Interventional Pain Medicine This page intentionally left blank Interventional Pain Medicine Edited by Anita Gupta , DO , PharmD Assistant Professor of Anesthesiology and Critical Care Hospital of the University of Pennsylvania Philadelphia, PA 1 1 Oxford University Press, Inc., publishes works that further Oxford University’s objective of excellence in research, scholarship, and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Copyright © 2012 by Oxford University Press, Inc. Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. ______________________________________ Library of Congress Cataloging-in-Publication Data Interventional pain medicine / edited by Anita Gupta. p. ; cm. Includes bibliographical references and index. ISBN 978-0-19-974060-4 (spiral bound) I. Gupta, Anita. [DNLM: 1. Pain—drug therapy. 2. Analgesics—therapeutic use. 3. Autonomic Nerve Block—methods. 4. Injections, Spinal—methods. WL 704] 616.0472—dc23 2011039717 ___________________________________ This material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and accounted for regularly. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. The publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim, any responsibility for any liability, loss or risk that may be claimed or incurred as a consequence of the use and/or application of any of the contents of this material. 9 8 7 6 5 4 3 2 1 Printed in China on acid-free paper To my loving father and mother, Ishwar Saran Pradip and Usha Gupta, for lighting my path of motivation and determination for caring for people and for teaching me that anything is possible. To my supportive husband and precious sons, Sanjeev M. Srinivas, Shaan R. Srinivas, and Jay R. Srinivas, for being the inspiration and reminding me of what is important in life. To my prestigious mentors at Georgetown, Penn, Hopkins, and NIH, Jane C. Ballantyne, Lee A. Fleisher, Michael A. Ashburn, Srinivasa N. Raja, Steve P. Cohen, Paul J. Christo, Lance Pohl, Martin Cheatle, Jonathan R. Gavrin, and Russell Wall, for giving me the guidance to become a leader in pain medicine and anesthesiology. To my cherished family and friends, Kavita Gupta, Sanjay Gupta, and Ayesha Malik, for giving me the support and confidence all through life challenges and reminding me that the best is yet to come. This page intentionally left blank vii Table of Contents Foreword ix Preface xi Contributors xiii Section 1: Introduction to Interventional Pain Management 1 1.1 Anatomy of the Spinal Cord for Pain Procedures 3 1.2 Pharmacotherapy for Pain Management 9 1.3 Imaging for Interventional Pain Management 15 1.4 Preparation for Interventional Spine Procedures 31 1.5 Basic Surgical Skills for Interventional Pain Procedures 39 Section 2: Cervical Spinal Injections 53 2.1 Cervical Inter-Laminar Epidural Injections 55 2.2 Cervical Transforaminal Epidural Steroid Injections 65 2.3 Cervical Median Branch Blocks and Radiofrequency Ablation 75 Section 3: Lumbar Spinal Injections 89 3.1 Lumbar Interlaminar Epidural Injections 91 3.2 Lumbar Transforaminal Epidural Injections 105 3.3 Medial Branch Blocks 113 3.4 Lumbar Radiofrequency Ablation 121 3.5 Discography 129 3.6 Biacuplasty 139 3.7 Kyphoplasty 149 3.8 Percutaneous Discectomy 157 Section 4: Pelvic and Sacral Injections 167 4.1 Caudal Epidural Injection 169 4.2 Caudal Adhesiolysis 179 4.3 Sacroiliac Joint Injections and Sacroiliac Joint Denervation Techniques 185 4.4 Sacroiliac Neurotomy 193 Section 5: Sympathetic Blocks 205 5.1 The Stellate Ganglion Block 207 5.2 Lumbar Sympathetic Nerve Block 219 5.3 Superior Hypogastric Plexus Block 225 5.4 Celiac Plexus Blocks and Splanchnic Nerve Blocks 235 viii 249 Section 6: Advanced Neuromodulation Interventions 6.1 Spinal Cord Stimulation 251 6.2 Intrathecal Drug Delivery Systems 271 Index 287 Table of Contents ix Foreword The genesis of this book was the need for a ready reference for new fellows embarking on a course of training in interventional pain management. Its intent was not to be a heavy book that could only be stored on a bookshelf, but a pocket-sized reference that could be carried, easily navigated, and available whenever a conceptual gap compromised the interventionalist’s ability to perform. The editor recog- nized this need in her own training and practice, and now that she teaches, has taken note of her fellows’ repeated frustration at not having reference book at hand with the answers to questions that arise at the bedside. The fact that Dr Gupta has managed to attract authors who are leaders in the field, including fellowship directors from programs throughout the US, confirms that indeed a need exists for such a book. The book is logically laid out, and each section covers the necessary material in a formulaic way: anatomy, indications, preparation, techniques, complications, clinical notes, and clinical pearls. The focus of the book is on technical aspects, and the book is adequately illustrated with fluoroscopic images and diagrams. The glossary, index, reading lists, and alphabetical contents make it easy to locate unfamiliar material, including where to look for information beyond this small book. Though this book is intended for new trainees in interventional pain management, it should also be noted that even the most seasoned practitioner will sometimes be required to perform an unfamiliar intervention, or will encounter an unusual clinical situation, in which case a ready reference book is invaluable. Thus, this book could well have utility not just for trainees, but for anyone practicing interventional pain management. Jane C . Ballantyne This page intentionally left blank xi Preface The care of pain patients requires a unique knowledge base and skill set that differs widely from that required for general patient management. The physiology of pain medicine is rapidly changing, with con- tinued advances made on interventions available to treat pain. The aim of this work is to provide, in one source, authoritative information from leaders in pain medicine to guide providers at the point of care for interventional pain therapies. It is intended to provide a rapid and accurate source of information relevant to the impact of the interventional management of pain patients. This handbook is an indispensi- ble resource for a variety of different pain practitioners who provide care to pain patients. This book provides point-of-care guide utilizing contributions of nationally and internationally recognized authors from institutions with advanced pain care practices and centers of excellence. I wish to acknowledge and thank the many outstanding faculty and fellows who contributed to the endeavor. I also want to sincerely thank Andrea Seils and Staci Hou from Oxford University Press for their dedication to this book and for making my vision for this work come to fruition. This page intentionally left blank xiii Contributors Reginald Ajakwe, MD Steven P. Cohen, MD Fellow, UCLA Pain Management Center Professor of Anesthesiology Department of Anesthesiology Uniformed Services University of the David Geffen School of Medicine at UCLA Health Sciences Los Angeles, CA Director of Pain Research Walter Reed Army Medical Center Neel Amin, MD Washington, DC American Pain Experts and Private Practice Pain Medicine Associate Professor Fort Lauderdale, FL Johns Hopkins School of Medicine Baltimore, MD Aisha Baqai, MD New York Presbyterian Hospital Alexander F. DeBonet, MD Weill Cornell Medical Center Clinical Fellow in Pain Medicine New York, NY Beth Israel Deaconess Medical Center Gaurav Bhatia, MD Harvard Medical School Department of Anesthesia and Critical Care Boston, MA University of Pennsylvania Hospital System Philadelphia, PA Timothy R. Deer, MD President and CEO Richard G. Bowman, MD The Center for Pain Relief Rehabilitation Director and The Center for Pain Relief, Inc. Clinical Professor of Anesthesiology