Lumbar Spine

Pain is a more terrible lord of mankind than even death itself. Albert Schweitzer

Limitations of Available Literature

• Studies vary in quality.

• Patient populations are heterogeneous. • Etiology of pain

• Duration of pain

• Different outcome measures • Pain

• Disability

• Absenteeism

Evidence-Based Medicine

• National Institute of Health

• Clearing House Guidelines

• Cochrane Reviews • Database of systematic reviews and meta-analyses

Evidence-Based Medicine

• Cochrane Reviews • Database of systematic reviews and meta-analyses

• But even these vary in quality, methods, etc.

Epidemiology of Pain

• Within the US:

• 40 million visit for new pain to PCP • Largest (41%) is for Musculoskeletal Pain Issues.

• Acute Pain 15-20%

• Sub acute Pain 50-60%

• Chronic Pain 25-30%

• Low Back Pain :Most common cause of work days missed

• Annual incidence 15-20% of Adult population with a life time incidence of 60-85% of the population.

• 14% US adults have serious Chronic back conditions.

“Low Back Pain”

• Locations: Costal Angles and Gluteal Folds

• 1st Episode commonly 20-40 Years of age • Commonly Moderate to Severe and debilitating

with anxiety • 31% will not fully recover within 6 months

• Recurrent back pain 25-62% of patients within 1-2 years • 33% moderate pain • 15% severe pain

What do I do? #1 Take a Breath and Relax

Don’t Rush into anything!

Currently:

• Low back pain 80% to 90% resolves in 4-6 weeks irrespective of the administration or type of treatment.

• 5% to 10% of patients developing persistent back pain.

• Relapse: Modern evidence 25%- 60% of patients have persistent pain, one year or longer after the initial episode.

Failed Back Syndrome

• FBSS is a subset of chronic low back pain, which is a type of chronic pain.

• In 2005 between 20 and 40 percent of spine surgery patients were diagnosed with FBSS

Anatomy and Diagnostic Studies: The Very Basic

Anatomy 101

1ST Types of Spine Pain :

Bursa

Discogenic /Annular

Facet Mediated

Joint

Ligament

Muscle

Nerve

SI joint Pain

Spinal nerves

Vertebral body

Another View

Region of spine

Anterior

1. Disc

2.Vetebral body

3.Ligament

Central

1.Cord

2. Dural

3.Vessels

4.Foramin

5.Pedicles

Posterior

1.Lamina

2.Transverse process

3.Spinous Process

4.Facet Joint

5.Myofascial

6.Ligament Flavum

Vertebral Body

1. Fracture 2. Degenerative endplate 1. Tumor 2. Infection 3. Hematoma 4. Schmorl node 5. Normal

annomolies 1. Sacralization 2. Lumbaralization 3. Incomplete

formation

What allows the spine to move?

Lumbar Facet Joint Pain Referral Patterns:

Central Canal

1. Spinal stenosis a. Central b. Foraminal c. Posterior d. Lateral Resess 2. Disc sequestered frament 3. Ligamentous hypertrophy 4. Schwanoma 5. Hematoma 6. Infection 7. Various Tumor 8. Trauma 9. Infarction 10. Vascular abnormality 11. Tetherd Cord

Examination Findings for Nerve root

Disk herniation

Affected nerve root Motor deficit

Sensory deficit Reflex Central Paracentral Lateral

L3 Hip flexion Anterior/medial thigh

Patella Above L2-L3 L2-L3 L3-L4

L4 Knee extension

Anterior leg/medial foot

Patella Above L3-L4 L3-L4 L4-L5

L5 Dorsiflexion\great toe

Lateral leg/dorsal foot

Medial hamstring

Above L4-L5 L4-L5 L5-S1

S1 Plantar flexion

Posterior leg/lateral foot

Achilles tendon

Above L5-S1 L5-S1 None

Lumbar Foraminal Zones

Lumbar Radicular / Nerve Root Referral Patterns:

Sacroiliac Joint Pain Referral Pattern:

• Sacroiliac Joint: pain referral maps upon applying a new injection/arthrography technique. Fortin JD et al.

• Part I: Asymptomatic volunteers. Spine 1994

• Part 2: Clinical evaluation. Spine 1994

• Distribution • Buttock pain (94%) • Lower lumbar pain (72%) • Lower extremity pain (50%) • Leg pain distal to the knee (28%) • Groin pain (14%) • Foot pain (12%) Slipman et al. Arch Phys Med Rehabil 2000

Sciatica?

• When a doctor says Sciatica what does this mean?

• What does he really mean?

• What should he really being telling you?

True Sciatica

• True Sciatica is compression of the Sciatic nerve as it leaves the pelvis and is not a spinal condition.

• Pain related to compression or irritation of a Spinal Nerve is Correctly termed “Radiculitis” or Radiculopathy.

My Back and The Front of my leg hurt?

• Numerous Causes? • Hip

• Peripheral Nerve

• Muscle

• Spinal Joint

• Spinal Nerve

Hip and Groin Symptoms/Signs

Anterior Lateral Posterior

Symptoms Stairs, Twist, Ambulation, Pivoting

Side Lying, Gait Dysfunction, Post-Laminectomy

Lying, Sit, Post-Laminectomy, LBP, Gait dysfunction

PE Palpation, Faber, IR, Thomas Test,

Palpation, Ober’s

Palpation, Patrick's, Piriformis

Diagnosis Intra-articular, Labrial, Psoas, Adductor Tendinitis

ITB Great Troch

SI joint Piriformis Ischial Bursitis Hamstring Tendonitis

Anterior Workup

• Physical

• X-ray

• If Negative failed Conservative management:

• Consider: • Diagnostic hip Injection

• MRI VS MRI Arthrogram

Lateral Workup

• Physical Examination • Leg Length

• Gait Analysis

• Diagnostic/Therapy • Stretching, Kenesiotaping

• Injection

• Modalities(Iontophoresis or US)

Posterior Workup

Physical • Pelvic Malrotation

• SI joint Stability

• Leg Length

• Gait Analysis

• Hamstring tightness

Diagnostic/ Therapeutic • US, Stretching

• SI joint belt

• Diagnostic Injection with Control

Where to start an evaluation?

What do I do? #1 Take a Breath and Relax

Don’t Rush into anything!

What to expect?

• History Taking: • Who, what, where, when and why? Your Past and Present?

• Patient Functional Abilities

• Time course: • Acute, Sub-Acute, Chronic, Acute on Chronic.

• Physical examination: • Should including all areas involved above and below the area of pain or

suspected problem.

• Last Studies: • Blood Tests, Radiologic, EMG/NCV, Diagnostic Injections.

Currently:

• Low back pain 80% to 90% resolves in about 6 weeks irrespective of the administration or type of treatment.

• 5% to 10% of patients developing persistent back pain.

• Relapse: Modern evidence 25%- 60% of patients have persistent pain, one year or longer after the initial episode.

6. Quality Care and Treatment: How does one choose?

What ever looks the Best? Pray and Hope for the Best?

Pharmacologic Approaches

• NSAIDs

• Antidepressants

• Antiepileptics

• Muscle relaxants

• Opioids

• Oral steroids

• Herbal medicine

NSAIDs vs. Placebo for Acute LBP

NSAIDs vs. Placebo for Chronic LBP

Herbal and Nutritional Medications

• Multiple Herbs have known anti-inflammatory properties • Tumeric

• Mustard

• Holy Basil

• Emue Oil

• Olive Oil

• Fish Oil

• Primary problem in US is reliability of products. • No regulation

• Certifications are not consistent

• Expensive for many patients

• Studies limited on efficacy and diagnosis beyond greater effect than placebo in acute phases

Herbal Medicine

• Most trials are of poor quality.

• Some do appear to reduce pain more than placebo:

Harpagophytum

procumbens

(devil's claw)

Salix alba

(white willow bark)

Capsicum frutescens

(cayenne)

NSAIDs

• Slightly effective for short-term symptomatic relief in patients with acute and chronic low-back pain without sciatica. • In patients with acute sciatica, no difference in effect

between NSAIDs and placebo was found. • Not more effective than other drugs (acetaminophen,

narcotic analgesics, and muscle relaxants).

• Side effects • Abdominal pain, diarrhea, edema, dry mouth, rash,

dizziness, headache, tiredness, etc. • Placebo and acetaminophen < NSAIDs < muscle relaxants

and narcotic analgesics

Oral Steroids for Lumbosacral Radiculopathy

• No Cochrane Review

• Some studies report improvement based on weight based steroid treatment. Utilizing theories of steroid in SCI patients. 1mg-1.5mg/kg.

• However no studies acute radiculopathy until recently

• 2012 Journal of Sports Radiculopathy in large disc hernation(no definition regarding size stated) • Prednisone 60mg tapering over 2 weeks

• Clinical and symptomatic improvement was noted compared to placebo

• However no long term change in need for surbery.

• Previous studies • Two double-blind placebo-controlled studies

– Haimovic and Beresford, 1986 • N=33, seven-day prednisone taper vs. placebo

• No significant difference between groups

– Holve and Barkan, 2008 • N=29, nine-day dexamethasone tape vs. placebo

• No significant difference between groups

Vitamin D

• Recent Articles in Jama 2016 suggest correlation in some patient between Vit. D level and supplementation and Pain relief.

• Supported by article in the nutritional literature and functional medicine literature

• No Double blind studies

Vitamin B Complex

• No studies to support beyond check for normal levels

• Some Suggest supplementing to high normal levels improves neuropathic symptoms.

• No blinded studies to support.

Hormonal Therapy

Testosterone

• Limited studies suggest men on hormonal therapy have less incidence or recurrence of back, joint and tendonopathy.

• Theory: testosterone helps regulate vascular density in tissue in men, as testosterone levels drop, vascular density decreases. This predisposes men to injury as they age.

• No blinded studies currently to support

Growth Hormone

• Increase muscle mass and decreased loss theorized

• Clinical case still reports only found

Muscle Relaxants

• Antispasmodic agents • Benzodiazepines

–Diazepam (Valium) – Tetrazepam

• Non-benzodiazepines –Tizanidine (Zanaflex) –Cyclobenzaprine (Flexeril) –Carisoprodol (Soma) –Methocarbamol (Robaxin) –Metaxalone (Skelaxin)

– Antispasticity agents – Baclofen (Lioresal) – Dantrolene (Dantrium)

Muscle Relaxants

• Strong evidence that non-benzodiazepines are effective for acute LBP, and that tetrazepam is effective for chronic LBP.

• Less convincing evidence on benzodiazepines for acute and non-benzodiazepines for chronic LBP.

• It is unknown if muscle relaxants are more effective than NSAIDs. – No trials directly compared these drugs.

Muscle Relaxants

• However, adverse effects are common – CNS: drowsiness, dizziness

– GI

– Dependency • Since NSAIDs do not cause dependency, some clinical guidelines advise avoiding muscle

relaxants except in nonresponders to NSAIDs.

Back Pain Management

• Nonpharmacologic approaches – Lifestyle changes

– Rehabilitation

– Psychological interventions

• Pharmacologic approaches

• Interventional/Neurostimulation approaches

Nonpharmacologic Approaches

• Bed rest vs. staying active

• Lumbar supports

• Superficial heat or cold

• Traction

• Massage

• Acupuncture

• TENS

• Exercise therapy

• Behavioral therapy

• Physical Therapy

• Chiropractic Therapy

Cold Therapy

Anecdotal evidence and case studies report short term benefits and symptomatic relief, but no studies could be found to support long term benefits of cold therapy.

Advice to Rest in Bed versus Advice to Stay Active

• Moderate-quality evidence shows that patients with acute LBP may experience small benefits in pain relief and functional improvement from advice to stay active compared to advice to rest in bed.

• Patients with sciatica experience little or no difference between the two approaches.

Lumbar Supports

• Available studies are of low quality.

• It remains unclear whether lumbar supports are more effective than no or other interventions for treating low-back pain.

Superficial Heat

• There is moderate evidence that heat wrap therapy reduces pain and disability for patients with back pain that lasts for less than three months. The relief has only been shown to occur for a short time and the effect is relatively small. – Heat treatments include hot water bottles, soft heated packs filled

with grain, hot towels, hot baths, saunas, steam, heat wraps, heat pads, electric heat pads and infra-red heat lamps.

• There is not enough evidence about the effect of the application of heat for back pain that lasts longer than three months.

Traction:

• Low back pain: studies consistently show that it is “probably not effective.”

• Neck pain: insufficient evidence

Massage

• Massage is beneficial for patients with subacute and chronic non-specific(myofascial) low-back pain in terms of improving symptoms and function.

• No head to head studies comparing medication or Stretching.

• Effects of massage are improved if combined with exercise and education.

• Benefits in chronic LBP are long-lasting (at least one year after end of sessions). – There is evidence that acupuncture massage is better than

classic massage, but this needs confirmation. – Massage therapy is costly, but it may save money in health

care provider visits, pain medications and costs of back care services.

Acupuncture

• The data do not allow firm conclusions about the effectiveness of acupuncture for acute low-back pain.

• For chronic low-back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment in the short-term only.

Laser Therapy

• New Treatment No double blind studies

• Clinical studies only

• Principles is light wave stimulation of cellular organelles stimulates protein synthesis

• Feels like deep penetrating heat to most patients.

Transcutaneous Electrical Nerve Stimulation (TENS)

• Consistent evidence that TENS does not improve disability due to back pain.

• Due to conflicting evidence, it is unclear if TENS is beneficial in reducing back pain intensity.

• 2010 AAN Guideline: “TENS is established as ineffective for the treatment of chronic low back pain. ... (TENS) is not recommended for the treatment of chronic low back pain.”

Behavioral Therapy

• Moderate-quality evidence that behavioral therapy is better than usual care in the short term. – No difference among behavioral techniques (operant, cognitive, respondent

therapy)

• Medium and long term: not superior to group exercises.

• This does not include activity Modification and Posture and Mechanic Correction

Spinal Manipulation(DC,DO,PT,MPT, MT, ETC)

• Higher Risk of Side effects with high velocity Manipulation compared to low velocity Manipulation

• 1-2 studies attempt to suggest correlation between frequent Manipulation and acceleration of degenerative disease, but no good sham or long term studies.

• Currently Large scale long term study occurring in China, results pending

• Current short term studies suggest Spinal manipulation was more effective in reducing pain and improving the ability to perform everyday activities than sham therapy and therapies known to be unhelpful. • Same for acute and chronic pain • No more or less effective than medication, physical therapy, or exercise.

Exercise Therapy

• In chronic LBP, exercise therapy was slightly effective at decreasing pain and improving function.

• In subacute LBP there is some evidence that a graded activity program improves absenteeism. • Evidence for other types of exercise is unclear.

• In acute LBP, exercise therapy is as effective as either no treatment or other conservative treatments.

General Principles of Pharmacotherapy

• Consider adverse effects as well as efficacy.

• Consider comorbidities. • Renal, hepatic impairment

• Select agents effective at treating multiple conditions.

• Consider interactions with patients’ other medications.

• Start low, go slow.

Nonpharmacologic Therapies for Acute and Chronic Low

Back Pain: A Review of the Evidence for an American Pain

Society/American College of Physicians Clinical Practice

Guideline (Ann Int Med 2007)

• There is good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation are all moderately effective for chronic or subacute (>4 weeks' duration) low back pain.

• There is fair evidence that acupuncture, massage, and yoga are also effective for chronic low back pain.

• For acute low back pain (<4 weeks' duration), the only nonpharmacologic therapies with evidence of efficacy are superficial heat (good evidence for moderate benefits) and spinal manipulation (fair evidence for small-to-moderate benefits).

• Evidence is insufficient to evaluate the efficacy of therapies for sciatica.

Medications for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline (Ann Int Med 2007)

• There is good evidence that the following are effective for pain relief:

– NSAIDs, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain). –The magnitude of benefit was moderate, except in the

case of TCAs (for which the benefit was small-to-moderate).

• There is fair evidence that acetaminophen, opioids, tramadol, benzodiazepines, and gabapentin (for radiculopathy) are effective for pain relief.

• There is good evidence that systemic corticosteroids are ineffective.

So Why Treat Worry about Pain?

• Evidence shows early intervention with anti-inflammatory regularly for 1-2 weeks.

• Decreases Risk of Permanent Nerve Damage.

• Risk of Chronic Pain

• Early Accurate Diagnosis also helps to prevent recurrence when proper preventative education is given.

Time Course

• Pre-morbid function

• Sudden onset or insidious?

• Flair of chronic condition?

• Relapsing/remitting?

• Progressive?

The “Red Flags”

• <55 years of Age • Sensory or Motor Deficits: ASIA Classification • Changes in Reflexes • Severe Functional Impairments • Major Focal or Multifocal Trauma • Positive Family History • Prior History of Relevant Disease

• Major trauma, new onset >55 yrs.

• Constitutional symptoms (fever, chills, weight loss) • Recent infection, IV drug use, immune suppression • Severe pain with rest, night pain • Neurologic weakness, cauda equina symptoms/signs • Fear avoidance behavior and reduced activity levels • Depression, low morale, social withdrawal • Social, financial of compensation problems

Physical Exam

Evidence Based

• Straight leg raising

• Atrophy

• Point tenderness over single vertebrae

• 3/5 SI provocation signs

• Waddell’s signs of non-organic pain

“Soft Findings”

• Range of motion

• Muscle tenderness

• SI tenderness

Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med. 2001 Feb;16(2):120-31.

Non-Specific Testing

• SLR • 10 studies found 7 reasonable studies with most has sensitivity and

specificity but most note and report multiple caveats: Patient flexibility or inflexibility, Secondary factors and gain, provider experience and bias issues.

• Slump Tests: Greater sensitivity than SLR but Less Specific

• CSLR: When Present noted Greater Sensitive and Specificity then SLR or Slump Test

• Facet Loading: 20-45% false positive rate

Majlesi J et all The sensitivity and specificity of the slump and the Straight Leg Raising test in patients with lumbar disc hernations J. Clin, Rheumatol 2008 Apr;14(2):87-91 Wiash J, Hall T. Agreement and correlation between the SLR and slump Tests in subjects with leg pain Validity of the fingertip to floor test and SLR test in patients with acute and subacute low back pain: a comparison by sex and radicular pain. J. Manipulative Physio ther, 2009 Mar-Apr;32(3):184-92 Ekedahl KH, Honsson B Frobell Rb Arch Phys Med Rehabil. 2010Aug: 91(8):1243-7 Schwarzer et all Clinical features of patinets with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine 1994 May 15. 19(10);1132-7.

Pain Generator: Facet

• Signs and Symptoms: • Pain Extension/Hyper-extension • Pain Rotation • Pain with Rotation & extension focal • Pain rising from flexed position • Pain on Palpation focal • Decrease motion w/ Movement or Blot Maneuver

5 or more 92% PPV response to single diagnostic

• Schwarzer AC, Aprill CN, Derby R, et al. Clinical features of patients with pain stemming from the lumbar zygapophyseal joints. Is the lumbar facet syndrome a clinical entity? Spine 1994b; 19: 1132-1137.

Pain Generators: SI Joint

• 3/6 pos. signs had sensitivity of 94% and specificity of 77% • Distraction

• Compression

• Gaenslen’s (left and right)

• Thigh thrust

• Sacral thrust

• Palpation

• Compared to diagnostic

block

Waddell’s Signs

•>3/5 negatively correlates with outcomes from surgery and P.T.

• Tenderness

• Simulation

• Regional (non-dermatome) disturbance

• Distraction

• Over-reaction

Waddell G Occupational low-back pain, illness behavior, and disability. Spine. 1991 Jun;16(6):683-5.

Diagnostic Studies Radiology 101

Image Studies (ACR)

Diagnostic

Testing in

Sub-acute

(MRI)

Bone X-Rays

Bone and Tissue CT Scan

Spine

Infection or Scar MRI with

Gadolinium

Pace Maker or Spinal Cord Stimulator

CT Myelogram

Disc Disease Discography

Joint MRI Arthrogram

Unclear Diagnostic Injection

Based on American College of Radiology Guidelines and Journal of Trauma

Diagnostic Tests

• What tests would you order? Acute Pain?

• Plain radiography: only indications are for severe acute trauma (i.e. fracture), scoliosis and spondylolisthesis. No Data studies show any value ie change in outcomes in acute low back pain.

• In absence of red flags: Diagnostic Studies are not recommended in the first 4-6week of low back symptoms as they do not result in change in clinical management.

Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med. 2001 Feb;16(2):120-31. National Guideline Clearinghouse Low back Pain American college of occupational and Environmental Medicine 2011. P333-796. National Guideline Clearinghouse Low back disorders American college of occupational and Environmental Medicine 2011. P366.

MRI: T1 versus T2

T1 T2

CT Scan of Lumbar Spine

Lumbar MRI

• My Disc is Torn, Herniated, bulging, etc.

Disc Pathology

Intradiscal: 1.Annular Tear 2. Discitis

3. Disc protrusion 4. Degenerative

Disc 4. Disc Herniation 5. Sequestered Fragment

Bone Scan

I have a Disc something or other & Sciatica! My DC/DO/MD told me:

• My MRI shows a disc bulge, protrusion or something!

• OK: So Now What?

• What should I do?

• Is a disc issue a big deal?

• Can A Disc Cause Sciatica?

• What is Sciatica?

MRI: The Hidden Truth!

• Large number of abnormal MRI findings found in asymptomatic individuals.

An MRI is Not specific! Evidence:

• 38-93% of asymptomatic people have evidence of degeneration on cervical and lumbar MRI.

Boos et al 1995, Boden et al 1990a, Boden et al 1990, Weishaupt 1998,Jarvik et al 2001, Kjaer 2005, Matsumoto et al 1998

• 52-81% have lumbar disc bulge in at least one level. Jensen et al 1994, Stadnik et al 1998

• 27-57% of normal subjects have a disc protrusion in Cervical or LS MRI

Jensen et al 1994, Weishaupt et al 1998, Stadnik et al 1998, Teresi et al 1998

MRI

• So While MRI is the Best single test for “red flags” concerns.

• Not Specific A Cause of Pain.

• Average of 63% asymptomatic controls > 40 years old have disc bulges

MRI

• Best single test for the “red flags”

• Caveat: 63% of asymptomatic controls > 40 years old have disc bulges

Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994 Jul 14;331(2):69-73.

EMG/NCV

• Positive EMG pre-op has been shown to improve

likelihood of a successful outcome postoperatively. Partanen 1991.

Advantage

• Assess neurophysiologic status.

• High specificity(85%) Robinson 1999

• Can suggest severity, chronicity or extent of the

• disorder.

Disadvantage

• Painful/expensive.

• Subject to interpretation.

• Relatively low sensitivity.

What is Causing My Pain? This is the #1Question!

Diagnostic Injections?

• Indications: • Pain Pattern suggestive but not consistent • PE and Radiographic evidence: Non-focal or too complex

• Proven valid method when: • Under Flouroscopy • Placebo or Comparative Anesthetic Control Injection

• What is their use? • Obtain Definitive Diagnosis • Prove Referral Pain Pattern • Unmask other Potential Pain Generators

• When multiple pathologies or issues present.

• American Society Interventional Pain Physicians ASIPP 2008 Interventional Guidelines

• International Society of Interventional Spine ISIS 2007

“Therapeutic Injections”

• Why is Pain Relief Variable? • Location / Pathology

• Procedure type / Medication used

• Post Procedure care

• Patient Conditioning

• Patient Co-morbid Factors

• Poor - No Compliance with Recommendations

• Medicare Limits Doctors! Only 3 injections within a 6 month period of time in a single region of the spine.

Medicare Limitations

• Medicare and Insurance Place Limits on Physicians • Only 3 Injections within a 6 month period is allowed in a region of the spine.

• Lumbar and SI are considered similar region but will allow 4 if one is SI.

• Joint injections traditionally no sooner then 1-3 months

• Follows and evaluations must be 2 weeks apart.

Diagnostic Injections?

• Indications: • Pain Pattern suggestive but not consistent • PE and Radiographic evidence: Non-focal or too complex

• Proven valid method when: • Under Flouroscopy • Placebo or Comparative Anesthetic Control Injection

• What are Diagnostic injections used For? • Obtain Definitive Diagnosis • Prove Referral Pain Pattern • Unmask other Potential Pain Generators

• When multiple pathologies or issues present.

• American Society Interventional Pain Physicians ASIPP 2008 Interventional Guidelines

• International Society of Interventional Spine ISIS 2007

What to expect from Diagnostic Injections?

0

2

4

6

8

10

12

0

2

4

6

8

10

12

Anethestic Steroid

Diagnostic Injections are used to?

• Determine the cause and source of pain when multiple pathologies exist on MRI or in patients whose examination is not conclusive

• Help differentiate Between: • Facet Disease

• Disc Disease

• Spinal Stenosis

• Hip Osteoarthritis

• SI joint Arthosis

• Nerve Compression

When Conservative Management Isn’t Adequate

Evidence Regarding Injection Therapy? Does any really exist?

Diagnostic SI joint Injection

•Without Control 40% in wrong location & 20-29% FP

•With 90%+ Accurate

SI Therapeutic Injections

• Steroid Injections • 58-80% significant relief at 6 months.

• Radiofrequency • 64%-89% significant relief at 1 year.

Pain Generator: Facet

• Pain Patterns overlap with Radiculitis, Radiculopathy, “Sciatica”, Discogenic Pain/

• LBP with referral into LE down to knee

• Neck with referral into the shoulder back or arm

AP VIEW: L5 vertebra for L4 medial branch neurotomy

TP

iap

sap

mp

LATERAL VIEW: L5 vertebra for L4 medial branch neurotomy

L5 sap

base of L5 TP

tip of L5 TP

OBLIQUE VIEW: Scotty dog silhouette

“ear” = sap

“eye” = pedicle

“snout” = TP

“forelimb” = iap

L4-5 z joint

L5 sap

medial branch

after emerging

from under the

mal

mal

medial branch

intermediate branch

lateral branch

L5 TP

The blue arrow

indicates where

the medial branch

disappears under

the mal

Lateral view of branches of the right L4 dorsal ramus

Pain Generator: Facet

• Diagnostic Injection • Facet Joint

• Medial Branch

• Both valid techniques when

in conjunction with a control block.

• Single injection 17-49% FFP

Facet Therapeutic

• Joint Injection • 38-62% Significant relief 3 month • 14-56% Significant relief 6 month

• Radiofrequency of Medial Branch Nerve

• 72-93% Significant relief 3 months • 40-93% Significant relief 6 months • 40-93% Significant relief 12 months

Pulsed Radiofrequency Ablation

• Destroys small unmylinated fibers

• Can be used for • Dorsal Roots Chronic Pain

• Intercostal Neuralgia

• Sympathetic Nerve Block

• Medicare Mandate and Insurance Mandate • Two Diagnostic Blocks with >75% relief prior to RFA.

Discogenic Pain

Disc level Location of pain Motor deficit

Position and Disc Pressure

Discography

• Indications: • To determine whether or not a lumbar disc is causing pain

• Unremitting LBP > 4 months

• Negative Diagnostic Imaging Studies

• Evaluation for Percutaneous disc procedures

• Evaluation of postsurgical patient for recurrent disc herniation or pseudoarthrosis.

Discography

• Multiple studies and protocol by various organizations

• No standard at this time.

• Carragee et al. 2000.

• Against Discography state false + secondary to Somatization

• Most studies contradict his findings. Derby 2006,07,08

• Study Design flaws

• Manchikanti et al 2001; did not find any impact on discography with or without somatization disorder results similar.

• Bogduk 2006, 2008 found excellent correlation between discography and determination of a disc causing pain when performed by a trained technician.

• 80% positive outcome for surgery when done properly .

Discography

• High intensity zone on T2-weight MRI sagittal images in the posterior annulus representative of a radial annular fissure • 90% positive predictive value with concordant discography

• Absence of HIZ does not exclude annular pathology or discogenic pain.

• Falco et al. ASIPP 2007.

A B

A B

S1

L5

L4

L3 L3

L4

L5

S1

What is measured?

• Open Pressure:

• Pain pressure:

• Max Pressure:

• Disc: Asymptomatic Painful

• Pain Score:___ (8 or more)

• Normal Pain Different Pain

• Pain refers to:

• Contrast & Spread: Epidural Nucleus Annular Tear DDD

• Disc Height:

A B

L5

S1

L4

L3 L3

L4

L5

S1

Grade I

Grade IV Grade III

Grade II

Patients should be instructed not to drive the day of the procedure

Patients should understand that they can expect a moderate increase in discomfort for 2-4 days

Prescriptions for analgesics as required

Patients are asked to report any unusual pain or pain not relieved by the prescribed medication.

Severe or unusual pain may be a symptom of discitis

POST-PROCEDURAL CARE

COMPLICATIONS

• Discitis • Incidence < 1%

• Most common organism Staph aureus

• E Coli with penetration of bowel

• Incidence reduced with the use of IV / intradiscal antibiotics

Discectomy

• Traditional Surgery

• Stryker Disc Decompressor

• Coblation

• Laser

• Endoscopic • Fallen out of favor because of unnecessary procedures having been

performed by many doctors who are not pain physicians or are but never fellowship trained and subsequently were performed without correct indications.

Translaminar ESI

• (Shotgun approach)

• Indications

• Disc pathologies

• Low Back Pain and Strain

• Radicular Pain

• Spinal Stenosis pain(level below)

• Previous Surgery

• NOT Diagnostic

• Benefit

• 6weeks: 75 - 90%

• 3months: 75 - 90%

• 6months: 75 - 90%

Transforaminal ESI

• Indications • Disc pathologies • Failed back • Nerve Entrapment • Post-op Epidural Fibrosis • Radicular Pain • Assist in assessment of

specific level when multi-level dz.

• Benefit • 6weeks: 63%-84% • 3months:63%-75% • 6months:56%-75%

Abdi et al 2007

What to expect from Epidural Injections?

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Anethestic Steroid

Epidemiology of Pain

• Within the US:

• 40 million visit for new pain to PCP • Largest (41%) is for Musculoskeletal Pain Issues.

• Acute Pain 15-20%

• Sub acute Pain 50-60%

• Chronic Pain 25-30%

• Low Back Pain :Most common cause of work days missed

• Annual incidence 15-20% of Adult population with a life time incidence of 60-85% of the population.

• 14% US adults have serious Chronic back conditions.

Low Back Pain

Treatment

Diagnosis

Future

Recurrence

New Treatment

Treatment Chronic Pain

Current

Recurrence

Recurrence

Treatment

Low Back Pain

Treatment

Prevention

Diagnosis

Risk Factors

Future

Treatment

Diagnosis Recurrence

New Treatment

Treatment Chronic Pain

Current

Recurrence

Recurrence

Treatment

You need to start thinking about multi-modal approach for Short and Long Term, but what step is most important?

1. Proper Diagnosis

2. Functional Impairments

3. Halt Inflammatory Process

4. Control Pain

5. Correct Mechanical Issues

6. Teach Adaptation if not correctable

7. Educate patient for long term

8. Provide Support Psychological, Physical

9. F/u, Home Equip. etc.

Long

Term

Proper Diagnosis

Control

Pain

Halt Dz. Process

Correct Body

Mechanics

Patient Education

Patient Compliance

Adapt Work

Co-morbid

Disease

Rehabilitation & Integrated Pain Management

Intervention

Physical Therapy

Occupational Therapy

Complementary Therapies

Psychology Religion

Modalities

Preventive Care

Medication

Prevention Through Balance

1. Balance

• Balance within Your Body. • Strength

• Flexibility

• Knowledge

• Ergonomics

• Balance within Your Mind.

• Balance within Your Life.

• Balance Your Soul.

Flexibility

Strength

Knowledge

Ergonomic Living

2. Knowledge

• Knowledge of Personal limits

• Knowledge of Environment

• Knowledge of Ergonomics

• Knowledge of Disease

• History

3. Know Your History

• Your Own History

• Your Parents

• Your Family

• Tell your Children

4. Know Your Risks! Treat Them!

• Smoking

• Flexibility

• Posture & Mechanics

• Weight

• Nutrition

• Stress

• Environment

• Work

• Pollution

• Kids

Inappropriate Mechanics

Ergonomics

Future

5. Early Intervention

• Go Early

• Think Preventive Care

• Think Cause Not Problem

• Don’t assume it is the same old problem

• Demand A Thorough Evaluation

• Correct Your Risk

• Remember Balance

• Listen To What You Don’t Want To Hear

• Follow Up and Follow Through

Education

Treatment Plan Should:

1. Determine and Confirm Diagnosis

2. Calm Inflammation contributing pain

3. Treatment the Pathology causing pain

4. Address the co-morbid diseases contributing

5. Educate regarding methods to prevent return of pain

6. Educate on proper body mechanics or adaptation to return to life.

7. Pain control without function is of no use!

Prevention

• Activity Modification

• Posture and Mechanics

• Work Hardening Programs

• Strengthening Conditioning

• Flexibility

• Evidence suggests helps with prevention of future incidence

• May prevent initial events

Flexibility Vs Inflexiblity

Conclusion

• Evidence-based medicine has limitations.

• Tailor therapy for the individual patient.

• A combination of approaches may be useful.

Remember nothing can Fix:

Chronic Pain Management Modern Therapies

Before and After

Pharmacologic Approaches

• NSAIDs

• Antidepressants

• Antiepileptics

• Muscle relaxants

• Opioids

• Oral steroids

• Herbal medicine

Antidepressants

No different from placebo for pain relief

TCA Antidepressants

No different from placebo for pain relief

FDA Approval of an Antidepressant for LBP?

• Duloxetine (Cymbalta) • Approved for fibromyalgia and painful diabetic neuropathy as well as anxiety

and depression.

• In August 2010, an FDA Advisory Panel voted 8 to 6 to approve it for chronic lower back pain.

Antiepileptics

• No Cochrane Review

• Gabapentin for radiculopathy • Two double-blind placebo-controlled studies

• Yildirim et al., 2003 • N=50, GBP 3600 mg/day vs. placebo

• Slightly but significantly more improvement in back pain at rest compared to placebo

• McCleane et al., 2001 • N=80, GBP 3600 mg/day vs. placebo

• Small but significant improvement in back pain with movement and in leg pain

• Side effects: drowsiness, dizziness, loss of energy

One of Many Theorized Pathways

• Antidepressants and Central Acting Agents are based on this theory • Cymbalta

• Nortriptyline

• Amitriptyline

• Lyrica

• Gabapentin

Opioids for Chronic LBP

• More effective than placebo on pain and on disability

Opioids for Chronic LBP

• No more effective than other analgesics on pain or disability.

Opioids for Chronic LBP

• But significantly more side effects than placebo: – Nausea

– Constipation – Dry mouth – Somnolence

– Dizziness – Vomiting – Anorexia – Pruritus

– Hyperhidrosis

Chronic Pain Behavior

• Chronic pain cycle

• Extrinsic locus of control

• Catastrophizing

• Childhood abuse

Neuromodulation SCS What is it?

Pacemaker for the Spine?

Neurostimulation Spinal Cord Stimulation

• Neurostimulation is a pain treatment that delivers low voltage electrical stimulation to the spinal cord to inhibit or block the sensation of pain

• Trial screening prior to full implantation.

• Trial is reversible whether positive or negative.

Neuromodulations:

• Spinal cord stimulators • Successful in 65% of failed back surgery

patients at 2 yrs

• North RB, Kidd DH, Petrucci L, Dorsi MJ. Spinal cord stimulation electrode design: a prospective, randomized, controlled trial comparing percutaneous with laminectomy electrodes: part II-clinical outcomes. Neurosurgery. 2005 Nov;57(5):990-6; discussion 990-6.

History • 1965 - The Gate Theory of Pain (Wall and

Melzack)Postulated central inhibition of pain by non

painful stimulus.

• 1967 - Norman Shealy - gate could be closed by stimulating Dorsal Columns.

• Paper turned down by Journal of Neurosurgery.

168

History (cont’d)

• March 1967 - Shealy implants first DCS by lami at T2-3.

• Patient #1 - 70 y.o. male with inoperable bronchogenic carcinoma.

• Obtained good pain relief.

• October 1967 - Patient #2 - 50 y.o. female with pelvic carcinomatosis, > 50% pain relief.

• Circuit design based on a modified Medtronic device for carotid sinus stimulation to control angina & HTN.

169

History (cont’d)

• 1969 - Shealy presents results to Harvey Cushing Society.

• Dorsal Column Stimulation Group formed. (500 pts for 5 years).

• 1972 - Avery Labs begins marketing DCS’s to all Neurosurgeons.

• Medtronic follows suit and changes design to platinum twisted tinsel wire.

• Oxidizes after 6 - 12 months.

170

History (cont’d)

• 1981 - Initial RF activated passive systems.

• Multi-channel multi-programmable neural stimulators

• 1985 - Advanced cardiac pacemaker technology develops.

• First non-invasively programmable totally implantable pulse generators (IPGs).

171

History (cont’d)

• 1987 - Dual multipolar lead systems are introduced.

• Development of Percutaneous leads.

• 1999 - Barolat - replaces the term Dorsal Column Stimulation with Spinal Cord Stimulation.

172

SCS Today What do we use it for?

Neuromodulation: Who is a Candidate?

Spinal Cord Stimulation (SCS) Type I and Type II CRPS

Upper or Lower extremity Painful Neuralgia Diabetes

Peripheral Arterial Disease

Chronic Back Pain Failed Back

Discogenic pain

Chronic Angina

Peripheral Nerve Stimulation (PNS) Consider in Type II if symptoms limited to single nerve

distribution

SCS: Implantable Pulse Generator or Radiofrequency System, PNS: Radiofrequency System

Stanton-Hicks M et al. Pain Practice. 2002; 2:1-16.

Current Indications (and growing)

Failed Back Surgery Syndrome.

Ischemic Peripheral Vascular Disease.

Atypical Trigeminal Neuralgia.

Refractory Angina Pectoris.

Phantom Limb Pain.

Post Thoracotomy Pain.

Multiple Plexopathies.

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Current Indications (cont’d)

CRPS (Formerly RSD).

Interstitial Cystitis.

Occipital Neuralgia.

Transformed Migraine.

Ilioinguinal Neuralgia.

Post Herpetic Neuralgia.

Post Cervical Laminectomy.

176

Medicare requires the following criteria to be met in order to reimburse costs for SCS:

• Pharmacological, surgical, physical, or psychological therapies have been tried and have not satisfactorily treated the patient; or they are considered unsuitable or contraindicated for the given patient.

• Patient must undergo screening including a physical and psychological evaluation.

• All facilities, equipment, and professional and support personnel are available to properly diagnose, treat, train, and follow up with the patient.

• Before permanently implanting an SCS system, physicians must demonstrate that implanted electrodes relieved pain during an SCS trial.

• Stimulator is implanted only as a late resort for patients with chronic intractable pain.

Failed Back Syndrome

• FBSS is a subset of chronic

low back pain, which is a

type of chronic pain.

• In 2005 between 20 and 40 percent of spine surgery patients were diagnosed with FBSS

Percentage of Pain Reduction for Different Treatments

• More patients receiving SCS achieved 50 percent or more pain relief compared with those who underwent reoperation.

• According to a study conducted by North et al. in 2005, 47 percent of patients who received SCS found that it relieved their pain by 50 percent or more; this is significantly more than the12 percent who achieved the same effect through reoperation.

Pain Reduction Comparison

SCS Studies evaluating Pain Reduction:

SCS Studies evaluating Medication Reduction:

SCS Cost Effectiveness:

• A cost-benefit analysis by Mekhail et al. in the Clinical Journal of Pain revealed that the cost savings associated with SCS was $30,221 per patient per year.

• Based on a randomized controlled SCS trial, North reported in 2007, “At a mean 3 years of follow-up, SCS is dominant [less expensive and more effective] than reoperation.”12 In this study, the mean cost per success was $177,901 for patients who crossed over to SCS. No crossovers to reoperation were successful, despite a mean per-patient cost of $260,584.

SCS Timing

• SCS for patients with FBSS is more effective the sooner an SCS system is implanted from the date of the previous failed surgery.

Neurostimulation System Implant Technique

185

Percutaneous Lead Placement

• Insert Touhy needle

• Confirm needle location with fluoroscopy and loss of resistance

• Introduce Guide wire

• Insert lead

• Confirm lead location with fluoroscopy

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Dual Lead Placement

• Insert second needle one level below/contralateral to first

• Place lead tips at same level or staggered

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Overview of Trial Procedure

• A percutaneous lead is positioned in the epidural space on the dorsal aspect of the spinal cord at the appropriate nerve root level(s).

• Electrical current from the lead generates paresthesias that can be adjusted in intensity and location to achieve the best pain coverage.

• Leads are attached to an external pulse generator (screener) which supplies the current.

• Patients can use the screener to adjust stimulation to meet pain management needs.

Intraoperative Screening

• Connect lead and screener

• Goal of matching stimulation to pain pattern

• Test by trying different electrode combinations and polarities

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Test Stimulation: Partial Percutaneous Lead Implant

• Least invasive initial approach

• Preferred test stimulation for surgical leads

• Lead secured to skin

• Programed Post Procedure and given Instruction

• Go home for 1-3 days then return.

• Upon Return Leads or Removed.

191

If SCS successful 2-3 weeks Leads are surgically implanted with generator in outpatient

surgery.

Implantation: Component Connections

• Neurostimulator/extension connection

• Implant Neurostimulator in pocket

• X-rays for system visualization

• Incisions closed

• Settings optimized with external programmer

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Surgical Lead Implantation

• Surgical lead alternative

• Make laminotomy

• Surgical lead insertion

194

Test Stimulation: Fully Implanted Technique

• Lead anchored to supraspinous ligament

• Retest the patient

• Extension externalized

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Test Stimulation: Fully Implanted Technique

• Employ local anesthetic for tunneling path

• Create stab wound on flank

• Tunneling to flank

• Pass extension through stab wound

• Connect extension

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Implantation: Pocket Creation and Tunneling

• Implantation option with >50% pain control

• Percutaneous extension removed

• Pocket site identified and created

• Extension connected with lead

• Pocket creation for connector and excess lead

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Postoperative Considerations

• Assure lead stability

• Review instructions with patient’s family

• Ensure patient’s full understanding of system operation

198

Important Information on Implanted Devices for Pain Therapy

• Possible complications • Infections

• Lead dislodgment

• Loss of functionality

• Surgical revision for reduction or loss of pain relief

• Interference may be caused by MRIs and other radio frequency devices

• Lead fracture

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Efficacy of Neurostimulation

Study Results Complications

Kemler, 2000

Randomized, Controlled

N=54, (36 SCS+PT – 24 received

permanent implant, 18 PT)

Follow-up = 6 months

• VAS scores decreased 2.4 cm in SCS+PT vs increased .2 cm in PT (p < .001)

• The proportion of patients with a score of 6 (“much improved”) for the global

perceived effect was much higher in SCS+PT vs. PT only (39% vs. 6%) (P=.01).

• The health related quality of life improved in the patients who actually underwent

implantation of SCS. VAS decreased 3.6 cm in this group

• No improvement in function

6 of 24 patients had a

total of 11

complications

Bennett, 1999

Retrospective multicenter

N=101 (Grp I=30, Grp II=71)

Avg follow-up: Grp I = 18.7 mos.,

Grp II = 23.5 mos.

• Group 1 single lead quad systems, II dual lead octapolar systems

• VAS decreased 3.7 in group I (p<.0001) and VAS decreased 6 in group II (p<.0001)

• Percentage overall satisfaction 70% in group I (p<.05) and 91% in group II (p<.05)

20 total complications,

(12 in 30 grp I pts, 8 in

71 grp II pts)

Oakley and Weiner, 1999

Prospective, 2 center

N=19, 10 Assessable

Avg Follow-up: 7.9 Months

• VAS decreased from 6.7 pre-implant to 4.5 post-implant

• 9/10 patients thought stimulation was worthwhile

• 30% full relief, 70% partial relief-80% obtained at least 50% pain relief

• Sickness Impact Profile and McGill Pain Rating Index significantly improved (p<.05),

Beck Depression Inventory showed trend toward improvement

4 patients had

complications (lead

repositioning or

replacement and IPG

implanted deeper)

Cavillo,1998

Retrospective

N=36 (24 SCS, 5 PNS, 7 SCS+

PNS)

Follow-up: 35 months

• Pain (as measured by VAS) 45.3% better with SCS (p<.0001), 51.3% better with

PNS (p<.0001), 63.5% better with both (p<.0001).

• 50% decrease in narcotic intake in 44% of pts; in remainder, analgesic 80% more

effective.

• QOL improved in “most”

• 41% RTW on modified duty

5 patients had

complications (2

infection at generator

site, 2 lead migration,

1 psychosis)

Kumar, 1997

Retrospective

N=12

Avg Follow-up: 41 months (range

6 - 89 months)

• 100% of patients experienced good (50-74%) to excellent (75-100%) long term relief

of pain (measured by VAS and modified McGill Pain Questionnaire)

• Only 17% of patients still required occasional narcotic medication

5 lead-related

complications

SCS Effectively Reduces Pain

• Randomized, Controlled Trial in 54 pts.

• SCS + Physical Therapy Group had a statistically significant

• Reduction in Pain measured by Visual Analogue Scale (p < .001)

• Improvement in Global Perceived Effect (p < .01)

-2.5

-2

-1.5

-1

-0.5

0

0.5

Kemler et al. New England Journal of Medicine. Volume 343, Number 9, August 31, 2000: 618-624.

Intention to Treat Group

(SCS + PT)

Control Group (PT)

Change in Pain Score (Visual Analogue Scale)

Patient Selection

• Objective evidence of pathology

• Inadequate pain relief and/or intolerable side effects from more conservative therapies

• Psychological evaluation

• Absence of drug-seeking behavior

Advantages of Implanted Neurostimulators for Pain

• Effective method of pain control

• Systems reprogrammable without surgery

• Patient control within physician set limits

• Nondestructive and minimally invasive compared with surgical alternatives

• Reduction or elimination of pain medications*

• Worldwide use by more than 100,000 patients

*Kumar K, Nath RK, Toth C. Neurosurgery. 1997

Peripheral Nerve Stimulation

Whose a Candidate?

• Patients Diagnosed with intractable chronic migraine may be candidates for peripheral nerve stimulation.

• Intractable chronic migraine is defined as headache lasting at least 4 hours per day for 15 or more days per month, not responding to three or more preventive drugs, and causing at least moderate disability (determined using a validated migraine disability instrument [e.g., MIDAS or HIT-6]).

Neurostimulation systems:

•Regulate the body’s electrical systems. • Like pacemakers, except that instead of sending pulses to the heart,

the leads carry the pulses to the occipital nerves, changing the way the pain signals are transmitted.

• This localized delivery does not produce lingering systemic side effects—a common problem with migraine drugs.

System Consists of:

• Leads and Extensions Wires that carry the pulses from the Neurostimulator to the nerves

• Neurostimulator A stopwatch-sized device containing the battery and electronics that create the pulses which stimulate the nerves

• Patient Programmer A remote control device that enables the patient to turn the Neurostimulator on and off and adjust power levels

• Clinician Programmer A remote control device that enables a clinician to program the Neurostimulator and adjust stimulation

ST. Jude Study

• A randomized double-blind, controlled study of chronic migraine sufferers who used St. Jude Medical PNS systems revealed the following:1

• Reduction in Overall Disability At 12 weeks, the Migraine Disability Assessment (MIDAS) questionnaire indicated participants in the active group had a 41% reduction in overall disability compared to a 13% reduction in the control group.

Number of Headache Days

• 36% decrease in their number of headache days compared to the control group which reported a 25% decrease.

Quality of Life:

At one year, 68% of patients reported that their quality of life improved, 26% reported that it stayed the same, and 5% reported that their quality of life deteriorated.

Recomendation

• At one year, 88% of patients reported that they would recommend the procedure to someone else and 12% reported that they would not.

Hope For the Future? Stem Cell Therapy and Platelet Therapies

Stem Cells

• Stem Cells are a Basic Undetermined Cells Located in various parts of the our bodies.

• Held in Reserve for emergency needs and creation of new tissue when we are injured.

• They theoretically have the ability to be anything.

• Like Children they can grow up to be what ever they want or are bent to be.

• But they Need Guidance.

Theory for Treatment

• By injecting these Stem Cells into an injured area they will differentiate or become the injured tissue and help in healing of injured areas.

Evidence

• Cardiac Studies have show Stem Cells injected into injured cardiac muscle help and become new muscle

• However there is no improvement in the function of the heart itself.

• Limited Case studies no control; No Science.

Evidence

• Cases are of patients with knee pain and a few with spinal disease • No evidence re: benefit

• It is not covered by insurance

• Extremely Expensive at present. Cash only business

• Remember majority of people with Disc disease recover within 6 months.

• The current studies are patient reports of improvement after injection 3-6 months later. So the recover is no faster the normal.

Platelet therapy

• Platelets are blood cells that have healing factors.

• Theory: • Inject Platelets into injured tissue that normally does not get a direct blood

supply. The Platelets will help speed up recovery.

• A few Case Studies with no control • Suggested Subjective improvement in pain and recovery.

• But these patients were not compared with controls

• Studies are not blinded. I.e. patients and doctors know.

Compression Fractures

• 700,000/ year in the United States

• Cost is $17 billion/year in the United States

Kyphoplasty