Pain Pathways Presented in November 2015.pptx

8/17/2019 Pain Pathways Presented in November 2015.pptx

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Pain Medicine Demystified:British Pain Society Pain Pathways

Dr Sanjeeva GuptaMD; DNB; FR!; F"PP; FFPMR!

onsu#tant in Pain Medicine

Bradford $eachin% &ospita#s N&S

Foundation $rust


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Pain Medicine Demystified: British Pain Society Pain Pathways

• Background• NICE low back pain guidelines in 2009

• Role of Precision diagnosis andmanagement

• Low back pain – eneral management

– !pecialist management

– Radicular pain management

– Recent e"idence


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Precision #iagnosis and$anagement of Pain

• %istor&

• P'&sical E(amination

• In"estigations

• )0 to *0+ of spinal pain cannot bediagnosed

• ,it' Precision diagnostic tec'ni-uesnearl& )0+ of spinal pain can bediagnosed


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.acet /oint $ediated Low Back PainE"aluation $edial Branc' Block

• .acet /ointIn1ections

• $edial Branc'Block

%ig' on t'e e&e3 of t'e !cott& dog3

L4

L5


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'

(

)

*

ap

r"ical .acet /oint Pain

C2

C4

C5


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Britis' Pain !ociet& PainPat'wa&s

• Pain 6Initial assessment 7 earl&management

• Low Back Pain and Radicular Pain• C'ronic widespread pain

• Neuropat'ic pain

• C'ronic Pel"ic pain• .or men and women

Copyright © [2012] Map ofMedicine Limited. All rights


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Low Back Pain and RadicularPain Pat'wa&

• 89 members representing Ps:P'&sio: Ps&c'olog&: !pinal !urger&:Neurosurger&: Pain $edicine:Patient Representati"es

• Pragmatic pat'wa& representing aconsensus opinion based on t'ebest a"ailable e"idence andpractical common sense


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;'e Pain Pat'wa&s were

publis'ed in t'e Britis' /ournal of


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LBP 6 Pat'wa&

• Emp'asis is on t'e principles of – !upported self6management

– Cogniti"e be'a"ioural t'erap& and

– $inimall& in"asi"e approac'es• Includes

– information on 'ow to identif& and manageRE# .L


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Low Back Pain eneral $anagement


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Back Pain eneral $anagement


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Low Back Pain eneral $anagemen


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Back Pain eneral $anagement


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LBP 6 $anagement

•


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LBP !pecialist$anagement

• ;o rule out red Dags and optimieself6care 7 p'armacot'erap&

• ;o perform a biops&c'osocialassessment in t'e conte(t of amultidisciplinar& team @$#;A

• ;o follow indi"idualised stepped

management approac' as part ofan $#;


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Low Back Pain !pecialist $anagement


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Britis' Pain !ociet& Pain Pat'wa&sLow Back Pain !pecialist $anagemen

Copyright © [2012] Map of Medicine Limited. All rights reserved

M hi+ ti , t # ! difi d h t di f id


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Le"el I E"idence obtained from multiple rele"ant 'ig' -ualit&randomied controlled trials FRE"idence obtained from multiple 'ig' -ualit& diagnostic

accurac& studiesLe"el II E"idence obtained from at least one rele"ant 'ig' -ualit&

randomied controlled trial or multiple rele"ant moderateor low -ualit& randomied controlled trials FRE"idence obtained from at least one 'ig' -ualit&diagnostic accurac& stud& or multiple moderate or low-ualit& diagnostic accurac& studies

Le"el III E"idence obtained from at least one rele"ant moderate orlow -ualit& randomied controlled trial stud& FRE"idence obtained from at least one rele"ant 'ig' -ualit&non6randomied trial or obser"ational stud& wit' multiplemoderate or low -ualit& obser"ational studies FRE"idence obtained from at least one moderate -ualit&diagnostic accurac& stud& in addition to low -ualit&studies

Le"el IG E"idence obtained from multiple moderate or low -ualit&rele"ant obser"ational studies FRE"idence obtained from multiple rele"ant low -ualit&diagnostic accurac& studies

Manchi+anti ,- et a#. ! modified approach to %radin% of evidence.

Pain Physician /01(; 12:3'1453'/) 612(7


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6t'e diagnostic accurac& and utilit& of facet

1oint ner"e in1ections in c'ronic spinalpain Pain P'&sician 2085? 8* E49)6E5>>

• Le"el I e"idence for diagnosticaccurac& of lumbar facet 1oint ner"eblocks wit' at least )5+ pain relief

as criterion standard

• Le"el II e"idence for – Cer"ical facet 1oint ner"e blocks wit' at

least *0+ pain relief as t'e criterionstandard


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e"idence s&nt'esis of t'erapeutic facet 1oint inter"entions in managing c'ronic

spinal pain Pain P'&sician 2085? 8* E5>56

E5*2

• Le"el II e"idence for long termimpro"ement of ./ pain for

– Lumbar and cer"ical radiofre-uenc&neurotom&

– ;'erapeutic facet 1oint ner"e blocks incer"ical: t'oracic and lumbar spine


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Pre"alence and #iagnosis of !I/Pain

Pre"alence of !I/pain was 80620+!c'warer: !pine: 20>8:8995: $aigne: !pine28:8**9: 899

!I/ was found to be a

source of post6fusionpain in >2+ ofpatients b& single I<block Kat / !pinal #isorders 8?9699 200> $ai ne Euro ! ine


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E"idence for !I/ Inter"entions;; !imopoulos: L $anc'ikanti: ! upta: et al

!&stematic re"iew of #iagnostic 6)5

• 88 diagnostic accurac& studies 7 84t'erapeutic studies

• Le"el II E"idence for diagnostic accurac&

• Le"el II to III E"idence for cooledradiofre-uenc& neurotom& in managing !I/pain


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#ancinatin%- shootin%- or

8e#ectric9 pain; trave#in%

down the #im in a

narrow and

R!D",!R P!"N

Presentation can

a#ter if treated

Bo%du+ N- Govind


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spinal nerve

dorsal root

ganglion

R!D",!R P!"N

N=

P,!/ P,3/

$NF

inter#eu+ins >- 1/

meta##oproteinases

"% M- "% G

"NF,!MM!$"=N

#eu+otriene B(

throma?ane

interferon

macropha%es

#ymphocytes

firo#asts

S$3R="DS


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;ransforamenal Epidural!teroid In1ection

L5

!8


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Radicular Pain


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RadicularPain


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Radicular Pain

• Imaging and In"estigations inPain $edicine

di l i


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Radicular Pain

#r ;im $aus: $a&o Cli


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,'at Can Mou !ee ,ould Mou In1ect!teroid

!8 !8


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,'at Can Mou !ee ,ould MouIn1ect !teroid


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#e( ;riam #e( ;riam #e( ;riam

+!urger&

0 2)+ 84+ 82+ 84+ 8*9+

50 +PainRelief

>8)+ 4>2+ )>2+ )>+ )>2+ )5)+

50 +F#Idecrease

2*+ >58+ *2+ )+ )0)+ 49+

2 Weeks 3 Months 6 Months

#/ Kenned&: et al Pain $edicine 2084? 85 @4A 54*655

Randomied: #B comparati"e eecti"eness trial0 mg ;riamcinalone FR 85 mg #e(amet'asone

r !im Ma"s# Mayo Clini

Number of In1ections


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Number of In1ections#/ Kenned&: et al Pain Medicine 2084? 85

@4A 54*655

No ofIn1ections

#e(amet'asone

N O 48

;riamcinalone

N O >)

P

8 In1ection N O 22 N O 2> 0>>

2 In1ections N O 82 N O 82 04)

> In1ections N O ) N O 8 00052

!pinal cord stimulation for c'ronic pain of


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!pinal cord stimulation for c'ronic pain ofneuropat'ic

NICE tec'nolog& appraisal guidance ;


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!ummar&• Pain Pat'wa&s

• Pain 6 Initial assessment and earl& management• Low Back Pain and Radicular Pain

• C'ronic widespread pain

• Neuropat'ic pain

• C'ronic Pel"ic pain @for men and womenA

• Low back Pain and Radicular Pain• Pragmatic: e"idence based w'ere possible

• Earl& diagnosis 7 management of Neuropat'ic 7 RadicularPain

• Patients sub1ected to !;ar; back tool to stratif& risk 7 guidemanagement

• ;ime based pat'wa&

• $ultidisciplinar& assessment

• !tepped management approac' empowers patients

d P ti id li


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ood Practice uidelinesof t'e .P$ and BP!

https$%%&&&.'ritishpainsociety.org%static%"ploads%reso"rces%(les%spinal)intervention)A*)+inal)April)201*)1.pdf

https$%%&&&.'ritishpainsociety.org%static%"ploads%reso"rces%(les%m'')201,)-) +/AL.pdf http$%%&&&.rcoa.ac."%node%220

https://www.britishpainsociety.org/static/uploads/resources/files/spinal_intervention_A5_Final_April_2015_1.pdfhttps://www.britishpainsociety.org/static/uploads/resources/files/mbb_2013_-_FINAL.pdfhttp://www.rcoa.ac.uk/node/2206http://www.rcoa.ac.uk/node/2206https://www.britishpainsociety.org/static/uploads/resources/files/mbb_2013_-_FINAL.pdfhttps://www.britishpainsociety.org/static/uploads/resources/files/mbb_2013_-_FINAL.pdfhttps://www.britishpainsociety.org/static/uploads/resources/files/spinal_intervention_A5_Final_April_2015_1.pdfhttps://www.britishpainsociety.org/static/uploads/resources/files/spinal_intervention_A5_Final_April_2015_1.pdf


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;'ank Mou

Pain Pathways Presented in November 2015.pptx

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