© 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
© 2012 HP-Anesco Interventional Pain Institute
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)
© 2012 HP-Anesco Interventional Pain Institute
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
© 2012 HP-Anesco Interventional Pain Institute
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)
© 2012 HP-Anesco Interventional Pain Institute
Mixed TypeCaused by a
combination of both primary injury and secondary effects
Nociceptive vs Neuropathic Pain
NociceptivePain
Caused 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)
© 2012 HP-Anesco Interventional Pain Institute
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
© 2012 HP-Anesco Interventional Pain Institute
Primary Goals
Relieve symptoms
Restore function
Return to work
Minimize disability
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Treatment options
Medications
Interventional Procedure
Rehabilitation
Surgical intervention
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Medications
Ease for patient
Symptom management
Cost of treating complications
Decreased productivity
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NSAID
Reduce synthesis of PGs
COX inhibitors (cyclooxygenase)
Diminish nociceptor activation
Block peripheral sensitization
Antipyretic
Anti-hyperalgesic
No sedation
Examples: Advil, Aleve, *Celebrex
© 2012 HP-Anesco Interventional Pain Institute
Side effects
Gastrointestinal ulceration
Renal dysfunction
Embryotoxic
Prolonged bleeding
PPI/H2 blockers for prevention
•Ex: Nexium, Prilosec, Zantac
© 2012 HP-Anesco Interventional Pain Institute
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
© 2012 HP-Anesco Interventional Pain Institute
OPIOIDS
Spinal cord
•Decreasing neurotransmitter release
•Blocking postsynaptic receptors
•Activating inhibitory pathways
Receptor subtypes
•mu> delta> kappa
Supraspinal analgesia
Examples: Morphine, Fentanyl, Burprenorphine
© 2012 HP-Anesco Interventional Pain Institute
Side effects
respiratory depression, severe bradycardia, decreased gastric motility, drowsiness, memory loss, impaired judgement
Addiction
Physiologic dependence
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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
© 2012 HP-Anesco Interventional Pain Institute
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
© 2012 HP-Anesco Interventional Pain Institute
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
© 2012 HP-Anesco Interventional Pain Institute
Transforaminal Epidural Injections
• More popular over the last decade.
• Steroid medication placed closer to the area of nerve root compression.
© 2012 HP-Anesco Interventional Pain Institute
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
© 2012 HP-Anesco Interventional Pain Institute
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;36:1897-1905
Safriel Y. Appl Radiol 2010;39:14-23
• In the face of increasing pain levels
• Transforaminal injections/ catheter techniques
© 2012 HP-Anesco Interventional Pain Institute
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
© 2012 HP-Anesco Interventional Pain Institute
Facet Pain - Interventional Treatment
Facet Joint Steroid Injection
• Effective and minimally invasive
• Fluoroscopy
• May be effective for weeks to months
© 2012 HP-Anesco Interventional Pain Institute
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.
© 2012 HP-Anesco Interventional Pain Institute
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
© 2012 HP-Anesco Interventional Pain Institute
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 injectionsGünaydin 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
© 2012 HP-Anesco Interventional Pain Institute
Physical Therapy
Hands-on care can motivate and push patients
Relief of symptoms
Restoration of function
No side effect or addiction
© 2012 HP-Anesco Interventional Pain Institute
Limitations
Limited care per week ( 3hr)
Cannot manage pain outside of therapy facility
Tendency for patient to resume pharmacologic therapy for pain treatment
Cost
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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
© 2012 HP-Anesco Interventional Pain Institute
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