The Management Of Spinal Pain Presented At Back Show 4.10.09
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Transcript of The Management Of Spinal Pain Presented At Back Show 4.10.09
The Management of Spinal Pain.
Dr. Christopher A. Jenner MB BS, FRCA
Consultant in Pain Medicine, Imperial Healthcare NHS Trust
Medical Director Spinal Healthcare
4th October 2009
Agenda
• Definition
• Physiology
• Acute/ Chronic
• Neuropathic
• Differences
• Treatment Options
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Definitions
• Pain. ‘An unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of tissue damage, or both.’ (IASP 2001)
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Definitions (2)
• Time-course:
• acute
• chronic
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Definitions (3)
• Type:
• nociceptive
• neuropathic
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Pain Physiology
(boring)
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Pain Physiology
(funky version)
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Noxious Stimulus
Impulse Transmission
Afferent sensory fibres
Spinal cord
Dorsal Horn
Synapse
Ca and Glutamate
Synaptic Cleft
Post Synaptic
Nociceptive Neuron
Pain perception
Brain
The Challenges of Chronic Pain
• Bio-psycho-social model
• Individual and societal costs
• Biological- pain/ suffering/ disability
• Psychological- anxiety/ depression
• Social- work/ relationship/ family/ benefits
Massive Financial Burden
• NHS/ DWP/ tax-payers
• Lower back pain (CSAG 1994)
• NHS £481 million
• The Exchequer £1.4 billion
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Physical and Alternative Treatments
Physiotherapy
Physical/ Alternative Treatments
• Physical- heat/ cold/ TENS/ hydro/ supports/ US/ IR
• Manipulation- PxTx/ chiropracter/ osteopathy/ deep tissue massage
• Alternative- acupuncture
Any Vets in the audience?
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5. (a) Veterinary practitioners?
Headache!
Pharmacological Treatment
Acute Pain Management
• Non-pharmacological
• RICE
• Pharmacological
• WHO ladder (amended from cancer) Step 1 paracetamol/ NSAID/ COX 2 Step 2 + weak opioids Step 3 + strong opioids
Pharmacological Treatment
• WHO analgesic ladder (abridged)
• + tramadol
• + opioids- buprenorphine TDD/ oxycontin/ fentanyl TDD
(New: sufentanyl TDD/ product X)
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Opioid Therapy
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Pharmacological treatment of Neuropathic Pain
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Neuropathic Pain Management
• Antidepressants- Amitryptilline
• Anticonvulsants- Gabapentin/ Pregabalin/ Carbamazepine/ Valproate
• Opioids
• Local Anaesthetics- Lignocaine/ EMLA
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• NMDA antagonists
• Sympatholytics
• GABA –ergics
• Capsaicinwww.londonpainconsultants.com
Future Agents for Neuropathic Pain
• Ziconotide (sea snail, conus magnus)
• P2X3- (purine) receptor antagonists (ATP) (knockout mice)
• Epibatidine (Equadorian poison dart frog)
• Morphine and ketamine
• Regular gabapentinwww.londonpainconsultants.com
Psychologicaly based therapy
Pain Management• Psychological
CBT
Operant Conditioning
Psychoanalysis
Relaxation
Biofeedback
• Psychiatricwww.londonpainconsultants.com
Pain Management Programmes
● Medication
• Goals (SMART- specific/ measured/ agreed/ realistic/ timed)
• Coping
• Contingency
• Pacing
• Education
• Pain Behaviours
• Reinforcement www.londonpainconsultants.com
Functional Restoration Programmes
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MRI scans
Minimally Invasive Pain Management
C-arm
Targets
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Spine Pain
Cervical/ Thoracic/ Lumbar>65% workload
Epidural Steroid Injections
Facet Joint Injections
Nerve Root Injections
Sacroiliac Joint Injection
Radiofrequency
• Radiofrequency denervation (destructive)
• Eg: medial branch (facet joint) blocks
• Pulsed radiofrequency (non-destructive)
• Eg: nerve roots
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Botulinum Toxin A
Other Minimally Invasive Techniques
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Epiduroscopy
IDET
Disc Dekompressor
Vertebroplasty/ Kyphoplasty
Musculoskeletal
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Shoulder
• Suprascapular nerve block
• Suprascapular pulsed radiofrequency
• Intra-articular
• Trigger point
• Botulinum Toxin A
Limbs
• Tenoperiostial injections
• Intra-articular
• Trigger points
• Intra-articular
• Botulinum Toxin A
Neuropathic Pain
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Complex Regional Pain Syndrome (CRPS)
• Upper Limb
• Stellate ganglion block
• Intravenous guanethidine block (IVG)
• Lower Limb
• Lumbar Sympathectomy
• Intravenous guanethidine block (IVG)
Other Neuropathic Pain
• Coeliac plexus block
• Ganglion of Impar block
• Hypogastric plexus block
• Pulsed radiofrequency to nerves
• EG: intercostal/ obturator
Advanced Pain Management Techniques
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Nerve Stimulation
Nerve Stimulation (2)
Intrathecal Pumps
Intrathecal Pumps (2)
The Future?
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The Future?
• Demographics
• Healthcare advances
• ↑ Patient expectations and involvement
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London Pain Consultants Pain Management Treatment and Therapy.mht
London Pain Consultants Clinics
• London • 15 Harley Street, W1G
• Wellington, NW8
• HSJSE, NW8
• Lindo Wing (St Marys), W2
• Surrey •Mount Alvernia, Guildford
The Team
• Consultant Pain Medicine (Dr.C.A.Jenner)
• Consultant Orthopaedic Spine Surgeon (Mr. Mo Akmal)
• Consultant Interventional Radiologist (Dr. D. Connel)
• Consultant Rheumatologist (Dr. Rees)
The Team (2)
• Consultant Gynaecologist (Miss D. Lyons)
• Consultant Neurologist (Dr. J. Ball)
• Consultant Psychologist (Dr J. Neilson)
• Specialist Physiotherapists (West London Physiotherapy- Sarah Morton, Cameron Tudor)
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Summary
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Summary
• Very common (1 in 7 UK)
• Time course- acute n chronic
• Nociceptive and neuropathic
• Multiple treatment modalities
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Any Questions