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Chronic pain syndromes

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Chronic pain syndromes, CRPS, LS radiculopathy, Neuralgia, Cancer pain,Low back ache

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Chronic pain syndromes

  1. 1. CHRONIC PAIN SYNDROMES : LBA, SCIATICA, CRPS, Trigeminal neuralgia, Cancer pain. Dr Aftab Hussain
  2. 2. What is Pain?  International Association for the Study of Pain (IASP) defines pain as An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage  The Joint Commission on Accreditation of Healthcare Organisation adopted pain as “the fifth vital sign”
  3. 3.  ACUTE v/s CHRONIC PAIN Acute Pain Chronic Pain Recent onset; usual duration 0-7 days Persisting > 3 months with less sudden and defined onset Cause usually known; usually a definable event More often leads to anxiety and persuit of remedy Pain usually subsides as healing progresses May or may not be the result of tissue damage More often leads to depression and other behavioral changes Pain persists, becoming a disease unto itself
  4. 4. COMMON FORMS OF CHRONIC PAIN  Musculoskeletal disorders  Chronic visceral disorders  Lesions of peripheral nerves, nerve roots, or dorsal root ganglia (including diabetic neuropathy, causalgia, phantom limb pain, and postherpetic neuralgia)  Lesions of the central nervous system (stroke, spinal cord injury, and multiple sclerosis), and cancer pain.
  5. 5. TYPES  The pain of most musculoskeletal disorders (eg, rheumatoid arthritis and osteoarthritis) is primarily nociceptive.  Pain associated with peripheral or central neural disorders is primarily neuropathic.  The pain associated with some disorders, eg, cancer and chronic back pain (particularly after surgery), is often mixed.
  6. 6. Dimensions of Chronic Pain Loneliness Hostility Social Factors Anxiety Depression Psychological Factors Pathological Process Physical Factors A.G. Lipman, Cancer Nursing, 2:39, 1980
  7. 7. LOW BACK PAIN and SCIATICA
  8. 8. Low Back Pain: Epidemiology  60%–90% lifetime prevalence  Second most common complaint to prompt a medical evaluation  Leading cause of long-term work disability  Disability and costs are related to pain, not to the disease process
  9. 9.  90 % of cases of LBP resolve without treatment within 6-12 weeks  40-50 % LBP cases resolve without treatment in 1 week  75 % of cases with nerve root involvement can resolve in 6 months  LBP and lumbar surgery are:  2nd and 3rd highest reasons for physician visits  5th leading cause for hospitalization  3rd leading cause for surgery
  10. 10. Causes of Low Back Pain  Lumbar “strain” or “sprain” – 70%  Degenerative changes – 10%  Herniated disk – 4%  Osteoporosis compression fractures – 4%  Spinal stenosis – 3%  Spondylolisthesis – 2%  Myofascial pain- frequency not defined.
  11. 11.  Spondylolysis, diskogenic low back pain or other instability – 2%  Traumatic fracture - <1%  Cancer – 0.7%  Inflammatory arthritis – 0.3%  Infections – 0.01%
  12. 12. Red Flags  History of cancer  Unexplained weight loss  Intravenous drug use  Prolonged use of corticosteroids  Older age • Major Trauma • Osteoporosis • Fever • Back pain at rest or at night • Bowel or bladder dysfunction
  13. 13. PATHOPHYSIOLOGY 3 compartment theory  ANTERIOR- bounded by ALL & PLL.  ALL stronger than PLL- broad and strong.  PLL is intact throughout length of spinal column.  From L1 it becomes progressively narrower until at L5-S1.  This inherent weakness is the point of greatest static & kinetic strain.
  14. 14.  MIDDLE-  Neuraxial compartment.  Contains structures within bony & ligamentous boundaries of spinal canal.  Includes PLL, epidural space, meninges, spinal cord, dorsal & ventral nerve roots, root sleeves and ligamentum flavum.
  15. 15. Anatomy of Lumbar spine
  16. 16.  POSTERIOR-  Contains facet joints, laminae, vertebral arches.  Innervated by dorsal rami of the spinal nerves.  LIGAMENTUM FLAVUM connecting the laminae can contribute to spinal stenosis by folding inward during UPRIGHT posture, EXTENSION of the back and through HYPERTROPHY.
  17. 17. INTERVERTEBRAL DISC  Inner 2/3- Nucleus pulposus (proteoglycan matrix)  Outer 1/3- Annulus fibrosus (fibrocartilaginous ring)  Aging : no. of viable cells decreased.  Necrosis : 2% in infancy to 50% in young to 80% in elderly.  Water content : Disc tends to dehydrate to 70%.  When overstressed disc protrude along the path of least resistance i.e. posterolaterally.
  18. 18. Other proposed theories  Immune mediated theory  Theory of oxidative stress SMOKING  Affects the vasculature of the disc.  Causes reduction of solute exchange capacity, cellular uptake and metabolism within the disc.
  19. 19. Herniated Disc  Herniation of the nucleus pulposus through the annulus fibrosis.  Radicular symptoms due to compression and stretching of the nerve roots exiting through the adjoining intervertebral foramen.  In more than 95% of cases, either L4-5or L5-S1 disc is affected. The straight-leg raising test is highly suggestive of disc herniation, although relatively nonspecific.
  20. 20. Disc Herniation vs Extrusion
  21. 21. Discogenic Pain  Degenerative disc disease is a leading cause of LBP.  Patients often present with deep, aching, axial midline pain that may extend into the buttock, hip, groin or even in the lower limb.  Pain often gets exacerbated by prolonged sitting, standing or bending forwards.  Common in those with frequent motion of the spine i.e. package handlers, truck drivers, jackhammer operators.
  22. 22. Spinal canal Stenosis  “spinal Stenosis” refer to central canal narrowing, lateral recess narrowing or foraminal narrowing.  The typical presentation of spinal stenosis is an elderly person with axial low back and leg pain (bilateral).  The pain is more severe when walking downhill as such activities cause extension of spine leading to further narrowing of spinal canal.  Patients are often seen bending forwards to obtain pain relief.
  23. 23. Myofascial Pain  Myofascial LBP often presents as deep aching pain that is aggravated by activity and position changes.  It may be localized to the low back or radiate into the buttock, sacrum, thigh, abdominal wall or even calf muscles, depending on the affected muscles.  On physical examination, a tender, taut band of muscle may be noted (trigger point) that when palpated results in a characteristic local twitch response.
  24. 24.  Various physiotherapy techniques (spray and stretch technique, massage) are used initially for relieving myofascial pain.  Injection of local anaesthetic with or without steroids into the trigger points may be helpful.  A recent trial has demonstrated that the injections with botulinium toxin type-A is an effective treatment in patients with chronic LBP.
  25. 25. What are the symptoms 0f LBA?  The main symptom is pain that shoots down one or both legs.  Numbness or tingling in the legs.  Sometimes the muscles are weak.  Rarely, there is a loss of bowel or bladder control.
  26. 26. Pathological Examination: Straight-leg raise (SLR): Elevation of lower extremity, seated or standing, resulting in neural tension at S1 nerve root with extremity pain.
  27. 27. Occupational Risk Factors:  Low job satisfaction  Monotonous or repetitious work  Educational level  Adverse employer-employee relations  Recent employment  Frequent lifting  Especially exceeding 25 pounds  Utilization of poor body mechanics in technique
  28. 28. DIAGNOSTIC TOOLS  1. Laboratory: • Performed primarily to screen for other disease etiologies  Infection  Cancer  Spondyloarthropathies • Specifics:  WBC  ESR or CRP  HLA-B27  Tumor markers: Kidney Breast Lung Thyroid Prostate
  29. 29.  2. Radiographs:  Usually 3 views adequate with obliques only if equivocal findings  Indications:  History of trauma with continued pain  Less than 20 years or greater than 55 years with severe or persistent pain  Noted spinal deformity on exam  Signs / symptoms suggestive of spondyloarthropathy  Suspicion for infection or tumor
  30. 30.  3. EMG / NCV ( Electrodiagnostics):  Can demonstrate radiculopathy or peripheral nerve entrapment, but may not be positive in the extremities for the first 3-6 weeks and paraspinals for the first 2 weeks  Would not be appropriate in clinically obvious radiculopathy  4. Bone scan:  Very sensitive but nonspecific  Useful for:  Malignancy screening  Detection for early infection  Detection for early or occult fracture
  31. 31.  5. Myelogram:  Procedure of injecting contrast material into the spinal canal with imaging via plain radiographs versus CT  Gold standard for evaluation of the spinal canal and neurological compression  With potential complications, as well as advent of MRI and CT, is less utilized.  6. CT:  Best for bony changes of spinal or foraminal stenosis  Also best for bony detail to determine:  Fracture  Degenerative joint diseases  Malignancy
  32. 32.  7. CT with myelogram:  Can demonstrate much better anatomical detail than myelogram alone  Utilized for:  Demonstrating anatomical detail in multi- level disease in pre-operative state  Determining nerve root compression etiology of disc versus osteophyte  Surgical screening tool if equivocal MRI or CT
  33. 33.  8. Discography (Diagnostic disc injection):  Less utilized as initial diagnostic tool due to high incidence of false positives as well as advent of MRI  Utilizations:  Diagnose internal disc derangement with normal MRI / myelogram  Determine symptomatic level in multi-level disease Criteria for response:  Volume of contrast material accepted by the disc, within normal of 0.5 to 1.5 cc  Resistance of disc to injection  Production of pain---MOST SIGNIFICANT
  34. 34.  9. MRI: • Best diagnostic tool for:  Soft tissue abnormalities: • Infection • Bone marrow changes • Spinal canal and neural foraminal contents  Benign vs. malignant compression fractures  Osteomyelitis evaluation  Evaluation with prior spinal surgery  Done if pain > 6 weeks  Has essentially replaced CT and myelograms for initial evaluations.
  35. 35.  MRI with Gadolinium contrast:  Gadolinium is contrast material allowing enhancement of intrathecal nerve roots  Utilization:  Assessment of post-operative spine---most frequent use  Identifying tumors / infection within / surrounding spinal cord
  36. 36.  10. Psychological tools:  Includes: • Pain Assessment Report, which combines:  McGill Pain Questionnaire  Mooney Pain Drawing Test • Middlesex Hospital Questionnaire • Cornell Medical Index • Eysenck Personality Inventory
  37. 37. What is sciatica?  Sciatica is a form of low back pain that runs down one or both legs, causing pain, numbness or tingling in the leg.
  38. 38. How does it occur?  The sciatic nerve is formed from a group of nerves that leave the spine and run down the leg.  Anything that causes irritation along the course of the nerve can cause sciatica.
  39. 39. COMMON CAUSES  Overuse of back  injury to back  Overuse or injury can cause muscle tension or spasm, back sprains, ligament or muscle tears  Joint problems irritating the sciatic nerve.  Infections, tumors, a ruptured disk, osteoporosis, spondylosis  Spinal stenosis
  40. 40. How is it treated?  Most people with low back pain and sciatica get better no matter what they do.  Often, medicines for pain and inflammation, such as ibuprofen and naproxen, can ease the pain.  Ice massage or deep heat may help.  Physical therapy sometimes helps back pain that doesn't get better with the usual medicines.
  41. 41. Treatment  Medications  NSAIDS  Membrane stabilizers  TCA  re-establish sleep patterns  reduce radicular dysesthesias  Muscle relaxants:  re-establish sleep patterns  more useful in myofascial/muscular pain  Narcotics: rarely indicated  Steroids: more useful for radiculitis  Non-narcotic analgesics
  42. 42. ROLE OF STEROIDS  Corticosteroids around nerve roots can reduce inflammatory oedema, with improvement of microcirculation.  Ectopic discharges from an injured nerve root are inhibited due to its membrane stabilizing effect.  The pro inflammatory action of phospholipase-A2 (released from injured disc) is also inhibited by epidural steroids.
  43. 43. Physical therapy • electrical stimulation/TENS • Postural education / body mechanics • Massage / mobilization / myofascial release • Stretching / body work • Exercise / strengthening • Traction
  44. 44. COMMON INTERVENTIONS:  Trigger point injection.  Traditional epidural steroid injection.  Transforaminal epidural injection.  Facet joint intra-articular block.  Steroids act against infammation and reduce edema.  Addition of hyaluronidase into epidural injectate improves the spread of local anaesthetic and steroid.
  45. 45. Epidural injection Midline Interlaminar L5-S1
  46. 46. USUAL PROTOCOL FOLLOWED  STEP 1 : Epidurography  STEP 2 : 80 mg methyl prednisolone + 1500 units of hyalase in 5 ml saline  STEP 3 : Adhesiolysis via percutaneous catheter  STEP 4 : Foraminal block given
  47. 47. Parasagittal Interlaminar
  48. 48. Transforaminal Approach L5-S1 Transforaminal
  49. 49. Facet Joint Interventions  Intra-articular injections  Medial branch block  Radiofrequency ablation
  50. 50.  Facet Joint Interventions Lumbar
  51. 51. Radiofrequency ablation  Alternating electric field with oscillating frequency 5,00,000 Hz.  Heat produced : Hottest part near the tip.  0.5 mA : 0.25 V MINIMUM ---> Discharge.  Cannula placed within 3 mm of nerve.  RFG 3 C PLUS , RADIONICS USA.  Adequate lesioning : 90 degrees C × 60 – 120 secs.  Myelinated fibres more resistant.
  52. 52. Radiofrequency Vs Chemical Neurolysis  Lesion size controlled.  Good monitoring of lesion temperature.  Good placement of electrode facilitated by electrical stimulation.  Performed ↓ LA with sedation.  Rapid recovery & low morbidity.  Ability to repeat radiofrequency if neural pathway regenerates.  Ability to utilize same cannula for different spinal lesions.
  53. 53. PULSED RADIOFREQUENCY  Better ---> No temp rise > 42 degrees C.  Total voltage applied 25 – 35 V.  Frequency 300 Hz × 30 ms out of a cycle.  Action similar to TENS.
  54. 54. MINIMALLY INVASIVE INTERVENTIONS  EPIDURAL NEUROPLASTY or EPIDURAL ADHESIOLYSIS with steroid, LA, hypertonic saline and hyaluronidase.  EPIDUROSCOPY / SPINAL CANAL ENDOSCOPY using a fiberoptic light source and flexible fiberoptic catheter.
  55. 55.  PERCUTANEOUS RADIOFREQUENCY DENERVATION of segmental spinal nerves by applying heat to denature the nerves that innervate painful facet joints.  PERCUTANEOUS DISC DECOMPRESSION USING NUCLEOPLASTY Co ablation technique used with thermal treatment and tissue removal.
  56. 56.  PERCUTANEOUS LASER DISC DECOMPRESSION (PLDD) Using Nd:YAG laser to “vaporise” a small portion of the nucleus pulposus.  INTRADISCAL ELECTROTHERMAL THERAPY (IDET) Catheter with an electrode passed into nucleus pulposus ↓ Heat applied to shrink collagen at a target temp of 65 – 75 degrees C
  57. 57. SPINAL CORD STIMULATION  Electrodes passed into the posterior epidural space for electrical stimulation of the spinal cord.  Approved by FDA .  SCS has become a standard treatment for patients with chronic pain in back or limbs who are not relieved from other treatment.
  58. 58. INTRATHECAL PAIN PUMPS INTRA THECAL DRUG DELIVERY  Through a catheter and pump to treat intractable pain both nociceptive and neuropathic.  Indicated when opioid requirements are high enough to cause side effects.  A/K/A INTRA THECAL POLYANALGESIA.
  59. 59. Intrathecal Pain Pumps  Size of a pacemaker .  Has access- pump usually has to be refilled as early as every 3 months- medication can be reconstituted when refilled – morphine, baclofen, bupivicaine, clonidine.  Pain pump is inserted under the skin;usually in abdomen/ catheter is threaded into the intrathecal space for continuous delivery.
  60. 60. PERCUTANEOUS VERTEBROPLASTY  t/t of osteoporotic body compression #.  Utilizes bone cement ( PMMA ), tobramycin and barium powder as non ionic contrast applied through a special needle under fluoroscopy.  It provides vertebral solidification. PERCUTANEOUS KYPHOPLASTY  Inflatable balloon applied inside collapsed vertebral body.
  61. 61. Kyphoplasty/Vertebroplasty
  62. 62. Kyphoplasty/Vertebroplasty  How it works – helps with axial load, cement is very hot and theory is that intraosseous nerve endings are burned and that helps with pain relief – usually immediate
  63. 63.  SURGERIES as laminectomy, micro discectomy, foramenotomy and spinal fusion considered: 1) Failure to respond to conservative mgt >3months 2) Profound / progressive neurological deficit 2) Recurring episodes of intactable sciatica involving same segment – to avoid cumulative disability of repeated events.
  64. 64. How can we help prevent sciatica?  Avoid lifting heavy weight.  Avoid frequent bending or other activities that make the pain worse.  Lose weight .  Do regular aerobic exercise to keep your back and abdominal muscles in shape (this can be as simple as walking),  Learn to lift properly. Bend your knees and hips and keep your back straight when you lift a heavy object.
  65. 65. Complex Regional Pain Syndrome
  66. 66. Complex Regional Pain Sydrome I (RSD)  History of initiating injury or immobilization  Continuing pain, allodynia, or hyperalgesia out of proportion to the initiating event  Evidence at some time of edema, changes in skin blood flow or abnormal pseudomotor activity in the painful area  No other cause of the pain exists
  67. 67. Complex Regional Pain Syndrome II (causalgia)  Differs from CRPS I by the presence of a known nerve injury  Devastating injury has occurred, which by definition has caused a major nerve injury .  The burning pain is often of extreme severity  Often, there is also significant vascular compromise.
  68. 68. Causes • Injuries to peripheral tissues (e.g., fractures, dislocations, and postoperative State) • Inflammatory conditions (e.g., fasciitis, tendonitis, bursitis, and arthritis) • Immobilization as a result of injury or cast application • Peripheral nerve injury resulting from direct compression or ischemia (e.g., brachial plexopathy, postherpetic neuralgia, and nerve root injury) • Central nervous system insults (e.g., head injury, ischemia, and brain tumor) • Spinal cord lesions • Idiopathic
  69. 69. DEVELOPMENT OF CRPS • Abnormal discharges in sympathetic and nociceptive afferents produced by trauma • Sensitization of peripheral sensory receptors produced by sympathetic hyperactivity • Formation of ephapses (artificial synapses) after peripheral nerve injury • Spontaneous neuronal ectopy at the site of demyelination or axonal injury • Central reorganization of pain processing
  70. 70. Pathophysiologic Mechanisms of CPRS • Sensory abnormalities • Autonomic dysfunction • Neurogenic inflammation • Motor abnormalities
  71. 71. Sensory Abnormalities in CRPS  Dysesthesia / hyperalgesia throughout the affected half of the body.  Increased thresholds to mechanical and thermal stimuli on the affected side.  Due to changes in the thalamus and cortex.  PET studies have demonstrated adaptive changes in the thalamus.
  72. 72. Autonomic Dysfunction  About 85% of CRPS report pain relief after sympathetic interruption; however, the pain relief is temporary in the majority of patients  Catecholamines can activate peripheral nociceptors after thermal or chemical sensitization in the absence of nerve injury  After nerve injury, surviving cutaneous afferents develop noradrenergic sensitivity.  Hyperhydrosis
  73. 73. Early phase Skin temperature and perfusion high Norepinephrine levels low Intermediate phase Temperature and perfusion either warmer or colder, depending on the level of sympathetic activity Late phase Skin temperature and perfusion low Norepinephrine levels low Skin lactate increased
  74. 74. Neurogenic Inflammation • Extensive plasma extravasation in patients with acute CRPS • Increased joint effusions, protein and synovial hypervascularity • Increased systemic CGRP in the acute phase • Increased tissue levels of TNFα and IL-6 • Increased production of nitric oxide from peripheral monocytes .
  75. 75. Motor Abnormalities • About 50% of CRPS patients develop – Decreased range of motion – Physiological tremor – Reduction in active motor force • About 10% of CRPS patients develop dystonia in the affected extremity.
  76. 76. STAGING OF CRPS
  77. 77. Stage I • Severe pain limited to the site of injury • Hyperesthesia • Localized swelling • Muscle cramps • Stiffness and limited mobility At onset, skin is usually warm, red, and dry; then may change to blue (cyanotic). • Increased sweating (hyperhydrosis).
  78. 78. Stage II • Severe and more diffuse pain. • Swelling tends to spread and it may change from a soft to hard (brawny) type. • Hair may become coarse then scant, nails may grow faster and become brittle, cracked, and heavily grooved. • Osteoporosis • Muscle wasting
  79. 79. Stage III • Marked wasting of tissue (atrophic) eventually becomes irreversible. • For many patients, the pain becomes intractable and may involve the entire limb. •A small percentage of patients have developed generalized reflex sympathetic dystrophy (RSD), affecting the entire body.
  80. 80. Complex Regional Pain Syndrome and the Sympathetic Nervous System  Interactions between sympathetic fibers and sensory fibers in the dorsal root ganglion  Sensitization of dorsal horn cells secondary to activation of afferent fibers by sympathetic efferent actions.
  81. 81. Role of psychological factors?  Sufferers may become seriously affected psychologically, and sometimes show features of major depression. (as expected in anyone who is in constant pain, who may have lost their job and had their family and social life shattered).
  82. 82. Pharmacologic Management  WHO Ladder  Non-opioid therapy / Co-analgesics  Opioids
  83. 83. Modified WHO Analgesic Ladder Proposed 4th Step Pain Step 1 Nonopioid  Adjuvant Pain persisting or increasing Step 2 Opioid for mild to moderate pain Nonopioid  Adjuvant Pain persisting or increasing Pain persisting or increasing Step 3 Opioid for moderate to severe pain Nonopioid Adjuvant Invasive treatments Opioid Delivery Quality of Life
  84. 84. Adjuvants Antidepressants  TCAs for neuropathic pain Anticonvulsants Corticosteroids Neuroleptics Alpha2 – agonists  Benzodiazepines  Antispasmodics  Muscle relaxants  NMDA-blockers  Systemic local anesthetics
  85. 85. Non-Pharmacologic Management  Exercise programs  Hypnosis  Counseling  Music  Acupuncture  Yoga  Cold/heat  Massage  Vibration  TENS units
  86. 86. Stellate ganglion block  The preganglionic sympathetic outflow to the upper extrimity is derived from T2-T9.  These fibres synapse with the postganglionic neurons in the stellate ganglion.  Therefore stellate ganglion block interrupts the sympathetic outflow to the upper extremity.
  87. 87. Dye spread around stellate ganglion Stellate ganglion block
  88. 88. Signs of successful stellate ganglion block  Eye: - ptosis, narrowing of palpebral fissure, miosis,lacrimation.  Face and neck:- anhidrosis, elevated local temp and nasal stuffiness  Plethysmographic evidence of improved cutaneous blood flow.
  89. 89. Intravenous regional blockade.  Intracath is inserted into a peripheral vein.  The limb is then isolated from the circulation for 20 min using a sphygmomanometer cuff inflated to supra-systolic level.  Guanethidine or another sympatholytic drug is then injected through the needle.  The procedure is often painful, and the drug is therefore usually combined with local anaesthetic.
  90. 90. TRIGEMINAL NEURALGIA
  91. 91. TRIGEMINAL NEURALGIA  Trigeminal neuralgia (TN), tic douloureux[ (also known as prosopalgia, the Suicide Disease or Fothergill's disease is a neuropathic disorder characterized by episodes of intense pain in the face, originating from the trigeminal nerve.  It has been described as among the most painful conditions known.  1 in 15,000 people suffer from TN
  92. 92.  TN symptoms usually appears after the age of 40,. It is more common in females than males.  The trigeminal nerve is a paired cranial nerve that has three major branches: the ophthalmic nerve (V1), the maxillary nerve (V2), and the mandibular nerve (V3). One, two, or all three branches of the nerve may be affected. 10-12% of cases are bilateral.
  93. 93. SIGNS AND SYMPTOMPS  The disorder is characterized by episodes of intense facial pain that last from a few seconds to several minutes or hours. The episodes of intense pain may occur paroxysmally.  A trigger area on the face so sensitive that touching or even air currents can trigger an episode.  It affects lifestyle as it can be triggered by common activities such as eating, talking, shaving and brushing teeth
  94. 94.  Wind, high pitched sounds, loud noises such as concerts or crowds, chewing, and talking can aggravate the condition in many patients. The attacks are said by those affected to feel like stabbing electric shocks, burning, pressing, crushing, exploding or shooting pain that becomes intractable.
  95. 95. ETIOLOGY Nerve compression at the opening from the inside to the outside of the skull; An enlarged blood vessel - possibly the superior cerebellar artery - compressing or throbbing against the microvasculature of the trigeminal nerve near its connection with the pons. Such a compression can injure the nerve's protective myelin sheath and cause erratic and hyperactive functioning of the nerve
  96. 96. MANAGEMENT Pharmacological  The anticonvulsants carbamazepine is the first line treatment; second line medications include baclofen, lamotrigine, oxcarbazepine, phenytoin, gabapentin, and sodium valproate.  Low doses of some antidepressants such as amitriptyline are thought to be effective in treating neuropathic pain. Surgical  Microvascular decompression appears to result in the longest pain relief.
  97. 97. Percutaneous procedure  Percutaneous radiofrequency trigeminal gangliolysis. (PRTG)  Percutaneous retrogasserian glycerol/phenol rhizotomy.  Percutaneous baloon microcompression. Percutaneous radiofrequency thermorhizotomy may also be effective as may gamma knife radio surgery .
  98. 98. CANCER PAIN  30% patients with cancer have pain at the time of diagnosis.  85% of patients with cancer have pain in advanced stages.  36% patients of people have pain sufficient enough to cause functional disability.
  99. 99. COMPONENTS OF CANCER PAIN  SENSORY  AFFECTIVE  PSYCHOLOGICAL
  100. 100. ETIOLOGY  Presence and progression of the tumor itself.  Indirect effect of the tumor i.e. metabolic , infective, venous or lymphatic obstruction.  Consequence of cancer treatment i.e. chemotherapy, radiotherapy and surgery.  Unrelated mechanisms like migraine or myofascial pain.
  101. 101. PAIN ASSESSMENT IN CANCER  Step wise approach  History, examination and data collection ending with clinical diagnosis.  Assessment involves features of pain like location, intensity, quality, timings, exacerbating and relieving factors and response to previous analgesia.  Psychological status of the patient.  Associated co-morbidities.
  102. 102. Management  Removing source of pain by surgery , chemotherapy, radiotherapy or other form of treatments.  Over the counter prescriptions (NSAIDs, Aspirin) or strong opioid medications. (Oral, I.V., patches) Patient controlled analgesia  Intravenous PCA is very advantageous for patient with chronic cancer pain .  It allows to self administer medication and find their own comfort zone between the side effects and pain control within limits set by the physician.
  103. 103. The PCA device is a computerised programmable lightweight battery operated portable pump with the capability of storage and retrieval of data by a microprocessor.
  104. 104.  3 modes of delivery 1. Continous per hour rate infusion. 2. Continous with boluses for breakthrough pain 3. Boluses with lock out time in mins set by the physician.  PCA can also be provided by the subcutaneous, epidural or intrathecal route.  Apart from various medical complication, another aspect limiting the widespread use of PCA is its cost.
  105. 105. Nerve blocks and interventions in cancer pain  Coeliac plexus block using Phenol/alcohol is especially helpful in Pancreatic cancer and and upper GI tumor pain.  Stellate ganglion block in head and arm cancers.  Lumbar sympathectomy in lower limb cancers.  Intercostal nerve blocks in pathological fracture of ribs.  Ganglion Impar block for Vulval cancer.  Procedure is carried under C-arm guidance.  In bony metastasis strengthening of bone is done by kyphoplasty and vertebroplasty.  TENS have also being utilized for pain relief albeit temporarily.  Intrathecal pumps for drug delivery.  Percutaneous cordotomy has been succesfully used for unilateral pain arising out of cancer pain in mesothelioma
  106. 106. Coeliac Plexus Block Crescent shaped dye spread around coeliac plexus
  107. 107. Pain insists upon being attended to --- C S Lewis THANKS

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