Imaging & Interventions

Imaging & Interventions

Overview

There is a trend of inadequately trained clinicians performing interventional procedures. This trend can potentially lead to serious complications and inappropriate utilization. A comprehensive assessment by a skilled pain specialist is necessary to identify which procedure is indicated for a given patient’s pain syndrome. Unfortunately, pain specialists are typically not involved in the multidisciplinary approaches of diagnosing and treating a pain patient early enough in his or her treatment, which can lead to suboptimal patient outcomes.

The activity was developed to address two emerging gaps:
According to consensus practice guidelines published April 2020 by the American Society of Regional Anesthesia: The past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of the procedures remain controversial. The committee determined that lumbar medial branch radiofrequency ablation (RFA) may provide benefit to well-selected individuals, with medial branch blocks (MBB) being more predictive than itra-articular (IA) injections. And that more stringent selection criteria are likely to improve denervation outcomes, but at the expense of more false-negatives.

In 2021, the American College of Radiology Committee on Drugs and Contrast Media of the ACR Commission on Quality and Safety updated the ACR Manual on Contrast Media. In addition to general safety updates, an entire chapter was added to address Nephrogenic systemic fibrosis (NSF). It is now generally accepted that gadolinium-based contrast agent (GBCA) exposure is a necessary factor in the development of NSF.

Outline

Interventions for Lumbar Facet Joint Pain, & Use of Contrast Agents in Interventional Pain Procedures

• Imaging in Pain Medicine
• Gadolinium: Friend or Foe?
  • 2021 Updates
  • Understanding hypersensitivity reactions
  • Identifying risk factors for vulnerable patients
• Facet Guidelines: UPDATED
• Ultrasound guided interventions
• Procedural Frontiers

Learning Objectives

As a result of participating in this activity, learners will be able/better able to:

• Manage the use of iodinated contrast media, including mitigating contrast media allergies
• Identify patients at risk of nephrogenic systemic fibrosis (NSF)
• Mitigate iatrogenic harms for at-risk patients associated with gadolinium-based contrast agents (GBCAs)
• Utilize prognostic blocks for patients receiving radiofrequency ablation

Desirable Physician Attributes

• Medical Knowledge [ACGME/ABMS] about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.
  
• Employ Evidence-based Practice [IOM] Integrate best research with clinical expertise and patient values for optimum care and participate in learning and research activities to the extent feasible.
• Patient Care [ACGME/ABMS & IOM] Provide care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health

Pain management domains and core competencies

• 1. Multidimensional nature of pain: What is pain?
  • Describes how cultural, institutional, societal, and regulatory influences affect assessment and management of pain
  • Demonstrates knowledge of the theories and science for understanding the physiology of pain and
    pain transmission

• 2. Pain assessment and measurement: How is pain recognized?
  • Demonstrates use of proper patient assessment, including physical exam and history, when treating pain
  • Describes patient, clinician, and system factors that can facilitate or interfere with effective pain assessment and management

• 3. Treatment: How is pain safely and effectively treated?
  • Develops a pain treatment plan based on benefits and risks of available treatments
  • Identifies appropriate multimodal pain treatment options as part of a comprehensive pain management plan

• 4. Context: How does context affect pain?
  • Uses an individualized pain management plan (including risk mitigation) that integrates the perspectives of patients, family and social support systems, and clinicians in the context of available
    resources

Accreditation & Designation

Release date: This activity was released 8/28/2021.

Termination date: The content of this activity remains eligible for CME Credit until 8/27/2024, unless reviewed or amended prior to this date.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.75 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure of Financial Relationships & Measures to Resolve of Conflicts of Interest

[Presenter] Scott Pritzlaff discloses the following financial relationships within the past 24 months: Consulting: SPR Therapeutics, EBT Medical, Nalu Medical

No other person with control of, or responsibility for, the planning, delivery, or evaluation of accredited continuing education has, or has had within the past 24 months, financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships have been mitigated. Materials were reviewed in advance of the activity by person(s) that do not have conflicts of interest related to the content. In some cases, content may have been modified as part of the review and mitigation process. All clinical recommendations are evidence-based and free of commercial bias (e.g., peer-reviewed literature, adhering to evidence-based practice guidelines).

Additional Reading

• Elahi, F., Reddy, C., & Ho, D. (2015). Ultrasound guided peripheral nerve stimulation implant for management of intractable pain after inguinal herniorrhaphy. Pain Physician, 18(1), E31-8.
• Benzon, H. T., Maus, T. P., Kang, H. R., Provenzano, D. A., Bhatia, A., Diehn, F., ... & Greenberger, P. A. (2021). The Use of Contrast Agents in Interventional Pain Procedures: A Multispecialty and Multisociety Practice Advisory on Nephrogenic Systemic Fibrosis, Gadolinium Deposition in the Brain, Encephalopathy After Unintentional Intrathecal Gadolinium Injection, and Hypersensitivity Reactions. Anesthesia & Analgesia, 10-1213.
• Manual, A. C. R. "On contrast media." (2020).
• Rogosnitzky, M., & Branch, S. (2016). Gadolinium-based contrast agent toxicity: a review of known and proposed mechanisms. Biometals, 29(3), 365-376.
• Olchowy, C., Cebulski, K., Łasecki, M., Chaber, R., Olchowy, A., Kałwak, K., & Zaleska-Dorobisz, U. (2017). The presence of the gadolinium-based contrast agent depositions in the brain and symptoms of gadolinium neurotoxicity-A systematic review. PloS one, 12(2), e0171704.
• Yerram, P., Saab, G., Karuparthi, P. R., Hayden, M. R., & Khanna, R. (2007). Nephrogenic systemic fibrosis: a mysterious disease in patients with renal failure—role of gadolinium-based contrast media in causation and the beneficial effect of intravenous sodium thiosulfate. Clinical Journal of the American Society of Nephrology, 2(2), 258-263.
• Cohen, S. P., Bhaskar, A., Bhatia, A., Buvanendran, A., Deer, T., Garg, S., ... & Zhao, Z. (2020). Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Regional Anesthesia & Pain Medicine, 45(6), 424-467.
• Bogduk N, Dreyfuss P, Govind J. A Narrative Review of Lumbar Medial Branch Neurotomy for the Treatment of Back Pain. Pain Med. 2009;10:1035-1045
• MacVicar J, Borowczyk J, MacVicar A, et al. Lumbar medial branch radiofrequency neurotomy in New Zealand. Pain Medicine 2013; 14: 639–645
• Lord SM, Barnsley L, Bogduk N. The utility of comparative local anesthetic blocks versus placebo-controlled blocks for the diagnosis of cervical zygapophysial joint pain. Clinical Journal Pain 1995 Sep;11(3): 208-213.
• Nath S, Nath CA, Pettersson K. Percutaneous lumbar zygapophysial (facet) joint neurotomy using radiofrequency current, in the management of chronic low back pain. A randomized double-blind trial. Spine 2008;33:1291–1297.
• Schofferman J, Kine G. Effectiveness of repeated radiofrequency neurotomy for lumbar facet pain. Spine 2004;29: 2471–2473.
• Tekin I, Mirzai H, Ok G, Erbuyun K, Vatansever D. A comparison of conventional and pulsed radiofrequency denervation in the treatment of chronic facet joint pain. Clinical Journal Pain 2007;23: 524–529.
• Van Kleef M, Barendse GA, Kessels A, et al. Randomized trial of radiofrequency lumbar facet denervation for chronic low back pain. Spine 1999; 24: 1937-1942.
• International Spine Intervention Society. Lumbar medial branch blocks. In: Bogduk N, ed. Practice guidelines for spinal diagnostic and treatment procedures. 2nd edn. San Francisco: International Spine Intervention Society, 2013: 457–88. 
• Marhofer, P., Greher, M., & Kapral, S. (2005). Ultrasound guidance in regional anaesthesia. British Journal of Anaesthesia, 94(1), 7-17.
• Greher, M., Scharbert, G., Kamolz, L. P., Beck, H., Gustorff, B., Kirchmair, L., & Kapral, S. (2004). Ultrasound-guided lumbar facet nerve block: a sonoanatomic study of a new methodologic approach. The Journal of the American Society of Anesthesiologists, 100(5), 1242-1248.
• Deer, T. R., Naidu, R., Strand, N., Sparks, D., Abd-Elsayed, A., Kalia, H., ... & Gulati, A. (2020). A review of the bioelectronic implications of stimulation of the peripheral nervous system for chronic pain conditions. Bioelectronic Medicine, 6(1), 1-13.
• Gofeld, M., & Agur, A. (2018). Peripheral nerve stimulation for chronic shoulder pain: a proof of concept anatomy study. Neuromodulation: Technology at the Neural Interface, 21(3), 284-289.