1. CHRONIC PAIN SYNDROMES : LBA, SCIATICA, CRPS, Trigeminal
neuralgia, Cancer pain. Dr Aftab Hussain
2. What is Pain? International Association for the Study of
Pain (IASP) defines pain as An unpleasant sensory and emotional
experience associated with actual or potential tissue damage, or
described in terms of such damage The Joint Commission on
Accreditation of Healthcare Organisation adopted pain as the fifth
vital sign
3. ACUTE v/s CHRONIC PAIN Acute Pain Chronic Pain Recent onset;
usual duration 0-7 days Persisting > 3 months with less sudden
and defined onset Cause usually known; usually a definable event
More often leads to anxiety and persuit of remedy Pain usually
subsides as healing progresses May or may not be the result of
tissue damage More often leads to depression and other behavioral
changes Pain persists, becoming a disease unto itself
4. COMMON FORMS OF CHRONIC PAIN Musculoskeletal disorders
Chronic visceral disorders Lesions of peripheral nerves, nerve
roots, or dorsal root ganglia (including diabetic neuropathy,
causalgia, phantom limb pain, and postherpetic neuralgia) Lesions
of the central nervous system (stroke, spinal cord injury, and
multiple sclerosis), and cancer pain.
5. TYPES The pain of most musculoskeletal disorders (eg,
rheumatoid arthritis and osteoarthritis) is primarily nociceptive.
Pain associated with peripheral or central neural disorders is
primarily neuropathic. The pain associated with some disorders, eg,
cancer and chronic back pain (particularly after surgery), is often
mixed.
6. Dimensions of Chronic Pain Loneliness Hostility Social
Factors Anxiety Depression Psychological Factors Pathological
Process Physical Factors A.G. Lipman, Cancer Nursing, 2:39,
1980
7. LOW BACK PAIN and SCIATICA
8. Low Back Pain: Epidemiology 60%90% lifetime prevalence
Second most common complaint to prompt a medical evaluation Leading
cause of long-term work disability Disability and costs are related
to pain, not to the disease process
9. 90 % of cases of LBP resolve without treatment within 6-12
weeks 40-50 % LBP cases resolve without treatment in 1 week 75 % of
cases with nerve root involvement can resolve in 6 months LBP and
lumbar surgery are: 2nd and 3rd highest reasons for physician
visits 5th leading cause for hospitalization 3rd leading cause for
surgery
10. Causes of Low Back Pain Lumbar strain or sprain 70%
Degenerative changes 10% Herniated disk 4% Osteoporosis compression
fractures 4% Spinal stenosis 3% Spondylolisthesis 2% Myofascial
pain- frequency not defined.
11. Spondylolysis, diskogenic low back pain or other
instability 2% Traumatic fracture - 6 weeks Has essentially
replaced CT and myelograms for initial evaluations.
35. MRI with Gadolinium contrast: Gadolinium is contrast
material allowing enhancement of intrathecal nerve roots
Utilization: Assessment of post-operative spine---most frequent use
Identifying tumors / infection within / surrounding spinal
cord
36. 10. Psychological tools: Includes: Pain Assessment Report,
which combines: McGill Pain Questionnaire Mooney Pain Drawing Test
Middlesex Hospital Questionnaire Cornell Medical Index Eysenck
Personality Inventory
37. What is sciatica? Sciatica is a form of low back pain that
runs down one or both legs, causing pain, numbness or tingling in
the leg.
38. How does it occur? The sciatic nerve is formed from a group
of nerves that leave the spine and run down the leg. Anything that
causes irritation along the course of the nerve can cause
sciatica.
39. COMMON CAUSES Overuse of back injury to back Overuse or
injury can cause muscle tension or spasm, back sprains, ligament or
muscle tears Joint problems irritating the sciatic nerve.
Infections, tumors, a ruptured disk, osteoporosis, spondylosis
Spinal stenosis
40. How is it treated? Most people with low back pain and
sciatica get better no matter what they do. Often, medicines for
pain and inflammation, such as ibuprofen and naproxen, can ease the
pain. Ice massage or deep heat may help. Physical therapy sometimes
helps back pain that doesn't get better with the usual
medicines.
41. Treatment Medications NSAIDS Membrane stabilizers TCA
re-establish sleep patterns reduce radicular dysesthesias Muscle
relaxants: re-establish sleep patterns more useful in
myofascial/muscular pain Narcotics: rarely indicated Steroids: more
useful for radiculitis Non-narcotic analgesics
42. ROLE OF STEROIDS Corticosteroids around nerve roots can
reduce inflammatory oedema, with improvement of microcirculation.
Ectopic discharges from an injured nerve root are inhibited due to
its membrane stabilizing effect. The pro inflammatory action of
phospholipase-A2 (released from injured disc) is also inhibited by
epidural steroids.
43. Physical therapy electrical stimulation/TENS Postural
education / body mechanics Massage / mobilization / myofascial
release Stretching / body work Exercise / strengthening
Traction
44. COMMON INTERVENTIONS: Trigger point injection. Traditional
epidural steroid injection. Transforaminal epidural injection.
Facet joint intra-articular block. Steroids act against infammation
and reduce edema. Addition of hyaluronidase into epidural injectate
improves the spread of local anaesthetic and steroid.
45. Epidural injection Midline Interlaminar L5-S1
46. USUAL PROTOCOL FOLLOWED STEP 1 : Epidurography STEP 2 : 80
mg methyl prednisolone + 1500 units of hyalase in 5 ml saline STEP
3 : Adhesiolysis via percutaneous catheter STEP 4 : Foraminal block
given
51. Radiofrequency ablation Alternating electric field with
oscillating frequency 5,00,000 Hz. Heat produced : Hottest part
near the tip. 0.5 mA : 0.25 V MINIMUM ---> Discharge. Cannula
placed within 3 mm of nerve. RFG 3 C PLUS , RADIONICS USA. Adequate
lesioning : 90 degrees C 60 120 secs. Myelinated fibres more
resistant.
52. Radiofrequency Vs Chemical Neurolysis Lesion size
controlled. Good monitoring of lesion temperature. Good placement
of electrode facilitated by electrical stimulation. Performed LA
with sedation. Rapid recovery & low morbidity. Ability to
repeat radiofrequency if neural pathway regenerates. Ability to
utilize same cannula for different spinal lesions.
53. PULSED RADIOFREQUENCY Better ---> No temp rise > 42
degrees C. Total voltage applied 25 35 V. Frequency 300 Hz 30 ms
out of a cycle. Action similar to TENS.
54. MINIMALLY INVASIVE INTERVENTIONS EPIDURAL NEUROPLASTY or
EPIDURAL ADHESIOLYSIS with steroid, LA, hypertonic saline and
hyaluronidase. EPIDUROSCOPY / SPINAL CANAL ENDOSCOPY using a
fiberoptic light source and flexible fiberoptic catheter.
55. PERCUTANEOUS RADIOFREQUENCY DENERVATION of segmental spinal
nerves by applying heat to denature the nerves that innervate
painful facet joints. PERCUTANEOUS DISC DECOMPRESSION USING
NUCLEOPLASTY Co ablation technique used with thermal treatment and
tissue removal.
56. PERCUTANEOUS LASER DISC DECOMPRESSION (PLDD) Using Nd:YAG
laser to vaporise a small portion of the nucleus pulposus.
INTRADISCAL ELECTROTHERMAL THERAPY (IDET) Catheter with an
electrode passed into nucleus pulposus Heat applied to shrink
collagen at a target temp of 65 75 degrees C
57. SPINAL CORD STIMULATION Electrodes passed into the
posterior epidural space for electrical stimulation of the spinal
cord. Approved by FDA . SCS has become a standard treatment for
patients with chronic pain in back or limbs who are not relieved
from other treatment.
58. INTRATHECAL PAIN PUMPS INTRA THECAL DRUG DELIVERY Through a
catheter and pump to treat intractable pain both nociceptive and
neuropathic. Indicated when opioid requirements are high enough to
cause side effects. A/K/A INTRA THECAL POLYANALGESIA.
59. Intrathecal Pain Pumps Size of a pacemaker . Has access-
pump usually has to be refilled as early as every 3 months-
medication can be reconstituted when refilled morphine, baclofen,
bupivicaine, clonidine. Pain pump is inserted under the
skin;usually in abdomen/ catheter is threaded into the intrathecal
space for continuous delivery.
60. PERCUTANEOUS VERTEBROPLASTY t/t of osteoporotic body
compression #. Utilizes bone cement ( PMMA ), tobramycin and barium
powder as non ionic contrast applied through a special needle under
fluoroscopy. It provides vertebral solidification. PERCUTANEOUS
KYPHOPLASTY Inflatable balloon applied inside collapsed vertebral
body.
61. Kyphoplasty/Vertebroplasty
62. Kyphoplasty/Vertebroplasty How it works helps with axial
load, cement is very hot and theory is that intraosseous nerve
endings are burned and that helps with pain relief usually
immediate
63. SURGERIES as laminectomy, micro discectomy, foramenotomy
and spinal fusion considered: 1) Failure to respond to conservative
mgt >3months 2) Profound / progressive neurological deficit 2)
Recurring episodes of intactable sciatica involving same segment to
avoid cumulative disability of repeated events.
64. How can we help prevent sciatica? Avoid lifting heavy
weight. Avoid frequent bending or other activities that make the
pain worse. Lose weight . Do regular aerobic exercise to keep your
back and abdominal muscles in shape (this can be as simple as
walking), Learn to lift properly. Bend your knees and hips and keep
your back straight when you lift a heavy object.
65. Complex Regional Pain Syndrome
66. Complex Regional Pain Sydrome I (RSD) History of initiating
injury or immobilization Continuing pain, allodynia, or
hyperalgesia out of proportion to the initiating event Evidence at
some time of edema, changes in skin blood flow or abnormal
pseudomotor activity in the painful area No other cause of the pain
exists
67. Complex Regional Pain Syndrome II (causalgia) Differs from
CRPS I by the presence of a known nerve injury Devastating injury
has occurred, which by definition has caused a major nerve injury .
The burning pain is often of extreme severity Often, there is also
significant vascular compromise.
68. Causes Injuries to peripheral tissues (e.g., fractures,
dislocations, and postoperative State) Inflammatory conditions
(e.g., fasciitis, tendonitis, bursitis, and arthritis)
Immobilization as a result of injury or cast application Peripheral
nerve injury resulting from direct compression or ischemia (e.g.,
brachial plexopathy, postherpetic neuralgia, and nerve root injury)
Central nervous system insults (e.g., head injury, ischemia, and
brain tumor) Spinal cord lesions Idiopathic
69. DEVELOPMENT OF CRPS Abnormal discharges in sympathetic and
nociceptive afferents produced by trauma Sensitization of
peripheral sensory receptors produced by sympathetic hyperactivity
Formation of ephapses (artificial synapses) after peripheral nerve
injury Spontaneous neuronal ectopy at the site of demyelination or
axonal injury Central reorganization of pain processing
70. Pathophysiologic Mechanisms of CPRS Sensory abnormalities
Autonomic dysfunction Neurogenic inflammation Motor
abnormalities
71. Sensory Abnormalities in CRPS Dysesthesia / hyperalgesia
throughout the affected half of the body. Increased thresholds to
mechanical and thermal stimuli on the affected side. Due to changes
in the thalamus and cortex. PET studies have demonstrated adaptive
changes in the thalamus.
72. Autonomic Dysfunction About 85% of CRPS report pain relief
after sympathetic interruption; however, the pain relief is
temporary in the majority of patients Catecholamines can activate
peripheral nociceptors after thermal or chemical sensitization in
the absence of nerve injury After nerve injury, surviving cutaneous
afferents develop noradrenergic sensitivity. Hyperhydrosis
73. Early phase Skin temperature and perfusion high
Norepinephrine levels low Intermediate phase Temperature and
perfusion either warmer or colder, depending on the level of
sympathetic activity Late phase Skin temperature and perfusion low
Norepinephrine levels low Skin lactate increased
74. Neurogenic Inflammation Extensive plasma extravasation in
patients with acute CRPS Increased joint effusions, protein and
synovial hypervascularity Increased systemic CGRP in the acute
phase Increased tissue levels of TNF and IL-6 Increased production
of nitric oxide from peripheral monocytes .
75. Motor Abnormalities About 50% of CRPS patients develop
Decreased range of motion Physiological tremor Reduction in active
motor force About 10% of CRPS patients develop dystonia in the
affected extremity.
76. STAGING OF CRPS
77. Stage I Severe pain limited to the site of injury
Hyperesthesia Localized swelling Muscle cramps Stiffness and
limited mobility At onset, skin is usually warm, red, and dry; then
may change to blue (cyanotic). Increased sweating
(hyperhydrosis).
78. Stage II Severe and more diffuse pain. Swelling tends to
spread and it may change from a soft to hard (brawny) type. Hair
may become coarse then scant, nails may grow faster and become
brittle, cracked, and heavily grooved. Osteoporosis Muscle
wasting
79. Stage III Marked wasting of tissue (atrophic) eventually
becomes irreversible. For many patients, the pain becomes
intractable and may involve the entire limb. A small percentage of
patients have developed generalized reflex sympathetic dystrophy
(RSD), affecting the entire body.
80. Complex Regional Pain Syndrome and the Sympathetic Nervous
System Interactions between sympathetic fibers and sensory fibers
in the dorsal root ganglion Sensitization of dorsal horn cells
secondary to activation of afferent fibers by sympathetic efferent
actions.
81. Role of psychological factors? Sufferers may become
seriously affected psychologically, and sometimes show features of
major depression. (as expected in anyone who is in constant pain,
who may have lost their job and had their family and social life
shattered).
82. Pharmacologic Management WHO Ladder Non-opioid therapy /
Co-analgesics Opioids
83. Modified WHO Analgesic Ladder Proposed 4th Step Pain Step 1
Nonopioid Adjuvant Pain persisting or increasing Step 2 Opioid for
mild to moderate pain Nonopioid Adjuvant Pain persisting or
increasing Pain persisting or increasing Step 3 Opioid for moderate
to severe pain Nonopioid Adjuvant Invasive treatments Opioid
Delivery Quality of Life
84. Adjuvants Antidepressants TCAs for neuropathic pain
Anticonvulsants Corticosteroids Neuroleptics Alpha2 agonists
Benzodiazepines Antispasmodics Muscle relaxants NMDA-blockers
Systemic local anesthetics
85. Non-Pharmacologic Management Exercise programs Hypnosis
Counseling Music Acupuncture Yoga Cold/heat Massage Vibration TENS
units
86. Stellate ganglion block The preganglionic sympathetic
outflow to the upper extrimity is derived from T2-T9. These fibres
synapse with the postganglionic neurons in the stellate ganglion.
Therefore stellate ganglion block interrupts the sympathetic
outflow to the upper extremity.
87. Dye spread around stellate ganglion Stellate ganglion
block
88. Signs of successful stellate ganglion block Eye: - ptosis,
narrowing of palpebral fissure, miosis,lacrimation. Face and neck:-
anhidrosis, elevated local temp and nasal stuffiness
Plethysmographic evidence of improved cutaneous blood flow.
89. Intravenous regional blockade. Intracath is inserted into a
peripheral vein. The limb is then isolated from the circulation for
20 min using a sphygmomanometer cuff inflated to supra-systolic
level. Guanethidine or another sympatholytic drug is then injected
through the needle. The procedure is often painful, and the drug is
therefore usually combined with local anaesthetic.
90. TRIGEMINAL NEURALGIA
91. TRIGEMINAL NEURALGIA Trigeminal neuralgia (TN), tic
douloureux[ (also known as prosopalgia, the Suicide Disease or
Fothergill's disease is a neuropathic disorder characterized by
episodes of intense pain in the face, originating from the
trigeminal nerve. It has been described as among the most painful
conditions known. 1 in 15,000 people suffer from TN
92. TN symptoms usually appears after the age of 40,. It is
more common in females than males. The trigeminal nerve is a paired
cranial nerve that has three major branches: the ophthalmic nerve
(V1), the maxillary nerve (V2), and the mandibular nerve (V3). One,
two, or all three branches of the nerve may be affected. 10-12% of
cases are bilateral.
93. SIGNS AND SYMPTOMPS The disorder is characterized by
episodes of intense facial pain that last from a few seconds to
several minutes or hours. The episodes of intense pain may occur
paroxysmally. A trigger area on the face so sensitive that touching
or even air currents can trigger an episode. It affects lifestyle
as it can be triggered by common activities such as eating,
talking, shaving and brushing teeth
94. Wind, high pitched sounds, loud noises such as concerts or
crowds, chewing, and talking can aggravate the condition in many
patients. The attacks are said by those affected to feel like
stabbing electric shocks, burning, pressing, crushing, exploding or
shooting pain that becomes intractable.
95. ETIOLOGY Nerve compression at the opening from the inside
to the outside of the skull; An enlarged blood vessel - possibly
the superior cerebellar artery - compressing or throbbing against
the microvasculature of the trigeminal nerve near its connection
with the pons. Such a compression can injure the nerve's protective
myelin sheath and cause erratic and hyperactive functioning of the
nerve
96. MANAGEMENT Pharmacological The anticonvulsants
carbamazepine is the first line treatment; second line medications
include baclofen, lamotrigine, oxcarbazepine, phenytoin,
gabapentin, and sodium valproate. Low doses of some antidepressants
such as amitriptyline are thought to be effective in treating
neuropathic pain. Surgical Microvascular decompression appears to
result in the longest pain relief.
97. Percutaneous procedure Percutaneous radiofrequency
trigeminal gangliolysis. (PRTG) Percutaneous retrogasserian
glycerol/phenol rhizotomy. Percutaneous baloon microcompression.
Percutaneous radiofrequency thermorhizotomy may also be effective
as may gamma knife radio surgery .
98. CANCER PAIN 30% patients with cancer have pain at the time
of diagnosis. 85% of patients with cancer have pain in advanced
stages. 36% patients of people have pain sufficient enough to cause
functional disability.
99. COMPONENTS OF CANCER PAIN SENSORY AFFECTIVE
PSYCHOLOGICAL
100. ETIOLOGY Presence and progression of the tumor itself.
Indirect effect of the tumor i.e. metabolic , infective, venous or
lymphatic obstruction. Consequence of cancer treatment i.e.
chemotherapy, radiotherapy and surgery. Unrelated mechanisms like
migraine or myofascial pain.
101. PAIN ASSESSMENT IN CANCER Step wise approach History,
examination and data collection ending with clinical diagnosis.
Assessment involves features of pain like location, intensity,
quality, timings, exacerbating and relieving factors and response
to previous analgesia. Psychological status of the patient.
Associated co-morbidities.
102. Management Removing source of pain by surgery ,
chemotherapy, radiotherapy or other form of treatments. Over the
counter prescriptions (NSAIDs, Aspirin) or strong opioid
medications. (Oral, I.V., patches) Patient controlled analgesia
Intravenous PCA is very advantageous for patient with chronic
cancer pain . It allows to self administer medication and find
their own comfort zone between the side effects and pain control
within limits set by the physician.
103. The PCA device is a computerised programmable lightweight
battery operated portable pump with the capability of storage and
retrieval of data by a microprocessor.
104. 3 modes of delivery 1. Continous per hour rate infusion.
2. Continous with boluses for breakthrough pain 3. Boluses with
lock out time in mins set by the physician. PCA can also be
provided by the subcutaneous, epidural or intrathecal route. Apart
from various medical complication, another aspect limiting the
widespread use of PCA is its cost.
105. Nerve blocks and interventions in cancer pain Coeliac
plexus block using Phenol/alcohol is especially helpful in
Pancreatic cancer and and upper GI tumor pain. Stellate ganglion
block in head and arm cancers. Lumbar sympathectomy in lower limb
cancers. Intercostal nerve blocks in pathological fracture of ribs.
Ganglion Impar block for Vulval cancer. Procedure is carried under
C-arm guidance. In bony metastasis strengthening of bone is done by
kyphoplasty and vertebroplasty. TENS have also being utilized for
pain relief albeit temporarily. Intrathecal pumps for drug
delivery. Percutaneous cordotomy has been succesfully used for
unilateral pain arising out of cancer pain in mesothelioma
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