Spinal Injections and A Rational Approach to Treating Low ...
[Pages:24]CCSU Sports Medicine Symposium - Tuesday March 3, 2020
Spinal Injections and A Rational Approach to Treating
Low Back Pain
Pietro A. Memmo, MD Interventional Physiatrist Orthopedic Associates of
Hartford
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Conflicts of Interest
Dr. Memmo does not have any financial or non-financial conflicts of interest or relationships to disclose, and I will not be discussing products in my presentation.
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Dr. Memmo's CV
Philosophy (St. Charles Seminary) Pre-Med (Columbia University) Medical School (Albert Einstein College) Internship/Medicine (Columbia
Presbyterian Medical Center) Physical Medicine (UMDMJ/Kessler) Fellowship: Spine/Pain (Beth Israel)
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CCSU Sports Medicine Symposium - Tuesday March 3, 2020
Our Goal
- "Diagnosis" - "Prognosis" - "Treatment Plan"
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Physiatrist Philosophy
Getting Patients Functional and Back to Work or Sporting Activity.....
...Safely ....Reasonably ....Incrementally
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Two Categories of Spine Pain
Mechanical Pain Neuropathic Pain
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CCSU Sports Medicine Symposium - Tuesday March 3, 2020
Mechanical Low Back Pain
Discogenic
? DDD ? Annular Tear
Facet Mediated SIJ 7
Neuropathic Pain
Radiculopathy: Radiating arm or leg pain
? Disc Herniation ? Spinal Stenosis
What can present like a Radiculopathy
? Sacroiliac Joint ? Annular Tear
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Anatomy
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CCSU Sports Medicine Symposium - Tuesday March 3, 2020
Anatomy
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Anatomy
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Anatomy-Disc Herniation
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CCSU Sports Medicine Symposium - Tuesday March 3, 2020
The Jelly Donut
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So how do you decide on source of the pain?
Physical exam
? Inspection- Atrophy/ Scoliosis ? Lumbar spine ROM/pain ? Palpation ? Sensory exam ? Motor exam ? Reflexes ? Provocative maneuvers
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So how do you decide on source of the pain?
Radiologic studies
? X-ray- good for arthritis and bony lesions (if evidence of instability, check flex/ext)
? CT scan- good for bony lesions/ not so good for soft tissue
? MRI- good for soft tissue ? Bone scan- good to determine if fractures are
acute as well as bony lesions
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CCSU Sports Medicine Symposium - Tuesday March 3, 2020
Pain Treatments
Do Nothing Physical Therapy Medications Injections Surgery
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Pain Treatments
Physical Therapy
? Goals include:
Lumbar stabilization Lower extremity stretching & strengthening Pain relief / modalities Assistive devices
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Pain Treatments
Medications
? NSAID's ? Muscle Relaxers ? Pure Pain Medicines ? Oral Steroids ? Anti-epileptics / Anti-depressants
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CCSU Sports Medicine Symposium - Tuesday March 3, 2020
Injections ? Epidural Steroids
Benefits of epidural steroids
? Due to presence of arachnoid villi in epidural space => steroids directly bathe the nerve roots
? May block "C-fiber" conduction
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Injections ? Epidural Steroids
Benefits of epidural steroids
? Studies have shown that radicular pain may be caused by inflammatory mediators (not just mechanical compression)
? Steroids inhibit the synthesis/ release of proinflammatory cascade and therefore decrease inflammation
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Saal, Spine 1990/ Odonnel, Spine 1988/ Takahashi, Spine, 1996
Injections ? Epidural Steroids
Controversy
? No evidence to support that steroids alter the rate of disc regression.
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CCSU Sports Medicine Symposium - Tuesday March 3, 2020
Injections ? Epidural Steroids
Small but not significant difference in favor of Discectomy versus Conservative care (Jama 2006)
No statistical difference between surgery and non-operative treatment of disc herniation (Clin Orthop Relat Res, 2015)
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Injections ? Epidural Steroids
Decreasing patient's pain Allows body to heal Allows patient to do physical therapy better
=> helps prevent recurrences Maximum of 3 epidural injections in a 12
month period of time.
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Fluoroscopy
Fluoroscope vs. no fluoroscope - Blind interlaminar injections are in the wrong place 13-30% of the time without fluoroscopy and contrast (Andrade, ISIS newsletter,1993, Mehta, Anesthesia 1985). - Transforaminal injections not possible without fluoroscopy.
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