Dr Namal Senasinghe MB.BS FFARCS DPMed FFPMCA Consultant in Pain Medicine Centre for Pain Medicine...
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Transcript of Dr Namal Senasinghe MB.BS FFARCS DPMed FFPMCA Consultant in Pain Medicine Centre for Pain Medicine...
Dr Namal Senasinghe MB.BS FFARCS DPMed FFPMCAConsultant in Pain Medicine
Centre for Pain Medicine
Canterbury Hospital, Kent, UK
Chronic Lower Back Pain
Potential sources for lower back pain
Ligaments - Supraspinous Post Longitudinal
ligaments
Muscular - Paraspinal M
Vertebral body and plates
Facets/SIJ
Patient Groups
1. Genuine back problems
2. Muscular Skeletal disorders & Fibromyalgia
3. Pt’s with secondary intentions
Clinical features
General Features Localized back pain Radiculopathy /
Radiculitis Muscular spasms Difficulty in walking Difficulty in getting
up History of trauma
Red Flags Features of cauda
equina Significant trauma Weight loss IVDA or HIV Severe unremitting
night time pain Fever
Management of Lower Back Pain
Pharmacological
Psychological
Behavioural
Complementary therapy
Interventional
Pharmacological Management
WHO Step Ladder
By the oral route
By the clock
Analgesic Types
1. Simple analgesics
2. Moderate
3. Strong
Simple Analgesics
Paracetamol
NSAIDS – Aspirin/Ibuprofen/Indometacin Diclofenac/ Meloxicam
COX 2 Inhibitors - Celecoxib (Celebrex) Etoricoxib (Arcoxia)
Cautions
All NSAIDS Cardiac/Hepatic/Renal Impairment
COX 2 LVF/Hypertension
Contraindications
Allergy/Hypersensitivity Bleeding peptic ulcers Severe heart failure
CVA IHD PVD Moderate ht failure
Moderate Analgesics
Codeine Phos Co- Codamol (8/500, 30/500) Tylex/Kapake
Strong Analgesics (Opiates)
BuprenorphineBuprenorphine HydromorphoneHydromorphone
CodeineCodeine MeptazinolMeptazinol
DextromoramideDextromoramide MethadoneMethadone
DextropopoxypheneDextropopoxyphene MorphineMorphine
DiamorphineDiamorphine OxycodoneOxycodone
DihydrocodeineDihydrocodeine PentazocinePentazocine
DipipanoneDipipanone PethidinePethidine
FentanylFentanyl TramadolTramadol
Anti Neuropathic Medication
Anti Epileptics – Gabapentin Pregablin
Antidepressants – Amitriptyline Dothiopin Duloxetine
Psychological
Psychological assessment Cognitive behavioural therapy Counselling Supportive psychotherapy Group therapy Relaxation Reflexology
Behavioural therapy
Pain management programmes
Back schools
Complimentary Therapy
Acupuncture Tai Chi TENS/SCENAR (self controlled electro neuro adaptive
regulation)
Reflexology Alexandra Aromatherapy – oil
Interventional Management
Epidural Steroids Facet Joint Injections/SIJ injections Radiofrequency Denervations Discography IDET Dorsal root ganglion denervations Spinal cord Stimulators Intrathecal pumps / Epidural pumps Cordotomy
EPIDURAL STEROID INJECTIONS
Indications
Radiculopathy / Radiculitis
MRI Scan – Positive findings of a disc prolapse
Nerve root compression
Drugs
Methylprednisolone 80mg
Triamcinolone 60mg
Local anaesthetic solution
Mechanism of Action
Samples from herniated discs contain high level of phospholipase A2.
Phospholipase A2 liberates arachidonic acid from cell membrane.
Steroids induce the synthesis of phospholipase A2 inhibitor preventing the release of a substrate for prostaglandin synthesis.
Steroids can block nociceptive input.
Contrast in the epidural space
Lumbar EpidurogramLumbar Epidurogram
Positive Predictors
Presence of nerve root irritation
Recent onset of symptoms
Absence of psychological overlay
Radicular pain and numbness
Short duration (< 6 months)
Advanced educational background
*(White et al)
Motor weakness correlating with the involved nerve root
Positive SLR Abnormality in the
EMG in the affected nerve root
Documentation of a herniated disc in radiological examination
Younger age group
Negative Predictors
Previous back surgery
Pain > 6 months Work related injury Unemployment
due to pain Presence of
pending litigation
Previous multi-drug therapy
Very high pain rating
Frequent sleep disturbances
Smoking
Complications
Flashing Nausea Vomiting Sweating Hypotension
Dural puncture Retinal
haemorrhage Epidural
haematoma
FACET JOINT INJECTIONS ( FJI )
The Lumbar Facet Syndrome
Intrduced by Ghormley in 1933 LBP with or without referred pain Catching/Locking Increased with standing/sitting Decreased with mobility Physical Exam - Inves – X’ray / MRI
Indications for FJI
Diagnostic
Therapeutic
Standard monitoring Local infiltration - 2% Lignocaine Drugs - 0.5% Bupivacaine Prednisolone 25 mg Complications - Intrathecal injections Haematoma Entry into spinal cord
Positive Predictors
Acute onset of pain Absence of leg pain Absence of muscle spasm Normal gait
RADIOFREQUENZY DENERVATION
Radiofrequency Lesion Generator (Radionics)
Uses of RF/Pulse RF denervations Facet & SIJ Denervation - RF Lumbar Sympathectomy - RF DRG – Pulse RF Stellate Ganglion – Pulse RF Suprascapular N – Pulse RF Illioinguinal N – Pulse RF
Discogram
Diagnostic test performed to view and assess the internal structure of a disc and determine if it is a source of pain
Expected results 1. Recreation of painful symptoms
2. Confirmation of diagnosis
IDET (Intradiscal Electrothermal Annuloplasty)
To treat discogenic back pain Procedure works by cauterizing the nerve
endings within the disc wall Minimally invasive out patient procedure
SPINAL CORD STIMULATOR
Used in failed back surgery syndrome (FBSS).
A lead with 2-4 electrodes is introduced into the epidural space @ L1/L2
Threaded up to T8/T9
Equipment
A totally implantable device (Implantable pulse generator - IPG). The patient has control only on the on-off button. The programming is done by the doctor using a special console from outside.
How does it work ?
A pulse is generated which activates the large A -alpha fibres & A -beta fibres in the dorsal horns of the spinal cord.
This inhibits the nociceptive input from the smaller A delta fibres & C fibres closing the gate.
Other uses of SCS
Complex regional pain syndrome Ischaemic leg pains Unstable angina Phantom limb pain Muscle spasm in MS
Surgical Option
Refer to Orthopaedic and Neurosurgical colleagues
Red flagsDisc prolapsesNeurological SymptomsCt back pain not responding to
interventions