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Published byQuentin Simmons Modified over 9 years ago
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Anthony Chiodo, MD, MBA University of Michigan Health System AAPMR Meeting 2015, Boston
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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
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Effective: NSAID’s, opioids, valium Ineffective: spinal cord stimulator, psychotherapy, acetaminophen, amitriptyline Effective alternatives: massage, marijuana. Acupuncture effective in some patients.
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No trials in SCI in pain management strategies, other than TENS All trials had designs that were deemed to have high likelihood of bias
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Spasticity Management Spine Intervention For stenosis For cervical and lumbar DDD For epidural fibrosis Dorsal Column Stimulator Intrathecal Morphine + Clonidine + Ziconitide Surgical Treatment: DREZ
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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
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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
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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
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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
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Pain Spasticity Autonomic dysreflexia
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Prior spinal cord trauma with spinal cord tethering Spina Bifida Chiari Malformation or tethered cord Idiopathic
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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
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