CHRONIC PAIN MANAGEMENT IN ORTHOPEDIC PRACTICEPPT.pptx

Latest Pain Management procedures described. These are useful for those practicing chronic pain management. It uses both USG guided and Fluoro guided procedures. Even Hybrid techniques are used now a days

1. Chronic Painful conditions & their MANAGEMENT - AN overview Dr.Madhu

2. Definition of pain An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage (IASP definition) TYPES OF PAIN 3 widely accepted pain types relevant for musculoskeletal pain: Nociceptive pain (including nociceptive inflammatory pain). This pain is common with acute pain when there is tissue damage like a torn muscle or sprained ankle Neuropathic pain - Arises as a result of nerve damage or disease ‘ Nociplastic pain – ‘pain that arises from altered nociception despite no clear evidence of tissue damage causing

3. Pharmacological/non pharmacological & multidisciplinary Pharmacological- nSAIDs / opiods /adjuvants like neurotrophic drugs/local analgesics/antidepressants and physical modalities Non-pharmacological – interventions Pain management is actually a multidisciplinary approach including pain physician/physiotherapist/physiatrist/psychologist/chiropractic /neurologist/cognitive behavioural therapy, relaxation techniques etc

4. WHY DO WE NEED OUR OWN PAIN MANAGEMENT UNIT We are only a part of clientele to interventional radiologist They have to deal with many other specialties and subspecialities Most of the radiologists are not trained in musculoskeletal pathologies and their interventions Even joint drainage is refused out of the working hours by most of the on call radiologists due to lack of training We cant expect available MSK radiologists to help us in interventional therapeutic procedures –only very few trained radiologists are available in any given set up

5. First of all why do we need image guidance when theSE procedures r done blindly for decades Except for superficial joints the success rate in reaching the right spot is 45% only as per the literature That means in every alternative patient we are depositing the therapeutic agent at a wrong place If no response with land mark guided blind procedures we are subjecting all of them to next available option - surgical procedure most of the times Where as image guidance after sufficient training gives a success rate of 94 to 98 % (literature based) and hence less number of patients are recruited for surgical procedures or at least they have some time before they undergo more morbid procedures Accurate deposition is very important when we are using regenerative substances like prp or gfc

6. Image-guided (ultrasound) corticosteroid injections potentially offer a significantly greater clinical improvement over blind (landmark-guided) injections in adults with shoulder pain

7. R/O LITERATURE on joint injections SHOWS, the average accuracy of the blind ACJI waS 45% (range 38–55%) compared to 100% with image guidance [18]. In 2015, Aly et al. found in their systematic review that the accuracy rate of the blind glenohumeral Joint was 72.5% versus 92.5% with ultrasound guidance

8. Why should we as an orthopedician get training in image guided procedures Lack of sufficient interventional musculoskeletal radiologists in any given set up They have their own priorities and in most of institutes their role is limited to image guided biopsies and deep seated collection aspirations Their number being one or none in most of the institutions We diagnose clinically, order imaging, correlate and make a therapeutic plan- may or may not be agreed by the radiologists many a times ( they treat the scan rather than the man- we want it the other way)

9. We may need multiple diagnostic procedures before finalizing the appropriate DEFINTIVE OR surgical procedure Interventional radiologist always looks this from his prospective. He wants to treat the scan rather than the man - in spite of surgeon wants a staged procedure WE NEED DNB BEFORE ACTUALLY PERFORMING THE RFA FOR OA KNEES WE NEED STAGED PROCEDURES FOR A PATIENT SUFFERING FROM DISC BLULGES WITH FACET ARTHRITIS TO DECIDE WHETHER ONLY DISCECTOMY IS NEEDED OR FUSION AS WELL. RADIOLOGISTS MAY NOT AGREE FOR MULTIPLE PROCEDURES FOR THE SAME PATIENT-FEEL ITS WASTE OF TIME AND RESOURCES BUT IT MAKES A LOT OF DIFFERENCE FOR THE PATIENT AND TREATING SURGEON

10. Basically image guided procedures are TWO TYPES Usg guided procedures Fluoro guided procedures Hybrid techniques – fluoro and usg guidance in combo

11. Usg guided procedures Joint interventions Other musculoskeletal interventions

12. Indications for USG guided procedures In brief all the procedures we were doing blindly- like intraarticular joint injections, bursal aspirations, closed tunnel injections like carpal or tarsal tunnel, other musculoskeletal interventions like PF, tennis elbow etc..

13. Basics of usg In USG- Tissues are seen as various shades of grey depending on their echogenicity - capacity to reflect the us waves- bone hyperechoic to fluid anechoic\ Denser the tissue more brighter it is- bone being most echogenic. Waves cant pass beyond the bone Any structure can be visualized either in long axis or short axis If the probe is placed in line with the structure to be examined its called long axis If the probe is placed perpendicular to the structure to be examined its called short axis Anisotropy – usually degenerated structure has hypoechoic appearance. Even placing the probe so that the waves are not perpendicular will give hypoechoic appearance confusing with degeneration or damage. there are certain Tricks to avoid this fallacy

14. Basics of needling In plane approach – needle is passed in line with usg probe – whole needle seen in profile Out of plane approach – needle is placed perpendicular to the probe. Needle is seen just as a dot. Difficult to assess the depth as the tip and shaft look alike misguiding the examiner about the depth Need adequate training before one can align the needle with the probe. Reason being width of the probe may look significant but actually beam is 1 mm or less More acute the angle of needle in relation to the probe more difficult is the visualization

15. In pLane and out of plane approach-needle

16. Needle visualization-in plane and out of plane approaches (diagrammatic representation)

17. Actual USG images – in plane vs out of plane

18. Why can’t an untrained physician get the same image compared to a trained one when we observe the radiologist or other trained personal doing the procedure and want to replicate it later – will not get the same pic Why ? Need to have sufficient knowledge of knobs on the machine- knobology Holding the probe in proper way/tricks in manipulating the probe Experience in needle visualization Patient positioning and positioning of the anatomical part for each specific examination Proper ergonomics and quality machine with good resolution

19. Many ways to skin a banana The ones I am describing is the widely practiced ones. You can develop your own way of doing each procedure once you progress beyond the basics

20. Shoulder joint Possible interventions Usg guided subacromial bursal injections Usg guided ia injections – posterior and anterior approach Sc joint interventions Ac joint interntions Biceps tendonitis interventions Some nerve blocks like suprascapular nerve entrapments

21. SASD bursal injection - One can see sasdb as a potential space between two fat lines Very difficult even for dedicated shoulder surgeons to reach it and deposit the medication accurately in the bursal sac without image guidance

22. Subacromial Subdeltoid Bursa Injection Anterolateral approach Patient position- Supine position with arm hanging down or Lateral position in the edge of the table with face n anterior trunk facing the surgeon and hand on the back pocket Probe position- Below the acromion in an oblique direction pointing towards the ear Needle- in plane approach-distal to proximal Joint position- CRASS or Modified CRASS position Evaluation- SASD bursa gets distended while the drug is injected

23. Normal sasd bursa

24. Showing the modified crass position for SASD bursal injection

25. Subacromial subdeltoid bursal injections

26. Biceps tendonitis Position of arm- neutral rotation Probe in short axis needle either from medial to lateral or lateral to medial depending upon the hand dominance of the operator and side affected-in plane approach

27. Biceps tendonitis-injection

28. Frozen shoulder Normal capacity of shoulder is around 30 ml In adhesive capsulitis < 10 ml Best way to deal – 2 stages Stage 1- ia depomedrol /stage 2- hydrodilatation Safe amount for hydro dilatation is 30 ml (5 ml LA + 25 ml saline + 1 cc of depomedrol ) Some people use up to 100 ml till the pop is heard - capsular rupture- no use – all the fluid will escape from the joint

29. Ia shoulder injections Posterior approach – posterior portal of scopy surgeons- in plane approach with probe in horizontal position below the spine of scapula Anterior approach – needle from anterior aspect and probe from posterior aspect- can see the dilation

30. Shoulder joint injections Posterior approach Patient position-Prone position with arm hanging down or Lateral position in the edge of the table with back facing the surgeon Probe position- Below the spine of the scapula in horizontal position Needle- in plane approach-medial to lateral (If lateral to medial more vertical needle position to avoid HH convexity) Joint position- Shoulder in neutral position and adduction Evaluation- Joint gets distended while the drug is injected Anterior approach Patient position-Lateral position on the edge of the table Probe position- Below the spine of the scapula in horizontal position on posterior side Needle- Entry 1 cm lateral to coracoid and 2 cms distal to the ACJ Anterior joint plane can be marked with probe horizontally located on the anterior shoulder with needle on the skin and beneath the probe Joint position- Shoulder in neutral position and bit of extension Evaluation- Joint gets distended while the drug is injected from anterior side. Probe on the posterior aspect shows the distension

31. Probe position and possible needle directions

32. Elbow joint injections and aspirations POST APP Patient position - Supine position with arm across the chest/Sitting position with hand on table/Prone position with hand on mayo table (surgeon behind the elbow) Probe position – Long axis of distal humerus and olecranon. Look for posterior fat pad and humeroulnar interval. Needle – In plane approach- P-D or D-P -In mid posterior plane of the arm-Needle tip can be seen entering into the capsule and distending the capsule Joint position – Elbow flexed and hand on the table or across the chest Evaluation – Injectate can be seen because of particulates

33. Probe position and location of joint recess

34. Medial epicondylitis Golfers elbow Patient position - Supine position with arm externally rotated or prone position with elbow flexed and FA on the back of the chest Joint position – According to patient’s position- supine or prone Probe position –In the long axis of the flexor pronator origin showing the ME, FP origin, MCL and MJL. Needle – In plane approach- D-P or P-D Evaluation – Either PRP (intralesional) or Steroid (peri lesional) is usually used

35. Golfers elbow

36. Lateral epicondylitis TENNIS ELBOW Patient position - Supine position Joint position – Elbow flexed and FA in pronation across the chest exposing the lateral epicondylar region Probe position –In the long axis of the common extensor origin showing the LE and Common Ext origin. Probe proximal end on the LE and distal end towards the Listers tubercle. Probe should be held with only 3 fingers to see the needle Needle – In plane approach- D-P or P-D Evaluation – Either PRP (intralesional) or Steroid (peri lesional) is usually used

37. Tennis elbow-probe and needle positions

38. WRIST JOINT INJECTIONS POST- IP App Patient position - Supine position with wrist supported over the towel Joint position – Elbow extended and FA in pronation over the table with a folded towel support underneath which allows some palmar flexion. Probe position –In the long axis of the extensor tendons. In mid position- RL joint seen. If you go bit lateral RS joint is seen Needle – In plane approach- D-P or P-D Evaluation – Particulate material can be seen while injection is going on

39. Wrist joint

40. Carpal Tunnel Injection - Cross section of the MN > 12 Square mm- indicative of CTS Patient position - Supine position Joint position – Elbow extended and FA in supination over the table Probe position –In the short axis over the median nerve at the distal wrist crease-entry of CT (over pisiform and Scaphoid tubercle) Needle – In plane approach- M-L or L-M. Take care of Radial artery and SR nerve. Injection is done deep first followed by superficial to the median nerve to avoid clouding of the target Evaluation – Particulate material can be seen while injection is done

41. Probe and needle position

42. Dequervains Injections Patient position - Supine position Joint position – Elbow extended and FA in mid-pronation over the table. Folded towel beneath the wrist to get ulnar deviation which facilitates the injection procedure Probe position –In the short axis of 1 st dorsal wrist compartment tendons Needle – In plane approach- D-P or P-D Careful- About radial artery and sup rad nerve

43. Probe and needle

44. Hand injections VARIOUS HAND CONDITIONS CAN BE TREATED WITH USG GUIDED INJECTIONS BEFORE OFFERING THEM THE SURGERY

45. 1 st CMC JOINT INJECTION Patient position - Supine position Joint position – Elbow extended and FA in mid-pronation over the table Probe position –In the long axis over the dorso radial aspect of the 1 st CMC joint Needle – In plane approach- D-P or P-D (move 1 st MC to confirm) / Even OOP approach can also be done-ring vibrations/bright dot and tissue movements will help Evaluation – Particulate material can be seen while injection is done

46. Probe and needle

47. Trigger finger injections Useful in mild to moderate triggering Fixed triggers better to go for surgery from the beginning probe in short axis to flexor tendons and needle in plane approach

48. Trigger finger injection

49. Lower extremity usg procedures Major joints- injections and aspirations Other MSK procedures

50. Hip joint HIP JOINT INJECTIONS >7 mm of capsular thickness or hypoechoic shadow indicates hip effusion Patient position - Supine position Joint position – Hip extended, Knee extended and leg internally rotated a bit Probe position –Place the probe over the femoral shaft initially and slide it superiorly towards the GT. Once GT is reached contour suddenly becomes irregular. At that point rotate the probe towards the umbilicus to get the sagittal oblique view for anterior hip showing head, neck and capsular reflection of proximal femur. Needle –In plane approach – Inferolateral to superomedial Evaluation – Particulate material can be seen while injection is going on. Injection should be free n capsular lift off should be seen. This approach can also be used for aspiration of the joint for pus or collection.

51. Probe and needle

52. Knee joint Knee capsular attachment is 14 mm distal to the articular surface of the tibia. Important to remember in case of proximal tibial pins Patient position - Supine position Joint position – Slight knee flexion Probe position – In long axis look for effusion in suprapatellar bursa. Then make the probe into short axis over the suprapatellar bursa n look for effusion over the trochlear notch. Needle – Turn the probe into short axis. Entry in the soft spot between VL and ITB. It is located 1 cm sup and lat to the superolateral corner of the patella. In plane approach - L-M Evaluation – Particulate material can be seen while injection is going on. Injection should be free n capsular lift off should be seen. This approach can also be used for aspiration of the joint for pus or collection.

53. Probe and needle

54. Ankle joint injections Patient position - Supine position Joint position – Knee 45 deg of flexion and ankle in slight plantar flexion Probe position – In long axis Needle –In plane approach – distal to proximal. Point of entry -either through the medial soft spot (medial to TA) or lateral soft spot (lateral to EDL) In medial approach talus and tibia are seen and in lateral approach talus and fibula are seen. Evaluation – Particulate material can be seen while injection is going on. Injection should be free n capsular lift off should be seen. This approach can also be used for aspiration of the joint for pus or collection. Image - In medial approach talus and tibia are seen and in lateral approach talus and fibula are seen.

55. Ankle joint injections

56. Other possible procedures in LL 1 st MTP joint injections Tarsal tunnel injections Peroneal sheath injections and PRPs Plantar fascial injections

57. Plantar fasciitis – usg guided injections

58. Fluoro guided procedures Spine interventions Major joint interventions

59. Spine interventions Why should a spine or orthopedic surgeon learn the spinal interventions Easy to learn compared to the complex surgical procedures Very attractive alternative from the patient view even though they know it may follow with surgical procedure in the future Useful as a diagnostic procedure prior to definitive surgical procedure The surgical procedure may be more morbid compared to simple injections

60. Why the patient need to be seen in dedicated clinic before the intervention As a general orthopedic surgeon we will be busy in disposing the patients if fracture clinic. Most of them will be coming for first time or subsequent visit - pain medications and physio will be sufficient. Most of the times. Ruling out the red flags is a must in early visits Critical neurological evaluation is not needed or not possible for all back or neck pain patients because of the patient load. Before patient is subjected to the intervention critical relevant history, clinical examination including specific dermatomal pattern, other neurological evaluation, special tests are mandatory Like wise image analysis, checking the mri date, suitable procedure for each patient, needle size needed (obese patients- we have upto 110 mm needles) drug history – any anticoagulant or bleeding disorders to be excluded Pt has to be explained the pros and cons of the procedure and the prerequisites before the procedure like 6 hours of avoiding solid food and taking liquid diet only for spinal procedures to minimize the gas shadows in the lumbar procedures and S1 foraminal injections mainly Calling patient from other clinics directly to the minor ot to perform the procedures may not be safe Need a dedicated clinic to follow-up the post procedure patients especially spinal procudres

61. Various possible spinal interventions

62. typical example Good example –patient with l3/4 and l4/5 disc bulges and facet arthritis in mri comes to us. We are in a dilemma whether to do simple discectomy or to add fusion. If so whether only at l3/4 or l4/5 or at both levels If surgeon asks for staged facet blocks first at l3/4 followed by l4/5 to make a decision- radiologist wont be happy and he wants to give a interlaminar block to tackle all the issues at a time in therapeutic point of view We are not keen in that aspect as surgeons. If we ourselves can do the procedures we can stage them multiple times and come to a proper conclusion about the pain generators and the type of surgical procedure needed for a particular patient When it comes to therapeutic or diagnostic purpose - the procedure is same and hence we can treat our patients ourselves

63. Are these interventions totally safe Complications are inevitable in any intervensions . These procedures are also not innocent Infection- arachnoiditis/epidural abcess Weakness or spinchteric dysfunction-usually temporary Quardriparesis – even a lumbar procedure can cause this dreaded complication. how?

64. How to avoid complications Learn from the experts in the field Do as many as cadaveric courses possible Know the Tips and tricks to minimize the complications Use various views/have good 3d anatomical idea of the structures you are intervening Start with lumbar procedures- then go to cervical (in afh no cervical procedures are done even in radiology dept) Master the techniques Get a qualification which is widely acceptable – to avoid legal issues Stick on to preservative free xylocaine and dexamethasone in the early carrier – then you can move onto the bupivacaine and depot preparations –long action and larger particles create the issues

65. Tfes injection Most commonly performed spinal intervention at the lumbar spine Better to avoid at c spine – due to close proximity of the root and verteberal artery in the vicinity Can be both diagnostic and therapeutic Its done when the pathology is anterior- prolapsed disc irritating the nerve root

66. LUMBAR TFES INJECTION TECHNIQUE Indication - For unilateral radicular pain Preparation - Keep one 10 cc syringe (1% lignocaine for local) one 3 cc syringe ( Omnipaque 350 dye) One 5 cc syringe with drug (usually 0.25% bupivacaine and Steroid mixture) ready/22 G spinal needle (black) is used with tip bent towards the notch for spearing the needle Patient position – Patient is asked to lie down in prone position on radiolucent table with a pillow underneath the abdomen. Pt prepped and draped with sterile precautions. Small towels sup and inf. Large towels onto the sides (Opposite to surgical draping) C arm position -from opposite side and monitor in front. Identify the level of interest and confirm the side to be intervened. Make proper AP and then square the level of interest. Make ipsilateral oblique view on the side of pathology-Scotty Dog. Usually, the lateral wall of the pedicle should come within the lateral wall of the vertebra in Scotty Dog position. Procedure - Give local after identifying the skin level of injection. Then pass the needle to 5 O clock (Right side) or 7 clock (Left side) position of the pedicle above for sub pedicular technique/In lateral view tip should be seen in anterosuperior quadrant If you are doing Kambins triangle technique then the needle should be targeted to nose and ear junction of the Scotty Dog/In lateral view the needle tip should just pass beyond the posterior border of the foramen and needle tip is typically located in the posteroinferior quadrant of the NF In both the techniques needle should first land on the bone in BULLS EYE VIEW (TUNNEL VIEW) and using the bent tip spear the needle into the foramen for safety of surrounding structures. Final check is done in the AP view where needle shouldn’t go beyond the medial border of the pedicle (dural injury risk) Once the needle position is confirmed 2 to 3 cc of dye is injected in small oliquets in live fluoro to avoid intravascular injection (danger is developing paraplegia as we use the particulate steroid which after entering the segmental artery can cause thrombosis of the anterior spinal artery). If no intravascular pattern is noted and dye pattern is confirmed then the drug is injected. You can see the vanishing of the dye in subsequent images

67. Safe triangle and kambins triangle ?

68. Anatomical images

69. Subpedicular (safe triangle) approach

70. Kambins triangle (supra- pediclar )approach

71. DYE PATTERNS with needle tip IN DIFFERENT LOCATIONS 1) Epidural -Dural margins/root sleeves are seen. Typical epidural pattern with fat globules (non-homogenous pattern) seen dye goes beyond the lateral border of the vertebra 2)Subdural – Sheath of dye is seen- uniform/No epidural fat globules/No root sleeve/No dye beyond the lateral border of the vertebra/ Rat tail appearance/Dye mass can be inflated and deflated 3)Intra thecal (subarachnoid) Faint dural margins/ No epidural fat/Dye can be made to move by tilting the pt in live fluoro / Dye is seen in the anterior thecal sac as a line just posterior to the vertebral bodies 4) Intravascular -Vanishing dye sign. As soon as you give the dye it disappears. How to know whether it is arterial or venous. In arterial pattern dye goes medially but never crosses the midline. In venous pattern mainly the dye goes laterally and can cross the midline

72. How tO select the proper technique WHEN TO USE SUBPEDICULAR AND WHEN TO USE KAMBINS TRAINGLE APPRAOCH Subpedicular injection is used for tackling the exiting nerve root. For example in L4/5 foraminal narrowing L4 root is affected it is tackled with L4 subpedicular injection. Where as in L4/5 para central disc bulge which affects the L5 root should be dealt with subpedicualr injection at L5 level as the traversing nerve root at L4/5 level becomes the exiting nerve root below the L5 pedicle (L5/S1 level) Kambins Triangle Injection is used when we need to deal with both exiting and traversing nerve roots at a given level. For example, if there is L4/5 neural foraminal narrowing and para central (subarticular) disc bulges affecting both the existing and traversing nerve roots at that level, then KT injection is best as it can tackle both the roots with single injection.

73. Other possible spinal interventions Interlaminar epidural Caudal epidural S1 nerve root blocks Facet joint injections Mbb (medial branch block) for facet arthropathy - each side at least 2 injections r needed Intradiscal procedures Veretebroplasty and kyphoplasty techniques Endoscopic interventions – kambins approach or interlaminar

74. Inter laminar epidurals Safe at lumbar compared to cervical Still safest procedure at c spine level compared to tfes at c spine level due to close proximity of the vertebral artert Used for bil radiculopathy with multilevel degenerative disc disease-more of posterior pathology (better not to use IL epidural for a patient with disc bulge irritating the nerve root where the pathology is more anterior)

75. Ap and lat views used for il epidural

76. Contralateral oblique image – safe view before penetrating the lig . flavum

77. CAUDAL EPIDURAL Useful only for pathologies at L5/S1 and L4/5 levels Drus wont reach higher levels beyond l4 Needle enters through he sacrococcygeal ligament in midline at sacral hiatus Sacral hiatus forms an equilateral triangle with both psiss Penetrate the scl and make the needle more abtuse angle to enter into the sacral canal Don’t go beyond s2 foramen- risk of dural rupture Take good volume to spread the drug along the whole foramen Usually 2 cc of drug/5 cc of 0.5% xylocard or 0.125% of bupivacaine + hyertonic dextrose are used Especially useful when there is post operative scarring or instrumentation in the vicinty of L4 to s1

78. Anatomy of cesi

79. Lat & Ap images- dye pattern in cesi

80. Facet joint injections Safe both at cervical and lumbar levels Need a positive clinical and mri images correlation before subjecting the patient to facet injections Facet arthropathy typically presents as back dominant pain/difficulty in sitting to standing position/difficulty in rotations of the trunk or neck/need to rotate the whole trunk to see to one side/paraspinal tenderness Relief of more than 50% of pain is diagnostic of facet arthropathy on facet blocks

81. FACET JOINT INJECTIONs

82. Dye injection & spread of dye after drug injection

83. Other Non spinal interventions in mid line of low back Si joint injections Ganglion impar block for coccydynia

84. Si joint arthritis - presentation Pain in the low paraspinal region Radiating pain mimicking sciatica Alternating pain on both sides even one side is affected because of off loading by the pt Prolonged sitting/sitting to standing/lying on the affected side/difficult in sleepng in the bed/getting in or out of the car or bed /getting up the stairs – difficult with associated pain Provocative tests – compression/distraction/pump handle/ geanslens /thigh thurst /faber tests - few of these may be positive Most reliable test is tenderness in dimple of venus

85. Tricky joint to enter-needs cl oblique view to visualize the sij

86. coccydynia Ganglion impar- terminal part of the sympathetic chain- sensory supply to the Perineum and sacrococcygeal area Useful in coccydynia/dyspareunia and other painful pelvic conditions As orthopedic surgeons we are interested in using it for coccygeal pains

87. Anatomy and various views used for ganglion impar block

88. Anatomy of ganglion impar

89. Other useful procedures pyriformis syndrome- for injections Diagnosed by no back pain/sciatica/fair test + ve / fluoro guidance is best Greater trochanteric bursitis injection and aspirations Usg guidance is better Iliopsoas bursal injections and aspirations Usg guidance is better

90. Orthobiologics – Prp / gfc / bmac Prp - platelet rich plasma Gfc - growth factor concentrate – released from activated platelets-less post procedure pain compared to prp /acellular mostly Bmac – contains higher concentrations of growth factors and mesenchymal stem cells obtained from bone marrow Useful in chronic tendinopathies, degenerative muscular or arthritic conditions

91. PRP OR GFC NEED SPECIAL KITS AND MACHINE 30 - 60 ML OF BLOOD YIELDS AROUND 3-4 CC OF PRP –contains 1 million platelets/ml NEED TO INJECT INTO THE DAMAGED OR DEGENERATED STRUCTURE ACcURATeLY USG GUIDANCE IS RECOMMENDED STRONGLY POST PROCEDURE PAIN IS COMMON-DON’T PRESCRIBE NSAIDS – CONTRADICTORY PRINCIPLES- Rx pain with pcm or tramadol PRP CANT BE COMBINED WITH STEROID FOR SAME REASON

92. Apart from pain, stiffness and improvement in rom MRI cartilage reconstruction done 8/12 after prp injection showed increase in cartilage volume and thickness

93. PRP PREPARATION STEPS

94. Zimmer- biomet prp machine

95. Catridge after centrifugation showing the prp layer

96. Growth factor concentrate Instead of injection the prp - delivering the gfc directly to the site of damage is known to be more attractive Its acellular mostly hence is less painful Claimed that less sessions are needed compared to prp Needs just one addition step of adding cacl2 and waiting period of 30 minutes Other steps are almost similar

97. Steps of gfc preparation

98. Steps of gfc preparation

99. Healing effects of gfc - non healing diabetic ulcers

100. Bmac - bone marrow aspirate concentrate Bone marrow aspirated from iliac crest – with or without floro guidance Subjected to centrifugation Concentrate is prepared by removing the water content from the plasma component The resulting bmac is injected to the site of pathology Useful in various spine, si joint, other large joint affections,and various soft tissue conditions It is considered the best source of GFC compared to PRP or prp activation in vitro Only prohibitive factor is the cost – three times more compared to prp preparation

101. The most important finding of our meta-analysis is that the administration of noncultured bone marrow aspirate concentrate (BMAC) can significantly reduce pain and improve knee function when compared to the scores before the therapy in almost all the evaluated studies

102. BMAC- Bone marrow aspirate concentrate

103. STEPS in bmac injections

104. Radiofrequency ablations Scope – excellent for knee joints (genicular blocks) Useful in other large joint painful conditions like hip and shoulder Provides long lasting benefit if you want to delay surgery (young age/post operative cases) Usually combined with ia prp or gfc injections Done as a Staged procedure Stage 1- ia hyalgan with rfa of sm / sl and im geniculars Stage 2 – ia prp or gfc stage 3 ia prp or gfc if needed stage 4 – ia prp or gfc

105. Meta analysis of rcts show rfa is efficacious at 6/12 and 1 year

106. Floro guidance or usg guidance Popular and more successful- usg guidance Locate the genicular arteries and ablate in that vicinity UNDER LOCAL ANESTHESIA Need to do sensory and motor stimulation prior to ABLATION FOR SENSORY STIMULATION-50 Hz/ motor 2v & 2 hz Conv. rfa 90 deg 120 secs & cooled rfa 60 deg 60 secs is sufficient Only sm / sl and im geniculars are ablated/il geniculars are typically spared due to close proximity of cpn ONCE PROCEDURE IS DONE SMALL AMOUNT OF DEPOT MEDROL IS DEPOSITED IN THAT AREA TO MINIMIZE POST PROCEUDRE PAIN

107. Can see the inferolateral geniculars spared due to close proximity to the CPN

108. Color doppler showing the geniculars -at metadiaphyseal junction

109. Probe position - sm genicular

110. What to do if we don’t have a Rfa machine * Even combining genicular blocks (steroid and anesthetic mixture) with either ia hyalgan or prp / gfc injections – can have a prolonged pain relief – adequate literature support Useful in young adults with early oa knees – non reconstructed acl /post aclr in non compliant patient or secondary oa due to other causes Genicular blocks are useful as a diagnostic procedure before subjecting the pt to more definitive rf ablation - should get >50% of pain relief

111. RFA machine and probes

112. Cooled rfa machine

113. COOL RFA PROBES – TECHNOLOGICAL OVER VIEW

114. Lesions in cooled rfa & conventional rfa

115. CRYO NUCLEOLYSIS-ALTERNATIVE FOR RFA USES NITROUS OXIDE GAS FOR COOLING EFFECT UPTO -30 TO -75 DEG DEPENDING UPON INDICATIONS SPECIAL PERCUTENEOUS PROBES ARE USEd TO DELIVER THE EFFECT AT DESIRED SITE ICE BALL IS PRODUCED AT THE TIP OF THE PROBE CAUSING NERVE INJURY IN CONTINUITY

116. cryo machine with probe and nitrous oxide cylinder

117. Cryoneurolysis is a promising intervention to improve outcomes in non-cancer knee pain populations, particularly in mild-to-moderate knee osteoarthritis and pre-total knee arthroplasty populations

118. Cryo ablation – lesion images vary based on length and diameter of probes

119. Which is better rfa or cryo ablation Conventional Rfa produces a smaller oval lesion – tip is inactive- need to place the probe parallel to the nerve/technically difficult/painful post procedure By making it cooled rfa – bigger circular lesion is produced – tip is active- can keep the probe perpendicular to the nerves-technically easy/still painful post procedure Cryo ablation- bigger lesion/pain less post procedure/ reversible/comparable with low grade nerve injuries-machine is costly including the probes

120. type of Lesions - RFA vs CRYO ABLATION In rfa – thermal injury – more time to regenerate-takes long time to recover in case of untoward effects- should be more precise and check with motor and sensory stimulation before actual ablation In cryo ablation – lesion is secondary to ice ball at the tip of probes-painless post procedure and reversible early – no need to worry much of untoward effects compared to RFA

121. For your patient listening for the sake of patients