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Advances in Pain Medicine 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 nerve 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 Nerves 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 greater occipital nerve is a spinal nerve, specifically the medial branch of the dorsal primary ramus of cervical spinal nerve 2. This nerve arises from between the first and second cervical vertebrae, along with the lesser occipital nerve. 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 ear and over the parotid glands. While under the trapezius, the medial branch of the posterior division of the third cervical nerve gives off a branch called the third occipital nerve (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
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