2. What is Pain?

4. Conceptualizing Chronic Pain Tissue Disruption Functional Disruption Environment and Treatment Expression of Pain

5. Where does Interventional Care fit?? Multidisciplinary pain management –Medical/interventional –Rehabilitation –Behavioral medicine/psychological –Surgical Interventional care modalities –Neuropathic (nerve injury) –Spinal

6. Disc Herniation Vertebral discs usually cushion & allow movement When damaged, they may impinge on spinal nerves, causing radiating pain Modic MT. Radiology 2007;245:43-61

7. Epidural Steroid Injection  Best for acute (recent onset) leg or arm pain  Not as effective for long term pain or central pain

8. Spinal (Facet Joint) Arthritis Joints on both sides, at every spinal level from head to sacrum Subject to gravity, time, and trauma Can develop osteoarthritis Also subject to rheumatological diseases (like Rheumatoid Arthritis) Cause axial (central) pain

9. Facet Arthritis Pain Patterns LumbarCervical

10. Pathology of Zygapohyseal (facet) Joints Subchondral hematomaArticular process fracture

11. Radiofrequency Facet Denervation Low risk, outpatient procedure 2 phases –diagnostic block –RF denervation About 75% of persons having ≥ 50% improvement with block get equivalent relief from denervation Effect lasts 12-18 months Best when paired with physical therapy

12. Radiofrequency Facet Denervation for Axial Spinal Pain Cervical Medial Branch Denervation Lumbar Medial Branch Blocks

13. Spinal cord stimulation A consideration for long-term, refractory pain due to –Nerve injury –Failed Back Syndrome –Some types of arterial insufficiency –Complex Regional Pain Syndrome 2 phase procedure –Trial phase –Implantation Preceded by Psychological evaluation

14. Generators ANS Boston Scientific Medtronic

15. Leads ANSBoston Scientific Medtronic

16. Electrodes Lead Implanted Pulse Generator Spinal Cord Stimulator Configuration

17. FBSS & Peripheral Vascular Disease Leg > back pain But, with newer technologies, back pain is better than in past. Lower extremity peripheral vascular disease Fewer amputations Van Buyten J-P. JPSM 2006;31(4S):S25-29 Ubbink DT. JPSM 2006;31(4S):S30-35

18. SCS outcomes in Complex Regional Pain Syndrome Initial benefit Eventual relapse Iraq & Afghanistan war injured vets with CRPSDutch people with CRPS Verdolin MH. Anesth Analg 2007;104:1557–60 Kemler MA. NEJM 2006;354:

19. Syndrome X Less frequent angina Briefer duration of anginal episodes Less nitrate use Sgueglia GA. Heart 2007;93;591-597

20. Low Arterial Flow (Raynaud’s) Sibell DM. Anesthesiology 2005;102(1):225-7. Neuhauser B. American Surgeon 2001. 67(11):1096-7

21. Intrathecal Drug Administration System for Refractory Pain/Adverse Effects Spinal Pump and CatheterSpinal Pump In Situ

22. Chronic pain changes lives. Treatment should, too. Involve Pain Psychology to Assist Adaptation & Coping Develop Rehabilitation Program to Improve Pain and Function Mesh Surgical Care with Amplifying Resources. Use Interventional Treatments with Lasting Effects!

23. To make an appointment with the OHSU Spine Center or with Dr. Sibell: Please Call (503) 418-1988