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Part 1 book “Atlas of pain medicine procedures” has contents: Fluoroscopy in interventional pain medicine, computed tomography guidance in pain managemen, ultrasound guidance for interventional pain management, radiation safety, equipment used in pain management, botulinum toxins,… and other contents.
Copyright © 2015 by McGraw-Hill Education All rights reserved Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher ISBN: 978-0-07-174637-3 MHID: 0-07-174637-4 The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-173876-7, MHID: 0-07-173876-2 eBook conversion by codeMantra Version 1.0 All trademarks are trademarks of their respective owners Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark Where such designations appear in this book, they have been printed with initial caps McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promotions, 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for any damages resulting therefrom McGraw-Hill Education has no responsibility for the content of any information accessed through the work Under no circumstances shall McGraw-Hill Education and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise This atlas is dedicated to: My mother Late Raniba Diwan for teaching me the meaning of life My family Indira, Sneh, Kaushal, and Shira for their love and unconditional support My grandchildren Jonathon and Belen for bringing joy to our lives My friends and my mentors who supported me and guided me to the path of knowledge My co-editor Peter Staats for his unwavering friendship and being a trusted counselor And, Department of Anesthesiology and Pain Medicine Weill Cornell Medical College and New York Presbyterian Hospital of Cornell University For being an integral part of my personal and professional success Sudhir Diwan To Mom and Dad You taught me how to change the world to make it a better place, one patient at a time, and more globally through theory and research To my children, Alyssa, Dylan and Rachel I am so proud of all three of you and the paths that you are forging I am confident that each of you will make the world a better place in your own way Most of all, to my wife Nancy, Thank you for your understanding and compassion Your unwavering support has made this book possible You make me, and everyone who knows you, a better person Peter S Staats Contents Section Editors Contributors Preface Introduction SECTION I: Basic Applications Mark J Lema Fluoroscopy in Interventional Pain Medicine David M Schultz Computed Tomography Guidance in Pain Management Ronil V Chandra, Thabele-Leslie Mazwi, Daniel Oh, Albert J Yoo, and Joshua A Hirsch Ultrasound Guidance for Interventional Pain Management Hariharan Shankar and Kanishka Rajput Radiation Safety Vikram B Patel Equipment Used in Pain Management Vikram B Patel Corticosteroids: Indications, Pharmacology, and Risks in Interventional Pain Management Carolyn Kim and Christopher Gharibo Local Anesthetics Christopher Voscopoulos and Mark J Lema Botulinum Toxins Charles E Argoff and Howard Smith Infection: Prevention, Diagnosis, and Management Dawood Sayed and Sudhir Diwan 10 Anticoagulation Guidelines Nirmala R Abraham, Cathy D Trame, and Sudhir Diwan 11 Sedation for Interventional Pain Procedures Nancy Staats 12 EMG and Nerve Conduction Studies Bridget T Carey 13 Documentation, Billing, and Coding Laxmaiah Manchikanti SECTION II: Head and Neck Injections Sudhir Diwan 14 Atlanto-Occipital Joint Injections Andrea Trescot 15 Atlanto-Axial Joint Injections Andrea Trescot 16 Cervical Nerve Root Blocks Stanley Golovac 17 Trigeminal Ganglion and Nerve Block Miles Day and Kenneth D Candido 18 Sphenopalatine Ganglion Block Samer Narouze 19 Occipital Nerve Blocks Andrea Trescot and Lawrence Kamhi 20 Periorbital Nerve Blocks (Supraorbital, Supratrochlear, and Infraorbital Nerves) Sanford Silverman SECTION III: Spinal Interventions Vikram B Patel 21 Interlaminar Epidural Steroid Injections: Cervical, Thoracic, Lumbar, and Caudal Raj Doshi, Vikram B Patel, and Salahadin Abdi 22 Transforaminal Epidural Steroid Injection Vikram B Patel 23 Facet Joint Interventions: Intra-Articular Injections, Medial Branch Blocks, and Radiofrequency Ablations Vikram B Patel and Sukdeb Datta 24 Lumbar Facet Joint Cyst Drainage and Injection Gerard P Varlotta, Christopher Gharibo, and Z.T Traeger 25 Dorsal Root Ganglion Blocks and Radiofrequency Procedures Seth A Waldman and Vladimir Kramskiy 26 Sacroiliac Joint Injections Sheetal Kerkar Patil, Honorio T Benzon, and Sudhir Diwan 27 Sacroiliac Joint Denervation Using Synergy System Leonardo Kapural and Amanda Toye 28 Sacroiliac Joint Denervation by Using Simplicity III Sudhir Diwan and Nimish Davé 29 Percutaneous Sacroplasty Harold Cordner and Michael E Frey 30 Percutaneous Facet Fusion Rinoo V Shah 31 Provocative Discogram Vikram B Patel and Sudhir Diwan 32 Percutaneous Disc Decompressions Sanjay Bakshi and Gerard W Abrahamsen 33 Hydrosurgery of Disc Didier Demesmin and Sagar Parikh 34 Percutaneous Radiofrequency Discectomy With Disk IT Samyadev Datta and Vikram B Patel 35 Intradiscal Electrothermal Therapy Jason E Pope and Nagy Mekhail 36 Intradiscal Biacuplasty Mark Yelle and Leonardo Kapural 37 Endoscopic Discectomy Sudhir Diwan, Kiran Patel, Kenneth Chapman, and Vikram B Patel 38 Minimally Invasive Lumbar Decompression (MILD procedure) Lora L Brown 39 Vertebral Augmentation Ramsin Benyamin, Ricardo Vallejo, Atiq Rehman, and Allen Burton 40 Epidural Lysis of Adhesions Rinoo V Shah 41 Vascular Complications of Spinal Interventions Scott E Glaser, Rinoo V Shah, and Peter S Staats SECTION IV: Sympathetic Blocks Andrea Trescot 42 Stellate Ganglion Block Richard S Epter 43 Thoracic (T2-3) Ganglion Block Michael Stanton-Hicks 44 Splanchnic Nerve Blocks Andrea Trescot 45 Celiac Plexus Block Using CT Guidance Kenneth D Candido and Nebojsa N Knezevic 46 Celiac Plexus Block Using Fluoroscopic Guidance Kenneth D Candido, Peter S Staats, Corey W Hunter, and Sudhir Diwan 47 Lumbar Sympathetic Block Joshua P Prager 48 Superior and Inferior Hypogastric Plexus Blocks Agnes Stogicza 49 Ganglion Impar Block Corey W Hunter and Sudhir Diwan damage and may lead to needle breakage (Figure 49-6) Figure 49-6 Illustration of the various configurations to a 22-gauge spinal needle for the alternative techniques described In an attempt to correct these predicaments, a curved needle technique6 was described which avoided some of the aforementioned problems but resulted in difficulty when attempting to pass through a calcified anococcygeal ligament; however, the overall flaws of the procedure were still the same In the subtransverse process approach, a curved needle is advanced just caudal to the transverse process of the coccyx.7 This results in less discomfort to the patient and allows the operator the choice of positioning the patient either prone or lateral There is, however, still an increased risk of contact to the rectum as the curve could potentially pass too far anterior A paramedian approach was described by McAllister et al8 where the operator uses a lateral approach using a double-bent needle to allow for better approximation to the ganglion Impar This is difficult for patients with rectal pain as it also requires a finger to be placed in the rectum TRANSSACROCCYGEAL APPROACH We advocate the most direct approach to the ganglion Impar The transsacroccygeal approach was first described by Wemm and Saberski (Figure 49-1).9 This technique minimizes the potential risk of rectal perforation as advancing the needle is precisely controlled and monitored in the lateral view of fluoroscopy It also circumvents the problems with altering the needle’s shape, while avoiding needle passage through the skin in close proximity to the patient’s pain complaints Our Preferred Technique The patient is placed in a prone position with a pillow under the abdomen to reduce the lumbar lordotic curvature (Figure 49-7) Figure 49-7 Patient positioned in the prone position with pillow under the abdomen The skin overlying the SCJ is identified with an AP fluoroscopic image, marked and prepared in a typical sterile fashion (Figures 49-4 and 49-8) Figure 49-8 Image on the left shows the skin marked for injection Image on the right demonstrates a representation of the underlying bony anatomy 1% lidocaine is then used to infiltrate the skin overlying the SCJ using the 25-gauge 1.5-in needle to provide adequate skin analgesia Contrast is drawn up into the 5-cc syringe with the connector tubing attached and primed Injectate is drawn up in the 10-cc syringe which consists of 40-mg of either triamcinolone or methylprednisolone and 4-cc of 0.25% bupivacaine Total 5-cc volume of injectate is recommended to cover the area of the elongated ganglion Impar The 22-gauge 3.5-in spinal needle is then advanced anteriorly through sacrococcygeal joint under fluoroscopic guidance into the most midline aspect Once the needle is suspected to have contacted the SCJ, the fluoroscopic view changed to lateral (Figure 49-5) to monitor the depth of the needle tip into the SCJ (Figure 49-9a) Figure 49-9 (A) Image on the left is a lateral fluoroscopic view of the needle with the tip lying in the SCJ (B) Image on the right is a lateral fluoroscopic image of the needle as the tip has passed just anterior to the SCJ and now lying in the retroperitoneal space The needle is then carefully advanced 1 millimeter at a time until the tip passes just anterior to the disc of the SCJ—this can be felt as a “loss of resistance” if the local anesthetic syringe is kept on the needle (Figure 499b) Once the needle is suspected to be just anterior to the SCJ, the syringe containing contrast is attached to the spinal needle via the connector 10 The needle is then aspirated to ensure that the needle is not intravascular 11 Contrast is injected under live-fluoroscopy into the retroperitoneal space and the spread of the dye should give a “reverse comma” appearance when seen on the lateral view (Figure 49-10) Figure 49-10 Lateral fluoroscopic image (left) with the needle tip just anterior to the SCJ in the retrorectal space (between the sacrum and the rectum) and contrast spread in the “reverse coma” appearance The image on the right is an illustration of the fluoroscopic image 12 Careful examination should be made to ensure there is no unintended contrast spread—within the SCJ itself, intravascular, or outside the space containing the ganglion Impar 13 Once proper placement has been ensured, the 5-cc syringe is removed and 10-cc syringe containing the injectate is attached to the tubing 14 The injectate is then injected slowly 15 The needle is then flushed and withdrawn 16 Sterile dressing is applied If additional control is desired, as well as extra assurance to avoid needle fracture, one can use a “needle-inside-needle” approach The technique described by Munir et al12 utilizes a 22-gauge 1.5-in needle inserted over the sacrococcygeal disc at the superior aspect of the intergluteal crease, just below the sacral hiatus The needle is then advanced under lateral fluoroscopic imaging until the tip is through the disc Then a 25-gauge 2-in spinal needle is introduced through the 22-guage introducer—the remaining steps are the same as those described above If the patient receives excellent but only temporary relief, the same procedure can be repeated using 1% lidocaine followed by 6% phenol in glycerin for neurolysis NEEDLE-IN-NEEDLE TECHNIQUE FOR RF This technique is used for radiofrequency neurolysis of the ganglion Impar The Teflon coating of an RF cannula can be damaged while advancing through the often calcified sacrococcygeal joint The tougher, larger 22-gauge needle is introduced first, and then RF cannula is passed through the first needle to place it anterior to the SCJ (Figure 49-11) Figure 49-11 Needle-in-needle technique A sturdy larger needle is used to enter the sacrococcygeal joint to minimize the damage to Teflon coating of the radiofrequency cannula Post-Procedure Follow-Up The patient should be followed up by telephone the next day for the potential complications and queried regarding immediate pain relief secondary to the local anesthetic effect The anti-inflammatory effect of the steroid will not be apparent for several days The patient should be advised to call the pain service for any procedure-related complications and/or any unexpected neurological deficit Patient should be monitored closely for following: Weakness Urinary or bowel incontinence Fever Bleeding Rectal bleeding Numbness Exacerbation of symptoms Potential Complications and Pitfalls While the transsacroccygeal offers the operator a more straightforward approach and considerably limits the potential complications compared to a lateral approach with angled or curved needle, there are still obstacles that could be encountered This approach can be challenging in those patients with a history of coccygectomy, arthritis of SCJ, or calcification of the tissue between the sacrum and coccyx.4 This can be of particular concern in the elderly and those exposed to radiation treatment to the area Other potential complications are: Infection (Figure 49-12) Figure 49-12 Magnetic Resonance Image (MRI) of a patient with coccygeal osteomyelitis Bleeding Rectal perforation Neurolytic injection into nerve roots or rectal cavity Cauda Equina Syndrome Nerve root injection (Neuritis) Intravascular injection Osteitis or periostitis Sacrococcygeal discitis 10 Hematoma 11 Inadvertent spread may potentially lead to motor, sexual, or bowel/bladder dysfunction Clinical Pearls These injections can be diagnostic as well as therapeutic The patients with positive diagnostic injections are generally candidates for radiofrequency (RF) ablation, cryoneurolysis, or neurolysis by phenol or alcohol The success of this procedure is most dependent on the exact location of the ganglion Impar relative to the SCJ As mentioned above, there is anatomical variability of the location of the ganglion, which can create variable results Patients can expect anywhere from 50% to 100% pain relief.1,10,11 Suggested Reading De Andres J, Chaves S Coccygodynia: a proposal for an algorithm for treatment J Pain 2003;4:257-266 Trescot AM Chapter 26: Interventions in managing female pelvic pain In: Manchikanti L, Singh V, eds Interventional Techniques in Chronic NonSpinal Pain American Society of Interventional Pain Physicians Publishing, Paducah, KY 2009 Antalok SJ Chapter 32: Interventions in managing male pelvic pain In: Manchikanti L, Singh V, eds Interventional Techniques in Chronic NonSpinal Pain American Society of Interventional Pain Physicians Publishing, Paducah, KY 2009 References Plancarte R, Amescua C, Patt R, et al Presacral neurectomy of the ganglion impar (Ganglion of Walther) Anesthesiology 1990;73:A751 Datir A, Connell D.: CT-guided injection for ganglion impar blockade: a radiological approach to the management of coccydynia Clinical Radiology 2010;65:21-25 Waldman SD: Altas of Interventional Pain Management, 2nd ed Philadelphia, PA: WB Saunders; 2004 McAllister RK, Carpentier BW, Malkuch G Sacral postherpetic neuralgia and successful treatment using a paramedical approach to the ganglion impar Anesthesiology, 2004; 101: 1471-1474 Chang-seok Oh et al Clinical implications of topographic anatomy on ganglion impar Anesthesiology 2004;101: 249-250 Nebab EG, Florence IM An alternative needle geometry for interruption of the ganglion impar Anesthesiology, 1997;86:1213-1214 Huang J Another modified approach to the ganglion of Walther block (ganglion of impar) Journal of Clinical Anesthesiology 2003;15:282-283 McAllister RK, Carpetier MD, Malkuch, G Sacral postherpetic neuralgia and successful treatment using a paramedical approach to the ganglion impar Anesthesiology 2004;101:1472-1474 Wemm K, Saberski L Modified approach to the ganglion impar (Ganglion of Walther) Regional Anesthesiology, 1995;20:544 10 Toshniwal GR, Dureja GP, Prahanth SM Trans-sacrococcygeal approach to ganglion impar block for management of chronic perineal pain: A prospective observational study Pain Physician 2007;10: 661-666 11 Swafford JB, Ratzman DM A trans-articular approach to blockade of the ganglion impar (ganglion of Walther) Regional Anesthesiology and Pain Medicine 1998;23:103 12 Munir MA, Zhang J, Ahmad M A modified needle-inside-needle technique for the ganglion impar block Canadian Journal of Anesthesiology 2004;51:915-917 ... Clinical Professor of Anesthesiology Director, Chronic Pain LSU Health Science Center Shreveport, Louisiana Contributors Salahadin Abdi, MD, PhD (Chapter 21) Professor and Chair Department of Pain Medicine Unit 409... Wayne State University School of Medicine Detroit, Michigan Z.T Traeger, DO (Chapter 24) Department of Rehabilitation Medicine NYU School of Medicine Rusk Institute of Rehabilitation Medicine New York, New York... Varlotta, DO, FACSM (Chapters 24 and 61) Associate Professor, Departments of Orthopaedic Surgery & Rehabilitation Medicine NYU School of Medicine, Rusk Institute of Rehabilitation Medicine New York, New York