Transcript An approach to Low Back Pain and Neuropathic Pain

An approach to Low
Back Pain and
Neuropathic Pain
Russ O’Connor
FRCPC (PMR), CASM, EMG
ObjectivesBy the end of the session the participant will be able to:
Outline common causes of low back pain in the
Paralympic athlete
Discuss things not to miss in Paralympic athletes with
low back pain- the so called RED FLAGS
Discuss treatment suggestions for athletes with low back
pain
Discuss how to manage neuropathic pain in the athlete
with a disability
Why is LBP worth talking about?
Common
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81% of AK and 62% BK amputees1
** of SCI
Prevalence in athletes ranges from 10 to 35%
Affects QOL/ sleep/ PERFORMANCE
Physical findings different?
Previous surgery
1Kulkarni
et al Clin Rehab. 2005; 19:81-6.room
Mr. A.S.
30 yo paraplegic sit skier- L2 burst # fused
with Harrington rods and right femur #
Long standing pain right thigh and shin.
Increased training since torino
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Pain increased
Spasms increased
New feeling in post thigh and new muscle
bulk right glut
Mr. AS
Pain
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Burning and electric shoot pain down thigh
medial shin and foot
Increased with workouts and ski days esp at
night
Settled with rest and gabapentin
Mr. AS
Bowel and bladder- no recent fu
Right post thigh pain and swelling with
stretch
Meds –
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Gabapentin 900-600-900
Baclofen 5 bid
Sedated
Mr. AS- Exam
LNSL L1 right and left
but has some feeling
to L3
Some flickers of
abduction on right
Level
Right
Left
L2
0
4
L3
1
1
L4
0
0
L5
0
0
S1
0
0
What do you want to know?
What makes you worried?
RED FLAGS for LBP in athlete
with a disability
Progressive pain
Increased
Weight loss
None
Fevers or ssx of infection
None
RED FLAGS for LBP in athlete
with a disability
CHANGE in:

Motor or sensory function
Muscle bulk or new atrophy
fasciculation's
New post thigh
sensation and bulk

Bowel or bladder function
None
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Spasticity
Increased
Mr. AS
Careful History - physical
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Increased pain
improved in motor sensory function
No new atrophy or fasciculation's
No change in bowel or bladder function
But no recent follow-up
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Increased in spasticity or tone
What do you think is wrong with
Mr. AS?
MSK
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Spinal
Hardware issue or instability
Fracture –
Facet degeneration
Spondylolysis or Spondylolisthesis
Deg disc disease – discogenic pain
Mechanical LB muscle Strain – overuse
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Peripheral
Buttock / hip
SI
Femur – rod, muscle
What do you think is wrong with
Mr. AS?
Neuro
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Spinal cord
Syrinx
SC compression from disc or central stenosis or infection
Central segmental neuropathic pain
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Nerve root
Disc or osteophyte
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Peripheral nerve
Pelvis, buttock
Mr. AS
Imaging – What would you order
1
3
2
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XR spine – no loosening
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Bone scan –
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CT – best for bone trauma, fast, cheaper
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MRI – best for disc or cord
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Urology follow up
MRI
best for disc or cord but hardware really
interferes with quality
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L2 central stenosis and at L4/5 as well
Significant artifact making comments on the
rest of the structures difficult
Treatment - Mr. AS
Goals to allow RTP with less pain and
spasms- depends on diagnosis
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Conservative – Stretching/ strengthening / PT
etc
Medications oral –
Medications injections
Trigger
Epidural
Botox
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Surgery?
Mr. AS
Oral medications
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Spasms – Baclofen 5 bid
Pain - Gabapentin 900/600/900
Seemed to be enough for awhile but
returned with more pain after training
Increased gabapentin and baclofen at
night
Mr. AS
Discussed with team
Saw – Neurosurgery
Mr. AS Returns
Increased pain – having to take more time
off
Central stenosis at L2 with preserved L5
function clinically and L4/5 pain pattern.
Mr. AS
Other options
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Decrease training – competition
Increase or change medications
Trial of injections
Trigger point
Nerve root
Epidural
Mr. AS
After L2 epidural steroid
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Neuropathic shooting and burning pain down
legs much better
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Still has activity related axial back pain
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Spasms persist
Prohibited list
L1
L2
Mr. AS
CT scan shows
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fused Tspine to L4
Severe stenosis at L2
Widening of disc space and moderate L4/5
canal stenosis
Severe foraminal stenosis at L4.5 and mod at
L5-S1
Mr. AS- Update
Going for second injection
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Still on Gabapentin and Baclofen
Has seen neurosurgery for opinion
Will consider L4/5 injection
Neuropathic pain
Why is it worth talking about?
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Common2-3 % general population
SCI 54% at 6 months and 75% @5y 1
Amputee 79.9%2
1MM
Backonja and Jordi Serra. Pain Medicine 2004; 5: S1 PS48-S59.
2Ephraim
et al. Arch of Phys Med and Rehab 2005; 86:10, P 1910-19.
Neuropathic pain
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Disabling- QOL, sleep, exercise, work, ADLs3
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Constant in up to 40% of people with SCI
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10% report severity of pain not paralysis prevents
employment
83% people with SCI who are employed state pain
interferes with work
Performance!!
3Widerstrom-Nog et al. Arch Phys Med Rehab 2001;82:1271-7.
Neuropathic pain
What is it?

IASP = "pains resulting from disease or
damage of the peripheral or central nervous
systems, and from dysfunction of the nervous
system”
Neuropathic Pain
Central
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Brain
SCI
Peripheral
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Root
Plexus
Nerve
Classification - Spinal cord injury –
Neuropathic pain
Above Level
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Compressive neuropathy arms
At Level
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Radiculopathy
SCord- syrinx, segmental injury
Below Level
Mr. AS
What kind of pain does Mr. AS have?
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Below the level of injury Neuropathic pain
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Axial Low back pain –
Nociceptive – musculoskeletal
Ms. BK
24 yo woman traumatic amputation right
below knee in a bicycle accident 3 y ago
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Medically well
Pain right leg over distal residual limb, focal
severe tenderness, with pressure or touch –
severe shooting and stabbing pain
Pain over right foot- feels like foot is being
crushed and occasionally like it is burned
What type of pain does Ms. BK
have?
Classification – Amputee
Neuropathic Pain
Phantom limb pain
Residual limb pain – stump
Neuroma
Other MSK causes for limb pain- Not neuropathic in origin
Skin, muscle, bone, joint, ligament
Presentation
Description
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Burning, shooting, lancinating, electric, itching
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Stimulus evoke pain –
hyperalgesia – hurts more than it should
Allodynia – ALL - everything hurts
Pathophysiology
Peripheral
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Nerve injury and regeneration – neuroma
Neuronal sprouts – aberrant depolarization and
increased expression of Na channels and voltage
gated Ca ch
Release of Sub P and glutamate
Central
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Central Spinal sensitization – NMDA receptor
Periaquaductal gray matter can modulate and
suppress or accentuate pain- opioid receptors
Altered connectivity – inapprop connections
CMAJ • August 1, 2006 • 175(3) | 269
Investigations
Look for treatable causes
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Peripheral nerve, plexus, root, SCI or brain causes
Systemic conditions
Diabetes, B12, thyroid, renal and liver disease
Infectious processes- shingles,
Toxic, nutritional defic

Focal conditions
Peripheral compression – carpal tunnel, ulnar,
radiculopathy, SCI
Nerve or SCI abnormality – tumor syrinx etc
Treatment
Look for underlying cause!
Treatment
Nonpharmacologic- desensitization,
contrast baths, TENS, CBT, meditation,
acupuncture
Pharmacologic –
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First-line- tricyclic antidepressant or
gabapentin
Second line – consider switching or adding
adjuvant agent
Third line – opioids* banned
Neuropathic pain in SCI
TCA’s less effective
There is level 1 evidence (based on two
RCTs) that tricyclic antidepressants do
not reduce post-SCI pain.
GO WITH NEURONTIN OR LYRICA IN SCI
ObjectivesBy the end of the session the participant will be able to:
Outline common causes of low back pain in the
Paralympic athlete
Discuss things not to miss in Paralympic athletes with
low back pain- the so called RED FLAGS
Discuss treatment suggestions for athletes with low back
pain
Discuss how to manage neuropathic pain in the athlete
with a disability
RED FLAGS for LBP in athlete
with a disability
Progressive pain
Weight loss
Fevers or ssx of infection
RED FLAGS for LBP in athlete
with a disability
CHANGE in:

Motor or sensory function
Muscle bulk or new atrophy
fasciculation's

Bowel or bladder function

Spasticity
Questions?
S9. GLUCOCORTICOSTEROIDS
All glucocorticosteroids are prohibited when administered orally,
rectally, intravenously or intramuscularly. Their use requires a
Therapeutic Use Exemption approval.
Other routes of administration (intraarticular /periarticular/
peritendinous/ epidural/ intradermal injections and inhalation)
require an Abbreviated Therapeutic Use Exemption except as noted
below.
Topical preparations when used for dermatological (including
iontophoresis/phonophoresis), auricular, nasal, ophthalmic, buccal,
gingival and perianal disorders are not prohibited and do not require
any form of Therapeutic Use Exemption.
The Prohibited List 2008 September 22, 2007 9
References:
Return to play after lumbar spine conditions and surgery. Clinics in sports
medicine – volume 23, issue 3, July 2004.
Lower back pain in the athlete: Common conditions and treatment primary
care: Clinics in office practice – volume 32, issue one, March 2005.
Management of back pain in patients with previous back surgery. The
American Journal of medicine – volume 121, issue 4, April 2008.
Chronic low back pain in traumatic Bourland amputees. Clinical
rehabilitation: 2005; 19: 81 to 86.
Pharmacologic management part two colon lesser studied neuropathic pain
diseases. Pain medicine volume 5; number S1: 2004.
Chronic pain management in spine disorders. Neurologic clinics – volume
25, issue to, may 2007.
John Scadding. Review article – neuropathic pain. ACNR: Volumes 3;
number 2 – may – June 2003.
S.C.I R. E.- chapter 14 pain and spinal cord injury.http://www.icord.org/scire/pdf/SCIRE_CH14.pdf