What is this Presentation really about Someone asked

What is this Presentation really about? Someone asked at the hospital about doing injections. What should I do now?

Objectives (The objectives sent to AANA for this lecture) 1. Describe various pain practices, training, and education involved. 2. Describe assets of TCU pain fellowship: advantages, necessity, why? 3. Describe 5 procedures commonly performed for low back pain. 1. 2. 3. 4. 5. Lumbar Interlaminar epidural steroid injections Transforaminal epidural steroid injections Facet Medial Branch Block testing Including L 5, (dorsal ramus of L 5) RFA of medial branch nerves Sacroiliac joint injection 4. Describe how to decide what injections to do, a very basic description of pain assessment

What does NSPM (Non-surgical Pain Management) mean • A basic description of what chronic pain practice entails. (Objective One) – Injections? Built into the practice – Deciding if injections should be done – Injection side effects, steroid side effects – Where do the patients get referred from – What should I know before attempting NSPM injections? (Objective two)

My Story Getting Started, I Digress • Knowing a really smart, visionary, caring person; Thomas Martin, hospital administrator at Lincoln Hospital – Necessity of hospital medical and administrative support • Family members with chronic pain • Fairly good state practice laws for CRNA’s • All parts of Objective two for the lecture

My Story Getting Started Describe 5 procedures commonly performed for low back pain. Objective 3 1. 2. 3. 4. 5. Lumbar Interlaminar epidural steroid injections Transforaminal epidural steroid injections Facet Medial Branch Block testing Including L 5, (dorsal ramus of L 5) RFA of medial branch nerves Sacroiliac joint injection Where does referral come from? • Depends on employment – 20% of PCP practice is low back pain appointments – Important to become, “spine experts”, must understand “spine jargon” – Referrals from Orthopedic and Neuro surgeons, PCP, “walk-ins”, Physical Therapists

Let’s look at an L 5 -S 1 PS left IL ESI

Interlaminar ESI

The View is Difficult at Times

Good dye flow, hmmmmmm

An example of dye flow

The Other ESI, Transforaminal Epidural Steroid Injection

Medial Branch Testing

The “Scotty Dog”

Pars Interarticularis FX

Oblique View

Transforaminal ESI, Where to start

Transforminal ESI

Medial Branch Testing

What’s wrong with this picture

Sacroiliac joint injection

RFA of the Medial Branch Nerves and Dorsal Ramus of L 5

Sacral ALA

One needle is a live one

Basic Back Pain Assessment, Initial Chart review Ø Most patients have imaging by the time pain providers see them in office, but not all Ø Must assess pain generator by symptoms and compare to imaging disease, usually on MRI Ø If imaging not present at initial pain appointment, must have approved diagnosis to obtain imaging in office visit chart

Every Patient Gets a Neurological Exam • • • Pinwheel Light touch Muscle strength Reflex testing Tuning fork sensation (most exams)

Cranial Nerves • Quick testing • Normally check all but Cranial Nerve One • Age appropriate

Joint Testing, Shoulder • Must have shoulder testing if needed – Neer’s (Impingement) – Hawkins (Impingement) – Drop arm (Impingement and rotator cuff tears) – Belly press – Lift off test – Adduction/External rotation Test (Supraspinatus and Infraspinatus) – Jobe Test (Supraspinatus)

Joint Testing, Hip Testing • Test for pain in the joint – Basic inward and outward rotation • Hip joint pain is rarely on the outside of the upper thigh, where a lot of patients think • A lot of hip pain appears as groin pain • Watch all patients walk, gives clues to what is really hurting

What testing for back pain • Straight leg raise test – Also called Lasague’s test. Pain should reproduce leg symptoms • Sacroiliac joint testing, five provocation tests – Patrick’s test – Gaenslen’s test – Thigh thrust – Distraction – Compression

To Conclude • 20%— 25% of PCP office visits are for low back pain • Important to match the symptoms with imaging, which can’t always be done • Read the patient, listen to them • Keep yourself healthy too!!!! Enjoy time away

Always chase Smallmouth

Cherish Largemouth