Anthony Chiodo, MD, MBAUniversity of Michigan Health SystemAAPMR 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

Modified Microsurgical DREZ Chun, World Neurosurgery, 2011

38 patients with SCI in the last 7 years with diffuse, continuous or thermal pain

5 thoracic, 33 thoracolumbar Note: Small to no likelihood of

infralesional pain generator or centralized pain

Results 75% pain reduction greater than 6

months All patients 79% Segmental 83% Diffuse 73% Burning 20%

Same results if continuous or intermittent

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