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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 – 2002)
• Pain Fellowship– Emory University (2006 – 2007)
• Residency– Mayo Clinic (2003 – 2006)
Certifications
• Board Certified, Pain Medicine (2007)
• Board Certified, Physical Medicine and Rehabilitation (2007)
Mechanical Low Back Pain
Denis G. Patterson, DO
Echo Project
11/18/2015
Introduction
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 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 year old age group when they visit the doctor
• The lumbar spine (low back) is a common area for pain
Basic Lumbar Spine Anatomy
Lumbar ArthritisAKA “Facet Joint Syndrome”
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 40 and progresses with age
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 lower extremity pain (usually not past the knee)
Facet Joint Syndrome
• Symptoms
- Low back stiffness, especially in the morning
- Pain with prolonged sitting or standing
Conservative Treatment Measures
Conservative Treatment Measures
• Modalities
• Medications
• Physical Therapy
• Injections
Modalities
• Ice
• Heat
• TENS
• Massage
• Traction
Medications
• Tylenol
• NSAIDS
• Ultram
• Nerve pain medications
• Narcotics
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 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 blocks and radiofrequency ablation
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.
• Most common levels L4-L5, L5-S1.
• Inject anesthetic and steroid.
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.• 1st set of blocks are performed with 1 ml 1%
preservative free lidocaine injected at each medial branch.– Provides 2-3 hours of relief
• 2nd 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
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
Discussion
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