Interdisciplinary Management Flashcards
Difference between medical assessment and PT assessment
Medical — more reliance on imaging and structural diagnosis while PT is more functional and biomechanical assessment.
Indications for epidural injections
- Lumbosacral disc herniation with radicular pain
- Cervical radicular pain
- Spinal stenosis with radicular pain
- Compression fracture of spine with radicular pain
GOAL = reduce radicular pain
MOA for epidural injections
- Inflammation of nerve root in epidural space provoked by leakage of disc material
- Compression off nerve root vasculature
And/or - Irritation of dorsal root ganglia from spinal stenosis
- Pain relief due to reduction in inflammatory process of afflicted nerve roots
Efficacy of epidural injections
Symptoms of back pain/radiculopathy of shorter duration have more sustained relief
Chronic cervical radicular pain = may benefit from epidural injections but data is weak and inconsistent
Risk and complications of epidural injections
Total dose of steroids limited due to negative effects of steroids on bones/joints/soft tissues, postural puncture headache, backache, bleeding, infection, nerve root injury
Indications for facet joint and SI joint injections
Facet joints — focal tenderness over facet joints, post laminectomy syndrome, post spinal fusion pain, low back pain with normal radiological findings
SI joint — focal tenderness over SI joint, positive provocative SI joint tests.
Efficacy for facet joint injections in chronic pain
- no clear differences between intra-articular facet joint injection with corticosteroid versus saline in pain or function.
- glucocorticoid injections into facet joint have NOT been shown to be effective treatment in low back pain
- American pain society guideline recommends against facet joint injection use
Efficacy for SI Joint injections
Poor evidence for short term and long term relief from Inter articular steroid injections, periarticular injections with steroids or botulin toxin
What is facet medial branch blocks and facet radio frequency ablation (RFA)
Medial branch block — Performing a temp block with lidocaine to see if patient experiences pain relief
If successful, proceed with RFA which is a high frequency electrical current runs through an insulated needle. Heat from the tip of the RFA device is targeted to create a small lesion within a nerve.
Efficacy for RFA in chronic pain
Discogenic pain = statistically significant pain reduction but no long term follow up or return to function assessment has been done
Chronic LBP = little additional benefit from normal treatment like regular exercise and psychological support
What are concerns for RFA with chronic pain
Medial branch also innervates muscles that provide stabilization and protection of spine so loss of sensation there do we really want that? Long term the nerve can repair and regrow but that regrowth can be painful
Indications for sympathetic block
Complex regional pain syndrome
Phantom limb pain
Vasomotor dysfunction
Swelling
Allogynia
Hyperalgesia
Skin trophic changes
What is a sympathetic block
Blocks are performed at lower third L2 or upper third of L3 and the injection of a local anesthetic drug around the nerve temporarily blocks the function of the nerve
Leads to vasodilation and improvement in blood flow to the limb.
Referral to PT is usually same day for exercise and mobs while patient is experiencing some of that pain relief
Efficacy of sympathetic block in chronic pain
Low quality and conflicting evidence
Not great
Indications for spinal cord stimulators
Failed back surgery
Complex regional pain syndrome
Peripheral neuropathy
Phantom limb pain
