The RF current heats the tissue, and the tissue in careful elevation and monitoring of the tissue temperature to turn heats the RF electrode tip. Temperature is the basic lesioning parameter, and Figure The measurement of electrode tip temperature size. It is desirable to hold the proper tip temperature ties, however, the above rules for homogeneous tissue and for 30—60 seconds to achieve the equilibrium lesion size.
The proper electrode size and tip temperature decades, as attested by a mass of successful clinical data using should be selected for a given target site to achieve a consist- the RF heating method. Among these It is important to have a sense of the size of the lesion that factors are the inhomogeneities in the tissue medium itself. An extensive discussion of this issue is given ity of the electrode to CSF bodies such as the ventricles can in papers by Cosman et al.
An example of this situation is RF stereotactic neurosurgeons using conventional electrodes of lesioning in the trigeminal ganglion.
The proximity of large straight, cylindrical tip geometry. These data for the most blood vessels also has an inhomogeneous cooling effect on part were accumulated in postmortem studies at varying the tissue near them. The placement of the RF electrode near times after the lesion was made, and some variation in the a bony structure may have the opposite effect, since a bony lesion size might be expected as a function of time.
As an mass is an insulator with lower blood circulation. Examples example from Table Lesions for cylindrical a b electrode tip shapes are typically prolate ellipsoids of revolu- tion. It is also seen that larger lesions can be made in the brain with larger electrode tips and higher temperatures. For Large Brain Gray example, lesions made in the cingulum with electrodes vessel having 1. Electrodes of greater diameter and length for equivalently high temperatures are accordingly larger.
CSF White Table This Low resistance Non-uniform impedances, suggests that some variation in lesion size has been used shunting of RF large blood vessels successfully in RF thalamotomies, but also that there is a current namely CSF reasonable norm for acceptable lesion parameters. The dimensions of the heat lesion and the electrode tip bottom. The length region; of the lesion can be assumed to be approximately 1—3 mm 2. A brief description is in a given situation. Targets in the spinal cord are discrete and critical. Associated Information on lesion size for very small RF electrodes, RF electrodes must be appropriately small, with temperature such as those used in the spinal cord, is rare but does exist.
The electrode can penetrate the In addition to the choice of the proper RF electrode size and pia and make very precise and discrete lesions in the spi- tip temperature, safe and effective lesion making is depend- nothalamic tract for the treatment of intractable pain. The ent on the following conditions: Sacral Ventral fibers spinocerebellar tract Lateral pyramidal tract Dorsal spinocerebellar tract Figure The KCTE tip includes a straight tip and an angled tip b to enable adjustment of the tip position in the spinal cord variations.
The diagram c illustrates the approach to the lateral spinothalamic tract under CT control. The set has four insulated cannulas with a removable readings, which are essential in such tight geometries. The cannulas have exposed tip lengths of Figure In practice, a cannula, with a stylet in Kanpolat CT Radionics electrodes, which have both straight place, is inserted into the trigeminal ganglion; the stylet can and bent-tip geometry.
Pain-Relieving Procedures - The Illustrated Guide (Hardcover)
These electrodes are used for percu- be removed, and a thermocouple TC temperature elec- taneous cordotomy and spinal tractotomies and embody trode can be inserted. The TC electrode is connected to the the important innovation of being computed tomography RF generator, and physiologic testing is done using the stim- CT -compatible. In this way, Sweet and other clinicians have reported excel- RF electrodes for lesioning in the trigeminal lent results for the relief of trigeminal pain since the early ganglion s. In the s, W. Tew and Eric Figure The Tew Kit includes an insulated cannula procedure: The curved tip can straight and curved Tew electrodes are also shown in Fig.
Both electrodes have TC temperature sensors built into their tip ends. The curved spring electrode is inserted, for making off-axis tip extensions. Cosman Sr and B. It had a set of by sensory stimulation. A gauge RF electrode, insulated except for an and back pain exposed 7 mm distal tip, could then be passed through the In the early s, C.
This electrode was designed to produce day version of this electrode system is the CSK Kit Cosman a heat lesion with temperature control near the medial Medical , shown in Fig. There were encouraging successes in the early days The CSK Kit Cosman Spinal Kit contains, in one of its of the technique, but the results were not always consistent. Cosman and lengths of 2, 4, 5, and 10 mm tip exposures. Other versions produced by Radionics in association with C. Because of the CSK Kit are offered with , , or gauge can- this electrode had a tissue-penetrating tip, an insulated shaft, nulas, with shaft lengths of 5, 10, 15, or 20 cm, and with a and integrated temperature sensor, it eliminated the need variety of tip lengths to accommodate different target sites for the spinal needles.
The RRE electrode is still offered by and patient sizes. The its especially rigid shaft. A modern- are two modes of RF output that are commonly used for a b c d Figure Axes are not to scale. As the temperature sensing TC probe inserted in it. The output waveforms for these two modes therm boundary, which tends to have an ellipsoidal shape are shown schematically in Fig.
Within this lesion volume, conventional, thermal or heat RF mode, which has been all cell structures are macroscopically destroyed by heat. It uses a continuous sinu- The action of pulsed RF on neural tissue is different from soidal RF waveform output, commonly referred to as con- continuous RF. Cosman, and coworkers in periods, the average temperature of the tissue near the elec- , uses a series of pulsed bursts of RF signal, referred to trode is not raised continuously or as high as for continuous as pulsed RF, or PRF.
Because the PRF voltage to treat peripheral nerves and the dorsal root ganglions is typically regulated to keep the average tip temperature in DRGs , and most commonly it has been applied to treat a nondestructive range, other mechanisms must produce the back and neck pain and neuropathies. The results have clinically observed pain-relieving effects. This is in contrast to some CRF applications in which connected to the output voltage V RF from an RF genera- there is considerable pain and discomfort to the patient tor.
Pain-Relieving Procedures: The Illustrated Guide
This is illustrated in Fig. To date, there for a pointed electrode that is commonly used for percutane- have been limited attempts to use PRF in the central ous pain procedures. Evidence for such destruction produce on charged structures and ions in the tissue.
The has been observed in vitro Cahana et al. However, it is unlikely zations, membrane voltages, and structure-modifying forces. All of these effects can play to an axon or dorsal root ganglion DRG. Calculations predict that after 60 seconds as long-term depression.
Multidisciplinary information is required if you intend to practice pain management at a high level of effectiveness. This includes anatomy and physiology, pain syndromes, diagnosis and management, and the correct use of interventional techniques. The Illustrated Guide provides you with a step-by-step guide to interventional techniques underpinned by a solid multidisciplinary knowledge base.
The text is enhanced by the wide use of illustrations, including amazing color 3D-CT images that enable you to easily visualize anatomy. The first part of the book gives the fundamentals you need for modern pain practice. The second part describes all commonly used procedures, using a head-to-toe organization. A special chapter covers more advanced techniques such as continuous analgesia, spinal cord and sacral stimulation, vertebroplasty and kyphoplasty. Then a motor stimulation test is conducted at 2 Hz.
The moving the C-arm in a cephalocaudal direction Fig. Then rotate the C-arm in an oblique fashion toward the muscles. At this point, an aspiration test is done. If blood is aspi- 3. If pulsed RF is to be performed, do this at 45 V for two rated, reposition the needle and aspirate again. In the case cycles of seconds. Block and RF lesioning of the median branch of L5 Step 8.
At this point, after careful negative aspiration, the local by the superior articular process of the sacrum and the ala anesthetic is injected. This should be repeated at each level of this bone. It then gives the medial and intermediate corresponding to the medial branch innervating the facet branches. There is no pedicle at this level. Advance the needle or the electrode in a tunneled vision which it came. Thus, the L4—L5 zygapophyseal joint is inner- fashion toward the junction. Move the C-arm to the lateral position. In the lateral 2. The rest of the procedure is the same as described above able for emergencies and are helpful to the patient and their Fig.
This complication may occur especially after RF lesioning. However, there are centers that place the electrode accu- Injecting deposteroid solution after lesioning is recommended. It has been speculated that when placed in Neuritis may develop after RF lesioning. If the needle or electrode is placed toward the neural foramen, segmental spinal injury and numbness in the Step 9. Postprocedural care related dermatome may develop. Monitoring of vital signs is man- view as well as by sensorial and motor stimulation tests.
After a satisfactory observation, the patient The incidence of infection is the same as with the other should be discharged with appropriate and adequate instruc- procedures. The upper lumbar facets are more oriented in the sagittal plane, and by the L5—S1 level they have rotated to a more oblique angle. The facet joints are oriented lateral to the sagittal plane from the midline pos- teriorly as follows: Because of the curvature of the upper lumbar facet joints, the posterior opening is usually more in the sagittal plan than the overall angle of the joint. The medial branch approach is preferred to the lumbar block and surgical resection of the lumbar sympathetic facet joint block.
One should not insist on entering the joint, nerves about this time. Others associated with expansion of because the volume of the joint is very small and it may be the technique are von Gaza; Mandl and Lawen in Germany; destroyed. Two techniques are described in this chapter: Anatomy Location of the lumbar sympathetic ganglion Figure The sympathetic ganglia of the lumbar sympathetic chain are variable in both number and position. In most cases, only four are found. There tends to be fusion of the three sacral nerves, where they pass on to their respective L1 and L2 ganglia in most patients, and ganglia are aggre- destinations in the lumbosacral plexus.
Considerable variability Each lumbar sympathetic chain enters the retroperitoneal is noted in the size of the ganglia, some being fusiform and space under the right and left crura, continuing inferiorly in as long as 10—15 mm, others being round and approximately the interval between the anterolateral aspect of the vertebral 5 mm long. They also tend to pass The sympathetic nervous system consists of preganglionic alongside the middle of the vertebral body. If RF is desired: The procedure of lumbar sympathetic block is commonly done in either prone or lateral positions.
The blind technique Step 4. Visualization is not recommended. Iden- tify the midpoint of the intervertebral space at the target Step 1. Prepare the patient before the procedure level, at any chosen level from L3 to L4. Adjust the lower Ascertain the type of analgesia or sedation before perform- endplate of the target vertebral body to be aligned by moving ing the invasive procedure.
It is important to start an intra- the C-arm in a cephalocaudal direction Fig. Next, rotate the C-arm obliquely to the ipsilateral side occur with this procedure. If a local anesthetic is considered until the tip of the transverse process almost disappears or neurolytic block is planned, mild sedation is all that is behind the lateral side of the vertebral body.
If pulsed RF is planned, the patient needs to be the C-arm, identify the width of the transverse process. The awake to respond to the stimulation test. Mark the surface landmarks for the needle entry Step 2. Place the patient in a prone position on the table.
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Next, rotate the C-arm laterally. The needle tip should 5. The position of and the lower one-third for the L5 vertebral body Fig. Then rotate the C-arm back to the posteroanterior posi- Step 1 is as described above. Position and monitor the patient Place the patient in the lateral decubitus position on the Step 7. The contrast solution should spread as a straight abdomen and thorax with pillows, so the patient feels line at the anterior border of the vertebral body in the lateral comfortable. Mark the surface landmark for entry point one should administer 5 ml of a combination of 40 mg meth- With the patient in a lateral position, a skin wheal is made ylprednisolone in 0.
Usually, L3 is chosen aiming to have a 3. If a neurolytic block is planned only for cancer patients , spread of a contrast over L2—L4 sympathetic ganglia. The needle is then advanced until it contacts the vertebral body. The dye should spread to form a line conform- ing to the anterolateral margin of the vertebral bodies L2— L4. If the spread of contrast dye is restricted to one ganglion, the procedure is then repeated with the second needle at an a adjacent level, i. Injection of local anesthetic A long-acting agent such as bupivacaine or ropivacaine is advantageous for both therapy and prognosis, because it enables enough time to evaluate the effects of sympatholysis and any effect this might have on the pain.
A concentration of 0. RF lesioning of the lumbar sympathetic chain After the steps are taken to position the patient as described earlier, the RF needle electrode is inserted as described in the prone position with or without cannulae. Stimulation test Stimulation is performed at 50 Hz for sensory and 2 Hz for motor stimulation. There should be an absence of fascicula- tion at the ventral root, dorsal plexus, or genitofemoral Figure The patient three-dimensional CT scan showing the position of the needles in each may feel slight paresthesia at the back during sensory stimu- level, L3, L4, and L5.
Thermocoagulation of the sympathetic ganglia Genitofemoral neuralgia develops especially if the lumbar 1. A lesion sympathetic block is performed at the L4—L5 level. The lesion tofemoral nerve is in close proximity with the lumbar sym- diameter should be approximately 10 mm for L2 and 15 mm pathetic chain along the fascia of the psoas muscle. Owing for L3 and L4. Thus multiple lesioning may be necessary to the effect of the local anesthetic or neurolytic agent, by moving the tip of the electrode.
Before each lesioning minor sensory loss or motor weakness at the quadriceps procedure, a motor and sensory stimulation test should be muscle may develop. Another cause of neuralgia may be repeated. Postprocedure observation Dural puncture particularly may occur if the lumbar sympa- After the procedure is completed, observe the patient for up thetic block is performed by a blind technique. It is almost to 2 hours. Monitoring of vital signs position of the needle by contrast material. Paraplegia may is mandatory. In addition, objectively document pain relief.
This is a very rare complication, which may develop to the Written instructions are preferable for emergencies and are ischemia of the anterior spinal artery. There will be an increase of resistance at the tip of the needle. The incidence of Low back pain or muscle spasm in the area may occur lasting neuritis is higher with alcohol. Alcohol should not be pre- 4—5 days after the procedure.
Pain-relieving procedures : the illustrated guide - sähkökirjat Pain Management - Terkko Navigator
The patient complains of hyper- occur owing to the wide lateral approach. The entry point esthesia in the groin. Normally it lasts 2—6 weeks. While the segmental nerve contin- lytic solution to the genitofemoral nerve. One should avoid ues its path in a caudal, lateral, and anterior direction, the using neurolytic agents in males. The needle tip should stay just at the anterior border communicating rami may even branch off from one seg- of the vertebral body.
The inferior vena cava lies at a distance mental nerve. Therefore, the relationship with the vertebral of 0. In the case of a posi- rami usually runs adjacent to the middle or caudal part of tive aspiration test, one should change the position of the the vertebral body Fig. It is an absolute contraindication to perform lumbar sympathetic block in such patients. Administration of approximately ml of lactate solution before the procedure is recommended. Prepare the patient before the procedure may cause systemic and toxic reactions.
Ascertain the type of analgesia or sedation before perform- ing the invasive procedure. However, one should consider the complications. The advantages of percutaneous RF lumbar sympathec- Ramus communicans tomy are as follows. Percutaneous block and lesioning of the rami communicantes History The history is as described in the section on percutaneous Figure Intravenous fen- If RF is desired: Position and monitor the patient Step 4.
Adjust the lower endplate of the target vertebral body 3. Obtain an intravenous access if drugs need to be to be aligned by moving the C-arm in a cephalocaudal direc- administered. Then turn the C-arm obliquely towards the ipsilateral 5. Locate the anatomical landmarks, the transverse process and the neural foramen, at the tar- Step 3. Drugs and equipment for L2 communicating ramus geted site Fig. Direction of the needle Step 8. Sensory stimulation is made between 0 and 1 V, at 50 Hz.
If pain vertebral body until a bony contact is made. If the needle radiating to the groin occurs at the L2 level, close proximity contacts the segmental nerve, the patient will complain of a to the genitofemoral nerve is indicated and the needle sudden pain; correct the needle position in a more cranial should be repositioned for retesting. During motor stimulation at 2 Hz up to 1 V, no response should be elicited. Position the C-arm laterally; the tip of the needle or elec- Step 9. RF lesioning trode should be in the middle portion of the vertebral body, 1. Inject 1 ml of contrast material.
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Place the C-arm back to the posteroanterior position. Postprocedure observation contrast material should be closely lateral to the vertebral After the procedure is completed, observe the patient for up body just caudal to the transverse process.
In case of hypotension, intravenous electrolyte 3. An aspiration test should be negative. After a satisfactory observation, discharge the patient with appropriate and adequate instructions given to their escort. Written instructions are preferable for emergencies and are helpful to the patient and their family. Complications Segmental nerve injury. Inadvertent puncture of the paravertebral artery. Helpful hints L2 communicating ramus lesion or block may be used in pain of discal origin.
The communicating ramus RF lesioning should be performed after a progrostic block with 0. If the pain disappears, one should continue with RF lesioning. His technique used saline to pressurize the disc and procaine solution to modulate the pain response Structure of the annulus generated. He showed that these patients have abnormal dis- lamella. Discographic patterns on radiographs helping the disc to return to its original arrangement follow- were shown to be abnormal.
They may Dallas Discogram Scale. The cells of the annulus, par- cardinal component of discography. Toward the inner annulus the cells can be more oval. Such features are not seen in cells tear. Bogduk stated that discography is a diagnostic tool of articular cartilage. Blood vessels The third morphologically distinct region is the cartilage present in the longitudinal ligaments adjacent to the disc endplate, a thin horizontal layer, usually less than 1 mm and in young cartilage endplates less than about 12 months thick, of hyaline cartilage.
This interfaces the disc and the old are branches of the spinal artery Figs The healthy adult disc has few if any blood vessels, but it has some nerves, mainly restricted to the outer lamellae, some of which terminate in proprioceptor. Pathway for diffusion of nutrients to disc, barrier between avascular proteoglycan-rich nucleus and vascular spongiosa of vertebra. Ventral rami Sinuvertebral Posterior nerve Lateral rami longitudinal ligament Medial ramus Figure Some of the nerves in discs foramen, when it then divides into a major ascending and also have glial support cells, or Schwann cells, alongside a lesser descending branch.
It has been shown in animal them. In addition, stances cause a chronic chemical sensitization within the the anterior longitudinal ligament receives afferent innerva- disc and cause pain. Nerves and blood vessels are increas- ingly found with degeneration. Cell proliferation occurs, leading to cluster formation, particularly in the nucleus.
Cell death also occurs, with the presence of cells with necrotic and apoptotic appearance. Discs from individuals as young as 2 years of age have some very mild cleft formation and granular changes to the nucleus. With increasing age comes an increased incidence of degenerative changes, including cell death, cell proliferation, mucous degeneration, granular change, and concentric tears.
With age and degeneration, the disc Grade 1. This is described as a grade appear to become more disorganized. In this condition, annular tears have completely Grade 0 is a normal disc, where no contrast material disrupted the disc architecture but do not affect the outer injected in the center of the disc has leaked from the con- contour of the annulus.
The entire annulus is disrupted. The grade 1 tear has leaked There is no leakage of injected dye on discography from the contrast material but only into the inner one-third of the disc, nor bulging or protrusion of the disc. This state of the annulus. There is no compressive effect on the corresponding grade 3 tear has leaked contrast completely through all three nerve root.
Many of these patients with grade 2 IDD com- zones of the annulus. This tear is believed to be painful plain of lower back pain, which may travel into the lower because the outer one-third of the disc has many tiny nerve limb and even past the knee into the lower leg and foot. The grade 4 tear is a more serious Grade 3.
During discography, tear with a concentric annular tear. The grade 5 tear includes contrast material leaks out of the back of the disc into the either a grade 3 or grade 4 radial tear that has completely epidural space. This condition is material from the disc into the epidural space. In some having sciatica as the grade 2 IDD patients.
There are two components to provocation discography. The second is a painless discogram in the adjacent discs. Lumbar discography disc stimulation or provocative discog- 6. Drugs and equipment for discography genic pain is suspected. The type of analgesia or sedation needs to be ascertained before performance of the invasive procedure. Patient response should be tify the midpoint of the intervertebral space at the target monitored and the dosage titrated to establish a level of level. Adjust the lower endplate of the target vertebral body sedation allowing the patient to be conversant and respon- to be aligned by moving the C-arm in a cephalocaudal direc- sive after needle placements.
Because the disc is avascular, tion Fig. Rotate the C-arm in the oblique projection so that the discographers use prophylactic antibiotics. Prophylactic superior articular process is positioned at the junction of the intravenous antibiotics 20 minutes before the procedure are posterior and middle thirds of the cephalad vertebral body recommended. Usual prophylaxis consists of intravenous Fig.
For patients Step 5. Position and monitor the patient symptoms, to prevent the confusion of pain, i.
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Place from the procedure or the pathology Figs Fix the head on the table with a strip of adhesive tape. Insert an intravenous cannula for injecting medication. A 10 cm, 22 gauge spinal needle is advanced in tunneled 4. Provide oxygen by nasal cannula. As a b Figure The C-arm should the C-arm laterally and advance the needle toward the be rotated obliquely in the cephalad direction until the iliac center of the intervertebral disc Fig. The needle tip should be in Note: If the needle tip is cen- tered on the anteroposterior view but posterior on the lateral image, the needle entered the disc too medially.
Injection into the disc can be performed using a pressure- controlled injection discomanometry. This is performed using a specially designed injection device and a pressure monitoring system. The opening pressure of the disc and the pressure at which the concordant pain is elicited can be accurately monitored using this method. After discography, 50— mg of cefazoline is injected in and back pain after lumbar discography. After a satisfactory the disc.
Written instructions are Step 8. Postprocedure care preferable for emergencies and are helpful to the patient and After completing the procedure, observe the patient for at least their family. Complications of discography are shown in Table The patient should be followed up for any evidence of subcutaneous bleed- Complications of discography Table In addition, objectively document the pain relief.