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

Agenda

• Definition

• Physiology

• Acute/ Chronic

• Neuropathic

• Differences

• Treatment Options

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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)

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Definitions (2)

• Time-course:

• acute

• chronic

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Definitions (3)

• Type:

• nociceptive

• neuropathic

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Pain Physiology

(boring)

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Pain Physiology

(funky version)

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Noxious Stimulus

Impulse Transmission

Afferent sensory fibres

Spinal cord

Dorsal Horn

Synapse

Ca and Glutamate

Synaptic Cleft

Post Synaptic

Nociceptive Neuron

Pain perception

Brain

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

Massive Financial Burden

• NHS/ DWP/ tax-payers

• Lower back pain (CSAG 1994)

• NHS £481 million

• The Exchequer £1.4 billion

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Physical and Alternative Treatments

Physiotherapy

Physical/ Alternative Treatments

• Physical- heat/ cold/ TENS/ hydro/ supports/ US/ IR

• Manipulation- PxTx/ chiropracter/ osteopathy/ deep tissue massage

• Alternative- acupuncture

Any Vets in the audience?

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5. (a) Veterinary practitioners?

Headache!

Pharmacological Treatment

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

Pharmacological Treatment

• WHO analgesic ladder (abridged)

• + tramadol

• + opioids- buprenorphine TDD/ oxycontin/ fentanyl TDD

(New: sufentanyl TDD/ product X)

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Opioid Therapy

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Pharmacological treatment of Neuropathic Pain

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Neuropathic Pain Management

• Antidepressants- Amitryptilline

• Anticonvulsants- Gabapentin/ Pregabalin/ Carbamazepine/ Valproate

• Opioids

• Local Anaesthetics- Lignocaine/ EMLA

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• NMDA antagonists

• Sympatholytics

• GABA –ergics

• Capsaicinwww.londonpainconsultants.com

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

Psychologicaly based therapy

Pain Management• Psychological

CBT

Operant Conditioning

Psychoanalysis

Relaxation

Biofeedback

• Psychiatricwww.londonpainconsultants.com

Pain Management Programmes

● Medication

• Goals (SMART- specific/ measured/ agreed/ realistic/ timed)

• Coping

• Contingency

• Pacing

• Education

• Pain Behaviours

• Reinforcement www.londonpainconsultants.com

Functional Restoration Programmes

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MRI scans

Minimally Invasive Pain Management

C-arm

Targets

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Spine Pain

Cervical/ Thoracic/ Lumbar>65% workload

Epidural Steroid Injections

Facet Joint Injections

Nerve Root Injections

Sacroiliac Joint Injection

Radiofrequency

• Radiofrequency denervation (destructive)

• Eg: medial branch (facet joint) blocks

• Pulsed radiofrequency (non-destructive)

• Eg: nerve roots

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Botulinum Toxin A

Other Minimally Invasive Techniques

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Epiduroscopy

IDET

Disc Dekompressor

Vertebroplasty/ Kyphoplasty

Musculoskeletal

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Shoulder

• Suprascapular nerve block

• Suprascapular pulsed radiofrequency

• Intra-articular

• Trigger point

• Botulinum Toxin A

Limbs

• Tenoperiostial injections

• Intra-articular

• Trigger points

• Intra-articular

• Botulinum Toxin A

Neuropathic Pain

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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)

Other Neuropathic Pain

• Coeliac plexus block

• Ganglion of Impar block

• Hypogastric plexus block

• Pulsed radiofrequency to nerves

• EG: intercostal/ obturator

Advanced Pain Management Techniques

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Nerve Stimulation

Nerve Stimulation (2)

Intrathecal Pumps

Intrathecal Pumps (2)

The Future?

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The Future?

• Demographics

• Healthcare advances

• ↑ Patient expectations and involvement

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London Pain Consultants Pain Management Treatment and Therapy.mht

London Pain Consultants Clinics

• London • 15 Harley Street, W1G

• Wellington, NW8

• HSJSE, NW8

• Lindo Wing (St Marys), W2

• Surrey •Mount Alvernia, Guildford

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)

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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Summary

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Summary

• Very common (1 in 7 UK)

• Time course- acute n chronic

• Nociceptive and neuropathic

• Multiple treatment modalities

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Case reports/ Blogs/ Links/ Appointments

dr.jenner@satellitesec.co.uk

0845 045 0250

Any Questions