Low back pain neurologists perspectives


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Low back pain neurologists perspectives

  1. 1. Low Back PainNeurologist’s perspectives Dr.A.V.Srinivasan
  2. 2.  Back pain is a common cause of referral to the neurology clinic Pain experience is the result of a multitude of processes, whereof the sensory input is one, that interact in a proposed neural network, the neuromatrix. Progress in Neurobiology August 2001; 64 (6): 613-637 Best Practice & Research Clinical Rheumatology Vol. 21, No. 1, pp. 153e166, 2007
  3. 3. Low Back Pain is more common
  4. 4. Prevalence of chronic painBest Practice & Research Clinical Rheumatology Vol. 21, No. 1, pp. 153e166, 2007
  5. 5. Best Practice & Research Clinical Rheumatology Vol. 20, No. 4, pp. 707-720, 2006
  6. 6. Differential diagnosis of low back pain Am Fam Physician 2007;75:1181-8, 1190-2
  7. 7.  The lumbar disc herniation is the most frequent disease of the spinal degenerative processes, and they cause of 30% to 80% of the low back pain cases Medicina (Kaunas) 2007; 43(8)
  8. 8. Cauda equina syndrome Single or double-level compression of the lumbosacral nerve roots located in the dural sac results in a polyradicular symptomatology clinically diagnosed as cauda equina syndrome. The cauda equina nerve roots provide the sensory and motor innervation of most of the lower extremities, the pelvic floor and the sphincters. Therefore, in a fully developed cauda equina syndrome, multiple signs of sensory disorders may appear such as low-back pain, saddle anesthesia, bilateral sciatica, then motor weakness of the lower extremities or chronic paraplegia and, bladder dysfunction. Progress in Neurobiology August 2001; 64 (6): 613-637
  9. 9. CES - Etiology Non-neoplastic compressive etiologies  Herniated lumbosacral discs  Spinal stenosis  Spinal neoplasms Non-compressive etiologies  Ischemic insults  Inflammatory conditions  Spinal arachnoiditis  Other infectious etiologies.Orendacavo J et al. Progress in Neurobiology August 2001; 64 (6): 613-637
  10. 10. Failed Back Syndrome • Failed back syndrome (FBS) is a well- recognized complication of surgery of the lumbar spine. It can result in chronic pain and disability, often with disastrous emotional and financial consequences to the patient. • "spinal cripples" Onesti ST. Failed back syndrome. Neurologist 2004 Sep; 10(5): 259-64.
  11. 11. Consequences of Untreated & Under treated Acute Pain Extensive and Persistent cascade ofneurochemical mediators triggered by tissue injury leads to a long-term, permanent, neurological change that can lead to SENSITIZATION ALLODYNIA HYPERALGESIA MAY evolve into chronic pain
  12. 12. Progression of Acute Pain toChronic Pain Chronic pain appears Because of an expression of the presence of Central Sensitization
  13. 13. SensitizationSensitization is a phenomenon ofinappropriate or disproportionate response to normal stimulus
  14. 14. Types of Sensitization Peripheral & Central
  15. 15. Peripheral Sensitization Occurs at the site of injury Primary afferent neurons are involved Exposure to prostaglandinsIncreased pain sensation at the site of injury
  16. 16. Central Sensitization Increased excitability of pain neurons (nociceptor neurons) in the dorsal horn of the spinal cord. Neurons detecting and transmitting pain display ‘plasticity’ • progressive increase in the response to repeated painful stimuli • all contribute to altered sensitivity to pain
  17. 17. Clinical Implications of Central Sensitization Increased response to a noxious stimulus (Hyperalgesia) Disproportionate response to pain syimulus (Allodynia) Prolonged / Persistent pain Referred pain
  18. 18. Central sensitization in low back pain In back pain patients, both hypoalgesia and hyperalgesia to electrical cutaneous stimulation is reported (Wilder-Smith et al., 2002). Hyperalgesia to pressure on the thumbnail was found in idiopathic chronic low-back pain patients compared to controls indicating generalized hyperalgesia (Giesecke et al., 2004). European Journal of Pain 11 (2007) 415–420
  19. 19. The distribution of experimental pain in controls and chronic low back patientsevoked by injection of hypertonic saline in infraspinatus and tibialis anteriormuscles. The evoked pain areas were significantly larger in the patients for bothmuscles. Dark shading indicates overlapping pain areas among subjects. European Journal of Pain 11 (2007) 415–420
  20. 20. Central Sensitization & Tramadol
  21. 21. Why Tramadol is SuperiorIn patients with Central Sensitization
  22. 22. TramadolAn Atypical Centrally Acting Analgesic 5HT uptake inhibition NA m-agonist uptake inhibtion
  23. 23. Role of Tramadol  Tramadol • Centrally acting opioid analgesic, binds to µ opioid receptors • Inhibits reuptake of NE and serotonin within pain pathways of CNS • Contribute to enhancing the descending pain inhibitory pathways
  24. 24. Role of Tramadol Down regulation of central sensitisation hence an ideal drug for Neuropathic pain “Enhances” descending inhibitory pathways Excellent Analgesic Efficacy Tolerated well even in very high dosages
  25. 25. Tramadol Most Logical Choice for a variety of Chronic Pain Conditions where central sensitisation plays a major role:Our experience in INDIA : OA /RA Flare Pain Neuropathic Pain Acute Radicular Back Pain Chronic Back Pain Fibromyalgia Pain Cancer Pain
  26. 26. Tramadol – Central Sensitization Inhibits reuptake of Binds to Mu opiods Serotonin and NE Mimicks the effects More in qty at the Enkephalins synapse Reduce the effects of Reduce the effects of Sub P Sub P Reduce the intensity of Reduce the intensity of the pain the pain Pain relief Pain relief Enhances descending inhibition
  27. 27. Best Practice & Research Clinical Rheumatology Vol. 19, No. 4, pp. 609–621, 2005
  28. 28. Best Practice & Research Clinical Rheumatology Vol. 19, No. 4, pp. 609–621, 2005
  29. 29. Treatment choice Should be evidence based and tailored as much as possible to suit the individual patient. Acetaminophen (paracetamol), mild opioids and NSAIDs are the first-line drugs for low back pain but there is no evidence that one is more effective than the others. Tramadol is proposed to be the better choice due to its pharmacological profile and effect on pain in several musculoskeletal disorders. Non-benzodiazepine muscle relaxants (with or without pain medication) could be considered as second-line drugs in acute low back pain, and cyclic antidepressants in chronic low back pain. Strong opioids could be considered in musculoskeletal pain when other treatment options have failed Best Practice & Research Clinical Rheumatology Vol. 21, No. 1, pp. 153-166, 2007 Best Practice & Research Clinical Rheumatology Vol. 19, No. 4, pp. 609–621, 2005
  30. 30. Symptoms to be used to tailor choice of treatmentBest Practice & Research Clinical Rheumatology Vol. 19, No. 4, pp. 609–621, 2005
  31. 31.  The benefits of medication in low back pain will increase if:  Medication is prescribed only for severe symptoms  The choice of medication is targeted on the main symptom  Patients understand the aim of the medication and how long it should be used before evaluation can take place  Medication should be taken on a time-contingent basis; this facilitates evaluation  Evaluation is based on the aim  The type of drug has been tailored on individual basis  The dose has been tailored on individual basis. Best Practice & Research Clinical Rheumatology Vol. 19, No. 4, pp. 609–621, 2005