New minimally invasive techniques thwart debilitating back pain.

Back pain is the leading cause of disability in the United States. Nearly 65 million people report experiencing a recent episode of back pain, which is a chronic problem for about 16 million American adults. For many, the ailment is severe enough to interfere with everyday activities.

Back pain collectively costs Americans more than $100 billion each year. This includes direct expenses, such as physician and treatment fees, as well as indirect outlays associated with lost wages and productivity, insurance and legal fees, and decreased quality of life.

When medication, physical therapy and steroid injections fail to relieve chronic back pain, some people are forced to accept invasive procedures as the next step in their treatments. However, a new wave of minimally invasive solutions is available to ease the torment associated with a variety of spinal disorders.

“The specialty of interventional pain medicine has evolved rapidly over the past year, and the major focus is on providing patients with access to corrective minimally invasive techniques for back pain,” reveals Kai McGreevy, MD, a board-certified neurologist, pain management specialist and the founder of McGreevy NeuroHealth. “The thrust behind this movement is the persistent need to provide patients with successful treatment options beyond invasive surgery, which carries a significant risk for complications and may require a prolonged hospital stay.”

Patients undergoing traditional back surgery are at a higher risk for postoperative pain requiring opioid pain killers, due in part to tissue trauma from large incisions, dissection and retraction. Risks also include bleeding known as “hematomas,” which can compress nerves and lead to paralysis if not identified and treated early. There are higher risks for wound infections and aspiration pneumonia (a lung infection caused by inhaling substances such as food, saliva, liquid or vomit) due to general anesthesia.

Although uncommon, there’s also a risk for neurological deficits, including trouble moving the legs, and for deep vein thromboses (DVTs), which are blood clots originating in the legs that can travel to the lungs and cause a potentially life-threatening condition called pulmonary embolism (PE).

“Interventional pain specialists have been moving toward minimally invasive procedures for years,” Dr. McGreevy notes. “Just as interventional cardiologists have created techniques for performing diagnostic and therapeutic procedures such as catheterization and stenting, interventional pain specialists have created minimally invasive procedures that are less harmful to the tissue through which our instruments pass.

“These are outpatient procedures that don’t require a hospital or overnight stay. They also require less depth of sedation, so patients are exposed to less anesthetic risk for aspiration. And the recovery from many of these procedures is nearly immediate. Patients are often encouraged to be up and walking right away, so there are fewer complications, such as DVTs.”

Spinal Stenosis

Dr. McGreevy, who uses the most advanced modalities, offers six minimally invasive treatments for back pain: indirect lumbar decompression with interspinous spacers (for example, Vertiflex^™), basivertebral nerve ablation (for example, Intracept^®), percutaneous SI joint fixation, percutaneous facet fusion, endoscopic rhizotomy and endoscopic discectomy.

“The Vertiflex procedure treats lumbar spinal stenosis, including moderate narrowing of the spinal canal and the neural foramina, where the nerve roots exit the spine,” Dr. McGreevy explains. “This places external pressure on the nerves, leading to nerve dysfunction and pain. Patients who exhibit symptoms of claudication are candidates for this procedure.”

Claudication is pain in the low back, buttocks, thighs and legs that is worse with standing and walking. Patients with this condition often assume a stooped position, as if walking behind a shopping cart, because the pain can be temporarily relieved with sitting or bending forward.

“The Vertiflex procedure uses an implantable device, a small interspinous spacer,” Dr. McGreevy describes. “Under fluoroscopic guidance, the spacer is inserted through a small cannula, or tube, between the bony projections at the back of each vertebra in the spine. The spacer spreads the spinous processes apart and lifts them so there is less pressure on the spinal nerves, easing pain.

“There is five-year data showing consistent results of pain relief, longer standing times and walking distances, and overall improved functioning. A recent study has shown that only 4 percent of patients undergoing this procedure went on to an open back surgery. The outcomes of this procedure are comparable to back surgery with fewer complications.”

Vertebrogenic Pain

Intracept is an ablation procedure to treat back pain that arises from degenerative disc disease. The pain of this condition is called vertebrogenic pain because it often begins in the vertebrae, not the discs.

“There’s a specific nerve bundle known as the basivertebral nerves that senses a problem with the intervertebral disc and surrounding vertebral endplates,” Dr. McGreevy educates. “That nerve bundle is situated within the back half of the vertebral bodies at each level. The process of degenerative disc disease involves a breakdown on the molecular level between the disc surface and the vertebral body surface.

“When there’s a breach in the barrier between those two structures, chemical changes occur that promote an inflammatory response in the disc and in the vertebral bodies surrounding the disc. We call those endplate or modic changes. When patients present with these changes on MRI, the likelihood of vertebrogenic pain is high and Intracept may be indicated.”

During the Intracept procedure, Dr. McGreevy uses fluoroscopic guidance to access the basivertebral nerve bundle responsible for receiving and sending pain signals toward the brain.

“Once we access that nerve bundle, we use radiofrequency energy to ablate the nerves and destroy them,” Dr. McGreevy states. “With the nerves destroyed, the signals do not reach the brain to register as pain. The benefit to ablating these nerves is that it is permanent. These unmyelinated nerves do not regenerate. Intracept carries positive five-year data showing consistent pain relief and improved functioning.”

Joint Maneuvers

The sacroiliac (SI) joints link the iliac bone (pelvis) and the sacrum (the shield-shaped bony structure at the base of the spine). There is an SI joint on the left and right sides of the lower back. SI joint dysfunction is responsible for approximately 30 percent of all low back pain.

“SI joint dysfunction is a common mechanical pain syndrome that can become chronic,” Dr. McGreevy observes. “It produces localized pain in the low back and buttocks and also a ‘pseudo-sciatica,’ with pain running down the back of the thigh and sometimes into the leg. Patients with SI joint dysfunction often have excessive laxity or excessive movement of the SI joint that creates friction and pain, typically worse with sitting, getting up from bed or from a seated position, and often doing chores. This syndrome is increased in patients with a history of lumbar fusion surgery.

“SI fixation is performed in a manner that’s similar to the approach used for an SI joint injection. Diagnostic SI joint injections are performed to determine candidacy for SI fixation. Having complete familiarity with spinal anatomy and the SI joint injection procedure enables the interventional pain physician to effectively access, treat and potentially stabilize the SI joint.”

During the fixation procedure, Dr. McGreevy uses fluoroscopic guidance to insert an allograft dowel (a small wedge of bone from a donor) that accomplishes two goals. The first is to distract the joint, thereby eliminating contact of the joint surfaces and relieving pain. The second is to fuse the bones into a single, stable unit at the fulcrum, thereby limiting excessive movement.

The procedure is minimally invasive, taking an approach from the backside in a manner that avoids excessive tissue trauma, in comparison to standard SI fusion surgery, which often requires three screws drilled through muscles and the iliac bone under general anesthesia. Standard surgery results in more postoperative pain and a risk of bleeding complications.

Similar to the SI joints, the facet joints connect the vertebral bones. These stabilizing joints enable the spine to bend, extend and twist, and protect spinal structures such as the discs and spinal cord. With degeneration, the facet joints may narrow or become enlarged with bone spurs, resulting in axial low back pain and dysfunction. When patients have facet-mediated low back pain, typically worsened with extension and rotation, for which diagnostic facet injections or radiofrequency ablation provide short-term relief, Dr. McGreevy may recommend a minimally invasive facet fusion to fix the problem.

“The minimally invasive facet fusion technique essentially follows the same concept as SI joint fixation,” the doctor observes. “Under fluoroscopic guidance, a similar allograft dowel is placed within the rear part of the posterior facet joints to fuse and stabilize them. So, the process is the same but we’re treating a different pain generator. Facet-mediated pain is the leading cause of low back pain, so this procedure is an excellent, minimally invasive option to open surgery in select patients.”

Direct Visualization

Vertiflex, Intracept, SI fixation and facet fusion are performed through small incisions in the back under fluoroscopic guidance. Endoscopic rhizotomy and endoscopic discectomy use direct visualization through an endoscope, a thin tube with a camera that is inserted through a tiny incision in the back.

“Rhizotomy is a procedure to selectively destroy the medial branch nerves that are responsible for pain, using radiofrequency ablation,” Dr. McGreevy describes. “The medial branch nerves supply the facet joints, which may become problematic due to arthritis.

“We’ve found that diseased facet joints can become so hypertrophied, or large, that it’s difficult to locate the medial branch nerves under fluoroscopic guidance, especially in advanced cases. Endoscopic rhizotomy gives us direct visualization so we can find the nerves and transect them to relieve pain.”

Using the same technology, endoscopic discectomy is a minimally invasive procedure for decompressing the nerves affected by a disc herniation in patients who experience lumbar radiculopathy, pain involving the lumbar nerve root.

“Using this technique, we can remove the herniated disc fragments or tissue that may be leaning against a nerve and causing pain,” Dr. McGreevy informs. “Likewise, if there are tears within the disc that weaken the disc and risk future herniation, we can seal those tears with radiofrequency and reduce the risk of reherniation. The value of direct visualization through endoscopy is helping to revolutionize our field.”

Revolution Embraced

Dr. McGreevy is dedicated to staying on the forefront of interventional pain medicine.

“We’re in the midst of a revolution in our field, and McGreevy NeuroHealth embraces that revolution. We plan to stay on top of advances in technology and techniques,” Dr. McGreevy insists. “We desire to give our patients access to the most advanced, minimally invasive treatments because we believe in doing less harm and increasing chances of success. These procedures have undergone randomized, controlled clinical trials and are increasingly gaining acceptance by traditional health insurance plans.

“We give our patients access to the most advanced, minimally invasive treatments.” – Dr. McGreevy

“Back pain is incredibly complex, and we intend to provide as many treatment options as possible. My neurology and imaging background helps me make very important decisions as to candidacy for these procedures. It is important to note that these minimally invasive procedures are not for everyone, and open surgery is still the standard of care in many cases. We provide an alternative for those patients that are not surgical candidates either due to other medical problems or the patient’s choice not to pursue surgery.

“No patient is a candidate for all of these procedures. It is unique — and valuable — that we have diagnostic technology on site, which we use as a tool for procedure selection for each patient.”

© FHCN article by Patti DiPanfilo. Photos by Jordan Pysz. mkb