Professional Documents
Culture Documents
1. History
2. Physical examination
3. Imaging
4. Blood tests
5. Nerve conduction studies
Slide from Dr J Richardson
ALL, disc,
vertebra
PLL, dura,
disc, vertebra
ST
ST
svn
svn
direct
branches
r. comm.
Laclaire et al Study
Sir,
In the above letter to the editor, Roger Chou implies that the results could be biased and concludes that, I quote,
It is difficult to see how the Nath et al trial could be taken as reliable evidence that radiofrequency denervation is
effective.
The reason for this, as quoted in the letter was
because the sham control group (which had higher baseline scores) had greater potential to experience
improvement from baseline (There is a mistake here as it was the active treatment group that had higher
baseline scores of pain, Not the sham group as stated)
Generalised Pain
Schwarzer. Spine 1995, Maigne. Spine 1996, Dreyfuss. Spine 1996, Slipman. Arch Phys
Med Rehabil 2000;81:334-338
SIJ Interventions
Vanelderen et al, in their review graded therapeutic intraarticular injections with corticosteroids and LA as 1 B+
Pascal Vanelderen, et al. Pain Practice, Volume 10, Issue 5, 2010 470478
RADICULAR PAIN
Presentation can
alter if treated
lancinating, shooting, or
electric pain; traveling
down the limb in a
narrow band.
Mechanism INFLAMMATION
RADICULAR PAIN
metalloproteinases
INFLAMMATION
Ig M, Ig G
NO
PLA2
PLE2
TNF
dorsal root
interleukins 8, 12
ganglion
leukotriene B4
thrombaxane
spinal nerve
macrophages
lymphocytes
fibroblasts
interferon
RADICULAR PAIN
metalloproteinases
INFLAMMATION
Ig M, Ig G
NO
PLA2
TNF
dorsal root
ganglion
PLE2
STEROIDS
interleukins 8, 12
leukotriene B4
thrombaxane
spinal nerve
macrophages
lymphocytes
fibroblasts
interferon
Radicular Pain
Epidurals Caudal, Interlaminar,
Transforamenal
Catheter Neuroplasty
Spinal endoscopy
Spinal cord stimulator
Transforaminal Epidural
For extrusions
Steroid seemed to increase the op. rate and was more
expensive
Bupavacaine only
Total Patients
28
27
Patients not
having surgery
20 (71%)
9 (33%)
P < 0.0004
Normally all would have been treated operatively
Treatment algorithm now includes 3 to 4 TFESI before considering surgery
Our Response
Careful patient selection, fluoroscopy and contrast
injection are needed for effective spinal injections.
Mon, 2011-09-26 11:59
http://www.bmj.com/content/343/bmj.d5278?tab=responses
Neuromodulation
NICE Technology appraisal guidance 159
Recommended for chronic pain of neuropathic
origin
Failed Back Surgery Syndrome
Complex Regional Pain Syndrome
Facet Joints
Intervertebral Discs
Ligaments
Dura mater
Nerve Root, DRG
Bone
Discs:
Infection, Trauma, Tumour
Muscles
C2-3
C3-4
C4-5
C5-6
C6-7
of referral maps
C2
C2
C3
C4
ap
C4
C5
C5
C6
Fluoroscopic Anatomy
Centroid of the articular pillar
Cervicogenic Headache
Third Occipital Nerve (TON)
B
longitudinal bisector
TON Evidence
Govind J, Bogduk N, et al. Radiofrequency neurotomy for the
treatment of third occipital headache. J Neurol Neurosurg Psychiat
2003; 74: 88-93
C2-3
C4-5
C6-7
C3-4
C5-6
Result
Yes
No
from CFJ
>90% Pain
Diagnosis
No
Yes
C5 Uncommon
C4, C8 rear
Might a differential
Imaging MRI
Disc herniation or Spondylosis
diagnosis apply?
Left C7 T.F.E.
AP view of an angiogram
obtained after injection
of contrast medium
Conventional fluoroscopic
exposure
Cervical TFESI
3 Prospective Study
1 RCT
Summary
Most patients with LBP, neck pain and upper and lower
limb radicular pain will recover with conservative
management
Precision diagnostic techniques allows us to identify the
source of persistent pain & guides further management
Obtaining a diagnosis stops further futile investigations
and prevent surgery