Gingerich back pain presentation (sept. 2012)

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Gingerich back pain presentation (sept. 2012)

  1. 1. Common Causes andTreatments for Chronic Low Back Pain Troy C. Gingerich, MDSoutheast Anesthesiology Pain Consultant Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  2. 2. Pain ManagementPain Management is a medical specialtythat focuses on finding and treating thesource of your pain and pain symptoms Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  3. 3. Goals Optimize Pain Control Minimize side effects, adverse outcomes, and costs Enhance functionality and psychological well- being Enhance the overall quality of life Ideal management is multidisciplinary, multidimensional Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  4. 4. Our ApproachOur overall approach to pain management can beviewed as a four-pronged approach that mayinclude one or more of the following components. Interventional techniques Medication management Rehabilitation Counseling Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  5. 5. Pain Definition ―an unpleasant sensory and EMOTIONAL experience associated with actual or potential tissue damage, or described in terms of such damage‖ (IASP) ―whatever the experiencing person says it is, existing whenever he says it does‖ (McCaffery and Pasero) Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  6. 6. Acute vs Chronic Acute - Pain during healing/repair of tissues Chronic - Pain present beyond healing and repair of tissues or that lasts beyond 3 months Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  7. 7. Duration of Pain Adults 20 years of age and over who report pain said that it lasted:  <1 month – 32%  1 to 3 months – 12%  3 months to 1 year – 14%  >1 year – 42% Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  8. 8. Timely TreatmentPrompt treatment of pain is Length of Time Off Work vital. 2%  The sooner pain is managed  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. 9. Timely TreatmentAnyone 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. 10. Pain Statistics• Pain is the #1 admitting diagnosis in US• Pain is the #1 reason for missed work in US• Chronic pain costs the US $100 Billion a year in direct medical costs, lost income and productivity• 76.5 million Americans reported that they have had a problem with pain that persisted for more than 24 hours in durationStewart et al, Work-related cost of pain in the US, IASP/10th World Congress on Pain 2002, as citedby Dr. John Stamatos, Medscape.com. Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  11. 11. Pain Statistics Pain affects more Americans than diabetes, heart disease and cancer combined.*Sources:Pain – 76.2 million people, National Centers for Health StatisticsDiabetes – 20.8 million people (diagnosed and estimated undiagnosed), American Diabetes AssocitionCoronary Heart Disease (including heart attack and chest pain) and Stroke – 18.7 million people, American Heart Association Southeast Anesthesiology Consultants, PA - Southeast Pain CareCancer – 1.4 million people, American Cancer Society
  12. 12. Effects of Uncontrolled Pain Limits patient activity, function Decreased appetite, weight loss Sleep loss Mood change Decrease in quality of life Multiple effects on families and social interactions 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
  13. 13. Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  14. 14. Comprehensive Exam History Physical Examination Psychosocial Evaluation Impression/Differential Diagnosis Diagnostic Evaluation Treatment Plan Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  15. 15. Low Back PainSoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  16. 16. Chronic Low Back Pain Risk Factors Age Fitness Level Diet Occupational Smoking Obesity Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  17. 17. Common Causes Malignant Benign Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  18. 18. MalignantCancer Primary—multiple myeloma Metastatic—prostate, breast, liverInfectious Discitis, Osteomyelitis, Epidural abscessSpinal Cord Compression Cauda Equina Syndrome, Conus Medullaris Syndrome Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  19. 19. Benign Radicular (Sciatic) Herniated Disc Spinal Stenosis Failed Back Surgery Syndrome Musculoskeletal (Axial) Facet joints Sacroiliac joint Myofascial Pain Syndrome Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  20. 20. Diagnostic Tests X-rays  Good for evaluating gross bone structure  Helps identify fractures and spondylolisthesis MRIs  Evaluate soft tissue, discs, nerves CT scans  More detailed imaging of bones and discs Other  CBC, ESR Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  21. 21. AnatomySoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  22. 22. AnatomySoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  23. 23. AnatomySoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  24. 24. Radicular Causes of Chronic Low Back Pain Herniated disc Spinal stenosis Failed back surgery syndrome (FBSS) Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  25. 25. Herniated DiscSoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  26. 26. Herniated DiscSoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  27. 27. Herniated Disc 90% lower lumbar discs (L4/5, L5/S1) Can present as low back pain or pain radiating into leg Can be associated with muscle spasms Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  28. 28. Spinal StenosisSoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  29. 29. Spinal StenosisSoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  30. 30. Spinal Stenosis Degenerated joints (―bone spurs‖), herniated disc, and thickening of the ligaments Can present as neurogenic claudication Most common in 5th decade of life Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  31. 31. Failed BackSurgery Syndrome Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  32. 32. Possible Causes of FBSS Continued degenerative process from the altered surgical anatomy Surgical nerve trauma Traction on neural elements from scar tissue Persistent pain secondary to central sensitization Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  33. 33. Musculoskeletal Causes of Low Back Pain Facet joints Sacroiliac joints Myofascial Pain Syndrome (MFPS) Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  34. 34. Lumbar FacetsSoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  35. 35. Facet JointsSoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  36. 36. Facet JointsSoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  37. 37. Lumbar FacetReferral Patterns Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  38. 38. Sacroiliac Joint  Where the back meets the pelvis/hip  Pain related to arthritis or malrotation of the joint  25% of low back painSoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  39. 39. Sacroiliac JointSoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  40. 40. Myofascial Pain Syndrome  Referred pain  Repetitive use  ―Knotted muscle‖Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  41. 41. Piriformis SyndromeSoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  42. 42. Treatments Conservative Advanced Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  43. 43. Treatment Continuum Advanced Pain Second-Tier Therapies Pain Therapies Neurostimulation Implantable First-Tier Pain Drug Pumps Opioids Surgical Intervention Therapies Neurolysis Neuromodulation Thermal Procedures NSAIDs Diagnosis TENS Psychological Rx Nerve Blocks Physical Rx OTC pain meds Chronic Pain Treatment ContinuumSource: Implantable Technologies: Spinal Cord Stimulation and Implantable Drug Delivery Systems, Elliot Krames, MD, Southeast Anesthesiology Consultants, PA - Southeast Pain CarePacific Pain Treatment Center, SF, www.painconnection.org
  44. 44. Conservative Physical therapy, Aqua therapy, Joint Mobilization, TENS unit Patient Education/Ergonomics Pharmacologic  NSAIDs  Muscle relaxants  Opioids Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  45. 45. Advanced: Interventional TherapyBlocks and Injections Epidural steroid injections Nerve root blocks Facet injections Sacroiliac joint injections Trigger point injections Spinal Cord Stimulation Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  46. 46. Epidural Steroid InjectionsSoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  47. 47. Epidural Steroid InjectionSoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  48. 48. Epidural Steroid Injections Series of ―3‖, three to four weeks apart Combination of local anesthetic and steroid Most effective for radicular pain Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  49. 49. Facet Joint InjectionsSoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  50. 50. Advanced TreatmentsRadiofrequency Ablation Radiofrequency is a minimally invasive procedure. A small radiofrequency current will travel through the electrode into the surrounding tissue, causing the tissue to heat and eliminate the pain pathways. Results usually last 6-9 months. Patient should be able to resume normal activities, including work, as soon as they feel able. Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  51. 51. Radiofrequency Ablation  Multiple nerves to each joint  Most common facet joints are L4/5 and L5/S1Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  52. 52. Radiofrequency AblationSoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  53. 53. Sacroiliac Joint InjectionSoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  54. 54. Trigger Point Injections  Best relief with combination of stretching exercises and heat therapy  Usually secondary, need to identify causeSoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  55. 55. Spinal Cord StimulationSoutheast Anesthesiology Consultants, PA - Southeast Pain Care
  56. 56. Advanced TreatmentsSpinal Cord Stimulation Stimulators use low voltage electrical signals to prevent messages of pain from reaching the brain. Instead of pain, patients feel a tingling sensation. Spinal cord stimulation is non- addictive, allowing patients to control their own therapy. Stimulators are very effective when a patient is suffering from neuropathic pain. Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  57. 57. Spinal Cord Stimulation Indications:  FBSS  Neuropathy of the extremity  Intractable low back and/or extremity pain  CRPS Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  58. 58. Spinal Cord Stimulation Gate theory Two phases process: trial and if successful then permanent Outpatient surgery Southeast Anesthesiology Consultants, PA - Southeast Pain Care
  59. 59. Questions???Southeast Anesthesiology Consultants, PA - Southeast Pain Care

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