An approach to Low Back Pain and Neuropathic Pain

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					An approach to Low
  Back Pain and
 Neuropathic Pain
    Russ O’Connor
FRCPC (PMR), CASM, EMG
                  Objectives-
By the end of the session the participant will be able to:

Outline common causes of low back pain in the
Paralympic athlete

Discuss things not to miss in Paralympic athletes with
low back pain- the so called RED FLAGS

Discuss treatment suggestions for athletes with low back
pain

Discuss how to manage neuropathic pain in the athlete
with a disability
       Why is LBP worth talking
               about?
Common
    81% of AK and 62% BK amputees1
    ** of SCI
    Prevalence in athletes ranges from 10 to 35%
Affects QOL/ sleep/ PERFORMANCE

Physical findings different?

Previous surgery
1Kulkarni   et al Clin Rehab. 2005; 19:81-6.room
                 Mr. A.S.
30 yo paraplegic sit skier- L2 burst # fused
with Harrington rods and right femur #
Long standing pain right thigh and shin.
Increased training since torino
   Pain increased
   Spasms increased
   New feeling in post thigh and new muscle
    bulk right glut
                   Mr. AS
Pain
   Burning and electric shoot pain down thigh
    medial shin and foot

   Increased with workouts and ski days esp at
    night

   Settled with rest and gabapentin
                 Mr. AS
Bowel and bladder- no recent fu

Right post thigh pain and swelling with
stretch

Meds –
   Gabapentin 900-600-900
   Baclofen 5 bid
   Sedated
            Mr. AS- Exam
LNSL L1 right and left   Level   Right   Left
but has some feeling
to L3                    L2      0       4
Some flickers of         L3      1       1
abduction on right
                         L4      0       0

                         L5      0       0

                         S1      0       0
 What do you want to know?
What makes you worried?
RED FLAGS for LBP in athlete
      with a disability
Progressive pain             Increased



Weight loss                  None



Fevers or ssx of infection   None
RED FLAGS for LBP in athlete
      with a disability
CHANGE in:
   Motor or sensory function      New post thigh
                                   sensation and bulk
      Muscle bulk or new atrophy
      fasciculation's

                                   None
   Bowel or bladder function

   Spasticity                     Increased
                    Mr. AS
Careful History - physical
   Increased pain
   improved in motor sensory function
   No new atrophy or fasciculation's
   No change in bowel or bladder function
      But no recent follow-up
   Increased in spasticity or tone
What do you think is wrong with
          Mr. AS?
MSK
    Spinal
       Hardware issue or instability
       Fracture –
       Facet degeneration
       Spondylolysis or Spondylolisthesis
       Deg disc disease – discogenic pain
       Mechanical LB muscle Strain – overuse

    Peripheral
       Buttock / hip
       SI
       Femur – rod, muscle
What do you think is wrong with
          Mr. AS?
Neuro
    Spinal cord
       Syrinx
       SC compression from disc or central stenosis or infection
       Central segmental neuropathic pain


    Nerve root
       Disc or osteophyte


    Peripheral nerve
       Pelvis, buttock
                            Mr. AS
    Imaging – What would you order
1      XR spine – no loosening

       Bone scan –

3      CT – best for bone trauma, fast, cheaper

2      MRI – best for disc or cord

       Urology follow up
                     MRI
 best for disc or cord but hardware really
interferes with quality

   L2 central stenosis and at L4/5 as well

   Significant artifact making comments on the
    rest of the structures difficult
         Treatment - Mr. AS
Goals to allow RTP with less pain and
spasms- depends on diagnosis
   Conservative – Stretching/ strengthening / PT
    etc
   Medications oral –
   Medications injections
      Trigger
      Epidural
      Botox
   Surgery?
                  Mr. AS
Oral medications
   Spasms – Baclofen 5 bid
   Pain - Gabapentin 900/600/900

Seemed to be enough for awhile but
returned with more pain after training

Increased gabapentin and baclofen at
night
              Mr. AS

Discussed with team

Saw – Neurosurgery
          Mr. AS Returns
Increased pain – having to take more time
off



Central stenosis at L2 with preserved L5
function clinically and L4/5 pain pattern.
                      Mr. AS
Other options
   Decrease training – competition
   Increase or change medications
   Trial of injections
      Trigger point
      Nerve root
      Epidural
                    Mr. AS
After L2 epidural steroid
   Neuropathic shooting and burning pain down
    legs much better

   Still has activity related axial back pain

   Spasms persist



                                       Prohibited list
L1
L2
                  Mr. AS
CT scan shows
   fused Tspine to L4
   Severe stenosis at L2
   Widening of disc space and moderate L4/5
    canal stenosis
   Severe foraminal stenosis at L4.5 and mod at
    L5-S1
            Mr. AS- Update
Going for second injection
   Still on Gabapentin and Baclofen


Has seen neurosurgery for opinion

Will consider L4/5 injection
                    Neuropathic pain
Why is it worth talking about?

     Common-
            2-3 % general population

           SCI 54% at 6 months and 75% @5y 1

           Amputee 79.9%2

1MM   Backonja and Jordi Serra. Pain Medicine 2004; 5: S1 PS48-S59.
2Ephraim   et al. Arch of Phys Med and Rehab 2005; 86:10, P 1910-19.
                  Neuropathic pain
   Disabling- QOL, sleep, exercise, work, ADLs3

   Constant in up to 40% of people with SCI

   10% report severity of pain not paralysis prevents
    employment

   83% people with SCI who are employed state pain
    interferes with work

   Performance!!


    3Widerstrom-Nog et al. Arch Phys Med Rehab 2001;82:1271-7.
           Neuropathic pain
What is it?

   IASP = "pains resulting from disease or
    damage of the peripheral or central nervous
    systems, and from dysfunction of the nervous
    system”
             Neuropathic Pain
Central
   Brain
   SCI


Peripheral
   Root
   Plexus
   Nerve
Classification - Spinal cord injury –
         Neuropathic pain
Above Level
    Compressive neuropathy arms


At Level
    Radiculopathy
    SCord- syrinx, segmental injury


Below Level
                    Mr. AS
What kind of pain does Mr. AS have?

   Below the level of injury -
       Neuropathic pain


   Axial Low back pain –
      Nociceptive – musculoskeletal
                     Ms. BK
24 yo woman traumatic amputation right
below knee in a bicycle accident 3 y ago
   Medically well

   Pain right leg over distal residual limb, focal
    severe tenderness, with pressure or touch –
    severe shooting and stabbing pain

   Pain over right foot- feels like foot is being
    crushed and occasionally like it is burned
What type of pain does Ms. BK
            have?
     Classification – Amputee
        Neuropathic Pain

Phantom limb pain

Residual limb pain – stump
     Neuroma

  Other MSK causes for limb pain- Not neuropathic in origin
                    Skin, muscle, bone, joint, ligament
               Presentation
Description

   Burning, shooting, lancinating, electric, itching

   Stimulus evoke pain –
      hyperalgesia – hurts more than it should
      Allodynia – ALL - everything hurts
             Pathophysiology
Peripheral
   Nerve injury and regeneration – neuroma
   Neuronal sprouts – aberrant depolarization and
    increased expression of Na channels and voltage
    gated Ca ch
      Release of Sub P and glutamate
Central
   Central Spinal sensitization – NMDA receptor
   Periaquaductal gray matter can modulate and
    suppress or accentuate pain- opioid receptors
   Altered connectivity – inapprop connections
CMAJ • August 1, 2006 • 175(3) | 269
                  Investigations
Look for treatable causes
   Peripheral nerve, plexus, root, SCI or brain causes
   Systemic conditions
      Diabetes, B12, thyroid, renal and liver disease
      Infectious processes- shingles,
      Toxic, nutritional defic
   Focal conditions
      Peripheral compression – carpal tunnel, ulnar,
      radiculopathy, SCI
      Nerve or SCI abnormality – tumor syrinx etc
      Treatment



Look for underlying cause!
                Treatment
Nonpharmacologic- desensitization,
contrast baths, TENS, CBT, meditation,
acupuncture
Pharmacologic –
   First-line- tricyclic antidepressant or
    gabapentin
   Second line – consider switching or adding
    adjuvant agent
   Third line – opioids* banned
     Neuropathic pain in SCI
 TCA’s less effective

There is level 1 evidence (based on two
 RCTs) that tricyclic antidepressants do
 not reduce post-SCI pain.

GO WITH NEURONTIN OR LYRICA IN SCI
                  Objectives-
By the end of the session the participant will be able to:

Outline common causes of low back pain in the
Paralympic athlete

Discuss things not to miss in Paralympic athletes with
low back pain- the so called RED FLAGS

Discuss treatment suggestions for athletes with low back
pain

Discuss how to manage neuropathic pain in the athlete
with a disability
RED FLAGS for LBP in athlete
      with a disability
Progressive pain

Weight loss

Fevers or ssx of infection
RED FLAGS for LBP in athlete
      with a disability
CHANGE in:
   Motor or sensory function
      Muscle bulk or new atrophy
      fasciculation's


   Bowel or bladder function

   Spasticity
Questions?
S9. GLUCOCORTICOSTEROIDS
All glucocorticosteroids are prohibited when administered orally,
rectally, intravenously or intramuscularly. Their use requires a
Therapeutic Use Exemption approval.
Other routes of administration (intraarticular /periarticular/
peritendinous/ epidural/ intradermal injections and inhalation)
require an Abbreviated Therapeutic Use Exemption except as noted
below.
Topical preparations when used for dermatological (including
iontophoresis/phonophoresis), auricular, nasal, ophthalmic, buccal,
gingival and perianal disorders are not prohibited and do not require
any form of Therapeutic Use Exemption.

The Prohibited List 2008 September 22, 2007 9
                     References:
Return to play after lumbar spine conditions and surgery. Clinics in sports
medicine – volume 23, issue 3, July 2004.
Lower back pain in the athlete: Common conditions and treatment primary
care: Clinics in office practice – volume 32, issue one, March 2005.
Management of back pain in patients with previous back surgery. The
American Journal of medicine – volume 121, issue 4, April 2008.
Chronic low back pain in traumatic Bourland amputees. Clinical
rehabilitation: 2005; 19: 81 to 86.
Pharmacologic management part two colon lesser studied neuropathic pain
diseases. Pain medicine volume 5; number S1: 2004.
Chronic pain management in spine disorders. Neurologic clinics – volume
25, issue to, may 2007.
 John Scadding. Review article – neuropathic pain. ACNR: Volumes 3;
number 2 – may – June 2003.
S.C.I R. E.- chapter 14 pain and spinal cord injury.-
http://www.icord.org/scire/pdf/SCIRE_CH14.pdf

				
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