Pain management in spinal cord injury

1. Pain management in spinal cord injury Kazuko L. Shem, M.D. Physical Medicine & Rehabilitation Santa Clara Valley Medical Center www.scvmed.org

2. SCVMC

3. Incidence of pain 65 - 95% of SCI individuals experience pain 50% musculoskeletal 30% neurogenic 5-45% experience severe disabling pain

4. Incidence of pain More common in patients with: Injuries due to gunshot wounds and violence Lower level of injury Incomplete SCI? Spasticity

5. Psychosocial factors Depression / Sadness Adjustment disorders Anger Anxiety Stress

6. Patient evaluation Detailed history quality of pain distribution of pain relieving factors aggravating factors Physical examination Diagnostic tests

7. Pain syndrome classification Musculoskeletal Neuropathic Visceral

8. Pain classification Above the level At the level Below the level

9. Musculoskeletal pain syndrome Bone, joint, muscle trauma Tendon inflammation Muscle spasm Overuse syndrome Instability of spine

10. Vertebral column pain Neck, middle back, low back pain Spine deformities Arthritis X-rays evaluate instrumentation placement evaluate degenerative changes

11. Mechanical instability of spine Most common after cervical spine injury Due to injury to ligaments, fx of spine Pain around the spine

12. Treatment for mechanical instability of spine Relieved by immobilization Rest, bracing Medications Anti-inflammatory medication Opiates Surgical fusion

13. Trigger points

14. Muscle spasm pain Pain with visible and palpable spasms Anti-inflammatory medications Anti-spasticity medications Baclofen Zanaflex Anti-spasm medications Flexeril, Robaxin, Skelexin

15. 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

16. Shoulder pain 50-95% prevalence Secondary to: Weight bearing Overuse Muscle imbalance

17. Shoulder pain: Differential diagnoses Rotator cuff tendinitis and tear Muscle pain Radiculopathy Arthritis

18. Elbow / Hand pain Elbow pain (32%) Hand pain (48%) Differential diagnosis Epicondylitis / tendinitis Olecranon bursitis Arthritis CTS, Ulnar nerve entrapment

19. Diagnostic tests Physical examination Plain x-ray MRI EMG

20. Treatment options Rest Therapeutic exercises Modalities Changes in positioning, ergonomics Changes in equipment Splints Weight reduction

21. Treatment options Anti-inflammatory medication Opioids Injections Acupuncture Surgical release for CTS

22. Neuropathic pain Nerve root entrapment Syringomyelia Transitional zone pain Central dysesthesia syndrome Nerve entrapment syndrome

23. Nerve root pain / radicular Unilateral pain in the single nerve root distribution At the level of spinal trauma Pain since the time of injury Lancinating, burning, stabbing, shooting, paroxysmal, allodynia, hyperesthesia

24. 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

25. 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

26. 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

27. Central pain syndrome Pain below the level of injury Constant Fluctuates with mood or activity Responds poorly to medications or other treatment

28. 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

29. Pain description Tingling Shooting Stabbing Squeezing Pressure Cold Numbness Muscle cramp

30. Exacerbating factors Noxious stimuli below the level of injury Fatigue Lack of distraction Smoking Psychological stress Overexertion Weather changes

31. Nerve entrapment syndrome Carpal tunnel syndrome Ulnar nerve entrapment at the wrist across the elbow Radial nerve entrapment

32. Nerve entrapment syndrome:risk factors Use of assistive devices Routine pressure relief Weight shifts Transfers Wheelchair mobility

33. Syringomyelia (Syrinx) Delayed onset, years New neurological deficits Constant, burning pain Pain to touch Diagnosed with MRI Treatment: shunt

34. Treatment Pharmacological Nerve blocks Physical Surgical Stimulation techniques Psychological Acupuncture

35. Pharmacological treatment Anticonvulsants Antidepressants Alpha-adrenergic agonists Opioids Anti-spasticity medication

36. Anti-seizure medications Carbamazepine (Tegretol) Valproate Gabapentin (Neurontin) Trileptal Topamax

37. 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

38. Anti-spasticity medication Relief of muscle spasms Baclofen Clonazepam Dantrium

39. Alpha adrenergic agonists Relief of neuropathic pain Clonidine Zanaflex

40. Capsacin Topical Applied to skin overlying the painful area Deplete peptides that cause pain from nerve ending

41. Opioids May be used in neuropathic pain Side effects Physical dependency Severe constipation Mild cognitive impairment Risk for addiction

42. Therapy Positioning Modify transfer techniques Splinting Padded gloves / elbow pads Exercise routines

43. Other interventions Acupuncture TENS unit Spinal cord stimulator Dorsal rhizotomy

44. TENS unit Electrical stimulation on skin More effective at the level of injury? Requires a therapist for set-up

45. Spinal cord stimulator Not generally helpful with SCI pain More effective with transitional zone or radicular pain Initial improvement in 20-75% of patients Long term efficacy in 10-40%

46. Surgical intervention Spine stabilization Removal of instrumentation Decompression of impinged nerve roots Decompression surgery for syrinx

47. 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

48. Psychological treatment Psychological assessment Cognitive behavioral therapy Relaxation techniques Biofeedback Peer support

49. 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

50. Visceral pain etiologies Kidney stones Bowel dysfunction (constipation) Appendicitis Gallbladder stones Gynecological

51. Contact Information 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