Gingerich back pain presentation (sept. 2012)

Southeast Anesthesiology Consultants, PA - Southeast Pain Care

Common Causes and Treatments for

Chronic Low Back Pain

Troy C. Gingerich, MDSoutheast Anesthesiology Pain

Consultant

Southeast Anesthesiology Consultants, PA - Southeast Pain Care

Pain Management

Pain Management is a medical specialty that focuses on finding and treating the source of your pain and pain symptoms

Southeast Anesthesiology Consultants, PA - Southeast Pain Care

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

Our Approach Our overall approach to pain management can beviewed as a four-pronged approach that may include one or more of the following components.

Interventional techniquesMedication managementRehabilitationCounseling

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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)

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Acute vs ChronicAcute vs Chronic Acute - Pain during healing/repair of tissues

Chronic - Pain present beyond healing and repair of tissues or that lasts beyond 3 months

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

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%

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Timely Treatment

Prompt treatment of pain is vital. The sooner pain is managed

the more likely patients are to return to normal daily living activities

94%

19%

2%

0% 20% 40% 60% 80% 100%Le

ngth

of T

ime

Off

Wor

k

Percentage Returning to Work

<90 days >90 days <2 yrs

J. McGill, J. Occupational Medicine, 1968

Southeast Anesthesiology Consultants, PA - Southeast Pain Care

Timely Treatment

Anyone 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

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 duration

Stewart et al, Work-related cost of pain in the US, IASP/10th World Congress on Pain 2002, as citedby Dr. John Stamatos, Medscape.com.

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Pain StatisticsPain 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 AssociationCancer – 1.4 million people, American Cancer Society

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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

Southeast Anesthesiology Consultants, PA - Southeast Pain Care

Comprehensive Exam

History Physical Examination Psychosocial Evaluation Impression/Differential Diagnosis Diagnostic Evaluation Treatment Plan

Southeast Anesthesiology Consultants, PA - Southeast Pain Care

Low Back Pain

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Chronic Low Back Pain Risk Factors Age Fitness Level Diet Occupational Smoking Obesity

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Common Causes

Malignant

Benign

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Malignant

CancerPrimary—multiple myelomaMetastatic—prostate, breast, liver

InfectiousDiscitis, Osteomyelitis, Epidural abscess

Spinal Cord CompressionCauda Equina Syndrome, Conus Medullaris Syndrome

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Benign Radicular (Sciatic)

Herniated DiscSpinal StenosisFailed Back Surgery Syndrome

Musculoskeletal (Axial)Facet jointsSacroiliac jointMyofascial Pain Syndrome

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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

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Anatomy

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Anatomy

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Anatomy

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Radicular Causes of Chronic Low Back Pain

Herniated disc Spinal stenosis Failed back surgery syndrome (FBSS)

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Herniated Disc

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Herniated Disc

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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

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Spinal Stenosis

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Spinal Stenosis

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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

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Failed Back Surgery Syndrome

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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

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Musculoskeletal Causes of Low Back

Pain

Facet joints Sacroiliac joints Myofascial Pain Syndrome (MFPS)

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Lumbar Facets

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Facet Joints

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Facet Joints

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Lumbar Facet Referral Patterns

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Sacroiliac Joint

Where the back meets the pelvis/hip

Pain related to arthritis or malrotation of the joint

25% of low back pain

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Sacroiliac Joint

Southeast Anesthesiology Consultants, PA - Southeast Pain Care

Myofascial Pain Syndrome

Referred pain Repetitive use “Knotted muscle”

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Piriformis Syndrome

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Treatments

Conservative

Advanced

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Treatment Continuum

Diagnosis

First-Tier Pain Therapies

Second-Tier Pain Therapies

Advanced Pain Therapies

Chronic Pain Treatment Continuum

NSAIDsTENSPsychological RxNerve Blocks

Physical RxOTC pain meds

OpioidsNeurolysisThermal Procedures

NeurostimulationImplantable Drug PumpsSurgical InterventionNeuromodulation

Source: Implantable Technologies: Spinal Cord Stimulation and Implantable Drug Delivery Systems, Elliot Krames, MD, Pacific Pain Treatment Center, SF, www.painconnection.org

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Conservative Physical therapy, Aqua therapy, Joint Mobilization,

TENS unit Patient Education/Ergonomics Pharmacologic

NSAIDs Muscle relaxants Opioids

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Advanced: Interventional

TherapyBlocks and Injections Epidural steroid injections Nerve root blocks Facet injections Sacroiliac joint injections Trigger point injections Spinal Cord Stimulation

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Epidural Steroid Injections

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Epidural Steroid Injection

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Epidural Steroid Injections

Series of “3”, three to four weeks apart Combination of local anesthetic and steroid Most effective for radicular pain

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Facet Joint Injections

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Advanced Treatments

Radiofrequency 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

Radiofrequency Ablation

Multiple nerves to each joint Most common facet joints are

L4/5 and L5/S1

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Radiofrequency Ablation

Southeast Anesthesiology Consultants, PA - Southeast Pain Care

Sacroiliac Joint Injection

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Trigger Point Injections

Best relief with combination of stretching exercises and heat therapy

Usually secondary, need to identify cause

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Spinal Cord Stimulation

Southeast Anesthesiology Consultants, PA - Southeast Pain Care

Advanced Treatments

Spinal 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.

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Spinal Cord Stimulation

Indications: FBSS Neuropathy of the extremity Intractable low back and/or extremity pain CRPS

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Spinal Cord Stimulation

Gate theory Two phases process: trial and if successful then

permanent Outpatient surgery

Southeast Anesthesiology Consultants, PA - Southeast Pain Care

Questions???