Download Pain in patients with spinal cord injury

Pain in patients with spinal cord injury
Naveen Kumar
Specialist Registrar in Spinal injuries &
Rehabilitation
Scope of the problem
l
47 – 96 (avg 66) % of SCI individuals experience pain ( Ref 19791995- 8 studies)
n
50% musculoskeletal
n
30% neurogenic
l
5 - 45% experience severe disabling pain
l
94% chronic pain
l
Comparative Neglect: Pain 2400 ( 1977-1997), 19 pain in SCI
Incidence of pain
l
More common in patients with:
n
Injuries due to gunshot wounds and violence
n
Lower level of injury
n
Incomplete SCI ?
n
Spasticity
Psychosocial factors
l
Depression / Sadness
l
Adjustment disorders
l
Anger
l
Anxiety
l
Stress
Patient evaluation
l
Detailed history
Quality Of Pain
n Distribution Of Pain
n Relieving Factors
n Aggravating Factors
n
l
l
Physical examination
Diagnostic tests
Pain syndrome classification
l
Musculoskeletal
l
Neuropathic
l
Visceral
Pain classification
Neuropathic
l
Above the level
l
At the level
l
Below the level
At-level Neuropathic pain
segmental
end-zone
Radicular
Mechanisms
– nerve root
compression/trauma
– spinal cord damage
– generation of nerve
activity
Below-level Neuropathic pain
l
l
l
l
central
dysaesthetic
remote
Phantom
Below-level Neuropathic pain
Mechanisms
l – Spinal cord and brain
l – Loss of inhibition
l – Sensitization of nerve cells
l – reorganisation?
Musculoskeletal pain syndrome
l
Bone, joint, muscle trauma
l
Tendon inflammation
l
Muscle spasm
l
Overuse syndrome
l
Instability of spine
Vertebral column pain
l
l
l
l
Neck, middle back, low back pain
Spine deformities
Arthritis
X-rays
evaluate instrumentation placement
n evaluate degenerative changes
n
Mechanical instability of spine
l
Most common after cervical spine injury
l
Due to injury to ligaments, fx of spine
l
Pain around the spine
Treatment for mechanical instability of spine
l
Relieved by immobilization
n
l
l
Rest, bracing
Medications
n
NSAIDs
n
Opiates
Surgical fusion
Muscle spasm pain
l
l
l
Pain with visible and palpable spasms
Anti-inflammatory medications
Anti-spasticity medications
Baclofen
n Tizanidine
n
Secondary overuse syndromes
l
More common in paraplegics
l
Pain in intact areas
l
Delayed onset
l
Shoulder pain: arthritis, tendinitis
l
Pain from CTS, ulnar nerve entrapment
l
Other arthritis
Shoulder pain
l
50-95% prevalence
l
Secondary to:
n
Weight bearing
n
Overuse
n
Muscle imbalance
Shoulder pain: Differential diagnoses
l
Rotator cuff tendinitis and tear
l
Muscle pain
l
Radiculopathy
l
Arthritis
Elbow / Hand pain
l
Elbow pain (32%)
l
Hand pain (48%)
l
Differential diagnosis
n
Epicondylitis / tendinitis
n
Olecranon bursitis
n
Arthritis
n
CTS, Ulnar nerve entrapment
Diagnostic tests
l
Physical examination
l
Plain x-ray
l
MRI
l
EMG
Treatment options
l
l
l
l
l
l
l
Rest
Therapeutic exercises
Modalities- TENS, Acupuncture
Changes in positioning, ergonomics
Changes in equipment
Splints
Weight reduction
Treatment options
l
Anti-inflammatory medication
l
Opioids
l
Injections
l
Acupuncture
l
Surgical release for CTS
Neuropathic pain
l
Nerve root entrapment
l
Syringomyelia
l
Transitional zone pain
l
Central dysesthesia syndrome
l
Nerve entrapment syndrome
Nerve root pain / radicular
l
Unilateral pain in the single nerve root
distribution
l
At the level of spinal trauma
l
Pain since the time of injury
l
Lancinating, burning, stabbing, shooting,
paroxysmal, allodynia, hyperesthesia
Transitional zone pain
l
l
l
l
l
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
l
Pain below the level of injury
l
Constant
l
Fluctuates with mood or activity
l
Responds poorly to medications or other
treatment
Pathophysiology of Neuropathic pain
l
“Imbalance hypothesis”
n
l
Imbalance between dorsal column and
spinothalamic tracts
“Pattern-generating mechanism” and “loss of
spinal inhibitory mechanisms”
Loss of inhibitory control
n Focal hyperactivity in the spinal cord and
thalamus
n
Pain description
l
l
l
l
l
l
l
l
Tingling
Shooting
Stabbing
Squeezing
Pressure
Cold
Numbness
Muscle cramp
Exacerbating factors
l
l
l
l
l
l
l
Noxious stimuli below the level of injury
Fatigue
Lack of distraction
Smoking
Psychological stress
Overexertion
Weather changes
Nerve entrapment syndrome
l
Carpal tunnel syndrome
l
Ulnar nerve entrapment
l
n
at the wrist
n
across the elbow
Radial nerve entrapment
Nerve entrapment syndrome: risk factors
l
Use of assistive devices
l
Routine pressure relief
l
Weight shifts
l
Transfers
l
Wheelchair mobility
Syringomyelia (Syrinx)
l
Delayed onset, years
l
New neurological deficits
l
Constant, burning pain
l
Pain to touch
l
Diagnosed with MRI
l
Treatment: shunt
Syringomyelia (Syrinx)
l
Delayed onset, years
l
New neurological deficits
l
Constant, burning pain
l
Pain to touch
l
Diagnosed with MRI
l
Treatment: shunt
Treatment
l
l
l
l
l
l
l
Pharmacological
Nerve blocks
Physical
Surgical
Stimulation techniques
Psychological
Acupuncture
Pharmacological treatment
l
Anticonvulsants
l
Antidepressants:
l
Alpha-adrenergic agonists
l
Opioids
l
Anti-spasticity medication
Anti-seizure medications
l
Carbamazepine (Tegretol)
l
Initially 100 mg, bd, gradually according to response; usual 200 mg
tds/qid, up to 1.6 g
l
Gabapentin (Neurontin)
l
300 mg on d1, then 300 mg BD d2, then 300 mg TDS on d3 Increase to
response in steps of 300 mg daily (in 3 divided doses) every 2–3 days to max.
3.6 g daily
Antidepressants
l
Tricylic antidepressants: amitriptyline (Elavil),
nortriptyline (orth hypo), imi & desipramine
l
Effective in neuropathic pain
l
Increase pain inhibitory mechanisms
l
May be used in combination with anti-seizure
medication
Anti-spasticity medication
l
Relief of muscle spasms
l
Baclofen
l
Clonazepam
l
Dantrium
Alpha adrenergic agonists
l
Relief of neuropathic pain
l
Clonidine: By mouth, 50–100 micrograms 3 times daily, increased every
second or third day; usual max. dose 1.2 mg daily
l
Zanaflex: over 18 years, initially 2 mg daily as a single dose increased
according to response at intervals of at least 3–4 days in steps of 2 mg daily (and given in
divided doses) usually up to 24 mg daily in 3–4 divided doses; max. 36 mg daily
Capsacin
l
Topical, 0.025%,
l
Applied to skin overlying the painful area,
a small amount 4 times daily
l
Deplete substance P,cause pain from
nerve ending
Opioids
l
May be used in neuropathic pain
l
Side effects
n
Physical dependency
n
Severe constipation
n
Mild cognitive impairment
n
Risk for addiction ( 3/52)
Therapy
l
Positioning
l
Modify transfer techniques
l
Splinting
l
Padded gloves / elbow pads
l
Exercise routines
Other interventions
l
Acupuncture
l
TENS unit
l
Spinal cord stimulator
l
Dorsal rhizotomy
TENS unit
l
Electrical stimulation on skin
l
More effective at the level of injury?
l
Requires a therapist for set-up
Spinal cord stimulator
l
Not generally helpful with SCI
pain
l
More effective with transitional
zone or radicular pain
l
Initial improvement in 20-75%
of patients
l
Long term efficacy in 10-40%
Surgical intervention
l
Spine stabilization
l
Removal of instrumentation
l
Decompression of impinged nerve roots
l
Decompression surgery for syrinx
Dorsal root rhizotomy
l
May be more effective in radicular pain
or neuropathic pain at the level of injury
l
Risks of cerebrospinal fluid leaks,
sensory or motor level changes
Psychological treatment
l
Psychological assessment
l
Cognitive behavioral therapy
l
Relaxation techniques
l
Biofeedback
l
Peer support
Visceral pain
l
Above, at or below the level of injury
l
Poorly localized if at or below the LOI
l
Non-specific symptoms:
n
Nausea, vomiting, anorexia
n
Autonomic dysreflexia
n
Fever
Visceral pain etiologies
l
Kidney stones
l
Bowel dysfunction (constipation)
l
Appendicitis
l
Gallbladder stones
l
Gynecological
Thank You