Laxmaiah Manchikanti Editor in Chief Alan D. Kaye Frank J.E. Falco Joshua A. Hirsch Editors Essentials of Interventional Techniques in Managing Chronic Pain 123 Essentials of Interventional Techniques in Managing Chronic Pain Laxmaiah Manchikanti Editor in Chief Alan D. Kaye • Frank J. E. Falco Joshua A. Hirsch Editors Essentials of Interventional Techniques in Managing Chronic Pain Editor in Chief Laxmaiah Manchikanti 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, KY, USA Editors Alan D. Kaye Frank J. E. Falco Chairman, Program Director, and Professor Medical Director Department of Anesthesia Mid Atlantic Spine and Pain Physicians LSU Health Science Center Newark, Delaware New Orleans, LA, USA Adjunct Associate Professor Temple University Medical School Joshua A. Hirsch Philadelphia, PA, USA Vice Chief of Interventional Care Service Line Chief of Interventional Radiology Director of Interventional Neuroradiology Chief of NeuroInterventional Spine Service Massachusetts General Hospital Boston, MA, USA ISBN 978-3-319-60359-9 ISBN 978-3-319-60361-2 (eBook) https://doi.org/10.1007/978-3-319-60361-2 Library of Congress Control Number: 2017961536 © Springer International Publishing AG 2018 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. 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Laxmaiah Manchikanti, Alan D. Kaye, Frank J.E. Falco, and Joshua A. Hirsch, all inter- nationally renowned interventional pain physicians, have written Essentials of Interventional Techniques in Managing Chronic Pain. They have devoted most of their lives to improving the pain management of patients globally. I am honored to write a Foreword for this monumental undertaking. To emphasize the importance of this book, I need to reiterate the definitions, statistics, and the multiple modalities of treatments available to us for treating chronic pain today and their potential adverse consequences. Chronic pain exists globally. The prevalence of chronic, per- sistent, disabling pain seems to be increasing with low back pain, neck pain, and other muscu- loskeletal disorders occupying the top five categories of disability with escalating costs, and numerous modalities of treatments ranging from over-the-counter acetaminophen to complex surgical fusions [1–12]. In addition to the costs and health economy impact, there are multiple issues related to diagnostic accuracy and therapeutic efficacy, as well as numerous complica- tions related to these therapies with almost over 16,000 deaths due to opioid poisoning in 2012, an increase of 300% since 1999 [8, 13]. Methadone alone contributed to 4418 deaths in 2011 [13], and there were over 8000 unintentional drug poisoning deaths from heroin in 2013, a 39% increase from 2012, and nearly doubling the 4400 deaths in 2011 [13]. Acetaminophen has been implicated in 1000 deaths a year [14]. Nonsteroidal antiinflamma- tory drugs (NSAIDs) have been reported to be responsible for almost 17,000 deaths with numerous gastrointestinal complications [9]. Spinal surgical fusions caused over 1000 deaths in 2008 [7]. Sadly, all modalities of treatments are increasing rapidly with evidence lacking for many of them. There are also numerous considerations, explosive use and safety, including the interventional techniques that are the subject of this book [11, 15, 16]. While accurate data is available in the United States and other developed countries, in many countries pain may be undertreated and have a higher prevalence than thought; these people may be unable to enjoy the benefits of new advances in interventional pain management. Chronic pain is a complex and multidimensional problem. Chronic pain is defined as pain that persists 6 months after an injury and beyond the usual course of an acute disease or a rea- sonable time for a comparable injury to heal; is associated with chronic pathologic processes that cause continuous or intermittent pain for months or years that may continue in the pres- ence or absence of demonstrable pathologies; may not be amenable to routine pain control methods; and healing may never occur [17]. Interventional pain management is defined as the discipline of medicine devoted to the diagnosis and treatment of pain-related disorders princi- pally with the application of interventional techniques in managing subacute, chronic, persis- tent, and intractable pain, independently or in conjunction with other modalities of treatment [17]. Similarly, interventional techniques have been defined as minimally invasive procedures, including percutaneous precision needle placement, with placement of drugs in targeted areas or ablation of targeted nerves; and some surgical techniques such as laser or endoscopic dis- cectomy, intrathecal infusion pumps, and spinal cord stimulators for the diagnosis and man- agement of chronic, persistent, or intractable pain [17]. Interventional pain management’s origins go back to 1884 with neural blockade and regional analgesia [18]. Since then, regional anesthesia and interventional techniques have evolved by leaps and bounds, now reaching v vi Foreword numerous claims of overuse, abuse, and fraud [17, 19]. Consequently, due to the changing dynamics of interventional pain management with the explosive increase in interventional techniques, accountable interventional pain management, and value-based practice, the perfor- mance of evidence-based, cost-effective, and clinically effective techniques are coming into play, which are enlightened in this book [17, 19]. Pain practice today is fortunate to have many physicians making this practice a professional part of their career. They come from all specialties, and education now has to reflect the advances pain practice has made in all those specialties, not just those in anesthesiology. The challenge today is to train pain physicians in such a way that they have a standardized curriculum during their residency and pain fellowship programs, followed by skilled practical training in anesthesiology, neurosurgery, physical medicine and rehabilitation, or psychiatry. Once trained, they need to be examined and tested periodically for their competency. This will raise the standard of pain practice, not only in the United States, but all over the world. Evidence-based medicine or evidence-based practice aims to apply the best available evidence gained from scientific methods to clinical decision-making [17, 18]. It seeks to assess the strength of evidence of the risks and benefits of treatments (including lack of treatment) and diagnostic tests. Evidence quality can range from meta-analyses and systematic reviews of double-blind, placebo-controlled clinical trials at the top end, down to conventional wisdom at the bottom. However, in the modern era, even with the development of comparative effective- ness research with numerous changes in health care philosophy, and without involvement of clinicians, evidence-based medicine has been minimized with overwhelming conflicts of inter- est, inappropriate analysis and lack of application of the principles of evidence-based medi- cine, focusing more on cost savings and policy decisions rather than evidence itself . This book, Essentials of Interventional Techniques in Managing Chronic Pain, fills the void where literature should conform to local necessities for information to be useful in that society. The format of the book is excellent; each chapter is consistent in describing an interventional technique in simple terms from history to complications and efficacy, stressing at all times technique and safety, encompassing evidence-based, cost effective, and value-based practice. Essentials of Interventional Techniques in Managing Chronic Pain accomplishes the ambi- tious goal of directly addressing the field writ large. Cincinnati, OH, USA P. Prithvi Raj References 1. US Burden of Disease Collaborators. The state of US health, 1999–2010: burden of diseases, injuries, and risk factors. JAMA. 2013;310:591–608. 2. Hoy D, March L, Brooks P, et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73:968–974. 3. Hoy D, March L, Woolf A, et al. The global burden of neck pain: estimates from the global burden of dis- ease 2010 study. Ann Rheum Dis. 2014;73:1309–1315. 4. Institute of Medicine (IOM). Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Washington, DC: The National Academies Press; 2011. 5. Garcia JB, Hernandez-Castro JJ, Nunez RG, et al. Prevalence of low back pain in Latin America: a system- atic literature review. Pain Physician. 2014;17:379–391. 6. Manchikanti L, Hirsch JA. Lessons learned in the abuse of pain relief medication: a focus on health care costs. Expert Rev Neurother. 2013;13:527–544. 7. Rajaee SS, Bae HW, Kanim LE, et al. Spinal fusion in the United States: analysis of trends from 1998 to 2008. Spine (Phila Pa 1976). 2012;37:67–76. 8. Dart RC, Surratt HL, Cicero TJ, et al. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2015;372:241–248. 9. Leavitt SB. NSAID dangers may limit pain-relief options. Pain-Topics News/Research UPDATES. March 14, 2010. http://updates.pain-topics.org/2010/03/nsaid-dangers-may-limit-pain-relief.html. 10. Moore A, Wiffen P, Kalso E. Antiepileptic drugs for neuropathic pain and fibromyalgia. JAMA. 2014;312:182–183. Foreword vii 11. Manchikanti L, Pampati V, Falco FJE, Hirsch JA. An updated assessment of utilization of interventional pain management techniques in the Medicare population: 2000–2013. Pain Physician. 2015;18:E115–E127. 12. Manchikanti L, Atluri S, Hansen H, et al. Opioids in chronic noncancer pain: have we reached a boil- ing point yet? Pain Physician. 2014;17:E1–E10. www.drugwarfacts.org/cms/causes_of_Death#sthash. vGhXfKev.dpbs. 13. Centers for Disease Control and Prevention, Warner M, Hedegaard H. NCHS Health E-Stat. Trends in drug-poisoning deaths involving opioid analgesics and heroin: United States, 1999–2012. 2014. www.cdc. gov/nchs/data/hestat/drug_poisoning/drug_poisoning.htm. 14. Annual Causes of Death in the United States. DrugWarFacts.org. 15. Manchikanti L, Benyamin R. Key safety considerations when administering epidural steroid injections. Pain Manag. 2015;5(4):261–272. 16. Rathmell JP, Benzon HT, Dreyfuss P, et al. Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a Multidisciplinary Working Group and National Organizations. Anesthesiology. 2015. [Epub ahead of print]. 17. Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for inter- ventional techniques of chronic spinal pain: part II: guidance and recommendations. Pain Physician. 2013;16:S49–S283. 18. Brown DL, Fink BR. The history of neural blockade and pain management. In: Cousins MJ, Bridenbaugh PO, editors. Neural blockade in clinical anesthesia and management of pain. 3rd ed. Philadelphia: Lippincott-Raven; 1998. p. 3–34. 19. Manchikanti L, Helm II S, Singh V, et al. Accountable interventional pain management: a collaboration among practitioners, patients, payers, and government. Pain Physician. 2013;16:E635–E670. Foreword Interventional Pain Management (IPM) is effective when it is practiced as intended and when there is an understanding of pain-triggering mechanisms. IPM’s foundation comes from clini- cal and basic science research and publications. What is known about IPM has been widely reported in multiple books, articles, and journals; however, a lot of them have not covered all aspects of IPM. The authors of this book have been key figures in the evolution of IPM and the American Society of Interventional Pain Physicians (ASIPP). They deserve our gratitude for their major effort in making this book, The Essentials of Interventional Techniques in Managing Chronic Pain, possible. The editors, Drs. Laxmaiah Manchikanti, Alan D. Kaye, Frank J.E. Falco, and Joshua A. Hirsch, have taken on a challenge that future readers will appreciate. It is evident that the intent is to present a body of work that includes evidence, outcomes, and basic and clinical research in the best interest of the patients that we all serve, as well as for providers of the best possible care. Complications and medico-legal consequences are not touched upon in a comprehensive manner because of the nature of the information. Looking at avoidable complications, one cannot rely upon one person’s experience alone. One experience tends to be just one opinion regarding a low frequency of recurring complications. One physi- cian may go through a lifetime of practicing without complications, and another physician may have two or more disasters in a short period of time. The field has very little evidence regarding complications from so-called evidence-based studies; rather it comes from poorly collected and published medico-legal and clinical experiences. The cost-effectiveness of IPM is favored when it is done appropriately, rather than when it is done because that is the only way that the practitioner approaches the problems of patients seeking help. Treatment algorithms continually need to be updated as new therapeutic inter- ventions and convincing evidence surfaces. Evaluating evidence is a peer-reviewed process and it is not an insurance company’s God-given right to deny therapy without compelling negative evidence. Some clinical studies may take 5–6 years from the preliminary data gather- ing to the conclusive multi-center prospective randomized double-blind placebo-controlled trials [1]. The contributors have accepted responsibility for their part of presenting the material, as it has become an essential component of IPM as a distinct medical specialty. ASIPP has grown and matured since its founding in 1998 from a handful of leaders under the relentless leader- ship of Laxmaiah Manchikanti and numerous individuals that have grown professionally and contributed their time and effort freely. There has not been a vested interest as a reason for the above, except the obvious love of the specialty. The contributors to this book have been chosen for their experience and knowledge of the field. The book is well structured. It represents and recognizes a long journey from John Bonica’s first major effort of a similar-sized book entitled, The Management of Pain [2]. The current book reflects much more pathophysiology, principles, new technologies, and pain- related interventions. The reader appreciates more neurosurgical type principles that go back to the pragmatic approaches of Harvey Cushing. Cushing recognized major reasons for neuro- surgery and operating on the brain because of the development of local anesthesia and radio- frequency thermocoagulation. Cushing also made a comment that a good neurosurgeon is a ix x Foreword good traveler. What he was implying was for a neurosurgeon to learn, go in, and visit those that were known to be excellent at whatever they were doing. Similarly, we can say that a good IPM physician attends many conferences, reads many articles, and reviews many other modern therapeutic educational opportunities to improve their safety and efficacy for providing care to their patients [3]. Throughout the book, the significance of evidence that comes from publications is evident. One has to remember that the evidence gathered is only as clinically relevant and valid as the question posed to gather the evidence. Studies may look statistically significant and be pub- lished in a highly rated journal, only to realize years later that the foundation of the study was flawed. Such an example is a study by Kemler et al., published in The New England Journal of Medicine on the usefulness of neuromodulation in upper extremity complex regional pain syndrome 1 (CRPS 1), as compared to conservative therapies [4]. Five years later, in a Letter to the Editor, the authors commented that there was no difference in the two therapies. However, every study subject had a surgical thoracic sympathectomy and not a single one of them returned to work. The study, after the fact, made it appear that neuromodulation is no better than conservative therapy, rather than the fact that individuals conducting the study did not know how to treat CRPS 1 [4]. Appropriate use of neuromodulation in treatment of upper extremity CRPS 1, published in Neurosurgical Treatment of Pain [5, 6], showed over 50% returned to work and had many years of effectiveness from the use of neuromodulation in spinal cord and peripheral nerve stimulation. The current book reflects the turning tide against the overuse of opioids and the increasing death rate from prescription use, abuse, and diversion. This restriction should be followed by a reduction in mortality figures; however, one has to remember that medications are needed, and if they are restricted, appropriately carried out IPM procedures will lead to a much improved quality of life in our patients. The perceived morbidity and mortality from IPM pro- cedures are low; however, not acceptable. The incidence of complications is similar to anesthe- siology mortality statistics in the 1960–1970s, when it was 1 in 10,700. Because of the Anesthesia Patient Safety Foundation’s recommendation of using improved monitoring with pulse oximetry, carbon dioxide, and oxygen monitoring and alarms, mortality has been reduced 20-fold. So far, in the medico-legal arena, every single complication from cervical, lumbar, thoracic, and transforaminal injections has been from a sharp needle intraneural and/or intra-arterial injection of local anesthetics, plus particulate steroids in the case of arteries. Blunt needle use is increasing worldwide but has not gained acceptance as the evidence would dictate. The incidence appears to be similar to the anesthesiology mortality rates before the Anesthesia Patient Safety Foundation’s recommendations. It is surprising that even major studies have virtually no recognizable incidence of compli- cations. New therapeutic modalities are coming, and with them, complications will follow. A previous example is the heat lesioning of discs without the ability to determine a safe location for the lesioning electrode within the disc (IDET). The device had no motor stimulation capa- bility, and inadvertently a misplaced intraspinal cannula electrode caused paralysis from the burning of the cauda equina. Simple motor stimulation prior to lesioning would have revealed proximity to the nerves. A new evolving field is the use of ultrasound guidance for regional anesthesia. The field is also expanding into chronic non-spinal pain procedures. The field of chronic pain medicine has grown dramatically in a different direction from ultrasound. Up-to-date experience, inappro- priate needle placement, and injection complications will follow as the use of ultrasound increases. Such examples include brachial plexopathy from interscalene injections. Also, the preoccupation for looking for targeted nerves and avoiding arteries has led to overlooking the proximity of the level of the injection. In a practice that has never seen a pneumothorax from an interscalene block, there have been two cases of pneumothoraces following ultrasound- guided procedures. The level of injection was overlooked. Foreword xi The most impressive aspect of this book is the vision of Laxmaiah Manchikanti for working with an impressive group of pain physicians in gathering all this information into one location. Nevertheless, it is also important for each practitioner to build a network of respected col- leagues and practitioners within the same field so they can turn to them for the best advice, especially in times of need. Neuromodulation came from humble beginnings and has blossomed with ever-improving technology. The procedure has grown unnecessarily complex and expensive but technology is also keeping up with the need for complex pain problems such as the recent successful US trial for high-frequency stimulation matching European outcome data. Even more exciting is mini- mizing the use of equipment with micro technology where a battery is not implanted. The receiver is so small that it is implanted within the electrode. Hopefully the outcome will exceed patient and practitioner expectations with fewer complications, better outcomes, and reduced costs. I strongly recommend this book. As one that has visited many homes of physicians that I have trained, instead of finding hungry young doctors eager to learn, nowadays I am finding experienced, respected, graying-haired physicians who are looking forward to going to work the next day. As each day brings new challenges, these challenges demand them to have an up-to-date library and The Essentials of Interventional Techniques in Managing Chronic Pain belongs there. Lubbock, TX, USA Gabor B. Racz References 1. Gerdesmeyer L, Wagenpfeil S, Birkenmaier C, et al. Percutaneous epidural lysis of adhesion in chronic lum- bar radicular pain: a randomized, double-blind, placebo-controlled trial. Pain Physician. 2013;16:185–196. 2. Bonica JJ. The Management of Pain. Philadelphia: Lea & Febiger; 1953. 3. Cushing H. Intracranial tumours: notes upon a series of two thousand verified cases with surgical-mortality percentages pertaining thereto. Springfield: Charles C Thomas; 1932. 4. Kemler MA, Barendse GA, van Kleef M, et al. Spinal cord stimulation in patients with chronic reflex dys- trophy. N Engl J Med. 2000;43:618–624. 5. Shetter AG, Racz GB, Lewis R, et al. Peripheral nerve stimulation. In: R North, editor. Neurosurgical man- agement of pain. New York: Springer-Verlag; 1997. 6. Calvillo O, Racz GBN, Diede J, et al. Neuroaugmentation in the treatment of complex regional pain syn- drome of the upper extremity. Acta Orthop Belg. 1998;64:57–63.