the nucleus pulposus of an intervertebral disc to render it visible under radiographs (33). The commonly practiced technical and evaluative components of discography include: sterile needle placement into the center of the IVD (nucleus pulposus), radio-opaque contrast instillation to provoke pain, radiological assessment of disc morphology, and clinical assessment of the intensity and concordancy of evoked pain in relation to baseline pain. Discogenic pain may contribute up to 26% of spinal pain. (12)

Percutaneous Disc Decompression/Discectomy It is done for contained disc prolapse & discogenic pain. (34-35) Here a 17G needle introduced into the diseased disc under C-arm guidance. Then a special motorized probe is introduced through this needle & then operated. It breaks the nucleus pulposus into fine particles and sucks it out. Success rate is nearly 80%. The advantages are: No cut, scar, epidural fibrosis & instability of normal anatomical structure. Hospital stay is less and less costly.

Ozone Nucleolysis It is done for both contained & non-contained disc prolapse & discogenic pain. (36-38) Here also a needle introduced into the diseased disc & ozone gas (2-10ml.) is injected. It causes some chemical changes so that the nucleus pulposus is dehydrated & it shrinks in size. Extruded & sequestrated disc also absorbs ozone and have the fate. Ozone has powerful anti-inflammatory action & thus nerve roots are not only mechanically decompressed, the chemical irritations are also taken care. It is also less costly and needs minimal hospital stay. Success rate is more than 80%.

Facet joint block/ radiofrequency (RF) neurotomy of medial branch Based on controlled diagnostic blocks of facet joints, in accordance with the criteria established by the International Association for the Study of Pain (IASP) (39), facet joints have been implicated as responsible for spinal pain in 15% to 45% of patients with low back pain 54% to 67% of patients with neck pain, and 42% to 48% of patients with thoracic pain (40-44) pain and mostly remains undiagnosed even with CT/MRI. Diagnostic block is the procedure that confirms it. Therapeutic facet joint injection with steroid/ RF ablation of medial branch of dorsal rami gives long-term relief. Open, controlled and uncontrolled clinical studies that evaluated the long term relief of back and leg pain from intra-articular facet joint injections are abundant (45-47).

Sacro-iliac (SI) joint steroid injection/RF neurotomy SI joint may be the source of low back pain in about 15 % cases. Utilizing single diagnostic blocks, the prevalence of sacroiliac pain would appear to be at least 13% and perhaps as high as 30% in the United States (48). Percutaneous radiofrequency neurotomy of sacroiliac joints or steroid injection into SI joint has been reported to provide long-term relief (49-50).

Percutaneous Vertebroplasty It is done for vertebral compression fracture (osteoporosis, cancer with metastasis, haemangioma of vertebral body etc.) with severe pain. (51-56) Here, an 11G needle is introduced through pedicle under C-arm guidance. Then low viscosity bone cement is introduced into the fractured bone. Caution should be taken so that bone cement does not come in contact with nerves in the epidural space/foramen. It stabilizes the spine and gives immediate pain relief.

Lumber sympathetic block Sympathetic dystrophy may be the cause of pain in a significant number of cases. (11,57) Neurolysis of Lumber sympathetic chain using alcohol/ phenol or RF ablation gives relief in Complex Regional Pain Syndrome/ causalgia/ Sympathetic dystrophy etc. (57-58) Similarly Neurolysis/ RF ablation of ganglion Impar and superior hypogastric plexus gives pain relief in low back, buttock and perineal area due malignancy of pelvic organs or in non-cancer chronic pain. (59-61) There are different choices of IPM procedures for similar type of problem. Before choosing a particular procedure, diagnostic intervention is advisable to assess the outcome of therapeutic procedure. In short IPM procedures have revolutionized the management of spinal pain.

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