Download - RF PARA A DOR SACROILÍACA.pptx
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RF PARA A DOR SACROILÍACA
Charles A Oliveira, FIPPPresidente do Capítulo latino americano do WIP-2011/13
Charles A Oliveira, FIPPPresidente do Capítulo latino americano do WIP-2011/13
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CURSOS SINGULAR
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I CONGRESSO DA SOBRAMID
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HISTÓRIA
EXAME FÍSICO
EXAMES DE IMAGEM ( Rx, TC, RNM, ...)
DIAGNÓSTICO
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DOR SACROILÍACA
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Intrarticulares Extrarticulares
Artrite Fraturas
Infecção Lesão ligamentar
Trauma Dor miofascial
Artropatias Entesopatias
Malignidades
CAUSAS
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DOR SACROILÍACA19-30%
EPIDEMIOLOGIA DA DOR ESPINHAL
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ARTRODESES 40-60%% DOR SACROILÍACA
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Distribuição da dor
◦ glúteos (94%)◦ região lombar baixa(72%)◦ membros inferiores(50%)◦ pernas, abaixo do joelho (28%)◦ virilha(14%)◦ pés(12%)
Illustration of pain referral patterns of the sacroiliac joint.
Schwarzer AC, Aprill CN, Bogduk N.The SIJ in Chronic LBP. Spine. 1995;20:31-37
PADRÕES DE DOR REFERIDA PARA A DOR SACROILÍACA
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10
TESTES PROVOCATIVOSTeste de Distração
Solomon J, Nadler SF, Prather H. Physical examination of the sacroiliac joint. In Malanga GA, Nadler SF (eds). Musculoskeletal Physical Examination: An Evidence-Based Approach. 2006 pp 227-249.
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11
TESTES PROVOCATIVOS
Solomon J, Nadler SF, Prather H. Physical examination of the sacroiliac joint. In Malanga GA, Nadler SF (eds). Musculoskeletal Physical Examination: An Evidence-Based Approach. 2006 pp 227-249.
Teste do cisalhamento posterior da coxa
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1. Teste de compressão
2. Teste de distração3. Sinal de Patrick
4. Teste deGaenslen5. Teste do
cisalhamento posterior
6. Teste do dedo (Fortin)
7. Teste de Gillet
Especificidade
Sensibilidade
3 ou mais 79% 85%
3 ou mais 78% 94%
EXAME FÍSICO
Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provo- cation tests and composites of tests. Man Ther. 2005;10:207– 218.. van der Wurff P, Buijs EJ, Groen GJ. A multitest regimen of pain provocation tests as an aid to reduce unnec- essary minimally invasive sacroiliac joint procedures. Arch Phys Med Rehabil. 2006;87:10–14.
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INFILTRAÇÃO INTRA-ARTICULAR
DIAGNÓSTICO
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1,5-3,0 ml
Fluoroscopia, TC ou USG são essenciais◦ Apenas 22% intra-articular sem fluoroscopia◦ (Rosenberg et al. Clin J Pain 2000)
INFILTRAÇÃO SACROILÍACA
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TÉCNICA
Posicionamento da agulha e injeção do contraste
Source: Hansen HC, Manchikanti L. Sacroiliac joint interventions. In: Manchikanti L, Singh V (eds). Interventional Techniques in Chronic Spinal Pain, ASIPP Publishing, Paducah, KY, 2007, pp 237-252.
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Maior articulação diartrodial
A parte anterior é uma articulação sinovial verdadeira
A parte posterior é uma sindesmose, consistindo do ligamento sacroilíaco, gluteos e piriformes.
ANATOMIA
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ASI anterior – ramos anteriores de L2-S2
ASI posterior – ramos posteriores de L5, ramos laterais de S1-S3
INERVAÇÃO
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Yin W. et al. Spine. 2003; 28(20):2419-2425
INERVAÇÃO
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1- Maior articulação axial do corpo com abundância em nociceptores2- Mútiplas fontes de dor3- Exames radiológicos apenas para afastar “red flags”4- Testes clínicos inespecíficos5- Infitração da ASI confirma o diagnóstico
1Cohen S. Anesth Analg. 2005: 101: 1440-14532Yin W. et al. Spine. 2003; 28(20):2419-2425
COMPLEXIDADE DO DIAGNÓSTICO
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Histórico – radiofrequência para DSI
2001, Técnica intra-articular(Ferrante)
2003, Técnica Yin2007, Radiofrequência pulsada2007, Técnica do duplo eletrodo2007, SINERGY® 2008, SIMPLICITY®
OPÇÕES DE TRATAMENTO
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Ferrante, 2001
Denerva apenas o terço inferior da ASI inferior e posterior
Técnica intraarticular
Anita Gupta,Anesthesiology News, Oct 2010
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Identificação de cada nervo sacral pelo método convencional
RF térmica Tempo de procedimento > 1,5 hr Alta exposição à radiação
Técnica de Yin, 2003
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L5, 1 lesão
S1, 3 lesões
S2, 3 lesões
S3, 2 lesões
SINERGYRF RESFRIADA – 9 LESÕES
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INERVAÇÃO
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INERVAÇÃO
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SINERGY
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foramen sacral
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agulha
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epsilon
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10mm
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10mm 15mm
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S1,S22:304:005:30
S32:304:00
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allows for perpendicular or oblique probe placement near the treatment site, due to spherical lesion shape
SINERGY: VANTAGENS
A B C
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Standard RF: 18 Gauge x 4 mm Tip
4 mmV = ‘x’ mm3
• Internal cooling doubles the lesion radius and increases the lesion volume by a factor of 8
Internally Cooled RF Probe 18 Gauge x 4 mm Tip
8 mmV = 8‘x’ mm3
SINERGY: VANTAGENS
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Maior risco de sangramento pelo tamanho do eletrodo
Custo elevado
SINERGY: DESVANTAGENS
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SINERGY - PROCEDIMENTO
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Simplicity
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Simplicity
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2
3
1
Simplicity
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Ponto de entrada único Diminuição do uso de Rx Cria uma lesão grande e homogênea
SIMPLICITY: VANTAGENS
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17 gaug: risco de sangramento
Obstáculos no posicionamento
SIMPLICITY: DESVANTAGENS
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1cm Abaixo e 1cm Lateral do Forame de S4
PROCEDIMENTO
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Procedimento
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Procedimento
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Dual or Bipolar technique
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care must be taken to keep the electrodes from being too far apart
Dual Electrode Technique
Cosman et al. Pain Practice, 2010, volume 11, isue 1, 3-22
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dual electrode technique: advantages
bipolarcooled monopolar
10X10 12X15 Cosman et al. Pain Practice, 2010, volume 11, isue 1, 3-22
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dual electrode technique:disadvantage
Cosman et al. Pain Practice, 2010, volume 11, issue 1, 3-22
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techinique
gauge
insertions
apr. time size lesion
evidence
intraarticular
monopolar
20 3 30min 3-4mm/per lesion
Yin monopolar
20 10 60-90min
3-4mm/per lesion
2C+
PRF pulsed 20 10 90min 2C+
dual electrode
bipolar 20 7 60-90min
15mm/per lesion
SInergy cooled monopolar
18 ele16intr
9 60-90min
10mm/per lesion
2B+
Simplicity bipolarmonopolar
17 1+1 30min 5cm/whole lesion
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techinique
gauge
insertions
apr. time size lesion
evidence
intraarticular
monopolar
20 3 30min 3-4mm/per lesion
Yin monopolar
20 10 60-90min
3-4mm/per lesion
2C+
PRF pulsed 20 10 90min 2C+
dual electrode
bipolar 20 7 60-90min
15mm/per lesion
SInergy cooled monopolar
18 ele16intr
9 60-90min
10mm/per lesion
2B+
Simplicity bipolarmonopolar
17 1+1 30min 5cm/whole lesion
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techinique
gauge
insertions
apr. time size lesion
evidence
intraarticular
monopolar
20 3 30min 3-4mm/per lesion
Yin monopolar
20 10 60-90min
3-4mm/per lesion
2C+
PRF pulsed 20 10 90min 2C+
dual electrode
bipolar 20 7 60-90min
15mm/per lesion
SInergy cooled monopolar
18 ele16intr
9 60-90min
10mm/per lesion
2B+
Simplicity bipolarmonopolar
17 1+1 30min 5cm/whole lesion
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techinique
gauge
insertions
apr. time size lesion
evidence
intraarticular
monopolar
20 3 30min 3-4mm/per lesion
Yin monopolar
20 10 60-90min
3-4mm/per lesion
2C+
PRF pulsed 20 10 90min 2C+
dual electrode
bipolar 20 7 60-90min
15mm/per lesion
SInergy cooled monopolar
18 ele16intr
9 60-90min
10mm/per lesion
2B+
Simplicity bipolarmonopolar
17 1+1 30min 5cm/whole lesion
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techinique
gauge
insertions
apr. time size lesion
evidence
intraarticular
monopolar
20 3 30min 3-4mm/per lesion
Yin monopolar
20 10 60-90min
3-4mm/per lesion
2C+
PRF pulsed 20 10 90min 2C+
dual electrode
bipolar 20 7 60-90min
15mm/per lesion
SInergy cooled monopolar
18 ele16intr
9 60-90min
10mm/per lesion
2B+
Simplicity bipolarmonopolar
17 1+1 30min 5cm/whole lesion
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techinique
gauge
insertions
apr. time size lesion
evidence
intraarticular
monopolar
20 3 30min 3-4mm/per lesion
Yin monopolar
20 10 60-90min
3-4mm/per lesion
2C+
PRF pulsed 20 10 90min 2C+
dual electrode
bipolar 20 7 60-90min
15mm/per lesion
SInergy cooled monopolar
18 ele16intr
9 60-90min
10mm/per lesion
2B+
Simplicity bipolarmonopolar
17 1+1 30min 5cm/whole lesion
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DOR SACROILÍACA
“Red flags”excluídos
Sim
Confirmar DSI com bloqueio diagnóstico
Positivo Negativo
Considerar infiltração intrarticular com
corticóide
Positivo
RF SACROILÍACA
Reconsiderar o diagnóstico
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O BLOQUEIO DIAGNÓSTICO DA ARTICULAÇÃO SACROILÍACA DEVE SER SEMPRE SER REALIZADO PARA A SUA CONFIRMAÇÃO DIAGNÓSTICA
RESUMO
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A RF DE SACROLÍACA PELA TÉCNICA DO TEM SE DEMONSTRADO UMA OPÇÃO TERAPÊUTICA RÁPIDA E EFICAZ NO TRATAMENTO DA DOR SACROILÍACA
RESUMO
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DEVEMOS SEMPRE REALIZAR UMA AVALIAÇÃO E TRATAMENTO MULTIPROFISSIONAL DO PACIENTE COM DOR CRÔNICA, COM INTERAÇÃO ENTRE A EQUIPE
RESUMO
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