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Anthony Chiodo, MD, MBAUniversity of Michigan Health SystemAAPMR Meeting 2015, Boston
Effects one in three patients Up to 80% report pain in a postal
survey- UE: 69%, Spine 61% Effects mood, function and quality of
life SCI patients are typically dissatisfied
with efforts to affect their pain
Effective: NSAID’s, opioids, valium Ineffective: spinal cord stimulator,
psychotherapy, acetaminophen, amitriptyline
Effective alternatives: massage, marijuana. Acupuncture effective in some patients.
No trials in SCI in pain management strategies, other than TENS
All trials had designs that were deemed to have high likelihood of bias
Spasticity Management Spine Intervention
For stenosis For cervical and lumbar DDD For epidural fibrosis
Dorsal Column Stimulator Intrathecal Morphine + Clonidine +
Ziconitide Surgical Treatment: DREZ
Not uncommon relationship between pain and spasticity
Focal treatment with use of botox and phenol
Trial process with bupivacaine blocks Generalized treatment with oral
medication and intrathecal baclofen Trial process with ITB trial
Powerful diagnostic tool: highly specific and sensitive vs. non-specific MRI
Effective short and long term pain management tool
Can direct to other effective therapies by identifying pain generator
The same mechanism that caused the initial injury influences other segments of the vertebral system
Flexion or extension moments at the cervical or lumbar spine
Compressive forces at the thoracic or lumbar spine
Surgical management of SCI changes mechanical spine dynamics
Lesion can be above or below the level of injury
Cervical degenerative disc and degenerative spine disease
Lumbar degenerative disc and degenerative spine disease
Cervical stenosis Lumbar stenosis Note: Relatively high lifetime incidence
of these disorders
Pain Spasticity Autonomic dysreflexia
T10 ASIA A SCI with zone of incompletion to L3 after an L2 burst fracture requiring an L1-5 PSF
Presented 13 years later with left leg pain with no change in neurological exam
MRI showed left L4-5 lateral recess stenosis Successfully treated with L5-S1 transforamenal epidural and L4-5 intra-articular facet block
T4 ASIA-A SCI presents 11 years after his injury with right leg pain and severe unilateral spasticity
Pain increased with standing and rotation, no symptoms in sitting
MRI reveals lumbar DDD with severe bilateral L4-5 facet hypertrophy
Bilateral L4-5 facet blocks relieved his pain and spasticity
C7 ASIA-A SCI after C6 burst fracture requiring C5-7 fusion and decompression
Presents 13 years later with right upper shoulder pain not relieved by physical therapy or trigger point injections
Cervical spine MRI showed right C3-4 and C4-5 paracentral disc bulges
Right C4-5 transforamenal epidural injection relieved his neck pain
T7 ASIA-A SCI after T8 fracture-dislocation requiring PSF T7-12
Pin level T10 right and T7 left with left chest wall dysesthesias at T8 and T9
Left T8-9 transforamenal epidural injection resulted in a transient complete improvement in his pain
Myelography demonstrated dye flow defect at T8
Surgical decompression and untethering relieved his chest wall pain
Implanted epidural electrodes with subcutaneous generator
Commonly used for neuropathic pain Patient needs to have adequate present sensation
in the painful distribution for it to be effective No demonstrated efficacy in below level
neuropathic pain: dorsal column degeneration Consideration for patients with at level
neuropathic pain and patients with incomplete SCI and neuropathic pain
Consideration for patients with CRPS
Intrathecal medication delivery for pain management
Typically effective for chronic nociceptive pain; not demonstrated for central pain states
Delivery system is the same with ITB Trial process with external pump
Treatment for patients with at level neuropathic pain Root injury Partial lesion at segment above SCI Scar formation
Least risk with patients with pain in the thoracic spine levels, although functional impact of such lesions has not been studied
Recurrence rate concerns
Modified Microsurgical DREZ Chun, World Neurosurgery, 2011
38 patients with SCI in the last 7 years with diffuse, continuous or thermal pain
5 thoracic, 33 thoracolumbar Note: Small to no likelihood of
infralesional pain generator or centralized pain
Results 75% pain reduction greater than 6
months All patients 79% Segmental 83% Diffuse 73% Burning 20%
Same results if continuous or intermittent
Cause for pain, spasticity and change in neurological function
Often associated with syrinx Typically at level of injury with syrinx
that could be above or below injury level Risk for recurrence If syrinx requires drainage, risk of
neurological change and loss of function
Pain: 66% Loss of function: 65.9% Weakness: 61.8% Sensory loss (dissociated: pain > light touch):
51.2% Spasticity: 39.6% Sweating: 21.2% Associated with valsalva and lying positions Weakness in the zone of the syrinx
Prior spinal cord trauma with spinal cord tethering
Spina Bifida Chiari Malformation or tethered cord
Idiopathic
404 patients with 486 surgeries > 90% of patients self-assessing arrest of
functional, motor and/or sensory loss > 50% of patients self-assessing improvement of
function 17 and 18% self-assessing improvement of motor
and sensory functions to a point greater than that achieved at any time post-injury,
59% reporting improvement of spasticity 77% reporting improvement of hyperhidrosis 46% decrease in neuropathic pain, 26% increase