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Pain management in spinal cord injury - PowerPoint

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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
SCVMC
               Incidence of pain

   65 - 95% of SCI individuals experience pain
     50%   musculoskeletal

     30%   neurogenic

   5-45% experience severe disabling pain
                  Incidence of pain

   More common in patients with:
     Injuries   due to gunshot wounds and violence
     Lower   level of injury
     Incomplete    SCI?
     Spasticity
              Psychosocial factors

   Depression / Sadness
   Adjustment disorders
   Anger
   Anxiety
   Stress
                Patient evaluation

   Detailed history
     quality of pain
     distribution of pain
     relieving factors
     aggravating factors

 Physical examination
 Diagnostic tests
      Pain syndrome classification

   Musculoskeletal

   Neuropathic

   Visceral
              Pain classification

   Above the level

   At the level

   Below the level
    Musculoskeletal pain syndrome

   Bone, joint, muscle trauma

   Tendon inflammation

   Muscle spasm

   Overuse syndrome

   Instability of spine
           Vertebral column pain

 Neck, middle back, low back pain
 Spine deformities
 Arthritis
 X-rays
     evaluate instrumentation placement
     evaluate degenerative changes
     Mechanical instability of spine

   Most common after cervical spine injury

   Due to injury to ligaments, fx of spine

   Pain around the spine
         Treatment for mechanical
            instability of spine

   Relieved by immobilization
     Rest,   bracing
   Medications
     Anti-inflammatory   medication
       Opiates
   Surgical fusion
Trigger points
              Muscle spasm pain

 Pain with visible and palpable spasms
 Anti-inflammatory medications
 Anti-spasticity medications
     Baclofen
     Zanaflex

   Anti-spasm medications
     Flexeril,   Robaxin, Skelexin
    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
                  Shoulder pain

   50-95% prevalence
   Secondary to:
     Weight   bearing
     Overuse

     Muscle   imbalance
Shoulder pain: Differential diagnoses

   Rotator cuff tendinitis and tear

   Muscle pain

   Radiculopathy

   Arthritis
                  Elbow / Hand pain

   Elbow pain (32%)
   Hand pain (48%)
   Differential diagnosis
     Epicondylitis   / tendinitis
     Olecranon    bursitis
     Arthritis
     CTS,   Ulnar nerve entrapment
                  Diagnostic tests

   Physical examination

   Plain x-ray

   MRI

   EMG
          Treatment options

 Rest
 Therapeutic exercises
 Modalities
 Changes in positioning, ergonomics
 Changes in equipment
 Splints
 Weight reduction
                 Treatment options

   Anti-inflammatory medication

   Opioids

   Injections

   Acupuncture

   Surgical release for CTS
             Neuropathic pain

 Nerve   root entrapment
 Syringomyelia

 Transitional   zone pain
 Central   dysesthesia syndrome
 Nerve   entrapment syndrome
        Nerve root pain / radicular

   Unilateral pain in the single nerve root
    distribution
   At the level of spinal trauma
   Pain since the time of injury
   Lancinating, burning, stabbing, shooting,
    paroxysmal, allodynia, hyperesthesia
                   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
                    Case study

   MRI:
     C2-3posterior osteophytes causing right-sided
     foraminal narrowing
   Treatment
     NSAIDs
     Trigger point injection
     Instructed patient to reposition the computer
      monitor to midline
        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
         Central pain syndrome

 Pain   below the level of injury
 Constant

 Fluctuates   with mood or activity
 Responds     poorly to medications or other
 treatment
    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
              Pain description

   Tingling
   Shooting
   Stabbing
   Squeezing
   Pressure
   Cold
   Numbness
   Muscle cramp
          Exacerbating factors

 Noxious stimuli below the level of injury
 Fatigue
 Lack of distraction
 Smoking
 Psychological stress
 Overexertion
 Weather changes
      Nerve entrapment syndrome

   Carpal tunnel syndrome
   Ulnar nerve entrapment
     at   the wrist
     across    the elbow

   Radial nerve entrapment
   Nerve entrapment syndrome:
           risk factors

 Use   of assistive devices
 Routine   pressure relief
 Weight   shifts
 Transfers

 Wheelchair   mobility
          Syringomyelia (Syrinx)

   Delayed onset, years
   New neurological deficits
   Constant, burning pain
   Pain to touch
   Diagnosed with MRI
   Treatment: shunt
                Treatment

 Pharmacological
 Nerve blocks
 Physical
 Surgical
 Stimulation techniques
 Psychological
 Acupuncture
     Pharmacological treatment

 Anticonvulsants

 Antidepressants

 Alpha-adrenergic    agonists
 Opioids

 Anti-spasticity   medication
         Anti-seizure medications

   Carbamazepine (Tegretol)
   Valproate
   Gabapentin (Neurontin)
   Trileptal
   Topamax
               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
      Anti-spasticity medication

 Relief   of muscle spasms

 Baclofen

 Clonazepam

 Dantrium
     Alpha adrenergic agonists

 Relief   of neuropathic pain

 Clonidine

 Zanaflex
                  Capsacin

 Topical

 Applied   to skin overlying the painful area

 Deplete   peptides that cause pain from
 nerve ending
                         Opioids

   May be used in neuropathic pain
   Side effects
     Physical   dependency
     Severe   constipation
     Mild   cognitive impairment
     Risk   for addiction
                   Therapy

 Positioning

 Modify   transfer techniques
 Splinting

 Padded    gloves / elbow pads
 Exercise    routines
            Other interventions

 Acupuncture

 TENS     unit

 Spinal   cord stimulator

 Dorsal   rhizotomy
                  TENS unit

 Electrical   stimulation on skin
 More   effective at the level of injury?
 Requires     a therapist for set-up
            Spinal cord stimulator

 Not   generally helpful with SCI pain
 More  effective with transitional zone or
  radicular pain
 Initial   improvement in 20-75% of patients
 Long      term efficacy in 10-40%
          Surgical intervention

 Spine   stabilization

 Removal    of instrumentation

 Decompression     of impinged nerve roots

 Decompression     surgery for syrinx
          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
         Psychological treatment

 Psychological    assessment
 Cognitive   behavioral therapy
 Relaxation   techniques
 Biofeedback

 Peer   support
                   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
       Visceral pain etiologies

 Kidney   stones
 Bowel   dysfunction (constipation)
 Appendicitis

 Gallbladder   stones
 Gynecological
          Contact Information

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

				
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posted:3/26/2008
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