Slide 1. Slide 2. Treatment Regimens for Acute and Chronic Pain Patients: How to Progress All Injured Workers to Working Status. What is Acute Pain?

Size: px

Start display at page:

Download "Slide 1. Slide 2. Treatment Regimens for Acute and Chronic Pain Patients: How to Progress All Injured Workers to Working Status. What is Acute Pain?"

Esmond Jonas Phelps
5 years ago
Views:

Physiologic response to tissue damage Warning signals damage/danger Helps locate problem source

1 Slide 1 Treatment Regimens for Acute and Chronic Pain Patients: How to Progress All Injured Workers to Working Status Anesco Interventional Pain Institute Slide 2 What is Acute Pain? Physiologic response to tissue damage Warning signals damage/danger Helps locate problem source Has biologic value as a symptom Responds to traditional medical model Life temporarily disrupted (self limiting)

2 Slide 3 What is Chronic Pain? Chronic pain is persistent or recurrent pain, lasting beyond the usual course of acute illness or injury, or more than 3-6 months, and adversely affecting the patient s well-being Pain that continues when it should not Slide 4 What is Chronic Pain? Difficult to diagnose & perplexing to treat Subjective personal experience Cannot be measured except by behavior May originate from a physical source but slowly it out-shouts and becomes the disease It has no biologic value as a symptom Life permanently disrupted (relentless)

3 Slide 5 Nociceptive vs Neuropathic Pain Nociceptive Pain Caused by activity in neural pathways in response to potentially tissue-damaging stimuli Mixed Type Caused by a combination of both primary injury and secondary effects Neuropathic Pain Initiated or caused by primary lesion or dysfunction in the nervous system CRPS* Postherpetic Postoperative pain Arthritis neuralgia Trigeminal neuralgia Sickle cell Neuropathic Mechanical crisis low back pain low back pain Central poststroke pain Distal Sports/exercise polyneuropathy injuries (eg, diabetic, HIV) *Complex regional pain syndrome Slide 6 Possible Descriptions of Neuropathic Pain Sensations Signs/Symptoms numbness tingling burning allodynia: pain from a stimulus that does not normally evoke pain thermal mechanical paresthetic lancinating hyperalgesia: exaggerated response to a normally painful stimulus electriclike shooting deep, dull, bonelike ache

4 Slide 7 Primary Goals Relieve symptoms Restore function Return to work Minimize disability Slide 8 Treatment options Medications Interventional Procedure Rehabilitation Surgical intervention

5 Slide 9 Medications Ease for patient Symptom management Cost of treating complications Decreased productivity Slide 10 NSAID Reduce synthesis of PGs COX inhibitors (cyclooxygenase) Diminish nociceptor activation Block peripheral sensitization Antipyretic Anti-hyperalgesic No sedation Examples: Advil, Aleve, *Celebrex

6 Slide 11 Side effects Gastrointestinal ulceration Renal dysfunction Embryotoxic Prolonged bleeding PPI/H2 blockers for prevention Ex: Nexium, Prilosec, Zantac Slide 12 Muscle relaxants Used to alleviate muscle spasms Example: carisoprodol, cyclobenzaprine, and methocarbamol Mechanism Not entirely known, GABA agonist, Ca channel Centrally acting causing sedation, anticholinergic side effects Dependence

7 Slide 13 OPIOIDS Spinal cord Decreasing neurotransmitter release Blocking postsynaptic receptors Activating inhibitory pathways Receptor subtypes mu> delta> kappa Supraspinal analgesia Examples: Morphine, Fentanyl, Burprenorphine Slide 14 Side effects respiratory depression, severe bradycardia, decreased gastric motility, drowsiness, memory loss, impaired judgement Addiction Physiologic dependence

8 Slide 15 Steroid Injections Steroids decrease inflammation (phospholipase A2) and swelling around the compressed or inflamed nerve around the dural sac Local anesthetics break the pain cycle while steroid decreases inflammation Volume of injected solution may wash away local inflammatory mediators or loosen adhesions Slide 16 Side effects Complication rate < 1% Safriel. Appl Radiol 2010; Temporary blood sugar elevation Cartilage damage Adrenal gland suppression Infection with sterile technique an infection occurs much less than 1% Intravascular injection embolism rare

9 Slide 17 Slide 18 Interlaminer Epidural Injection Between spinous process In the past these were done without x-rays The steroid injection placed right over the dural sac Far from area of nerve compression May be effective with broad based disc bulges

10 Slide 19 Transforaminal Epidural Injections More popular over the last decade. Steroid medication placed closer to the area of nerve root compression. Slide 20 Transforaminal Epidural Injections

11 Slide 21 Effectiveness of Transforaminal Epidural Injections Transforaminal approach may be more effective due to deposition of steroid in anterior epidural space Ackerman et al. Anesth Analg 2007;104: Location of transforaminal injection at the level of the disc herniation (preganglionic) may be more effective than at site of exiting nerve root Jeong et al. Radiology 2007; 245: % patients with low-grade nerve compression respond favorably compared to 26% with high grade disc related nerve compression Ghahremann and Bogduk. Pain Med 2011;12: Slide 22 Frequency of Epidural Injections Historically 3 injections over 4-6 weeks Incorrect needle placement 30-40% without fluoroscopy Augmentation of pain relieving effects Recent trends Use of fluoroscopy confirms accuracy Additional injections provided on the basis of patients response to prior injections Manchkanti et al. Spine 2011;36: Safriel Y. Appl Radiol 2010;39:14-23 In the face of increasing pain levels Transforaminal injections/ catheter techniques

12 Slide 23 Epidural Injections vs. Surgery Decreased Operative rates 55 patients with 6 weeks of conservative treatment Surgical Candidates Group 1 epidural with LA + steroids. 23% had surgery Group 2 epidural with LA only. 67 % had surgery Riew etal. J Bone Joint Surg Am 2000;82A: year follow-up 81% did not opt for surgery Riew etal. J Bone Joint Surg Am 2006;88: Cost savings Karppinen et al. Spine 2001; Slide 24

13 Slide 25 Facet Pain - Interventional Treatment Facet Joint Steroid Injection Effective and minimally invasive Fluoroscopy May be effective for weeks to months Slide 26

to 12 hours Radiofrequency Neurotomy 30-50% of patients have long term relief Patient selection critical for success Cohen et al.

14 Slide 27 Facet Pain - Interventional Treatment Median nerve branch blocks Small medial or lateral nerves travel into the spine Do not effect muscles or sensation in arms or legs Identifies and confirms the pain source 50-80% improvement during the first 6 to 12 hours Radiofrequency Neurotomy 30-50% of patients have long term relief Patient selection critical for success Cohen et al. Spine J 2008;8: van Kleef et al. Spine, 1999;24: Slide 28 Radiofrequency Neurotomy Lumbar Spine Cervical Spine

15 Slide 29 Sacroiliac Joint Pain Inflammation of one or both of the sacroiliac joints Mechanical dysfunction dull low unilateral back pain Pain in region of posterior superior iliac spine (PSIS) Aggravated by standing up from a seated position Lifting the knee towards the chest during stair climbing Increases with prolonged sitting or walking Referred into hip, groin, buttock and back of the thigh Occasionally down the leg but rarely to the foot Provocative tests - inconclusive Slide 30 Sacroiliac Joint Pain Treatment Conservative Stretching exercises (e.g., knee to chest) Anti inflammatory medication Sacroiliac Joint injection Fluoroscopy 75% reduction in pain May require multiple injections Radiofrequency Neurotomy Günaydin et al. Rheumatol Int 2006;26: Muhlner MB. Curr Rev Musculosket Med 2009;2:10-4. Vallejo et al. Pain Med 2006;7:429-34

16 Slide 31 Sacroliliac Pain Slide 32 Physical Therapy Hands-on care can motivate and push patients Relief of symptoms Restoration of function No side effect or addiction

17 Slide 33 Limitations Limited care per week ( 3hr) Cannot manage pain outside of therapy facility Tendency for patient to resume pharmacologic therapy for pain treatment Cost Slide 34 Psychological Pain Control Biofeedback provides biophysiological feedback to patient about some bodily process the patient is unaware of (e.g., forehead muscle tension). Relaxation systematic relaxation of the large muscle groups. Acupuncture Counter-irritation may close the spinal gating mechanism in pain perception. Expectancy Reduced anxiety from belief that it will work. Distraction Trigger release of endorphins

18 Slide 35 Role of the pain physician at ANESCO Communication with Case Managers/Adjusters Minimize use and dependency on medication Improve outcomes through early intervention Physical therapy Encourage return to work Minimize cost to insurer and employer Slide 36 Thank you

Facet Joint Syndrome / Arthritis

Facet Joint Syndrome / Arthritis Overview Facet joint syndrome is an arthritis-like condition of the spine that can be a significant source of back and neck pain. It is caused by degenerative changes to