Diagnosis and evaluation


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Diagnosis and Evaluation

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Diagnosis and evaluation

  1. 1. Failed Back Surgery Syndrome – Part 1 Diagnosis and Evaluation Richard K. Osenbach, M.D. Division of Neurosurgery Duke University Medical Center Brought to you by
  2. 2. Chronic Pain – Scope of the Problem 9% – 28% of the population suffers from moderate to severe chronic non-cancer pain American Pain Society (2002); Chronic pain in America: roadblocks to relief 86 million Americans suffer from chronic pain 66 million Americans partially/totally disabled 8 million disabled by LBP 65,000 cases of permanent disability diagnosed annually 100 billion dollars in annual economic losses 40 million physician visits per year 515 million lost workdays annually Business Week (1999) Brought to you by
  3. 3. Pain Types NOCICEPTIVE PAIN results from ongoing activation of mechanical, thermal, or chemical nociceptors typically opioid-responsive eg. pain related to mechanical instability NEUROPATHIC PAIN spontaneous or evoked pain that occurs in the absence of ongoing tissue damage typically opioid-resistant*** eg. pain secondary to nerve root injury Brought to you by
  4. 4. Neuropathic Pain Pain in absence of ongoing tissue damage Pain in an area of sensory loss Paroxysmal or spontaneous pain Characteristics of pain: burning, pulsing, stabbing Allodynia, hyperalgesia, or dysesthesias Delay in onset following injury Presence of major neurological deficit Poor response to opioids Brought to you by
  5. 5. Biopsychosocial Model of Pain Pain Behavior Suffering Pain Nociception Brought to you by
  6. 6. Failed Back Surgery Syndrome FBSS is a term applied to a heterogeneous group of individuals who share only one characteristic - continued back and/or extremity pain following one or more spinal operations 15% of patients will experience persistent or recurrent symptoms Spectrum of abnormalities ranging from purely organic to purely psychological, but in most cases consists of a physiological abnormality complicated by psychological factors FBSS is perhaps the prototypical example of chronic pain as a biopsychosocial disorder Brought to you by
  7. 7. Failed Back Patient Profile Pain and suffering often disproportionate to any identifiable disease process Depression Physical deconditioning Inappropriate use of physician-prescribed medications Superstitious beliefs about bodily functions Failure to work or perform expected physical and cognitive activities No active medical problems that can be remediated with the expectation of relief of pain Brought to you by
  8. 8. The “Ds” of FBSS Disuse Deconditioning Drug misuse Dependence Depression Disability Brought to you by
  9. 9. Post-operative Causes of Back Pain Deconditioning Trauma Muscle spasm Wrong level fused Myofascial pain Insufficient levels fused Spinal instability Pseudomeningocele Diskogenic pain Graft donor site pain Facet arthropathy Psychosocial factors Infection Pseudarthrosis Loose hardware Arachnoiditis Brought to you by
  10. 10. Post-operative Causes of Leg Pain Retained disk fragment Arachnoiditis Recurrent HNP Synovial cyst Far lateral disk Root sleeve meningocele Lateral recess stenosis Loose hardware Inadequate decompression Facet fracture Wrong level decompressed Psychosocial factors Nerve root injury Retained foreign body Epidural fibrosis Brought to you by
  11. 11. Goals of Chronic Pain Management in Patients with FBSS Functional improvement Functional improvement Functional improvement!!! Improvement in physical activities and exercise tolerance Reduction in narcotic use Reduction in healthcare consumption Return to work Pain reduction Brought to you by
  12. 12. Principles of Chronic Pain Management 1. “Single most important ingredient is the existence of health care providers who are willing to work together as a team.” 2. Providers must take an interest in chronic disease and not be overly focused on acute illness as is fostered by the biomedical model 3. Commitment of the provider to the patient Brought to you by
  13. 13. Principles of Chronic Pain Management 4. Patient must be motivated to change their lives and must be willing to do the therapeutic work 5. Treatment represents the beginning of a journey to reclaim one’s life from the pain problem; long-term support is required to maintain success 6. Patient selection is a key to success. Attempting to treat the untreatable results in demoralization of the treatment team Brought to you by
  14. 14. Multidisciplinary Pain Management Collaborative efforts of a group of providers Physicians Nurses Psychologists Physical Therapists Vocational counselors Social workers Support staff Team work is essential Extensive interactions between team members Adequate space Brought to you by
  15. 15. Multidisciplinary Pain Programs No single accepted format Generic concept and plan common to all programs of this type Based on biopsychosocial model of pain Complaint of pain generated by a combination of events in any particular patient Simultaneously address all issues Present patient with a single treatment program that encompasses all the TREATABLE issues Brought to you by
  16. 16. Common Features of Multidisciplinary Pain Management Physical therapy and rehabilitation Medication management Patient education about pain and body function Psychological treatments Coping skills training Vocational assessment Therapies targeted toward improving the likelihood of return to work Surgical interventions for selected patients Brought to you by
  17. 17. Multidisciplinary Pain Clinic Personnel Physicians Neurosurgeon Orthopedic surgeon Anesthesiologist Neurologist Physiatrist Internal medicine Psychiatrist Addictionologist Nurses Psychologists Physical Therapist Occupational Therapist Vocational counselor Social worker Dietician Recreational staff Administrative support staff Brought to you by
  18. 18. Failed Back Surgery Syndrome Surgical Complications Disk space infection Iatrogenic instability Nerve root injury Retained disk fragment Recurrent disk herniation Inadequate decompression Complications of fusion and instrumentation Adhesive arachnoiditis Brought to you by
  19. 19. Failed Back Surgery Syndrome Physician Decision Making Poor patient selection Poor patient selection Poor patient selection Poor patient selection Poor patient selection Poor patient selection Poor patient selection Brought to you by
  20. 20. The most common cause of failed back syndrome is poor judgment on the part of the physician. Surgery prescribed as a last resort, with a hope and a prayer that it might alleviate the pain. Brought to you by
  21. 21. When in doubt, it’s a good idea to take a history and examine the patient Brought to you by
  22. 22. Evaluation of the Patient with FBSS Detailed pain history including prior treatments and MOST IMPORTANTLY the outcome of each Obtain appropriate imaging studies (including those on which surgical decisions were based) Attempt to establish the underlying cause of the pain; however………. Brought to you by
  23. 23. DO NOT get caught up in an endless search for THE PAIN GENERATOR Brought to you by
  24. 24. Romancing the Pain Generator Brought to you by
  25. 25. Pain History Where is it located? Does the pain radiate? When did it start and under what circumstances? What is the quality of the pain? What is the severity of the pain (VAS scores) What factors make it worse? What factors make it better? Are there associated symptoms? Brought to you by
  26. 26. Pain History Effect of pain on sleep Medications taken for pain Health professionals consulted Patient’s beliefs concerning the cause of pain Expectations of outcome of treatment Family expectations Pain reduction required for “reasonable activities Brought to you by
  27. 27. Treatment History What therapies have been tried and what were the outcomes? Physical therapy Injections  Epidural steroids, nerve root blocks, facet blocks, etc Medication history What drugs? Dose? How long? Effect? Brought to you by
  28. 28. Physical Examination Rarely diagnostic Principally serves to establish the current level of physical impairment Lack of physical abnormality should not be used to deny a patient evaluation and therapy if indicated Brought to you by
  29. 29. Examination of the Lumbar Spine Inspection, palpation, and evaluation of ROM Abnormalities of muscle tone Local tenderness Reduced ROM Neurological exam Muscle strength Sensation Reflexes Nerve root tension signs Sciatic and femoral stretch test Brought to you by
  30. 30. Imaging Studies Static plain radiographs Spinal alignment Flexion/extension views Instability Computed tomography (CT) Bony surgical defects Hardware placement Fusion mass Magnetic resonance imaging (MRI) Soft tissue and neural structures Radionuclide imaging Technetium99 bone scan Indium111 WBC scan Brought to you by
  31. 31. Surgically-Correctable Pathology Brought to you by
  32. 32. Surgically-Correctable Pathology Brought to you by
  33. 33. Electrophysiological Studies EMG is likely of greater utility in FBSS than in primary low back pain and sciatica Greatest use is for establishing the presence of a peripheral neuropathy May be helpful for defining a feigned neurological deficit Rarely using in decision-making regarding treatment Brought to you by
  34. 34. Diagnostic Blockade Rationale is straightforward In practice, it is much more complicated Specificity may be low Single blocks (positive or negative) have a high error rate Placebo controls provide the most accurate information Multiple blocks using different agents BLOCKS ARE ADJUNCTS AND SHOULD NEVER BE SUBSTITUTED FOR SOUND CLINICAL JUDGEMENT ! Brought to you by
  35. 35. Sensitivity and Specificity of Diagnostic Blocks Differences in pain processing Technical aspects Incorrect needle placement Large volumes of anesthetic Effects local anesthetics Psychological issues Environmental cues, expectations, anxiety, etc. Placebo response Brought to you by
  36. 36. Facet Block Blockade of the innervation of the facet joint will relieve pain in some patients with facet disease Brought to you by
  37. 37. Facet Block Rarely useful in patient with FBSS Transitional facet disease above a fused level Anatomy obliterated and accurate block not possible Blockade of pseudarthrosis may sometimes be useful Brought to you by
  38. 38. Selective Nerve Root Block Must be done accurately to provide any useful information One root at a time Small volume of local anesthetic without steroids Confirm the presence of an adequate block Confirm findings on repetitive blocks Brought to you by
  39. 39. Therapeutic Heat Increases muscle temperature, decrease spindle sensitivity, increases blood flow Pain relief, increase in tissue extensibility, reduction of muscle spasm Superficial heat Greatest effect 0.5cm from skin Deep heat Ultrasound diathermy  Heat up to 5cm deep to skin  Treatment of deep soft tissues Hydrotherapy Buoyancy minimizes stress to joints Brought to you by
  40. 40. Cold Therapy Affects muscle spindle and may modulate neurotransmitters Provides longer pain relief than heat Ice and gel packs, vapocoolant sprays, cold baths Particularly useful for trigger points, Treatment of choice for acute injuries Brought to you by
  41. 41. TENS Electrical energy transmitted from skin surface Rationale based on “Gate Theory” of pain Most effective at high-frequency, low-intensity “Acupuncture TENS” – high-intensity, low-frequency Questionable benefit for chronic back pain Brought to you by
  42. 42. Therapeutic Exercise and Massage Essential for restoration of function “Hurt” vs. “Harm” Stretching exercises Strengthening exercises Aerobic exercises Therapeutic massage Brought to you by
  43. 43. Brought to you by
  44. 44. Anticonvulsant Agents (AEDS) Similarities in pathophysiology of neuropathic pain and epilepsy All AEDS ultimately act on ion channels Efficacy of AEDS most clearly established for neuropathic conditions characterized by episodic lancinating pain Most clinical studies have focused on DPN and PHN Use of AEDS in patients with FBSS is nearly entirely empiric Brought to you by
  45. 45. Antidepressant Analgesics Relieves all components of neuropathic pain Clear separation of analgesic and antidepressant effects Although other agents (eg anti-epileptics)) may be regarded as 1st line therapy over antidepressants, there is no good evidence for this practice More selective agents are either less effective or not useful (serotonergic, noradrenergic) Brought to you by
  46. 46. Guidelines for Use of Antidepressants in Pain Management Eliminate all other ineffective analgesics Start low and titrate slowly to effect or toxicity Nortriptyline or amitriptyline for initial treatment Move to agents with more noradrenergic effects Consider trazodone in patients with poor sleep pattern Try more selective agents if mixed agents ineffective Do NOT prescribe monoamine oxidase inhibitors Tolerance to anti-muscarinic side effects usually takes weeks to develop Withdraw therapy gradually to avoid withdrawal syndrome Brought to you by
  47. 47. Antidepressants for LBP-RCT Author Agent No. Effect Comments Jenkins et al., 1976 Imipramine 50mg 4 weeks 44/59 No Parallel design Alcott et al., 1982 Imipramine 150mg 8 weeks 41/50 No Parellel design; poss role for pain Godkin et al., 1990 Trazadone 200mg 42 No Parellel design Serotonergic agent Usha et al., 1996 Fluoxetine 20mg Elavil 25mg Placebo 4 weeks 59 Yes Parallel design Fluoxetine more effective with fewer SE Atkinson et al., 1998 Nortriptyline 100mg Inert placebo 57/78 Yes Parallel design Non-depressed pts Dickens et al., 2000 Paroxetine 20mg 61/92 No Parellel design Brought to you by
  48. 48. Opioid Therapy - RCT Pain Type Study Control Results Nociceptive Arner & Meyerson, 1988 Placebo Pos Kjaersgaard-Anderson, 1990 Paracetamol Pos*** Neuropathic Arner & Meyerson, 1988 Placebo Neg Dellemijn & Vanneste, 1997 Placebo/Valium Pos Kupers, et al., 1991 Placebo Pos Rowbotham et al., 1991 Placebo Pos Idiopathic Arner & Meyerson, 1988 Placebo Neg Kupers, et al., 1991 Placebo Neg Moulin et al., 1996 Benztropine Pos*** Unspecified Arkinstall et al., 1995 Placebo Pos*** Mays et al., 1987 Placebo/Bupiv Pos Brought to you by
  49. 49. Opioid Therapy – Prospective Uncontrolled Studies Pain Type Reference Results Nociceptive McQuay et al., 1992 Pos Neuropathic Fenollosa et al., 1992 Pos McQuay et al., 1992 Mixed Urban et al., 1986 Pos Idiopathic McQuay et al., 1992 Neg Mixed/Unspecified Auld et al. 1985 Pos Gilmann & Lichtigfeld, 1981 Pos Penn and Paice, 1987 Pos Plummer et al., 1991 Mixed Brought to you by
  50. 50. Tramadol for LBP Brought to you by
  51. 51. NSAIDS for Chronic LBP One systematic reviews of 2 studies within framework of Cochrane Collaboration NSAID vs. Placebo Better short-term pain relief NSAID vs. Acetominophen (N=4) No difference in short-term pain relief Better overall improvement Brought to you by
  52. 52. Corticosteroids Useful in the short term for treatment of radicular pain Limited role in the long-term treatment of FBSS Epidural or transforaminal steroids for selected patients Cochrane Review (Nelemans, et al., 2002) Most trials included patients with radicular pain No significant difference in pain relief after 6 weeks or 6 months between ESI and placebo Brought to you by
  53. 53. Topical Treatments Aspirin preparations Eg. aspirin in chloroform Local anesthetics Topical 5% lidocaine patch EMLA Eutectic mixture of local anesthetics Capsaicin Brought to you by
  54. 54. Lidocaine Patch for LBP Brought to you by
  55. 55. Cannabinoids Strong laboratory data supporting an analgesic effect of cannabinoids Efficacy of cannabinoids in human has been modest at best Effectiveness hampered by unfavorable therapeutic index Campbell (2001) – systematic review of 9 clinical trials of cannabinoids Cancer pain (5), Chronic non-cancer pain (2), acute pain (2) Analgesic effect estimated equivalent to 50-120mg codeine Adverse effects reported in all studies RCT have shown modest benefits when compared with placebo Increased incidence of psychiatric illness and cognitive dysfunction Brought to you by
  56. 56. Botulinum Toxin for Chronic LBP World Congress Brought to you by
  57. 57. Multidisciplinary Treatment Outcomes Decrease in pain self-rating by about 30% Opioid consumption reduced by about 60% Pain-related physician visits decrease by 60% Physical activities increase by 300% Gainful employment occurs in 60% Brought to you by
  58. 58. Comprehensive Pain Management Pain Reduction 0 10 20 30 40 50 60 70 80 90 100 Discharge 3 Month 1 Year Rosomoff Comprehensive Pain Center, 1999-2005 Brought to you by
  59. 59. Comprehensive Pain Management Functional Improvement 0 10 20 30 40 50 60 70 80 90 100 Discharge 3 Months 1 Year Rosomoff Comprehensive Pain Center, 1999-2005 Brought to you by
  60. 60. 0 10 20 30 40 50 60 70 80 90 100 Discharge 3 Months 1 Year Comprehensive Pain Management QOL Improvement Rosomoff Comprehensive Pain Center, 1999-2005 Brought to you by
  61. 61. Comprehensive Pain Management Employed/Work Ready 0 10 20 30 40 50 60 70 80 90 100 Discharge 3 Months 1 Year Rosomoff Comprehensive Pain Center, 1999-2005 Brought to you by
  62. 62. Comprehensive Pain Management Opioid Usage 0 10 20 30 40 50 60 70 80 90 100 Discharge 3 Months 1 Year Rosomoff Comprehensive Pain Center, 1999-2005 Brought to you by
  63. 63. Comprehensive Pain Management Patient Satisfaction 0 10 20 30 40 50 60 70 80 90 100 Discharge 3 Months 1 Year Rosomoff Comprehensive Pain Center, 1999-2005 Brought to you by
  64. 64. Treatment Outcomes Flor et. al., Pain 1992 Metanalysis of 65 studies with 3,089 patients Average pain reduction 20% (0-60%) Return to work 67% Standard treatments (24%) Dramatic reductions in health care consumption and additional surgery Steig et al (Pain 1986) - $280,000 savings in health care expenses up to retirement Okifuji et al (1998) – 280 million saving per year if patients receiving standard medical/surgical treatments were treated in a multidisciplinary clinic Brought to you by
  65. 65. So What’s The Problem? It is difficult to obtain funding and reimbursement for this type of healthcare , despite the fact that more outcome data are available than for any other type of chronic pain treatment Brought to you by
  66. 66. “The only antidote for mental suffering is physical pain” “That’s the most ridiculous thing I’ve ever heard.” Brought to you by
  67. 67. This platform has been started by Parveen Kumar Chadha with the vision that nobody should suffer the way he has suffered because of lack and improper healthcare facilities in India. We need lots of funds manpower etc. to make this vision a reality please contact us. Join us as a member for a noble cause. Brought to you by
  68. 68. Our views have increased the mark of the 10,000  Thank you viewers  Looking forward for franchise, collaboration, partners. Brought to you by
  69. 69. -011 25464531,-011 41425180,-011 66217387 +-91 9818308353,+-91 9818569476 othermotherindia@gmail.com . - .www other mother in : . . - - - ?https //www facebook com/pages/Other Mother Nursing Crusade/224235031114989 ref=hl : . . ? _ _ _http //www linkedin com/profile/view id=326103341&trk=nav responsive tab profile : .https //twitter com/othermotherindi : . . -https //cparveen wix com/other mother A WORLDWIDE MISSITION Contact Us:- JOIN US Saxbee Consultants Details :-www.parveenchadha.com Brought to you by