“Ask The Expert” How to Treat Back Pain Case Presentation 1
“Ask The Expert” How to Treat Back Pain ABCs of Musculoskeletal Care November 30 – December 1 2007, San Francisco Sibel Demir-Deviren, MD Assistant Clinical Professor Spine Center University of California, San Francisco Case Presentation 1 4Deep, aching, stabbing pain 410/10 with VAS 4Sitting and walking make the pain worse 4Standing and bed rest make it better 4She came to clinic with her mom 4Severely limited in her ADL Case Presentation 1 434 years old female presents to clinic with complaint of severe LBP with right groin pain for 3 months 4She was thrown against a wall while she was practicing martial arts 4She went to ER and pelvis 3 views x-rays were taken 4She was told everything was WNL 4No evidence of fracture was reported Case Presentation 1 4She has tried Advil 600 mg 3 times a day for a week → didn’t get any relief 4She hasn’t tried any other NSAIDs 4She has had PT 4She hasn’t had any injections 1 Case Presentation 1 4PMH: asthma and too many sports injuries 4Medications: no medication for pain 4Allergies: Sulfa, septra 4PE: Case Presentation 1 hShe prefers to stand up during the PE hROM is severely limited with moderate pain in every direction hParaspinal muscle spasm hNeurologically intact Case Presentation 1 Case Presentation 1 2 Treatment Options for Chronic LBP 4Medications 4Physical Therapy 4Injections 4CAM 4Cognitive Behavioral Treatments 4Multidisciplinary rehabilitation NSAIDs 4Evidence supports the efficacy of NSAIDs in the treatment of chronic LBP hBased on 6 randomized controlled trials • pain, disability and mobility improved in 50-85% of patients chronic LBP within 2-8 weeks hVarious type of NSAIDs are equally effective hLimited evidence shown that NSAIDs are more effective than acetaminophen Schnitzer et al, 2004 Medications 4NSAIDs 4Muscle relaxants 4Antidepressants 4Topical medications 4Opioids Muscle Relaxants and Benzodiazepines 4There is a good evidence that muscle relaxants can provide short term relief h64% in tetrazepam vs. 29% in placebo Arbus et al, 1990 4Carisoprodol (Soma), drug abuse and dependency 4Short term use in acute exacerbations hMetaxalone (skelaxin) least sedating 4Sleep assistive medication hBaclofen or tizanidine (zanaflex) 4Don’t use benzodiazepines with opioids 3 Antidepressants 4Based on 7 RCT 4Produce moderate symptom reduction with Chronic LBP 4Analgesic effects hTricyclic antidepressants hSSRIs are not beneficial 4This effect is independent of patient’s depression status Staiger et al 2003 Exercise Therapy 4Does it matter which exercise? hMulticentered RCT hDirectional preference of patients were identified – Repeated lumbar flexion extension side glide rotation hRandomized to 3 groups – Directional exercise matching their preference – Exercise opposite to their DP – Evidence based care hThe matched group had statistically significant improvement than others in pain intensity, disability, medication use, recovery, work interference Long et al 2004 Physical Therapy 4Exercise therapy 4Thermal modalities 4Traction 4TENS 4Massage therapy 4Back School 4Lumbar supports Back School 4Education on anatomy, body mechanics, muscle function and posture, advice on physical activity 45 RCTs evaluated back school compared to other conservative treatments 4Better short and intermediate term pain relief and improvement Cochrane Review, 2005 4 Case Presentation 1 4Lumbar spine MRI was ordered 4Flexeril 10 mg tid 4Diclofenac 50 mg tid for a week trial hShe will let us know how she is doing in a week 4PT hStabilization of lumbar spine hImproving flexibility of lower extremity muscles hImproving cardiovascular fitness hBack school hHome exercise program Case Presentation 1 Case Presentation 1 T2 sagittal images Case Presentation 1 T2 axial image at L2-3 T1 sagittal images 5 Case Presentation 1 T2 axial image at L4-5 Case Presentation 1 T1 axial image at L4-5 Case Presentation 1 T1 axial image at L2-3 Case Presentation 1 4Amitriptyline 4She stopped taking Flexeril 42 months after trying all conservative treatments 4Still limited in her ADL because of bilateral groin and left hip pain 4She had bilateral L2 TFE at L2-3 and left L4 TFE at L4-5 4Started pilates 4The pain is completely gone for 15 months 6 Case Presentation 1 Sclerotomes 4She was 100% back to ADL for 15 months 4She stopped taking all the medications 4She started to experience another flare up 4Mainly left hip pain with mild buttock pain. 4The pain gets worse with sitting 4She started taking amitriptyline and diclofenac 4She couldn’t exercise because of the pain Case Presentation 1 4She had left L4 TFE at L4-5 for both diagnostic and therapeutic purposes 4100% relief from the injection for 6-7 weeks 4She started PT in 3 days after the injection 4The pain came back as both left hip and buttock pain 4She had left L4 and L5 TFE at L4-5 and L5-S1 levels 4She is again pain free Case Presentation 2 480 years old female presents to clinic with complaint of LBP with mainly left anterior thigh pain 4Sharp, throbbing, constant pain 48-10/10 with VAS 4Severely limited in her ADL 7 Case Presentation 2 4Very nice, highly educated lady 4Very bad historian Case Presentation 2 T2 axial image at L2-3 Case Presentation 2 4PMH: unremarkable 4Allergies: Opioids 4PE: Muscle strength: 4/5 in all lower extremity muscles SLR was negative bilaterally Case Presentation 2 T2 axial image at L3-4 8 Case Presentation 2 T2 axial image at L4-5 Case Presentation 2 T2 sagittal images Case Presentation 2 T2 axial image at L5-S1 Case Presentation 2 T1 sagittal images 9 Dermatomes 4Study on dermatomes by mean of selective nerve block hBlock nerve roots with 1.5cc 2% lidocaine hIdentified the boundaries with tactile method • L4 88% • L5 82% • S1 83% Case Presentation 2 4Left L2 and L3 TFE was performed 4She didn’t get any relief from the injection 4PT was also prescribed 4Meanwhile she started to complain about not able to think clearly. Spine 1993;18(13):1782-6 Case Presentation 2 4She was seen by Neurology 4CBC, RFT, LFT, Ca, P, Mg, TSH, RPR, free T4, B12, EEG, MRI: All WNL 4Because of incredible fear, anxiety and depression, she was not able to think clearly 4She was very worried she would never walk again 4She was also very worried that she would run out of money soon if she was not able to return to work Cadaver Studies 4Sensory rootlets have unusual segmental arrangement in many cases which is less common in motor rootlets Spine 1984;9(1):23-30 10 Case Presentation 2 4Left L4 and L5 SNRB was performed 4She experienced concordant pain during L5 SNRB 4She had 100% relief from the SNRB for one day Response to steroid is a predictor of Surgical Outcome 4Retrospective clinical study 471 patients with radicular pain 41-2 ml 2% lidocaine and 6 mg betamethasone 4Patients who had 80% relief from the ESIs had greater than 95% success in achieving average of 90% leg-pain relief after decompression Derby et.al. Spine 1992; 17(6 Suppl): S176-83 Case Presentation 2 4She underwent laminoforaminotomies bilaterally with medial facetectomies for decompression of L4 and L5 nerve roots 4She is a happy camper Indications for Selective Nerve Root Blocks 4Atypical extremity pain 4Patients with equivocal imaging studies 4Patients with equivocal neurologic examination 4Patients with multilevel imaging abnormalities, to be able to define affected level 4For anomalous innervations 4Patients with transitional vertebrae 4Postoperative unexplainable or complex recurrent pain 4Patient with known cause of pain whom would get benefit from temporary pain relief 11 Case Presentation 3 431 years old female presents to clinic with complaint of severe back with left buttock pain for 6 weeks 48/10 with VAS 4Sharp, shooting, stabbing, penetrating, numbing pain which is worse in the morning 4Numbness in the genital area and in the toes on the left side 4Wakes up at night because of the pain 4Sitting and walking make the pain worse 4Severely limited in her ADL 4She can’t work 4She was recommended to have discectomy Case Presentation 3 4Ibuprofen 800 mg tid 4Lortab 5/500 qid 4She has had ESI → didn’t get any relief 4She hasn’t had PT Case Presentation 1 4PMH: healthy 4Medications: Ibuprofen, lortab and birth control pills 4Allergies: No known drug allergies 4PE: hROM is moderately limited with moderate pain in every direction hParaspinal muscle spasm hNeurologically intact 12 Pharmacologic Treatment for Neuropathic Pain 4TCA 4Other antidepressants 4Gabapentin 4Other anticonvulsants 4Tramadol 4Topical drugs 4Nonsteroidal anti-inflammatory medications 4Steroids 4Opioids 4NMDA receptor antagonists 4Others: Baclofen, Clonidine TCA 4Analgesia is independent of antidepressive effect 4Analgesia is often achieved at lower dosage and faster 4Initiate treatment with amitriptyline and switch to alternative TCA if some pain relief is achieved, but side effects are troublesome 4Initial dose is 10-20 mg qhs and then titrate every 3-7 days by 10-25 mg/day up to 75-150 mg/day as tolerated 4NNH for withdrawal for TCA was 14.7 420% of participants with drew because of intolerable side effects 4Na channel blockers TCA hinhibit ectopic discharge in nociceptive fibers 4Inhibit reuptake of NE and serotonin hresponsible from partial restoration of inhibitory controls 4Increase expression of leu-enkephalin hmimic therapeutic opioid effects 4Amitriptyline,Imipramine, Clomipramine hbalanced serotonin and noradrenalin reuptake blocker hNNT: 2.1 4Nortriptyline,Desipramine hmainly inhibit noradrenalin reuptake blocker hNNT: 2.5 TCA 4TCAs must be used cautiously in patients with a history of cardiovascular disease, glaucoma, urinary retention, autonomic neuropathy, seizure and bipolar disorders 4Side effects: dry moth and eyes, blurry vision, urinary constipation, constipation, weight gain, erectile dysfunction, night sweats, orthostatic hypotension, palpitation, cardiac arrhythmias 4Block the effect of certain antihypertensive drugs like clonidine or guanethidine 4Increase side effects of thyroid supplements 4Increase sedative effects of alcohol and other sedatives 13 Gabapentin 413 RCT 48 provides evidence for the effectiveness of gabapentin 42 studies compared gabapentin with amitriptyline (Morello 1999, Dallocchia 2000) 4NNT was 4 4NNH for minor side effects was 3.7 4NNH for withdrawal was 26.1 (Cochrane review 2005, Finnerup 2005) Tramadol 413 RCT 48 provides evidence for the effectiveness of gabapentin 42 studies compared gabapentin with amitriptyline (Morello 1999, Dallocchia 2000) 4Effective dose is 200-400 mg/day 4NNT was 4 4NNH for minor side effects: 3.7 and withdrawal: 26.1 4Side effects: dizziness, dry mouth, constipation and somnolence 4Decrease seizure threshold 4Serotonergic syndrome with other serotonergic medications Gabapentin 4Initial dose is 100-300 mg qhs or tid and then titrate every 17 days by 100-300 mg/day up to 1,800 mg/day as tolerated 4An adequate trial would be include 3-8 weeks for titration plus 1-2 weeks at the max tolerated dosage 4Side effects: dizziness 24% somnolence 20% headache 10% diarrhea 10% confusion 7% nausea 8% mild peripheral edema Case Presentation 3 4Amitriptyline was prescribed 4We told her that she would sleep like a baby with amitriptyline 4She called back in 3 days complain about not able to sleep at all 4Amitriptyline increases the effect of caffeine (Cochrane review 2005, Finnerup 2005) 14 Results of TFE 4Prospective, randomized, double blinded clinical trial 4182 patients with radicular pain hOne study compared TFE, interlaminar ESI and paravertebral local anesthetic 4TFE was more effective than interlaminar ESI (68% versus 53%) 4Patients were assessed at 3 weeks and 3 months Results of TFE 4A case control study 440 patients with single level disc herniation confirmed with MRI 4All patient had radicular symptoms 4TFE was more effective than interlaminar ESI (70% versus 45%) 4TFE resulted in fewer long term surgical intervention than interlaminar ESI Kraemer et. al. Eur Spine J 1997; 6: 357-361 Case Presentation 3 4She had left L5 and S1 TFE 4She started PT in 4 days after the injection 4PT hStabilization of lumbar spine hImproving flexibility of lower extremity muscles hImproving cardiovascular fitness hBack school hHome exercise program Schaufele et. al. Pain Physician 2006; 9: 361-366 Case Presentation 3 4In 2 weeks hnumbness is completely gone h3/10 with VAS hstill takes ibuprofen, amitriptyline and Lortab hback to work part-time with limitations hstill limited in her ADL 4She had another left L5, S1 TFE 4Continue with PT and medications 15 Case Presentation 3 4In 3 weeks h2/10 with VAS hstop taking Lortab hTakes ibuprofen prn 4Continue with PT, ibuprofen and amitriptyline Case Presentation 3 4In 6 weeks hNo pain hstop taking all the medications 4She has started pilates 4She is back to work full time Thank you 16
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