Essentials of Interventional Techniques in Managing Chronic Pain (eBook)

Laxmaiah Manchikanti, MD Chairman of the Board and Chief Executive Officer, ASIPP and SIPMS Medical Director Pain Management Center of Paducah Paducah, Kentucky Clinical Professor Anesthesiology and Perioperative Medicine University of Louisville Louisville, Kentucky USAAlan D. Kaye, MD, PhDChairman, Program Director, and ProfessorDepartment of AnesthesiaLSU Health Science CenterNew Orleans, Louisiana USAFrank J.E. Falco, MDMedical DirectorMid Atlantic Spine and Pain PhysiciansNewark, DelawareAdjunct Associate ProfessorTemple University Medical SchoolPhiladelphia, Pennsylvania USAJoshua A. Hirsch, MDVice Chief of Interventional CareService Line Chief of Interventional RadiologyDirector of Interventional NeuroradiologyChief of NeuroInterventional Spine ServiceMassachusetts General HospitalHarvard Medical SchoolBoston, Massachusetts USA

Foreword 5
References 6
Foreword 8
References 10
Preface 11
Contents 13
Contributors 16
Part I: Basic Considerations 20
1: Evolution of Interventional Techniques 21
Introduction 21
History 21
Definitions 22
Development 22
Organizations 22
Specialty Designation 22
Board Certification 22
Accountable Interventional Pain Management 22
Evolving Role 24
Key Points 25
References 31
2: Chronic Pain: Pathophysiology and Mechanisms 33
Introduction 33
Pain Signaling 33
Key Terminology 33
Transduction 34
Nociceptors 34
Transmission 34
Nerve Fibers 34
Modulation 37
Peripheral Mechanisms 37
Central Spinal Mechanisms 37
Central Supraspinal Mechanisms 40
Perception 40
Conclusion 42
Key Points 42
References 42
3: Pharmacology and Clinical Relevance of Commonly Used Drugs 44
Introduction 44
Local Anesthetics 44
Local Anesthetic Groups 44
Liposomal Bupivacaine 45
Interactions with Local Anesthetics 45
Risks with Local Anesthetic Use 45
Local Anesthetic Systematic Toxicity 46
Systemic Toxicity Related to Local Anesthetics 46
Management of Local Anesthetic Systemic Toxicity 46
Corticosteroids 46
Compounded Steroids and Fungal Meningitis 48
Contrast Agents 48
Neurolytic Agents 49
Alcohol 49
Phenol 49
Adverse Effects of Neurolytics 49
Key Points 49
References 50
4: Compliance and Documentation for Interventional Techniques 52
Documentation Requirements 52
History and Physical 52
Indications and Medical Necessity 53
Procedural Documentation 53
Documentation in Ambulatory Surgical Centers (ASCs) 53
History and Physical Examination 53
History 53
Physical Examination 54
Preoperative Requirements 54
Preoperative Medical Record Requirements 54
Anesthesia Requirements 54
Anesthetic Risk and Evaluation 55
Intra- and Postoperative Documentation Requirements 55
Procedural Documentation 55
Discharge/Disposition 55
Documentation for Hospital Outpatient Department 56
Informed Consent 56
History and Physical Examination 56
Monitoring 56
Intra- and Postoperative Documentation Requirements 56
Procedural Documentation 56
In-Office Documentation 56
Key Points 56
References 56
5: Sedation for Interventional Techniques 58
Introduction 58
History 58
Medical Necessity 59
Evidence Base 60
Diagnostic Interventions 60
Therapeutic Interventions 61
Role of Sedation for Interventional Techniques 62
Definitions of Levels of Sedation 63
Considerations for Procedural Sedation 63
Monitoring 63
Sedation Depth Monitoring 63
Medications 64
Benzodiazepines 64
Opioids 64
Propofol 64
Ketamine 65
Dexmedetomidine 66
Naloxone (Reversal Agents) 66
Flumazenil (Reversal Agents) 66
Recovery and Discharge 66
Side Effects and Complications 66
Key Points 67
References 67
6: Antithrombotic and Antiplatelet Therapy 69
Thrombotic Risks with Discontinuation 69
Interventional Pain Management Practice 70
Key Points 73
References 73
Part II: Spinal Interventional Techniques 76
7: Anatomy of the Spine for the Interventionalist 77
Introduction 77
Anatomical Planes 77
Spinal Column 77
Fluoroscopic Anatomy 82
Bony Elements 84
Spondylolysis and Spondylolisthesis 84
Ligaments of the Spine 85
Cervical Spine 87
Thoracic Spine 90
Lumbar Spine 90
Sacrum 90
Spinal Cord and Nerve Roots 94
The Spinal Cord and Its Coverings 95
Blood Supply to the Spinal Cord 99
Key Points 99
References 102
8: Radiology of the Spine for the Interventionalist 103
Introduction 103
Imaging Modalities 103
Plain X-Rays and Fluoroscopy 103
Nuclear Medicine 104
Computed Tomography (CT) 104
Magnetic Resonance Imaging (MRI) 104
Myelography 105
Degenerative Lumbosacral Spine 105
Intervertebral Disc Disease 105
Inflammatory Reaction to Intervertebral Disc Disease 106
Facet Disease 107
Combination: Central Canal Stenosis 107
Neural Foraminal Narrowing 109
Degenerative Sacroiliac (SI) Joint Disease 109
Postoperative Spine 110
Degenerative Thoracic Spine 110
Disc Protrusion 110
Costochondral Joint Abnormalities 111
Kyphosis 111
Degenerative Cervical Spine Disease 112
Disc Protrusion 112
Disc Extrusion 112
Chronic Disc/Osteophyte Complex 113
Central Cervical Spinal Canal Stenosis 113
Facet Joint Degenerative Disease with Osteophytic Spurring 113
Narrowed Neural Foramen from Disc/Osteophyte Complex Affecting the Uncinate Process 113
Traumatic Injuries 114
Infectious Diseases of the Spine and Cord 118
Key Points 120
References 122
9: Fluoroscopy in Interventional Pain Management 123
Introduction 123
History 123
Technical Aspects 124
Fluorescence 124
The Fluoroscopic Imaging Chain 126
The X-Ray Generator 126
The X-Ray Tube 126
Image Intensifier 128
Collimation 128
Optical Coupling 129
Analogue to Digital Converter 130
Fluoroscopy Table and Pad 130
Configuration of Fluoroscopic Systems 130
Radiation Safety 131
Indications and Clinical Applications 134
Precautions 135
Key Points 135
References 136
10: Needle Manipulation Techniques 138
Introduction 138
Preinjection Setup 138
Set Up the Room 138
Orient the Fluoroscope 138
Position the Patient 139
Visualize the Target 141
Choose the Skin Insertion Point 141
Advance the Needle in Small, Incremental Fashion to the Target 142
Local Anesthesia 142
The Art of Needle Placement 142
History of Spinal Needles 143
Using Tactile Techniques for Needle Placement 143
Pearl 144
The Loss-of-Resistance Technique 144
Pearl 145
Using Fluoroscopy for Needle Placement 145
Planning Prior to Needle Insertion 145
Needle Orientation to the Fluoroscopy Beam 145
Needle Density as It Pertains to Visibility 146
Pearl 147
Tracking Needle Tip Position 147
Steering Needles Within the Body 148
Specific Types of Needle Bevels 148
Steering the Needle 149
Needle Hub Rotation 149
Needle Hub Notch 150
Pearl 150
Bending the Needle Shaft 150
Needle Shaft Bowing 150
Bowing the Needle into an Arc Configuration to Facilitate L5/S1 Transforaminal Injection 150
Control the Tip of the Needle 151
Assuring the Location of the Needle Tip 151
Needle Aspiration 151
Injection of Contrast 151
Injection of Active Medication 151
Key Points 152
References 152
11: Lumbar Epidural Injections 153
Introduction 153
History 153
Pathophysiology 154
Evidence Base 154
Indications 157
Anatomy 157
Epidural Space 159
Nerves 161
Vasculature 163
Technical Aspects 165
Lumbar Interlaminar Epidural Injections 165
Extra-epidural Placement 173
Lumbar Transforaminal Epidural Injections 173
Critical Anatomy 173
Technical Implications 177
Safe Triangle Approach 179
Inferior or Kambin’s Triangle Approach 179
First Sacroiliac Transforaminal 181
Extraneural Placement of Needle 184
Caudal Epidural Injections 186
Extra-epidural Placement 191
Side Effects and Complications 191
Precautions 192
Key Points 195
References 196
12: Thoracic Epidural Injections 199
Introduction 199
History 199
Pathophysiology 199
Evidence Base 200
Indications 200
Anatomy 200
Technical Aspects 206
Thoracic Epidural Injections 206
Extra-epidural Placement 208
Thoracic Transforaminal Epidural Injections 211
Critical Anatomy 211
Technical Implications 213
Supraneural Approach 214
Infraneural Approach 214
Side Effects and Complications 216
Precautions 217
Key Points 217
References 218
13: Cervical Epidural Injections 221
Introduction 221
History 221
Pathophysiology 222
Evidence Base 222
Indications 224
Anatomy 224
Technical Aspects 230
Interlaminar Epidural Injections 230
Extra-epidural Placement 234
Transforaminal Epidural Injections 240
Critical Anatomic Considerations 241
Safety Considerations 243
Technique 245
Extraneural Placement of Needle 247
Side Effects and Complications 247
Precautions 248
Key Points 249
References 249
14: Percutaneous Adhesiolysis 253
Introduction 253
History 253
Pathophysiology 254
Evidence Base 255
Rationale 255
Indications 255
Anatomy 257
Technical Aspects 263
Racz Technique 267
The Caudal Approach 267
Interlaminar Lumbar Approach 269
Manchikanti Technique 271
Myelographic or Subarachnoid Patterns 273
Subdural Placement 275
Transforaminal Approach 276
Side Effects and Complications 279
Precautions 280
Key Points 281
References 282
15: Discography 285
Introduction 285
History 285
Pathophysiology 286
Role of Discography 286
Rationale 288
Validity 288
Evidence Base 288
Indications 289
Anatomy 289
Technical Aspects 289
Lumbar Discography 290
Positioning 290
Needles 292
Disc Injection 292
Post Discography Imaging 294
Cervical Discography 294
Anterior Approach 294
Anterolateral Approach 298
Disc Injection 298
Post Discography CT Imaging 303
Thoracic Discography 303
Disc Entry 303
Disc Injection 305
Post Discography CT Imaging 306
Side Effects and Complications 306
Precautions 308
Key Points 309
References 309
16: Percutaneous Lumbar Thermal Annular Procedures 313
Introduction 313
History 313
Intradiscal Electrothermal Therapy (IDET) 314
DiscTRODE 314
Biacuplasty 314
Side Effects and Complications 317
Conclusion 318
Key Points 319
References 319
17: Lumbar Percutaneous Mechanical Disc Decompression 321
Introduction 321
History 321
Pathophysiology 321
Herniated Disc 322
Rationale 324
Evidence Base 325
Indications 326
Anatomy 327
Technical Aspects 332
Automated Percutaneous Lumbar Discectomy 335
Percutaneous Lumbar Laser Discectomy 338
Mechanical High RPM Device or Dekompressor 340
Hydrodiscectomy 340
Nucleoplasty 344
Postoperative Care of Mechanical Disc Decompression Patients 345
Side Effects and Complications 345
Precautions 345
Key Points 346
References 346
18: Sacroiliac Joint Interventions 349
Introduction 349
History 349
Pathophysiology 349
Evidence Base 351
Indications 351
Diagnosis 351
History and Physical Exam 352
Diagnostic Sacroiliac Joint Injections 352
Anatomy 352
Structure 352
Innervation 353
Technical Aspects 353
Diagnostic Blocks 353
Radiofrequency Techniques 354
Side Effects and Complications 357
Precautions 358
Key Points 358
References 358
19: Lumbar Facet Joint Interventions 360
Introduction 360
History 360
Pathophysiology 360
Evidence Base 361
Diagnosis of Lumbar Facet Joint Pain 362
Diagnostic Facet Joint Nerve Blocks 363
Principles 363
Rationale 363
Validity 364
Therapeutic Facet Joint Interventions 364
Indications 364
Anatomy 364
Structure 364
Innervation 364
Technical Aspects 367
Lumbar Facet Joint Intra-articular Injections 367
Medial Branch Blocks 368
L1–L4 Medial Branch Blocks 370
Prone Position Oblique 370
Prone Position Anteroposterior 372
L5 Dorsal Ramus Blocks 373
Radiofrequency Neurotomy 373
Side Effects and Complications 375
Precautions 376
Key Points 377
References 377
20: Thoracic Facet Joint Interventions 380
Introduction 380
History 380
Pathophysiology 380
Evidence Base 381
Diagnosis of Thoracic Facet Joint Pain 382
Diagnostic Facet Joint Nerve Blocks 382
Principles 382
Rationale 383
Validity 383
Therapeutic Facet Joint Interventions 383
Indications 383
Anatomy 383
Structure 383
Features 385
Innervation 385
Relation to Spinous Processes 387
Relation to Vascular Structures 387
Technical Aspects 387
Intra-articular Thoracic Facet Joint Injections 389
Medial Branch Blocks 390
Radiofrequency Neurotomy 391
Side Effects and Complications 391
Precautions 393
Key Points 393
References 394
21: Cervical Facet Joint Interventions 397
Introduction 397
History 397
Pathophysiology 398
Evidence Base 399
Diagnosis of Cervical Facet Joint Pain 399
Diagnostic Facet Joint Nerve Blocks 400
Principles 400
Rationale 400
Validity 400
Therapeutic Facet Joint Interventions 401
Indications 402
Anatomy 402
Structure 402
Features 402
Innervation 402
Relation to Vascular Structures 406
Technical Aspects 406
Intra-articular Cervical Facet Joint Injections 406
Posterior Approach 406
Lateral Approach 409
Cervical Medial Branch Blocks 410
Posterior Approach 412
Lateral Approach 413
Radiofrequency Neurotomy 415
Conventional Radiofrequency 415
Pulsed Mode Radiofrequency 415
Typical Cervical Levels 416
C7 Medial Branch Neurotomy Technique 417
Third Occipital Nerve 418
Precautions 418
Side Effects and Complications 419
Key Points 419
References 420
22: Atlanto-Occipital and Atlanto-Axial Joint Injections 423
Introduction 423
History 423
Pathophysiology 423
Evidence Base 424
Atlanto-Axial Joint Injection 424
Diagnosis 424
Physical Examination 425
Anatomy 425
Nerves 426
The Vertebral Artery 426
Technical Aspects 427
Atlanto-Occipital Injection Under Fluoroscopic Guidance 427
Atlanto-Occipital: Ultrasound-Guided Technique 427
Atlanto-Axial Injection Under Fluoroscopic Guidance 428
Atlanto-Axial: Ultrasound-Guided Technique 429
Precautions 430
Side Effects and Complications 430
Key Points 430
References 431
23: Percutaneous Image-Guided Lumbar Decompression 432
Introduction 432
History 432
Pathophysiology 433
Evidence Base 433
Rationale 434
Indications 434
Anatomy 434
Technical Aspects 436
Precautions 437
Side Effects and Complications 438
Key Points 439
References 439
24: Vertebroplasty, Kyphoplasty, and Sacroplasty 440
Introduction 440
History 440
Pathophysiology 440
Evidence Base 441
Indications 441
Diagnosis/Pre-procedural Workup 441
Anatomy 444
Technical Aspects 444
Vertebroplasty and Kyphoplasty 444
Pre-procedure 444
Procedure 444
Sacroplasty 447
Pre-procedure 447
Procedure 447
Post-procedure and Follow-Up Care 449
Side Effects and Complications 449
Precautions 449
Key Points 450
References 450
Part III: Nonspinal and Peripheral Nerve Blocks 452
25: Ultrasound Basics 453
Introduction 453
Principles of Ultrasound 453
Basic Concepts of Ultrasound Imaging 456
Knobology: Understanding Your Machine 456
Key Points 457
References 457
26: Trigeminal Nerve Blocks and Neurolysis 459
Introduction 459
History 459
Pathophysiology 459
Diagnosis 461
Evidence Base 461
Anatomy 461
Technical Aspects 462
Percutaneous Trigeminal Ganglion Procedures 462
Trigeminal Ganglion Block or Neurolysis 463
Other Approaches to Trigeminal Ganglion Neurolysis 465
Block of the Maxillary and Mandibular Nerves 465
Block of the Terminal Sensory Branches of the Trigeminal Nerve 465
Side Effects and Complications 467
Precautions 467
Key Points 467
References 468
27: Occipital Nerve Blocks and Neurolysis 470
Introduction 470
History 470
Pathophysiology 470
Symptoms 471
Diagnosis 471
Differential Diagnosis Includes Possible Sources of Pain 471
Evidence Base 471
Contraindications [36] 472
Indications 472
Anatomy 472
Technical Aspects 473
Precautions 475
Side Effects and Complications 475
Key Points 476
References 476
28: Suprascapular Nerve Blocks and Neurolysis 478
Introduction 478
History 478
Pathophysiology 478
Evidence Base 479
Chronic Pain 479
Acute Pain 479
Indications 479
Anatomy 479
Technical Aspects 480
Blind Technique 481
Direct Approach 481
Superior Approach 481
Posterior Approach 481
Anterior Approach 481
Posteromedial Approach 481
Radiographic Technique 481
Ultrasound Technique 482
Suprascapular Neurolysis 484
Precautions 485
Side Effects and Complications 485
Key Points 485
References 485
29: Chest Wall Blocks and Neurolysis 487
Introduction 487
History 487
Pathophysiology 487
Evidence Base 488
Diagnosis 488
Anatomy 488
Interventional Technique 489
Blind Intercostal Nerve Blocks 489
Medications 490
Ultrasound-Guided Intercostal Nerve Blocks 490
Fluoroscopically Guided Intercostal Nerve Blocks 491
Radiofrequency Ablation of Intercostal Nerves 491
Intercostal Chemical Neurolysis 492
Precautions 492
Side Effects and Complications 492
Key Points 493
References 493
30: Abdominal Wall Blocks and Neurolysis 495
Introduction 495
Transversus Abdominal Plane Block 495
Applications 495
Anatomy 495
Technical Aspects 496
Precautions 496
Rectus Sheath Block 496
Indications 497
Anatomy 497
Technical Aspects 497
Precautions 498
Paravertebral Block 498
Anatomy 498
Technical Aspects 498
Precautions 499
Ilioinguinal and Iliohypogastric Nerve Block 500
Anatomy 500
Technical Aspects 500
Precautions 501
Conclusion 501
Key Points 501
References 502
31: Upper Extremity Nerve Blocks and Neurolysis 503
Introduction 503
Brachial Plexus Block 503
History 503
Pathophysiology 503
Evidence Base 503
Anatomy 503
Technical Aspects 504
Interscalene BP Block 504
Supraclavicular BP Block 505
Infraclavicular BP Block 505
Precautions 505
Side Effects and Complications 505
Axillary Nerve Block 505
History 505
Pathophysiology 505
Evidence Base 505
Diagnosis 505
Anatomy 505
Physical Examination and Testing 505
Technical Aspects 506
Ultrasound-Guided Injection 506
Precautions 506
Side Effects and Complications 506
Radial Nerve Block 506
History 506
Pathophysiology 506
Diagnosis 506
Physical Examination 507
Anatomy 507
Technical Aspects 508
Radial Tunnel Injection 508
Blind Technique 508
Ultrasound-Guided Technique 508
Superficial Radial Nerve at Wrist 508
Blind Injection Technique 508
Ultrasound Guidance 508
Neurolysis 508
Precautions 508
Side Effects and Complications 508
Median Nerve Block 508
History 508
Pathophysiology 508
Evidence Base 508
Diagnosis 508
Physical Examination 509
Diagnostic Testing 509
Anatomy 509
Technical Aspects 509
Blind Technique 509
Ultrasound Guidance 509
Neurolysis 510
Precautions 510
Side Effects and Complications 510
Ulnar Nerve Block 510
History 510
Pathophysiology 510
Evidence Base 510
Diagnosis 510
Physical Examination 510
Anatomy 511
Technical Aspects 511
Blind Injections 511
Ultrasound Guidance 511
Precautions 511
Side Effects and Complications 511
Key Points 511
References 511
32: Lower Extremity Nerve Blocks and Neurolysis 514
Introduction 514
Genitofemoral Nerve Blocks 514
History 514
Pathophysiology 514
Evidence Base 514
Diagnosis 514
Differential Diagnosis 515
Anatomy 515
Technical Aspects 515
Blind Technique 515
Fluoroscopic Guidance 515
Ultrasound Guidance 515
CT Guidance 515
Neurolysis 515
Lateral Femoral Cutaneous Nerve Blocks 515
History 515
Pathophysiology 516
Evidence Base 516
Diagnosis 516
Differential Diagnosis 516
Anatomy 516
Technical Aspects 516
Blind Technique 516
Ultrasound Guidance 516
Neurolysis 516
Obturator Nerve Block 517
History 517
Pathophysiology 517
Evidence Base 517
Diagnosis 517
Physical Examination 517
Anatomy 517
Technical Aspects 517
Blind Technique 517
Fluoroscopic Guidance 517
Ultrasound Guidance 517
Neurolysis 518
Common Peroneal Nerve Block 518
History 518
Pathophysiology 518
Diagnosis 518
Anatomy 518
Technical Aspects 518
Blind Technique 518
Ultrasound Guided 518
Tarsal Tunnel Injection 518
History 518
Pathophysiology 518
Diagnosis 519
Differential Diagnosis 519
Anatomy 519
Technical Aspects 519
Blind Technique 519
Ultrasound Guided 519
Digital Blocks of the Foot for Interdigital Neuritis (Morton’s Neuroma) 519
History 519
Pathophysiology 519
Diagnosis 520
Anatomy 520
Technical Aspects 520
Blind Technique 520
Ultrasound Guidance 520
Side Effects and Complications 520
Key Points 520
References 520
Part IV: Sympathetic Interventional Techniques 522
33: Sphenopalatine Ganglion Blocks 523
Introduction 523
History 523
Evidence Base 523
Indications 525
Preoperative Evaluation 525
Anatomy 526
Technical Aspects 527
Intranasal Approach 527
Infrazygomatic Approach 527
Transnasal Approach 529
Radiofrequency Lesioning 531
Precautions 532
Side Effects and Complications 532
Key Points 532
References 532
34: Cervical and Thoracic Sympathetic Blocks 534
Introduction 534
History 534
Pathophysiology 535
Evidence Base 536
Local Anesthetic Blocks 537
Indications 537
Diagnosis 538
Anatomy 539
Technical Aspects 541
Stellate Ganglion Block 542
Classic Anterior Approach 544
Modified Oblique Technique 547
Upper Thoracic Sympathetic Block 548
Neurolytic Procedures 549
Clinical Signs of Successful Stellate Ganglion Block 549
Precautions 550
Side Effects and Complications 550
Key Points 551
References 551
35: Lumbar Sympathetic Block and Neurolysis 554
Introduction 554
History 554
Pathophysiology 554
Indications 555
Evidence Base 555
Anatomy 555
Technical Aspects 558
Anatomic Variations 558
Technique 558
Approaches to Lumbar Sympathetic Block 559
Paramedian (Classic Mandl’s) Approach 559
Lateral (Reid’s) Approach 559
Transdiscal Lumbar Sympathetic Block 562
Paradiscal Extraforaminal Technique 564
Chemical Neurolytic Block 568
RF Lesioning 568
Sluijter’s Technique 569
Gauci’s Technique 571
Side Effects and Complications 572
Key Points 573
References 573
36: Hypogastric Plexus Blocks 575
Introduction 575
History 575
Pathophysiology 575
Diagnosis 576
Evidence Base 576
Indications 576
Anatomy 576
Technical Aspects 578
Classic Superior Hypogastric Block 578
Precautions, Side Effects, and Complications 579
Transdiscal Superior Hypogastric Block 579
Precautions, Side Effects, and Complications 579
Transsacral Inferior Hypogastric Block 579
Precautions, Side Effects, and Complications 580
Alternate Techniques 580
Precautions, Side Effects, and Complications 582
Key Points 582
References 582
37: Ganglion Impar Blockade 583
Introduction 583
History 583
Pathophysiology 583
Evidence Base 583
Indications 584
Anatomy 584
Technical Aspects 584
Original Technique 586
Modified Needle-Inside-Needle Technique 588
Trans-sacral Technique 588
Position Confirmation 588
Neurolysis 590
Thermocoagulation: A Modified Approach 591
Landmarks and Needle Positioning 591
Magnetic Resonance Neurography 593
Cryoablation 593
The Paramedian Approach 594
The Direct Approach 594
Thermocoagulation 594
Radiofrequency Ablation: Needle-in-Needle Technique 595
Precautions 595
Side Effects and Complications 595
Key Points 595
References 596
38: Celiac Plexus Blocks and Splanchnic Nerve Blocks 597
Introduction 597
History 597
Pathophysiology 598
Evidence Base 598
Indications 598
Anatomy 598
Technical Aspects 602
Celiac Plexus Blockade 602
Splanchnic Nerve Blocks 605
Neurolysis 605
Precautions 607
Side Effects and Complications 607
Key Points 607
References 608
Part V: Soft Tissue and Joint Injections 610
39: Trigger Point Injections 611
Introduction 611
History 611
Pathophysiology 612
Evidence Base 612
Diagnosis 612
Trigger Point Injections 613
Mechanism of Action 613
Technical Considerations 613
Injection Procedure 613
Precautions 614
Side Effects and Complications 614
Key Points 615
References 615
40: Tendon Insertion, Tendon Sheath, and Bursa Injections 617
Introduction 617
Upper Extremity Injections 617
Subacromial-Subdeltoid Bursa 617
History 617
Pathophysiology 617
Evidence Base 617
Diagnosis 618
Anatomy 618
Ultrasound-Guided Injection Technique 618
Biceps Tendon Sheath 618
History 618
Pathophysiology 618
Evidence Base 619
Diagnosis 619
Anatomy 619
Ultrasound-Guided Injection Technique 619
De Quervain’s Tenosynovitis 620
History 620
Pathophysiology 620
Diagnosis 620
Evidence Base 620
Anatomy 620
Ultrasound-Guided Injection Technique 620
Lower Extremity Injections 621
Iliopsoas Bursa 621
History 621
Pathophysiology 621
Evidence Base 621
Diagnosis 621
Anatomy 621
Ultrasound-Guided Injection Technique 621
Greater Trochanteric Bursa (Greater Trochanteric Pain Syndrome) 622
History 622
Pathophysiology 622
Evidence Base 622
Diagnosis 622
Anatomy 622
Ultrasound-Guided Injection Technique 622
Pes Anserine Bursitis 623
History 623
Pathophysiology 623
Evidence Base 623
Diagnosis 623
Anatomy 623
Ultrasound-Guided Injection Technique 623
Retrocalcaneal Bursitis 624
History 624
Pathophysiology 624
Evidence Base 624
Diagnosis 624
Anatomy 624
Ultrasound-Guided Injection Technique 624
Side Effects and Complications 625
Precautions 625
Key Points 625
References 625
41: Botulinum Toxin Injections for Chronic Pain 628
Introduction 628
History 628
Physiology and Pharmacology 628
Migraine 629
Arthritis 629
Myofascial Pain Syndrome 630
Trigeminal Neuralgia 630
Other Pain Syndromes 631
Conclusion 631
Key Points 631
References 631
42: Upper Extremity Joint Injections 633
Introduction 633
General Technique 633
Needle and Syringe Size 633
Sterile Preparation 633
Local Anesthesia 633
Glucocorticoid Injection 634
Complications 634
Noninfectious Complication 634
Infectious Complication 634
Shoulder Injection 634
Introduction 634
Pathophysiology 635
Evidence Base 635
Acromioclavicular Joint 635
Indications and Diagnosis 635
Interventional Technical Aspects 635
Ultrasound-Guided Acromioclavicular Joint Injection 635
Glenohumeral Joint 636
Indications 636
Interventional Technical Aspects 636
Landmark Approach 636
Anterior Approach 637
Posterior Approach 637
Fluoroscopic-Guided Glenohumeral Joint Injection 637
Ultrasound-Guided Glenohumeral Joint Injection 637
Elbow Joint 637
Introduction 637
Pathophysiology 637
Evidence Base 637
Indications and Diagnosis 638
Interventional Technical Aspects 638
Carpal Tunnel 639
Introduction 639
Pathophysiology 639
Evidence Base 639
Indications and Diagnosis 639
Interventional Technical Aspects 639
Ultrasound-Guided Carpal Tunnel Injection 639
Precautions 639
Key Points 640
References 641
43: Lower Extremity Joint Injections 642
Introduction 642
Femoroacetabular Joint Injection (Hip Joint) 642
Introduction 642
History 642
Pathophysiology 642
Evidence Base 643
Diagnosis 643
Relevant Anatomy 643
Muscle 643
Neurovasculature 643
Interventional Technical Aspects 644
Preparation 644
Fluoroscopy 644
Ultrasound 644
Side Effects and Complications 644
Knee Joint (Femoral Tibial Joint) Injection 646
Introduction 646
History 646
Pathophysiology 646
Evidence Base 646
Diagnosis 646
Relevant Anatomy [39] 647
Interventional Technical Aspects [19, 40] 647
Preparation 647
Fluoroscopy 647
Ultrasound 647
Side Effects and Complications 648
Tibiotalar Joint (Ankle) 648
Introduction 648
History 648
Pathophysiology 648
Diagnosis 649
Evidence Base 649
Relevant Anatomy [18] 649
Muscles/Tendons/Ligaments 649
Neurovasculature 649
Interventional Technical Aspects 649
Preparation 649
Fluoroscopy Guided 650
Lateral Mortise [49, 57] 650
Ultrasound 650
Side Effects and Complications 651
Key Points 651
References 651
Part VI: Implantables 653
44: Spinal Cord Stimulation 654
Introduction 654
History 654
Pathophysiology 655
Evidence Base 655
Rationale 656
Indications 657
Anatomy 657
Technical Aspects 658
The Spinal Cord Stimulator Trial 660
Lead Placement Technique 660
Side Effects and Complications 662
Precautions 662
Key Points 663
References 663
45: Intrathecal Drug Delivery Systems 666
Introduction 666
History 666
Indications 667
Anatomy 667
Intrathecal Pumps 668
Technical Aspects 669
Psychological Evaluation 669
Trialing 671
Permanent Implant 671
Abdominal Incision 672
Drugs 673
Side Effects and Complications 673
Granuloma 674
Precautions 674
Key Points 674
References 675
46: Peripheral Nerve Stimulation 677
Introduction 677
History 677
Pathophysiology 677
Evidence Base 678
Rationale 679
Indications 680
Anatomy 680
Technical Aspects 681
Occipital Nerve Stimulation (ONS) 682
Anatomy 682
Technical Aspects 682
Description of the ONS Procedure 682
ONS Complications 683
Trigeminal Nerve Stimulation (TNS) 683
Stimulation of the Peripheral Branches of the Trigeminal Nerve 684
Interstitial Cystitis (IC) 684
Side Effects and Complications 685
Precautions 685
Key Points 686
References 687
Index 690