Option of interventional pain therapy in multimodal treatment of chronic cancer and non-cancer pain Established role when pharmacotherapy or surgery not suitable Indications well accepted Evidence for efficacy moderate to strong

1. Updates in Interventional Pain
Management
Dr Ho Kok Yuen
MBBS, MMed (Anaes), FIPP, DAAPM
Consultant Anaesthesiologist
President, Pain Association of Singapore
Clinical Director, Pain Management Service, Raffles Hospital
Adjunct Associate Professor, Duke-NUS Medical School

2. Multimodal Approach
Medication
management
Interventional
procedures
Physical
therapy
Psychological
therapy

3. Interventional Pain Therapy
INDICATIONS
• Pain persisting for > 3-6 months despite
optimising pharmacotherapy
• Intolerable side effects to drug therapy
• Aversion to taking long-term medication
• Not suitable for surgery

4. Types of Chronic Pain
• Headache
• Neck pain
• Axial back pain
– Discogenic
– Facet joints
– Sacroiliac joint
• Radicular pain (upper and/or lower extremities)
• Neuropathic pain
– Trigeminal neuralgia
– Complex regional pain syndrome
– Failed back surgery syndrome with persistent radiculopathy
• Cancer pain

5. Aetiology of Radicular Pain
• Disc herniation
• Chemical inflammation from degenerated
intervertebral disc
• Facet joint hypertrophy
• Epidural scarring
Racz GB, et al. Current Review of Pain 1999;3:333-41
Olmarker Km Rydevik B. Orthopedic Clin NA 1991;22:223-33

6. Cervical Radiculopathy
• Commonly due to
herniated intervertebral
disc
• Neck pain that radiates
to the shoulders and
arms
• Numbness or weakness
in the arms, hands and
fingers

7. Lumbar Radiculopathy
• Nerve root irritation
caused by mechanical
compression or chemical
inflammation from a
herniated disc
• Sharp, lancinating pain in
dermatomal distribution
• May be associated with
numbness or weakness

8. Epidural Steroid Injection
Strong evidence for short-term pain relief
Moderate evidence for long-term pain relief
(68% had significant pain relief of at least 1 year)
Manchikanti L, et al. Pain Physician 2000;3:7-42
Stav A, et al. Acta Anaesthesiol Scand 1993;37:562-6

10. Radicular Pain Algorithm
• Patients not responding to epidural steroid
injections may require:
– Disc decompression
– Epidural neuroplasty
– Spinal cord stimulation
– Surgery
Buenaventura RM, et al. Pain Physician 2009;12:233-51
Parr AT, et al. Pain Physician 2009;12:163-88

11. Nucleoplasty
• Intradiscal coblation technique to decompress a
contained, herniated disc
• Relieves mechanical pressure on nerve root to reduce
radicular pain
• Alters expression of inflammatory cytokines leading to
a decrease in IL-1 and increase in IL-8
Manchikanti L, et al. Pain Physician 2009;12:561-72

12. Nucleoplasty Reduces Intradiscal Pressure
Chen Y, et al. Spine 2003;28:661-665

13. Epidural Neuroplasty
• Radicular pain due to epidural fibrosis and nerve root
entrapment
– Failed back surgery syndrome
• Patients with peridural scars after lumbar discectomy
are 3.2X more likely to have recurrent radicular pain
• Periradicular fibrosis (Preop 0.67%; Postop 11%; > 2
op 47%)
• Can be offered to patients who do not respond to
epidural injections (Level I evidence)
Epter RS, et al. Pain Physician 2009;12:361-78

14. Epidural Neuroplasty
• Needle entry through
sacral hiatus
• Insertion of Racz
catheter toward area of
filling defect
• Injection of
hyaluronidase,
bupivacaine and
dexamethasone
• Followed by contrast to
see opening up of scar
tissue

15. Lumbar Facet Joint Arthropathy
• Commonest cause of LBP
– Working age population:
prevalence 10-15%
– Older population: prevalence
> 40%
• Worse on lumbar extension
and lateral rotation
• Pain may radiate into the
posterior thigh

16. Cervical Facet Joint Arthropathy
• Degeneration of cervical
facet joints
• Presents with axial neck
pain, worse with neck
movements
• Cause of cervicogenic
headache
– Frequently misdiagnosed
as migraine

17. Convergence between Cervical and Trigeminal
Afferents in the Trigemino-cervical Nucleus
Humphrey T. J Comp Neurol 1952;97:143-209. Kerr FW. Exp Neurol 1961;4:134-48.
Bogduk N. Neurol Clin N Am 2004;22:151-71
Pars caudalis of the
spinal tract nucleus of
trigeminal nerve
extends caudally to
grey matter from
upper 3 cervical spinal
cord segments

18. C2
C4
C3

19. L4
L5

20. Facet Joint Injection
• LA (bupivacaine) and corticosteroid injection
into facet joints
• Lumbar spine: mean duration of pain relief 6.5
months in 82% of patients
• Cervical spine: 80-93% of patients with pain
relief at 6 months
Manchikanti L, et al. Pain Physician 2001;4:24-98
Boswell MV, et al. Pain Physician 2005;8:101-14
Manchikanti L, et al. Pain Physician 2006;9:333-46
Hechelhammer L, et al. Eur Radio 2007;17:959-64

21. Radiofrequency Ablation
• RF thermoablation
performed for patients
with temporary pain
relief to facet joint
injections
• RF energy generates
heat at needle tip to
denervate facet joints
• Median duration of
pain relief 18 months

22. Referral Pattern of Facet Joint Pain

23. Atlanto-occipital Joint Pain
• Condition frequently under-diagnosed
• May have a history of whiplash injury
• Patient presents with occipital headaches
• Commonly associated with neck pain because of
arthritis involving of the entire cervical spine
• Pain on flexion and extension (nodding)
• Tenderness on deep palpation inferior to the
nuchal line, in suboccipital region

26. Atlanto-Axial Joint Pain
• Patient presents with occipital headache
• Pain on lateral rotation
• May complain of “clicking” sound
• Tenderness on palpation over the suboccipital
muscles

27. OP

28. C2
C3

29. Sacroiliac Joint Pain

30. Sacroiliac Joint Injection
• Diagnostic and
therapeutic
injection of LA
and triamcinolone
into the SI joint

32. Cooled RF Conventional RF

33. Cooled RF Denervation of SI Joint
• Cooled RF
technology enlarges
lesion along lateral
edge of sacral
foramina
• RCT (Cohen): 57%
of patients had >50%
pain relief at 6
months
Cohen SP, et al. Anesthesiology 2008; 109:279-288

34. Retrospective Study
2-Year Data (n=20)
Ho KY, et al. Unpublished data
Pain reduction from 7.4 to 3.1

35. Trigeminal neuralgia
• Commonly affects
women above 50 years
old
• Pain in cheek or jaw
• Sharp burning or
stabbing pain lasting
seconds to minutes
• Pain worse with eating,
talking, brushing teeth
etc.

36. Trigeminal Ganglion RFL

37. Failed Back Surgery Syndrome
• Persistence of back or leg pain postoperatively
despite an anatomically successful surgery
• May be due to recurrent disc herniation,
spondylolisthesis or epidural scarring
• Similarly, failed neck surgery syndrome exists

39. Spinal Cord Stimulation
• Electrical stimulation
of dorsal column of
the spinal cord
• 1 or 2 electrodes
placed in the epidural
space
• Pulse generator
(battery) placed in
subcutaneous pocket

40. Implantable Pulse Generator Percutaneous Leads

42. Spinal Cord Stimulation

43. Clinically Significant Pain Relief
≥50% leg pain relief at
24 months, continued
greater effect with SCS
in the per treatment/ITT
analyses over 24
months
Kumar K, et al. Pain 2007;132:179-188
47% vs. 7%

44. Van Buyten JP, et al. Eur J Pain 2001;5:299-307
10-Year Follow Up:
Improvement in QOL

45. Cancer PainCancer Pain
• Majority of cancer pain can be controlled by
following WHO 3-Step Ladder guideline
• 10-20% require more intensive measures
• 8% required nerve blocks
• 8% required neurolytic blocks
• 3% intrathecal analgesia
Grond S, et al. J Pain Symptom Manage 1991;6:411-22
Zech DFJ, et al. Pain 1995;63:65-76
Stjernsward J, et al. J Pain Symptom Manage 1996;12:65-72

46. Sympathetic Blocks
• Useful for cancer pain
involving visceral organs
• Neurolysis with alcohol or
phenol performed in
almost all cases
• Coeliac plexus
– Pancreas, oesophagus,
stomach
• Superior hypogastric plexus
– Rectum, vagina
• Ganglion impar
– Perineum

47. Coeliac Plexus Block
Treats cancer arising from:
• Distal oesophagus
• Stomach
• Duodenum and small intestines
• Ascending to mid-transverse colon
• Pancreas
• Adrenal glands
• Spleen
• Liver and biliary system

48. Coeliac Plexus Neurolysis

49. Coeliac Plexus Neurolysis – Fluoroscopy

50. Superior Hypogastric Plexus
• Plexus lies anterior to sacral
promontory (L5-S1 level) in
retroperitoneal space
• Effective for cancer pain
involving
– Descending and sigmoid colon
– Rectum
– Pelvic organs e.g. bladder,
prostate, prostatic urethra,
testes, uterus, ovary, vagina
fundus
Plancarte R, et al. Anesthesiology 1990;73:236-9. De Leon-Casasola OA, et al. Pain 1993;54:145-51.
Plancarte R, et al. Reg Anesth 1997;22:562-568

51. Superior Hypogastric Plexus Neurolysis

52. Ganglion Impar Neurolysis
• Ganglion impar is the
unpaired ganglion at
the most caudal
portion of sympathetic
chain
• Treats cancer involving
the perineum
Foye PM. Reg Anesth Pain Med 2007;32;269

54. Ganglion Impar Neurolysis
Ho KY, et al. Anesthesiology 2006;105: 861-862

55. Intrathecal Neurolysis
• Injection of alcohol or phenol into IT space
• Produce discrete neurolysis to posterior cords,
while sparing motor block
• Most effective when pain is somatic, unilateral
and localised to 2-3 dermatomes
• Useful for pleural and rib metastasis
Gerbershagen HU. Acta Anaesthesiol Belg 1981;32:45-57

56. PHENOL
ALCOHOL

57. Intrathecal Drug Delivery
• Effective pain control by delivering opioids and non-
opioids directly to the spinal cord
• Lower doses of opioids required to control pain
• Fewer side effects when compared to systemic
opioid administration
• Dosage adjustments possible to meet changing
patient needs
• Reversible and non-destructive treatment
Nocom G, Ho KY, Perumal M. Ann Acad Med Singapore 2009;38:150-155
Huerto A, Ho KY. SGH Proceedings 2007;16:4-11

58. Intrathecal Drug Reservoir
Intrathecal Catheter Personal Therapy
Monitor

62. Intrathecal Drug Delivery System
86.2% metastatic disease
Pasuthanchart K, et al. Ann Acad Med Singapore 2009;38:943-6

63. Significant Reduction in Oral Opioid Use
Pasuthanchart K, et al. Ann Acad Med Singapore 2009;38:943-6
P = 0.005
571.9±156.0
40.4±18.5

64. Significant Reduction in Pain Score
Pasuthanchart K, et al. Ann Acad Med Singapore 2009;38:943-6
71 ± 21
22 ± 16
P < 0.001

66. IT Drug Delivery
Intrathecal Drug Delivery
• Systematic review supports IT opioid therapy for pain
not adequately controlled by systemic treatment
• IT drug therapy, when compared to conventional
medical therapy
• Reduced pain scores
• Improved quality of life
• less drug toxicity
• May even increase survival
Smith TJ, et al. J Clin Oncol 2002;20;4040-9.
Smith TJ, et al. Ann Oncol 2005;16:825-33.
Smith TJ, Coyne PJ. J Palliat Med 2005;8:736-42.

67. Summary
• Option of interventional pain therapy in
multimodal treatment of chronic cancer and
non-cancer pain
• Established role when pharmacotherapy or
surgery not suitable
• Indications well accepted
• Evidence for efficacy moderate to strong