Anesco Interventional Pain Institute

1. Treatment Regimens for Acute and Chronic Pain Patients: How to Progress All Injured Workers to Working Status Anesco Interventional Pain Institute

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)

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

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)

5. Nociceptive vs Neuropathic Pain Nociceptive Pain Caused by activity in neural pathways in response to potentially tissue-damaging stimuli Neuropathic Pain Initiated or caused by primary lesion or dysfunction in the nervous system MixedType Caused by a combination of both primary injury and secondary effects CRPS* Postherpeticneuralgia Postoperativepain Trigeminalneuralgia Arthritis Sickle cellcrisis Neuropathic low back pain Mechanicallow back pain Central post-stroke pain Distalpolyneuropathy (eg, diabetic, HIV) Sports/exerciseinjuries *Complex regional pain syndrome

6. Sensations numbness tingling burning paresthetic lancinating electriclike shooting deep, dull, bonelike ache Signs/Symptoms allodynia: pain from a stimulus that does not normally evoke pain thermal mechanical hyperalgesia: exaggerated response to a normally painful stimulus Possible Descriptions of Neuropathic Pain

7. Primary Goals Relieve symptoms Restore function Return to work Minimize disability

8. Treatment options Medications Interventional Procedure Rehabilitation Surgical intervention

9. Medications Ease for patient Symptom management Cost of treating complications Decreased productivity

10. NSAID Reduce synthesis of PGs COX inhibitors (cyclooxygenase) Diminish nociceptor activation Block peripheral sensitization Antipyretic Anti-hyperalgesic No sedation Examples: Advil, Aleve, *Celebrex

11. Side effects Gastrointestinal ulceration Renal dysfunction Embryotoxic Prolonged bleeding PPI/H2 blockers for prevention • Ex: Nexium, Prilosec, Zantac

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

13. OPIOIDS Spinal cord • Decreasing neurotransmitter release • Blocking postsynaptic receptors • Activating inhibitory pathways Receptor subtypes • mu> delta> kappa Supraspinal analgesia Examples: Morphine, Fentanyl, Burprenorphine

14. Side effects respiratory depression, severe bradycardia, decreased gastric motility, drowsiness, memory loss, impaired judgement Addiction Physiologic dependence

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

16. Side effects Complication rate < 1% Safriel. ApplRadiol 2010;39 14-23 • Temporary blood sugar elevation • Cartilage damage • Adrenal gland suppression • Infection – with sterile technique an infection occurs much less than 1% • Intravascular injection – embolism rare

18. 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 Interlaminer Epidural Injection

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

20. Transforaminal Epidural Injections

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;104:1217-22 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; 245:584-90. 75% patients with low-grade nerve compression respond favorably compared to 26% with high grade disc related nerve compression Ghahremann and Bogduk. Pain Med 2011;12:871-79

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;36:1897-1905 Safriel Y. Appl Radiol 2010;39:14-23 • In the face of increasing pain levels • Transforaminal injections/ catheter techniques

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:1589-93 • 5 year follow-up – 81% did not opt for surgery Riew etal. J Bone Joint Surg Am 2006;88:1722-5 Cost savings Karppinen et al. Spine 2001;26-2587-2595

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

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 Cohen et al. Spine J 2008;8:498-504 • Radiofrequency Neurotomy • 30-50% of patients have long term relief • Patient selection critical for success van Kleef et al. Spine, 1999;24:1937-1942.

28. Radiofrequency Neurotomy Lumbar Spine Cervical Spine

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

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 Günaydin et al. Rheumatol Int 2006;26:396-400 • Radiofrequency Neurotomy Muhlner MB. Curr Rev Musculosket Med 2009;2:10-4. Vallejo et al. Pain Med 2006;7:429-34

31. Sacroliliac Pain

32. Physical Therapy Hands-on care can motivate and push patients Relief of symptoms Restoration of function No side effect or addiction

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

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

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

36. Thank you