The Pain Source

By Chris Faubel, M.D. –

Best done under fluoroscopic-guidance so the crest can be visualized and you can ensure an even distribution of injection sites (red X's).

To learn about Iliolumbar Syndrome, follow this link.

CPT codes: 

• 20550 “Injection(s); single tendon sheath, or ligament, aponeurosis”
• 77002 “Fluoroscopic guidance for all types of needle placement, i.e., biopsy, aspiration, injection, or localization device”

PROCEDURE TECHNIQUE:

Solution:  Varies depending on the number of sites that you plan to inject.  Typically, I inject four sites and use a 4-ml solution consisting of 3-ml of 0.5% bupivicaine and 1-ml of Depo-Medrol 40mg/ml.  You can also use just local anesthetic if the patient has an elevated blood sugar.

Position:  Prone

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• Iliolumbar Syndrome
• VIDEOS: Lumbar Facet Injections under Fluoroscopy
• VIDEO: Hip Intraarticular Steroid Injection Under Fluoroscopy
• VIDEO: Glenohumeral Shoulder Intraarticular Steroid Injection Under Fluoroscopy
• Complications of Cervical Transforaminal Epidural Steroid Injections

** click the blue article titles below for the abstracts
note: recent additions will be added to the top of the list

Adverse Effects

1 - Epidural steroid injections do not induce weight gain

• Curr Drug Saf. 2007 May;2(2):113-6.

Prospective evaluation of 100 patients who received a series of three lumbar ESIs (once a month for three months)

40 mg methylprednisolone acetate (Depo-Medrol) for each injection

No significant change in weight gain

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12 - Intrathecal hydromorphone for intractable nonmalignant pain: a retrospective study

• Pain Med. 2006 Jan-Feb;7(1):10-5.

Retrospective review of 24 patients using intrathecal hydromorphone as a solo analgesic

Average pain scores decreased significantly

11 - Implantable drug delivery systems (IDDS) after failure of comprehensive medical management (CMM) can palliate symptoms in the most refractory cancer pain patients

• J Palliat Med. 2005 Aug;8(4):736-42.

Randomized clinical trial (30 patients) to evaluate whether IDDS could help the most refractory patients failed by expert CMM

Pain scores reduced by 27%

Survival time of 3 months may be long enough for the IDDS implant to be cost effective.

Patients with refractory cancer pain, whom failed expert comprehensive medical management with high-dose opioids, derived benefit from IDDS.

10 - Pain management, including intrathecal pumps

• Curr Pain Headache Rep. 2005 Aug;9(4):243-8.

Review

Randomized trial of 202 patients with pain scores of 7.5 or higher.

IDDS vs CMM: Pain scores reduced = 52% vs 39%;  Drug toxicity scores reduced = 50% vs 17%;  IDDS patients lived longer

Randomized trial of 30 patients

IDDS in patients who failed CMM: Pain scores reduced = 27%

9 - Intrathecal drug delivery for treatment of chronic low back pain: report from the National Outcomes Registry for Low Back Pain

• Pain Med. 2004 Mar;5(1):6-13.

166 patients trialed;  136 patients implanted

Pain scores reduced:  47% for low back pain;  31% for leg pain [at 12 months]

Oswestry scores reduced at least one level in 65% of patients [at 12 months]

Satisfaction:  85%

8 - Management of chronic intractable angina – spinal opioids offer an alternative therapy

• Pain. 2003 Mar;102(1-2):163-6.

7 patients who failed prior cardiac surgeries

Bolus doses of either morphine or fentanyl into either the epidural (2) or intrathecal (5) spaces

Viable alternative for patients who have failed traditional management

7 - Successful treatment of restless legs syndrome with an implanted pump for intrathecal drug delivery

• Acta Anaesthesiol Scand. 2002 Jan;46(1):114-7.

2 patients who failed conventional care with dopaminergic drugs

Intrathecal delivery of morphine and bupivacaine

Total resolution of all symptoms with few side effects

6 - Managing chronic nonmalignant pain with continuous intrathecal morphine

• J Neurosci Nurs. 1998 Aug;30(4):233-9, 243-4.

12 patients followed for one year

Pain relief of 42% (on the McGill pain questionnaire)

Subjective improvement in ADLs.  One patient returned to work.

Complications of implantation occurred in 33.3% of the patients and were successfully managed without discontinuing therapy.

5 - Intrathecal morphine pump as a treatment option in chronic pain of nonmalignant origin

• Surg Neurol. 1998 Jan;49(1):92-8; discussion 98-9.

11 patients with either failed back syndrome (9) or neuropathic pain (2) of other causes

Up to 3-year follow-up

Good to excellent pain relief in 73%

Two patients experienced bladder dysfunction requiring pump removal.

4 - Cost-effectiveness of long-term intrathecal morphine therapy for pain associated with failed back surgery syndrome

• Clin Ther. 1997 Jan-Feb;19(1):96-112; discussion 84-5.

Even taking the cost of complications and pump replacement into consideration, intrathecal morphine therapy appears to be cost-effective when compared with medical management for selected patients when the duration of therapy exceeds 12 to 22 months.

3 - Intrathecal administration of morphine and bupivacaine in the treatment of severe pain in chronic pancreatitis

• Ned Tijdschr Geneeskd. 1996 Jul 6;140(27):1410-2.

Case report of a patient with severe pain from chronic pancreatitis (patient had failed numerous medical and surgical therapies)

Adequate pain relief was achieved with intrathecal morphine and bupivacaine

2 - Intrathecal infusion systems for treatment of chronic low back and leg pain of noncancer origin

• South Med J. 1996 Mar;89(3):295-300.

26 patients with an average follow-up of 23 months

Pain relief (good to excellent) in 77%

Daily functioning increased 50%

9 catheter complications

1 - Long term treatment of intractable reflex sympathetic dystrophy with intrathecal morphine

• Can J Neurol Sci. 1995 May;22(2):153-9.

2 patients with intractable leg pain, swelling and autonomic changes after a leg injury.  Failed medical and surgical options (sympathectomies)

Relatively satisfactory symptom control.  Temporary increases in morphine dose was used for exacerbations.

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12 - Spinal cord stimulation for patients with refractory angina and previous coronary surgery

• Ann Thorac Surg. 2006 Nov;82(5):1704-8

51 patients who failed multiple percutaneous and surgical revascularizations and optimal medical therapy, and are NOT candidates for further revascularization attempts (CCS class III/IV angina)

>50% reduction of weekly anginal episodes in 88%

CCS class decreased to II

Significantly improved quality of life

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6 - Effectiveness of repeated radiofrequency neurotomy for lumbar facet pain

• Spine. 2004 Nov 1;29(21):2471-3.

Each RF neurotomy had a mean duration of relief = 10.5 months

The repeat ablations were successful more than 85% of the time (and some of the patients had up to 4 repeated procedures)

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• Research – Thoracic Radiofrequency Neurotomy
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2 – Radiofrequency medial branch neurotomy in litigant and nonlitigant patients with cervical whiplash: a prospective study

• Spine. 2001 Jun 15;26(12):E268-73

46 patients who failed 20 weeks of conservative care

Both groups had significant improvement in pain scores and reported symptoms.  No significant difference between the groups was seen.

“…the potential for secondary gain in patients who have cervical facet arthropathy as a result of a whiplash injury does NOT influence response to treatment.”

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• Research – Lumbar Radiofrequency Neurotomy
• Research – Thoracic Radiofrequency Neurotomy
• Innervation of Lumbar Facet Joints
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• VIDEO: Cervical Facet Injection

** click the blue article titles below for the abstracts
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1 - Percutaneous facet denervation in chronic thoracic spinal pain

• Acta Neurochir (Wien). 1993;122(1-2):82-90.

40 patients with chronic thoracic pain of more than 12 months (failed conservative treatment)

After 2 months: Pain-free = 47.5%;  >50% relief = 35%

After 31 months (average f/u):  Pain-free = 44%;  >50% relief = 39%

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3 - Transforaminal steroid injections in the treatment of cervical radiculopathy. A prospective outcome study

• Acta Neurochir (Wien). 2005 Oct;147(10):1065-70

Reduced need for operative treatment (because of radicular and neck pain relief).

“Routine transforaminal injection treatment prior to surgery seems rewarding, but the complication risk must be taken into consideration.”

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12 - Comparison of the effectiveness of interlaminar and bilateral transforaminal epidural steroid injections in treatment of patients with lumbosacral disc herniation and spinal stenosis

• Clin J Pain. 2009 Mar-Apr;25(3):206-10

Looked at patients with axial low back pain only (no radiculopathy)

In patients with spinal stenosis (SS), the bilateral transforaminal ESI produced better results than the interlaminar approach.

Authors believe this was because there is more scaring with SS, and this limits the amount of injectate to the ventral epidural space.

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By Chris Faubel, MD –

aka “trigger thumb injection”, “trigger digit injection”

Indications

• Trigger Finger
  • ICD-9 code:
    • 727.03 “trigger finger” (acquired)
  • ICD-10 code:
    • M65.3 “trigger finger“ nodular tendinous disease

CPT code: 20550 “Injection(s); single tendon sheath, or ligament, aponeurosis”

Materials Needed

• Pen – clicking type
• Gloves – non-sterile
• Alcohol swabs (or povidone-iodine)
• Band-aid
• Tuberculin needle/syringe (27-gauge, o.5″ needle with 1-ml syringe)
• Injectate
  • 0.3-0.4-ml of 40mg/ml Depo-Medrol or Kenalog
  • 0.3-0.4-ml of 1% lidocaine

Technique / Procedure Steps

1. Always start with informed consent from the patient, and then a time-out to verify correct patient and injection site.
2. Mark the injection site with the pen tip in order to leave an impression in the skin.
3. Clean the skin thoroughly with as many alcohol swabs as needed (usually only 1-2 are needed).
4. Patient position: Perform lying supine or seated with the hand supinated.
5. With the tuberculin needle/syringe, enter the skin a few millimeters either distally or proximally to the nodule (triggering site) at about a 30-degree angle.
6. Aspirate to make sure you’re not in any vessel.
7. After negative aspiration, inject the full contents of the syringe, unless lots of resistance is met (means intratendinous needle tip position).  Withdraw very slightly, or reposition completely, and try again.
8. Withdraw the needle after syringe if fully empty, and apply band-aid.

Tips

• Finding the injection site
  • Palpate the volar flexor tendon sheath and tendon in the distal palm, feeling for a nodule.
  • Finger/extend the triggering digit to find the triggering site and nodule.
• Numbing the skin
  • Find out all about “Taking the Sting Out” (of injections) by going here.
  • Since I use a tiny tuberculin needle, most patients have no problem with the injection and don’t need any extra lidocaine skin wheal, although some freezing spray may help.
• After the injection
  • Have the patient move their involved digit (flex/extend) while you throw away supplies.
  • Then, re-palpate the nodule so they can see the immediate results of the lidocaine.
  • Explain to the patient that the lidocaine will wear off in an hour or so, and that they will be back to their normal pain until the steroids start kicking in (anywhere from 1-7 days).
  • May also ask the patient to not do much repetitive activity with that digit for 12-24 hours.

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