overview of interventional procedures and medical …overview of interventional procedures and...

Overview of Interventional Procedures and Medical

CannabisChristina Gonzaga, DO

Medical Director

Park Nicollet Pain Management Clinic

St. Louis Park, Minnesota

April 27, 2018

AgendaAbout Me

Disclosures

Objectives

Overview of Pain

Specialized Tests

Case 1

Intervention

Case 2

Medical Cannabis

References

About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References

Introduction


Abbreviated Curriculum Vitae

• Medical Director

• Pain and PM&R Boarded

• BA in history from Loyola University Chicago

• DO from Western University of Health Sciences Pomona, CA

• Residency: St. Vincent’s Manhattan, NS-LIJ

• Fellowship: Anesthesia pain, Thomas Jefferson University, Philadelphia

I have nothing to disclose


Learning objectives

• The state of pain care today• Review of the pain history and physical

examination• Brief review of interventional pain procedures • Review of medical cannabis: risks, benefits and

the future


Current State of Pain Care

Patients with Pain

Rehab Services

External Pain Clinics

Primary Care

Chiro

Mental Health

Emergency Center

Urgent Care

PMR

Addiction Medicine

Surgical Services


Why do we need to design a better way?

• Increases in opioid related deaths• CDC guidelines

“Unless the nation develops an increased tolerance to chronic pain, reduction in opioid leaves a vacuum that will be filled with other therapies.”12


Interdisciplinary Care Model

Patients with Pain

Pain-boarded

Physician

MTM Pharmacy

Rehab

Services (OT/PT)

Pain Psychology

Nursing Care Coordination


Role of the Pain Physician

• Team player: Collaborate with all members of the interdisciplinary team

• Trouble shoot medical aspects of the patient • Medication management and interventional management • Goals: Keep in mind the CDC guidelines. Decrease to

lowest effective dose, work with the individual needs of patients, work along side team to educate, guide, and help patients develop multiple tools to help them manage pain.


Interventional Procedures

•Back to the basics: history and physical

•Do not treat the diagnostic exam, treat the person in front of you

•Talk and LISTEN to your patient


History Location

Character

Severity

Timing

Onset

Duration

Frequency

Alleviating and aggravating factors

Associated signs and symptoms


Back Pain RED FLAGS Back pain in childrenConstant progressive pain at nightHistory of cancer/Marked weight loss Use of systemic steroidsIntense pain with minimal motion/structural deformityDrug abuse or HIV infectionSystemic illnessDifficulty with urination

Loss of anal sphincter tone or fecal incontinence, saddle anesthesiaWidespread progressive motor weakness or gait disturbance Inflammatory disorders (ankylosing spondylitis) Marked morning stiffnessPeripheral joint involvementPersisting severe restriction of motion


Physical Examination

• Observation:• Skin, muscle mass, bony structures,

as well as observation of overall posture

• Position of lumbar spine (Scoliosis)• Gait

• Palpation:• Bones• Facet joints• Ligaments and inter-discal spaces• Muscles

Active range of motion Forward flexion (Discogenic?)

Extension (Facet joints?)

Side bending (Facet joints?)

Rotation (Facet joints?)

Neurologic Examination Manual muscle testing

Pinprick and light touch sensation

Reflexes

Balance

Babinski


Sensation and Sensory ExaminationMechanical Nociceptors:

• Pin prick and pinch

Heat Nociceptors:• Temperature greater than 45 degrees Celsius

Polymodal Nociceptors:• Respond equally to mechanical, heat , and chemically noxious stimuli

Fast Pain:• Transmitted by well-localized myelinated A-fibers and is characterized by sharp, shooting pain

Slow Pain:• Transmitted by unmyelinated C fibers and is characterized as dull, poorly localized burning pain


Motor Examination: Muscle Grading

• 5 Normal: Complete range of motion against gravity with full resistance

• 4 Good: Complete range of motion against gravity with some resistance

• 3 Fair: Complete range of motion against gravity

• 2 Poor: Complete range of motion with gravity eliminated

• 1 Trace: Evidence of slight contractility; No joint motion

• Zero: No evidence of contractility


Muscle Stretch Reflexes/DTRs

Grading:

0 = No response

1+ = Reduced (less than expected)

2+ = Normal

3+ = Moderately hyperactive (greater than expected)

4+ = Hyperactive with clonus (upper motor neuron sign)


Commonly Test Nerve Root Levels

C5-C6 Biceps reflex

C7-C8 Triceps reflex

L3-L4 Patellar reflex

S1-S2 Achilles reflex


What’s the root cause?Root Dermatome Muscle Weakness

C4 Shoulder Levator Scapulae (Shoulder shrug)

C5 Lateral arm Deltoid

C6 Lateral forearm, first and second finger

Biceps, Extensor carpi radialis (weakness in wrist extension)

C7 Middle finger Triceps (weakness in elbow extension)

C8 Fourth, fifth finger; medial forearm

FDP; Finger flexion of middlefinger

T1 Medial arm Dorsal inter-ossei; Difficulty in keeping fingers abducted against resistance


Root Dermatome Muscle Weakness

L1 Back, over the greater trochanter and groin

None

L2 Back, front of thigh to knee Psoas, hip abductors

L3 Back, upper buttock, front of thigh and knee, medial lower leg

Psoas, quadriceps

L4 Inner buttock, outer thigh, inside of leg, dorsum of foot

Tibialis anterior, extensor hallucis; quadriceps

L5 Buttock, back and side of thigh; lateral aspect of leg; dorsum of foot; inner half of sole and first, second, and third toes

Extensor hallucis, peroneals, gluteus medius, ankle dorsiflexors,hamstrings, calf wasting



Root Dermatome Muscle Weakness

S1 Buttock, back of thigh, and lower leg

Calf and hamstrings; wasting of gluteus, plantar flexors

S2 Buttock, back of thigh, and lower leg

Calf and hamstrings; wasting of gluteus, plantar flexors

S3 Groin , inner thigh None

S4 Perineum, genitals, lower sacrum

Bladder, rectum


Dermatomes


Upper Extremity Dermatomes


Lower Extremity Dermatomes



Abdominal muscle strength Pelvis stabilizer strength i.e. gluteus medius and

gluteus maximusTightness or stiffness of hamstringsTightness or stiffness or hip flexorsTightness or stiffness of hip rotatorsOther specialized musculoskeletal examinations


Spurling’s Test: Cervical radiculopathy

• Extension and side-bending impinges the neural foramen and causes shootingpain down that arm


Drop Arm Test

• May be sign of rotator cuff tear

• Careful to differentiate possible weakness of deltoid versus a cervical root problem


Yergason’s Test

• Palpate the bicipital groove• Examiner provides resistance• Patient actively tries to pronate while examiner supinates/external rotates arm• Pain in groove may be sign of bicep tendinitis


Patrick’s Test

• Stresses the hip and sacroiliac joints• Same side hip pain = degenerative disease of hip• Opposite side pain may be due to SI joint dysfunction• AKA: FABER


Tinel’s sign for CTS

• Test for carpal tunnel syndrome• Tap over carpal tunnel, testing median nerve• Pain shooting down first three digits is a positive test


Phalen’s test for CTS

• Hold for 1 minute• Tests the median nerve• Pain shoots down first three digits


Straight Leg Raise

• Stretches the sciatic nerve• Positive from about 30-70 degrees• Anything greater than 70 may be due to hamstring tightness


Gaenslen’s Test

• Testing for SI joint pain• If pain is reproduced, then it is positive• Note, the symptomatic leg is off the table


Slump Test

Patient at edge of table with legs hanging down

Patient actively flexes through cervical, thoracic and lumbar spine

Examiner performs a straight leg raise

Once symptoms are elicited, the examiner asks the patient is asked to extend the cervical spine

Positive if cervical extension alleviates the symptoms

May show impaired neural tissue mobility

Sensitize with ankle dorsiflexion


Slump Test


Iliac Compression Test

• Compress directly over iliac crest• Pain on same side may be SI joint pain• Pain on opposite side may be caused by greatertrochanteric bursitis (make sure to check)


McMurray Test: Lateral Meniscal Tear


McMurray Test: Medial Meniscal Tear


Case Study

• A 65 year old female presents to your office with a 1 year history of chronic low back pain. PMHx: HTN. PSHx: None. Denies loss of bowel or bladder. MRI review shows some degenerative changes, mild neuro foraminal stenosis, moderate central canal stenosis. No signs of radicular leg pain are exhibited. Gait is intact and non antalgic. No assistive device noted. Transfers independently. Normal muscular examination and neurological examination. Denies back pain waking her up at night. No acute loss of weight. She notes when she extends her back pain is exacerbated. No buttock pain noted. You decide that there are no immediate dangers, so you send her to PT. She asks for medications. Given she has no kidney issues, liver issues, or GI bleeds, you advise her to intermittent use either Tylenol or ibuprofen and send her out. You’ll see her after PT.


Interventional Pain ProceduresINTERVENTIONAL PROCEDURE TYPES REASONS TO DO THEM

Epidurals: transforaminals and interlaminars, selective nerve root blocks, caudal

Stenosis, spondylopathy with radicular symptoms

Intercostal nerve blocks Intercostal neuritis, rib pain, post herpetic neuralgia

Peripheral joint injections (hip, knee, shoulder), piriformis injections

Hip arthritis, subacromial bursitis, shoulder arthritis, knee osteoarthritis, greater trochanteric bursitis, piriformis syndrome, iliopsoas bursitis

Sacroiliac joint injection Buttock pain

Lumbar, thoracic, and cervical rhizotomies, sacroiliac rhizotomy, facet injections

Axial pain, facet arthropathy, sacroiliac joint pain.(No radicular symptoms)

Coccyx injection Coccydynia


Interventional ProceduresINTERVENTIONAL PROCEDURE TYPES REASONS TO DO THEM

Peripheral joint rhizotomies (Genicularnerves, femoral articular branch and obturator nerve)

Knee pain post total knee, hip pain post total hip replacement, hip labral tear, AVN, hip osteoarthritis

Lumbar sympathetic blocks, stellate ganglion block

Sympathetic mediated pain, upper and lower extremity CRPS, often precedes stimulator trials/implants

Vertebroplasty, Kyphoplasty (use of balloon) Non-traumatic osteoporotic compression fracture

Intrathecal pain pumps Cancer pain, chronic pain ?

Spinal cord stimulators Failed back syndrome, CRPS, peripheral chronic nerve pain

Ganglion Impar Block Blocks relieve perineal pain from cancer of the cervix, endometrium, bladder, rectum.


How about that case?The patient comes back to you with continued low back pain. Minimal improvement after 6 weeks of PT. She is looking for

further input and your professional opinion on this pain.

What will you offer her next?

1. Live with the pain

2. Facet joint injection

3. Lumbar frequency ablation

4. Spinal cord stimulator trial

5. Early retirement


Facet joint injections, medial branch blocks, and radiofrequency ablations


Radiofrequency Ablation

• Etiology: Axial Pain w/o radicular symptoms

• 2 Medial Branch blocks vs. intraarticular injections

• Burn twice between 70-80 degrees Celsius

• Typically lasts 4-12 months; large variability


Conclusions• Level II evidence for long-term effectiveness of radiofrequency

ablation in lumbar and cervical spines, for facet joint medial branch blocks in cervical, thoracic, and lumbar spine

• Level III evidence for thoracic radiofrequency ablation, lumbar and cervical intraarticular joint injections

• Cohen, et al suggest (case control study) suggest medial branch blocks over facet joints lead to better outcomes than intra-articular joint injections 15


Lumbar Radiculopathy

• Epidemiology

• Occurs in approximately 3-5% of the population

• Men and women are affected equally

• Men are most commonly affected in their 40s

• Women are most commonly affected between ages 50-60


1

Epidurals • Widely accepted• Safety and effectiveness accepted• Literature shows most effectiveness in the first couple of weeks• Some literature shows longer than one year• Randomized controlled trials are rare• Trial designs often have low enrollees• Possible that anesthetic alone may be as effective as using

steroid and anesthetics• Suggestion that epidurals may help to decrease opioid intake in

certain groups2,3,4


Spinal Cord Stimulators

• Failed Back Surgical Syndrome (FBS) • Radicular pain syndrome or radiculopathies

resulting in pain secondary to FBS or herniated disk• Post-laminectomy pain• Multiple back operations• Unsuccessful disk surgery• Degenerative Disk Disease (DDD)/herniated disk

pain refractory to conservative and surgical interventions

• Epidural fibrosis• Arachnoiditis or lumbar adhesive arachnoiditis• Complex Regional Pain Syndrome (CRPS)• Peripheral nerve pain ?About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References

Spinal Cord Stimulation

• Should be a last resort

• Requires a trial prior to implantation

• Psychological work up needed

• Ability to operate the programming is important


Spinal Cord Stimulators: Possible Benefits

• Long-term pain relief

• Improved quality of life

• Successful pain disability reduction

• May be less expensive and more clinically effective that re-operation for failed back surgical syndrome

• Decreased opioid usage

• Decreased reported subjective pain scores

7 ,8, 9


We’ve come a long way…


Case Study• A 39 year old male construction worker presents to your office.

PMHx and PSHx unremarkable. He is used to some amount of low back pain but now has developed pain down the right leg. States that it has been going on for 8 weeks. No loss of bowel or bladder. Started gradually and has worsened. He feels subjectively weak in the right lower extremity. Burning pain. History reveals no red flags. He has slight weakness in right quadriceps. No atrophy noted. Antalgic gait, off-loading the right leg. No assistive device needed. You sent him to PT for a few weeks (traction and therapeutic exercises) with no improvement in pain. MRI without contrast ordered.


Lumbar MRI findings


Physical examination

• 4/5 in right knee extension

• No wasting noted

• Decreased right patellar reflex


Question #1

What nerve root is affected?

a. L2b. L3c. L4d. L5e. S1


What do you do next?

• Right L4 epidural• Consideration of multiple

(2-3)• Have him complete PT• If all fails, referral to for

surgery consultation


Medical Cannabis


Cannabinoids: Subgroups

1. Endogenous endocannabinoids

2. Botanicals (phytocannabinoids): 60 identified

3. Synthetic Derivatives


Dr. Raphael Mechoulam discovers the first cannabinoid Δ-tetrahydrocannabinol (THC) in 1964

Endocannabinoid System

• ECS modulates the sensitivity to neurotransmitters like NE and serotonin

• Human experience of pain and response to stress involves interaction of endocannabinoids through endorphins and cortisol release

10About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References

Important Receptors: Research for the FutureCB1:

• Accounts for psychotropic action of THC and its analgesic effects.

• Pre-synaptic activation of CB1 inhibits GABA (“Stop”) or Glutamate (“Go”) pathways.

• Present in areas of the brain and play a role in memory, mood, sleep, appetite and pain sensation.

CB2:

• Theorized to modulate persistent inflammatory and neuropathic pain conditions.


FDA Approved Synthetic Cannabis Pharmaceuticals Dronabinol (Marinol): 1986

• Synthetic Delta-9 THC

• FDA approved for treatment of nausea and vomiting for patients in cancer treatment, appetite stimulant for AIDS patients, analgesics to ease neuropathic pain in multiple sclerosis patients

Nabilone (Cesamet):

• Synthetic cannabinoid similar to THC

• FDA approved for treatment of nausea and vomiting in patients undergoing cancer treatment


Pharmacology and Pharmacokinetics of THC13

• Major psychoactive delta-9 tetrahydrocannabinol (THC)

• Oral: Low bioavailability (6-20%). Peak plasma concentrations after 1-6 hours and half life of 20-30 hours.

• Inhalation: Peak concentration of THC occurs in 2-10 min and rapid decline for 30 minutes.


Minnesota: Approved Conditions for Medical Cannabis

• Cancer associated with severe/chronic pain, nausea or severe vomiting, or severe wasting

• Glaucoma• HIV/AIDS• Tourette’s Syndrome• Amyotrophic Lateral Sclerosis (ALS)• Seizures including those including those characteristic of epilepsy• Severe muscle spasms including those characteristic of multiple sclerosis• Crohn’s Disease• Terminal illness, with a life expectancy of less than one year, if the illness or treatment

produces severe/chronic pain, nausea or severe vomiting, cachexia or severe wasting• Intractable Pain• Post-Traumatic Stress Disorder (PTSD)


Arizona: Approved Conditions• Acquired immune deficiency syndrome (AIDS) • Amyotrophic lateral sclerosis (ALS)• Crohn's disease • Human immunodeficiency virus (HIV) • Agitation of Alzheimer's disease • Cancer• Glaucoma• Hepatitis C• Post-Traumatic Stress Disorder (PTSD) • IF A CHRONIC OR DEBILITATING DISEASE OR MEDICAL CONDITION OR THE

TREATMENT FOR A CHRONIC OR DEBILITATING DISEASE OR MEDICAL CONDITION CAUSES: Cachexia or wasting syndrome, severe and chronic pain, severe nausea, seizures, including epilepsy characteristics, severe or persistent muscle spasms, including those characteristic of multiple sclerosis


Medical Cannabis

• Inhaled as smoke or vapor

• Liquid or oral extracts

• Topicals/Balms: CBD only (federally legal)


Smoked or Vaporized Cannabis11

• Rapid onset, short duration of action

• RCT are limited to short time frames and small patient populations

• One study showed smoked cannabis increased pain tolerance

• Another study showed no therapeutic effect against a pain stimuli at 2% THC but increased pain experience at 8%. Suggestion of a therapeutic window

• Multiple studies looking at HIV neuropathy or neuropathic pain are promising for decrease in VAS pain rating


Oral and Oral-Mucosal Cannabis11

• Longer onset, longer duration of action

• Variable duration effects

• Effects vary among different populations

• Study: Women with higher estrogen responded with better pain relief

• Study: Men appeared to have better pain relief response


THC: CBD11 Ratios

• Cannador® cannabis extract (various THC: CBD). Phase III RCT of 2THC: 1: CBD n=630. Decrease in pain related to spasms.

• Nabixamols (Sativex®) THC: CBD Multiple studies demonstrate pain relief in chronic pain. Suggestion that combination is more effective than THC alone.


Dosing

• Complex question

• There is no standardized dosing

• Variable as each person is different (genetics of endocannabinoid system, metabolism, tolerance, past exposure)

• Conversion from smoked to oral dosing unknown

• Titrate slowly


Short Comings

• Products also are not standardized

• Ratios of THC: CBD not well understood in terms of most appropriate dosing• The most popular theory is that the more neuropathic and inflammatory pain issues

do better with higher THC while the most chronic, intractable wide musculoskeletal pain does better with higher CBD.

• Drug-Drug interactions can occur

• Side Effects

• Long term effects are unknown

• Cost prohibitive

• Legal issues: Federal Vs. State


Drug-Drug Interactions13

• Potentiate CNS depressant effects with benzodiazepines, alcohol, opioids

• Possible mania induced when combined with SSRIs

• Increased tachycardia and delirium with TCAs and sympathomimetics

• Increase risk of immunosuppression with corticosteroids

• May decrease effectiveness of anti-psychotics


Side Effects and Risks

• Impairment of memory (cognitive change), decrease motor coordination, altered judgement

• High dosing of THC may cause psychosis

• Increased heart rate

• Nausea and vomiting (“cannabinoid hyperemesis syndrome”)

• Dry mouth

• Dizziness and headache

• Sedation

10, 11, 13About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References

Side Effects and Risks• Dependence and addiction

• Increased risk of pulmonary issues (similar to smoking)

• Increased risk of lower birth weights, possible affect on neurodevelopment

• Possible increased risk of cancer

• Increased risks of traffic accidents

• May cause liver fibrosis in HCV patients

• May cause acute pancreatitis

• Withdrawal symptoms10, 11, 13


The Final Question

A 35 year old male comes to your clinic with complaints of global wide spread pain. He is a poor historian but further digging into his chart, discussion with former clinicians, and further probing of the patient the true details of his history come to light. He has a history of chronic low back pain, global wide spread pain, history of substance abuse, and schizophrenia. He has a long history of non compliance with treatment plans, well-documented acute psychotic episodes, and the current use of Zyprexa, a second generation anti-psychotic.

Is this a good candidate for medical cannabis?

1. Yes.

2. No.


The future of cannabis

• With the liberalization of use, it is important well-done, double blinded RCT are done and that their length of study is substantial

• Possible that using specific cannabinoids for specific conditions may prove beneficial14

• Goal: Decrease pain. Do not exchange one epidemic for another


Medical Cannabis: Summary • Every patient deserves care that is safe and based on medical evidence

• Limited moderate-level evidence reveals some promising use in pain13

• Conflicting literature13

• Observational studies find a decrease in opioid addiction and overdoses in states that legalize12

• May act synergistically with opioids11

• Lack of high quality, long term clinical trials12

• Considered an experimental drug

• Death has not be associated with use of medical cannabis

• There are risks


The End


Thank you for your time!

•Contact information: [email protected]


mailto:[email protected]

References1. Taruli AW, Raynor EM. Lumbosacral radiculopathy. Neurol Clinic 25 (2): 387-405.

2. Bayer, F et al. Non-operative treatment of lumbar spinal stenosis. (2016). Technology and Health Care, 551-557

3. Manchiakanti, L et al. Transforaminal epidural injections in chronic lumbar disc hernation: A randomized, double-blind, active-control trial. (2014). Pain Physician, 17: E489-E501.

4. Zhai, J et al. Epidural Injection with and without steroid in managing chronic low-back pain: A Metanalysis of 10 randomized controlled trials. (2017). American Journal of Therapeutics 24, e259-e269.

5. Manchiakanti, L et al. A Systemic Review and Best Evidence Synthesis of Effectiveness of Therapeutic Facet Joint Interventions in Managing Chronic Spinal Pain. (2015). Pain Physician, 18: E535-582.

6. Kumar, K et. al. The effects of spinal cord stimulation in neuropathic pain are sustained: a 24 hour follow-up of the prospective randomized controlled multicenter trial of the effectiveness of spinal cord stimulation.( 2008) . Neurosurgery. 63(4):762-770.

7. Harke, H et .al. Spinal cord stimulation in sympathetically maintained complex regional pain syndrome type I with severe disability. A prospective clinical study. Eur J Pain. (2005). 9(4);363-373.

8. North RB, Kidd D, Shipley J, Taylor RS. Spinal cord stimulation versus reoperation for failed back surgery syndrome: a cost effectiveness and cost utility analysis based on a randomized, controlled trial. Neurosurgery. 2007;61(2):361-369

9. Sanders, R et. al Patient Outcomes and Spinal Cord Stimulation: A Retrospective Case Series Evaluating Patient Satisfaction, Pain Scores, and Opioid Requirements. Pain Practice (2016). Volume 16, Issue 7, 899-904.

10. Kim, P and Fishman, M. Cannabis for Pain and Headaches: Primer. Curr Pain Headache Rep. (2017). 21:19 3-11.

11. Andrade, C. Cannabis and Neuropsychiatry, 1: Benefits and Risks. J Clin Psychiatry. (2016). 77: 5 e551-554.

12. Choo, E. Opioids Out, Cannabis In: Negotiating the Unknowns in Patient Care for Chronic Pain. JAMA. (2016). Volume 316, November 17: 1763-1764.

13. Parmar, J. et al. Medical Cannabis patient counseling points for health care professionals based on trends in the medical uses, efficacy, and adverse effects of cannabis-based pharmaceutical drug. Research in Social and Administrative Pharmacy 12. (2016). 638-654.

14. Goldenberg, M. Et. Al. The impact of cannabis and cannabinoids for medical conditions on health related quality of life: a systemic review and meta-analysis. Drug and Alcohol Dependence. 174 (2017). 80-90.

15. Cohen, S. et. Al. Medial Branch Blocks or Intraarticular Injections as a Prognostic Tool Before Lumbar Facet Radiofrequency Denervation. Regional Anesthesia and Pain Medicine. (2015). Volume 4, Number 4: 376-382,.


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