pain syndromes: back pain and sciatica - western · pdf file•ct plus myelography ....
TRANSCRIPT
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Low Back Pain and
Sciatica
Gareth Shemesh, MD
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Low Back Pain: Epidemiology
• 60%–90% lifetime prevalence
• Second most common complaint to prompt a medical evaluation
• Leading cause of long-term work disability
• US healthcare costs: $33 billion/y
• Disability and costs related to pain, not to the disease process
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Disk Herniation With Sciatica
• 90% of ruptured disks at L4-L5 and L5-S1
• 90% of patients with back pain and sciatica will recover without surgery
– At least 50% within 6 wk
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Low Back Pain and Sciatica: Nociceptive/ Inflammatory Pain
Mechanisms
• Activation and sensitization of the nerve root nervi nervorum from root compression/traction
• Sensitization of the nociceptors of the annulus fibrosus, periosteal spinal structures, and ligaments, due to acute inflammation, eg, status post trauma
• Hyperalgesia (deep spinal and dermatomal) due to central sensitization
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Radicular and Discogenic Neuropathic Pain Mechanisms
• Ectopic activity of the nerve root nervi nervorum
• Sensitization and ectopic activity of the nociceptors innervating spinal periosteal structures, ie, annuli and ligaments
• Possible role of abnormal nociceptors overgrown within the intradiscal space, postsurgical epidural scars, degenerated facet joints
• CNS sensitization and reorganization
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Failed-Back-Surgery Syndrome
Reoperations
• 60% due to post–spinal surgery complications
• 40% due to uncorrected or new structural abnormalities of the spine
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Failed-Back-Surgery
Syndrome Postsurgical causes of back pain
• Recurrent or retained disk fragment
• Postoperative instability
• Dural adhesions
• Root injury
• Arachnoiditis
• Pseudomeningocele
• Failure to relieve the original pathologic condition
• Postoperative wound and disk infection
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Back Pain and Sciatica: Comprehensive Assessment
• History
–Medical
–Psychosocial
–Family
–Previous trials
• General examination
–Musculoskeletal
–Neurologic
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Back Pain and Sciatica: Pain Assessment
• Description
• Duration
• Intensity
• Alleviating factors
• Aggravating factors
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Assessment of Patients With Low Back, Hip, and Leg Pain
• Neurologic exam
– DTRs, strength, sensitivity, gait
• Regional exam of spine and leg
– Inspection for scoliosis or skin rash, palpation for bone tenderness
• Sciatic- and femoral-nerve stretching tests
– SLR, reverse and contralateral SLR maneuver
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Assessment of Patients With Low Back, Hip, and Leg Pain
• Provocative mechanical joint tests
– Truncal flexion for discogenic pain or spine instability
– Truncal extension for facet joint disease
– Patrick’s maneuver for hip disease (FABER test of both hips for SI joint disease)
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Back Pain and Sciatica: Imaging Evaluation
• Lumbosacral x-ray studies with flexion/ extension/oblique views
• MRI of the spine
• CT with 3-D reconstruction
• CT plus myelography
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Assessment of Chronic Back Pain and Sciatica: Diagnostic
Blocks • Facet blocks to rule out facet joint
pain
• Provocative diskograms or disk blockade to rule out discogenic pain and pain associated with segmental spinal instability
• Selective root blocks to determine location of root pain generator
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Assessment of Acute Back Pain and Sciatica: “Red Flags”
• Nighttime pain, fever, weight loss, history of cancer
• Fever, IV drug abuse
• Bladder, bowel dysfunction; leg weakness
• Trauma
• Neoplasm
• Infection (diskitis, epidural abscess)
• Cauda-equina syndrome
• Compression Fx
History Possible Diagnosis
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Back Pain and Sciatica
MRI of the spine if patient demonstrates
• “Red flags”
• Neurologic deficits or progressive neurologic signs and symptoms
• Pain persisting more than 6 wk
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Management of Acute and Chronic Back Pain
General considerations • Primary therapy related to etiology • Patient expectations • Patient education related to pain
treatment • Pain treatment cost-effectiveness • Prevention of back pain exacerbations • Prevention of unnecessary surgery and
suffering (failed-back-surgery syndrome)
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Management of Back Pain
• Pharmacologic agents
– Opioid analgesics
– Anti-inflammatories
– Adjuvants and nonopioid analgesics
• Nonpharmacologic therapies
– Rehabilitative
– Interventional
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Management of Back Pain
• Comprehensive assessment of patients is essential to form the appropriate treatment plan.
• In the majority of cases, pharmacologic treatment is the main approach.
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Management of Acute Back
Pain
• Overall, 90% of patients will recover within 2 months without need for any invasive procedure.
• The management of acute back pain without sciatica or neurologic deficits calls for a conservative approach with analgesics and no bed rest.
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Management of Acute Back
Pain • With sciatica and no neurologic deficits
– Conservative management with analgesics
– Bed rest for 2–3 d
– Activities as tolerated
– Neurologic consultation as needed
• With sciatica and positive neurologic deficit – Individualized length of rest
– Analgesics
– MRI study plus urgent neurologic or emergent neurosurgical evaluation, according to progression of deficits and symptoms
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Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
• Inhibition of cyclooxygenase activity
• COX-1 and COX-2 drugs
• Toxicity: Gastrointestinal, renal, platelet aggregation
• Multiple drugs
• “Ceiling” dose effect
• Peripheral and central analgesic action
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Acetaminophen
• Minimal anti-inflammatory action
• Central analgesia
• No GI or platelet-aggregation toxicity
• Serious dose-dependent hepatotoxicity
• “Ceiling” dose effect
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Disabling Back Pain: Opioid Therapy
• Consider opioid responsiveness
• Dosing: Short-acting plus long-acting or controlled-release opioid preparations
• In-hospital dose titration for severe cases: IV PCA technique
• Consider opioid rotation
• Combine with physical therapy and other analgesics
• Consider cost
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Chronic Back Pain: Opioid Therapy
Combination products
• Codeine
• Oxycodone
• Hydrocodone
• Dihydrocodeine
Single-entity agents
• Fentanyl
• Levorphanol
• Methadone
• Morphine
• Oxycodone
• Hydromorphone
• Tramadol
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Acute and Chronic Back Pain: Opioid Therapy
Short-acting opioids
• Combination products
• Hydromorphone
• Morphine
• Oxycodone
• Oral transmucosal fentanyl
• Tramadol
Long-acting opioids
• Morphine CR
• Oxycodone CR
• Fentanyl CR
• Methadone
• Levorphanol
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Chronic Back Pain: Opioid Therapy
• Discuss
– Addiction
– Physical dependence
– Tolerance
– Side effects
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Nonopioid Adjuvant Analgesics
• Antidepressants
– TCAs (nortriptyline, amitriptyline, desipramine)
– SSRIs (paroxetine, sertraline, fluoxetine)
– Venlafaxine
• Alpha 2-adrenergic agonists
– Tizanidine, clonidine
TCA = tricyclic antidepressant; SSRI = selective serotonin reuptake inhibitor
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Nonopioid Adjuvant Analgesics
– Gabapentin
– Carbamazepine
– Clonazepam
– Valproate
– Lamotrigine
–Tiagabine
–Topiramate
–Oxcarbazepine
–Zonisamide
–Mexiletine
Antiepileptics and Antiarrhythmics
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Rehabilitative Therapies for Back Pain
• Exercises for strength and flexibility
• Weight-control management
• Behavioral relaxation techniques
• Alternative medicine and physiatric modalities
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Interventional Pain Medicine and Spinal Surgeries
• Intrathecal infusion devices
• Spinal cord stimulator
• Percutaneous radiofrequency denervation
• Neurolytic procedures
• Diskectomy
• Decompression (laminectomy, foraminotomy)
• Spinal stabilization
• Vertebroplasty
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Chronic Back Pain: Conclusions
• High prevalence and major socioeconomic cost
• Numerous therapies, which should be individualized and based on detailed assessment
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Back Pain and Sciatica:
Conclusions • Patients experiencing back pain
and sciatica should receive a comprehensive assessment and prompt, effective treatments.
• Contemporary standard care of back pain and sciatica may include the use of opioid analgesics.
• Invasive therapeutic options must be limited to a few carefully selected patients.
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Questions?