Medicolegal Overview Of Pain Medicine 11.11.10
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Medicolegal Overview Of Pain Medicine 11.11.10

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Overview of the Medicolegal aspects of Pain Medicine.

Overview of the Medicolegal aspects of Pain Medicine.

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Medicolegal Overview Of Pain Medicine 11.11.10 Presentation Transcript

  • 1. Overview of Pain Medicine.Dr. Christopher A. Jenner MB BS, FRCA, FFPMRCAConsultant in Pain Medicine, Imperial Healthcare NHS Trust Medical Director London Pain Consultants and Spinal Healthcare 11th November 2010
  • 2. Agenda• Definition• Physiology• Acute/ Chronic• Neuropathic• Differences• Treatment Options www.londonpainconsultants.com
  • 3. 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) www.londonpainconsultants.com
  • 4. Definitions (2)• Time-course: • acute • chronic www.londonpainconsultants.com
  • 5. Definitions (3)• Type: • nociceptive • neuropathic www.londonpainconsultants.com
  • 6. Nociceptive Pain www.londonpainconsultants.com
  • 7. Neuropathic Pain www.londonpainconsultants.com
  • 8. Pain Physiology (boring) www.londonpainconsultants.com
  • 9. Pain Physiology (funky version) www.londonpainconsultants.com
  • 10. Epidemiology• 1 in 5 of adults suffers from chronic pain• 1 in 3 in the elderly population (Blyth et al 2001)• 70% of people living with chronic pain are under the age of 60 years. (European Journal of Pain, 2006)• 49% of people living with chronic pain are forced to take time of work. (British Pain Society, 2005)
  • 11. Physical and Alternative Treatments
  • 12. Physical/ Alternative Treatments • Physical- heat/ cold/ TENS/ hydro/ supports/ US/ IR • Manipulation- PxTx/ chiropracter/ osteopathy/ deeptissue massage • Alternative- acupuncture
  • 13. Any Vets in the audience? www.londonpainconsultants.com
  • 14. 5. (a) Veterinary practitioners?
  • 15. Headache!
  • 16. Pharmacological Treatment
  • 17. Pharmacological Treatment• WHO analgesic ladder (abridged)• + tramadol• + opioids- buprenorphine TDD/ oxycontin/ fentanyl TDD(New: sufentanyl TDD/ product X) www.londonpainconsultants.com
  • 18. Opioid Therapy www.londonpainconsultants.com
  • 19. Pharmacological treatment of Neuropathic Pain www.londonpainconsultants.com
  • 20. Neuropathic Pain Management• Antidepressants- Amitryptilline• Anticonvulsants- Gabapentin/ Pregabalin/ Carbamazepine/ Valproate• Opioids• Local Anaesthetics- Lignocaine/ EMLA
  • 21. • NMDA antagonists• Sympatholytics• GABA –ergics• Capsaicin www.londonpainconsultants.com
  • 22. 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 gabapentin www.londonpainconsultants.com
  • 23. Psychologicaly based therapy
  • 24. Pain Management• Psychological CBT Operant Conditioning Psychoanalysis Relaxation Biofeedback• Psychiatric www.londonpainconsultants.com
  • 25. Pain Management Programmes● Medication• Goals (SMART- specific/ measured/ agreed/ realistic/ timed)• Coping• Contingency• Pacing• Education• Pain Behaviours• Reinforcement www.londonpainconsultants.com
  • 26. Functional Restoration Programmes www.londonpainconsultants.com
  • 27. MRI scans
  • 28. Other Imaging
  • 29. Minimally Invasive Pain Management
  • 30. C-arm
  • 31. Targetswww.londonpainconsultants.com
  • 32. Spine PainCervical/ Thoracic/ Lumbar >65% workload
  • 33. Radiofrequency
  • 34. • DESTRUCTIVE- Radiofrequency denervation• Eg: medial branch (facet joint) blocks• NON-DESTRUCTIVE- Pulsed radiofrequency• Eg: nerve roots
  • 35. Botulinum Toxin A
  • 36. Other Minimally Invasive Techniques www.londonpainconsultants.com
  • 37. Musculoskeletal www.londonpainconsultants.com
  • 38. Shoulder• Suprascapular nerve block• Suprascapular pulsed radiofrequency• Intra-articular• Trigger point• Botulinum Toxin A
  • 39. Limbs• Tenoperiostial injections• Intra-articular• Trigger points• Intra-articular• Botulinum Toxin A
  • 40. Neuropathic Pain www.londonpainconsultants.com
  • 41. Complex Regional Pain Syndrome (CRPS)• Upper Limb • Stellate ganglion block • Intravenous guanethidine block (IVG)• Lower Limb • Lumbar Sympathectomy • Intravenous guanethidine block (IVG)
  • 42. Other Neuropathic Pain• Coeliac plexus block• Ganglion of Impar block• Hypogastric plexus block• Pulsed radiofrequency to nerves• EG: intercostal/ obturator
  • 43. Advanced Pain Management Techniques www.londonpainconsultants.com
  • 44. Nerve Stimulation
  • 45. Nerve Stimulation (2)
  • 46. Intrathecal Pumps
  • 47. Intrathecal Pumps (2)
  • 48. The Future? www.londonpainconsultants.com
  • 49. The Future?• Demographics• Healthcare advances• ↑ Patient expectations and involvement www.londonpainconsultants.com
  • 50. Summary• Very common (1 in 7 UK)• Time course- acute n chronic• Nociceptive and neuropathic• Multiple treatment modalities www.londonpainconsultants.com
  • 51. Medicolegal Case HistoriesDr. Christopher A. Jenner MB BS, FRCAConsultant in Pain Medicine, Imperial Healthcare NHS Trust Medical Director London Pain Consultants andSpinal Healthcare 11th November 2010
  • 52. Anatomy of a Medicolegal Report• Pre Accident/ Incident• Post Accident/ Incident• Summary• Pain History• Pain Scores• Previous Treatments
  • 53. • Employment and ADL• Examination Opinion (including causation)• Prognosis• Treatment Plan (costed)• Glossary and additional info
  • 54. 49F Severe RTA Cervical Facet Joint n Secondary Myofacial Pain Syndrome• Emotionally distressed• Interim payment• Clinical pain psychology• Meds and MIPM• Discharged• Case concluded
  • 55. 52 F School Secretary• Poor working environment• Cramped• High stress• WRULD• Ongoing case
  • 56. 32 F Post Spinal Surgery• Medical Negligence case• Unrecognised haematoma formation• Complicated by infection• Musculoskeletal pain• Neuropathic leg pain
  • 57. 34M Industrial Accident• High pressure oil jet• Traumatic amputation little/ middle/ ring fingers• Phantom limb pain• Neuropathic stump pain• Phantom sensations
  • 58. 22M Industrial Accident• Skip fell on foot• Crush injury• Traumatic amputation• Surgical intervention• Phantom limb pain• Neuropthic stump pain• Phantom sensations
  • 59. 47 F Post Hysterectomy• Medical Negligence case• Genitofemoral neuralgia•
  • 60. 42F Cosmetic Filler• Medical Negligence case• Facial Neuropathic Pain• Auriculotemporal nerve• Improving on medication and local nerve blocks• ongoing
  • 61. New Instructions• Practice Manager for full details and TnC• Competitive discounts for volume report writing instructions
  • 62. • www.londonpainconsultants.com• www.spinal-healthcare.com
  • 63. AnyQuestions