Advanced concepts in interventional spine care

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					11. Stiles EG. Osteopathic manipulation in a hos-
pital environment. J Am Osteopath Assoc.

12. Wallace E, McPartland JM, Jones JM III, Kuchera
WA, Buser BR. In: Ward RC, ed. Foundations for                                                  Advanced concepts in
Osteopathic Medicine. Philadelphia, Pa: Williams &
Wilkins; 1997; pp 945, 947.
                                                                                                interventional spine care
13. Borsook D, ed. The Massachusetts General Hos-
pital Handbook of Pain Management. Boston,                                                      GERALD E. DWORKIN, DO
Mass: Little Brown; 1996.

14. Raj PP. Practical Management of Pain. St Louis,
Mo: Mosby; 2000.

15. Guyton AC, Hall JE. Textbook of Medical Phys-
iology. 10th ed. Philadelphia, Pa: WB Saunders Co;
2000; pp 274-277.

16. West JB. Best and Taylor’s Physiologic Basis of    This review of interventional treatment of the spine emphasizes the need for
Medical Practice. 11th ed. Baltimore, Md: Williams     aggressive pain control as a means of preventing persistent pain. The use and
& Wilkins; 1985; pp 322, 323.
                                                       application of lumbar epidural injections, facet blocks/denervation, lysis of
17. Kuchera ML, Kuchera WA. Osteopathic Con-           epidural adhesions, thermal annuloplasty, radiofrequency neurotomy, and
siderations in Systemic Dysfunction. Columbus,         nucleoplasty are the treatment options described. These descriptions are not
Ohio: Greyden Press; 1994.
                                                       all-inclusive of advanced treatment options for patients with spine pain.
18. Herman EP. Postoperative adynamic ileus: its             (Key words: disk disruption, disk herniation, facet syndrome, failed
prevention and treatment by osteopathic manip-         back surgery syndrome, leg pain, lysis of adhesions, nonsteroidal anti-inflam-
ulation. The DO. October 1965;(6):163-164.
                                                       matory drugs [NSAIDs], nucleoplasty coablation, radiofrequency neurotomy,
19. Millard FP. Applied Anatomy of the Lymphatics.     spine pain, thermal annuloplasty)
Kirksville, Mo: The Journal Printing Co; 1922.

20. Steele KM. Treatment of the acutely ill hospi-
talized patient. In: Ward RC, ed. Foundations for
Osteopathic Medicine. Philadelphia, Pa: Williams &
Wilkins; 1997; p 1045.

21. Radjieski JM. Effect of osteopathic manipula-
                                                       C    are of the individual with painful
                                                            spine conditions has evolved over
                                                       many years. The founder, Andrew
                                                                                                        any given time. Although it is true that
                                                                                                        60% to 90% of that number have self-
                                                                                                        limiting or short-term pain, 1-year follow-
tive treatment on length of stay for pancreatitis: a
randomized pilot study. J Am Osteopath Assoc.          Taylor Still, MD, DO, and the early prac-        up will show that up to 50% will report
1998;98:264-272.                                       titioners of osteopathic medicine real-          recurrence. A recent study showed that
22. Tong D, Frances C. Postoperative pain control      ized that the spine represented an inter-        13% to 50% will have moderate to severe
in ambulatory surgery. Surg Clin North Am.             woven structure with a dynamic                   chronic pain and, importantly, 31% of
1999;79:401-430.                                       relationship between spinal compo-               patients with chronic back pain have had
23. Goldstein FJ, Jeck S, Nicholas A, Berman MA,       nents. They understood how abnormal              spine surgery.1 The long-term functional
Lerario M. Effect of pre-operative morphine and        preexisting structural conditions can be         sequela of persistent spinal pain is related
postop osteopathic manipulative treatment [OMT]        exacerbated by injury, leading to fur-           to the cumulative effects of mechanical
upon postop pain after total abdominal hysterec-
tomy [abstract]. J Am Osteopath Assoc.                 ther structural dysfunction. As osteo-           dysfunction, chronic inflammatory medi-
2001;101:471.                                          pathic physicians and diagnosticians,            ators, and central pain mechanisms.2
                                                       our skill lies in identifying the primary             The lumbar spine undergoes uni-
24. Andersson GB. A comparison of osteopathic
spinal manipulation with standard care for patients    spine diagnosis as well as secondary             versal degenerative changes.3 This degen-
with low back pain. N Engl J Med. 1999;341:1426-       diagnoses that may be caused by the              eration occurs over time, even without
1431.                                                  primary process. Tertiary diagnostic cat-        obvious insult or injury. Etiologic factors
                                                       egories will present themselves as a             are complex but interrelated. The spine
                                                       result of chronicity of primary and sec-         segment that is composed of a three-joint
                                                       ondary processes. Overall, our goal is           complex, including the two facet joints
                                                       to limit pain and promote functional             and the intervertebral disk, is prone to
                                                       restoration.                                     interrelated degenerative changes. These
                                                            Low back pain remains one of the            changes occur regardless of which region
                                                       most common ailments, responsible for            suffers initially. For example, synovial
                                                       more than 5 million sufferers of pain at         injury in the facet joint can lead to facet
                                                                                                        capsular laxity and instability that causes
                                                                                                        additional stress on the intervertebral
                                                       Correspondence to Gerald E. Dworkin, DO, Well-
                                                       ness Center—2nd Floor, 1503 Lansdowne Ave,       disk. This stress results in radial annular
                                                       Darby, PA 19023.                                 tears and internal disk disruption (IDD).

S8 • JAOA • Supplement 3 • Vol 102 • No 9 • September 2002                                        Dworkin • Advanced concepts in interventional spine care
This cascading process generally results                                                             Lumbar stenosis
in bony enlargement of the articular pro-                                                            The second radicular syndrome involves
cesses and osteophytes at the vertebral                    Checklist                                 lumbar canal stenosis and often affects
bodies (ie, spinal stenosis). This process                                                           elderly individuals. It is characterized by
is greatly accelerated in the face of spinal                                                         pain during walking with relief during
pain syndromes with their resultant per-                      Radicular syndromes                    rest, and it must be distinguished from
sistent inflammatory mediators.4 Fur-                         Disk herniation                        vascular claudication.
                                                              Lumbar stenosis
ther, chronic spinal inflammatory con-                        Failed back surgery syndrome                 The pathophysiology of spinal
ditions following disk herniation, spine                                                             stenosis is best understood in terms of
surgery, or trauma can lead to epidural                       Nonradicular syndromes                 the degenerative cascade. Chronic stress
fibrosis, adhesions, and scar formation.5                     Facet syndrome                         and injury to the facet joints and inter-
                                                              Internal disk disruption
The resultant irritability of the nerve root                                                         vertebral disk lead to combined lesions
contributes to persistent pain states.                                                               that produce simultaneous central and
      It is useful to characterize back pain         Figure. Conditions included in radicular syn-   lateral spinal stenosis. There is often loss
into either radicular (nerve irritation) syn-        dromes and in nonradicular syndromes.           of disk height. The superior facet of the
dromes (Figure), accounting for 5% to                                                                lower vertebrae moves upward and for-
15% of cases of spinal pain, or nonradic-                                                            ward on the inferior facet of the upper
ular (without nerve compression) syn-                widely used. Medications, however, are          vertebrae, thereby narrowing the inter-
dromes (Figure), accounting for the                  preferentially distributed in the dorsal        vertebral foramen and causing radicular
remaining 85% to 95% of such patients.               aspect of the spinal canal away from            symptoms.3
Specific spinal conditions may fit into              inflammatory reactions occurring in ven-              Physical therapy is used to main-
this classification, and their respective            tral aspects of the canal. In addition,         tain flexibility; assistive devices are used
interventional treatment protocols serve             much of the medication will flow cra-           for safe ambulation. Response to ESIs,
to illustrate use of advanced treatment              niad and may miss the primary site of           especially via the caudal approach, may
techniques.                                          inflammation.8                                  be good, particularly early in the clinical
                                                           Many pain practitioners believe that      course. Surgical treatment is by decom-
Disk herniation                                      the caudal technique is the initial epidural    pressive laminectomy.
The pathophysiology of leg pain after                injection of choice. It remains quite safe
disk herniation involves large amounts of            and preferentially affects the epidural         Failed back surgery syndrome
inflammatory mediators that are released             space around L5-S1, but may also allow          Failed back surgery syndrome typically
on disruption of the disk. These inflam-             anti-inflammatory effect as high up as          involves radicular symptoms that are
matory mediators increase the sensitivity            L3-4. If an initial caudal epidural or          observed after failed back surgery;
and firing of the dorsal root ganglion.6             translaminar epidural method is not suc-        epidural adhesions are present. Even
In addition, the inflamed nerve root is              cessful after one or two injections, a trans-   after successful back surgery, several
painful when pressed or stretched.                   foraminal epidural injection should be          related effects to the surgery itself occur,
                                                     strongly considered.8 This approach             including perineural fibrosis, some
Illustrative case study                              requires image guidance using fluo-             degree of persistent chemical irritation,
A 35-year-old man, after lifting, has pain pri-      roscopy with improved target specificity        and often venous congestion with
marily into his legs, associated with numb-          over other ESIs. It will also provide diag-     reduced nutrient delivery to neural struc-
ness, tingling, and worsening with bending           nostic information because of its selec-        tures.5,11 These side effects, often related
and lifting. Physical examination revealed           tivity.9 In addition to image guidance,         to the appearance of scars and adhesions,
positive straight leg raising with restricted        contrast is mandatory to verify that the        may be of low clinical importance or may
flexion of the lumbar spine, decreased sensa-        epidural injection spreads ventrally and        cause severe radicular pain. In the event
tion in the S1 distribution. The magnetic res-       ensure that the injection is not intravas-      of significant radicular pain after spine
onance imaging (MRI) study confirmed disk            cular.                                          surgery, an interventional treatment may
herniation at L5-S1.                                       Using a combination of exercise sta-      include lysis of adhesions procedures.
      Conservative treatment includes                bilization program and ESIs, Saal et al10             There are several treatment tech-
short-term bed rest (ie, less than 2 to 3            had 45 of 52 patients responding with           niques described in the literature.5,8,11
days), along with nonsteroidal anti-                 good to excellent outcomes. Further,            One common method includes intro-
inflammatory drugs (NSAIDs) and pain                 serial MRIs demonstrated significant res-       duction of a flexible catheter through a
medicine as needed. Physical therapy                 olution of the disk herniation at 1 year.       caudal approach via an introducer
can be initiated to restore range of                       Adverse effects of ESIs can include       needle.11 This procedure is done under
motion, reduce muscle spasm, and main-               headache (especially if there is dural          image guidance, allowing the flexible
tain mobility and muscle strength.                   damage), as well as infection, bleeding, a      catheter to be directed toward regions
      If epidural steroid injections (ESIs)          7- to 10-day increase in blood sugar (from      of clinical relevance and scar formation.
are to be considered, there are three major          use of cortisone), hypertension, pedal          Contrast may be used to see regions
routes.7 The translaminar approach is                edema, and congestive heart failure.            where scar tissue appears. These regions,

Dworkin • Advanced concepts in interventional spine care                                   JAOA • Supplement 3 • Vol 102 • No 9 • September 2002 • S9
when approached with the catheter, can             ture of a degenerative disk and often a high-   pathologic process clearly established by
be infiltrated by relatively large volumes         intensity zone, which correlates with annular   diskography and who have had a failed
of fluid, including saline solution, corti-        rupture and disk degeneration. Often, how-      response to at least 6 months of conser-
sone, and anesthetic agents.                       ever, MRI is nondiagnostic with minimal         vative therapy and are facing surgery as
     Hyaluronidase, an enzyme useful               findings.                                       the sole therapeutic option. Additional
in reducing adhesiveness of scar tissue,                 This patient has IDD, which is dif-       criteria include largely preserved disk
may be added before instillation of fluid.         ferentiated from disk herniation by the         height, back pain greater than leg pain,
Overall, the process seems to reduce               lack of findings on MRI. Intolerance to sit-    intolerance of sitting, good tolerance of
fibrosis and inflammation and increase             ting and lack of significant findings on        standing, posterior annular deficit, high
neural mobility. This process is enhanced          MRI (other than loss of height) make one        motivation with no significant psychi-
by the use of specific stretching exercises        suspect IDD. A definitive diagnosis, how-       atric history, and no demonstrable facet
given to patients after the procedure.             ever, requires diskography.12                   disease.20
     Two types of nonradicular (or axial)                The pathophysiology of painful IDD             Proposed mechanisms for thermal
back pain include facet syndrome (15% of           involves innervation of the outer               annuloplasty include thermal modifica-
those presenting with axial spine pain),           annulus16; this region is densely inner-        tion of collagen, thermocoagulation of
and IDD (accounting for 39% of cases).12           vated, and disrupted portions of the disk       annular nociceptors, and volume con-
                                                   become infiltrated with neurovascular           traction of the disk itself. Postprocedure
Facet syndrome                                     bundles. Inflammatory mediators                 care includes 6 weeks with no signifi-
The facet syndrome is associated with              heighten nociception and sensitize the          cant bending, twisting, or lifting; wearing
posttraumatic facet synovitis. Physical            nerve endings. Pressurizing the disk, vis-      a corset for the first 2 weeks; and aggres-
findings include back pain, worsened               à-vis sitting or lifting, will provoke pain.    sive stabilization exercises beginning
with extension. Pain radiates locally, gen-              The use of diskography can be quite       week 3 or 4.
erally across the back and often into the          helpful in diagnosing IDD.17 Indications             For patients whose leg pain is
proximal aspect of the thigh, groin, and           include equivocal disk disease on MRI           greater than that of the back but who
upper lumbar region. This important                or computed tomography (CT) scans,              have minimal disk herniation on MRI
cause for axial spine pain is difficult to         multiple-level disk disease, postsurgical       and who have had a failed response to 6
determine radiologically. Often, diag-             spine with pain, and painful disk in con-       months of conservative treatment, an
nostic medial branch or facet joint blocks         junction with posterior fusion. Diskog-         additional percutaneous mode of therapy
can be done under image guidance.13                raphy is also used as a preliminary test for    is available. Nucleoplasty coablation uses
Resolution of symptoms after introduc-             spinal fusion to evaluate disks above and       radiofrequency technology to ablate and
tion of a local anesthetic such as bupiva-         below the contemplated fusion region.18         coagulate soft tissue within the nucleus
caine hydrochloride to the facet joint or                During diskography, needles are           of the involved disk. This procedure acts
its nerve is diagnostic. This pain can             placed under image guidance into each           to decompress contained herniated disk
resolve, albeit temporarily, after medial          disk under study and then pressurized           material percutaneously. Postprocedure
branch blocks or injections into the facet         to provoke pain. Familiar or concordant         therapy is similar to that for thermal
joints.14 A more definitive treatment              pain is highly correlated with a signifi-       annuloplasty.
modality includes radiofrequency neu-              cant pain-generating disk. Postdiskog-
rotomy of the nerve to the facet joint.15 An       raphy CT scans, as well as plain film x-ray     Comment
electrode is placed along the medial               studies, will demonstrate annular tears         Preventing the disabling sequelae of per-
branch nerve under fluoroscopic guid-              within the disk.18 Recording disk pres-         sistent low back pain is of great impor-
ance. Radiofrequency current is then               sure during the test can be helpful in clas-    tance. An organized approach is helpful,
applied to the distal tip of the probe,            sifying IDD. Medical histories of IDD have      particularly when many therapeutic
causing an increase in temperature that            been evaluated in several studies. In one       options are included. This article by no
denervates the nerve for up to 6 months.           such investigation, after 1-year follow-up,     means accounts for all advanced treat-
     Internal disk disruption accounts for         14 of 17 patients with IDD had worsened         ment options but may serve as a resource
a large percentage of individuals with             pain if no interventions were offered.12        for both patient and practitioner.
nonradicular pain syndromes, ie, pain                    If individuals have undergone con-
without nerve compression.                         servative treatment for several months          References
                                                   and have failed to improve, other options       1. Manchikanti L, Pampati V, Fellows B, Beyer CD,
Illustrative case study                            must be considered. Minimally invasive          Damron KS, Barnhill RC, et al. Characteristics of
                                                                                                   chronic low back pain in patients in an interven-
A 42-year-old male attorney with a history of      procedures include thermal annuloplasty         tional pain management setting: A prospective
low back pain off and on for 5 years has a         utilizing radiofrequency. Other thermal         evaluation. Pain Physician. 2001;4(2):131-142.
severe episode of pain 1 week before the office    annuloplasty techniques include resis-          2. Weinstein J. Recent advances in the neurophys-
visit. He presents with minimal leg pain,          tive heating such as intradiskal electro-       iology of pain. Physical Medicine and Rehabilitation:
localized back pain, and significant intolerance   thermography.19                                 State of the Art Reviews. 1990;4(2):201-220.
to sitting more than 15 minutes. Lying down              Candidates for thermal annuloplasty       3. Kirkald-Willis WH, Bernard T Jr. Pathology and
lessens his pain. The MRI study shows a pic-       include patients who have a diskogenic          pathogenis of the low back pain. In: Managing

S10 • JAOA • Supplement 3 • Vol 102 • No 9 • September 2002                                  Dworkin • Advanced concepts in interventional spine care
Low Back Pain. 4th ed. Philadelphia,Pa: Churchill Liv-
ingstone; 1999; pp 65-95.
4. Saal J. The role of inflammation in lumbar pain.
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5. Manchikanti L, Pampati V, Fellows B, Rivera J,
Beyer CD, Damron KS. Role of one day epidural                                                            analgesics—current clinical and
adhesiolysis in management of chronic low back
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                                                                                                         regulatory perspectives
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6. Olmarker K, Rydebik B. Pathophysiology of sci-                                                        WILLIAM VILENSKY, DO, RPH
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7. Woodward J, Herring S, Windsor R, Dreyer S,
Lester J, Lagattula F. Epidural procedures in spine
pain management. In: Lennard T, ed. Physiatric
Procedures and Clinical Practice. Philadelphia, Pa:
Hanley & Belfus, Inc; 1995; pp 260-291.
8. Manchikanti L, Singh V, Kloth D, Slipman CW,
Jasper JF, Trescot AM, et al. Interventional tech-        Barriers to appropriate prescribing of opioids include the deficit in educating
niques in the management of chronic pain: Part 2.0.       medical students in core curricula. Other barriers include physicians’ lack of
Pain Physician. 2001;4(1):24-96.
                                                          knowledge of pain management, failure to educate their patients or include
9. Slipman CW, Zacharia I. The role of diagnostic         them in treatment options, and failure to take adequate medical histories and
selective nerve root blocks in the management of
spinal pain. Pain Physician. 2001;4(3):214-226.           obtain records of their patients’ previous treatment. In addition, physicians often
10. Saal JA. Intervertebral disc herniation: Advances
                                                          lack the ability to distinguish the patient who is suffering pain from the addict.
in nonoperative treatment. Physical Medicine and          Patients, too, may fear that opioid therapy may cause addiction. This article pro-
Rehabilitation: State of the Art Reviews.                 vides an overview of guidelines and federal regulations for prescribing opioids,
                                                          along with some caveats, in the hope that physicians and patients alike will
11. Racz G, et al. Lysis of Adhesions in the Epidural     appreciate that pain management is an integral part of treatment. And, that treat-
Space: Techniques of Neurolysis. Boston, Mass:
Kluwer Academic; 1989; pp 57-72.                          ment is aimed at decreasing or eradicating pain and maintaining patients’
12. Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine
                                                          function to the greatest possible degree while monitoring and treating side
G, Bogduk N. The prevalence and clinical features         effects.
of internal disc disruption in patients with chronic            (Key words: addiction myths, analgesics, federal regulations, morphine,
low back pain. Spine. 1995;20:1878-1883.                  opioids, pain management, prescription guidelines)
13. Dreyfuss P, Lagattuta F, Kaplansky B, Heller B.
Zygapophyseal joint injection techniques in the
spinal axis. In: Lennard T, ed. Physiatric Procedures
                                                                                                                  Old concepts
and Clinical Practice. Philadelphia, Pa: Hanley &
Belfus, Inc; 1995.
14. Manchikanti L, Pampati V, Bakhit CE, Rivera JJ,
                                                          P    ain management in the United
                                                               States has labored under “myths”
                                                          regarding use of morphine, a natural
                                                                                                                  Myths have made their way into medical
                                                                                                                  practice, causing both physicians and
Beyer CD, Damron KS, et al. Effectiveness of lumbar       alkaloid of the opium plant, and syn-                   patients to become wary and weary of
facet joint nerve blocks in chronic low back pain:
A randomized clinical trial. Pain Physician.              thetic analgesics (opioids) that have sim-              using opioids for pain management. The
2001;4(1):101-117.                                        ilar characteristics. During the past 15                term pain management should now be
15. Windsor R, Dreyer S. Facet joint nerve abla-          years, physicians in both pain and                      used instead of pain treatment. Treatment
tion. In: Lennard T, ed. Physiatric Procedures and        addiction medicine have recognized                      implies that the pain exists and the physi-
Clinical Practice. Philadelphia, Pa: Hanley & Belfus,     and heralded the need for change in                     cian has to fight the battle to quell the
Inc; 1995.
                                                          attitudes in treating patients in pain as               pain; management refers to addressing
16. Nachemson AL. Causes and cure of low back
pain and sciatica, April, 1991: The lumbar spine: an      well as those who suffer from the neu-                  the pathologic process causing the pain
orthopedic challenge. Spine. 1976;1:59-61.                robiologic disease of addiction. Those                  and preventing its appearance.
17. Bogduk N, Aprilo C, Darby R. Discography. In:         myths have raised the prescribing                            In a 1954 JAMA report, Rayport1
White AH, Schofferman JA, eds. Spine Care. St             stakes that in the past escalated physi-                stated that 27% of patients who were
Louis, Mo: Mosby-Year Book; 1995; pp 219-239.             cians’ fears and governmental restrictive               given morphine for pain had become
18. Fortin J. Lumbar and thoracic discography with        regulations.                                            addicted. In 1980, changes in attitude
CT and MRI correlations. In: Lennard T, ed. Physi-                                                                were seen in a study by Porter and Jeck2
atric Procedures and Clinical Practice. Philadelphia,
Pa: Hanley & Belfus, Inc; 1995.                                                                                   that concluded that only 4 of 11,882
19. Saal JA, Saal JS. Intradiscal electrothermal treat-   Dr Vilensky is a clinical associate professor of psy-   patients given opioids in the hospital had
ment for chronic discogenic low back pain. Spine.         chiatry at the University of Medicine and Den-          difficulty in discontinuing such use. In
2000;25:2622-2627.                                        tistry of New Jersey–New Jersey Medical School, in
                                                          Newark, NJ.                                             1982, Perry and Heidrich3 found that
20. Saal JA, Saal JS. Intradiscal electrothermal treat-        Correspondence to William Vilensky, DO, RPh,       none of approximately 10,000 burn
ment for chronic discogenic low back pain with            Executive Medical Director, Forensic & Educational
two year follow-up. Proceedings of the North
                                                                                                                  patients became addicted to opioids used
                                                          Consultants, 110 S Nassau Ave, Margate, NJ 08402-
American Spine Society. 15th Annual Meeting,              2520.                                                   in their management of pain. In lecturing
New Orleans, La, September 5-7, 2000; pp 5-7.                  E-mail:                      and questioning physicians and nurses

Vilensky • Opioid analgesics—current clinical and regulatory perspectives                            JAOA • Supplement 3 • Vol 102 • No 9 • September 2002 • S11

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