Anesco Interventional Pain Institute

© 2012 HP-Anesco Interventional Pain Institute

Anesco Interventional Pain Institute

Treatment Regimens for Acute and Chronic Pain Patients: How to Progress All Injured Workers to

Working Status


What is Acute Pain?

• Physiologic response to tissue damage

• Warning signals damage/danger

• Helps locate problem source

• Has biologic value as a symptom

• Responds to traditional medical model

• Life temporarily disrupted (self limiting)


What is Chronic Pain?

• Chronic pain is persistent or recurrent pain, lasting beyond the usual course of acute illness or injury, or more than 3 - 6 months, and adversely affecting the patient’s well-being

• Pain that continues when it should not


What is Chronic Pain?

• Difficult to diagnose & perplexing to treat

• Subjective personal experience

• Cannot be measured except by behavior

• May originate from a physical source but slowly it “out-shouts” and becomes the disease

• It has no biologic value as a symptom

• Life permanently disrupted (relentless)


Mixed TypeCaused by a

combination of both primary injury and secondary effects

Nociceptive vs Neuropathic PainNociceptive

PainCaused by activity in neural pathways in

response to potentially tissue-damaging

stimuli

Neuropathic

PainInitiated or caused by

primary lesion or dysfunction in the nervous system

Postoperativepain

Mechanicallow back pain

Sickle cellcrisis

ArthritisPostherpeti

cneuralgia

Neuropathic low back pain

CRPS*

Sports/exerciseinjuries

*Complex regional pain syndrome

Central post-stroke pain

Trigeminalneuralgia

Distalpolyneuropathy (eg, diabetic, HIV)


Possible Descriptions of Neuropathic Pain• Sensations

• numbness

• tingling

• burning

• paresthetic

• lancinating

• electriclike

• shooting

• deep, dull, bonelike ache

• Signs/Symptoms

• allodynia: pain from a stimulus that does not normally evoke pain

• thermal

• mechanical

• hyperalgesia: exaggerated response to a normally painful stimulus


Primary Goals

Relieve symptoms

Restore function

Return to work

Minimize disability


Treatment options

Medications

Interventional Procedure

Rehabilitation

Surgical intervention


Medications

Ease for patient

Symptom management

Cost of treating complications

Decreased productivity


NSAID

Reduce synthesis of PGs

COX inhibitors (cyclooxygenase)

Diminish nociceptor activation

Block peripheral sensitization

Antipyretic

Anti-hyperalgesic

No sedation

Examples: Advil, Aleve, *Celebrex


Side effects

Gastrointestinal ulceration

Renal dysfunction

Embryotoxic

Prolonged bleeding

PPI/H2 blockers for prevention

•Ex: Nexium, Prilosec, Zantac


Muscle relaxants

Used to alleviate muscle spasms

Example: carisoprodol, cyclobenzaprine, and methocarbamol

Mechanism

• Not entirely known, GABA agonist, Ca channel

Centrally acting causing sedation, anticholinergic side effects

Dependence


OPIOIDS

Spinal cord

•Decreasing neurotransmitter release

•Blocking postsynaptic receptors

•Activating inhibitory pathways

Receptor subtypes

•mu> delta> kappa

Supraspinal analgesia

Examples: Morphine, Fentanyl, Burprenorphine


Side effects

respiratory depression, severe bradycardia, decreased gastric motility, drowsiness, memory loss, impaired judgement

Addiction

Physiologic dependence


Steroid Injections

• Steroids decrease inflammation (phospholipase A2) and swelling around the compressed or inflamed nerve around the dural sac

• Local anesthetics “break the pain cycle” while steroid decreases inflammation

• Volume of injected solution may “wash away” local inflammatory mediators or loosen adhesions


Side effects

Complication rate < 1% Safriel. Appl Radiol 2010;39 14-23

• Temporary blood sugar elevation

• Cartilage damage

• Adrenal gland suppression

• Infection – with sterile technique an infection occurs much less than 1%

• Intravascular injection – embolism rare



Interlaminer Epidural Injection

Between spinous process

• In the past these were done without x-rays

• The steroid injection placed right over the dural sac

• Far from area of nerve compression

• May be effective with broad based disc bulges


Transforaminal Epidural Injections

• More popular over the last decade.

• Steroid medication placed closer to the area of nerve root compression.


Transforaminal Epidural Injections


Effectiveness of Transforaminal Epidural Injections

• Transforaminal approach may be more effective due to deposition of steroid in anterior epidural space Ackerman et al. Anesth Analg 2007;104:1217-22

• Location of transforaminal injection at the level of the disc herniation (preganglionic) may be more effective than at site of exiting nerve root Jeong et al. Radiology 2007; 245:584-90.

• 75% patients with low-grade nerve compression respond favorably compared to 26% with high grade disc related nerve compression Ghahremann and Bogduk. Pain Med 2011;12:871-79


Frequency of Epidural Injections

• Historically 3 injections over 4-6 weeks• Incorrect needle placement 30-40% without

fluoroscopy• Augmentation of pain relieving effects

• Recent trends • Use of fluoroscopy confirms accuracy• Additional injections provided on the basis of patients

response to prior injections Manchkanti et al. Spine

2011;36:1897-1905Safriel Y. Appl Radiol 2010;39:14-23

• In the face of increasing pain levels • Transforaminal injections/ catheter techniques


Epidural Injections vs. Surgery

• Decreased Operative rates• 55 patients with 6 weeks of conservative treatment• “Surgical Candidates”

• Group 1 – epidural with LA + steroids. 23% had surgery

• Group 2 – epidural with LA only. 67 % had surgery Riew etal. J Bone Joint Surg Am 2000;82A:1589-93

• 5 year follow-up – 81% did not opt for surgery Riew etal. J Bone Joint Surg Am

2006;88:1722-5

• Cost savings Karppinen et al. Spine 2001;26-2587-2595



Facet Pain - Interventional Treatment

Facet Joint Steroid Injection

• Effective and minimally invasive

• Fluoroscopy

• May be effective for weeks to months



Facet Pain - Interventional Treatment

Median nerve branch blocks

• Small medial or lateral nerves travel into the spine

• Do not effect muscles or sensation in arms or legs

• Identifies and confirms the pain source

• 50 -80% improvement during the first 6 to 12 hoursCohen et al. Spine J 2008;8:498-504

• Radiofrequency Neurotomy• 30-50% of patients have long term relief

• Patient selection critical for success van Kleef et al. Spine, 1999;24:1937-1942.


Lumbar Spine Cervical Spine

Radiofrequency Neurotomy


Sacroiliac Joint Pain

• Inflammation of one or both of the sacroiliac joints

• Mechanical dysfunction – dull low unilateral back pain

• Pain in region of posterior superior iliac spine (PSIS)• Aggravated by standing up from a seated position

• Lifting the knee towards the chest during stair climbing

• Increases with prolonged sitting or walking

• Referred into hip, groin, buttock and back of the thigh

• Occasionally down the leg but rarely to the foot

• Provocative tests - inconclusive


Sacroiliac Joint Pain

Treatment• Conservative

• Stretching exercises (e.g., knee to chest)• Anti inflammatory medication

• Sacroiliac Joint injection• Fluoroscopy• 75% reduction in pain• May require multiple injections

Günaydin et al. Rheumatol Int 2006;26:396-400

• Radiofrequency NeurotomyMuhlner MB. Curr Rev Musculosket Med 2009;2:10-

4.

Vallejo et al. Pain Med 2006;7:429-34


Sacroliliac Pain


Physical Therapy

Hands-on care can motivate and push patients

Relief of symptoms

Restoration of function

No side effect or addiction


Limitations

Limited care per week ( 3hr)

Cannot manage pain outside of therapy facility

Tendency for patient to resume pharmacologic therapy for pain treatment

Cost


Psychological Pain Control

Biofeedback – provides biophysiological feedback to patient about some bodily process the patient is unaware of (e.g., forehead muscle tension).

Relaxation – systematic relaxation of the large muscle groups.

Acupuncture

• Counter-irritation – may close the spinal gating mechanism in pain perception.

• Expectancy

• Reduced anxiety from belief that it will work.

• Distraction

• Trigger release of endorphins


Role of the pain physician at ANESCO

Communication with Case Managers/Adjusters

Minimize use and dependency on medication

Improve outcomes through early intervention

Physical therapy

Encourage return to work

Minimize cost to insurer and employer


Thank you

Documents

Anesco Interventional Pain Institute