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TREATMENTS AND INDICATIONS
- EPIDURAL STEROID INJECTIONS
- INTRATHECAL STEROID INJECTIONS
- NERVE BLOCKS WITH LOCAL ANAESTHETICS
- ARTICULAR BLOCK
- REGIONAL SYMPATHETIC BLOCKS
- TRIGGER POINT INJECTIONS
- RADIOFREQUENCY TREATMENTS
- NEUROLYTIC BLOCKS
- BOTULINUM TOXIN TREATMENTS
- OZONE THERAPY
- ADHESIOLYSIS AND RADIOFREQUENCY THROUGH EPIDURAL CATHETER
- IMPLANTABLE NEUROSTIMULATORS
- IMPLANTABLE INFUSION SYSTEMS
The arsenal of useful drugs in the pain clinic has expanded considerably in recent years. New drugs and routes of administration make for better treatment adaptation. Nevertheless, the WHO pain ladder is still the reference point, the transition to oral or transdermal opioids is more accepted and better tolerated with the current pharmacopoeia. Drugs with specific activity in the treatment of neuropathic pain are available to the clinician. Specialised management makes it possible to tailor regimens to obtain optimal outcomes in specific patients.
Epidural steroid injection is one of the most frequently used treatments in the Pain Clinic.
It is performed on an outpatient basis with radiological control.
Epidural injections can be given via different routes (translaminar, caudal or transforaminal) depending on the treatment objective.
The risks stem from the actual injection, as well as those derived from the administration of corticosteroids.
Accidents associated with this technique exist, although their frequency is very low.
Steroid administration may cause an increase in blood sugar levels, increased blood pressure, nervousness, fluid retention, gastric discomfort. The frequency and intensity of these symptoms is low.
In diabetic or hypertensive patients , control should be increased in the days following this procedure.
Epidural steroid injection is indicated in spinal pain syndromes:
- Lower back pain
Its effectiveness is greater for pain that irradiates to the extremities than for axial pain.
The injection of intrathecal steroids consists of accessing the subdural space to inject a dose of corticosteroids. Widely used years ago, it has currently fallen into disuse out of fear of a certain complication, namely chemical arachnoiditis. However, it is still indicated in postherpetic neuralgia resistant to all kinds of treatment.
Indication. Treatment-resistant post-herpetic neuralgia.
Local anaesthetic nerve blocks can be used for diagnosis or for treatment.
If there is any doubt as to the involvement of a nerve root in the patient's process, a local anesthetic block and the disappearance or not of symptoms will confirm whether or not the blocked nerve is related to the process to be treated.
In terms of therapy, they have proved their effectiveness in the treatment of different syndromes, such as herpetic pain (at the onset of symptoms).
The pain generated by inflammation can be reduced by the administration of corticosteroids, local anaesthetics or other substances in the affected joints or related nerves. The posterior vetrebral, sacroiliac and coxofemoral articulations can also benefit from this kind of blocks.
These blocks are intended to halt sympathetic system-mediated response in a specific territory.
They are performed on an outpatient basis, may require radiological control and are repeated on several sessions.
In this case, they are performed with local anaesthetics that cause a temporary block.
In some cases, the persistence of symptoms or their severity can require the indication of a longer block that will be obtained with the injection of a neurolytic substance or radiofrequency thermocoagulation.
- Stellate ganglion block.
- Lumbar sympathetic block
- Brachial plexus block
- Epidural block
- Superior hypogastric and celiac plexus blocks
Indications: CRPS I and II in the upper and lower extremity (stellate ganglion, brachial plexus, epidural and lumbar sympathetic block). Sympathetic-mediated pain in the region of the face and the neck (Stellate Ganglion). Abdominal or pelvic pain with a sympathetic component (celiac and hypogastric plexus).
Pain and vascular syndromes, RAYNAUD, chronic ischaemia, Martorell ulcers. Sympathetic block and sympathectomy are also indicated in the treatment of palmar and plantar HYPERHYDROSIS.
Trigger point injections are one of the treatments that are considered in patients with Myofascial syndrome.
The trigger points are located manually or by electromyography, and are groups of muscle fibres with disordered contractor activity, that the patient is usually aware of and trigger pain in territories distant from the point by exercising pressure on them.
The injection of small doses of local anaesthetic agents into these points provides symptom relief and facilitates physical therapy.
Botulinum Toxin can be used to prolong the effects of trigger point injections.
Electric current run through a tissue produces heat, and a temperature above 45°C produces permanent changes in tissues.
Radiofrequency uses high-frequency electric currents which, by controlling the electric parameters and the characteristics of the electrode, can be used to create highly-limited lesions.
Different effects have been demonstrated when a structure is subjected to a pulsed electric current at temperatures below 45°C.
These effects are sought in techniques that use pulsed radiofrequency, that do not destroy any tissue, but rather alter the biological behaviour of the neurons that receive this pulse.
- Radiofrequency thermal coagulation of the medial branch of the dorsal ramus. It is responsible for the pain impulses of the posterior vertebral articulations at lower back or cervical level.
- Radiofrequency treatment of the dorsal root ganglion. For the treatment of radiculopathies at any level.
- Radiofrequency treatment of the L2 ramus communicans. For the treatment of pain originating in the lumbar (intervertebral) disk.
- Radiofrequency lumbar sympathectomy. For the treatment of resistant lower back pain or complex regional pain syndromes type 1.
- Peripheral nerve radiofrequency. It is useful in the treatment of pain syndromes in territories with a given innervation, as in occipital (Arnold's) neuralgia and in occipital nerve or frozen shoulder treatment and the treatment of the suprascapular nerve. The femoral cutaneous or intercostal nerves can also be treated with radiofrequency.
- Other radiofrequency treatments include trigeminal neuralgia, or radiofrequency of the sphenopalatine ganglion in atypical facial neuralgia or cluster cluster headaches.
Scar neuromas or Morton's neuroma also respond to this treatment.
In most cases, neurolytic blocks are indicated in cancer pain, but they may also be indicated in benign, albeit resistant, pain syndromes, such as chronic pelvic pain, chronic proctalgia or chronic vulvodynia.
The principle underpinning all these procedures is the injection of a neurolytic substance (phenol) into the nerve structure that collects pain information from the affected territory. The procedure is performed under radiological control.
- Celiac plexus block
- Chemical splenectomy
- Hypogastric plexus block
- Ganglion impar block
Botulinum toxin produces a temporary denervation of the muscle fibre.
The fundamental indications are myofascial syndromes.
In the case of deep muscles such as the psoas or the piriformis muscle, the injection is performed under radiological control.
The possible utility of botulinum toxin injections in the cranial musculature for the treatment of tension-headache or migraine was recently published.
- Trigger point injection with botulinum toxin
- Injection of the deep muscles (psoas, piriformis, quadratus lumborum) with botulinum toxin
- Treatments for headache with botulinum toxin
Ozone (O3) has anti-inflammatory properties and the capacity to break down the proteoglycans that make up the disc's nucleus pulposus. This effect may reduce the size of the hernia and the resulting symptoms.
Contained disc herniation is the main indication, and it may be proposed in patients in whom other strategies have failed.
- Ozone discolysis
In adhesiolysis, a special catheter is run through the epidural space, and by means of a mechanical effect and the injection of different substances, is intended to improve radicular pain or claudication originated by disk diseases, canal stenosis or previous surgery.
Modern catheters can also be used to perform radiofrequency treatments, making it possible to propose radiofrequencies of the dorsal root ganglion in patients with column instrumentations or foraminal stenoses that would make another procedure with this treatment virtually impossible.
Certain types of pain resistant to other treatments can be improved through the electrical stimulation of the posterior cords. This is performed through an electrode implanted in the epidural space.
After a trial period of a few days, if the mechanism proves to be effective, a subcutaneous generator (like a pacemaker), which can be remote-programmed, is implanted.
Pain of the extremity after failed back surgery or Complex Regional Pain Syndrome of the extremity are indications for treatment.
Epiduroscopy is a diagnostic and therapeutic procedure consisting of the passage of an optical system in the epidural canal that can be used to explore the presence of adherences, inflammatory areas and permeability of the intervertebral foramina. Drug, instrumental or radiofrequency treatments may be applied through a supplementary canal at the levels at which lesions are detected. It is more sensitive and specific than MRI in diagnosing epidural fibrosis.
Sometimes, administering drugs near the desired action site allows us to improve efficacy or reduce doses.
To this end, we can implant catheters in the epidural or intrathecal space in order to administer opioids, anaesthetics or, occasionally, other pain control drugs.
If the need for treatment continuues, we can implant devices which, connected to these catheters, can deliver the medicine continuously via different mechanisms.
- Intrathecal catheters
- Epidural catheters
- Infusion pumps