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Issues in Pain Management:

Issues in Pain Management:. The Patient with Chronic Low Back Pain. Robin Hamill-Ruth. Chronic Low Back Pain. Demographics Anatomy Evaluation Management Options Medical Adjunctive therapies Interventional Case Reports. Chronic LBP: Demographics.

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Issues in Pain Management:

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  1. Issues in Pain Management: The Patient with Chronic Low Back Pain Robin Hamill-Ruth

  2. Chronic Low Back Pain • Demographics • Anatomy • Evaluation • Management Options • Medical • Adjunctive therapies • Interventional • Case Reports

  3. 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)

  4. 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

  5. Chronic LBP: The Good News? • Recovery from LBP • 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

  6. Differential Dx of LBP and Sciatica • Sacroiliitis, SI dysfunction • Piriformis syndrome • Iliolumbar syndrome • Quadratus lumborum syndrome • Trochanteric bursitis • Ischiogluteal bursitis • Facet syndrome • Meralgia paresthetica • Fibromyositis/Fibromyalgia • GI, GU, Vascular, Intraabdominal

  7. Assessment: History • S = site • C = character • R = radiation • O = onset • D = discriminating features (time course, what aggravates, what relieves, etc)

  8. 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

  9. “Quantifying” Pain • Assessment • VAS (verbal, visual) • pain • sleep • mood • function • Draw your pain • Self, significant other report • Pain scales, inventories

  10. History 2 • Past medications including dose, response, why stopped • Past interventions and therapies • Current meds, allergies • Past med history • ROS • Social, work history

  11. 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

  12. 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

  13. Radiologic Evaluation • Plain Films • MRI • CT • CT Myelogram • Discogram • Angio- and venograms

  14. 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

  15. Pharmacologic Options • Acetaminophen • Beware of other sources, toxic doses, other hepatotoxic agents • Anti-inflammatory Agents: Nonspecific • Piroxicam, Indocin, Ketorolac • Naproxen • Ibuprofen • Diclofenac, Nabumetone • Cox II specific agents • Rofecoxib, Celecoxib, Parecoxib, Etoricoxib, Valdecoxib, etc

  16. 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

  17. 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

  18. 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)

  19. Adjuvant Medications • Anticonvulsants • Pro: Neuropathic pain: lancinating, burning • Con: Ataxia, sedation, confusion (esp elderly) • Drugs • Carbamazepine (Tegretol) • Gabapentin (Neurontin) • Lamotrigine (Lamictal) • Topiramate (Topomax) • Trileptal, etc • Clonazepam

  20. 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

  21. Adjuvant Medications • Muscle Relaxants • Muscle spasm (acute strain/sprain, fibromyalgia) • Spasticity due to denervation (baclofen, dantrolene) • Secondary effects: • Sleep, anxiolysis • anti-neuropathic effect (baclofen)

  22. Adjuvant Medications • Topical agents • NSAID preparations • Capsaicin • Lidoderm • Cica-care type skin covers • Commercial OTC preps

  23. 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)

  24. 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)

  25. Adjuvant Therapies • Education • Weight loss • Exercise, Yoga • Heat, cold, elevation, rest • Massage, TENS • Physical Therapy • strengthening, mobility, aquatics, low impact aerobics

  26. Psychologic Therapy • Counseling • Pain counseling • Grief, depression • Pacing strategies • Appropriate goal setting • Self-regulation techniques • Self-hypnosis • Relaxation training • Biofeedback

  27. Interventional Techniques • Advantages: • “One shot” • Simple • Low risk • Disadvantages • Positioning, technical difficulties • Cost • Cumulative steroid doses • Anticoagulation?

  28. 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

  29. Sacroiliac Joint Injection

  30. SNRB L1, Epidurogram

  31. SNRB L1, Lateral View

  32. Selective Nerve Root Block: AP View

  33. SNRB: Lateral View

  34. S1 Selective Transforaminal Block

  35. Epidural Steroid Injection

  36. Epidural Steroid Injection

  37. ESI: Lateral View

  38. Medial Branch Nerve Block

  39. Medial Branch Nerve Block

  40. Medial Branch N Blocks, Oblique

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