Interventional pain management using fluoroscopy and ultrasound imaging techniques

Interventional injection therapies play a major role in the management of various pain conditions and are becoming an integral part of the multidisciplinary therapies required to improve and rehabilitate pain patients. Many of these procedures have historically been performed without imaging guidance. Imaging–guided techniques with fluoroscopy or ultrasound increase the precision of these procedures and help confirm needle placement. Imaging–guided techniques should lead to better results and reduced complication rates and they are now becoming more popular. These improvements are probably due in part also to better patient selection by experienced pain physicians.publishersversionPeer reviewe

Pulsed Radiofrequency Effects on the Lumbar Dorsal Root Ganglion of the Domestic Porcine : Pilot Study

Introduction. Pulsed radiofrequency (PRF) is a percutaneous minimal invasive procedure for chronic pain management that can be used when conservative treatment methods have been ineffective. The effectiveness of PRF was demonstrated in various good quality randomized control studies, but mechanisms of action are still unclear. Aim of the Study. The aim of our study is to analyse the histological effects of PRF on the domestic porcine dorsal root ganglion (DRG), and evaluate the expression of biomarkers in gangliocytes of the subject(s). Materials and Methods. A total 3 domestic porcines were investigated. Under general anaesthesia and X-ray control, DRG PRF was performed. Four lumbar DRGs (L1, L2, L3, L4) were randomly treated. The opposite side DRGs was used as control. One month after the procedure the animal was euthanized. The lumbar region of the spine was placed in 10% formaldehyde for a month. After this fixation DRG samples were prepared for slide analysis. They were embedded in paraffin in order to obtain 3mm thick sections, which were then cut by microtome and collected on slide glasses. Using standard immunohistochemical reactions, the materials were tinted to define biomarkers neurofilaments (NF), glial fibrillary acidic protein (GFAP), heat shock protein – 70 (Hsp-70) expression and apoptosis by transferase-mediated dUTP nick-end labeling (TUNEL) analysis. Results. The number of cells with NF (26,0 ± 3,0 vs 16,1 ± 3,3; p<0,05), GFAP (12,0 ± 1,3 vs 3,2 ± 0,9; p<0,05) and Hsp-70 (10,0 ± 1,6 vs 4,2 ± 1,0; p<0,05) expression, were larger in the PRF side comparing with the control side. Additionally, glial cells in spinal ganglia of both sides demonstrated immunoreactivity. The instances of apoptosis were not significantly different, in statistical terms, between the control and experimental sides (18,0 ± 4,0 vs 20,0 ± 4,0; p=0,35). Conclusions. PRF in spinal gangliocytes of lumbar region increases neural tissue cytoskeleton factors like NF and GFAP suggesting about active regeneration processes into the cells 1 month after the procedure. Spinal gangliocytes one month after PRF treatment notably increases Hsp-70 expression suggesting about activation of cellular activity and inhibitory role reducing of oxidative stress. Similar number of apoptotic cells in spinal ganglia of lumbar region after PRF and control side suggests about inhibitory role of PRF on programmed cell death and stimulation of cell survival.publishersversionPeer reviewe

Plexus brachialis strain and compression deformation in the costo-axillary-brachial region : A cadaveric study

Objective: The aim of this study was to clarify the role of different mechanisms in nerve injury during arm abduction positions. The tasks were to determine the strain deformation of the plexus brachialis during arm abduction, to measure the pressures in the neurovascular bundle in the cervico-costoclavicular-axillary area, and evaluate the histological changes of nerve after the stretch test. Material and Methods: During the cadaveric study on 7 specimens 7-20 h after death, strain deformation of plexus brachialis as well as compression deformation caused by the surrounding structures of the neurovascular bundle were investigated in the arm abduction position of 0°, 90°, 12°, 150°, and 180°. One nerve sample was studied histologically after 15% stretch on the bench. Results: The relative strain deformation of 3%-23% was documented during 0° to 180° abduction tests. The strain deformation from 0° to 90° was significant (P<0.001). The mean pressure change in the bundle was 13.6 mm Hg at 90°, 53.7 mm Hg at 120°, 73.4 mm Hg at 150°, and 89.0 mm Hg at 180° arm abduction. An increase in pressure was significant in the intervals: 0°-90° (P<0.001), 91°-120° (P<0.001), 121°-150° (P<0.001) and 151°-180° (P<0.05). Conclusions: Nerve traction and tissue compression arising during the arm abduction above 90° were found to be sufficient to induce lesions in neural bundles of the plexus brachialis.publishersversionPeer reviewe

Ultrasonoskopijas un fluoroskopijas kontrolēto pretsāpju epidurālo blokāžu salīdzinājums pacientiem ar mugurkaula deģeneratīvajām slimībām. Promocijas darba kopsavilkums

The study was carried out in Pauls Stradins Clinical University Hospital Anesthesiology and Reanimatology Clinic and Riga 2nd Hospital. Defence: on June 16th 2014, at 15.00 during Rīga Stradiņš University Promotional Council of Medicine open meeting at 16 Dzirciema Street, in the Lecture theatre Hippocrates.Thesis “Ultrasound versus fluoroscopic-controlled analgesic epidural blockade in patients with degenerative diseases of the spine” dedicated to the comparative analysis of quality and effectiveness of the procedure. Epidural steroid injections have been used for treatment of lower back pain and irradiate pain in the legs for many years. Steroids are entered into the epidural space at the target intervertebral level in order to achieve the right level of pathological changes to reduce the inflammatory process and pain. Present Practice Guidelines for Chronic Pain Management suggest that the procedure should be performed with appropriate fluoroscopic image guidance to confirm correct site of pathology and epidural space. In Latvia fluoroscopic-controlled epidural blockade is carried out only in a few specialized pain rooms, but in most cases blockades are performed based on anatomical landmarks without application of visualization technique. This fact can be explained by fluoroscopic equipment costs, unavailability and the radiation risk during the procedure. In the past 5 years ultrasonography has been increasingly used in the field of regional anesthesia as visualization technique, to facilitate spinal and epidural anesthesia performance and avoid fluoroscopic control risks. However, the application of the ultrasonography in chronic pain management is still in the development stage. The aim of the study was to show that ultrasound is equivalent visualization method to fluoroscopy for epidural blockades in patients with low back pain secondary to degenerative spine diseases. Our study for the first time in Latvia epidural block was performed after spinal ultrasound visualization. The current study was designed to evaluate procedure accuracy, technical difficulty, and analgesic and functional improvements of ultrasound-assisted interlaminar epidural steroid injections in comparison to fluoroscopy-guided injection, as well as researched side effects and complications. The study have shown that blockade performed after ultrasound spine visualization can achieve equivalent analgesia and functional disability reduction effect compared with the clinical efficacy of the traditional fluoroscopic-controlled blocks (“gold” standard in pain medicine) in patients with low back pain. To summarize, the research data shows that epidural blockade efficiency and performance characteristics are dependent on patient demographics, physical and clinical parameters. Procedure outcomes dependent of the patient’s age, body mass index, numbers of morphological changes in spine, and other clinical indicators such as pain intensity, degree of functional disability index and back pain duration. The results of this study demonstrate that the ultrasound-assisted can be an alternative to fluoroscopic controlled epidural injections method, if the patient is allergic to contrast, fluoroscopy is contraindicated or not available.The Doctoral Thesis was carried out with the support of the European Social Fund program “Project support for doctoral and post-doctoral studies in medical sciences”

Ultrasound Versus Fluoroscopic-Controlled Analgesic Epidural Blockade in Patients with Degenerative Diseases of the Spine. Doctoral Thesis

Promocijas darbs izstrādāts VSIA Paula Stradiņa universitātes Anestezioloģijas un reanimatoloģijas klīnikā un Rīgas 2. slimnīcā. Aizstāvēšana: 2014. gada 16. jūnijā plkst. 15.00 Rīgas Stradiņa universitātes Medicīnas promocijas padomes atklātā sēdē Rīgā, Dzirciema ielā 16, Hipokrāta auditorijā.Promocijas darbs “Ultrasonoskopijas un fluoroskopijas kontrolēto pretsāpju epidurālo blokāžu salīdzinājums pacientiem ar mugurkaula deģeneratīvajām slimībām” veltīts procedūru kvalitātes un efektivitātes salīdzinošai analīzei. Epidurālās blokādes jau daudzus gadus tiek pielietotas muguras sāpju ārstēšanai. Steroīdi tiek ievadīti epidurālajā telpā mugurkaula noteiktā starpskriemeļu spraugā ar nolūku sasniegt tieši patoloģisko izmaiņu līmeni, lai samazinātu iekaisuma procesu un sāpes. Pašreizējās ASV Reģionālās anestēzijas un sāpju medicīnas asociācijas vadlīnijas rekomendē šo procedūru veikt fluoroskopijas kontrolē patoloģijas vietas un epidurālās telpas stāvokļa precizēšanas nolūkā. Arī Latvijā epidurālās blokādes fluoroskopijas kontrolē tiek veiktas tikai dažos specializētajos sāpju kabinetos, taču vairumā gadījumu blokādes joprojām tiek veiktas bez vizualizācijas tehnikas pielietošanas, balstoties uz anatomiskiem orientieriem. Šo faktu var izskaidrot ar fluoroskopijas aparatūras dārdzību un nepieejamību, kā arī radiācijas risku procedūras laikā. Pēdējos 5 gados pasaulē kā vizualizācijas metodi reģionālajā anestēzijā arvien vairāk izmanto ultrasonoskopiju ar mērķi atvieglot muguras jostas daļas epidurālās anestēzijas veikšanu un izvairīties no fluoroskopiskas kontroles riskiem. Tomēr tās piemērošana hronisku sāpju ārstēšanai joprojām ir attīstības stadijā. Darba mērķis bija pierādīt, ka ultrasonoskopija ir fluoroskopijai līdzvērtīga epidurālo pretsāpju blokāžu vizualizācijas metode pacientiem ar muguras sāpēm un mugurkaula deģeneratīvajām saslimšanām. Mūsu pētījumā pirmo reizi Latvijā epidurālās blokādes tika veiktas pēc mugurkaula ultrasonoskopiskas vizualizācijas. Darbā iegūti dati par ultrasonoskopijas un fluoroskopijas kontrolē veikto epidurālo blokāžu kvalitāti, tehniskās grūtības un efektivitāti, nosakot to atsāpināšanas un funkcionālās nespējas mazināšanas efektu, kā arī izpētītas veikto epidurālo blokāžu blaknes un komplikāciju riski. Promocijas darbā ir pierādīts, ka blokādēs, pirms kurām veikta mugurkaula vizualizācija ar ultrasonoskopijas metodi, iespējams panākt līdzvērtīgu atsāpināšanas un funkcionālās nespējas mazināšanas efektu, salīdzinot ar klīnisko efektivitāti pēc tradicionāli fluoroskopijas kontrolē veiktajām blokādēm („zelta” standartu sāpju medicīnā) pacientiem ar muguras sāpēm. Apkopojot pētījuma datus, ir redzams, ka epidurālās blokādes efektivitāte un izpildes īpatnības ir atkarīgas no pacientu demogrāfiskajiem, fiziskajiem un klīniskajiem parametriem. Procedūras iznākumu ietekmē pacientu vecums, ķermeņa masas indekss un morfoloģisko mugurkaula izmaiņu daudzums, kā arī tādi klīniskie rādītāji kā sāpju stiprums, funkcionālās nespējas pakāpe un muguras sāpju ilgums. Iegūtie dati pierāda, ka ultraskaņas metode var būt alternatīva fluoroskopiski kontrolētai epidurālās steroīdu injekcijas veikšanai, ja pacientam ir alerģija pret kontrastu vai rentgenoskopija ir kontrindicēta vai nav pieejama.Promocijas darbs veikts ar ESF projekta “Atbalsts doktorantiem studiju programmas apguvei un zinātniskā grāda ieguvei Rīgas Stradiņa universitātē” atbalstu