Discogenic Back Pain: Pathophysiology and Treatment

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Discogenic Back Pain: Pathophysiology and Treatment"

Transcription

1 The 33 rd Annual Spring Meeting of KNS, 2015 Evidence-Based Approach of Spinal Pain Discogenic Back Pain: Pathophysiology and Treatment Ki-Jeong Kim M.D. Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital

2 Nomenclature Discogenic back pain Pain innate to intervertebral disc A damaged vertebral disc, particularly degenerative changes of IVD Internal disc disruption A condition characterized by degradation of the nuclear matrix and the development of fissures inside the disc. Histologic term Degenerative disc disease Various conditions related with degeneration of an IVD Painful degenerative disc disease discogenic back pain

3 Internal Disc Disruption Crock HV (1970) A distinct clinical entity with respect to other painful processes Such as segmental instability, disc prolapse, DDD, etc Morphologic features Annular tears Degradation of nucleus matrix Disc collapse with endplates failure Absence of significant modifications of the disc external contour No compression of nervous elements.

4 Disc Structural Failure Anular tears Disc prolapse Endplate damage & Schmorl s nodes Internal disc disruption Disc narrowing, radial bulging, & osteophytes MA Adams, PJ Roughley, Spine, 2006

5 Pain Mechanism Mechanical transduction of nociception Internally disrupted disc depressurized NP stress in posterior anulus Chemical nociception Degraded matrix material inflammatory mediators, cytokine, noxious agents Neo-innervation Along with radial fissures (Freemont AJ et al, 1997)

6 Painful vs. Non-painful disc IDD disc degeneration Different composition and structure of painful disc from non-painful degenerated disc Independent condition starting as a focal disorder of AF The histological hallmarks of painful disc Annulus radial tears Radial fissures occur at an earlier age than degenerative changes Prevalence does not increase over time Starting from the external annulus, densely vascularized and innervated granulation tissue develops along the radial fissures

7 Radial Fissure Visualization through injecting contrast medium into the NP Strong correlation between a disc w/ grade 3 or 4 fissure and being painful upon disc stimulation (Moneta GR et al., 1994) Radial fissure: independent of age

8 Prevalence IDD in chronic low back pain: 26 42%

9 Symptoms Triggering activities: pressure within the disc space Standing or sitting for prolonged periods Leaning forward Sneezing and coughing Provocation of pain when rising from sitting Location of pain Centralization: midline back pain, competent anulus High sensitivity, poor specificity Peripheralization: leg pain anular breach

10 Diagnosis Discogenic pain is not amenable to conventional means of assessing diagnostic tests Pain is a physiological symptom It cannot be photographed, radiographed, or biopsied. No physical reference standard for discogenic pain

11 Provocation Discography Reproduction of patients back pain was reproduced when contrast medium was injected into certain discs Pressure threshold & symptom (O Neill C et al. 2001, 2004) 3 subgroups of response: Low-pressure group distinct symptomatic disc Mid-pressure group High-pressure group normal disc

12

13 IASP guideline for provocation discogrphy Concordant pain 7/10 Pressure < 50 psi Grade 3 anular tear Volume limit 3.5 ml A painless control disc

14 False Positive in Asymptomatic False-positive rate for asymptomatic subjects 3.0% (95 CI 0 9%) per patient 2.1% (95% CI 0 6%) per disc Reliable test with a low false-positive rate in asymptomatic volunteers without confounding factors

15 High Signal Intenistity Zone in MRI HIZ: Oveall 1658 cases: sensitivity 45%, specificity 88%, Likelihood ratio 3.8 (95% CI: ) HIZ is not absolutely diagnostic of a painful disc Its presence substantially increases the chances that the affected disc will be the source of pain.

16 Modic changes Type 1: inflammatory edema Associated with disruption and fissuring of the endplate, IL-6, IL-8, PGE2 Resolve or evolve into type 2 Type 2: fatty infiltration, persist and not change in appearance Pain: type 1 and 2, not type 3 Patients with CLBP: 19-59% prevalence, median 6% OR of type 1 & 2 in LBP: Type 1 & 2: correl w/ painful disc stimulation LR 3.4 (95% CI: )

17 Diagnostic Tools 53 articles,where IVD itself was considered the principal source of patient s pain and was the main target of the treatment.

18

19

20 Treatment options Medications Physiotherapy Exercise Injection procedures Intradiscal Epidural Surgery Thermal Anular Procedures (TAP) Fusion Artificial disc replacement

21 Intradiscal injection Steroid Positive results Feffer HL (1969) & Wilkinson HA et al. (1980) RCT: Simmons JW et al. (1992) Khot A et al (2004) No significant different between 2 groups

22 Epidural injections Mechanism of action Steroid or local anesthetics: not well understood Neural blockade: interrupts nociceptive input, etc Corticosteroids: reduce infammation Routes Caudal Interlaminar Transforaminal No data was available to assess the evidence.

23 Caudal epidural injections Evidence: fair (Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, size, or consistency of included studies)

24 Interlaminar injection Evidence: fair for short-term and long-term relief with steroids or with local anesthetic.

25 Thermal Anular Procedures (TAP) Intradiscal electrothermal treatment (IDET) disctrode Biacuplasty

26 Therapeutic Concepts of TAPs Application of heat across the damaged annulus To denervate the annulus, leading to pain relief (Mazin, 2010). The heat reconfigures collagen structure (Derby, 2003).

27 IDET 1996 by Saal JS et al. Heat to the posterior annulus using convection technology 5 cm active tip placed at the nucleoannular junction

28

29 Evidence supporting the efficacy of IDET is limited to fair. Positive result: 1 randomized, 4 observational studies Negative result: 1 randomized (poor), 1 observational studies Undetermined: 1 observational study

30 disctrode 2005 by Finch PM et al. Heat to the posterior annulus using ionic heating created by a monopolar radiofrequency device

31 Evidence of disctrode is limited (Evidence is insufficient to assess effects on health outcomes) No benefit: 1 randomized study

32 Biacuplasty 2008 by Kapural L et al. Cooled bipolar radiofrequency device (TransDiscal )

33 Evidence of biacuplasty is limited to fair Positive: 1 randomized trial

34 Lumbar Fusion: 5 RCTs

35

36 Fusion vs. non-operative Tx No significant difference when compared with the nonoperative group. Significant improvement in ODI in fusion groups in 3 studies. Overall improvement of 7.39 points (ODI) in favor of lumbar fusion Unclear: clinically significant difference? Either lumbar fusion or non-operative management and physical therapy remain 2 acceptable treatment methods.

37 TDR: 7 RCTs Reference Sample Inclusion Diagnosis Device Fusion Follow up Berg et al. 152 DDD, 1-2 level MRI Charite, Prodisc, Maverick PLF, PLIF 2 yr Blumenthal et al. 304 DDD, single level, L4-S1 Discography Charite BAK 2 yr Gornet et al. 577 DDD, single level, L4-S1 Maverick ALIF (LT-CAGE) Hellum et al. 172 DDD Various device Behavioral Moreno et al. 32 DDD, single level, L4-S1, no instability, Modic 1 or 2 Sasso et al. 67 DDD, single, L1- S1 Charite ALIF 26 mos MR/CT/FEX Flexicore 360 fusion 2 yr Zigler et al. 236 DDD, single, L3- S1 MR/CT/FEX/ discography Prodisc 360 fusion 2 yr

38

39 TDR vs. rehab: 1 study Favor of surgery Not reach clinical relevance TDR vs. fusion: 6 studies VAS back (2): higher improvement in TDR, low quality of evidence VAS leg (2): no difference ODI improvement (5): higher in TDR,, low quality of evidence Below the predefined clinically relevant difference: VAS back & ODI

40 Discogenic LBP 26-42% of chronic low back pain Fundamental key for treatment: standard diagnostic measure Provocation discography Most reliable method when properly performed Pressure, volume, radial fissure, control disc False positive rate: 9.3% (per patient), 6.0% (per disc) MRI HIZ: sensitivity 45%, specificity 88%, Likelihood ratio 3.8 Modic change (type 1 & 2): sensitivity 24%, specificity 83%, LR 3.4

41 Evidence of Therapeutic Modalities Procedures Intradiscal steroid injection Caudal epidural injection Interlaminar epidural injection IDET disctrode Biacuplasty Lumbar fusion (vs. non-op) Lumbar TDR (vs. rehab) Lumbar TDR (vs. fusion) Evidence No effect Fair Fair Fair - limited Limited Fair - limited No significant difference ODI improvement: favors fusion Favors TDR, not reach clinical relevance Low quality evidence favors TDR, below clinically relevant difference

42

Imaging for Lumbar Degenerative Disc Disease

Imaging for Lumbar Degenerative Disc Disease Imaging for Lumbar Degenerative Disc Disease Muhammad A. Munir, MD Diplomat American Board of Anesthesiology and Pain Management Spectrum of Imaging Modalities Radiography, Fluoroscopy and techniques modified

More information

Discogenic Pain: Diagnosis and Treatment

Discogenic Pain: Diagnosis and Treatment Discogenic Pain: Diagnosis and Treatment James P. Rathmell, M.D. Professor of Anesthesiology University of Vermont College of Medicine Burlington, Vermont, USA Cottage Sunrise Westford, Vermont 2005 Learning

More information

INJECTION TECHNIQUES. Jwalant S. Mehta MS (Orth) MCh (Orth) FRCS (Orth)

INJECTION TECHNIQUES. Jwalant S. Mehta MS (Orth) MCh (Orth) FRCS (Orth) INJECTION TECHNIQUES Jwalant S. Mehta MS (Orth) MCh (Orth) FRCS (Orth) TYPES OF INJECTIONS Nerve root block Epidural Discogram SI joint injection Facet block Pars block IDET Coccyx injection OUTLINE Purpose

More information

Low Back Pain (LBP) Prevalence. Low Back Pain (LBP) Prevalence. Lumbar Fusion: Where is the Evidence?

Low Back Pain (LBP) Prevalence. Low Back Pain (LBP) Prevalence. Lumbar Fusion: Where is the Evidence? 15 th Annual Cleveland Clinic Pain Management Symposium Sarasota, Florida Lumbar Fusion: Where is the Evidence? Gordon R. Bell, M.D. Director, Cleveland Clinic Low Back Pain (LBP) Prevalence Lifetime prevalence:

More information

OUTLINE. Anatomy Approach to LBP Discogenic LBP. Treatment. Herniated Nucleus Pulposus Annular Tear. Non-Surgical Surgical

OUTLINE. Anatomy Approach to LBP Discogenic LBP. Treatment. Herniated Nucleus Pulposus Annular Tear. Non-Surgical Surgical DISCOGENIC PAIN OUTLINE Anatomy Approach to LBP Discogenic LBP Herniated Nucleus Pulposus Annular Tear Treatment Non-Surgical Surgical Facet Joints: bear 20% of weight Discs bear 80% of weight Neural Foramen

More information

CLINICAL DIAGNOSIS OF LUMBAR DISCOGENIC PAIN

CLINICAL DIAGNOSIS OF LUMBAR DISCOGENIC PAIN CLINICAL DIAGNOSIS OF LUMBAR DISCOGENIC PAIN Dr Mark Laslett, FNZCP, PhD, Dip.MT, Dip.MDT Registered Physiotherapy Specialist (Musculoskeletal) PhysioScholar Seminar Sept 1 2014 The normal disc is innervated

More information

Anterior Approaches for Lumbar Interbody Fusion. Glen Manzano, MD

Anterior Approaches for Lumbar Interbody Fusion. Glen Manzano, MD Anterior Approaches for Lumbar Interbody Fusion Glen Manzano, MD Anterior Techniques ALIF Lateral transpsoas approaches (XLIF/DLIF) Anterior Approaches - Contraindications ALIF Contraindications Calcified

More information

Imaging for Painful Degenerative Disc Disease. No Disclosures. Outline Imaging of the Painful Disc. Rationale Imaging of the Painful Disc

Imaging for Painful Degenerative Disc Disease. No Disclosures. Outline Imaging of the Painful Disc. Rationale Imaging of the Painful Disc Imaging for Painful Degenerative Disc Disease No Disclosures Thomas M. Link, MD, PhD Professor of Radiology UCSF San Francisco Thomas M. Link, MD, PhD Professor of Radiology UCSF San Francisco Rationale

More information

Coflex Dynamic Interlaminarinterspinous. stabilization device for lumbar degenerative disease (Initial Experience)

Coflex Dynamic Interlaminarinterspinous. stabilization device for lumbar degenerative disease (Initial Experience) Coflex Dynamic Interlaminarinterspinous distraction stabilization device for lumbar degenerative disease (Initial Experience) Mohamed Mohi Eldin, MB-BCH, M.Sc., MD Prof. of Neurosurgery, Faculty of Medicine,

More information

Treating Bulging Discs & Sciatica. Alexander Ching, MD

Treating Bulging Discs & Sciatica. Alexander Ching, MD Treating Bulging Discs & Sciatica Alexander Ching, MD Disclosures Depuy Spine Teaching and courses K2 Spine Complex Spine Study Group Disclosures Take 2 I am a spine surgeon I like spine surgery I believe

More information

INTERVERTEBRAL DISC A SOURCE OF PAIN? - LOW BACK PAIN: PROBLEMS AND FUTURE DIRECTIONS -

INTERVERTEBRAL DISC A SOURCE OF PAIN? - LOW BACK PAIN: PROBLEMS AND FUTURE DIRECTIONS - INTERVERTEBRAL DISC A SOURCE OF PAIN? - LOW BACK PAIN: PROBLEMS AND FUTURE DIRECTIONS - - Case reports - KALID MALIK * AND NINOS J JOSEPH ** Abstract Objective: The objective of this article is to provide

More information

Spinal Surgery 2. Teaching Aims. Common Spinal Pathologies. Disc Degeneration. Disc Degeneration. Causes of LBP 8/2/13. Common Spinal Conditions

Spinal Surgery 2. Teaching Aims. Common Spinal Pathologies. Disc Degeneration. Disc Degeneration. Causes of LBP 8/2/13. Common Spinal Conditions Teaching Aims Spinal Surgery 2 Mr Mushtaque A. Ishaque BSc(Hons) BChir(Cantab) DM FRCS FRCS(Ed) FRCS(Orth) Hunterian Professor at The Royal College of Surgeons of England Consultant Orthopaedic Spinal

More information

Corporate Medical Policy

Corporate Medical Policy Corporate Medical Policy Diagnosis and Treatment of Sacroiliac Joint Pain File Name: Origination: Last CAP Review: Next CAP Review: Last Review: diagnosis_and_treatment_of_sacroiliac_joint_pain 8/2010

More information

Post operative Spinal Imaging- A multimodality approach

Post operative Spinal Imaging- A multimodality approach Post operative Spinal Imaging- A multimodality approach UKRC June 2014 Dr Sajid Butt Consultant Radiology, RNOH Summary Common Spinal Surgeries Image Optimisation Spinal Instrumentation Clinical Scenarios

More information

Spine DJD Nomenclature. Sonia K Ghei, MD

Spine DJD Nomenclature. Sonia K Ghei, MD Spine DJD Nomenclature Sonia K Ghei, MD Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology http://www.asnr.org/spine_nomenclature/

More information

Imaging of the Spine. Dr Nicola Bees Consultant Radiologist

Imaging of the Spine. Dr Nicola Bees Consultant Radiologist Imaging of the Spine Dr Nicola Bees Consultant Radiologist Imaging of the Spine Types of Imaging available Value of Imaging in back pain With red flags Without red flags Imaging Guidelines Terminology

More information

Imaging degenerative disk disease in the lumbar spine. Elaine Besancon MS III Dr. Gillian Lieberman

Imaging degenerative disk disease in the lumbar spine. Elaine Besancon MS III Dr. Gillian Lieberman Imaging degenerative disk disease in the lumbar spine Elaine Besancon MS III Dr. Gillian Lieberman Learning Objectives Anatomy review Pathophysiology of degenerative disc disease Common sequelae of disk

More information

Patients with chronic low back pain will be considered for surgical management under the following circumstances:

Patients with chronic low back pain will be considered for surgical management under the following circumstances: T17 Spinal Surgery for Non Acute Lumbar Conditions Policy Policy author: Ipswich and East Suffolk and West Suffolk CCGs Policy start date: September 2014 Review date: September 2016 Policy summary This

More information

Prevalence of annular tears and disc herniations on MR images of the cervical spine in symptom free volunteers

Prevalence of annular tears and disc herniations on MR images of the cervical spine in symptom free volunteers Prevalence of annular tears and disc herniations on MR images of the cervical spine in symptom free volunteers 1 European Journal of Radiology September 2005, 55, 409 414 C.W. Ernst, T.W. Stadnik, E. Peeters,

More information

Approach to Primary Care Evaluation of Low Back Pain. Kirk Whetstone, MD OhioHealth Neurological Physicians Medical Spine

Approach to Primary Care Evaluation of Low Back Pain. Kirk Whetstone, MD OhioHealth Neurological Physicians Medical Spine Approach to Primary Care Evaluation of Low Back Pain Kirk Whetstone, MD OhioHealth Neurological Physicians Medical Spine Disclosure Statement I have no relevant disclosures or conflicts of interest to

More information

DIFFERENTIAL DIAGNOSIS OF LOW BACK PAIN. Arnold J. Weil, M.D., M.B.A. Non-Surgical Orthopaedics, P.C. Atlanta, GA

DIFFERENTIAL DIAGNOSIS OF LOW BACK PAIN. Arnold J. Weil, M.D., M.B.A. Non-Surgical Orthopaedics, P.C. Atlanta, GA DIFFERENTIAL DIAGNOSIS OF LOW BACK PAIN Arnold J. Weil, M.D., M.B.A. Non-Surgical Orthopaedics, P.C. Atlanta, GA MEDICAL ALGORITHM OF REALITY LOWER BACK PAIN Yes Patient will never get better until case

More information

Efficacy of Epidural Steroid Injections for Lumbar Radiculopathy. Dr Chris Milne Sports Physician Hamilton

Efficacy of Epidural Steroid Injections for Lumbar Radiculopathy. Dr Chris Milne Sports Physician Hamilton Efficacy of Epidural Steroid Injections for Lumbar Radiculopathy Dr Chris Milne Sports Physician Hamilton Clinical Background 1-Low back pain is common 2-Early resolution is the usual outcome 3-A small

More information

ISPI Newsletter Archive Lumbar Spine Surgery

ISPI Newsletter Archive Lumbar Spine Surgery ISPI Newsletter Archive Lumbar Spine Surgery January 2005 Effects of Charite Artificial Disc on the Implanted and Adjacent Spinal Segments Mechanics Using a Hybrid Testing Protocol Spine. 30(24):2755-2764,

More information

An Algorithmic Approach to Diagnosis and Management of Low Back Pain

An Algorithmic Approach to Diagnosis and Management of Low Back Pain Manchikanti, Singh An Algorithmic Approach to Diagnosis and Management of Low Back Pain 597 An Algorithmic Approach to Diagnosis and Management of Low Back Pain Laxmaiah Manchikanti, MD Vijay Singh, MD

More information

Sample Treatment Protocol

Sample Treatment Protocol Sample Treatment Protocol 1 Adults with acute episode of LBP Definition: Acute episode Back pain lasting

More information

Discogenic Low Backache A clinical and MRI correlative study A DISSERTATION SUBMITTED TO UNIVERSITY OF SEYCHELLES AMERICAN INSTITUTE OF MEDICINE

Discogenic Low Backache A clinical and MRI correlative study A DISSERTATION SUBMITTED TO UNIVERSITY OF SEYCHELLES AMERICAN INSTITUTE OF MEDICINE Discogenic Low Backache A clinical and MRI correlative study A DISSERTATION SUBMITTED TO UNIVERSITY OF SEYCHELLES AMERICAN INSTITUTE OF MEDICINE IN PARTIAL FULFILLMENT OF THE REGULATIONS FOR THE AWARD

More information

POST SURGICAL RETURN OF RIGHT LEG PAIN. TREATED SUCCESSFULLY WITH COX FLEXION DISTRACTION DECOMPRESSION ADJUSTING

POST SURGICAL RETURN OF RIGHT LEG PAIN. TREATED SUCCESSFULLY WITH COX FLEXION DISTRACTION DECOMPRESSION ADJUSTING POST SURGICAL RETURN OF RIGHT LEG PAIN. TREATED SUCCESSFULLY WITH COX FLEXION DISTRACTION DECOMPRESSION ADJUSTING A 47 year old white married female was seen for the chief complaint of low back and right

More information

MRI AND DISCOGRAPHY OF ANNULAR TEARS AND INTERVERTEBRAL DISC DEGENERATION

MRI AND DISCOGRAPHY OF ANNULAR TEARS AND INTERVERTEBRAL DISC DEGENERATION MRI AND DISCOGRAPHY OF ANNULAR TEARS AND INTERVERTEBRAL DISC DEGENERATION A PROSPECTIVE CLINICAL COMPARISON 0. L. OSTI, R. D. FRASER From the Royal Adelaide Hospital, South Australia We attempted to correlate

More information

6-Month Results of Transdiscal Biacuplasty on Patients with Discogenic Low Back Pain: Preliminary Findings

6-Month Results of Transdiscal Biacuplasty on Patients with Discogenic Low Back Pain: Preliminary Findings 1 Research Paper International Journal of Medical Sciences 2011; 8(1):1-8 Ivyspring International Publisher. All rights reserved. 6-Month Results of Transdiscal Biacuplasty on Patients with Discogenic

More information

Age Changes in the Lumbar Spine

Age Changes in the Lumbar Spine Age Changes in the Lumbar Spine 1. Age changes in vertebrae & intervertebral discs 2. Age changes in facet joints 3. Spinal stenosis Acknowledgment: The slides are the work of Professor James Taylor &

More information

Does the pain radiating down your legs, buttocks or lower back prevent you from walking long distances?

Does the pain radiating down your legs, buttocks or lower back prevent you from walking long distances? Does the pain radiating down your legs, buttocks or lower back prevent you from walking long distances? Do you experience weakness, tingling, numbness, stiffness, or cramping in your legs, buttocks or

More information

Serial MR Imaging of Annular Tears in Lumbar Intervertebral Disks

Serial MR Imaging of Annular Tears in Lumbar Intervertebral Disks AJNR Am J Neuroradiol 23:1105 1109, August 2002 Serial MR Imaging of Annular Tears in Lumbar Intervertebral Disks Fletcher M. Munter, Bruce A. Wasserman, Hsiu-Mei Wu, and David M. Yousem BACKGROUND AND

More information

Upright Positional MRI of the Lumbar Spine. Clinical Radiology Volume 63, Issue 9, September 2008, Pages

Upright Positional MRI of the Lumbar Spine. Clinical Radiology Volume 63, Issue 9, September 2008, Pages Upright Positional MRI of the Lumbar Spine 1 Clinical Radiology Volume 63, Issue 9, September 2008, Pages 1035-1048 F. Alyas, D. Connell, A. Saifuddin The authors are from the Department of Radiology,

More information

The Dehydrated Lumbar Intervertebral Disk on MR, its Anatomy, Biochemistry and Biomechanics

The Dehydrated Lumbar Intervertebral Disk on MR, its Anatomy, Biochemistry and Biomechanics NRJ Digital - The Neuroradiology Journal 1: 639-644, 2011 www.centauro.it The Dehydrated Lumbar Intervertebral Disk on MR, its Anatomy, Biochemistry and Biomechanics V. HAUgHToN Radiology Department, Wisconsin

More information

Minimally Invasive Spine Surgery For Your Patients

Minimally Invasive Spine Surgery For Your Patients Minimally Invasive Spine Surgery For Your Patients Lukas P. Zebala, M.D. Assistant Professor Orthopaedic and Neurological Spine Surgery Department of Orthopaedic Surgery Washington University School of

More information

NON SURGICAL SPINAL DECOMPRESSION. Dr. Douglas A. VanderPloeg

NON SURGICAL SPINAL DECOMPRESSION. Dr. Douglas A. VanderPloeg NON SURGICAL SPINAL DECOMPRESSION Dr. Douglas A. VanderPloeg CONTENTS I. Incidence of L.B.P. II. Anatomy Review III. IV. Disc Degeneration, Bulge, and Herniation Non-Surgical Spinal Decompression 1. History

More information

Spinal Stenosis and Radiculopathy: A Case Report. Nicole Miller, SDPT. 68 Year Old Female with. A Case Report. Nicole Miller, SDPT 12/30/2009

Spinal Stenosis and Radiculopathy: A Case Report. Nicole Miller, SDPT. 68 Year Old Female with. A Case Report. Nicole Miller, SDPT 12/30/2009 Spinal Stenosis and Radiculopathy: A Case Report Nicole Miller, SDPT Graphics Concept A 68 Year Old Female with Spinal Stenosis and Radiculopathy: A Case Report Nicole Miller, SDPT 2 Graphics Concept B

More information

X Stop Spinal Stenosis Decompression

X Stop Spinal Stenosis Decompression X Stop Spinal Stenosis Decompression Am I a candidate for X Stop spinal surgery? You may be a candidate for the X Stop spinal surgery if you have primarily leg pain rather than mostly back pain and your

More information

15. Discogenic Low Back Pain

15. Discogenic Low Back Pain papr_408 1..20 EVIDENCE-BASED MEDICINE Evidence-Based Interventional Pain Medicine according to Clinical Diagnoses 15. Discogenic Low Back Pain Jan Willem Kallewaard, MD*; Michel A. M. B. Terheggen, MD*;

More information

An Algorithmic Approach for Clinical Management of Chronic Spinal Pain

An Algorithmic Approach for Clinical Management of Chronic Spinal Pain Pain Physician 2009; 12:E225-E264 ISSN 2150-1149 Evidence-Based Medicine An Algorithmic Approach for Clinical Management of Chronic Spinal Pain Laxmaiah Manchikanti, MD 1, Standiford Helm, MD 2, Vijay

More information

DISC DEGENERATION. Disc Degeneration Grading system Pfirrmann [Spine 2001:26: 1873] Hyperintense Normal: Height.

DISC DEGENERATION. Disc Degeneration Grading system Pfirrmann [Spine 2001:26: 1873] Hyperintense Normal: Height. DISC DEGENERATION TIMING of MRI findings In MRI, the Thompson [Spine 1990;15:411-5.] In conventional MRI, the first sign of degeneration is inhomogeneity of the intranuclear cleft followed by bulging of

More information

LOW BACK PAIN. common of these conditions include: muscle strain ( pulled muscle ), weak core muscles

LOW BACK PAIN. common of these conditions include: muscle strain ( pulled muscle ), weak core muscles LOW BACK PAIN Most episodes of low back pain are caused by relatively harmless conditions. The most common of these conditions include: muscle strain ( pulled muscle ), weak core muscles (abdominal and

More information

ABNORMALITIES IN DISC MORPHOLOGY

ABNORMALITIES IN DISC MORPHOLOGY ABNORMALITIES IN DISC MORPHOLOGY The terminology for disc abnormalities is very CONFUSING and INCONSISTENT in the literature. To address the remaining needs and in hopes of securing endorsement sufficient

More information

https://www.laserspineinstitute.com/back_problems/foraminal_stenosis/e...

https://www.laserspineinstitute.com/back_problems/foraminal_stenosis/e... Questions? Call toll free 1-866-249-1627 Contact us today. We're here for you seven days a week. MRI Review Consultation Live help Call 1-866-249-1627 Chat Live Home Laser Spine Institute Laser Spine Institute's

More information

Imaging of Normal and Abnormal Vertebral bone Marrow

Imaging of Normal and Abnormal Vertebral bone Marrow Imaging of Normal and Abnormal Vertebral bone Marrow Dr Philippa Tyler Consultant Radiologist The Royal National Orthopaedic Hospital, Stanmore Systematic review marrow change (fat / oedema/ sclerosis/fibrosis/

More information

Advances In Spine Care. James D. Bruffey M.D. Scripps Clinic Division of Orthopaedic Surgery Section of Spinal Surgery

Advances In Spine Care. James D. Bruffey M.D. Scripps Clinic Division of Orthopaedic Surgery Section of Spinal Surgery Advances In Spine Care James D. Bruffey M.D. Scripps Clinic Division of Orthopaedic Surgery Section of Spinal Surgery Introduction The Spine - A common source of problems Back pain is the #2 presenting

More information

Non Surgical Management of Back pain. Dr Pankaj Wadhwa MBBS,MD(Anaesth),DNB,Dip.Acu, FIPP, Fellowship in Pain Management.

Non Surgical Management of Back pain. Dr Pankaj Wadhwa MBBS,MD(Anaesth),DNB,Dip.Acu, FIPP, Fellowship in Pain Management. Non Surgical Management of Back pain. Dr Pankaj Wadhwa MBBS,MD(Anaesth),DNB,Dip.Acu, FIPP, Fellowship in Pain Management. MAGNITUDE OF THE PROBLEM It is one of the commonest experiences of humankind. It

More information

Aim of current study 05/09/2014. Spine J)

Aim of current study 05/09/2014. Spine J) Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type I changes): a double-blind randomized clinical controlled trial of efficacy (Albert et al. 2013 Eur Spine

More information

Surgical Procedures of the Spine

Surgical Procedures of the Spine Surgical Procedures of the Spine Jaideep Chunduri, M.D. Orthopaedic Spine Surgeon Beacon Orthopaedics and Sports Medicine Beacon Spine Center Objectives Discuss the 4 most common procedures performed in

More information

Spinal Pain: Diagnosis and Interventional Procedures

Spinal Pain: Diagnosis and Interventional Procedures Spinal Pain: Diagnosis and Interventional Procedures Dr Ilias Drivas MBBS FRANZCR Diagnostic and Interventional Radiologist Alfred Imaging Group Staff Specialist Royal Prince Alfred Hospital Overview Go

More information

.org. Cervical Spondylosis (Arthritis of the Neck) Anatomy. Cause

.org. Cervical Spondylosis (Arthritis of the Neck) Anatomy. Cause Cervical Spondylosis (Arthritis of the Neck) Page ( 1 ) Neck pain can be caused by many things but is most often related to getting older. Like the rest of the body, the disks and joints in the neck (cervical

More information

1 Operative Management of Common Spinal Conditions

1 Operative Management of Common Spinal Conditions 1 Operative Management of Common Spinal Conditions 2 Brett Menmuir Reno Orthopedic Clinic ROC Overview What was I thinking? Herniated Disc Stenosis Low Back Pain Neck Pain Sacroiliac Joint Dysfunction

More information

Pain Management. the primary procedure allowable reimbursement; 50% of add-on. Injection/Destruction Procedures

Pain Management. the primary procedure allowable reimbursement; 50% of add-on. Injection/Destruction Procedures Pain Management In addition to the General Guidelines, this section applies to the unique guidelines for Pain Management services. I. Reimbursement for Pain Management Services A. Pain Management Base

More information

Cervical Spine Surgery. Orthopaedic Nursing Seminar. Dr Michelle Atkinson. Friday October 21 st 2011. Cervical Disc Herniation

Cervical Spine Surgery. Orthopaedic Nursing Seminar. Dr Michelle Atkinson. Friday October 21 st 2011. Cervical Disc Herniation Cervical Spine Surgery Dr Michelle Atkinson The Sydney and Dalcross Adventist Hospitals Orthopaedic Nursing Seminar Friday October 21 st 2011 Cervical disc herniation The most frequently treated surgical

More information

All About Herniated Discs Anatomy & Pathology

All About Herniated Discs Anatomy & Pathology All About Herniated Discs Anatomy & Pathology Conflict of Interest Disclosure DR. HABER CERTIFIES THAT, TO THE BEST OF HIS KNOWLEDGE, NO AFFILIATION OR RELATIONSHIP OF A FINANCIAL NATURE WITH A COMMERCIAL

More information

On Cervical Zygapophysial Joint Pain After Whiplash. Spine December 1, 2011; Volume 36, Number 25S, pp S194 S199

On Cervical Zygapophysial Joint Pain After Whiplash. Spine December 1, 2011; Volume 36, Number 25S, pp S194 S199 On Cervical Zygapophysial Joint Pain After Whiplash 1 Spine December 1, 2011; Volume 36, Number 25S, pp S194 S199 Nikolai Bogduk, MD, PhD FROM ABSTRACT Objective To summarize the evidence that implicates

More information

PAIN: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

PAIN: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Low Back Pain Sherif A. Roushdy MD Dual Certified - Pain Medicine Under Auspice of the American Board of Anesthesiology ABIM Advanced Spine Associates Spring Lake Park, MN PAIN: An unpleasant sensory and

More information

Treatment Concepts for Degenerative Spinal Diseases PARADIGM SPINE

Treatment Concepts for Degenerative Spinal Diseases PARADIGM SPINE Treatment Concepts for Degenerative Spinal Diseases PARADIGM SPINE What You Need To Know About Your Spine It is important to understand the role of the spine, the changes that occur in your spine as your

More information

STATE OF WEST VIRGINIA SUPREME COURT OF APPEALS MEMORANDUM DECISION

STATE OF WEST VIRGINIA SUPREME COURT OF APPEALS MEMORANDUM DECISION STATE OF WEST VIRGINIA GARY E. GOSNELL, Claimant Below, Petitioner SUPREME COURT OF APPEALS FILED March 27, 2015 RORY L. PERRY II, CLERK SUPREME COURT OF APPEALS OF WEST VIRGINIA vs.) No. 14-0614 (BOR

More information

Ultrasound Guided Percutaneous Tenotomy for the Treatment of Chronic Tennis Elbow. John M. Mcshane, M.D. McShane Sports Medicine Villanova, PA

Ultrasound Guided Percutaneous Tenotomy for the Treatment of Chronic Tennis Elbow. John M. Mcshane, M.D. McShane Sports Medicine Villanova, PA Ultrasound Guided Percutaneous Tenotomy for the Treatment of Chronic Tennis Elbow John M. Mcshane, M.D. McShane Sports Medicine Villanova, PA Tennis Elbow Disorder affecting the common extensor tendon

More information

Effects of Vertebral Axial Decompression (VAX-D) On Intradiscal Pressure

Effects of Vertebral Axial Decompression (VAX-D) On Intradiscal Pressure Effects of Vertebral Axial Decompression (VAX-D) On Intradiscal Pressure Gustavo Ramos, M.D., William Marin, M.D. Journal of Neursurgery 81:35-353 1994 Departments of Neurosurgery and Radiology, Rio Grande

More information

PARADIGM SPINE. Minimally Invasive Lumbar Fusion. Interlaminar Technology

PARADIGM SPINE. Minimally Invasive Lumbar Fusion. Interlaminar Technology PARADIGM SPINE Minimally Invasive Lumbar Fusion Interlaminar Technology Lumbar Fu Minimally Invasive With the introduction of pedicle screws in the 1980s and cages in the 1990s, lumbar fusion with instrumentation

More information

Spinal Decompression

Spinal Decompression Spinal Decompression Spinal decompression is just one more tool we have to treat radiculopathy. With appropriate education and exercises, this modality has been proven to assist in the resolution of symptoms

More information

Nonoperative Management of Herniated Cervical Intervertebral Disc With Radiculopathy. Spine Volume 21(16) August 15, 1996, pp 1877-1883

Nonoperative Management of Herniated Cervical Intervertebral Disc With Radiculopathy. Spine Volume 21(16) August 15, 1996, pp 1877-1883 Nonoperative Management of Herniated Cervical Intervertebral Disc With Radiculopathy 1 Spine Volume 21(16) August 15, 1996, pp 1877-1883 Saal, Joel S. MD; Saal, Jeffrey A. MD; Yurth, Elizabeth F. MD FROM

More information

MR Spectroscopy in Non-Herniated Painful, Herniated Painful, and Non-Painful Lumbar Discs: a technical development study

MR Spectroscopy in Non-Herniated Painful, Herniated Painful, and Non-Painful Lumbar Discs: a technical development study MR Spectroscopy in Non-Herniated Painful, Herniated Painful, and Non-Painful Lumbar Discs: a technical development study PG Lactate col L Tanenbaum 2, D Bradford 3,4, J Lotz 3,4, P Kane 4, J Claude 4,

More information

(Formerly Sacroiliac Joint Arthrography and Injection)

(Formerly Sacroiliac Joint Arthrography and Injection) Protocol Diagnosis and Treatment of Sacroiliac Joint Pain (Formerly Sacroiliac Joint Arthrography and Injection) Medical Benefit Effective Date: 04/01/12 Next Review Date: 01/13 Preauthorization* Yes Review

More information

Intradiscal Electrothermal Treatment for Chronic Lower Back Pain Patients with Internal Disc Disruption

Intradiscal Electrothermal Treatment for Chronic Lower Back Pain Patients with Internal Disc Disruption Yonsei Medical Journal Vol. 46, No. 4, pp. 539-545, 2005 Intradiscal Electrothermal Treatment for Chronic Lower Back Pain Patients with Internal Disc Disruption Si-Young Park, 1 Seong-Hwan Moon, 1 Moon

More information

MANUSCRIPT PUBLICATIONS

MANUSCRIPT PUBLICATIONS YUNG CHEN, MD Appointments Faculty, Assistant Professor Founder / Director of Interventional Spine Center Founder / Director of Interventional Spine Cadaver Course Director of Interventional Spine Fellowship

More information

1. Proposal Abstract. Table 1. Degeneration distribution of tested discs Grade I Grade II Grade III Grade IV Grade V # of discs tested 13 9 12 5 1

1. Proposal Abstract. Table 1. Degeneration distribution of tested discs Grade I Grade II Grade III Grade IV Grade V # of discs tested 13 9 12 5 1 1. Proposal Abstract Purpose: Chronic low back pain (LBP) is a common musculoskeletal disorder that significantly impacts public health. However the mechanism of chronic LBP is still not fully understood.

More information

Reza Mobasheri Consultant Orthopaedic Spinal Surgeon

Reza Mobasheri Consultant Orthopaedic Spinal Surgeon Reza Mobasheri Consultant Orthopaedic Spinal Surgeon Low Back Pain Chronic non-specific LBP leading cause of disability in Global Burden of Disease reports 1990 and 2010 Rarely attributable to a specific

More information

Final Topic Refinement Document Pain Management Injection Therapies for Low back Pain Project ID ESIB0813

Final Topic Refinement Document Pain Management Injection Therapies for Low back Pain Project ID ESIB0813 Date: 9/19/14 Topic: Pain Management Injection Therapies for Low-back Pain Evidence-based Practice Center: Pacific Northwest Evidence-based Practice Center Agency for Healthcare Research and Quality Task

More information

Sciatica: Low back and Leg Pain Diagnosis and Treatment Options. Presented by Devesh Ramnath, MD Orthopaedic Associates Of Dallas Baylor Spine Center

Sciatica: Low back and Leg Pain Diagnosis and Treatment Options. Presented by Devesh Ramnath, MD Orthopaedic Associates Of Dallas Baylor Spine Center Sciatica: Low back and Leg Pain Diagnosis and Treatment Options Presented by Devesh Ramnath, MD Orthopaedic Associates Of Dallas Baylor Spine Center Sciatica Compression of the spinal nerves in the back

More information

How does neuropathophysiology affect the signs and symptoms of spinal disease?

How does neuropathophysiology affect the signs and symptoms of spinal disease? 1 How does neuropathophysiology affect the signs and symptoms of spinal disease? Kidd BL, Richardson PM. FROM ABSTRACT: Best Practices and Research Clinical Rheumatology January 2002;16(1):31-42 A complex

More information

Patient Information. Anterior Lumbar Interbody Fusion

Patient Information. Anterior Lumbar Interbody Fusion Patient Information Anterior Lumbar Interbody Fusion Table of Contents Anatomy of the Spine 2 The Healthy Spine 3 General Treatment Options 4 General Conditions of the Lumbar Spine 5 What is Spondylolisthesis?

More information

visualized. The correct level is then identified again. With the use of a microscope and

visualized. The correct level is then identified again. With the use of a microscope and SURGERY FOR SPINAL STENOSIS Laminectomy A one inch (or longer for extensive stenosis) incision is made in the middle of the back over the effected region of the spine. The muscles over the bone are moved

More information

Back & Neck Pain Survival Guide

Back & Neck Pain Survival Guide Back & Neck Pain Survival Guide www.kleinpeterpt.com Zachary - 225-658-7751 Baton Rouge - 225-768-7676 Kleinpeter Physical Therapy - Spine Care Program Finally! A Proven Assessment & Treatment Program

More information

Corporate Medical Policy Automated Percutaneous and Endoscopic Discectomy

Corporate Medical Policy Automated Percutaneous and Endoscopic Discectomy Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: percutaneous_discectomy 9/1991 5/2016 5/2017 5/2016 Description of Procedure or Service Traditionally, discectomy

More information

Etiology of Long-term Failures of Lumbar Spine Surgery

Etiology of Long-term Failures of Lumbar Spine Surgery PAIN MEDICINE Volume 3 Number 1 2002 Etiology of Long-term Failures of Lumbar Spine Surgery Alexis Waguespack, MD, Jerome Schofferman, MD, Paul Slosar, MD, and James Reynolds, MD SpineCare Medical Group,

More information

Low back pain. Quick reference guide. Issue date: May 2009. Early management of persistent non-specific low back pain

Low back pain. Quick reference guide. Issue date: May 2009. Early management of persistent non-specific low back pain Issue date: May 2009 Low back pain Early management of persistent non-specific low back pain Developed by the National Collaborating Centre for Primary Care About this booklet This is a quick reference

More information

Medical Policy An independent licensee of the Blue Cross Blue Shield Association

Medical Policy An independent licensee of the Blue Cross Blue Shield Association Percutaneous Intradiscal Electrothermal (IDET) Annuloplasty and Page 1 of 10 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Percutaneous Intradiscal Electrothermal

More information

Low Back Injury in the Industrial Athlete: An Anatomic Approach

Low Back Injury in the Industrial Athlete: An Anatomic Approach Low Back Injury in the Industrial Athlete: An Anatomic Approach Earl J. Craig, M.D. Assistant Professor Indiana University School of Medicine Department of Physical Medicine and Rehabilitation Epidemiology

More information

Chronic whiplash and whiplash-associated disorders: An evidence-based approach

Chronic whiplash and whiplash-associated disorders: An evidence-based approach Chronic whiplash and whiplash-associated disorders: An evidence-based approach 1 Journal of the American Academy of Orthopedic Surgeons October 2007;15(10):596-606 Schofferman J, Bogduk N, Slosar P. FROM

More information

The Spine Segment. Providing the full spectrum of spine care. Indiana Spine Group. Welcome

The Spine Segment. Providing the full spectrum of spine care. Indiana Spine Group. Welcome The Spine Segment Fall 2005 Indiana Spine Group Welcome Welcome to the fall issue of spine news from the Indiana Spine Group s quarterly enewsletter The Spine Segment. Each issue will provide you with

More information

TREATMENT OF AN L5/S1 EXTRUDED DISC HERNIATION USING SPINAL DECOMPRESSION: A CASE STUDY. Jack Choate, DC

TREATMENT OF AN L5/S1 EXTRUDED DISC HERNIATION USING SPINAL DECOMPRESSION: A CASE STUDY. Jack Choate, DC TREATMENT OF AN L5/S1 EXTRUDED DISC HERNIATION USING SPINAL DECOMPRESSION: A CASE STUDY Jack Choate, DC ABSTRACT Objective: To discuss a case of an acute lumbar disc herniation that was successfully treated

More information

Hitting a Nerve: The Triggers of Sciatica. Bruce Tranmer MD FRCS FACS

Hitting a Nerve: The Triggers of Sciatica. Bruce Tranmer MD FRCS FACS Hitting a Nerve: The Triggers of Sciatica Bruce Tranmer MD FRCS FACS Disclosures I have no financial disclosures Objectives - Sciatica Historical Perspective What is Sciatica What can cause Sciatica Clinical

More information

Percutaneous Transforaminal Endoscopic Spine Surgery: Introduction - Part 1

Percutaneous Transforaminal Endoscopic Spine Surgery: Introduction - Part 1 Percutaneous Transforaminal Endoscopic Spine Surgery: Introduction - Part 1 Anthony T. Yeung, M.D. Orthopaedic Spine Surgeon Arizona Institute for Minimally Invasive Spine Care Phoenix, AZ Christopher

More information

LOW BACK PAIN. To help alleviate the pain, PHYSICAL THERAPY, MODALITIES, INJECTIONS, MEDICATIONS OR SURGERY may be necessary.

LOW BACK PAIN. To help alleviate the pain, PHYSICAL THERAPY, MODALITIES, INJECTIONS, MEDICATIONS OR SURGERY may be necessary. LOW BACK PAIN Anatomy Conditions: Facet Joint Syndrome Muscular Spasm Pinched Nerve Spinal Stenosis Discogenic Low Back Pain Sacroiliac Joint Pain Vertebral Compression Fracture Procedures: Epidural &

More information

Herniated Lumbar Disc

Herniated Lumbar Disc Herniated Lumbar Disc North American Spine Society Public Education Series What Is a Herniated Disc? The spine is made up of a series of connected bones called vertebrae. The disc is a combination of strong

More information

Cooled RF Systems. Cooled RF Systems. Reimbursement Guide

Cooled RF Systems. Cooled RF Systems. Reimbursement Guide Kimberly-Clark* Reimbursement Guide Kimberly-Clark * Pain Management Cooled RF Systems Reimbursement Guide Table of Contents Introduction... 3 Disc Biacuplasty (TransDiscal* System)... 5 SInergy* System...

More information

Sciatica Yuliya Mutsa PTA 236

Sciatica Yuliya Mutsa PTA 236 Sciatica Yuliya Mutsa PTA 236 Sciatica is a common type of pain affecting the sciatic nerve, which extends from the lower back all the way through the back of the thigh and down through the leg. Depending

More information

Cervical Spine Radiculopathy: Convervative Treatment. Christos K. Yiannakopoulos, MD Orthopaedic Surgeon

Cervical Spine Radiculopathy: Convervative Treatment. Christos K. Yiannakopoulos, MD Orthopaedic Surgeon Cervical Spine Radiculopathy: Convervative Treatment Christos K. Yiannakopoulos, MD Orthopaedic Surgeon Laboratory for the Research of the Musculoskeletal System, University of Athens & IASO General Hospital,

More information

DISCOGENIC PAIN TREATMENT

DISCOGENIC PAIN TREATMENT DISCOGENIC PAIN TREATMENT CLINICAL POLICY Policy Number: OUTPATIENT 037.12 T2 Effective Date: February 1, 2016 Table of Contents BENEFIT CONSIDERATIONS.. APPLICABLE LINES OF BUSINESS/PRODUCTS... NON-COVERAGE

More information

Patient Guide to Stenosis

Patient Guide to Stenosis Patient Guide to Stenosis For Your Spinal Education Compliments of Your Spine Health Professional Dr. Schlesinger & Dr. Thomas Arkansas Neurosurgery Clinic 501-661-0077 www.arneuro.com Stenosis Description:

More information

INTERVENTIONAL PROCEDURES PROGRAMME

INTERVENTIONAL PROCEDURES PROGRAMME NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE INTERVENTIONAL PROCEDURES PROGRAMME Interventional procedure overview of percutaneous intradiscal thermocoagulation for lower back pain Introduction This overview

More information

Image-guided Spine Procedures for Relief of Severe Lower Back Pain:

Image-guided Spine Procedures for Relief of Severe Lower Back Pain: Image-guided Spine Procedures for Relief of Severe Lower Back Pain: A Guide to Epidural Steroid Injection, Facet Joint Injection, and Selective Nerve Root Block. PETER H TAKEYAMA MD HENRY WANG MD PhD SVEN

More information

MRI of Bone Marrow Radiologic-Pathologic Correlation

MRI of Bone Marrow Radiologic-Pathologic Correlation MRI of Bone Marrow Radiologic-Pathologic Correlation Marilyn J. Siegel, M.D. Mallinckrodt Institute of Radiology Washington University School of Medicine St. Louis, MO and Visiting Scientist, AFIP, Washington,

More information

Nomenclature and Standard Reporting Terminology of Intervertebral Disk Herniation

Nomenclature and Standard Reporting Terminology of Intervertebral Disk Herniation 167 Nomenclature and Standard Reporting Terminology of Intervertebral Disk Herniation Richard F. Costello, DO a, *, Douglas P. Beall, MD a,b MAGNETIC RESONANCE IMAGING CLINICS Magn Reson Imaging Clin N

More information

Electrodiagnostic Testing Electromyogram and Nerve Conduction Study

Electrodiagnostic Testing Electromyogram and Nerve Conduction Study Electrodiagnostic Testing Electromyogram and Nerve Conduction Study North American Spine Society Public Education Series What Is Electrodiagnostic Testing? The term electrodiagnostic testing covers a

More information

EPIDURAL STEROID AND FACET INJECTIONS FOR SPINAL PAIN

EPIDURAL STEROID AND FACET INJECTIONS FOR SPINAL PAIN MEDICAL POLICY EPIDURAL STEROID AND FACET INJECTIONS FOR SPINAL PAIN Policy Number: 2015T0004W Effective Date: December 1, 2015 Table of Contents BENEFIT CONSIDERATIONS COVERAGE RATIONALE APPLICABLE CODES..

More information

HEADACHES AND THE THIRD OCCIPITAL NERVE

HEADACHES AND THE THIRD OCCIPITAL NERVE HEADACHES AND THE THIRD OCCIPITAL NERVE Edward Babigumira M.D. FAAPMR. Interventional Pain Management, Lincoln. B. Pain Clinic, Ltd. Diplomate ABPMR. Board Certified Pain Medicine No disclosures Disclosure

More information