Pain ManagementNew Concepts for a New Generation Solomon KAMSON, M.D., PhD.
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
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
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
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
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
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
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
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.