Issues in Pain Management:

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Issues in Pain Management

• The Patient with
• Chronic Low Back Pain

Robin Hamill-Ruth
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Chronic Low Back Pain

• Demographics
• Anatomy
• Evaluation
• Management Options
• Medical
• Adjunctive therapies
• Interventional
• Case Reports

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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)

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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

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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

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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

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Assessment History

• S site
• C character
• R radiation
• O onset
• D discriminating features (time course, what
  aggravates, what relieves, etc)

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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 workers comp issues

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Quantifying Pain

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

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History 2

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

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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,
  Patricks, facet loading)
• Abdomen, chest, vascular, adjacent joints

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Waddells 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 gt poor outcome to spine surgery

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Radiologic Evaluation

• Plain Films
• MRI
• CT
• CT Myelogram
• Discogram
• Angio- and venograms

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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

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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

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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

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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

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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)

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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

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Medications Tramadol

• Tramadol (Ultram)
• opiate effects
• serotonergic effects
• Max dose 400 mg/day
• Problems
• Lowered seizure threshold
• Increased risk of seizures with TCA gt SSRI
• ? non-addicting

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Adjuvant Medications

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

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Adjuvant Medications

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

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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)

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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)

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Adjuvant Therapies

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

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Psychologic Therapy

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

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Interventional Techniques

• Advantages
• One shot
• Simple
• Low risk
• Disadvantages
• Positioning, technical difficulties
• Cost
• Cumulative steroid doses
• Anticoagulation?

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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

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Sacroiliac Joint Injection
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SNRB L1, Epidurogram
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SNRB L1, Lateral View
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Selective Nerve Root Block AP View
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SNRB Lateral View
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S1 Selective Transforaminal Block
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Epidural Steroid Injection
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Epidural Steroid Injection
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ESI Lateral View
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Medial Branch Nerve Block
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Medial Branch Nerve Block
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Medial Branch N Blocks, Oblique
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Medial Branch N Block, AP
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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 gt 3-6 months
• opiates, local anesthetic, baclofen, clonidine

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When and Whom to Refer

• 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, youre uncomfortable
• Patient wants another opinion

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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 -gt 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.

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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.

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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.

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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

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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.

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Adjuvant Medications/Treatments

• Glucosamine/Chondroitin
• Hyaluronate preparations (Synvisc)
• Iontophoresis
• TENS
• Orthotic devices