Challenging Cases: Part I Johnathan Goree, MD Director of Interventional Pain Management Services Assistant Professor Department of Anesthesiology University of Arkansas for Medical Sciences

Case #1 55 y/o male who presents to your clinic with severe back and bilateral leg pain s/p L3-5 posterior fusion 9 months ago. He describes the pain as severe, constant, worse with standing and ambulation. Rates the pain as 4-8/10 on Numeric Pain Scale. Denies weakness or other alarm signs.

Case #1 PMH: Depression, Anxiety, GERD, HTN PSH: L3-5 posterior decompression and fusion, Laparoscopic Hiatal Hernia Repair 10 years ago. NKDA

Case #1 What questions would you like to know?

Case #1 Past Pain Treatments: Gabapentin (drowsiness), Oxycodone 10mg TID (discontinued) Physical Therapy (20 visits post operatively focused on core strengthening and posture training) Epidural x 1 (40% decrease of pain for 1 month) Current Medications: Xanax 1mg TID, Hydrocodone 10mg TID, Soma 350mg BID, Zaleplon 10MG QHS, Valsartan 160mg daily

Case #1 Social: Patient works as a partner in a corporate law firm Mother unexpectedly died from colon cancer 6 months ago Wife filed for divorce 3 months ago after he discovered that she was having an affair Drinks 1 bottle of red wine per day since death of mother. Feels that this helps him cope.

Case #1 Focused Examination: Point tenderness to L3-5 facets and paraspinal muscles Pain with lumbar extension and flexion Positive Straight Leg Raise No Discernable Weakness Pain with ambulation over 10 yards Confirmatory of Post laminectomy Syndrome

Case #1 Where do you start with this patient?

Case #1 Problem List Polypharmacy Depression Alcoholism Post Laminectomy Syndrome Opioid Dependence Normal Grieving

Problem #1: Polypharmacy Combination of Opioid, Benzodiazepine, and Carisoprodol is associated with a high risk of overdose. Can either of these be weaned or replaced? D/c of Carisoprodol and Zaleplon Start Lyrica and Tizanadine Some patients who fail gabapentin can tolerate lyrica Tizanadine alpha 1 muscle relaxant Sedating Associated with toxicity in patients with liver disease Anti-neuropathic properties

Problem #2: Depression Is Venlafaxine an appropriate anti-depressant? Patient had tried zoloft and paxil in the past Patient felt like this was the most effective anti-depressant she had used. So it was continued SNRIs have been shown to have anti-neuropathic qualities compared to SSRIs Are there any other treatments that could be suggested? Encouraged regular appointments with a therapist

Problem #3: Alcoholism How do we determine if this patient has a problem with alcohol abuse? How do we discuss alcohol treatment? Is discussion of her alcoholism more important, less important, or a part of her issues with polypharmacy? Should we discuss them in tandem? Discussed alcoholism as a separate entity, patient began to attend AA meetings. Has unfortunately relapsed.

Problem #4: Post Laminectomy Syndrome What are causes of Post Laminectomy Syndrome Severe facet disease above and below a fusion (normally 3-10 years post surgery Adjacent segment disease (1-5 years after surgery) Surgical scarring around cord or nerve roots (3-6 months after surgery) Is there a treatment for Severe Post Laminectomy Syndrome that is opioid sparing? MRI positive for large amount of scarring around nerve roots and cord. Early facet arthritis Facet arthritis treated with Radiofrequency Ablation. Discussed Neuromodulation/Dorsal Column Stimulation, patient is considering.

Problem #5: Opioid Dependence Is this dosage of opioid appropriate for this patient? After above interventions, able to wean patient to hydrocodone 10mg as needed 45 tablets per month. Patient felt that some of his opioid use was due to depression/anxiety

Problem #6: Normal Grieving Is the patient’s reaction to his recent tragedies appropriate? Encouraged Grief Counselling with his therapist.