Dr Jonathan Kuttner Dr Keith Laubscher Dr Ian Wallbridge North/Thur_Room4_0830-Pain 101 Rotorua June 2018.pdf · • IS, FMS, OA, “LP”, “WAD” Central sensitisation: A physiological

Dr Jonathan KuttnerMusculoskeletal & Pain Specialist

Auckland

14:00 - 16:00 WS #18: Musculoskeletal Medicine 3

Dr Keith LaubscherPain Specialist

Auckland

Dr Ian WallbridgeMusculoskeletal Physician

Rotorua

Practical Pain Management- Interventional for Lumbar and Cervical Spinal Pain

Keith LaubscherAuckland 2018

Dr Keith Laubscher FAFMM FFPMANZCA PainCare

Outline

1 Why treat pain? - Pain as a disease

2 Principles: General consideration for IPM

Pain management -general

3 Interventions

- Cervical somatic

- Lumbar somatic

- Lumbar radicular pain

- Cervical radicular

- CRPS


Why treat pain

Chronic pain prevalence: -New Zealand 16.9% (lasted or expected to last 6 months or more) (Bligh F et al. NZMJ 2011: 124; 1337; 63-76)

Pain related suffering, disability and economic cost to society may be more important than the underlying aetiology

Fine PG. Pain Medicine 2011; 12: 996–1004


Pain as a disease: Consequences

• Distress – anxiety, depression

• Disability

• Destitute

• Drugged:

• Dementia – cognitive impairment

• Death


“Thus, it is important to effectively manage pain in its early stages before it progresses to further affect patients’ function.”

Fine, Perry G. "Long‐Term Consequences of Chronic Pain: Mounting Evidence for Pain as a Neurological Disease and Parallels with Other Chronic Disease States." Pain medicine 12, no. 7 (2011): 996-1004

“it is axiomatic that pain can be safely treated as a symptom only when the underlying cause is known and when all treatment directed towards this has been completed”

The Pain Clinic: A clinic for the management of intractable pain: McEwen B, de Wilde F, Dwyer B: MJA : 8thMay 1965: 1: 676-682


General considerations in interventional pain management

1 Clinical diagnosis (and red flags)

2 Pain duration: acute vs chronic

3 Type of pain: “mechanistic pain classification”(Central sensitisation vs Chronic pain)

4 Treatment options: Individualized management(Psycho-physical; Pharmacological; Interventional; Surgery)


Considerations IPM 1

Clinical diagnosis


Considerations IPM 2Pain duration

-Pain duration – terminology

-Treatment for acute and chronic pain will differ


Acute 0 to 6 weeks

Subacute6 to 12 weeks

Chronic> 12 weeks

Considerations IPM 3Mechanistic classification of pain

• Nociceptive – somatic, somatic referred, visceral

• Neuropathic (nerve damage)

– Peripheral eg radicular

– Central eg cauda equina, myelopathy

• Neuroplastic pain/Dysfunctional pain

(“Central sensitisation”/“Pain syndrome”/“Pain disorder” (????)

• Mixed

So what about?

• Myofascial pain = pain, tender/trigger points, referral, ROM, weakness


Considerations IPM 3aNeuroplastic pain, pain syndromes, sensitisation and chronic pain

Mismatch conundrum

Pain vs pathology and “pain syndromes”

• IBS, FMS, OA, “CLBP”, “WAD”

Central sensitisation: A physiological phenomenon and not a diagnosis(Any sensory experience greater in amplitude, duration and spatial extent than that would be expected from a defined peripheral input under normal circumstances qualifies as potentially reflecting a central amplification due to increased excitation or reduced inhibition. These changes could include a reduction in threshold, exaggerated response to a noxious stimulus, pain after the end of a stimulus, and a spread of sensitivity to normal tissue)C Woolf.Pain 152 (2011) S2-S15


Sensitization*Increased responsiveness of nociceptive neurons to their normal input, and/or recruitment of a response to normally subthreshold inputs.• …..neurophysiological term ; may only be inferred indirectly from

phenomena such as hyperalgesia or allodynia.

Central sensitization*Increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input.• include increased responsiveness due to dysfunction of endogenous

pain control systems.

Peripheral sensitization*Increased responsiveness and reduced threshold of nociceptive neurons in the periphery to the stimulation of their receptive fields.



Central Sensitisation- bedside recognition

• No agreed diagnostic criteria

Clinical features:• History -neurological descriptors

Examination - ↓ threshold, ↑ response, ↑extent ↑duration • Sensory: dynamic allodynia ; secondary punctate hyperalgesia or pressure

hyperalgesia; cold allodynia• Regional and remote hyperalgesia • Temporal summation and after sensations• (Non-dermatomal sensory deficits)

CS as a component of wider syndrome:• Multisystem sensitivities • Nonspecific symptoms: fatigue, sleep, cognitive difficulties

Experimental laboratory: not today


Differential diagnosis of widespread pain.

• Connective tissue: SLE, Sjogren’s syndrome

• Inflammatory:

• Malignancy: myeloma, leukaemia, paraneoplastic

• Neurological: multiple sclerosis, neuropathy

• Muscle: myelopathy,

• Endocrine/Metabolic : Hypo and hyperthyroid, Diabetes, Hyperparathyroid, Acromegaly

• Infection: Hepatitis B/ C, Lyme disease

• Drugs: statins, (opioids)


Treating the cause and central sensitisationRFN for Cervical zygapophysial joint pain

• 53 patients WAD grade 2

• Standardise measures pre and post RFN

• Improvements in pain, disability, local and widespread hyperalgesia , NFR threshold, and brachial plexus provocation test responses, and ROM (all P < 0.0001).

• Changes were early within 1 month, and sustained at 3 months

Smith, Ashley Dean, et al. "Cervical radiofrequency neurotomy reduces central hyperexcitability and improves neck movement in individuals with chronic whiplash." Pain Medicine 15.1 (2014): 128-141.


Sensitisation managementEffective treatment – when possible

• Kosek E, Ordeberg G. Abnormalities of somatosensory perception in patients with painful osteoarthritis normalize following successful treatment. Eur J Pain 2000;4(3):229–38

• Graven-Nielsen T, Wodehouse T, Langford RM, Arendt-Nielsen L, Kidd BL. Normalization of widespread hyperesthesia and facilitated spatial summation of deep-tissue pain in knee osteoarthritis patients after knee replacement. Arthritis Rheum 2012; 64(9):2907–16

• Aranda‐Villalobos, Pilar, et al. "Normalization of widespread pressure pain hypersensitivity after total hip replacement in patients with hip osteoarthritis is associated with clinical and functional improvements." Arthritis & Rheumatism65.5 (2013): 1262-1270.

• Seminowicz DA, Wideman TH, Naso L, et al. Effective treatment of chronic low back pain in humans reverses abnormal brain anatomy and function. J Neurosci 2011;31(20):7540–50.

Considerations IPM 4Individualized managementTreatment options (and tensions)


Management IPM5

Biopsychosocial approach

Clinical assessment-Diagnosis-Red flags, Neurology-Psychosocial factors

Investigations red flags or chronic

Management;• Explanation• Reassurance• Activation• Exercises• Analgesia

Review: (measurement of Pain VAS and function)Dr Keith Laubscher FAFMM FFPMANZCA PainCare

Pain management 1The Indahl Approach (Indahl, Spine, 1995)


Pain management 2


Pain management 3Medication


Pain management 4 Specific interventional approachesX-ray guided pain management procedures

• Targeted chemical or physical modality under x-ray eg LA +/- corticosteroid or heat

• Diagnostic and/or therapeutic value

• Patient awake

• Contrast to confirm correct placement

Examples:

• Epidural/Transforaminal injection

• Sacroiliac injection

• Facet joint injection

• Atlanto-axial joint

• Radiofrequency neurotomy


Pain management 4 Surgery



Acute Cervical Spinal Pain

Cervical spinal pain of uncertain aetiology, Sprain, Mechanical CSP, Non –specific CSP


Acute Cervical Spinal Pain

Cervical spinal pain of uncertain aetiology, Sprain, Mechanical CSP, Non –specific CSP

Assessment: • Red flags• Yellow flags

Management:

Conservative• BSP - “Indahl”• Physical therapy• Symptom relief; Adequate analgesia

incl opiate +-co-analgesics eg TCA, spasm

• Reassess

Refer - red flags

Refer specialist• If no improvement 6 weeks or

unrelieved pain– x-ray, “screening” bloods– MRI (?)

• Intervention= ESI (various routes)• Surgery


Vilfredo Pareto5 July 1848 – 19 August 1923)

Chronic Cervical Spinal PainEpidemiology: Incidence 15- 40%Clinical: Neck +/- shoulder 2/3, headache 1/3Common• Whiplash associated neck pain

(80% better at 12 months)• Cervical spinal pain of uncertain aetiology,

Sprain, Mechanical CSP, Non –specific CSP

Uncommon• Fracture, Tumour, Infection• Arthropathies - Spondylosis (80% age 50)• Aneurysms• Neurological • Referred visceral: anterior neck (oesophagus,

pharynx), angina; shoulder, headache disorder, systemic (eg FM)

• Neurological deficit myelopathy, radiculopathyDr Keith Laubscher FAFMM FFPMANZCA PainCare

Whiplash associated disorder - Diagram of injuries identified


Partial avulsions of discs from vertebral bodies, in extension

Facet haemarthroseswith # of C7

Bruising of vascular synovial folds

Haematoma around C2

Distraction injuries Compression injuries

Natural historyWhiplash

1:5 = 20%


Natural historyWhiplash

• 50% have ongoing pain and disability at 1 year

• No advantage from early multidisciplinary intervention

Sterling M. Physiotherapy management of whiplash-associated disorders (WAD). Journal of physiotherapy. 2014 Mar 31;60(1):5-12.

Jull G, Kenardy J, Hendrikz J, Cohen M, Sterling M. Management of acute whiplash: a randomized controlled trial of multidisciplinary stratified treatments. PAIN®. 2013 Sep 30;154(9):1798-806.


Chronic cervical painPrecision diagnosis

Specific pain sources

• Facet (Zygapophysial )joint -55%

• Discogenic pain -16%

• Lateral atlanto-axial joint -9%.

The nature of neck pain in a private pain clinic in the United States. Pain Med. 2008 Mar;9(2):196-203. Yin W, Bogduk N.


Cervical facet joint “pain maps”


Cervical facet joint – Intra-articular corticosteroid injection

• Maybe useful acute and failed medical mx

• Under fluoroscopy

• LA and corticosteroid

• Effectiveness:

– “Short term” benefit

– “improvement in pain and function” in 20% at 3 - 6 months


Lateral atlanto-axial jointIntra-articular joint injection (C1-2)

• Focal suboccipital pain • Headache• Dizziness, tinnitus,, visual sx

• Reduced rotation at C1-2


Lateral atlanto-axial jointIntra-articular joint injection injection (C1-2)

• Subacute

• ?role in chronic

• Difficult injection with risks

Effectiveness: (50% relief)

• 20 % more than 3 months

• 12 % more than 9 months


Cervical facet- joint: Diagnostic blocks


Cervical facet joint

• Facet joint single most common focus – axial pain

• Somatic /referred pain pattern

• No specific clinical or radiological feature

• Easily tested - controlled double blind local anaesthetic nerve block (MBB)


Facet joint Nerve blocks and radiofrequency neurotomy

PRECISION DIAGNOSIS

Diagnostic Nerve Block

Target specific under x-ray

Volume 0.3 ml – 0.5 ml

Spread limited

Controlled: double blind comparative local anaesthetic or placebo controlled

Sensitivity 54; Specificity 88

Reliable 85% (ie 15 % positive also respond to placebo


Lumbar - facet jointPrecision diagnosis


L5S1 Lignocaine

L4-5,L5S1 Bupiviccaine

Cervical radiofrequency neurotomy

Technical

• Heating course of nerve to joint

• Under fluoroscopy

• Local anaesthetic

• Specific electrode

• 80 -850 C 2 – 6 lesions 90 sec each

• 1-2 hours


Cervical RFNEffectiveness

104 patients, 5 -300 monthsPositive MBB

Result 68% patients achieved a successful outcome.Relief median 20-26 months, 60% still relief at follow-up.

Successful: Complete relief > 6 months, Complete restoration of ADLNo need further health careReturn to work. Failed to meet any of these criteria = failed treatment.

MacVicar, J., Borowczyk, J. M., MacVicar, A. M., Loughnan, B. M., & Bogduk, N. (2012). Cervical medial branch radiofrequency neurotomy in New Zealand. Pain medicine, 13(5), 647-654.



Acute lumbar spinal pain

Acute lumbar spinal pain of uncertain aetiology, Sprain, Mechanical CSP, Non –specific CSP

• Common; mostly somatic • Variable course and recovery• Precise diagnosis often not

possible, nor needed• Serious causes are rare; excluded

with careful history & examination

Assessment: • Red flags• Yellow flags

Management: Conservative• BSP - Indahl• Physical therapy• Symptom relief; Adequate analgesia

+-co-analgesics eg TCA, spasm• Reassess

Refer - red flags

Refer specialist assessment:• If no improvement 4-6 weeks or

unrelieved pain– x-ray, “screening” bloods– MRI (?)



Chronic lumbosacral spinal pain “Chronic /persistent low back pain”

Was acute at one stage

At 12 months: 1/3 not fully recoveredHenschke BMJ 2008

At 12 months -75% not fully recovered-90% stopped consultingCroft BMJ 1998

Some 14% are highly disabled.Von Korff, 1993

2 month status predicts the 12 month statusKlennerman, 1995


Vilfredo Pareto5 July 1848 – 19 August 1923)

Chronic lumbosacral spinal pain “Chronic low back pain”

Epidemiology: Incidence 36 -72%Disabling in 10%

Common• Lumbar spinal pain of uncertain aetiology,

Mechanical LBP, Non –specific LBP

Uncommon• Fracture, Tumour, Infection• Arthropathy - Spondylosis (80% age 50)• Vascular• Neurological

• Referred visceral: Urogenital, AAA, GIT, Pancreas, systemic (eg FM)

• Neurological deficit cauda equina, radiculopathy


Chronic lumbosacral spinal pain ”Reductionist approach to management

Validated sources of CLBP:

intervertebral disc –• prevalence 40%

zygapophysial (facet) joint)10 -15% younger injured workers; 40% older non-injured population

Sacroiliac joints15 -20%


Sacroiliac joint

General comment

Complex joint

Nerve supply complex

- L4,5, S1, 2 dorsal rami + anterior

Prevalence 15% of LBP (anaestheticinjection)

Clinical

Somatic +/-referred pain

No typical clinical or radiological features

Laslett’s tests maybe useful :

Cluster 2/4 LR 4

Dx: Gold Std: joint injection

? placebo controlled



Sacroiliac joint injection - utility

Therapeutic efficacy50% relief in 60 % , 4 –6 weeks

Indication: Persistent sacroiliac region pain

Diagnostic:Medico-legalSurgical planning (positive + negative result useful)

New treatmentsPercutaneous radiofrequency neurotomy ?? More studies needed…….


Facet (Zygapophysial) Joint Pain

Incidence 15-40%

Clinical • Somatic +/- referred pain

• Considerable overlapping patterns

• No single specific feature on clinical examination,

• Revells tests -conflicting

• No specific features MRI, CT scan, Bone scan(?)

• Gold Std: nerve block


Lehman, American Journal of Neuroradiology 35.3 (2014)


Facet joint Intra-articular joint injection

Clinical efficacy:“improvement in pain and function” in 30-50%, at 3 months; 20 -50% at 6 monthsevidence is moderate for short- and long-term pain relief.

Indications: • Somatic subacute LBP • Pain despite medical

Technical factors • more difficult, time consuming• over-penetration• False + 32%• Effectiveness ?



• Nerve Supply



PRECISION DIAGNOSIS

Diagnostic Nerve Block

Target specific under x-ray

Volume 0.3 ml – 0.5 ml

Spread limited

Controlled: double blind comparative local anaesthetic or placebo controlled

Sensitivity 54; Specificity 88

Reliable 85% (ie 15 % positive also respond to placebo


Lumbar – facet joint Precision diagnosis

Indication:

• Persistent somatic lumbosacral pain (VAS > 4/10)

• Pain despite medical management

• Activity restriction

Utility

• Diagnostic

• Medicolegal

• (Surgical planning)

• Therapeutic RFN


block

needle

desirable electrode placement


Lateral view, L4 neurotomy, with electrode withdrawn. The tip of the electrode lies against the mid portion of the neck of the superior articular process.


Lumbar RFNEfficacy

109 patients, 5 -418 monthsPositive MBB

Result 56% patients achieved a successful outcome.Relief median 17–33 months, 70% still relief at follow-up.

Successful: Complete relief > 6 months, Complete restoration of ADLNo need further health careReturn to work. Failed to meet any of these criteria = failed treatment

MacVicar, J., Borowczyk, J. M., MacVicar, A. M., Loughnan, B. M., & Bogduk, N. (2013). Lumbar medial branch radiofrequency neurotomy in New Zealand. Pain Medicine, 14(5), 639-645.



Acute and persistent lumbar radicular pain/radiculopathy

Radicular pain = neuropathic pain stimulation of nerve root or ganglion.Maybe chemical and physical

Radiculopathy = Loss of function (sensory and/or motor)

Somatic pain may co-exist.

Cause: Disc lesion, Stenosis, Other

Natural history:Disc protrusion: - Most start to improve < 6weeks, - 50% resolve <12 weeks

Stenosis:-Variable Dr Keith Laubscher FAFMM FFPMANZCA PainCare

Natural history“Sciatica”


Lumbar radicular pain and radiculopathy

Assessment:Management: • Refer Red flags Cauda equina

=surgery

• Conservative• BSP • Symptom relief; Adequate analgesia

incl opiate +-co-analgesics eg TCA, Gabapentin

• Refer: specialist assessment• If no improvement 4-6 weeks or

earlier if unrelieved pain– x-ray, “screening” bloods– / MRI

• Intervention= ECI (various routes)• Surgery


Intervention for radicular painLumbar epidural corticosteroid injection

Indication:Radicular pain“Failed” medical

Route: (picture)• Caudal• Interlaminar• Transforaminal injection

Controversies in literature:• Studies variable (patient

selection, route, X-ray guided, corticosteroid, volume, control)

• Outcome - “Short term” ….…• What to inject• Injectate contamination


Lumbar epidural corticosteroid injection

Effectiveness:• TFIS > ILECI > Caudal

PIVD: • 60% patients - 50% relief 2 months, 40%

sustained 12 months• NNT 3• Restores function, reduces need for other

healthcare, reduces need for surgery• Cost effective

Spinal stenosis: • Limited data (acute –on-chronic)• 50% patients - 50% relief 6 months (or more)


Lumbar epidural corticosteroid injection


2 4 6 8 2 4 6 8 10 12 16 18 20 22 24

Acute and persistent cervical radicular pain and radiculopathy

Incidence: 80/100 000

Cause: Disc protrusion, spondylosis or combination

Pathophysiology: compression, inflammation, central changes.

Clinical: Pain sharp, shooting, • paraesthesia > sensory, reflex, motor • C7 and C6 most common• 90% improve 5 year without surgery

(less favourable at tertiary centre)

Risk for chronicity• Pain severity• Radicular symptoms or signs• No association with radiographic change


Acute and persistent cervical radicular pain and radiculopathy

MyelopathyPressure on spinal cord

Incidence: not known

Clinical: Acute or insidious• Vague and variable• Clumsiness weakness stiffness, Gait and balance• Bladder Bowel eg Urinary urge frequency• Lhermitte Sign, Grip test and release test:.

Inverted radial reflex. Sustained clonus , Hoffmann's sign:

Management: Refer for surgical assessment• 80% improve with surgery


Acute and persistent cervical radicular pain and radiculopathy Assessment:Management:

Refer Red flags

Conservative• BSP • Symptom relief; Adequate analgesia incl

opiate +-co-analgesics eg TCA, Gabapentin

Refer: specialist assessment• If no improvement 4-6 weeks or

unrelieved pain– x-ray, “screening” bloods– MRI



Intervention for radicular pain Cervical epidural corticosteroid injection

• For radicular pain• Under X-ray• LA and corticosteroid

• Two approaches

– Interlaminar– Transforaminal

Take Home Message

• Useful pain relief for 50% of patients

• Second injection dependant on effect of 1st injection

• Not a long term repeat therapy


Cervical epidural corticosteroid injectionInterlaminar

Effectiveness

defined as 50% relief or more +/- 50% improvement in function)

Disc Herniation

70% good or very good relief – for 1 year

-1-3 injection


Cervical epidural corticosteroid injectionTransforaminal

Effectiveness:

• 50% patients - 50% relief 1 month; 30% patients by 12 months

• Surgery avoided approx 50% in 2 separate studies

Controversies:

• 23 reported serious side effects

• Recent move away from particulate local anaesthetics

Engel, A., King, W., & MacVicar, J. (2014). The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: A systematic review with comprehensive analysis of the published data. Pain Medicine, 15(3), 386-402


Summary lumbar intervention efficacy

Acute low back pain: NA

Lumbar radicular pain: Epidural Corticosteroid Injection• PIVD: 60% patients - 50% relief 2 months, 40%

sustained 12 months• Restores function, reduces need for other healthcare,

reduces need for surgery• Spinal stenosis: ~ 50% patients - 50% relief 6 months

Persistent /Chronic low back pain:• SIJ corticosteroid injection: 50% relief in 60 % , 2 months• Facet joint cotricosteroid injection: “improvement in pain/

function” in 50% at 3 months; 30% at 6 months• Facet joint FFN: 60% near complete relief 17- 33 months


Summary cervical intervention efficacy

Acute cervical: NA

Cervical radicular pain: Epidural Corticosteroid Injection 50% relief in 50% patients 1 month; 30% patients 12 months; Surgery avoided in approx 50%

Persistent /Chronic cervical pain • Atlantoaxial joint Corticosteroid Injection : short term benefit; 50% relief in 20

% > 3 months; 12 % > 9 months• Cervical facet Corticosteroid Injection : short term benefit; “improvement in

pain/function” in 20% at 3 months• Cervical facet RFN: 68% near complete relief for 20 months; repeatable.


RFN outcomes

65 % Successful: Complete relief > 6 months, Return to work.

80% pts experience 80% reduction in pain

55 % Successful: Complete relief > 6 months, Return to work.


Specific mechanisms and specific management



Specific interventional approaches


Pain Cases 101

Dr Keith Laubscher

PainCare

Auckland 2018


Purpose of assessment

• CAUSE:

– Diagnosis (RED FLAGS: Serious or sinister pathology); History Exam Inv

• MECHANISM:

– Nociceptive /Neurogenic/ “Central sensitisation”

• DURATION:

– Acute /Chronic

• CONTEXT:

– Psychosocial- biological (YELLOW FLAG)

• MANAGEMENT:

– Personalised: Surgery vs Interventional vs Pharmacological vs “Pain

Management”


Clinical Assessment

• Pain: SOCRATES

• Fxn: ADL, Work, Social

• Psychosocial: mood, expectations

• Rx: Meds, Physical

• PMH and Meds:

• Exam:

• PDx

• Mx Inv.

• DIAGNOSIS

• MANAGEMENT:


Rame S NHI: HQH6352

40-year-old Syrian tailor NZ 20 year

dived into a pool, struck his head 2 years ago; dazed, helped out

fractures superior endplates lower cervical and upper thoracic and C5/6 disc bulge

Pain left lower cervical trapezius, medial scapula border. Less so right. sharp, hot, or numbness. worse head forward, ors arms out in front. intermittent frontal headache tightness. VAS 3 -6/10, with activity modification.

Fxn: Wakes in night. At work

Psych: flashbacks, irritable. worried; Married 1st baby on the way

Rx: Physiotherapy extensive. Paracetamol 1g bd, Tramadol 50mg prn nausea and cognitive impairment. Nortriptyline no benefit.

PMH: N

Exm: Reduced ROM, tight paravertebral; no neurology

PDx: Persistent post-traumatic cervical spinal pain -past fractures


Inv: BPI disability index: 3.3/10.

HAD scores: Anxiety 6, depression 3.

MRI (26.5.16) and SPECT scan cervical spine (17.10.16): C5/6 disc bulge, anterior deformities wedging upper thoracic spine T1, T2, T3 with Modic type II signal change at some levels, possibly T4; increased radiotracer uptake at C5/6 endplate, right C6/7 facet, less so left C6/7 facet, anterior osteophytes C6/7 and T2 end-plate.

Diagnosis

Mx: Surgery; Pain intervention; Medication: PPP

FInv:

DIAGNOSIS:

MANAGEMENT:





Desmond N NHI: LQX103049 chef own take-away Ex-Macua, NZ 30 years, married 2 children, Moderate ETOH non smokerP: 8 weeks; shifting furniture; lumbosacral aching; fleeting paraesthesia in shins; BBC –ve ; VAS 7-9/10Fxn: Struggling physical work Psych: limited English; worried; not keen medicationRx: Chiropractor, Acupuncture no benefit; CelebrexPMH: NCExm: Reduced LROM, tight paravertebral; no neurologyInv: X-ray NHAD anxiety 12; depression 5 PDx: Persistent somatic lumbar spinal pain; Anxiety symptomsInv: MRI L2/3 small right disc protrusion; minor changes L3/4L 4/5

DASS21: Depression 26 / 42; Anxiety 26 / 42; Stress 26 / 42; PCS 25 / 52

DIAGNOSIS:

MANAGEMENT: Surgery; Pain intervention; Medication: PPP


Desmond N NHI: LQX1030


Susan B NHI: LNF7805 50 Business Consultant; Married 2 children; Etoh occ, Non-smoke- veSlip/fall onto buttock wet kitchen floor 10 days; Left lumbosacral thigh calf aching stabbing paraesthesia; BBC -veFxn: Off - ADL’s; Chores, work, ↓↓sleepPsy: Distress, anxiousRx: Diclofenac SR 75mg bd (dyspepsia), Codeine 60mg QID, Paracetamol2QID. Tramadol - 0 help. (amitriptyline not taken –fear of constipation)PMH: Asthma; pneumonia; acne rosacea; vitreous detachment; Migraine; IBS(with tendency to constipation); Hypertension; Rosacea; uterine fibromyoma; gynaecological pain (endometriosis); Anxiety disorder; laparoscopy; caesarean section.Med: Laxsol, Isotretinoin, Rosex gel, Bricanyl, Symbicort, Clonazepam, Propranolol prn.Ex: Distress; crutches; lying in waiting room, movement nil; AJ ↓; Sensation ↓ dorsum lat foot; WMP –veInv: X-ray - age related change, minimal marginal spurring.BPI disability index: 9.1/10.HAD scores: anxiety 15, depression 11.PDx: Acute post-traumatic lumbar spinal pain with left S1 radicular pain; Medical co-morbidities; Anxiety


Inv: MRI : L5S1 disc herniation left S1 nerve root compressionDIAGNOSIS:MANAGEMENT: Surgery; Pain intervention; Medication: PPPAdd Amitriptyline; TFI

Progress: at 1month)Residual pain – VAS 3 -7/10 (back)RTWWalking dailyRx: Naproxen 750mg daily, Amitriptyline 25mg at night and she uses Paracetamol/Codeine x2 prn.


Susan B NHI: LNF7805 MRI


Garth R NHI: VCF681435 Sales Married Sales rep4 months; shifting furniture; Lumbosacral and posterior thighs, right then more left, groin thigh anterior shin; aching Fxn: Limited exercise; working; ↓↓ sleep Psych: Frustrated > worried, not keen medicationRx: Chiropractor; Physio; Celecoxib prn, Amitriptyline prnPMH:NCExm: Gait OK, heel toe, squat, reduced extension; tender lumbosacral, paravert tight; SLR buttock groin pain over 600 ; ↓int rotn hip; Positive Patrick test, WMP -vePDx: Persistent lumbar spinal pain with right leg pain.

Right groin pain ?? separate pathology Inv: X-ray right hip, lumbar spine, pelvis - NormalHAD: NCDiagnosis


Management:

• Medication: Regular Celebrex, Amtriptyline (no help)

• AdInv: Imaging:

SPECT CT LUMBAR SPINE (23.4.18) No abnormal uptake is seen in the lumbosacral spine and pelvis and hip joints.

MRI RIGHT HIP (23.4.18) Right acetabular labral tear with extensive intralabral cyst formation.Cystic change at the right femoral head / neck junction. Preserved right hip joint articular cartilage.

Dx: Persistent lumbar spinal pain with right leg pain.

-L4/5 disc bulge, L5S1 central left paracentral herniation

• Acetabular labral injury, dysplasia

MANAGEMENT: Surgery; Pain intervention; Medication: PPP


Garth R NHI: VCF6814 MRI




Judy W NHI: GAG040874; Retired, married, adult children; min ETOH, non-smoke, activeLBP left jarring over waves 3 /12 settled physio.Fall off e-bike 1 month ago; stabbing right buttock; paraesthesia lateral calf; bladder urge; VAS 5 - 9/10. Fxn: ADL’s difficult, Sleep fine. Psych: health related worry. Going overseasRx: Paracetamol 1g tds, Codeine 30mg prn, Gabapentin 600mg am 300mg noon and pm( sedation).PMH: Hypertension; past CVA with left-sided weakness; PMR; osteoporosis; burns right hand child skin grafts; appendix; hysterectomy; cataracts.Medication: Candesartan, Ezetimibe, Plendil, Clopidogrel 75mg daily, Prednisone 7mg daily, Zoledronate infusions annually. All/Intol: Tramadol – cognition, Prednisone - anxietyExm: Stooped; right antalgic; tender right paravertebral; SLR over 600 but pain, no neurology perineal ∆PDx:Inv: BPI disability index: 6.3/10.HAD scores: Anxiety 10, depression 10. X-ray ; mild curvature convex to the left mid lumber region, no fractures, disc degenerative change multiple levels, osteoarthrosis lower lumbar facet joints.


DiagnosisManagement:• Medication:• AdInv: Imaging:• MRI lumbar spine (21.5.18) shows

insufficiency fracture of L2, multilevel spondylosis most marked at L4/5, zygapophysial joint arthrosis, a L5/S1 right synovial cyst with associated spinal stenosis. There appears to be a left L4 pars defect – not active (not reported).

DIAGNOSIS:• RX MANAGEMENT: Surgery; Pain

intervention; Medication: PPP


Judy W NHI: GAG0408 MRI




Peter C PCD7352

73-year-old, USA NZ 30 years, Married adult children

LBP on and off teens - fall on coccyx. Exacerbation 3 years ago bending doing shoelaces.

Variable right +/- left lumbosacral region., aching. VAS 2- 6/10, variable, activity dependent, once flared days to settle.

Fxn: cant drive long, cant sail restore boat,

Rx: physio +++, home programme; Paracetamol 1g most days, Codeine prn, Diclofenac for exercise

Psych: earnest, frustrated, wants fix, wants to do more, avoid medication. ACC now declined

PMH:: Hypercholesterolaemia; musculoskeletal chest pain, mild coronary artery disease (angiogram 2015); bladder neck excision, sinus surgery, cataracts, dental implants.

Meds: Simvastatin. Zopiclone prn

Ex: Taller, slim build. Flexion distal tibia, Extension and rotation aggravate; nil Neurological. No WMP.

Inv: BPI disability index: 2.6/10. HAD scores: NC

X-ray multilevel spondylosis, ZJ OA, L5S1 spondylolisthesis

PDx: Persistent right more than left lumbosacral pain.

-Lumbar spondylosis, L5S1 spondylolisthesis, zygapophysial osteoarthrosis


Inv: MRI lumbar spine (9.7.13) notes multilevel disc disease, severe bilateral L5/S1 facet arthrosis, mild dextroconvex scoliosis centred on L2. Bone scintigram (26.6.13) notes increased uptake in the posterior elements L5/S1 on the right, less marked on the left.CT bilateral L5/S1 facet joint injection pain records that his pain reduced to zero.

DIAGNOSIS:RX MANAGEMENT: Surgery; Pain intervention; Medication: PPPMBB RFN

Outcome


Peter C PCD7352 MRI


27 tyre fitter Partner

3 years ago; lifted a heavy truck tyre with workmate who lost control – he took load; aching left lumbosacral/sacroiliac area; no paraesthesia but left foot feel different lateral aspect; leg feels stiff with walking, tendency to give way; BBC -; VAS pain 5/10 on average.

Fxn: ↓↓ sleep; RTW after off 3/12; exercises worse but maintains core stability home

Psych: partner off two years back problems. No ETOH; smoker; regular cannabis; “worrying whether ever be right”. “no one knows why he has pain”; “find out what was going on and help resolve his pain”.

Rx: Panadol, Codeine, NSAID, Amitriptyline no help; Extensive physiotherapy, acupuncture, massage, chiropractic treatment; TP focal injection to helped ST with post-injection flare.

PMH: Nil. No rheumatological

Exm: small very slim; very tender left sacroiliac area; associated skin drag cool to touch. variable altered sensation on the lateral aspect of the dorsum of the foot and calf on the left; figure four +ve sacral thrust tests +ve; WMP -ve

Px: Persistent left lumbosacral region pain; Psychosocial factors


Inv:

BPI disability index average: 7/10.

HAD scores; anxiety 9, depression 9.

Xray: normal

DIAGNOSIS

FInv:

CT scan (8.10.12) notes subcortical cyst within the left ilium likely relates to small overlying area of cartilage damage but is unlikely to be of significance.

MRI lumbar spine (11.9.14) 3mm area of low T1 signal surrounded by bone marrow oedema in the ilium adjacent to the left lower sacroiliac joint. The sacroiliac joint is otherwise normal.

Managment:

Inv:

DIAGNOSIS:


• RX MANAGEMENT: Surgery; Pain intervention; Medication: PPP• SIJ Injection/block•

• Outcome: TO DO•

• Recurring episodes • MRI changes persist MRI LUMBAR SPINE 07/10/2015 •

• RX MANAGEMENT: Surgery; Pain intervention; Medication: PPP




Boris C DNH0997 MRI



Documents

Dr Jonathan Kuttner Dr Keith Laubscher Dr Ian Wallbridge North/Thur_Room4_0830-Pain 101 Rotorua June 2018.pdf · • IS, FMS, OA, “LP”, “WAD” Central sensitisation: A physiological