INTERVENTIONAL PAIN

MANAGEMENT IN ELDERLY
ASEP NUGRAHA HERMAWAN
 CURRICULUM VITAE
• Nama : Asep Nugraha Hermawan, dr. Sp.S
• Pekerjaan : Neurolog RSUD Sumedang
• Pendidikan :
• Dokter Umum Fakultas Kedokteran UNPAD 2005.
• Spesialisasi Neurologi Fakultas Kedokteran UNPAD 2015.

• Kursus dan Workshop :

• Kertha Usada Hospital Training for interventional Pain Management, March 2015.
• Workshop Musculoskeletal Injection Technique Guiding by USG & injectable substances. Continuing medical education on neurology VII
(UNPAD). April 2016
• Pain Camp Education. Pokdi Nyeri PERDOSSI. March 2017
• Workshop Ultrasonography Guided Musculoskeletal Injection Technique. Continuing Medical Eeducation on Neurology VIII (UNPAD).
May 2017.
• Intensive Course and Hands on Training in Musculoskeletal Ultrasound. Indonesian society of ultrasound (ISUM)-World Federation for
Ultrasound in Medicine and Biology (WFUMB) Center of Education (Jakarta WFUMB-COE). Januari 2018.
• USG Guided Injection for Headache and Neck Workshop on Cadaver and Volunteer. Indonesian Pain Academy, May 2018
• Workshop Spine Ultrasound & C Arm Guided for Low Back Pain Intervention. Pain Intervention Scientific Update, June 2018
 INTRODUCTION

WHY IS THIS IMPORTANT ?

• Pain is common in elderly
 INTRODUCTION

WHY IS THIS IMPORTANT ?

• Pain management challenges in older adult :
• Age–associated pharmacodynamic and
pharmacokinetic changes to specific
drugs (physiologic changes)
• Multiple comorbidities which often
necessitates polypharmacy

More susceptible to the potential

side effects and toxicities of
systemic pain medications
 INTRODUCTION

Interventional pain management

techniques :
• Targeted specific nociceptive
transmission sites
• Reduce pain without the end-organ
systemic effects associated with
systemic pain medications.
INTRODUCTION

INTERVENTIONAL PAIN MANAGEMENT :

• The discipline of medicine devoted to the
diagnosis and treatment of pain-related
disorders
• Principally with the application of
interventional techniques
• Independently or in conjunction with other
treatment modalities.
(Brooks et al., 2016)
 INTRODUCTION
• Numerous interventional pain management techniques offer older patients an
alternative treatment plan if conservative management is ineffective or
contraindicated.
• The most common pain problem in older adults : low back pain (LBP) and knee pain
 LOW BACK PAIN

POTENTIAL CAUSES OF LOW BACK PAIN IN ELDERLY :

• Non-specific low back pain
• Low back pain with radiculopathy
• Osteoporotic vertebral fractures
• De novo degenerative lumbar scoliosis (DNDLS)
• Tumors/cancers
• Spinal infection
• Visceral diseases
Collectively, it is difficult to identify the sources of non-specific
LBP because its causes are usually multifactorial
(Wong et al., 2017)
 NON-SPECIFIC LOW BACK PAIN

• Originate from different pain sources :

• Lumbar spine : • Non-lumbar spine :
• Facet joint osteoarthritis • Sacroiliac joint
• Disc degeneration • Myofascial pain
• Lumbar degenerative
spondylolisthesis
 FACET JOINT
• A true synovial joint
• The facet joints and their
capsules are well
innervated by the medial
branches of the dorsal
primary rami of the
spinal nerves, where both
free nerve endings
• Facet Joint Osteoarthritis
(FJ OA)
 FACET JOINT OSTEOARTHRITIS

• Facet joint pain : 52% in patients more than 65

years old and 30% in all adults. (Manchikanti et
al., 2001)
• Lumbar facet joint osteoarthritis highest at L4–
L5, followed by L5–S1
 FACET JOINT OSTEOARTHRITIS
• Localized LBP, + referred pain
• The pain may be aggravated during trunk
extension, ipsilateral lateral flexion, and/or
rotation  facet loading
• Referred pain is predominantly in the buttock and
the thigh; radiation past the knee is rare.
• Needs to be differentiated from true radicular
pain
• Radicular pain tends to travel farther distally in
the limb than lumbar facet joint pain, and can be
associated with neurologic findings such as motor
or sensory loss, or diminished reflexes
 FACET JOINT ARTHROPATHY

• No examination maneuvers are • BUT, up to a 45% false-positive rate when the

pathognomonic for symptomatic FJ OA physical examination findings are correlated
• In routine clinical practice, back pain to DIAGNOSTIC MEDIAL BRANCH BLOCKS
that worsens with lumbar trunk
extension, ipsilateral lateral flexion,
and/or rotation, or straightening from • CT scan and MRI
flexion
• Pain with palpation over the facet joint
• Para-spinal muscles spasm
 LUMBAR FACET INJECTIONS

• Injections for lumbar facet–

mediated pain can be performed
by :
• Injecting directly into the joint
• Injection at the junction of the
superior articular process and
transverse process or the site of
the medial branch (MB) nerve
rests
• However, the evidence is limited to
poor for intraarticular injections
 LUMBAR FACET INJECTIONS

• The evidence for diagnostic accuracy of facet joint nerve blocks is good
• A criterion standard of 75% pain relief with ability to perform prior painful movements without
significant pain.

American Society of Interventional Pain Physicians (ASIPP), 2013

 LUMBAR FACET INTERVENTIONS

• Indications for therapeutic facet joint interventions are based on the diagnosis established with a
positive response to diagnostic blocks
• Therapeutic facet joint interventions  the evidence is good for radiofrequency neurotomy in the
lumbosacral region

American Society of Interventional Pain Physicians (ASIPP), 2013

 SACROILIAC JOINT ARTHROPATHY
• A true diarthrodial joint located at the junction of
the sacrum and ilium
• The average surface area has been estimated to be
approximately 17.5 cm2
• Its innervation has been described as arising mainly
from the dorsal rami of S1–S3, with contributions
from L5 and S4 in many individuals
 SACROILIAC JOINT ARTHROPATHY
• The SI joint has been implicated as the source of
pain in between 13% and 30% of patients with
chronic non radicular low back pain.
• Unilateral pain below L5
• The presence of three or more positive provocative
tests appears to have reasonable sensitivity and
specificity in identifying those individuals who will
positively respond to diagnostic SIJ injections
(Greater than 75% sensitivity and specificity )
 SACROILIAC JOINT ARTHROPATHY
PROVOCATIVE TEST

Laslett, 2006
 SACROILIAC JOINT ARTHROPATHY
PROVOCATIVE TEST

Laslett, 2006
 SACROILIAC JOINT ARTHROPATHY
PROVOCATIVE TEST

Laslett, 2006
 SACROILIAC JOINT ARTHROPATHY
PROVOCATIVE TEST

Laslett, 2006
 SACROILIAC JOINT ARTHROPATHY

• The reference standard for diagnosis remains

low-volume anesthetic blocks
• A positive response is considered ≥ 75%
relief (good evidence) or with ability to
perform previously painful movements

Cohen et al., 2013

 SACROILIAC JOINT INTERVENTION

• Conservative measures are considered first-line therapy for patients with SI joint
pain.
• If conservative measures fail to reduce the patient’s symptoms  Therapeutic
Intervention
• For therapeutic sacroiliac joint interventions with intraarticular injections or
radiofrequency neurotomy, the joint should have been positive utilizing controlled
diagnostic blocks.
 SACROILIAC JOINT INTERVENTION
• The best recommendation at this time is to use these injections as adjuncts to a
multimodal analgesia regimen with the understanding that it can likely help
patients in the short term (3 months) but evidence about its long-term (>3 months)
results is lacking.

• RadioFrequency ablation of the lower lumbar dorsal rami and S1–3(4) lateral
branches has been shown to provide pain relief lasting up to 1 year. (American
society of interventional pain physicians (ASIPP), 2013)
 LOW BACK PAIN
LOW BACK PAIN WITH RADICULOPATHY

• Compression of nerve roots or spinal meninges by degenerated spinal structures (e.g., Herniated
discs, facet joints, hypertrophic ligamentum flavum)
 LOW BACK PAIN
LOW BACK PAIN WITH RADICULOPATHY

• The clinical presentation of radiculopathy

depends on the location of neural tissue
compression
 LOW BACK PAIN
LOW BACK PAIN WITH RADICULOPATHY

• Lumbar spinal stenosis (LSS) secondary to degenerative changes at a single or

multiple level(s) (e.g., Osteophytes and hypertrophic ligamentum flavum) may
lead to unilateral or bilateral radiculopathy and neurogenic claudication with or
without LBP
• Neurogenic claudication is characterized by numbness and heaviness of legs after
prolonged walking, which can be eased by a flexed position (e.g., Forward
leaning or sitting)
 LUMBAR EPIDURAL INJECTIONS

• Lumbar epidural steroid injections (ESI)  Transforaminal, interlaminar, caudal

• Indication : Lumbar spinal stenosis, lumbar disc herniation, degenerative changes
in the lumbar vertebrae, and lumbosacral radicular pain
 LUMBAR EPIDURAL INJECTIONS

• Studies specific to older adults are limited, but most include a wide range of age
groups
• There is general consensus that ESI provide at least short-term benefit (weeks to
months)
• ESI seem to provide some short-term pain relief and functional improvement and
should be considered as part of a pain treatment plan for older patients with low
back and/or leg pain.
 LUMBAR EPIDURAL INJECTIONS

• The evidence for epidural steroid injection efficacy is strongest for short term relief of lumbosacral
radicular pain.
• The strongest evidence for trans-foraminal epidural steroid injection (TFESI) use is for relief of
unilateral lumbosacral radicular pain.
• The evidence suggests using inter-laminar epidural steroid injection (ILESI) in patients with bilateral
and/ or multi-level lumbosacral radicular pain.
• The data correlates efficacy of caudal epidural steroid injection (CESI) in low level bilateral or
multilevel lumbosacral radicular pain as well as in patients with history of lumbar surgery
 TAKE HOME MESSAGE

• Pain is common in elderly

• Physiologic changes, comorbidities and polypharmacy in older adults make them more susceptible
to the potential side effects and toxicities of particular systemic medications.
• Interventional pain management techniques that target specific nociceptive transmission sites can
reduce pain without the end-organ systemic effects associated with oral pain medications.
• Numerous interventional pain management techniques offer older patients an alternative
treatment plan if conservative management is ineffective or contraindicated.