Contact Information Denis G Patterson DO Nevada Advanced

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Contact Information Denis G. Patterson, DO Nevada Advanced Pain Specialists www. nvadvancedpain. com patterson@nvadvancedpain.

Contact Information Denis G. Patterson, DO Nevada Advanced Pain Specialists www. nvadvancedpain. com patterson@nvadvancedpain. com

Education and Training • DO – Michigan State University College of Osteopathic Medicine (1998

Education and Training • DO – Michigan State University College of Osteopathic Medicine (1998 – 2002) • Pain Fellowship – Emory University (2006 – 2007) • Residency – Mayo Clinic (2003 – 2006)

Certifications • Board Certified, Pain Medicine (2007) • Board Certified, Physical Medicine and Rehabilitation

Certifications • Board Certified, Pain Medicine (2007) • Board Certified, Physical Medicine and Rehabilitation (2007)

Mechanical Low Back Pain Denis G. Patterson, DO Echo Project 3/16/2016

Mechanical Low Back Pain Denis G. Patterson, DO Echo Project 3/16/2016

Introduction

Introduction

Introduction • Life expectancy continues to increase in the US • > 65 year

Introduction • Life expectancy continues to increase in the US • > 65 year old age group grew by 30% between 1994 – 1999

Introduction • Fear of the aging population is “having pain” • Chances of having

Introduction • Fear of the aging population is “having pain” • Chances of having pain increase with each decade of life • Pain leads to negative consequences for health, decreased function, and quality of life

Introduction • Pain is one of the most common complaints for the > 65

Introduction • Pain is one of the most common complaints for the > 65 year old age group when they visit the doctor • The lumbar spine (low back) is a common area for pain

Basic Lumbar Spine Anatomy

Basic Lumbar Spine Anatomy

Lumbar Arthritis AKA “Facet Joint Syndrome”

Lumbar Arthritis AKA “Facet Joint Syndrome”

Facet Joint Syndrome • It is a general term for age-related wear and tear

Facet Joint Syndrome • It is a general term for age-related wear and tear affecting the facet joints • Also known as lumbar osteoarthritis

Facet Joint Syndrome • The condition usually appears in men and women older than

Facet Joint Syndrome • The condition usually appears in men and women older than 40 and progresses with age

Facet Joint Syndrome • Causes: - Drying and loss of elasticity in the lumbar

Facet Joint Syndrome • Causes: - Drying and loss of elasticity in the lumbar disks - Stiffening of the ligaments connecting bones and muscles

Facet Joint Syndrome • Symptoms: - Low back, hip or buttock pain - Cramping

Facet Joint Syndrome • Symptoms: - Low back, hip or buttock pain - Cramping lower extremity pain (usually not past the knee)

Facet Joint Syndrome • Symptoms - Low back stiffness, especially in the morning -

Facet Joint Syndrome • Symptoms - Low back stiffness, especially in the morning - Pain with prolonged sitting or standing

Conservative Treatment Measures

Conservative Treatment Measures

Conservative Treatment Measures • Modalities • Medications • Physical Therapy • Injections

Conservative Treatment Measures • Modalities • Medications • Physical Therapy • Injections

Modalities • Ice • Heat • TENS • Massage • Traction

Modalities • Ice • Heat • TENS • Massage • Traction

Medications • Tylenol • NSAIDS • Ultram • Nerve pain medications • Narcotics

Medications • Tylenol • NSAIDS • Ultram • Nerve pain medications • Narcotics

Physical Therapy • Goals: - Pain relief - Improve posture/biomechanics - Improve motion -

Physical Therapy • Goals: - Pain relief - Improve posture/biomechanics - Improve motion - Improve strength - Improve function - Resume regular activities

Facet Injections • Gold standard for diagnosis of facet mediated spine pain • Radiographic

Facet Injections • Gold standard for diagnosis of facet mediated spine pain • Radiographic findings - joint space narrowing, hypertrophy, sclerosis, tropism • Pain is not always related to radiographic findings

Facet Injections • Two types of injections – Intra-articular joint injections – Medial branch

Facet Injections • Two types of injections – Intra-articular joint injections – Medial branch blocks and radiofrequency ablation

How Do We Do These Procedures? • Contrast-enhanced with fluoroscopic guidance. – May pre-medicate

How Do We Do These Procedures? • Contrast-enhanced with fluoroscopic guidance. – May pre-medicate with prednisone and Benadryl if allergic. • Used to ensure needle placement and proper medication flow. • Safety. • Question non-response in blind injections.

Facet Intra-Articular Injections • Fluoroscopic localization. • Use of contrast confirms intraarticular needle placement.

Facet Intra-Articular Injections • Fluoroscopic localization. • Use of contrast confirms intraarticular needle placement. • Most common levels L 4 -L 5, L 5 -S 1. • Inject anesthetic and steroid.

Medial Branch Block • Similar results to intra-articular facet injection without entering the joint.

Medial Branch Block • Similar results to intra-articular facet injection without entering the joint. • Targets the medial branch of the dorsal primary ramus. • Diagnoses pain originating from facet joint. • Identifies patients who will benefit from radiofrequency ablation.

Medial Branch Block • Performed as a series of 2 blocks. • 1 st

Medial Branch Block • Performed as a series of 2 blocks. • 1 st set of blocks are performed with 1 ml 1% preservative free lidocaine injected at each medial branch. – Provides 2 -3 hours of relief • 2 nd set of blocks performed with 1 ml 0. 5% preservative free bupivacaine at each medial branch. – Relief lasts 4 -6 hours. • Positive response defined as 50% pain reduction.

Medial Branch Block

Medial Branch Block

Medial Branch Block

Medial Branch Block

Radiofrequency Ablation (RF) • Electrical current produced by a radio wave is used to

Radiofrequency Ablation (RF) • Electrical current produced by a radio wave is used to to heat tip of needle and destroy medial branch and eliminate painful signal from facet joint. • Procedure is similar to medial branch block except wire is placed through needle at target point instead of anesthetic. • Medial branch is then lesioned for 120 seconds at 80 degrees. • Provides 9 -12 months of relief. – Nerve grows back with time.

Questions

Questions

Discussion

Discussion