Pain Management of Spinal Disorders
In order to treat pain, it is important to attempt to define it. Webster's Dictionary defines pain as a sensation of hurting or strong discomfort in some part of the body caused by injury, disease, or functional disorder and transmitted through the functional nervous system. Furthermore, it is the sensation that one feels when hurt mentally or physically, especially distress, great anxiety, anguish, grief, etc. The International Society for the Study of Pain Management defines pain as an unpleasant sensory and an emotional experience associated with actual or potential tissue damage or described in terms of such damage.
Chronic pain is defined as pain which lasts for more than three months and is associated with significant impairment of activities of daily living and/or work activities. Thus, pain is not merely to be identified with nociception. Patients have affective responses to pain. Ongoing pain may result in different problems to different people. Functional impairments may vary depending upon the patient's individual physical and emotional response to pain as well as the responsibilities involved in their life and vocational activities.
Learn about the various techniques used to relieve your pain in our pain management slideshow.
Goals in pain management certainly involve the complete remediation of the nociceptive etiology whenever possible. However, there are times when the focus is on managing the pain. Functional goals must be addressed. This may include activities of daily living, homemaking, recreation, sexuality, childcare and vocational issues. Treatment must be done with appropriate utilization of medical services. Appropriate medication usage is urged. Psychological support must be delivered when needed. At times, marital support may be required. The patient must be educated about the nature of their problem. Good biomechanics and ergonomics as well as a therapeutic exercise program is encouraged.
There are five basic options utilized in the treatment of pain. These options include addressing lifestyle issues, therapeutic exercise program, medications, injections, and potentially surgery. Beyond these mainstream options, there are a variety of alternative strategies including acupuncture, manipulation, and herbal remedies.
Lifestyle issues may include tobacco cessation, weight reduction and substance absence. Patients who smoke decrease blood flow to the intervertebral discs. Smoking has been associated with an increase in back pain over time. Furthermore, should a fusion be required, there is less chance of success. Patients who cough may also induce a valsalva which can cause disc herniations. Patients who are injured often gain weight over time. This is secondary to inactivity as well as a variety of medications including anti-depressants and membrane stabilizers which may induce weight gain. Once the patient has gained a significant amount of weight, it becomes very difficult to lose it since they are not able to be as active because of their pain. Finally, unauthorized drug usage and alcohol usage may contribute toward dysphoria and other functional impairment. All these issues must be addressed in conjunction with the other treatments.
Exercise is certainly the backbone of treatment in the conservative management of spinal disorders. Patients with axial pain should be mobilized within two to seven days. Patients with radicular pain should not be at bed rest for a prolonged basis. In general, the patient should be mobilized within a comfortable level as rapidly as possible. Bed rest causes deconditioning and muscular and joint stiffness. Exercises to strengthen and stretch the back should be initiated as rapidly as possible. These exercises should not induce severe axial or radicular pain. Modalities including moist heat, ice and electrical stimulation can be utilized to decrease discomfort so the patient can begin to exercise. Patients who exercise improve aerobic endurance which improves muscle endurance. The body fatigues less and good biomechanics are maintained. In general, patients who exercise improve their overall health care and rate pain as less severe. Exercise can assist with weight reduction.There is some evidence that aerobic activity increases discal nutrition. Finally, patients feel good about trying to help themselves. The patient enters a partnership with the physician in attempting to improve their condition.
There are a variety of other techniques that can be used therapeutically to support exercises. Good body mechanics should be taught to the patient. Specific instruction in body mechanics should involve activities at home including homemaking and childcare. Recreational activities should be addressed. Finally, vocation should be addressed. The patient's workstation should be ergonomically correct. Work tolerance and vocational counseling may be appropriate as well.
Medications are often utilized in the treatment of spinal disease. Non-steroidal anti-inflammatories should be taken on a straight rather than on an as needed basis in order to obtain an anti-inflammatory effect. The patient must observed carefully to make sure that they do not have gastrointestinal distress. Peptic ulcer disease is certainly a risk with non-steroidal anti-inflammatories. Long term usage requires monitoring of renal and liver function. Narcotics may well be appropriate in the acute patient. In general, these should be delivered on a regular as opposed to a PRN basis. Patients must be observed for side effects including sedation, constipation, urinary dysfunction and dysphoria. There is a place for the treatment of chronic pain with narcotics as well. In general, patients should be monitored appropriately and the goals of narcotic usage should be addressed thoroughly. Pain management and improved function may be included among these goals. Tricyclic anti-depressants may be utilized for pain and sleep. Anticholinergic side effects must be monitored carefully. Cardiac, GI, and urinary side effects are common. Weight gain may be significant. Membrane stabilizers, such as the anti-seizure medications, may be useful for the treatment of neuropathic pain.
Spinal injections may be quite effective. Epidural steroid injections may be delivered via a transforaminal or a translaminar approach. The use of fluoroscopy is advised able to assure proper placement of the medication. These injections have been proven to give significant pain relief for leg more than back pain and the patient may get relief for up to three months. No more than three to four injections per year may be delivered. Other sites which may cause pain in the spine include facet or sacroiliac joints. Diagnostic and therapeutic injections may be delivered under fluoroscopy to these sites. In general, spinal injection treatments should be accompanied by an active treatment program which involves learning good biomechanics and proper exercise techniques.
Finally, there are times when surgical options should be considered. Patients with leg pain secondary to a mechanical impingement of the nerve root may respond dramatically to the surgical decompression. This becomes emergent if the patient has evidence a neurogenic bowel or bladder. Progressive weakness is also an indication for more acute surgery. Patients who are recalcitrant to conservative management over eight to twelve weeks are surgical candidates as well. Patients with lower extremity pain which is produced by chemical radiculitis as opposed to a mechanical impingement do not respond very well to surgery. Patients with axial pain secondary to spondylolisthesis may be candidates for surgery if they do not respond to conservative management as well. Finally, there are times when lumbar fusion for discogenic pain may be appropriate.
Up to ninety percent of patients with pain secondary to a spinal etiology are able to respond to conservative management. Each patient must be assessed on an individual basis so that a program specific to their needs can be created for them. There are certainly times when we are not able to completely resolve pain. In these cases, pain and function must be addressed so that we can maximize the patient's quality of life.
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