Transcript Issues in Pain Management:

Issues in Pain Management:
The Patient with
Chronic Low Back Pain
Robin Hamill-Ruth
Chronic Low Back Pain
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Demographics
Anatomy
Evaluation
Management Options
– Medical
– Adjunctive therapies
– Interventional
• Case Reports
Chronic LBP: Demographics
• 80% of Americans experience LBP at some point
during their lifetime.
• Annual prevalence of LBP about 30%
• Most common cause of disability under age 45
• Accounts for 12.5% of all sick days (Frank, 1993)
• Second most common reason for visits to MD (Hart,
1995)
• 5th leading cause of hospital admission (Taylor, 1994)
Chronic LBP: Demographics
• Each year, 3-4% of population is temporarily
disabled, 1% of working age population is
permanently, totally disabled
• Annual cost to US in 1980 estimated at 85
million dollars/year
• Between 1971 and 1981, # disabled grew 14
times the rate of population growth
• Prevalence rising with increasing age up to 65
years after which it declines
Chronic LBP: The Good News?
• Recovery from LBP
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60-70% recover by 6 weeks
80-90% improve by 12 weeks
Recovery after 12 weeks is “slow and uncertain”
Those with isolated LBP recover more quickly
than those with sciatica
– non-work related back symptoms cause less lost
time from work than work related symptoms
Differential Dx of LBP and Sciatica
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Sacroiliitis, SI dysfunction
Piriformis syndrome
Iliolumbar syndrome
Quadratus lumborum syndrome
Trochanteric bursitis
Ischiogluteal bursitis
Facet syndrome
Meralgia paresthetica
Fibromyositis/Fibromyalgia
GI, GU, Vascular, Intraabdominal
Assessment: History
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S = site
C = character
R = radiation
O = onset
D = discriminating features
(time course, what aggravates, what
relieves, etc)
Confounding Conditions
• Depression, grief
• Confusion, memory deficits
• Medical conditions
– ASCVD, DM, Obesity, CRF, COPD, Sleep apnea
• Psycho-socio-economics
• money
• transportation
• other responsibilities
• litigation, disability worker’s comp issues
“Quantifying” Pain
• Assessment
– VAS (verbal, visual)
• pain
• sleep
• mood
• function
– Draw your pain
– Self, significant other report
– Pain scales, inventories
History 2
• Past medications including dose, response,
why stopped
• Past interventions and therapies
• Current meds, allergies
• Past med history
• ROS
• Social, work history
Physical Exam
• General
• Spine visual, palpation, percussion
• Posture, gait, movement during change in
position
• Neuro (sensation, strength, tone, reflexes)
• ROM, flexibility
• Provacative maneuvers (eg. SLR, distracted
SLR, Patrick’s, facet loading)
• Abdomen, chest, vascular, adjacent joints
Waddell’s Signs: Nonorganic Pathology
1.Nonanatomic tenderness
2.Simulation test (axial loading)
3.Distraction sign (eg. SLR v. DSLR)
4.Regional sensory or motor disturbance
(stocking distrib, diffuse motor weakness)
5.Overreaction
3+ positive => poor outcome to spine surgery
Radiologic Evaluation
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Plain Films
MRI
CT
CT Myelogram
Discogram
Angio- and venograms
Goals of Therapy
• Educate the patient
– differential diagnosis
– management options
– realistic goals, pacing
• Address sleep dysfunction
• Manage depression
• Improve function physically, emotionally,
socially
• Decrease pain
Pharmacologic Options
• Acetaminophen
– Beware of other sources, toxic doses, other
hepatotoxic agents
• Anti-inflammatory Agents: Nonspecific
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Piroxicam, Indocin, Ketorolac
Naproxen
Ibuprofen
Diclofenac, Nabumetone
• Cox II specific agents
– Rofecoxib, Celecoxib, Parecoxib, Etoricoxib,
Valdecoxib, etc
NSAIDs
• Advantages:
– antiinflammatory, analgesic, limited
sedation, non-addicting, +cheap, available
OTC
• Concerns:
– available OTC in multiple preps, GI effects,
renal and hepatic toxicity, platelet effects,
fluid retention
Adjuvant Medications: Steroids
• Steroids
– Oral, injection, topical, iontophoresis
– 3 doses of depo prep over 4-6 weeks, 4 mo.
holiday
– Concerns:
• Adrenal suppression
• Effect on glucose (DM), sodium excretion
(HTN, CHF)
• Osteoporosis
• Altered wound healing, immunity
Adjuvant Medications
• Antidepressants
– TCAs (elavil, doxepin, nortrip): v. low dose
• sleep, anti-neuropathic effect
• ataxia, orthostasis, constipation
– Trazodone
• low dose, primarily for sleep
– SSRIs (Paxil, Prozac)
– SNRIs (Effexor)
Adjuvant Medications
• Anticonvulsants
– Pro: Neuropathic pain: lancinating, burning
– Con: Ataxia, sedation, confusion (esp elderly)
• Drugs
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Carbamazepine (Tegretol)
Gabapentin (Neurontin)
Lamotrigine (Lamictal)
Topiramate (Topomax)
Trileptal, etc
Clonazepam
Medications: Tramadol
• Tramadol (Ultram)
– opiate effects
– serotonergic effects
– Max dose: 400 mg/day
• Problems
– Lowered seizure threshold
– Increased risk of seizures with TCA > SSRI
– ? non-addicting
Adjuvant Medications
• Muscle Relaxants
– Muscle spasm (acute strain/sprain,
fibromyalgia)
– Spasticity due to denervation (baclofen,
dantrolene)
– Secondary effects:
– Sleep, anxiolysis
– anti-neuropathic effect (baclofen)
Adjuvant Medications
• Topical agents
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NSAID preparations
Capsaicin
Lidoderm
Cica-care type skin covers
Commercial OTC preps
Medications: Opiates
• Chronic Opiate Therapy
– Trial of short-acting medication ??
• Darvocet
• Hydrocodone (Vicodin, Lortab)
• Oxycodone (Roxicodone, Percocet, Tylox)
• Hydromorphone (Dilaudid)
• Morphine (MSIR, Roxanol)
• Hydromorphone (Dilaudid)
Medications: Opiates
• Chronic Opiate Therapy
– Long-acting Agents
• Methadone
• Morphine SR (MS Contin, Kadian,
Oramorph SR)
• Oxycondone SR (Oxycontin)
• Fentanyl Patch (Duragesic)
• Hydromorphone SR (Dilaudid SR in
future)
Adjuvant Therapies
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Education
Weight loss
Exercise, Yoga
Heat, cold, elevation, rest
Massage, TENS
Physical Therapy
– strengthening, mobility, aquatics, low impact
aerobics
Psychologic Therapy
• Counseling
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Pain counseling
Grief, depression
Pacing strategies
Appropriate goal setting
• Self-regulation techniques
– Self-hypnosis
– Relaxation training
– Biofeedback
Interventional Techniques
• Advantages:
– “One shot”
– Simple
– Low risk
• Disadvantages
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Positioning, technical difficulties
Cost
Cumulative steroid doses
Anticoagulation?
Interventional Techniques
• Trigger Point Injections
• Joint Injections (steroid, hyaluronate)
• Epidural Steroid Injections
– translaminar vs. transforaminal
• Medial Branch Nerve Blocks, Denervation
• Implantable Spinal Cord Stims, Intrathecal
Pumps
• Intradiscal Electrothermal Therapy (IDET)
• Vertebroplasty
Sacroiliac Joint Injection
SNRB L1, Epidurogram
SNRB L1, Lateral View
Selective Nerve Root Block: AP View
SNRB: Lateral View
S1 Selective Transforaminal Block
Epidural Steroid Injection
Epidural Steroid Injection
ESI: Lateral View
Medial Branch Nerve Block
Medial Branch Nerve Block
Medial Branch N Blocks, Oblique
Medial Branch N Block, AP
Implantable Therapies
• Spinal Cord Stimulator
– Fairly focal pain, eg. Single extremity
radiculopathy, ischemia, neuropathic or
sympathetically-maintained pain
• Intrathecal Pump
– Refractory pain or intolerance to adequate
dosage of medications
– longevity > 3-6 months
– opiates, local anesthetic, baclofen, clonidine
When and Whom to Refer
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Possible procedural answer
NSAIDs, PT, low dose opiates,
Intolerance of multiple medications
Not responding to simple interventions
Significant psycho-social issues impeding function
Concerns with polypharmacy, possible abuse issues
You want another opinion, you’re uncomfortable
Patient wants another opinion
Osteoarthritis: Case Report
• 82 yo female referred for implantation of intrathecal
pump for refractory LBP
• Xrays: severe DJD, stenosis
• Pt (and husband) reports worst time is sleeping. Inspite
of PE, films, feels she functions just fine during the day.
– On Coumadin, Cox II agents -> inadequate relief.
– Percocet qhs only lasts 2 hours
– Recommendations: Methadone 5 mg. PO qhs with
acetaminophen, PRN
• Result: Both she and her husband slept much better,
both satisfied with regimen.
Arthritis: Case Report
• 78 yo male with long hx steroid dependent RA,
with osteoporosis, compression fractures,
degenerative disc disease and facet arthropathy.
• Presents with acute compression fracture T12,
bilat. T 12 radiculopathy, secondary muscle
spasm and marked LBP due to facet arthropathy.
• Effectively bedridden. History complicated by
severe peripheral neuropathy, problems with
ataxia and frequent falls. Also has PHN R flank,
low abdomen.
Arthritis: Case Report, cont.
• Amitriptyline 10 qhs--good pain relief, sleep;
increased falls
• Oxycodone--constipation, sedation
• Methadone--good pain relief but severe
constipation, lethargy
• Low dose gabapentin caused increased ataxia,
falls, confusion
• Ultram was actually tolerated well with partial
relief.
Arthritis: Case Report, Interventions
• Vertebroplasty of T12 gave some relief of back
pain, but patient fell several days later, which
led to vertebroplasty at T11
• Bilateral T12 SNRBs done x2 with steroid for
persistent radicular pain with some
improvement
• Lumbar diagnositic facets gave good
temporary relief so did radiofrequency ablation
of medial branch nerves
• Trigger point injections in paraspinous muscles
gave excellent relief
Arthritis: Case Report, Conclusion
• Lidoderm to flank/abdomen for PHN
• Physical therapy improved mobility, endurance.
– Pt given walker for stability
– Home exercise program, +/- compliance
– TENS for myofascial component added
• Pain, sleep improved. Back at work. Falls improved
with elimination of multiple medication.
• Effexor added recently for further mood modulation.
• Recommended counseling re. Grief, loss of previous
level of function. Declined by patient.
Adjuvant Medications/Treatments
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Glucosamine/Chondroitin
Hyaluronate preparations (Synvisc)
Iontophoresis
TENS
Orthotic devices