Anthony Chiodo, MD, MBA University of Michigan Health System AAPMR Meeting 2015, Boston

 Effects one in three patients  Up to 80% report pain in a postal survey- UE: 69%, Spine 61%  Effects mood, function and quality of life  SCI patients are typically dissatisfied with efforts to affect their pain

 Effective: NSAID’s, opioids, valium  Ineffective: spinal cord stimulator, psychotherapy, acetaminophen, amitriptyline  Effective alternatives: massage, marijuana. Acupuncture effective in some patients.

 No trials in SCI in pain management strategies, other than TENS  All trials had designs that were deemed to have high likelihood of bias

 Spasticity Management  Spine Intervention  For stenosis  For cervical and lumbar DDD  For epidural fibrosis  Dorsal Column Stimulator  Intrathecal Morphine + Clonidine + Ziconitide  Surgical Treatment: DREZ

 Not uncommon relationship between pain and spasticity  Focal treatment with use of botox and phenol  Trial process with bupivacaine blocks  Generalized treatment with oral medication and intrathecal baclofen  Trial process with ITB trial

 Powerful diagnostic tool: highly specific and sensitive vs. non-specific MRI  Effective short and long term pain management tool  Can direct to other effective therapies by identifying pain generator

 The same mechanism that caused the initial injury influences other segments of the vertebral system  Flexion or extension moments at the cervical or lumbar spine  Compressive forces at the thoracic or lumbar spine  Surgical management of SCI changes mechanical spine dynamics  Lesion can be above or below the level of injury

 Cervical degenerative disc and degenerative spine disease  Lumbar degenerative disc and degenerative spine disease  Cervical stenosis  Lumbar stenosis  Note: Relatively high lifetime incidence of these disorders

 Pain  Spasticity  Autonomic dysreflexia

 T10 ASIA A SCI with zone of incompletion to L3 after an L2 burst fracture requiring an L1-5 PSF  Presented 13 years later with left leg pain with no change in neurological exam  MRI showed left L4-5 lateral recess stenosis  Successfully treated with L5-S1 transforamenal epidural and L4-5 intra-articular facet block

 T4 ASIA-A SCI presents 11 years after his injury with right leg pain and severe unilateral spasticity  Pain increased with standing and rotation, no symptoms in sitting  MRI reveals lumbar DDD with severe bilateral L4-5 facet hypertrophy  Bilateral L4-5 facet blocks relieved his pain and spasticity

 C7 ASIA-A SCI after C6 burst fracture requiring C5-7 fusion and decompression  Presents 13 years later with right upper shoulder pain not relieved by physical therapy or trigger point injections  Cervical spine MRI showed right C3-4 and C4-5 paracentral disc bulges  Right C4-5 transforamenal epidural injection relieved his neck pain

 T7 ASIA-A SCI after T8 fracture-dislocation requiring PSF T7-12  Pin level T10 right and T7 left with left chest wall dysesthesias at T8 and T9  Left T8-9 transforamenal epidural injection resulted in a transient complete improvement in his pain  Myelography demonstrated dye flow defect at T8  Surgical decompression and untethering relieved his chest wall pain

 Implanted epidural electrodes with subcutaneous generator  Commonly used for neuropathic pain  Patient needs to have adequate present sensation in the painful distribution for it to be effective  No demonstrated efficacy in below level neuropathic pain: dorsal column degeneration  Consideration for patients with at level neuropathic pain and patients with incomplete SCI and neuropathic pain  Consideration for patients with CRPS

 Intrathecal medication delivery for pain management  Typically effective for chronic nociceptive pain; not demonstrated for central pain states  Delivery system is the same with ITB  Trial process with external pump

 Treatment for patients with at level neuropathic pain  Root injury  Partial lesion at segment above SCI  Scar formation  Least risk with patients with pain in the thoracic spine levels, although functional impact of such lesions has not been studied  Recurrence rate concerns

 Cause for pain, spasticity and change in neurological function  Often associated with syrinx  Typically at level of injury with syrinx that could be above or below injury level  Risk for recurrence  If syrinx requires drainage, risk of neurological change and loss of function

 Pain: 66%  Loss of function: 65.9%  Weakness: 61.8%  Sensory loss (dissociated: pain > light touch): 51.2%  Spasticity: 39.6%  Sweating: 21.2%  Associated with valsalva and lying positions  Weakness in the zone of the syrinx

 Prior spinal cord trauma with spinal cord tethering  Spina Bifida  Chiari Malformation or tethered cord  Idiopathic

 404 patients with 486 surgeries  > 90% of patients self-assessing arrest of functional, motor and/or sensory loss  > 50% of patients self-assessing improvement of function  17 and 18% self-assessing improvement of motor and sensory functions to a point greater than that achieved at any time post-injury,  59% reporting improvement of spasticity  77% reporting improvement of hyperhidrosis  46% decrease in neuropathic pain, 26% increase