Introduction to Interventional Therapies for

Pain Management

Bart Morlion, MD, PhD



The Leuven Center for Algology & Pain Management

University Hospitals Leuven, KU Leuven – University of Leuven

Multimodal approach: role of IPM ?

•  Natural course of disease

•  Pharmacotherapy
•  Physiotherapy
•  Psychotherapy
•  Interventional pain therapy
•  Surgery
Targeted pharmacotherapy
•  Cognitive-behavorial therapy
Neuroablative procedures
•  Social and vocational support
Neuromodulation
•  Lifestyle & healthy diet
Minimal invasive percutaneous
•  CAM
procedures
•  …
Chronic Low Back Pain (LBP)

•  LBP: Pain in the back area from below the costal margin to the gluteal fold.

•  Chronic LBP: LBP on most days in a 3-month period



•  Lifetime prevalence

84%

•  1-year prevalence

50%

•  Point prevalence

25%

•  Leading specific cause of Years Lived with Disability

in all developed countries

•  Frequent use of healthcare and welfare resources, and 
one of the leading causes of absence from work

•  Prevalence not decreased despite sharp increase 
in number of therapies, surgical procedures and 
interventional pain procedures

Morlion B. . Nat. Rev. Neurol. 462-473 (2013); Savigny, P et al BMJ 338, 1441–1445 (2009)
LBP - paradigm shifts

Over centuries from bronze age till 20th century: sprains (± spirits)


Watchful waiting (± ailments)



20th Century 40s-70s: concept of ‘pain generators’

•  Goal of the therapy: elimination of pain generators by interventional
pain management and surgery

•  Creation of injection clinics and explosion of spinal surgery with
focus on discs

•  Critique: poor patient selection

•  Outcomes

•  Short term: weak and controversial evidence, less evidence on functionality

•  Long-term: lacking to disappointing

 Diagnos(c  blocks  
 Ra(onale  based  on  the  belief  that  pain  is  transmi7ed  by  a  simple  and  
direct  wiring  system  
Blocks  target  peripheral  nocicep(ve  driven  mechanisms  whereas  chronic  
pain  is  mainly  a  centrally  driven  phenomenon  
272 PART 3 Neuropharmacology of Neural Systems and Disorders

Somatosensory
cortex

Descending
projections Intralaminar
from amygdala thalamic nucleus
Ventroposterolateral
thalamic nucleus (VPL
Periaqueductal
gray area

Brainstem
reticular
formation

Rostroventral Neospinothalamic tract

medulla
Paleospinothalamic tract

Spinoreticular tract

Descending Ascending
pathways pathways

Spinal cord
Dorsal
root
Primary
ganglion Ascending
afferent
Dorsal pathways
nociceptive
horn
axons
Spinal cord
Diagnostic blocks: 
high risk for type I errors

True
positive True positive False positive
Outcome of IPM

• Outcome

•  Specific treatment effects?

•  Natural course of disease

•  Non-specific treatment effects


•  Placebo…

•  Hawthorne effect

•  Regression to the mean

• Large interindividual variability in pain perception and
response to analgesic interventions

• Anatomic variations

• Systemic variables

•  Absorption of local anesthetics

•  Circulating mediators (e.g. IL-1)

Anatomic variations

M. Kottlors and F. X. Glocker
M. Kottlors and F. X. Glocker

FIG. 3. A: Extraspinal herniation (arrow) on the left side without any

intraspinal part. B: Rudimentary rib bone (arrow). C: No intraspinal
compression of the caudal nerve roots (arrows).

of the second-to-last lumbar nerve root resembles the L-5

nerve root innervation, and that the last lumbar nerve root
resembles the S-1 nerve root of patients with 5 lumbar
vertebrae. Our findings are in agreement with those of
FIG. 2. An AP (A) and lateral (B) radiography study of the lumbar Young et al.,22 who found that in cases of lumbosacral
spine showing 6 lumbar vertebrae. F . 1. Schematic drawings of normal
IG transitional
and abnormal lumbarvertebrae,
spines. A: Normalno
lumbarstrict
spine withinnervation pattern can be
5 vertebrae: a mediolateral
disc herniation at the level L4/5 causes a compression of the L-5 nerve root and clinical L-5 syndrome, and at the level L5/S1 it
causes a compression of the S-1 nerve Kottlors
determined. and
root and clinical S-1 Glocker
syndrome. B and E: SixJ. Neurosurg
lumbar Spine
vertebrae: a mediolateral disc
herniation at the level L5/6 can cause a clinical L-5 or S-1 syndrome. C: Six lumbar vertebrae: an extraspinal disc herniation at
2010
Guidelines: guiding practice or confusing?

Radiofrequency denervation for neck and back pain

•  radiofrequency denervation can provide short-term pain relief

for a small proportion of people with specific joint problems in
the neck.

•  conflicting evidence about effects for low-back joint pain

•  some evidence that it does not relieve pain from low-back disc
problems.

•  

Niemisto L, Kalso EA, Malmivaara A, Seitsalo S, Hurri H.
Cochrane Database of Systematic Reviews 2010 (2003), Issue 1

BMJ 2003
 Practice Guidelines for Chronic Pain Management
An Updated Report by the American Society of Anesthesiologists Task Force on
Chronic Pain Management and the American Society of Regional Anesthesia and
Pain Medicine*

Pragma(c  approach?  
P RACTICE Guidelines are systematically developed recom-
mendations that assist the practitioner and patient in mak-
ing decisions about health care. These recommendations may
Methodology
A. Definition of Chronic Pain
For these Guidelines, chronic pain is defined as pain of a
be adopted, modified, or rejected according to clinical needs and etiology not directly related to neoplastic involvement, as
•  Trigger  Point  Injec.ons.  The  literature  is  insufficient  to  evaluate  the  
constraints and are not intended to replace local institutional
policies. In addition, Practice Guidelines developed by the
ciated with a chronic medical condition or extending in d
ration beyond the expected temporal boundary of tissue
American Society of Anesthesiologists (ASA) are not intended as
efficacy  of  trigger  point  injec(ons  (i.e.,  compared  with  sham  trigger  
standards or absolute requirements, and their use cannot guar-
antee any specific outcome. Practice Guidelines are subject to
jury and normal healing, and adversely affecting the funct
or well-being of the individual.

point  injec(on)  as  a  technique  for  providing  pain  relief  B.The

for   pa(ents  
revision as warranted by the evolution of medical knowledge,
Purposes of the Guidelines
technology, and practice. They provide basic recommendations with  
purposes of these Guidelines are to (1) optimize p
chronic  pain  (Category  D  evidence).  Studies  with  observa(onal   findings  
that are supported by synthesis and analysis of the current liter-
control, recognizing that a pain-free state may not be atta
ature, expert and practitioner opinion, open forum commen-
able; (2) enhance functional abilities and physical and p
tary, and clinical feasibility data.
suggest  that  trigger  point  injec(ons  may  provide  relief  tients;
for  andp(4)a(ents  
minimize adversew ith  
chologic well-being; (3) enhance the quality of life of
This document updates the “Practice Guidelines for
Chronic Pain Management,” adopted by the ASA in 1996
outcomes.

myofascial  pain  for  assessment  periods  ranging  from  1  C.to  Focus

and published in 1997.1
4  months  
These Guidelines focus on the knowledge base, skills, a
(Category  B2  evidence).     * Developed by the American Society of Anesthesiologists Task
range of interventions that are the essential elements of eff
Force on Chronic Pain Management: Richard W. Rosenquist, M.D.
tive management of chronic pain and pain-related problem
(Chair), Iowa City, Iowa; Honorio T. Benzon, M.D., Chicago, Illi-
nois; Richard T. Connis, Ph.D., Woodinville, Washington; Oscar A.
The Guidelines recognize that the management of chro
•  Consultants,  ASA  members,  and  ASRA  members  agree  tpain hat   trigger  point  
De Leon-Casasola, M.D., Buffalo, New York; D. David Glass, M.D.,
occurs within the broader context of health care, inclu
Lebanon, New Hampshire; Wilhelmina C. Korevaar, M.D., Bala
ing psychosocial function and quality of life. These Gui
Cynwyd, Pennsylvania; Nagy A. Mekhail, M.D., Ph.D., Cleveland,

injec(ons  should  be  used  for  pa(ents  with  myofascial  psomatic ain.  
Ohio; Douglas G. Merrill, M.D., Iowa City, Iowa; David G. Nicki-
lines apply to patients with chronic noncancer neuropath
novich, Ph.D., Bellevue, Washington; James P. Rathmell, M.D.,
(e.g., myofascial), or visceral pain syndromes. T
Boston, Massachusetts; Christine Nai-Mei Sang, M.D., M.P.H., Bos-
Guidelines do not apply to patients with acute pain from
ton, Massachusetts; and Dana L. Simon, M.D., Des Moines, Iowa.

Recommenda)ons  for  trigger  point  injec)ons.  Trigger  injury p oint   i njec(ons  

The Task Force thanks Timothy R. Deer, M.D. for his early contri-
or postoperative recovery, cancer pain, degenerat
butions (September 2006-June 2008) to the development of these
Practice Guidelines. major joint disease pain, headache syndromes (e.g., migra

may  be  considered  for  treatment  of  pa(ents  with  myofascial   pain  
of thea s  or face. In addition,
and cluster), temporomandibular joint syndrome, or trige
Received from American Society of Anesthesiologists, Park Ridge,
inal or other neuralgias head
Illinois. Submitted for publication October 22, 2009. Accepted for
publication October 22, 2009. Supported by the American Society of
Guidelines do not apply to pediatric patients and do
part  of  a  mul(modal  approach  to  pain  management.     address
Anesthesiologists and developed under the direction of the Com-
the administration of intravenous drugs or surg
mittee on Standards and Practice Parameters, Jeffrey L. Apfelbaum,
interventions other than implanted intrathecal drug deliv
M.D. (Chair), and the American Society of Regional Anesthesia
and Pain Medicine (ASRA). Approved by the ASA House of Dele-
systems and nerve stimulators.
gates on October 21, 2009. Approved by the ASRA Board of Direc-
tors on September 19, 2009. A complete bibliography used to
develop these Guidelines, arranged alphabetically, is available as
Supplemental Digital Content 1, http://links.lww.com/ALN/A565. ! Supplemental digital content is available for this article. Dire
URL citations appear in the printed text and are available
Address correspondence to the American Society of Anesthesiol-
ogists: 520 North Northwest Highway, Park Ridge, Illinois 60068- both the HTML and PDF versions of this article. Links to th
digital files are provided in the HTML text of this article on th
2573. These Practice Guidelines, as well as all ASA Practice Param-
eters, may be obtained at no cost through the Journal Web site, Anesthesiology 2010
Journal’s Web site (www.anesthesiology.org).
 Practice Guidelines for Chronic Pain Management
An Updated Report by the American Society of Anesthesiologists Task Force on
Chronic Pain Management and the American Society of Regional Anesthesia and
Pain Medicine*

Recommenda)ons  for  nerve  

P blocks   RACTICE Guidelines are systematically developed recom-
mendations that assist the practitioner and patient in mak-
Methodology
A. Definition of Chronic Pain

   
ing decisions about health care. These recommendations may
For these Guidelines, chronic pain is defined as pain of a
be adopted, modified, or rejected according to clinical needs and etiology not directly related to neoplastic involvement, as
constraints and are not intended to replace local institutional ciated with a chronic medical condition or extending in d

•  Celiac  plexus  blocks  using  local  anesthe(cs  with  or  without  steroids  may  
policies. In addition, Practice Guidelines developed by the ration beyond the expected temporal boundary of tissue
American Society of Anesthesiologists (ASA) are not intended as jury and normal healing, and adversely affecting the funct
standards or absolute requirements, and their use cannot guar- or well-being of the individual.
be  used  for  the  treatment  of  pain  secondary  to  chronic  pancrea((s.  
antee any specific outcome. Practice Guidelines are subject to
revision as warranted by the evolution of medical knowledge,
B. Purposes of the Guidelines
technology, and practice. They provide basic recommendations
•  Lumbar  sympathe(c  blocks  or  stellate  ganglion  blocks  control, may   be  thatuased  
pain-free a s  may not be atta
The purposes of these Guidelines are to (1) optimize p
that are supported by synthesis and analysis of the current liter-
recognizing
ature, expert and practitioner opinion, open forum commen-
state
able; (2) enhance functional abilities and physical and p
components  of  the  mul(modal  treatment  of  CRPS  if  uchologic
sed  
tary, and clinical feasibility data.
i n   t
well-being;
This document updates the “Practice Guidelines forhe  
(3) enhance the quality of life of
tients; and (4) minimize adverse outcomes.
Chronic Pain Management,” adopted by the ASA in 1996
presence  of  consistent  improvement  and  increasing  dC.ura(on  
and published in 1997.1
Focus
of  pain  
relief.  Sympathe(c  nerve  blocks  should  not  be  used  for  
rangelofong-­‐term  
These Guidelines focus on the knowledge base, skills, a
* Developed by the American Society of Anesthesiologists Task
interventions that are the essential elements of eff
Force on Chronic Pain Management: Richard W. Rosenquist, M.D.
tive management of chronic pain and pain-related problem
(Chair), Iowa City, Iowa; Honorio T. Benzon, M.D., Chicago, Illi-

treatment  of  non-­‐CRPS  neuropathic  pain.    

nois; Richard T. Connis, Ph.D., Woodinville, Washington; Oscar A.
The Guidelines recognize that the management of chro
De Leon-Casasola, M.D., Buffalo, New York; D. David Glass, M.D.,
pain occurs within the broader context of health care, inclu
Lebanon, New Hampshire; Wilhelmina C. Korevaar, M.D., Bala
ing psychosocial function and quality of life. These Gui
Cynwyd, Pennsylvania; Nagy A. Mekhail, M.D., Ph.D., Cleveland,

•  Medial  branch  blocks  may  be  used  for  the  treatment  olines f   f
applyacet-­‐mediated  
Ohio; Douglas G. Merrill, M.D., Iowa City, Iowa; David G. Nicki-
to patients with chronic noncancer neuropath
novich, Ph.D., Bellevue, Washington; James P. Rathmell, M.D.,
somatic (e.g., myofascial), or visceral pain syndromes. T
Boston, Massachusetts; Christine Nai-Mei Sang, M.D., M.P.H., Bos-

spine  pain.     Guidelines do not apply to patients with acute pain from
ton, Massachusetts; and Dana L. Simon, M.D., Des Moines, Iowa.
The Task Force thanks Timothy R. Deer, M.D. for his early contri-
injury or postoperative recovery, cancer pain, degenerat
butions (September 2006-June 2008) to the development of these
Practice Guidelines. major joint disease pain, headache syndromes (e.g., migra

•  Peripheral  soma(c  nerve  blocks  should  not  be  used  for   inal orlong-­‐term  
and cluster), temporomandibular joint syndrome, or trige
Received from American Society of Anesthesiologists, Park Ridge,
other neuralgias of the head or face. In addition,
Illinois. Submitted for publication October 22, 2009. Accepted for
publication October 22, 2009. Supported by the American Society of

treatment  of  chronic  pain.    

Guidelines do not apply to pediatric patients and do
Anesthesiologists and developed under the direction of the Com-
address the administration of intravenous drugs or surg
mittee on Standards and Practice Parameters, Jeffrey L. Apfelbaum,
interventions other than implanted intrathecal drug deliv
M.D. (Chair), and the American Society of Regional Anesthesia
and Pain Medicine (ASRA). Approved by the ASA House of Dele-

 
systems and nerve stimulators.
gates on October 21, 2009. Approved by the ASRA Board of Direc-
tors on September 19, 2009. A complete bibliography used to
develop these Guidelines, arranged alphabetically, is available as
! Supplemental digital content is available for this article. Dire
   
Supplemental Digital Content 1, http://links.lww.com/ALN/A565.
URL citations appear in the printed text and are available
Address correspondence to the American Society of Anesthesiol-
both the HTML and PDF versions of this article. Links to th
 
ogists: 520 North Northwest Highway, Park Ridge, Illinois 60068-
2573. These Practice Guidelines, as well as all ASA Practice Param- Anesthesiology 2010
digital files are provided in the HTML text of this article on th
 Practice Guidelines for Chronic Pain Management
An Updated Report by the American Society of Anesthesiologists Task Force on
Chronic Pain Management and the American Society of Regional Anesthesia and
Pain Medicine*

•  …other  treatment  modali(es  should  be  a7empted  before  considera(on  

P
of  the  use  of  abla(ve  techniques.  
RACTICE Guidelines are systematically developed recom-
mendations that assist the practitioner and patient
ing decisions about health care. These recommendations may
in mak-
Methodology
A. Definition of Chronic Pain
For these Guidelines, chronic pain is defined as pain of a

•  Radiofrequency
 abla)on:
be adopted, modified, or rejected according to clinical needs and
constraints and are not intended to replace local institutional
policies. In addition, Practice Guidelines developed by the
etiology not directly related to neoplastic involvement, as
ciated with a chronic medical condition or extending in d
ration beyond the expected temporal boundary of tissue

•  Conven(onal  (e.g.,  80°C)  or  thermal  (e.g.,  67°C)  radiofrequency  abla(on  

American Society of Anesthesiologists (ASA) are not intended as jury and normal healing, and adversely affecting the funct
standards or absolute requirements, and their use cannot guar- or well-being of the individual.
antee any specific outcome. Practice Guidelines are subject to
of  the  medial  branch  nerves  to  the  facet  joint  should  bB.e  Purposes
performed  
of the Guidelines for  
revision as warranted by the evolution of medical knowledge,
technology, and practice. They provide basic recommendations

low  back  (medial  branch)  pain  when  previous  diagnos(c  

The purposes of these Guidelines are to (1) optimize p
control,o r   t herapeu(c  
that are supported by synthesis and analysis of the current liter-
recognizing that a pain-free state may not be atta
ature, expert and practitioner opinion, open forum commen-
able; (2) enhance functional abilities and physical and p

injec(ons  of  the  joint  or  medial  branch  nerve  have  provided   temporary  
tary, and clinical feasibility data.
chologic well-being; (3) enhance the quality of life of
This document updates the “Practice Guidelines for
tients; and (4) minimize adverse outcomes.
Chronic Pain Management,” adopted by the ASA in 1996
relief.     and published in 1997.1
C. Focus
These Guidelines focus on the knowledge base, skills, a

•  Conven(onal  radiofrequency  abla(on  may  be  performed   for  ofnchronic

eck  painp ain  
* Developed by the American Society of Anesthesiologists Task
range of interventions that are the essential elements of eff
Force on Chronic Pain Management: Richard W. Rosenquist, M.D.
tive management
(Chair), Iowa City, Iowa; Honorio T. Benzon, M.D., Chicago, Illi- and pain-related problem
nois; Richard T. Connis, Ph.D., Woodinville, Washington; Oscar A.
The Guidelines recognize that the management of chro

•  Water-­‐cooled  radiofrequency  abla(on  may  be  used  for   chronic  

De Leon-Casasola, M.D., Buffalo, New York; D. David Glass, M.D.,
pain occurs within the broader context of health care, inclu
Lebanon, New Hampshire; Wilhelmina C. Korevaar, M.D., Bala
ing psychosocial function and quality of life. These Gui
Cynwyd, Pennsylvania; Nagy A. Mekhail, M.D., Ph.D., Cleveland,
Ohio; Douglas G. Merrill, M.D., Iowa City, Iowa; David G. Nicki-

sacroiliac  joint  pain.    

lines apply to patients with chronic noncancer neuropath
novich, Ph.D., Bellevue, Washington; James P. Rathmell, M.D.,
somatic (e.g., myofascial), or visceral pain syndromes. T
Boston, Massachusetts; Christine Nai-Mei Sang, M.D., M.P.H., Bos-
Guidelines do not apply to patients with acute pain from
ton, Massachusetts; and Dana L. Simon, M.D., Des Moines, Iowa.
The Task Force thanks Timothy R. Deer, M.D. for his early contri-

•  Conven(onal  or  thermal  radiofrequency  abla(on  of  the   majord orsal   rheadache
oot  syndromes (e.g., migra
injury or postoperative recovery, cancer pain, degenerat
butions (September 2006-June 2008) to the development of these
Practice Guidelines. joint disease pain,
and cluster), temporomandibular joint syndrome, or trige
Received from American Society of Anesthesiologists, Park Ridge,

ganglion  should  not  be  rou(nely  used  for  the  treatment   of  dolumbar  
inal or other neuralgias of the head or face. In addition,
Illinois. Submitted for publication October 22, 2009. Accepted for
publication October 22, 2009. Supported by the American Society of
Guidelines not apply to pediatric patients and do
Anesthesiologists and developed under the direction of the Com-

radicular  pain.    
address the administration of intravenous drugs or surg
mittee on Standards and Practice Parameters, Jeffrey L. Apfelbaum,
interventions other than implanted intrathecal drug deliv
M.D. (Chair), and the American Society of Regional Anesthesia
and Pain Medicine (ASRA). Approved by the ASA House of Dele-
systems and nerve stimulators.
   
gates on October 21, 2009. Approved by the ASRA Board of Direc-
tors on September 19, 2009. A complete bibliography used to
develop these Guidelines, arranged alphabetically, is available as
  Supplemental Digital Content 1, http://links.lww.com/ALN/A565. ! Supplemental digital content is available for this article. Dire
URL citations appear in the printed text and are available
Address correspondence to the American Society of Anesthesiol-
both the HTML and PDF versions of this article. Links to th
ogists: 520 North Northwest Highway, Park Ridge, Illinois 60068-
2573. These Practice Guidelines, as well as all ASA Practice Param- Anesthesiology 2010
digital files are provided in the HTML text of this article on th
 Lumbar  facet  pain  

Technique   Evalua.on  
Intra-­‐ar(cular  injec(ons   2B±  
Radiofrequency  treatment  of  the  rami  mediales  (medial   1B+  
branches)  and  
LumbarL5  
Facet pPain
rimary  
• 461 rami  dorsales  

Figure 2. Pain referral pattern of lumbar facet pain adapted

from McCall et al.23 “Illustration: Rogier Trompert Medical Art.
http://www.medical-art.nl.”
Van  Kleef  M.  Pain  Prac7ce,  Volume  10,  Issue  5,  2010  459–469    
 Anatomical  
considera(ons  
 Localized low back pain > 6 weeks in duration

Red flags ruled out

Prac(ce  Algorithm  for  

Yes
Lumbar  Facet  Pain  
Tenderness overlying the facet joint(s)
Referral leg pain limited to above the knee except in rare circumstances;
Pain worsened with extension, flexion or rotation toward the ipsilateral side(s)

Indicative for facet complaints

Diagnostic block produces ≥ 50% pain reduction

Yes

Radiofrequency (RF) treatment of the rami

mediales (medial branches) and L5 primary
rami dorsales Figure 3. Practice algorithms for the
treatment of lumbar facet pain.
Van  Kleef  M.  Pain  Prac7ce  2010  
 Lumbasacral  radicular  pain  
Technique   Evalua.on  
Interlaminar corticosteroid administration   2B±  
Transforaminal corticosteroid administration in 2B+  
“contained herniation”  
Transforaminal corticosteroid administration in 2B-­‐  
“extruded herniation”  
Radiofrequency lesioning at the level of the spinal 2A-­‐  
ganglion (DRG)  
Pulsed radiofrequency treatment at the level of the 2C+  
spinal ganglion  
Spinal cord stimulation (FBSS only)   2A+  
Adhesiolysis-­‐epiduroscopy   2B±  
Van  Boxem  Pain  Prac7ce,  Volume  10,  Issue  4,  2010  339–358    
 Lumbosacral radicular pain Prac(ce  Algorithm  for  
“Red flags” ruled out Lumbosacral  pain  
Yes

Conservative treatment was adequately carried out

without conclusive results (VAS≥4)

Yes

Subacute problem Chronic problem

Confirm the suspected level by using a

(Transforaminal) epidural diagnostic block
corticosteroid administration

Consider pulsed radiofrequency

treatment adjacent to the ganglion spinale
(DRG)

Insufficient result

SCS recommended for FBSS

Consider epiduroscopy/adhesiolysis in a Figure 1. Practice algorithm for the

study context in specialized centers treatment of lumbosacral radicular
syndrome.Van  Boxem  Pain  Prac7ce  2010    
Eur Spine J
DOI 10.1007/s00586-011-2007-z

R E V I E W A RT I C L E

Epidural steroid injections in the management of low-back pain

with radiculopathy: an update of their efficacy and safety
Michel Benoist • Philippe Boulu • Gilles Hayem

•  ESI  have  a  moderate  short-­‐term  effect  in  the  management  of  LBP  
with  radiculopathy.    
 
Received: 25 March 2011 / Revised: 30 July 2011 / Accepted: 21 August 2011
! Springer-Verlag 2011
•  Severe  neurological  complica(ons  are  excep(onal,  but  call  for  
research  for  alterna(ve  approaches  tbetween
Abstract o  the  the
foramen   as  well  found
principal pathologies as  for  
a moderate
Introduction Epidural steroid injections (ESIs) have been
means   to   d etect   a n   eventual  
widely used for over 50 years in the treatment of low-back
a rterial   i njury.    
term benefit of ESIs versus placebo in patients with
herniation and radiculitis, in keeping with the cl
pain with radiculopathy. Most interventional pain physicians experience. ESIs are generally well tolerated and
strongly believe in their efficacy and safety. Recent Cochrane complications are related to technical problems. Ca
systematic reviews have disclosed controversial results and paraplegia, complicating the foraminal route and rela
 Cervical facet-related pain

5. Cervical Facet Pain • 115

•  Pain clinic: > 50% of patients with neck pain may

suffer from facet-related pain.

•  Unilateral pain without radiation to the arm

C 2-3

•  Painful or limited rotation and retroflexion

C 3-4
C 4-5
Tuberculum anterius

•  Exclude red flags and radiculopathy

C 5-6 C 6-7
Tuberculum posterius
Ganglion spinale (DRG)

•  No direct correlation between degenerative

Ramus dorsalis

changes on imaging
Facet joint

Ramus medialis of the

ramus dorsalis (Medial branch)

N. spinalis, ramus ventralis

A. vertebralis sinistra

Figure 2. Radiation pattern of cervical facet pain (illustration:

Rogier Trompert Medical Art. http://www.medical-art.nl).
Figure 1. Innervation of the cervical vertebral column and the
facet joints (illustration: Rogier Trompert Medical Art. http://
Cervical facet pain

Technique Evaluation

Intra-articular injections 0
Therapeutic (repetitive) cervical ramus 2B+
medialis (medial branch) of the cervical
ramus dorsalis block (local anesthetic with
or without corticosteroid)


Radiofrequency treatment of the ramus 2C+
medialis (medial branch) of the cervical
ramus dorsalis

Van Eerd et al. Pain Practice 2010; 10, 113–123

 Localized uni/bilateral neck pain
> 6 weeks

Exclude red flags Treatment algorithm for

Yes cervical facet pain

Neurological disorders ?

None Yes

Radiation not past the shoulder Neurological tests

Pain with pressure on the facet joint
Potential painful and/or limited
extension and/or rotation Tuberculum anterius

Tuberculum posterius
Ganglion spinale (DRG)
Ramus dorsalis
Working diagnosis
Cervical “facet pain”
Facet joint

Ramus medialis of the

ramus dorsalis (Medial branch)
Diagnostic block > 50 % pain relief

N. spinalis, ramus ventralis

Yes No

Re-evaluation A. vertebralis sinistra

Therapeutic (repetitive) cervical ramus medialis

Fi
(medial branch) the cervical ramus dorsalis block
Ro
block (local anesthetic with or without corticosteroid. Figure 1. Innervation of the cervical vertebral column and the
Figure 3. Clinical practice algorithm
RF cervical ramus medialis (medial branch)
for treatment of cervical facet jointsRF,(illustration: Rogier Trompert Medical Art. http://
facet pain.
of the ramus dorsalis/facet www.medical-art.nl).
radiofrequency treatment.
Van Eerd et al. Pain Practice 2010; 10, 113–123
Cervical Radicular Pain

Technique Evaluation

Interlaminar corticosteroid administration 2B+

Transforaminal corticosteroid administration 2B-
Radiofrequency treatment adjacent to the dorsal 2B+
root ganglion (DRG)
Pulsed radiofrequency treatment adjacent to the 1B+
DRG
Spinal Cord Stimulation 0

Van Zundert et al. Pain Practice, Volume 10, Issue 1, 2010 1–17
III.A CLINICAL PRACTICE ALGORITHM

Cervical radicular pain

Red flags excluded?

Practice algorithm for
Yes
cervical radicular pain

Conservative treatment was adequately
carried out without satisfactory results (VAS>4)

Yes

Subacute pain Chronic pain

Confirmation of the presumed causative level with a

Interlaminar corticosteroid selective diagnostic block
administration

Pulsed radiofrequency treatment adjacent to the

cervical dorsal root ganglion (DRG)

Poor or short lasting result

Conventional radiofrequency adjacent to the

cervical DRG

Poor result

Consider study-related SCS

Van Zundert et al. Pain Practice, 2010
 classically described, particularly in their early course.
Anterior spinal artery syndrome and cerebellar ischemia
are devastating complications of CTES injection. The
solitary and often small or discontinuous anterior spinal
Cervical transforaminal ESI: dangerous?
artery is susceptible to decreased perfusion without
reinforcing arteries (Gillilan, 1958). In many animal
models, cervical segmental medullary vessels enter at
nearly every spinal level from the vertebral artery. Humans,
Fig. 6. Left side of cadaver 10. Left is inferior, right is superior. (A) The cut
however, may have only one or two of these vessels feeding
end of the left vertebral artery (LVA) is shown at top left. The subclavian
artery (SCA, bottom left) gives off a costocervical trunk (CT) and two deep into the anterior spinal artery. Primate research showed that
cervical arteries (DC). The DC arteries and branches course through the occlusion of the segmental medullary arteries leading to
posterior aspect of the intervertebral foramina of C5-6, C6-7, and C7-T1.
The C7 and C8 ventral rami are pulled medially toward the spinal cord. A
•  Cerebellar herniation and anterior spinal syndrome
25-gauge needle (bottom left) and 22-gauge needle (bottom right) enter the
foramen; the 25-gauge needle is cannulating the DC artery branch.

resulting in paralysis, stroke, and death.

Arrowheads depict the course of two of the DC arteries, with the most
medial arrowhead at the target area for transforaminal injection. The
branches of C5-6 contribute to an anastamosis of small arteries that supply a

•  Proposed mechanisms:
segmental medullary artery to the anterior spinal artery. (B) The C7 and C8
ventral rami are shown in their natural position with needles in place. The
more superior 22-gauge needle (right) was too large to cannulate the DC
•  Vasospasm
artery at the midsagittal area of the foramen. The vertebral artery (VA),
subclavian artery (SCA), and costocervical trunk (CT) are shown top left.
Arrowheads show the continuation of the DC arterial branches at
•  Embolism from particulate containing steroids

approximately the level of a transforaminal epidural needle placement.
The anterior surface of the spinal cord is clearly seen at the top.
•  Direct needle trauma to a radicular artery that supplies the
previously reported to enter the intervertebral foramina
anterior spinal artery or Inthe
posteriorly. the posterior spinal
present study, seven of theartery.

eight spinal
arterial branches from the ascending or deep cervical
•  Discussion: are non-particulate steroids safer?

arteries entered the foramina posteriorly. In the two deep
dissections, three of these arterial vessels would have been

•  The incidence of complications:

easily cannulated during CTES. Two other cadavers (4 and
7) had extremely tiny or absent medially projecting spinal
segmental branches from the vertebral artery on the same

1.64% for TF and up to 16.8% for IL

side that ascending or deep cervical arteries gave off spinal
Fig. 7. An illustration of a cervical transforaminal needle cannulating a
branches. These dissections indicate that the ascending and segmental artery contributed by the ascending cervical artery. Steroid
deep cervical arteries were also potentially the main supply particles (purple) are shown coalescing in the anterior spinal artery. (By
to the cervical anterior spinal artery. The presence of permission of Mayo Foundation for Medical Education and Research.)
Scanlon GC et al Spine 2007; Rathmell JP et al. Anesthesiology 2004; Baker R et al. Pain 2003
Huntoon MA. Pain 2005; Furman MB et al. Spine 2003; Dreyfuss P et al. Pain Med 2006
Clinical Outcomes of Cervical Radiculopathy following Epidural Steroid
Injection: a Prospective Study with Follow-Up for more than 2 Years. 

•  > 80% of CR patients who were surgical candidates, surgery

was avoided using ESI. `

•  significant factors predisposing failure of ESI were intensity of
symptom and a previous episode of CR.

•  ESI is therefore considered a safe and effective treatment to
choose before undergoing surgery.

Lee et al. Spine 2011 Publish Ahead of Print DOI: 10.1097/BRS.0b013e31823b4d1f

General warning: do not sedate !

• Routine sedation should not be given to the patient not

to mask the complications.

• If necessary, use only conscious-sedation

Principle of Ionic Heating by Radiofrequency (RF)

Organ LW. Appl Neurophysiol 1976

History of Treating the Disc With Heat

Intradiscal RF IDET DiscTRODE Transdiscal, Baylis,

Sluijter, Smith and Nephew, Tyco / Radionics, Kimberly-Clarke
1994 1998 2000 2007?
 Simple
percutaneous IT
catheter

Intrathecal  
drug   Tunneled IT
catheter
therapy  

Implantable Drug
Delivery Systems
Celiac plexus block for pancreatic cancer pain in adults

• Opioid consumption was significantly lower in the CPB group

than the control group (P < 0.00001)

• Although statistical evidence is minimal for the superiority of
pain relief over analgesic therapy, the fact that CPB causes
fewer adverse effects than opioids is important for patients.
Further studies and RCTs are recommended to demonstrate
the potential efficacy of a less invasive technique under EUS
guidance.

Arcidiacono PG, Calori G, Carrara S, McNicol ED, Testoni PA.. 
Cochrane Database of Systematic Reviews 2011, Issue 3.



Celiac plexus neurolysis: techniques

 Spinal Cord
Stimulation
SCS

Deep Brain
Neuromodula(on   Stimulation
DBS

Motor Cortex
Stimulation
MCS
IPM: conclusion

• Part of a multimodal approach

• EBM & practice guidelines under debate

• Can palliate natural course of disease

• Can facilitate rehabilitation for chronic pain

• Relative good balance between benefit and risks especially in
comparison with surgical techniques

• Prerequisites:

•  Multidisciplinary approach and trained physician

•  Careful monitoring, safety first

•  Awake patient is your partner in safety: avoid sedation

•  Educational aspects

•  Need for large RCTs