MANAGING CHRONIC PAIN SYNDROMES FOLLOWING SPINAL CORD INJURY Martin Grabois, M.D. Professor and Chairman, Physical Medicine and Rehabilitation; Professor, Anesthesiology Baylor College of Medicine Houston, Texas Managing Chronic Pain Syndromes Following Spinal Cord Injury Presentation Goals 1. Understand the significance of the problem looking at demographic information. 2. Appreciation of various classification systems available and utilizing one as the source of the discussion. 3. Discussion on general evaluation technique and treatment options. 4. Presentation of the different syndromes seen from their characteristics, evaluation and treatment techniques. 5. Appreciation of the results that can be achieved. Managing Chronic Pain Syndromes Following Spinal Cord Injury Prevalence Difference in methods and population make direct comparison difficult Year Author N % Pain 1947 Davis et al 471 27 1953 Bitterek et al 125 30 1979 Nepomuecno et al 200 25 1986 Woolsey 100 18 1987 Kumar et al 992 63 1988 Rose et al 885 49 1988 Britell et al 144 49 1988 PVA Survey 912 45 Managing Chronic Pain Syndromes Following Spinal Cord Injury Classification Concepts Site of Trauma Radicular Below Level of Lesion Central Pain MS Pain Psychological Syringomyelia Visceral RSD Managing Chronic Pain Syndromes Following Spinal Cord Injury Classification System Pain Visceral Somatic Superficial Central Psychic Deep Initial Delayed Conduction Conduction Conduction Conduction Preoccupation From From From From Within Skin Connective Tissue Viscera, E.G. CNS E.G. Cognitive Peripheral Nerve Muscles Bowels Cord Processes Bones Bladder Thalamus Managing Chronic Pain Syndromes Following Spinal Cord Injury TIRR Classification System • Segmental Pain • Spinal Cord Pain • Visceral Pain • Mechanical Pain • Psychic Pain Managing Chronic Pain Syndromes Following Spinal Cord Injury Evaluation • History • Physical Exam • Functional • Psycho-Social • Pain Questionnaire Managing Chronic Pain Syndromes Following Spinal Cord Injury Evaluation Clinical: History and Physical Functional Psychosocial Diagnostic Tests Managing Chronic Pain Syndromes Following Spinal Cord Injury The Reliability of Pain Classification Pain Class Diagnosed Confirmed Reliability Central 24 24 100% Musculoskeletal 20 19 95% Syringomyelic 11 8 73% Managing Chronic Pain Syndromes Following Spinal Cord Injury Anatomy of the Pain System Central Control Process Motor Mechanisms Motivational-Affective System (Central Intensity Monitor) Sensory-Discriminative Sysem (Spatio-Temporal Analysis) Gate Control System L Input S Managing Chronic Pain Syndromes Following Spinal Cord Injury PAIN SYNDROMES Pain Type Time of Onset Character Duration Aggravating Diminishing Possible Causative Post Injury Factors Factor Factors ----------------------------------------------------------------------------------------------------------------------------------------------------------- Segmental Days to weeks Burning; stabbing Seconds Rest Activity Slow fibre conduction Cauda equina from skin Spinal Cord Weeks to Tingling; numbness Constant Activity Rest All fibre conduction months within cord Visceral Weeks to Burning Constant Variable Variable Slow fibre conduction months from viscera Mechanical Weeks to Dull; aching Variable Activity Rest Slow fibre conduction months from muscle or ligaments Psychic Variable Variable Variable Variable Variable Preoccupation with unpleasant environmental stimuli Managing Chronic Pain Syndromes Following Spinal Cord Injury Treatment of Spinal Cord Injury Pain Syndromes Classification Drug PT Blocks Psycho-Social Surgery Segmental Tregretal TENS Nerve Doral Root Ent Blocks Zone Cordotom Spinal Cord Tricylic Epidural Anti- Stimulation depressants Baclofen Anticonvulsants Visceral Valium Heat, Ice, NSAID Tens, US, Position Mofication Psychic Behavior modification Psychosocial intervention Managing Chronic Pain Syndromes Following Spinal Cord Injury Deafferentation Pain After Spinal Cord Injury Percentage 0 10 20 30 40 50 60 70 80 90 100 Acetaminophen __________________________________ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Aspirin ______________________________________________ __ __ __ __ __ __ __ __ __ Diazepang ________________ __ __ __ __ __ __ __ __ Propoxyphene ______________ __ __ __ __ __ __ __ __ __ Oxycodone Hydrochloride ____ __ __ __ __ AcataminophenOxycodone Hydro- __ __ __ __ __ __ __ __ chloride Morphine Hydrochloride __ __ __ __ __ __ __ __ __ __ __ __ Meperidine Hydrochloride Propoxyphene Napsylate __ __ __ __ __ __ __ __ __ __ __ __ [Key: ________Used Before Injury __ __ __ Used After Injury] Managing Chronic Pain Syndromes Following Spinal Cord Injury Chronic Pain Modifier Questionnaire Substance Increases Pain Decreases Pain Have/Has No Effect on Pain Cigarettes 0% 0% 100% Beer 0% 100% 0% Marijuana 0% 100% 0% Acetaminophen 0% 66% 34% Wine 0% 100% 0% Mixed Drinks 0% 75% 25% Aspirin 0% 60% 40% Diazapam 0% 100% 0% Lioresal 0% 60% 40% Clonazepam 0% 0% 0% Heroin 0% 100% 0% Cocaine 0% 100% 0% Crack 0% 0% 0% Propoxyphene 0% 50% 50% Oxycodone Hydro- 0% 66% 34% chloride Acetaminophen 0% 66% 34% Oxycodone Hydrochloride Morphine Hydrochloride 0% 0% 0% Meperdine Hydro- 0% 100% 0% chloride Propoxyphene 0% 75% 25% Napsylate Others 0% 0% 100% Managing Chronic Pain Syndromes Following Spinal Cord Injury Summary