SCI Pain Rancho Slides

8/8/2019 SCI Pain Rancho Slides

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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


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SCVMC


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Incidence of pain

65 - 95% of SCI individuals experience pain

50% musculoskeletal

30% neurogenic

5-45% experience severe disabling pain


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Incidence of pain

More common in patients with:

Injuries due to gunshot wounds and violence

Lower level of injury

Incomplete SCI?

Spasticity


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Psychosocial factors

Depression / Sadness

Adjustment disorders

Anger

Anxiety Stress


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Patient evaluation

Detailed history

quality of pain

distribution of pain

relieving factors

aggravating factors

Physical examination Diagnostic tests


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Pain syndrome classification

Musculoskeletal

Neuropathic

Visceral


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Pain classification

Above the level

At the level

Below the level


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Musculoskeletal pain syndrome

Bone, joint, muscle trauma

Tendon inflammation

Muscle spasm

Overuse syndrome

Instability of spine


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Vertebral column pain

Neck, middle back, low back pain

Spine deformitiesArthritis

X-rays

evaluate instrumentation placement

evaluate degenerative changes


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Mechanical instability of spine

Most common after cervical spine injury

Due to injury to ligaments, fx of spine

Pain around the spine


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Treatment for mechanical

instability of spine

Relieved by immobilization

Rest, bracing

Medications

Anti-inflammatory medication

Opiates

Surgical fusion


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Trigger points


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Muscle spasm pain

Pain with visible and palpable spasms

Anti-inflammatory medicationsAnti-spasticity medications

Baclofen

Zanaflex

Anti-spasm medications Flexeril, Robaxin, Skelexin


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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


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Shoulder pain

50-95% prevalence

Secondary to:

Weight bearing

Overuse

Muscle imbalance


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Shoulder pain: Differential diagnoses

Rotator cuff tendinitis and tear

Muscle pain

Radiculopathy

Arthritis


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Elbow / Hand pain

Elbow pain (32%)

Hand pain (48%) Differential diagnosis

Epicondylitis / tendinitis

Olecranon bursitis

Arthritis

CTS, Ulnar nerve entrapment


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Diagnostic tests

Physical examination

Plain x-ray

MRI

EMG


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Treatment options

Rest

Therapeutic exercises Modalities

Changes in positioning, ergonomics

Changes in equipment

Splints

Weight reduction


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Treatment options

Anti-inflammatory medication

Opioids

Injections

Acupuncture

Surgical release for CTS


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Neuropathic pain

Nerve root entrapment

Syringomyelia

Transitional zone pain

Central dysesthesia syndromeNerve entrapment syndrome


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Nerve root pain / radicular

Unilateral pain in the single nerve root

distributionAt the level of spinal trauma

Pain since the time of injury

Lancinating, burning, stabbing, shooting,

paroxysmal, allodynia, hyperesthesia


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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


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Case study

MRI:

C2-3 posterior osteophytes causing right-sided

foraminal narrowing

Treatment

NSAIDs

Trigger point injection Instructed patient to reposition the computer

monitor to midline


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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


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Central pain syndrome

Pain below the level of injury

Constant

Fluctuates with mood or activity

Responds poorly to medications or othertreatment


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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


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Pain description

Tingling

Shooting

Stabbing

Squeezing

Pressure

Cold Numbness

Muscle cramp


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Exacerbating factors

Noxious stimuli below the level of injury

Fatigue

Lack of distraction

Smoking

Psychological stress

Overexertion

Weather changes


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Nerve entrapment syndrome

Carpal tunnel syndrome

Ulnar nerve entrapment

at the wrist

across the elbow

Radial nerve entrapment


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Nerve entrapment syndrome:

risk factors

Use of assistive devices

Routine pressure relief

Weight shifts

Transfers

Wheelchair mobility


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Syringomyelia (Syrinx)

Delayed onset, years

New neurological deficits Constant, burning pain

Pain to touch

Diagnosed with MRI

Treatment: shunt


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Treatment

Pharmacological

Nerve blocks

Physical

Surgical

Stimulation techniques

Psychological

Acupuncture


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Pharmacological treatment

Anticonvulsants

Antidepressants

Alpha-adrenergic agonists

Opioids

Anti-spasticity medication


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Anti-seizure medications

Carbamazepine (Tegretol)

Valproate

Gabapentin (Neurontin)

Trileptal

Topamax


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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


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Anti-spasticity medication

Relief of muscle spasms

Baclofen

Clonazepam

Dantrium


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Alpha adrenergic agonists

Relief of neuropathic pain

Clonidine

Zanaflex


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Capsacin

Topical

Applied to skin overlying the painful area

Deplete peptides that cause pain from

nerve ending


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Opioids

May be used in neuropathic pain

Side effects Physical dependency

Severe constipation

Mild cognitive impairment

Risk for addiction


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Therapy

Positioning

Modify transfer techniques

Splinting

Padded gloves / elbow padsExercise routines


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Other interventions

Acupuncture

TENS unit

Spinal cord stimulator

Dorsal rhizotomy


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TE

NS unit

Electrical stimulation on skin

More effective at the level of injury?

Requires a therapist for set-up


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Spinal cord stimulator

Not generally helpful with SCI pain

More effective with transitional zone orradicular pain

Initial improvement in 20-75% of patients

Long term efficacy in 10-40%


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Surgical intervention

Spine stabilization

Removal of instrumentation

Decompression of impinged nerve roots

Decompression surgery for syrinx


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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


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Psychological treatment

Psychological assessment

Cognitive behavioral therapy

Relaxation techniques

Biofeedback

Peer support


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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


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Visceral pain etiologies

Kidney stones

Bowel dysfunction (constipation)

Appendicitis

Gallbladder stones

Gynecological


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ContactInformation

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

Date post:	10-Apr-2018
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SCI Pain Rancho Slides

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