gingerich back pain presentation (sept. 2012)
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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
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
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)
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
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%
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
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.
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
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
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
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
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Chronic Low Back Pain Risk Factors Age Fitness Level Diet Occupational Smoking Obesity
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Common Causes
Malignant
Benign
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Malignant
CancerPrimary—multiple myelomaMetastatic—prostate, breast, liver
InfectiousDiscitis, Osteomyelitis, Epidural abscess
Spinal Cord CompressionCauda Equina Syndrome, Conus Medullaris Syndrome
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Benign Radicular (Sciatic)
Herniated DiscSpinal StenosisFailed Back Surgery Syndrome
Musculoskeletal (Axial)Facet jointsSacroiliac jointMyofascial Pain Syndrome
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
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
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Anatomy
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Anatomy
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Anatomy
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Radicular Causes of Chronic Low Back Pain
Herniated disc Spinal stenosis Failed back surgery syndrome (FBSS)
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Herniated Disc
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Herniated Disc
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
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
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Spinal Stenosis
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Spinal Stenosis
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
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
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Failed Back Surgery Syndrome
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
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
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Musculoskeletal Causes of Low Back
Pain
Facet joints Sacroiliac joints Myofascial Pain Syndrome (MFPS)
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Lumbar Facets
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Facet Joints
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Facet Joints
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Lumbar Facet Referral Patterns
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Sacroiliac Joint
Where the back meets the pelvis/hip
Pain related to arthritis or malrotation of the joint
25% of low back pain
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Sacroiliac Joint
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Myofascial Pain Syndrome
Referred pain Repetitive use “Knotted muscle”
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Piriformis Syndrome
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Treatments
Conservative
Advanced
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
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
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Conservative Physical therapy, Aqua therapy, Joint Mobilization,
TENS unit Patient Education/Ergonomics Pharmacologic
NSAIDs Muscle relaxants Opioids
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Advanced: Interventional
TherapyBlocks and Injections Epidural steroid injections Nerve root blocks Facet injections Sacroiliac joint injections Trigger point injections Spinal Cord Stimulation
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Epidural Steroid Injections
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Epidural Steroid Injection
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Epidural Steroid Injections
Series of “3”, three to four weeks apart Combination of local anesthetic and steroid Most effective for radicular pain
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Facet Joint Injections
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
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
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Radiofrequency Ablation
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Sacroiliac Joint Injection
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Trigger Point Injections
Best relief with combination of stretching exercises and heat therapy
Usually secondary, need to identify cause
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
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.
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Spinal Cord Stimulation
Indications: FBSS Neuropathy of the extremity Intractable low back and/or extremity pain CRPS
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Spinal Cord Stimulation
Gate theory Two phases process: trial and if successful then
permanent Outpatient surgery
Southeast Anesthesiology Consultants, PA - Southeast Pain Care
Questions???