Advanced Pain Procedures

Alaa Abd-Elsayed, MD, MPH Medical Director, UW Pain Services Medical Director, UW Chronic Pain Management Section Head, Chronic Pain Management Board of Directors, State Medical Board, Wisconsin Asisstant Professor of Anesthesiology UW-Madison USA 2 SCS Gate theory

Wireless technology

6 1. Lay electrodes on skin over targeted vertebrae level. Use Fluoro to confirm.

2. Use pen to skin-mark where the first Marker Band lays on skin This will be the skin-needle entry point. Flexibility in Antenna Placement

8 Indications:

1- CRPS 2- Failed back surgical syndrome Cost effectiveness:

Neurostimulation Outcome Questionnaires were returned by 128 patients. The mean patient age was 46 ± 12.5 years (range 21–71 years) and the mean implant duration was 3.1 ± 2.3 years (range 0.5–8.9 years). The mean per patient total reimbursement of spinal cord stimulation/peripheral stimulation absent pharmacotherapy was $38,187. Patients treated with spinal cord stimulation/peripheral nerve stimulation for pain management achieved reductions in physician office visits, nerve blocks, radiologic imaging, emergency department visits, hospitalizations, and surgical procedures, which translated into a net annual savings of approximately $30,221 and a savings of $93,685 over the 3.1-year implant duration. The large reduction in healthcare utilization following spinal cord stimulation/peripheral nerve stimulation implantation resulted in a net per patient per year cost savings of approximately $17,903.

Mekhail NA, Aeschbach A, Stanton-Hicks M. Cost benefit analysis of neurostimulation for chronic pain. Clin J Pain. 2004 Nov-Dec;20(6):462-8. Transforaminal DRG Stimulator Placement

Transforaminal DRG Entry Approach

13 gauge bent tip Coudé® needle is used to place the stimulator through the Kambin triangle directly to nerve bundle

Similar to placement for a standard DRG nerve block

13 DRG Transforaminal Approach

AP LAT

14

Devices to stimulate the dorsal root ganglion (DRG) became available in the mid-2010s for treating chronic pain, particularly in areas that were hard to treat with traditional spinal cord stimulation, such as the hand, chest, abdomen, foot, knee or groin

(2015), International Neuromodulation Society 12th World Congress Neuromodulation: Medicine Evolving Through Technology June 6–11, 2015 Montreal, Canada. Neuromodulation: Technology at the Neural Interface, 18: e107–e399. Peripheral nerve stimulation If you name it you can stim it • Causes • Trauma • Oral, Facial, and Dental surgery • Infection (i.e., Zoster) • Referred Pain (Cervicogenic Headache, TMJ) • Trigeminal Neuralgias (Classic, Secondary) • Various Chronic Headache conditions (Migraine, Cluster, Trigeminal Autonomic Cephalgia) CranioFacial Device Placements Headache Multiple Devices • Bilateral Supraorbital and Occipital Cranial Pain • Two Incisions Stellate Ganglion Placement Suprascapular Neuralgia Median Neuralgia

Superior Cluneal Nerve Middle Cluneal Neuralgia/SI Infrapatellar Saphenous Neuralgia/Genicular Posterior Tibial Nerve

Intrathecal drug delivery

Indications:

Cancer pain

Non cancer pain

Spasticity FDA approved medications for intrathecal drug delivery

Morphine

Ziconotide

Sacroiliac joint fusion

37 Headache and Atypical Facial Pain: Cranial Nerve Blocks and Radiofrequency Ablation Alaa Abd-Elsayed, MD, MPH Medical Director, UW Pain Services Medical Director, Pain Clinic Assistant Professor of Anesthesiology University of Wisconsin-Madison Objectives:

a) Describe relevant anatomy of cranial nerves, mainly trigeminal nerve b) Mention different approaches, osseous landmarks/ targets for nerve blocks c) Describe common complications of facial nerve blocks d) Briefly describe trigeminal neuralgia epidemiology, presentation, treatment options e) Brief descriptions of other facial pain syndromes Trigeminal nerve Anatomy

History:

Trigeminal neuralgia was first described more than 300 years ago.

Aretaeus of Cappadocia (ancient Greek physician), known for one of the earliest descriptions of migraine and trigeminal neuralgia which he described as spasms and distortions of the countenance took place.

Nicholaus Andre described the term tic douloureux in 1756.

John Fothergill was the first to give a full and accurate description of this condition in a paper titled "On a Painful Affliction of the Face," which he presented in London in 1773.

Osler described trigeminal neuralgia in great and accurate detail in his 1912 book The Principles and Practice of Medicine.

In 1900, Cushing reported a method of total ablation of the gasserian ganglion to treat trigeminal neuralgia. Epidemiology:

In 1968, Penman reported the US prevalence of trigeminal neuralgia (TN) as approximately 107 men and 200 women per 1 million people.

By 1993, Mauskop reported 40,000 patients have this condition at any particular time, with an incidence of 4-5 cases per 100,000.

More recent estimates suggest the prevalence is approximately 1.5 cases per 10,000 population, with an incidence of approximately 15,000 cases per year.

Rushton and Olafson reported that approximately 1% of patients with multiple sclerosis (MS) develop trigeminal neuralgia.

Jensen et al. noted that 2% of patients with trigeminal neuralgia have multiple sclerosis. Patients with both conditions often have bilateral trigeminal neuralgia. No geographic tendency or racial differences have been found for trigeminal neuralgia.

Females are affected up to twice as often as males (range, 3:2 to 2:1).

In 90% of patients, the disease begins after age 40 years, with a typical onset of 60-70 years.

Patients who present with the disease when aged 20-40 years are more likely to suffer from a demyelinating lesion in the pons secondary to multiple sclerosis.

Trigeminal neuralgia was reported in children.

Another risk factor for this syndrome is hypertension. Central Peripheral Components Function Cell bodies connection distribution

Sensory branches of the ophthalmic, maxillary, and Afferent general Gasserian General sensibility Sensory nucleus V mandibular nerves somatic ganglion to skin, mucous membranes of the face and head

Branches to temporalis, masseter, Efferent special Mastication Motor nucleus V Motor nucleus V pterygoids, visceral mylohyoid, tensor tympani, and palati

Sensory endings in Afferent Muscular Mesencephalic Mesencephalic muscles of proprioceptive sensibility nucleus V nucleus V mastication Attacks of trigeminal neuralgia can be triggered by certain actions or movements, such as:

•Talking •Smiling •Chewing •Brushing your teeth •Washing your face •Light touch •Shaving or putting on make-up •Swallowing •kissing •Cool breeze or air conditioning •Head movements •Vibrations, such as walking or a car journey Management

•Pharmacologic therapy •Procedures •Surgery (e.g., microvascular decompression) •Radiation therapy (i.e., gamma knife surgery) Medication management trials should always precede the contemplation of a more invasive approach, as medical therapy alone is adequate treatment for 75% of patients .

Single-drug therapy may provide immediate and satisfying relief.

Carbamazepine is the only FDA approved medication. Over the years, patients may require a second or third drug to control breakthrough episodes and finally may need surgical intervention.

Lamotrigine and baclofen are second-line therapies.

Controlled data for adding a second drug when the first fails exist only for the addition of lamotrigine to carbamazepine.

Gabapentin has demonstrated effectiveness in TN, especially in patients with multiple sclerosis. Procedures:

Trigeminal nerve block

Trigeminal nerve RFA Surgical management:

Gamma knife surgery (GKS), and microvascular decompression (MVD)

Ninety percent of patients are pain-free immediately or soon after any of the operations, but the relief is much more long-lasting with microvascular decompression Techniques for the Trigeminal Nerve Block

Supraorbital and Supratrochlear Nerves Supra-orbital neuralgia is a painful disorder of the supra-orbital nerve, which may be damaged or not functioning properly.

Causes May be caused by an accident (a direct hit to the forehead in the area supplied by this nerve), by infections (inflammation of the frontal sinus) and can be due to unknown causes.

Signs and symptoms The main complaint is usually a unilateral pain in the forehead. The pain is sometimes triggered by touch.

The complaints often resemble those caused by inflammation of the frontal sinus.

Infraorbital Nerve

Mental Nerve

Occipital Nerves The is a , specifically the medial branch of the dorsal primary ramus of cervical spinal nerve 2.

This nerve arises from between the first and second , along with the .

It innervates the skin along the posterior part of the scalp to the vertex. It innervates the scalp at the top of the head, over the and over the parotid glands. While under the , the medial branch of the posterior division of the third cervical nerve gives off a branch called the (also known as the least occipital nerve), which pierces the trapezius and ends in the skin of the lower part of the back of the head.

It lies medial to the greater occipital and communicates with it. Occipital neuralgia is a neurological condition in which the occipital nerves are inflamed or injured.

Occipital neuralgia can be confused with a migraine, or other types of headache, because the symptoms can be similar.

But occipital neuralgia is a distinct disorder that requires an accurate diagnosis to be treated properly. Symptoms of Occipital Neuralgia

Occipital neuralgia can cause very intense pain that feels like a sharp, jabbing, electric shock in the back of the head and neck.

Other symptoms of occipital neuralgia may include: Aching, burning, and throbbing pain that typically starts at the base of the head and radiates to the scalp Pain on one or both sides of the head Pain behind the eye Sensitivity to light Tender scalp Pain when moving the neck Causes of Occipital Neuralgia

Occipital neuralgia is the result of compression or irritation of the occipital nerves due to injury, entrapment of the nerves, or inflammation. Many times, no cause is found.

There are many medical conditions that are associated with occipital neuralgia, including: • Trauma to the back of the head • Neck tension and/or tight neck muscles • Osteoarthritis • Tumors in the neck • Cervical disc disease • Infection • Gout • Diabetes • Blood vessel inflammation

Nerves to the Ear

Sphenopalatine Ganglion The sphenopalatine ganglion (SPG) is a collection of nerve cells that is closely associated with the trigeminal nerve, which is the main nerve involved in headache disorders.

It contains autonomic nerves and sensory nerves. Autonomic nerves are specialized nerves that control organ functions including gut and bladder movements, beating of the heart, sweating, salivation, tearing and other secretions. In the SPG, these autonomic nerves supply the lacrimal glands (which produce tears) and the inner lining of the nose and sinuses (which produce nasal discharge or congestion).

The SPG is located just behind the bony structures of the nose. Role in headache disorders

The SPG has connections to the brainstem (where cluster and migraine attacks may be generated) and to the meninges (coverings of the brain) by the trigeminal nerve.

Inflammation and opening of the blood vessels around the meninges occur, which activate pain receptors that send pain impulses through the trigeminal nerve and eventually to the sensory area of the brain and are perceived as pain.

In migraine and cluster headache, nerves carrying these pain signals pass through the SPG, with some making connections to the autonomic nerves. This explains why in cluster headache, and sometimes in migraine, we see autonomic features including tearing of the eyes and nasal congestion or discharge. We call this the trigeminal autonomic reflex.

Sphenopalatine Ganglion Block Can be done to treat the following conditions:

Trigeminal neuralgia Sphenopalatine neuralgia Migraine headaches Cluster headaches Atypical facial pain Cancer pain of the head and neck Tongue and mouth pain Temporomandibular joint (TMJ) pain2 Paroxysmal hemicrania Block Techniques

Glossopharyngeal Nerve

Radiofrequency ablation Abd-Elsayed A, Nguyen S, Fiala K. Radiofrequency Ablation for Treating Headache. Curr Pain Headache Rep. 2019 Mar 4;23(3):18.

Variable Pre-RFA Post-RFA p value Pain Scores Mean ± SD 5.69 ± 2.86 ± 2.29 < 0.001 2.23 Median 5 2 Percentiles (25-75) 4-8 1-5 Range 0.5-10 0-10 Variable Post-RFA value Percent Improvement 62.6 ± 33.7 (0-100) (range)a Duration Relief, days 182.8 ± 154.5 (0-730) (range)b Hoffman LM, Abd-Elsayed A, Burroughs TJ, Sachdeva H. Treatment of Occipital Neuralgia by Thermal Radiofrequency Ablation. Ochsner J. 2018 Fall;18(3):209-214.

A total of 50 patients were identified; 4 patients were excluded because of insufficient data as a result of loss to follow-up. A significant difference was found between preprocedure and postprocedure patient-reported pain scores (6.7 vs 2.7, respectively; P < 0.001), equating to a mean reduction in pain scores 1-month postprocedure of 4.0 ± 3.3. The mean patient-defined percent pain relief was 76.3% ± 25.0%. The mean patient-reported length of relief was 6.5 ± 5.1 months. Trigeminal neuralgia is characterized by:

1- Paroxysmal pain.

2- Normal sensation on exam.

3- Pain on brushing teeth

4- All of the above. Shingles mostly affects the following branch of trigeminal nerve:

1- V1

2- V2

3- V3

4- All of the above Sphenopalatine ganglion is attached to:

1- V1

2- V2

3- V3

4- Glossopharyngeal nerve References:

Piagkou, M et al. "The pterygopalatine ganglion and its role in various pain syndromes: from anatomy to clinical practice." Pain Pract. 2012;12(5):399-412.

Jenkin,s B et.al. "Neurostimulation for Primary Headache Disorders, Part 1: Pathophysiology and Anatomy, History of Neuromodulation in Headache Treatment, and Review of Peripheral Neuromodulation in Primary Headaches." Headache 2011;51:1254-1266.

Martelletti P et.al."Neuromodulation of chronic headaches: position statement from the European Headache Federation." J Headache Pain 2013;14(1):86.

Khan, S et.al. "Sphenopalatine ganglion neuromodulation in migraine: What is the rationale?" Cephalalgia 2014;34(5:382–391.

Schoenen J et.al. "Stimulation of the sphenopalatine ganglion (SPG) for cluster headache treatment. Pathway CH-1: a randomized, sham- controlled study." Cephalalgia2013 Jul;33(10):816-30.

Niamtu J et.al. Local Anesthetic block for the head and neck for cosmetic facial surgery , II: techniques for the upper and mid face. Cosmetic Dermatology, 2004, Vol. 17, No. 9. Windsor R et.al. Sphenopalatine Ganglion Blockade: A Review and Proposed Modification of the Transnasal Technique. Pain Physician. 2004;7:283-286.

Nader A et.al. Ultrasound-Guided Trigeminal Nerve Block via the Pterygopalatine Fossa: An Effective Treatment for Trigeminal Neuralgia and Atypical Facial Pain. Pain Physician 2013; 16:E537-E545 THANK YOU Questions?

[email protected] Nerve Blocks and Implants for Treating Pelvic Pain

Alaa Abd-Elsayed Medical Director, UW Pain Services Medical Director, UW Pain Clinic University of Wisconsin School of Medicine and Public Health Madison, Wisconsin

Objectives:

1. Anatomy of nerves in pelvic region 2. Most common blocks for treating pelvic pain 3. Role of Neuromodulation in treating pelvic pain 4. Role of intrathecal pump in treating pelvic pain Ganglion Impar Block Anatomy Indications:

Perineal pain originating from:

Perineum Distal rectum Anus Distal urethra Vulva Distal third of the vagina

Technique Hypogastric Plexus Block Anatomy Indications

•Bladder •Urethra •Uterus •Vagina •Vulva •Perineum •Prostate •Penis •Testes •Rectum •Descending colon Technique Pudendal Nerve Block The sensory and motor innervation of the perineum is derived from the pudendal nerve, which is composed of the anterior primary divisions of the second, third, and fourth sacral nerves. The pudendal nerve’s 3 branches include the following:

1. Dorsal nerve of clitoris, which innervates the clitoris 2. Perineal branch, which innervates the muscles of the perineum, the skin of the labia majora and labia minora, and the vestibule 3. Inferior hemorrhoidal nerve, which innervates the external anal sphincter and the perianal skin Anatomy Technique

Symphysis Pubis Joint Injection Indications:

1. DJD 2. Arthritis 3. Pain Technique Sacroiliac Joint Injection Indication:

1. Diagnose SIJ pain 2. Treat SIJ pain 3. DID 4. Osteoarthritis of the joint Anatomy Technique Role of Neuromodulation

Case Intrathecal Pump

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