Contact Information

Denis G. Patterson, DO

Nevada Advanced Pain Specialists

www.nvadvancedpain.com

patterson@nvadvancedpain.com

Education and Training

• DO– Michigan State University College of

Osteopathic Medicine (1998 – 2002)

• Pain Fellowship– Emory University (2006 – 2007)

• Residency– Mayo Clinic (2003 – 2006)

Certifications

• Board Certified, Pain Medicine (2007)

• Board Certified, Physical Medicine and Rehabilitation (2007)

Mechanical Low Back Pain

Denis G. Patterson, DO

Echo Project

11/18/2015

Introduction

Introduction

• Life expectancy continues to increase in the US

• > 65 year old age group grew by 30% between 1994 – 1999

Introduction

• Fear of the aging population is “having pain”

• Chances of having pain increase with each decade of life

• Pain leads to negative consequences for health, decreased function, and quality of life

Introduction

• Pain is one of the most common complaints for the > 65 year old age group when they visit the doctor

• The lumbar spine (low back) is a common area for pain

Basic Lumbar Spine Anatomy

Lumbar ArthritisAKA “Facet Joint Syndrome”

Facet Joint Syndrome

• It is a general term for age-related wear and tear affecting the facet joints

• Also known as lumbar osteoarthritis

Facet Joint Syndrome

• The condition usually appears in men and women older than 40 and progresses with age

Facet Joint Syndrome

• Causes:

- Drying and loss of elasticity in the lumbar disks

- Stiffening of the ligaments connecting bones and muscles

Facet Joint Syndrome

• Symptoms:

- Low back, hip or buttock pain

- Cramping lower extremity pain (usually not past the knee)

Facet Joint Syndrome

• Symptoms

- Low back stiffness, especially in the morning

- Pain with prolonged sitting or standing

Conservative Treatment Measures

Conservative Treatment Measures

• Modalities

• Medications

• Physical Therapy

• Injections

Modalities

• Ice

• Heat

• TENS

• Massage

• Traction

Medications

• Tylenol

• NSAIDS

• Ultram

• Nerve pain medications

• Narcotics

Physical Therapy

• Goals:

- Pain relief

- Improve posture/biomechanics

- Improve motion

- Improve strength

- Improve function

- Resume regular activities

Facet Injections

• Gold standard for diagnosis of facet mediated spine pain

• Radiographic findings - joint space narrowing, hypertrophy, sclerosis, tropism

• Pain is not always related to radiographic findings

Facet Injections

• Two types of injections

– Intra-articular joint injections

– Medial branch blocks and radiofrequency ablation

How Do We Do These Procedures?

• Contrast-enhanced with fluoroscopic guidance.– May pre-medicate with

prednisone and Benadryl if allergic.

• Used to ensure needle placement and proper medication flow.

• Safety.

• Question non-response in blind injections.

Facet Intra-Articular Injections

• Fluoroscopic localization.

• Use of contrast confirms intraarticular needle placement.

• Most common levels L4-L5, L5-S1.

• Inject anesthetic and steroid.

Medial Branch Block

• Similar results to intra-articular facet injection without entering the joint.

• Targets the medial branch of the dorsal primary ramus.

• Diagnoses pain originating from facet joint.

• Identifies patients who will benefit from radiofrequency ablation.

Medial Branch Block

• Performed as a series of 2 blocks.• 1st set of blocks are performed with 1 ml 1%

preservative free lidocaine injected at each medial branch.– Provides 2-3 hours of relief

• 2nd set of blocks performed with 1 ml 0.5% preservative free bupivacaine at each medial branch.– Relief lasts 4-6 hours.

• Positive response defined as 50% pain reduction.

Medial Branch Block

Medial Branch Block

Radiofrequency Ablation (RF)

• Electrical current produced by a radio wave is used to to heat tip of needle and destroy medial branch and eliminate painful signal from facet joint.

• Procedure is similar to medial branch block except wire is placed through needle at target point instead of anesthetic.

• Medial branch is then lesioned for 120 seconds at 80 degrees.

• Provides 9-12 months of relief.– Nerve grows back with time.

Questions

Discussion