Pain Management

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Pain Management

  1. 1. Pain ManagementNew Concepts for a New Generation Solomon KAMSON, M.D., PhD.
  2. 2. 70-80% of the U.S. populationeventually experiences back-pain* only 15% of back-pain patients have adefinitive diagnosis* many patients carry a diagnosis ofchronic sprain or strain Von Korff M, Saunders K The course of back Pain inprimary care. Spine 21:2833-9,1996Wahlgren DR et al. One year follow up of first onset lowback pain. Pain 73:213-221,1997
  3. 3. Epidemiology• 70-80% of the U.S. population eventually experiences back-pain• Only 15% of back-pain patients have a definitive diagnosis• Many patients carry a diagnosis of chronic sprain or strain Von Korff M, Saunders K The course of back Pain in primary care. Spine 21:2833-9,1996 Wahlgren DR et al. One year follow up of first onset low back pain. Pain 73:213-221,1997
  4. 4. Why is Specific Diagnosis Elusive?Low back Pain Spine Pain• Initial short term recovery • Clinical examination is often 70-80% non-focal• At one year follow up 25-48% • Imaging studies often may not will report recurrence correlate with clinical pain syndromes• 13-15% will have moderate to severe chronic pain • Red flag conditions are usually evident by history and clinical examination such as acuteVon Korff M, Saunders K The course of back Pain in primary care. Spine 21:2833-9,1996 neurological deficit requireWahlgren DR et al. One year follow up of first onset low immediate medical attention back pain. Pain 73:213-221,1997
  5. 5. BACK PAIN   RADICULAR NON-RADICULAR 5 - 15% 85 - 95%  NEURAL IRRITATION PAIN WITHOUT NERVEOR COMPRESSION COMPRESSIONDisc Herniation Internal Disc Disruption (>39%)Canal / Recess Stenosis Facets (15%)Osteophytes SI Joints (12%)Spondylolisthesis Soft TissueTumors Fractures / MechanicalExtra-spinal causes
  6. 6. Spine Pain Without Neurologic Signs or Symptoms SOURCE Definitive Diagnosis Appropriate Therapy
  7. 7. Innervation of the Lumbar Spine • Sino-vertebral nerve • Median branch nerve • Dorsal root ganglion
  8. 8. INJECTION TECHNIQUE• Selective nerve root injection with fluoroscopic guidance
  9. 9. Lateral Recess Stenosis
  10. 10. SYNOVIAL CYST
  11. 11. SYNOVIAL CYST
  12. 12. Prevalence of Spinal Pain• Lumbar facet joint pain: 15-40%• Lumbar disc pain: 39% >66%• Sacroiliac joint pain: 12%• Cervical facet joint pain: 54% (s/p whiplash)• Cervical disc pain: ?
  13. 13. Degenerative Facet CascadeFacet degeneration Facet dysfunction Synovitis Cartilaginous destruction Capsular Instability Degenerative Subluxation Facet HypertrophySpondylolysis Spondylolisthesis Spinal Stenosis
  14. 14. Facet Referred Pain Gluteal Trochanteric Proximal thigh Groin Lumbar Considerable overlap Fukui s, Ohseto K, Shiotani M, Ohno K, Karasawa H, Naganuma Y. Distribution of referred pain from lumbar zygapophyseal joints and dorsal rami. Clin J Pain 13:303-307,1997
  15. 15. Facet Injections• Utility Mainly diagnostic Rarely therapeutic• Technique Intra-articular Medial Branch Block
  16. 16. Diagnosing Facet Syndrome Neither clinical examination nor imaging is reliable for diagnosis of facet syndrome •Diagnostic Injections is gold standardSchwarzer A, Derby R, Aprill CN et al. Pain from lumbar zygapophyseal joints. A test oftwo models J Spine Dis 7:331-8:1994
  17. 17. Sacro-iliac Joint Pain Syndrome
  18. 18. SI Joint Arthrogram
  19. 19. Posterior Epidural Space
  20. 20. Cervical Facet Pain Referral Patterns
  21. 21. Cervical Pain: Facets • Stimulation of zygapophyseal joints causes pain in normal volunteers • In patients with neck pain produces relief with anesthetizing joints Dwyer et al Spine 15:453-457,1990 Bogduk Spine 7:319-330,1982 Wedel & Wilson. Reg Anesth 10:7-11,1985 Dussault & Nicolet. J Can Assoc Radiol 36:79-80,1985
  22. 22. Cervical Facet Innervation
  23. 23. Facet Injections• Radio frequency ablation medial branch provides most definitive treatmentDryfuss P, Holbrook B, Pauza K, Joshi A, McLarty J, Bogduk N. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine 25:1270-7,2000Lord SM, Barnsley L, Wallis BJ and Bogduk N. A randomized double blinded controlled trial of percutaneous radiofrequency neurotomy for the treatment of chronic cervical zygapophysial joint pain. N Engl J Med 335:1721-1726,1996
  24. 24. Cervical Medial Branch Rhizotomy
  25. 25. Upper Thoracic and Cervical • C7-T2 Facet Pain
  26. 26. INTERVERTEBRAL DISC
  27. 27. INNERVATION OF THE DISC
  28. 28. INNERVATION OF THE DISC
  29. 29. Nucleus pulposis• 70-90% H2O• 65% proteoglycans• 15-20% type 2 collagen• non-collagenous proteins• cartilage cells• enzymes
  30. 30. ANNULUS FIBROSIS• 60-70% H2O• 50-60% type 1 collagen• 15-20% proteoglycans• 10% elastic fibers• chondrocytes• fibroblasts
  31. 31. I.D.D. = AXIAL BACK PAIN• THEORETICALLY A CONSTANT DEEP ACHING PAIN IS PRESENT SECONDARY TO CHEMICAL NOCICEPTION THAT IS AGGRAVATED BY ANY MOVEMENT THAT MECHANICALLY STRESSES THE AFFECTED DISC• HIP PAIN, THIGH PAIN, GROIN PAIN
  32. 32. DIAGNOSING I.D.D.• History• physical exam• imaging studies• DIAGNOSTIC DISCOGRAPHY
  33. 33. HIGH INTENSITY ZONE High Intensity Zone
  34. 34. DIAGNOSTIC DISCOGRAPHY• The role of diagnostic discography is to identify a pathological and painful disc and distinguish it from a disc that is not painful.• Diagnostic discography provides information about the structure and sensitivity of discs that can not be obtained from any other source.• It is a highly reliable and specific dx. test when performed correctly.
  35. 35. DIAGNOSTICDISCOGRAPHY
  36. 36. DIAGNOSTICDISCOGRAPHY
  37. 37. Lytic Isthmic Spondylolisthesis
  38. 38. Principles Of Co-Management1. Communication • Visit, phone, write DIRECTLY!2. Graduated (incremental) Progression • Pain Management to Minimally Invasive Surgery• Rehabilitation Reconditioning and Prevention

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