Dr Ian Wallbridge. Musculoskeletal Specialist Rotorua. 11:30-12:00 Managing Intractable Spinal pain

Transcription

1 Dr Ian Wallbridge Musculoskeletal Specialist Rotorua 11:30-12:00 Managing Intractable Spinal pain

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3 2 years of pain

4 2 years of pain

5 2 years of pain

6 Intractable spinal pain KEY POINT #1 2 types: SOMATIC PAIN RADICULAR PAIN

7 Somatic pain Somatic referred pain Stimulation of peripheral endings of nociceptive afferent fibers From soma (latin) body typically facet /z joints

8 Somatic pain Z joint SI joint Somatic referred pain Stimulation of peripheral endings of nociceptive afferent fibers From soma (latin) body typically facet / SI joints

9 Radicular pain Neurogenic pain Stimulation or irritation of the nerve roots or dorsal root ganglion of a spinal nerve Typically prolapsed disc

10 Radicular pain Neurogenic pain Stimulation or irritation of the nerve roots or dorsal root ganglion of a spinal nerve Typically prolapsed disc

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15 2 years of pain

16 2 years of pain

17 2 years of pain

18 FAD Key point #1 Fear/Frustration Depression/Dissatisfaction Anger/Anxiety

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31 The correlation between abnormal radiological findings and pain is poor Bogduk N, McGuirk B. Management of Acute and chronic neck pain. An Evidence Based Approach. Elslvier Gore DR, Sepic SB, Gardner GM. Roentgenographic findings of the cervical spine in asymptomatic people. Spine 1986; 1: Elias F. Roentgen findings in the asymptomatic cervical spine. NY State J Med 1958; 58: Heller CA, Stanley P, Lewis-Jones B, Heller RF. Value of X-ray examinations of the cervical spine. Brit Med J 1983; 287: Van der Donk J, Schouten ISAG, Passchier J, van Romunde LKJ, Valkenburg HA. The associations of neck pain with radiological abnormalities of the cervical spine and personality traits in a general population. J Rheumatol 1991; 18: Fridenberg ZB, Miller WT. Degenerative disc disease of the cervical spine: a comparative study of asymptomatic and symptomatic patients. J Bone Joint Surg Am 1963; 45A:

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34 Thoracic zygapophysial joints

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36 The correlation between abnormal radiological findings and pain is poor Bogduk N, McGuirk B. Management of Acute and chronic neck pain. An Evidence Based Approach. Elslvier Gore DR, Sepic SB, Gardner GM. Roentgenographic findings of the cervical spine in asymptomatic people. Spine 1986; 1: Elias F. Roentgen findings in the asymptomatic cervical spine. NY State J Med 1958; 58: Heller CA, Stanley P, Lewis-Jones B, Heller RF. Value of X-ray examinations of the cervical spine. Brit Med J 1983; 287: Van der Donk J, Schouten ISAG, Passchier J, van Romunde LKJ, Valkenburg HA. The associations of neck pain with radiological abnormalities of the cervical spine and personality traits in a general population. J Rheumatol 1991; 18: Fridenberg ZB, Miller WT. Degenerative disc disease of the cervical spine: a comparative study of asymptomatic and symptomatic patients. J Bone Joint Surg Am 1963; 45A:

37 Cervical zygapophysial joints

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42 KEY POINT #3 Can t diagnose clinically

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47 C5,6 medial branch blocks

48 C5,6 medial branch blocks C5-6 zygapophysial joint

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50 C5,6 medial branch blocks C5-6 zygapophysial joint

51 KEY POINT #3

52 KEY POINT #3 FACET JOINT PAIN ONLY DIAGNOSED BY MBB S

53 5 mm

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58 lateral PA

59 lateral PA lateral PA

60 Randomised controlled trial 24 patients selected on the basis of 100% relief from placebo-controlled medial branch blocks The criteria for a successful outcome were complete relief of pain restoration of activities of daily living, and no need for continuing health care for neck pain. RF neurotomy Sham treatment Lord SM, Barnsley L, Wallis B, McDonald GM, Bogduk N. Percutaneous radio frequency neurotomy for chronic cervical zygapophyseal joint pain. N Eng J Med 1996;335:

61 Randomised controlled trial 24 patients selected on the basis of 100% relief from placebo-controlled medial branch blocks The criteria for a successful outcome were complete relief of pain restoration of activities of daily living, and no need for continuing health care for neck pain. Results, median duration of complete relief: RF neurotomy 263 days Sham treatment eight days Lord SM, Barnsley L, Wallis B, McDonald GM, Bogduk N. Percutaneous radio frequency neurotomy for chronic cervical zygapophyseal joint pain. N Eng J Med 1996;335:

62 James Borowczyk John MacVicar Christchurch cervical medial branch radiofrequency neurotomy published in the Pain Medicine journal (Vol 13, No 5, 2012).

63 Key Point # 4 Quebec task force clinical classification of whiplash associated disorders RF neurotomy is the gold standard for treatment against which all other treatments should be measured

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65 Disc Facet joint SI joint Other source

66 Facet joint pain Z joint Noxious stimulation of the facet joints in normal volunteers provokes pain in the low back and referred to the lower limb. Chronic low back pain can be relieved by anaesthetising the facet joints in a number of patients with chronic low back pain

67 Facet joint pain In young patients with a history of injury, the prevalence of ZA joints as a cause of low back pain is about 15% (+/- 5%). In older patients attending a Rheumatology clinic, and in heterogenous patients attending a pain clinic, the prevalence was about 40%. Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk, N. Clinical features of pain stemming from the lumbar zygapophyseal joints. Is the lumbar facet joint syndrome a clinical entity? Spine 1994; 19: Schwarzer A, Wang S, Bogduk N, McNaught PJ, Laurent R. Prevalence and features of zygapophyseal joint pain: a study of an Australian population with chronic low back pain. Ann Rheum Dis 1995; 54: Manchikanti L, Pampati V, Fellows B, Backhit CE. Prevalence of zygopophyseal joint pain in chronic low back pain. Pain Phys 1999; 2: 59-64

68 Diagnosing facet joint pain KEY POINTS No clinical features help to distinguish facet joint pain from other causes of low back pain

69 Diagnosing facet joint pain KEY POINTS No clinical features help to distinguish facet joint pain from other causes of low back pain Facet joint pain can not be diagnosed by clinical examination

70 Diagnosing facet joint pain KEY POINTS No clinical features help to distinguish facet joint pain from other causes of low back pain Facet joint pain can not be diagnosed by clinical examination Facet joint pain can not be diagnosed by imaging

71 Diagnosing facet joint pain KEY POINTS No clinical features help to distinguish facet joint pain from other causes of low back pain Facet joint pain can not be diagnosed by clinical examination Facet joint pain can not be diagnosed by imaging The only reliable diagnosis is made using controlled medial branch blocks. Schwarzer et at 1994, Schwarzer et al 1995, Manchikanti et al 1999

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75 lateral

76 James Borowczyk John MacVicar Christchurch, New Zealand Lumbar medial branch radiofrequency Neurotomy in NZ Pain Medicine 2013;14:

77 Sacroiliac joint pain SI joint Noxious stimulation of the SI joints in normal volunteers provokes low back pain. Fortin JD, Dwyer AP, West S, Pier J. Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique: Part 1: asymptomatic volunteers. Spine 1994; 19:

78 Sacroiliac joint pain Studies using controlled diagnostic blocks of this joint showed that the prevalence of pain arising from this joint in patients with chronic low back pain was between 13 and 19%. Schwarzer A, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995; 20: Maigne JY, Aivaliklis A, Pfefer, F. Results of sacroiliac joint block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 1996; 21:

79 Somatic or radicular referred pain? A B

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82 Radicular pain TFI 2 year outcome 1/3 : 1/3 : 1/3 Best for small /moderate prolapse Radiation small 60 mgy EBM massive compared to CT guided

83 KEY POINTS Somatic vs Radicular

84 KEY POINTS Somatic vs Radicular History and pain maps ARE useful

85 KEY POINTS Somatic vs Radicular History and pain maps ARE useful Clinical tests and Radiology NOT useful

86 KEY POINTS Somatic vs Radicular History and pain maps ARE useful Clinical tests and Radiology NOT useful Needles NOT knives for diagnosis and (usually)treatment

87 FAD Fear/Frustration Depression/Dissatisfaction Anger/Anxiety

88 FADE Fear/Frustration Depression/Dissatisfaction Anger/Anxiety EXPECTATION