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Gingerich back pain presentation (sept. 2012)
1. Common Causes and
Treatments for Chronic
Low Back Pain
Troy C. Gingerich, MD
Southeast Anesthesiology Pain Consultant
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
2. Pain Management
Pain Management is a medical specialty
that focuses on finding and treating the
source of your pain and pain symptoms
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
3. Goals
ī§ Optimize Pain Control
ī§ Minimize side effects, adverse outcomes, and
costs
ī§ Enhance functionality and psychological well-
being
ī§ Enhance the overall quality of life
ī§ Ideal management is multidisciplinary,
multidimensional
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
4. Our Approach
Our overall approach to pain management can be
viewed as a four-pronged approach that may
include one or more of the following components.
ī§Interventional techniques
ī§Medication management
ī§Rehabilitation
ī§Counseling
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
5. Pain Definition
ī§ âan unpleasant sensory and EMOTIONAL experience
associated with actual or potential tissue damage, or
described in terms of such damageâ (IASP)
ī§ âwhatever the experiencing person says it is, existing
whenever he says it doesâ (McCaffery and Pasero)
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
6. Acute vs Chronic
ī§ Acute - Pain during healing/repair of tissues
ī§ Chronic - Pain present beyond healing and repair
of tissues or that lasts beyond 3 months
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
7. Duration of Pain
ī§ Adults 20 years of age
and over who report pain
said that it lasted:
ī§ <1 month â 32%
ī§ 1 to 3 months â 12%
ī§ 3 months to 1 year â
14%
ī§ >1 year â 42%
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
8. Timely Treatment
Prompt treatment of pain is
Length of Time Off Work
vital. 2%
ī§ The sooner pain is managed
ī the more likely patients 19%
are to return to normal daily 94%
living activities
0% 20% 40% 60% 80% 100%
Percentage Returning to Work
<90 days >90 days <2 yrs
J. McGill, J. Occupational Medicine, 1968
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
9. Timely Treatment
Anyone who has had pain for more
than 2 weeks with no pain relief
should be evaluated by a
Pain Management Specialist.
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
10. Pain Statistics
âĸ Pain is the #1 admitting diagnosis in US
âĸ Pain is the #1 reason for missed work in US
âĸ Chronic pain costs the US $100 Billion a year in direct
medical costs, lost income and productivity
âĸ 76.5 million Americans reported that they have had a
problem with pain that persisted for more than 24
hours in duration
Stewart et al, Work-related cost of pain in the US, IASP/10th World Congress on Pain 2002, as cited
by Dr. John Stamatos, Medscape.com.
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
11. Pain Statistics
Pain affects more Americans than diabetes,
heart disease and cancer combined.
*Sources:
Pain â 76.2 million people, National Centers for Health Statistics
Diabetes â 20.8 million people (diagnosed and estimated undiagnosed), American Diabetes Assocition
Coronary Heart Disease (including heart attack and chest pain) and Stroke â 18.7 million people, American Heart Association
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Cancer â 1.4 million people, American Cancer Society
12. Effects of Uncontrolled Pain
ī§ Limits patient activity, function
ī§ Decreased appetite, weight loss
ī§ Sleep loss
ī§ Mood change
ī§ Decrease in quality of life
ī§ Multiple effects on families and social interactions
ī§ Thus, adequate pain control is essential to ensure
patients are able to function, sleep, maintain social
relationships, and improve overall quality of life
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
18. Malignant
Cancer
Primaryâmultiple myeloma
Metastaticâprostate, breast, liver
Infectious
Discitis, Osteomyelitis, Epidural abscess
Spinal Cord Compression
Cauda Equina Syndrome, Conus Medullaris Syndrome
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
19. Benign
ī§ Radicular (Sciatic)
Herniated Disc
Spinal Stenosis
Failed Back Surgery Syndrome
ī§ Musculoskeletal (Axial)
Facet joints
Sacroiliac joint
Myofascial Pain Syndrome
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
20. Diagnostic
Tests
ī§ X-rays
ī§ Good for evaluating gross bone structure
ī§ Helps identify fractures and spondylolisthesis
ī§ MRIs
ī§ Evaluate soft tissue, discs, nerves
ī§ CT scans
ī§ More detailed imaging of bones and discs
ī§ Other
ī§ CBC, ESR
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
24. Radicular Causes of
Chronic Low Back Pain
ī§ Herniated disc
ī§ Spinal stenosis
ī§ Failed back surgery syndrome (FBSS)
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
27. Herniated Disc
ī§ 90% lower lumbar discs (L4/5, L5/S1)
ī§ Can present as low back pain or pain radiating into
leg
ī§ Can be associated with muscle spasms
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
30. Spinal Stenosis
ī§ Degenerated joints (âbone spursâ), herniated disc,
and thickening of the ligaments
ī§ Can present as neurogenic claudication
ī§ Most common in 5th decade of life
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
32. Possible Causes
of FBSS
ī§ Continued degenerative process from the altered
surgical anatomy
ī§ Surgical nerve trauma
ī§ Traction on neural elements from scar tissue
ī§ Persistent pain secondary to central sensitization
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
33. Musculoskeletal
Causes of Low Back Pain
ī§ Facet joints
ī§ Sacroiliac joints
ī§ Myofascial Pain Syndrome (MFPS)
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
38. Sacroiliac Joint
ī§ Where the back meets the
pelvis/hip
ī§ Pain related to arthritis or
malrotation of the joint
ī§ 25% of low back pain
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
44. Conservative
ī§ Physical therapy, Aqua therapy, Joint Mobilization,
TENS unit
ī§ Patient Education/Ergonomics
ī§ Pharmacologic
ī§ NSAIDs
ī§ Muscle relaxants
ī§ Opioids
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
45. Advanced: Interventional
Therapy
Blocks and Injections
ī§ Epidural steroid injections
ī§ Nerve root blocks
ī§ Facet injections
ī§ Sacroiliac joint injections
ī§ Trigger point injections
ī§ Spinal Cord Stimulation
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
46. Epidural Steroid
Injections
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
47. Epidural Steroid
Injection
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
48. Epidural Steroid
Injections
ī§ Series of â3â, three to four weeks apart
ī§ Combination of local anesthetic and steroid
ī§ Most effective for radicular pain
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
49. Facet Joint
Injections
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
50. Advanced Treatments
Radiofrequency Ablation
ī§ Radiofrequency is a minimally
invasive procedure.
ī§ A small radiofrequency current
will travel through the electrode
into the surrounding tissue,
causing the tissue to heat and
eliminate the pain pathways.
ī§ Results usually last 6-9 months.
ī§ Patient should be able to resume
normal activities, including work,
as soon as they feel able.
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
51. Radiofrequency Ablation
ī§ Multiple nerves to each joint
ī§ Most common facet joints are
L4/5 and L5/S1
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
52. Radiofrequency
Ablation
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
53. Sacroiliac Joint
Injection
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
54. Trigger Point
Injections
ī§ Best relief with combination of
stretching exercises and heat
therapy
ī§ Usually secondary, need to
identify cause
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
55. Spinal Cord
Stimulation
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
56. Advanced Treatments
Spinal Cord Stimulation
ī§ Stimulators use low voltage
electrical signals to prevent
messages of pain from
reaching the brain. Instead of
pain, patients feel a tingling
sensation.
ī§ Spinal cord stimulation is non-
addictive, allowing patients to
control their own therapy.
ī§ Stimulators are very effective
when a patient is suffering from
neuropathic pain.
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
57. Spinal Cord
Stimulation
ī§ Indications:
ī§ FBSS
ī§ Neuropathy of the extremity
ī§ Intractable low back and/or extremity pain
ī§ CRPS
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
58. Spinal Cord
Stimulation
ī§ Gate theory
ī§ Two phases process: trial and if successful then
permanent
ī§ Outpatient surgery
Southeast Anesthesiology Consultants, PA - Southeast Pain Care