RT Book, Section
A1 Pino, Carlos A.
A1 Rathmell, James P.
A2 Longnecker, David E.
A2 Mackey, Sean C.
A2 Newman, Mark F.
A2 Sandberg, Warren S.
A2 Zapol, Warren M.
SR Print(0)
ID 1144137900
T1 Interventional Management of Chronic Pain
T2 Anesthesiology, 3e
YR 2017
FD 2017
PB McGraw-Hill Education
PP New York, NY
SN 9780071848817
LK accessanesthesiology.mhmedical.com/content.aspx?aid=1144137900
RD 2024/04/19
AB KEY  POINTSThe  best  pain  medicine  allows  practitioners  to  strike  a  reasonable  balance  between  interventional  and  noninterventional  management.  This  practice  pattern  is  sustainable,  and  those  adopting  a  balanced  style  of  practice  will  be  able  to  adapt  to  evolving  scientific  evidence  that  appears  to  support  pain  treatment,  regardless  of  the  type  of  treatment.Although  the  evidence  supporting  the  need  for  routine  radiographic  guidance  is  still  evolving,  the  intuitive  appeal  of  this  more  precise  approach  has  evolved  to  the  point  where  most  practitioners  now  perform  at  least  a  portion  of  their  injections  using  fluoroscopic  guidance.  The  use  of  ultrasound  to  guide  accurate  needle  placement  has  extended  from  the  realm  of  regional  anesthesia  to  the  pain  clinic,  and  has  proved  useful  for  performing  a  number  of  injections  used  to  treat  persistent  pain,  including  stellate  ganglion  block.The  key  to  safety  and  success  of  any  interventional  pain  technique  is  a  clear  understanding  of  normal  anatomy.  The  procedures  described  in  this  chapter  require  an  understanding  of  the  normal  anatomy  of  the  spine,  including  the  epidural  and  subarachnoid  spaces,  zygapophyseal  joints,  intervertebral  disks,  and,  most  importantly,  the  spinal  cord  with  its  somatic  and  sympathetic  components.Epidural  steroid  injections  are  efficacious  in  the  treatment  of  acute  lumbosacral  radicular  pain  and  radiculopathies  secondary  to  herniated  intervertebral  disks.  Epidural  steroid  injections  also  have  been  used  to  treat  back  pain  secondary  to  degenerative  disk  disease,  spinal  stenosis,  trauma,  spondylolysis  or  spondylolisthesis,  and  in  pain  following  laminectomy.  The  epidural  space  can  be  approached  through  the  interlaminar  space  (median  or  paramedian),  intervertebral  foramen  (transforaminal),  or  sacral  hiatus  (caudal).  The  approach  selected  depends  on  patient  selection,  indication  for  injection,  the  practitioner’s  experience,  and  availability  of  imaging.  We  are  still  lacking  large-scale  studies  comparing  clinical  outcomes  with  the  transforaminal  versus  the  interlaminar  approach.Many  practitioners  continue  to  use  sympathetic  blockade  as  part  of  a  multidisciplinary  approach  to  treating  complex  regional  pain  syndrome.  Sympathetic  blocks  provide  one  tool  that  can  reduce  pain  and  facilitate  functional  recovery.Intraarticular  facet  injection  has  been  largely  supplanted  by  radiofrequency  treatment  techniques  for  facet-related  pain.  Clinical  experience  and  a  limited  number  of  published  observational  studies  suggest  that  intraarticular  injection  of  local  anesthetic  and  steroid  leads  to  relief  of  facet-related  pain  that  is  of  limited  duration.  In  contrast,  radiofrequency  treatment  is  safe  and  effective  in  producing  longer-term  pain  relief  in  the  same  group  of  patients.Diskography  is  a  diagnostic  test  in  which  radiographic  contrast  is  injected  into  the  nucleus  pulposus  of  the  intervertebral  disk.  Although  originally  developed  for  the  study  of  disk  herniation,  diskography  now  is  used  most  commonly  to  identify  symptomatic  disk  degeneration.  The  usefulness  of  this  diagnostic  test  remains  controversial  and  has  dramatically  declined  in  recent  years  because  of  fears  that  the  test  itself  may  accelerate  disk  degeneration.Intrathecal  morphine  and  other  opioids  are  now  widely  used  as  adjuncts  in  the  treatment  of  acute  and  chronic  pain,  and  a  number  of  agents  show  promise  as  analgesic  agents  with  spinal  selectivity.  Patient  selection  for  intraspinal  pain  therapy  is  empiric  and  remains  the  subject  of  debate.  In  general,  intrathecal  drug  delivery  is  reserved  for  patients  with  severe  pain  that  does  not  ...