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The Management Of Spinal Pain Presented At Back Show 4.10.09

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The Management Of Spinal Pain.

Presented At The Back Show, Earls Court Centre, London.

4th October 2009.

Published in: Health & Medicine
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The Management Of Spinal Pain Presented At Back Show 4.10.09

  1. 1. The Management of Spinal Pain. Dr. Christopher A. Jenner MB BS, FRCA Consultant in Pain Medicine, Imperial Healthcare NHS Trust Medical Director Spinal Healthcare 4 th October 2009
  2. 2. Agenda <ul><li>Definition </li></ul><ul><li>Physiology </li></ul><ul><li>Acute/ Chronic </li></ul><ul><li>Neuropathic </li></ul><ul><li>Differences </li></ul><ul><li>Treatment Options </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  3. 3. Definitions <ul><li>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) </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  4. 4. Definitions (2) <ul><li>Time-course: </li></ul><ul><li>• acute </li></ul><ul><li>• chronic </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  5. 5. Definitions (3) <ul><li>Type: </li></ul><ul><li>• nociceptive </li></ul><ul><li>• neuropathic </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  6. 8. Pain Physiology <ul><li>(boring) </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  7. 10. Pain Physiology (funky version) www.londonpainconsultants.com
  8. 12. Noxious Stimulus
  9. 13. Impulse Transmission
  10. 14. Afferent sensory fibres
  11. 15. Spinal cord
  12. 16. Dorsal Horn
  13. 17. Synapse
  14. 18. Ca and Glutamate
  15. 19. Synaptic Cleft
  16. 20. Post Synaptic
  17. 21. Nociceptive Neuron
  18. 22. Pain perception
  19. 23. Brain
  20. 24. The Challenges of Chronic Pain <ul><li>Bio-psycho-social model </li></ul><ul><li>Individual and societal costs </li></ul><ul><li>Biological- pain/ suffering/ disability </li></ul><ul><li>Psychological- anxiety/ depression </li></ul><ul><li>Social- work/ relationship/ family/ benefits </li></ul>
  21. 25. Massive Financial Burden <ul><li>NHS/ DWP/ tax-payers </li></ul><ul><li>• Lower back pain (CSAG 1994) </li></ul><ul><li>• NHS £481 million </li></ul><ul><li>• The Exchequer £1.4 billion </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  22. 26. Physical and Alternative Treatments
  23. 27. Physiotherapy
  24. 28. Physical/ Alternative Treatments <ul><li>• Physical- heat/ cold/ TENS/ hydro/ supports/ US/ IR </li></ul><ul><li>• Manipulation- PxTx/ chiropracter/ osteopathy/ deep tissue massage </li></ul><ul><li>• Alternative- acupuncture </li></ul>
  25. 29. Any Vets in the audience? <ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  26. 30. 5. (a) Veterinary practitioners?
  27. 31. Headache!
  28. 32. Pharmacological Treatment
  29. 33. Acute Pain Management <ul><li>Non-pharmacological </li></ul><ul><li>• RICE </li></ul><ul><li>Pharmacological </li></ul><ul><li>• WHO ladder (amended from cancer) </li></ul><ul><li>Step 1 paracetamol/ NSAID/ COX 2 </li></ul><ul><li>Step 2 + weak opioids </li></ul><ul><li>Step 3 + strong opioids </li></ul>
  30. 35. Pharmacological Treatment <ul><li>• WHO analgesic ladder (abridged) </li></ul><ul><li>• + tramadol </li></ul><ul><li>• + opioids- buprenorphine TDD/ oxycontin/ fentanyl TDD </li></ul><ul><li>(New: sufentanyl TDD/ product X ) </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  31. 36. Opioid Therapy <ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  32. 39. Pharmacological treatment of Neuropathic Pain <ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  33. 40. Neuropathic Pain Management <ul><li>Antidepressants- Amitryptilline </li></ul><ul><li>Anticonvulsants- Gabapentin/ Pregabalin/ Carbamazepine/ Valproate </li></ul><ul><li>Opioids </li></ul><ul><li>Local Anaesthetics- Lignocaine/ EMLA </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  34. 41. <ul><li>NMDA antagonists </li></ul><ul><li>Sympatholytics </li></ul><ul><li>GABA –ergics </li></ul><ul><li>Capsaicin </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  35. 42. Future Agents for Neuropathic Pain <ul><li>Ziconotide (sea snail, conus magnus) </li></ul><ul><li>P2X3- (purine) receptor antagonists (ATP) (knockout mice) </li></ul><ul><li>Epibatidine (Equadorian poison dart frog) </li></ul><ul><li>Morphine and ketamine </li></ul><ul><li>Regular gabapentin </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  36. 43. Psychologicaly based therapy
  37. 44. Pain Management <ul><li>Psychological </li></ul><ul><li>CBT </li></ul><ul><li>Operant Conditioning </li></ul><ul><li>Psychoanalysis </li></ul><ul><li>Relaxation </li></ul><ul><li>Biofeedback </li></ul><ul><li>• Psychiatric </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  38. 45. Pain Management Programmes <ul><li>● Medication </li></ul><ul><li>• Goals (SMART- specific/ measured/ agreed/ realistic/ timed) </li></ul><ul><li>• Coping </li></ul><ul><li>• Contingency </li></ul><ul><li>• Pacing </li></ul><ul><li>• Education </li></ul><ul><li>• Pain Behaviours </li></ul><ul><li>• Reinforcement www.londonpainconsultants.com </li></ul>
  39. 46. Functional Restoration Programmes www.londonpainconsultants.com
  40. 47. MRI scans
  41. 51. Minimally Invasive Pain Management
  42. 53. C-arm
  43. 54. Targets www.londonpainconsultants.com
  44. 56. Spine Pain Cervical/ Thoracic/ Lumbar >65% workload
  45. 57. Epidural Steroid Injections
  46. 58. Facet Joint Injections
  47. 59. Nerve Root Injections
  48. 60. Sacroiliac Joint Injection
  49. 61. Radiofrequency
  50. 62. <ul><li>Radiofrequency denervation (destructive) </li></ul><ul><li>Eg: medial branch (facet joint) blocks </li></ul><ul><li>Pulsed radiofrequency (non-destructive) </li></ul><ul><li>Eg: nerve roots </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  51. 63. Botulinum Toxin A
  52. 64. Other Minimally Invasive Techniques www.londonpainconsultants.com
  53. 65. Epiduroscopy
  54. 66. IDET
  55. 67. Disc Dekompressor
  56. 68. Vertebroplasty/ Kyphoplasty
  57. 69. Musculoskeletal www.londonpainconsultants.com
  58. 70. Shoulder <ul><li>Suprascapular nerve block </li></ul><ul><li>Suprascapular pulsed radiofrequency </li></ul><ul><li>Intra-articular </li></ul><ul><li>Trigger point </li></ul><ul><li>Botulinum Toxin A </li></ul>
  59. 71. Limbs <ul><li>Tenoperiostial injections </li></ul><ul><li>Intra-articular </li></ul><ul><li>Trigger points </li></ul><ul><li>Intra-articular </li></ul><ul><li>Botulinum Toxin A </li></ul>
  60. 73. Neuropathic Pain www.londonpainconsultants.com
  61. 74. Complex Regional Pain Syndrome (CRPS) <ul><li>• Upper Limb </li></ul><ul><li>• Stellate ganglion block </li></ul><ul><li>• Intravenous guanethidine block (IVG) </li></ul><ul><li>• Lower Limb </li></ul><ul><li>• Lumbar Sympathectomy </li></ul><ul><li>• Intravenous guanethidine block (IVG) </li></ul>
  62. 75. Other Neuropathic Pain <ul><li>Coeliac plexus block </li></ul><ul><li>Ganglion of Impar block </li></ul><ul><li>Hypogastric plexus block </li></ul><ul><li>Pulsed radiofrequency to nerves </li></ul><ul><li>EG: intercostal/ obturator </li></ul>
  63. 76. Advanced Pain Management Techniques www.londonpainconsultants.com
  64. 77. Nerve Stimulation
  65. 78. Nerve Stimulation (2)
  66. 79. Intrathecal Pumps
  67. 80. Intrathecal Pumps (2)
  68. 81. The Future? www.londonpainconsultants.com
  69. 82. The Future? <ul><li>Demographics </li></ul><ul><li>• Healthcare advances </li></ul><ul><li>• ↑ Patient expectations and involvement </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  70. 83. www.londonpainconsultants.com
  71. 85. London Pain Consultants Clinics <ul><li>London </li></ul><ul><li>• 15 Harley Street, W1G </li></ul><ul><li>• Wellington, NW8 </li></ul><ul><li>• HSJSE, NW8 </li></ul><ul><li>• Lindo Wing (St Marys), W2 </li></ul><ul><li>• Surrey </li></ul><ul><li>• Mount Alvernia, Guildford </li></ul>
  72. 86. The Team <ul><li>Consultant Pain Medicine (Dr.C.A.Jenner) </li></ul><ul><li>Consultant Orthopaedic Spine Surgeon (Mr. Mo Akmal) </li></ul><ul><li>Consultant Interventional Radiologist (Dr. D. Connel) </li></ul><ul><li>Consultant Rheumatologist (Dr. Rees) </li></ul>
  73. 87. The Team (2) <ul><li>Consultant Gynaecologist (Miss D. Lyons) </li></ul><ul><li>Consultant Neurologist (Dr. J. Ball) </li></ul><ul><li>Consultant Psychologist (Dr J. Neilson) </li></ul><ul><li>Specialist Physiotherapists (West London Physiotherapy- Sarah Morton, Cameron Tudor) </li></ul>
  74. 88. www.spinal-healthcare.com
  75. 89. Summary www.londonpainconsultants.com
  76. 90. Summary <ul><li>Very common (1 in 7 UK) </li></ul><ul><li>Time course- acute n chronic </li></ul><ul><li>Nociceptive and neuropathic </li></ul><ul><li>Multiple treatment modalities </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  77. 91. Case reports/ Blogs/ Links/ Appointments [email_address] 0845 045 0250
  78. 92. <ul><li>Any Questions </li></ul>

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