sci pain rancho slides
TRANSCRIPT
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Pain management in spinal cord
injury
Kazuko L. Shem, M.D.
Physical Medicine & Rehabilitation
Santa Clara Valley Medical Center
www.scvmed.org
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SCVMC
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Incidence of pain
65 - 95% of SCI individuals experience pain
50% musculoskeletal
30% neurogenic
5-45% experience severe disabling pain
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Incidence of pain
More common in patients with:
Injuries due to gunshot wounds and violence
Lower level of injury
Incomplete SCI?
Spasticity
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Psychosocial factors
Depression / Sadness
Adjustment disorders
Anger
Anxiety Stress
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Patient evaluation
Detailed history
quality of pain
distribution of pain
relieving factors
aggravating factors
Physical examination Diagnostic tests
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Pain syndrome classification
Musculoskeletal
Neuropathic
Visceral
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Pain classification
Above the level
At the level
Below the level
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Musculoskeletal pain syndrome
Bone, joint, muscle trauma
Tendon inflammation
Muscle spasm
Overuse syndrome
Instability of spine
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Vertebral column pain
Neck, middle back, low back pain
Spine deformitiesArthritis
X-rays
evaluate instrumentation placement
evaluate degenerative changes
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Mechanical instability of spine
Most common after cervical spine injury
Due to injury to ligaments, fx of spine
Pain around the spine
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Treatment for mechanical
instability of spine
Relieved by immobilization
Rest, bracing
Medications
Anti-inflammatory medication
Opiates
Surgical fusion
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Trigger points
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Muscle spasm pain
Pain with visible and palpable spasms
Anti-inflammatory medicationsAnti-spasticity medications
Baclofen
Zanaflex
Anti-spasm medications Flexeril, Robaxin, Skelexin
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Secondary overuse syndromes
More common in paraplegics
Pain in intact areas Delayed onset
Shoulder pain: arthritis, tendinitis
Pain from CTS, ulnar nerve entrapment
Other arthritis
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Shoulder pain
50-95% prevalence
Secondary to:
Weight bearing
Overuse
Muscle imbalance
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Shoulder pain: Differential diagnoses
Rotator cuff tendinitis and tear
Muscle pain
Radiculopathy
Arthritis
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Elbow / Hand pain
Elbow pain (32%)
Hand pain (48%) Differential diagnosis
Epicondylitis / tendinitis
Olecranon bursitis
Arthritis
CTS, Ulnar nerve entrapment
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Diagnostic tests
Physical examination
Plain x-ray
MRI
EMG
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Treatment options
Rest
Therapeutic exercises Modalities
Changes in positioning, ergonomics
Changes in equipment
Splints
Weight reduction
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Treatment options
Anti-inflammatory medication
Opioids
Injections
Acupuncture
Surgical release for CTS
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Neuropathic pain
Nerve root entrapment
Syringomyelia
Transitional zone pain
Central dysesthesia syndromeNerve entrapment syndrome
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Nerve root pain / radicular
Unilateral pain in the single nerve root
distributionAt the level of spinal trauma
Pain since the time of injury
Lancinating, burning, stabbing, shooting,
paroxysmal, allodynia, hyperesthesia
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Case study
49 YO male with C4-5 quadriplegia x 20 years
Numbness and pain on the right side of his
face and neck when turning his head to the
right while driving and looking at a computer
monitor
Physical Examination: Trigger point in the right upper cervical PSM
Symptom reproduction with head turning to the R
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Case study
MRI:
C2-3 posterior osteophytes causing right-sided
foraminal narrowing
Treatment
NSAIDs
Trigger point injection Instructed patient to reposition the computer
monitor to midline
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Transitional zone pain
At the border of normal sensation and numb
skin
Bilateral
Burning, aching, allodynia, tingling
Pain within first few months of injury
Injury to the gray matter of dorsal horn
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Central pain syndrome
Pain below the level of injury
Constant
Fluctuates with mood or activity
Responds poorly to medications or othertreatment
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Pathophysiology of neuropathic pain
Imbalance hypothesis
Imbalance between dorsal column and
spinothalamic tracts
Pattern-generating mechanism and loss of
spinal inhibitory mechanisms
Loss of inhibitory control Focal hyperactivity in the spinal cord and
thalamus
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Pain description
Tingling
Shooting
Stabbing
Squeezing
Pressure
Cold Numbness
Muscle cramp
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Exacerbating factors
Noxious stimuli below the level of injury
Fatigue
Lack of distraction
Smoking
Psychological stress
Overexertion
Weather changes
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Nerve entrapment syndrome
Carpal tunnel syndrome
Ulnar nerve entrapment
at the wrist
across the elbow
Radial nerve entrapment
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Nerve entrapment syndrome:
risk factors
Use of assistive devices
Routine pressure relief
Weight shifts
Transfers
Wheelchair mobility
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Syringomyelia (Syrinx)
Delayed onset, years
New neurological deficits Constant, burning pain
Pain to touch
Diagnosed with MRI
Treatment: shunt
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Treatment
Pharmacological
Nerve blocks
Physical
Surgical
Stimulation techniques
Psychological
Acupuncture
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Pharmacological treatment
Anticonvulsants
Antidepressants
Alpha-adrenergic agonists
Opioids
Anti-spasticity medication
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Anti-seizure medications
Carbamazepine (Tegretol)
Valproate
Gabapentin (Neurontin)
Trileptal
Topamax
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Antidepressants
Tricylic antidepressants: amitriptyline (Elavil),
nortriptyline, imipramine, desipramine Effective in neuropathic pain
Increase pain inhibitory mechanisms
May be used in combination with anti-seizure
medication
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Anti-spasticity medication
Relief of muscle spasms
Baclofen
Clonazepam
Dantrium
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Alpha adrenergic agonists
Relief of neuropathic pain
Clonidine
Zanaflex
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Capsacin
Topical
Applied to skin overlying the painful area
Deplete peptides that cause pain from
nerve ending
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Opioids
May be used in neuropathic pain
Side effects Physical dependency
Severe constipation
Mild cognitive impairment
Risk for addiction
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Therapy
Positioning
Modify transfer techniques
Splinting
Padded gloves / elbow padsExercise routines
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Other interventions
Acupuncture
TENS unit
Spinal cord stimulator
Dorsal rhizotomy
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TE
NS unit
Electrical stimulation on skin
More effective at the level of injury?
Requires a therapist for set-up
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Spinal cord stimulator
Not generally helpful with SCI pain
More effective with transitional zone orradicular pain
Initial improvement in 20-75% of patients
Long term efficacy in 10-40%
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Surgical intervention
Spine stabilization
Removal of instrumentation
Decompression of impinged nerve roots
Decompression surgery for syrinx
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Dorsal root rhizotomy
May be more effective in radicular pain
or neuropathic pain at the level of injury
Risks of cerebrospinal fluid leaks,
sensory or motor level changes
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Psychological treatment
Psychological assessment
Cognitive behavioral therapy
Relaxation techniques
Biofeedback
Peer support
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Visceral pain
Above, at or below the level of injury
Poorly localized if at or below the LOI
Non-specific symptoms:
Nausea, vomiting, anorexia
Autonomic dysreflexia
Fever
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Visceral pain etiologies
Kidney stones
Bowel dysfunction (constipation)
Appendicitis
Gallbladder stones
Gynecological
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ContactInformation
Kazuko Shem, MD
Nancy Jorgensen, NP
Santa Clara Valley Medical Center
Physical Medicine & Rehabilitation
2400 Moorpark Avenue, Suite 100
San Jose, CA 95128
(408)885-5920, (800)314-4611