the management of spinal pain presented at back show 4.10.09
DESCRIPTION
The Management Of Spinal Pain. Presented At The Back Show, Earls Court Centre, London. 4th October 2009.TRANSCRIPT
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The Management of Spinal Pain.
Dr. Christopher A. Jenner MB BS, FRCA
Consultant in Pain Medicine, Imperial Healthcare NHS Trust
Medical Director Spinal Healthcare
4th October 2009
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Agenda
• Definition
• Physiology
• Acute/ Chronic
• Neuropathic
• Differences
• Treatment Options
www.londonpainconsultants.com
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Definitions
• Pain. ‘An unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of tissue damage, or both.’ (IASP 2001)
www.londonpainconsultants.com
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Definitions (2)
• Time-course:
• acute
• chronic
www.londonpainconsultants.com
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Definitions (3)
• Type:
• nociceptive
• neuropathic
www.londonpainconsultants.com
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Pain Physiology
(boring)
www.londonpainconsultants.com
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Pain Physiology
(funky version)
www.londonpainconsultants.com
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Noxious Stimulus
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Impulse Transmission
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Afferent sensory fibres
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Spinal cord
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Dorsal Horn
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Synapse
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Ca and Glutamate
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Synaptic Cleft
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Post Synaptic
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Nociceptive Neuron
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Pain perception
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Brain
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The Challenges of Chronic Pain
• Bio-psycho-social model
• Individual and societal costs
• Biological- pain/ suffering/ disability
• Psychological- anxiety/ depression
• Social- work/ relationship/ family/ benefits
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Massive Financial Burden
• NHS/ DWP/ tax-payers
• Lower back pain (CSAG 1994)
• NHS £481 million
• The Exchequer £1.4 billion
www.londonpainconsultants.com
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Physical and Alternative Treatments
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Physiotherapy
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Physical/ Alternative Treatments
• Physical- heat/ cold/ TENS/ hydro/ supports/ US/ IR
• Manipulation- PxTx/ chiropracter/ osteopathy/ deep tissue massage
• Alternative- acupuncture
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Any Vets in the audience?
www.londonpainconsultants.com
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5. (a) Veterinary practitioners?
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Headache!
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Pharmacological Treatment
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Acute Pain Management
• Non-pharmacological
• RICE
• Pharmacological
• WHO ladder (amended from cancer) Step 1 paracetamol/ NSAID/ COX 2 Step 2 + weak opioids Step 3 + strong opioids
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Pharmacological Treatment
• WHO analgesic ladder (abridged)
• + tramadol
• + opioids- buprenorphine TDD/ oxycontin/ fentanyl TDD
(New: sufentanyl TDD/ product X)
www.londonpainconsultants.com
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Opioid Therapy
www.londonpainconsultants.com
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Pharmacological treatment of Neuropathic Pain
www.londonpainconsultants.com
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Neuropathic Pain Management
• Antidepressants- Amitryptilline
• Anticonvulsants- Gabapentin/ Pregabalin/ Carbamazepine/ Valproate
• Opioids
• Local Anaesthetics- Lignocaine/ EMLA
www.londonpainconsultants.com
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• NMDA antagonists
• Sympatholytics
• GABA –ergics
• Capsaicinwww.londonpainconsultants.com
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Future Agents for Neuropathic Pain
• Ziconotide (sea snail, conus magnus)
• P2X3- (purine) receptor antagonists (ATP) (knockout mice)
• Epibatidine (Equadorian poison dart frog)
• Morphine and ketamine
• Regular gabapentinwww.londonpainconsultants.com
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Psychologicaly based therapy
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Pain Management• Psychological
CBT
Operant Conditioning
Psychoanalysis
Relaxation
Biofeedback
• Psychiatricwww.londonpainconsultants.com
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Pain Management Programmes
● Medication
• Goals (SMART- specific/ measured/ agreed/ realistic/ timed)
• Coping
• Contingency
• Pacing
• Education
• Pain Behaviours
• Reinforcement www.londonpainconsultants.com
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Functional Restoration Programmes
www.londonpainconsultants.com
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MRI scans
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Minimally Invasive Pain Management
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C-arm
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Targets
www.londonpainconsultants.com
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Spine Pain
Cervical/ Thoracic/ Lumbar>65% workload
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Epidural Steroid Injections
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Facet Joint Injections
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Nerve Root Injections
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Sacroiliac Joint Injection
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Radiofrequency
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• Radiofrequency denervation (destructive)
• Eg: medial branch (facet joint) blocks
• Pulsed radiofrequency (non-destructive)
• Eg: nerve roots
www.londonpainconsultants.com
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Botulinum Toxin A
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Other Minimally Invasive Techniques
www.londonpainconsultants.com
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Epiduroscopy
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IDET
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Disc Dekompressor
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Vertebroplasty/ Kyphoplasty
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Musculoskeletal
www.londonpainconsultants.com
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Shoulder
• Suprascapular nerve block
• Suprascapular pulsed radiofrequency
• Intra-articular
• Trigger point
• Botulinum Toxin A
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Limbs
• Tenoperiostial injections
• Intra-articular
• Trigger points
• Intra-articular
• Botulinum Toxin A
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Neuropathic Pain
www.londonpainconsultants.com
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Complex Regional Pain Syndrome (CRPS)
• Upper Limb
• Stellate ganglion block
• Intravenous guanethidine block (IVG)
• Lower Limb
• Lumbar Sympathectomy
• Intravenous guanethidine block (IVG)
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Other Neuropathic Pain
• Coeliac plexus block
• Ganglion of Impar block
• Hypogastric plexus block
• Pulsed radiofrequency to nerves
• EG: intercostal/ obturator
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Advanced Pain Management Techniques
www.londonpainconsultants.com
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Nerve Stimulation
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Nerve Stimulation (2)
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Intrathecal Pumps
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Intrathecal Pumps (2)
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The Future?
www.londonpainconsultants.com
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The Future?
• Demographics
• Healthcare advances
• ↑ Patient expectations and involvement
www.londonpainconsultants.com
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London Pain Consultants Pain Management Treatment and Therapy.mht
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London Pain Consultants Clinics
• London • 15 Harley Street, W1G
• Wellington, NW8
• HSJSE, NW8
• Lindo Wing (St Marys), W2
• Surrey •Mount Alvernia, Guildford
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The Team
• Consultant Pain Medicine (Dr.C.A.Jenner)
• Consultant Orthopaedic Spine Surgeon (Mr. Mo Akmal)
• Consultant Interventional Radiologist (Dr. D. Connel)
• Consultant Rheumatologist (Dr. Rees)
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The Team (2)
• Consultant Gynaecologist (Miss D. Lyons)
• Consultant Neurologist (Dr. J. Ball)
• Consultant Psychologist (Dr J. Neilson)
• Specialist Physiotherapists (West London Physiotherapy- Sarah Morton, Cameron Tudor)
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www.spinal-healthcare.com
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Summary
www.londonpainconsultants.com
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Summary
• Very common (1 in 7 UK)
• Time course- acute n chronic
• Nociceptive and neuropathic
• Multiple treatment modalities
www.londonpainconsultants.com
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Any Questions