new therapies for back pain - ohsu spine center
TRANSCRIPT
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New Therapies for Back Pain
David Sibell, MD, DABA, SCPMOHSU Spine Center
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What is Pain?
• International Association for the Study of Pain definition:
Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
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Conceptualizing Chronic Pain
Tissue Disruption
Functional Disruption
Environment and Treatment
Expression of Pain
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Where does Interventional Care fit??
• Multidisciplinary pain management– Medical/interventional– Rehabilitation– Behavioral medicine/psychological– Surgical
• Interventional care modalities– Neuropathic (nerve injury)– Spinal
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Disc Herniation
• Vertebral discs usually cushion & allow movement
• When damaged, they may impinge on spinal nerves, causing radiating pain
Modic MT. Radiology 2007;245:43-61
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Epidural Steroid Injection
Best for acute (recent onset) leg or arm pain
Not as effective for long term pain or central pain
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Spinal (Facet Joint) Arthritis
• Joints on both sides, at every spinal level from head to sacrum
• Subject to gravity, time, and trauma• Can develop osteoarthritis• Also subject to rheumatological diseases
(like Rheumatoid Arthritis)• Cause axial (central) pain
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Facet Arthritis Pain Patterns
Lumbar Cervical
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Pathology of Zygapohyseal (facet) Joints
Subchondral hematoma Articular process fracture
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Radiofrequency Facet Denervation
• Low risk, outpatient procedure• 2 phases
– diagnostic block– RF denervation
• About 75% of persons having ≥ 50% improvement with block get equivalent relief from denervation
• Effect lasts 12-18 months• Best when paired with physical therapy
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Radiofrequency Facet Denervation for
Axial Spinal Pain
Cervical Medial Branch Denervation
Lumbar Medial Branch Blocks
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Spinal cord stimulation
• A consideration for long-term, refractory pain due to – Nerve injury– Failed Back Syndrome– Some types of arterial insufficiency– Complex Regional Pain Syndrome
• 2 phase procedure– Trial phase– Implantation
• Preceded by Psychological evaluation
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Generators
ANS
Boston Scientific
Medtronic
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Leads
ANS Boston ScientificMedtronic
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•Electrodes
•Lead
•Implanted Pulse Generator
Spinal Cord Stimulator Configuration
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FBSS & Peripheral Vascular Disease
• Leg > back pain• But, with newer
technologies, back pain is better than in past.
• Lower extremity peripheral vascular disease
• Fewer amputations
Van Buyten J-P. JPSM 2006;31(4S):S25-29Ubbink DT. JPSM 2006;31(4S):S30-35
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SCS outcomes in Complex Regional Pain Syndrome
• Initial benefit• Eventual relapse
Iraq & Afghanistan war injured vets with CRPS Dutch people with CRPS
Verdolin MH. Anesth Analg 2007;104:1557–60Kemler MA. NEJM 2006;354:
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Syndrome X
• Less frequent angina
• Briefer duration of anginal episodes
• Less nitrate use
Sgueglia GA. Heart 2007;93;591-597
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Chronic pain changes lives.Treatment should, too.
• Involve Pain Psychology to Assist Adaptation & Coping
• Develop Rehabilitation Program to Improve Pain and Function
• Mesh Surgical Care with Amplifying Resources.
• Use Interventional Treatments with Lasting Effects!
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To make an appointment with the OHSU Spine Center or with Dr. Sibell:
Please Call (503) 418-1988