Chronic Cervical and Shoulder pain

Transcription

1 Chronic Cervical and Shoulder pain Dr Arif Ghazi BSc MBBS FCARCSI FFPMCAI FIPP Consultant in Pain Medicine Clinical Lead for Pain Services, Whipps Cross University Hospital, Barts Health Honorary Consultant in Community Pain, Royal Free Hospital The Pain Unit, Wellington Hospital

2 Early risers? Late revellers?

3 Outline Current theories of pain mechanisms Medical management Overview of interventions

4 Last of a long line of specialists, over-investigated

5 Background Incidence 24/1000 patients in general practice Prevalence 35/1000 per year 60% women 60% recover in one year, pain can recur Winters, 2008

6 Diagnosis History: localization, radiation Pain other joints, fever, malaise, weight loss, dyspnoea, angina pectoris (exclude Pancoast tumour) Examination

7 Pain definition The word pain comes from the french peine, from latin poena, punishment, penalty, torment, hardship, suffering.

8 Pain definition Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage The International Association for the Study of Pain Bonica JJ. The need of a taxonomy. Pain. 1979;6(3):247 8

9 Types of pain Nociceptive or Neuropathic pain Somatic pain Referred pain (Visceral pain)

10 Pain mechanisms Mechanism based theories of pain: Specificity theory Pattern theory Summation theory Gate control theory Central sensitization

11 Specificity theory (Bell 1811): specific pathways and specific receptors for pain. Nociceptive pain - Spinothalamic tract ascending pathway.

12 Pattern theory (Goldscheider 1894): certain patterns of nerve activation were produced by summation of sensory input from the skin in the dorsal horn. Previously it was believed that the skin had only one type of sensation. He described the skin as a mosaic pattern containing a number of different perceptive organs (pressure, warmth, cold).

13 Summation theory (Livingstone, Hardy, Wolff 1955): The importance of interaction between various neurons, the sympathetic and the somatic nervous systems in developing secondary hyperalgesia the exacerbation of pain with repeated stimuli.

14 Gate theory 1965, Melzack & Wall

15 Gate theory A conceptual framework to bridge the old mind-body dichotomy pain an intersection between physiology & psychology. The information coming in over C fibers is modulated through pre-synaptic inhibition from β-fibers in the substantia gelatinosa. This gating mechanism depends on the relative quantity of the information coming in from the larger fibers v smaller fibers. Two mechanisms in which the pain gets through the gate is either: damage to the β-fibers, allowing spontaneous pain or activation of C fibers by excessive stimulation through inflammation or pressure on the C fibers.

16 Gate theory

17 Central sensitization Neural Plasticity (Woolf 2000): the capacity of neurons to change their structure, function, or chemical profile via activation, modulation, and modification, contributing to hypersensitivity. This may include neuroactive proinflammatory cytokines, growth factors, microglial cells, and changes in genetic transcription.

18 Targets for novel analgesics

19 Neuropathic medications Antidepressants Amitryptilline, Duloxetine Anticonvulsants: Pregabalin, Gabapentin

20 Neck pain cervical facet joint pain referral

21 Cervical facet joint

22 Shoulder pain C5 nerve root block

23 64% asymptomatic subjects had disc abnormality ( 38% > 1 level) NEJM 1994, 331:2, 69-73

24 Figure 3a. Right-sided C6 radiculopathy in 47-year-old man. Strobel K et al. Radiology 2004;233: by Radiological Society of North America

25 T1 T2

26 Cervical nerve root block

27 The Rate of Detection of Intravascular Injection in Cervical Transforaminal Epidural Steroid Injections With and Without Digital Subtraction Angiography Original Research Article PM&R, Volume 1, Issue 7, July 2009, Pages James P. McLean, James D. Sigler, Christopher T. Plastaras, Cynthia Wilson Garvan, Joshua D. Rittenberg Double the rate of detection of intravascular injection in CTFESI with DSA 17 v 35%

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29 Case 1 Mr TS 45year old man, right handed Persistent left neck and shoulder pain, left arm weakness

30 Case 1 No benefit after multiple cervical surgical procedures No benefit from medications -(tramadol, oxycodone, amitriptyline, pregabalin)

31 Case 1 Management Left C6 nerve root block with pulsed radiofrequency

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38 Anesthesiology: September Volume 2 - Issue 5 - ppg

39 Shoulder pain Suprascapular nerve

40 Suprascapular n Superior trunk bulk sensation post, med, sup capsule Axillary n - posterior cord inf, lat ant capsule Subscapular n post cord ant capsule, Lateral pectoral, musculocutaneous n lat cord assist suprascapular n

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47 Shoulder pain Suprascapular nerve

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49 Case 2 81year old lady Ms ST frozen shoulder right dominant arm Wheelchair bound, previous left hemi-plegia following right CVA

50 Case 2 Pain and swelling in right shoulder restricting function and unable to tolerate physiotherapy Re-accumulation of fluid following capsule aspiration.

51 Case 2 Polypharmacy, intolerant of most analgesics except paracetamol Wishes to avoid sedation

52 Case 2 Management Suprascapular nerve block with pulsed RF USS guided. Significant benefit over six months. Now able to tolerate physiotherapy, which improved movement and prevented the re-accumulation of fluid No longer requires any analgesics.

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54 Questions?