Low back pain neurologists perspectives
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Transcript of Low back pain neurologists perspectives
Low Back PainNeurologist’s perspectives
Dr.A.V.SrinivasanDr.A.V.Srinivasan
Back pain is a common cause of referral to Back pain is a common cause of referral to the neurology clinicthe neurology clinic
Pain experience is the result of a multitude Pain experience is the result of a multitude of processes, whereof the sensory input is of processes, whereof the sensory input is one, that interact in a proposed neural one, that interact in a proposed neural network, the neuromatrix.network, the neuromatrix.
Progress in Neurobiology August 2001; 64 (6): 613-637Best Practice & Research Clinical Rheumatology Vol. 21, No. 1, pp. 153e166, 2007
Low Back Pain is more common
Prevalence of chronic pain
Best Practice & Research Clinical Rheumatology Vol. 21, No. 1, pp. 153e166, 2007
Best Practice & Research Clinical Rheumatology Vol. 20, No. 4, pp. 707-720, 2006
Differential diagnosis of low back pain
Am Fam Physician 2007;75:1181-8, 1190-2
The lumbar disc herniation is the most The lumbar disc herniation is the most frequent disease of the spinal degenerative frequent disease of the spinal degenerative processes, and they cause of 30% to 80% of processes, and they cause of 30% to 80% of the low back pain casesthe low back pain cases
Medicina (Kaunas) 2007; 43(8)
Cauda equina syndrome Single or double-level compression of the lumbosacral Single or double-level compression of the lumbosacral
nerve roots located in the dural sac results in a polyradicular nerve roots located in the dural sac results in a polyradicular symptomatology clinically diagnosed as cauda equina symptomatology clinically diagnosed as cauda equina syndrome. syndrome.
The cauda equina nerve roots provide the sensory and motor The cauda equina nerve roots provide the sensory and motor innervation of most of the lower extremities, the pelvic floor innervation of most of the lower extremities, the pelvic floor and the sphincters. Therefore, in a fully developed cauda and the sphincters. Therefore, in a fully developed cauda equina syndrome, multiple signs of sensory disorders may equina syndrome, multiple signs of sensory disorders may appear such as appear such as low-back pain, saddle anesthesia, bilateral low-back pain, saddle anesthesia, bilateral sciatica, then motor weakness of the lower extremities or sciatica, then motor weakness of the lower extremities or chronic paraplegia and, bladder dysfunctionchronic paraplegia and, bladder dysfunction..
Progress in Neurobiology August 2001; 64 (6): 613-637
CES - Etiology Non-neoplastic compressive etiologiesNon-neoplastic compressive etiologies
Herniated lumbosacral discs Herniated lumbosacral discs Spinal stenosisSpinal stenosis Spinal neoplasms Spinal neoplasms
Non-compressive etiologiesNon-compressive etiologies Ischemic insultsIschemic insults Inflammatory conditionsInflammatory conditions Spinal arachnoiditis Spinal arachnoiditis Other infectious etiologies. Other infectious etiologies.
Orendacavo J et al. Progress in Neurobiology August 2001; 64 (6): 613-637
Failed Back Syndrome
• Failed back syndrome (FBS) is a well-Failed back syndrome (FBS) is a well-recognized complication of surgery of the recognized complication of surgery of the lumbar spine. It can result in chronic pain lumbar spine. It can result in chronic pain and disability, often with disastrous and disability, often with disastrous emotional and financial consequences to emotional and financial consequences to the patient. the patient.
• "spinal cripples""spinal cripples"
Onesti ST. Failed back syndrome. Neurologist 2004 Sep; 10(5): 259-64.
Consequences of Untreated & Under treated Acute Pain
Extensive and Persistent cascade of neurochemical mediators triggered by
tissue injury leads to a long-term, permanent, neurological change that can
lead to
SENSITIZATION
ALLODYNIA
HYPERALGESIA
MAY evolve into chronic pain
Progression of Acute Pain to Chronic Pain
Chronic pain appearsChronic pain appears
Because of an expression of the presence Because of an expression of the presence ofof
Central SensitizationCentral Sensitization
Sensitization
SensitizationSensitization is a phenomenon of is a phenomenon of inappropriate or disproportionate inappropriate or disproportionate
response to normal stimulusresponse to normal stimulus
Types of Sensitization
Peripheral & CentralPeripheral & Central
Peripheral Sensitization
Occurs at the site of injuryOccurs at the site of injury
Primary afferent neurons are involvedPrimary afferent neurons are involved
Exposure to prostaglandinsExposure to prostaglandins
Increased pain sensation at the site of injuryIncreased pain sensation at the site of injury
Central Sensitization
Increased excitability of pain neurons Increased excitability of pain neurons (nociceptor neurons) in the dorsal horn of the (nociceptor neurons) in the dorsal horn of the spinal cord.spinal cord.
Neurons detecting and transmitting pain display Neurons detecting and transmitting pain display ‘‘plasticity’plasticity’
• progressive increase in the response to repeated progressive increase in the response to repeated painful stimulipainful stimuli
• all contribute to altered sensitivity to painall contribute to altered sensitivity to pain
Clinical Implications of Central Sensitization
Increased response to a noxious stimulus Increased response to a noxious stimulus (Hyperalgesia)(Hyperalgesia)
Disproportionate response to pain syimulus Disproportionate response to pain syimulus (Allodynia)(Allodynia)
Prolonged / Persistent painProlonged / Persistent pain Referred painReferred pain
Central sensitization in low back pain
In back pain patients, both hypoalgesia and hyperalgesia to electrical cutaneous stimulation is reported (Wilder-Smith et al., 2002).
Hyperalgesia to pressure on the thumbnail was found in idiopathic chronic low-back pain patients compared to controls indicating generalized hyperalgesia (Giesecke et al., 2004).
European Journal of Pain 11 (2007) 415–420
The distribution of experimental pain in controls and chronic low back patients evoked by injection of hypertonic saline in infraspinatus and tibialis anterior muscles. The evoked pain areas were significantly larger in the patients for both muscles. Dark shading indicates overlapping pain areas among subjects. European Journal of Pain 11 (2007) 415–420
Central Sensitization & Tramadol
Why Tramadol is Superior
In patients with Central SensitizationIn patients with Central Sensitization
Tramadol An Atypical Centrally Acting Analgesic
NA uptake
inhibtion
5HT uptake inhibition
m-agonist
Role of Tramadol
TramadolTramadol• Centrally acting opioid analgesic, binds Centrally acting opioid analgesic, binds
to to µ µ opioid receptorsopioid receptors• Inhibits reuptake of NE and serotonin Inhibits reuptake of NE and serotonin
within pain pathways of CNSwithin pain pathways of CNS• Contribute to enhancing the descending Contribute to enhancing the descending
pain inhibitory pathwayspain inhibitory pathways
Role of Tramadol
Down regulation of central sensitisationDown regulation of central sensitisation hence an hence an ideal drug for Neuropathic painideal drug for Neuropathic pain
““Enhances” Enhances” descending inhibitory pathwaysdescending inhibitory pathways
Excellent Analgesic EfficacyExcellent Analgesic Efficacy
Tolerated well even in very high dosagesTolerated well even in very high dosages
Tramadol Most Logical Choice for a variety of Chronic Pain Most Logical Choice for a variety of Chronic Pain
Conditions where central sensitisation plays a major role:Conditions where central sensitisation plays a major role:
Our experience in INDIAOur experience in INDIA :: OA /RA Flare PainOA /RA Flare Pain Neuropathic Pain Neuropathic Pain Acute Radicular Back PainAcute Radicular Back Pain Chronic Back PainChronic Back Pain Fibromyalgia PainFibromyalgia Pain Cancer PainCancer Pain
Tramadol – Central Sensitization
Binds to Mu opiods
Mimicks the effects Enkephalins
Reduce the effects of Sub P
Reduce the intensity of the pain
Pain relief
Enhances descending inhibition
Inhibits reuptake of Serotonin and NE
More in qty at the synapse
Reduce the effects of Sub P
Reduce the intensity of the pain
Pain relief
Best Practice & Research Clinical Rheumatology Vol. 19, No. 4, pp. 609–621, 2005
Best Practice & Research Clinical Rheumatology Vol. 19, No. 4, pp. 609–621, 2005
Treatment choice Should be evidence based and tailored as much as possible Should be evidence based and tailored as much as possible
to suit the individual patient. to suit the individual patient. Acetaminophen (paracetamol), mild opioids and NSAIDs Acetaminophen (paracetamol), mild opioids and NSAIDs
are the first-line drugs for low back pain but there is no are the first-line drugs for low back pain but there is no evidence that one is more effective than the others. evidence that one is more effective than the others.
Tramadol is proposed to be the better choice due to its Tramadol is proposed to be the better choice due to its pharmacological profile and effect on pain in several pharmacological profile and effect on pain in several musculoskeletal disorders.musculoskeletal disorders.
Non-benzodiazepine muscle relaxants (with or without Non-benzodiazepine muscle relaxants (with or without pain medication) could be considered as second-line drugs pain medication) could be considered as second-line drugs in acute low back pain, and cyclic antidepressants in in acute low back pain, and cyclic antidepressants in chronic low back pain.chronic low back pain.
Strong opioids could be considered in musculoskeletal Strong opioids could be considered in musculoskeletal pain when other treatment options have failedpain when other treatment options have failed
Best Practice & Research Clinical Rheumatology Vol. 21, No. 1, pp. 153-166, 2007 Best Practice & Research Clinical Rheumatology Vol. 19, No. 4, pp. 609–621, 2005
Symptoms to be used to tailor choice of treatment
Best Practice & Research Clinical Rheumatology Vol. 19, No. 4, pp. 609–621, 2005
The benefits of medication in low back pain will The benefits of medication in low back pain will increase if:increase if: Medication is prescribed only for severe symptomsMedication is prescribed only for severe symptoms The choice of medication is targeted on the main The choice of medication is targeted on the main
symptomsymptom Patients understand the aim of the medication and how Patients understand the aim of the medication and how
long it should be used before evaluation can take placelong it should be used before evaluation can take place Medication should be taken on a time-contingent basis; Medication should be taken on a time-contingent basis;
this facilitates evaluationthis facilitates evaluation Evaluation is based on the aimEvaluation is based on the aim The type of drug has been tailored on individualThe type of drug has been tailored on individual basisbasis The dose has been tailored on individual basisThe dose has been tailored on individual basis..
Best Practice & Research Clinical Rheumatology Vol. 19, No. 4, pp. 609–621, 2005