Chronic Pain SAQs - Final FRCA

Dr. Richard Walker

FRCA, Dip MS Med, MLCOM, FFPMRCA

Consultant in Pain Medicine

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A 60 year old man is referred to you with Reflex Sympathetic Dystrophy following an injury at the elbow 6 months earlier. Outline the treatment.

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Overview
CRPS I = RSD, CRPS II = Causalgia Symptoms
Neuropathic pain vibrational + thermal allodynia Sympathetic over activity Secondary muscle wasting, joint contractures, osteopaenia / osteoporosis

Signs
Allodynia, cold, sweaty peripheral limb ? Signs of peripheral nerve injury

Ix
Thermograms, EMG, triple phase bone scan, ? MRI c/spine r/o disc, ? MRI scan elbow
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Treatment Options
Reduce the pain, rehabilitate the arm, rehabilitate the brain multi-disciplinary team work Oral Dugs
Gabapentin / pregabalin titration + TCA (amitriptyline) Multi-modal analgesics (paracetamol + NSAID + opioid) ? Nifedipine for peripheral vasoconstriction ? Ketamine 30 80 mg per day (NMDA blocker)

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Treatment Options
Occupational Therapy ++ Psychological Assessment / Support Nerve Blockade
Guanethidine Biers Block x 3 Diagnostic Stellate Thoracoscopic sympathectomy ? IV lignocaine infusion

Treatment Specific for peripheral nerve injury Spinal Cord Stimulation Trial Implantation
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List with examples the causes of neurogenic pain. What symptoms are produced ? What treatments are available ?

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Causes of neurogenic pain

Ischaemic - Central post stroke pain, PVD Compression - Peripheral / Spinal nerve entrapment Degenerative - Multiple Sclerosis Inflammatory Sciatica with disc annular tear Infective Post Herpetic Neuralgia, Guillain Barre Post Traumatic Surgery + other trauma iliohypogstric neuralgia post hernia Toxic alcoholic peripheral neuropathy, heavy metals Metabolic Diabetic Peripheral Neuropathy, vitamin deficiency Autoimmune RA / SLE / PAN Hereditary Charcot Marie Tooth (Myelin)
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Symptoms
Pain
Spontaneous burning, shooting, electrical, formication Evoked
Hyper(hypo)aesthesia, Hyper(hypo)algesia Allodynia thermal and vibrational Nerve irritation signs on stretching

Referred spinal root / plexus / peripheral nerve

Signs of Nerve Dysfunction

Tingling, numbness, weakness, wasting, fasciculations Sympathetic over activity

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Treatment (1)
Oral Medications
Anti-depressants TCAs amitriptyline Anti-convulsants pregabalin / gabapentin (calcium channel), carbamazepine (sodium channel) Anti-arrhythmics IV lignocaine, oral mexiletine, flecainaide, tocainide (sodium channel) Simple analgesics (paracetamol + NSAID + opioid) weak activity Ketamine orally 30 80 mg / day (NMDA)

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Treatment (2)
Topical
Lignocaine patch (5%) Capsaicin 0.025%, 0.075% (substance P depletion c fibres) Barrier methods (cling film)

Injections
IV lignocaine infusion Somatic / spinal nerve block, Epidural steroids (inflammatory sciatica) IVRA (guanethidine) Continuous epidural / nerve block techniques

Stimulation
Spinal cord stimulation
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What methods are available for therapeutic nerve blockade ? Explain the mechanism of action of each method.

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Methods (1)
Mechanical (rubbing)
A beta stimulation dorsal horn gate theory reversible nerve blockade

Ischaemia (tourniquets)
Intraneuronal hypoxia reversible loss of nerve function

Acupuncture / Dry Needling

A delta stimulation - dorsal horn gate theory reversible nerve blockade

Electrical Stimulation
TENS A-beta stimulation dorsal horn gate theory reversible nerve blockade Spinal cord stimulation ? Dorsal horn mechanism uncertain

Local anaesthetic
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Methods (2)
Radiofrequency
High frequency heats needle tip to 80 deg C permanent nerve disruption Pulsed RF heats to 42 deg C reversible loss of nerve function

Alcohol / Phenol
Coagulation of vasa nervorum permanent nerve disruption secondary to hypoxia

Cryotherapy
Rapid cooling of neurons intraneuronal ice formation permanent nerve disruption

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Draw a labelled diagram of the anatomical relations of the stellate ganglion. How is it blocked and what are the possible complications ?

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Anatomy

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Anatomical Relations
Sympathetic outflow to head and neck = T1 T4-6 Stellate = fused 1st thoracic and inferior cervical ganglion Posteriorly - neck of the first rib, C7 transverse process Anteriorly
Lower part - dome of the diaphragm Upper part vertebral artery

Medially longus colli muscle Laterally anterior / medius scalene muscles

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Technique
Stand on the side to be blocked 2 operators / full precautions / monitoring / IV access Anterior para-tracheal approach / semi-reclining C6 level = middle cervical ganglion not stellate Chassaignacs Tubercle = C6 transverse process = level with cricoid cartilage Pull carotid gently towards you / hit bone and pull back 2 mm 1 blue needle / connecting tubing / 10 ml syringe De-aerate the system bubbles + vertebral artery 10 ml x 50 / 50 2% lignocaine / 0.5% bupivacaine 0.5 ml increments aspirate for blood and CSF
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Technique

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Successful Block

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Complications
Common
Hoarseness / lump in the throat (recurrent laryngeal) Horners Haematoma T1 neuralgia inner arm / chest wall Brachial plexus block Phrenic Nerve Block (bilateral injections inadvisable) Pneumothorax Infective osteitis (transverse process sterility!!)

Uncommon

Life threatening
Vertebral artery injection immediate CNS effects Intra-dural injection total spinal
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Describe the anatomy of the coeliac plexus What are the indications for its therapeutic blockade.

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Anatomy

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Anatomy
Largest of the sympathetic plexuses (parasympathetic fibres pass straight through without synapsing) Supplies stomach liver, biliary tract, pancreas, spleen, kidneys, adrenal, omentum, small and large bowel Greater Splanchnic Nerve T5-6 to T9-10 Lesser Splanchnic Nerve T10-11 Least Splanchnic Nerve T11-12
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Indications
Diagnostic
To assess whether pain has visceral origin or not when the cause of the pain is uncertain

Therapeutic
Acute pain relief during surgery Chronic pancreatitis management (LA only) Upper GI cancer pain management (Neurolytic)

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Technique

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Describe the features and management of phantom limb pain.

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Pain Classification
Phantom Pain
Neuropathic pain in the amputated limb Burning, stabbing, shooting, cramping, clawed digits

Stump Pain
Pressure sensitive pain around the stump
Tissue ischaemia / infection Major nerve trunk neuroma formation Interferes with wearing a prosthesis

Phantom Experiences
Sensory experiences in the amputated limb
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Causes
Poor surgical technique nerve trunk too close to stump Poor peri-operative pain management
? Improved by multi-modal analgesia we see them too late ? epidurals infusions ? Intravenous Ketamine

Protracted time course

incidence in traumatic amputation

Dorsal Horn Sensitisation NMDA receptors Silent Channels sodium channel blockers Cortical Remapping - Homunculus

Co-existing history of sciatica in the same leg

Lumbar MRI to check for disc lesion

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Management
Exclude treatable causes - Sciatica, stump neuroma Psychological support Oral medication
TCA + gabapentin / pregabalin, ? Oral Ketamine

Injections
LA Sympathetic Blocks (not phenol) Stump neuroma desensitisation Caudal epidural steroid for sciatica Intravenous lignocaine infusion

Mirror Box Therapy (Ramachandran) for clawed toes Surgical Stump Refashioning prosthetic comfort Implantation
Spinal Cord Stimulation Deep brain stimulation
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What aims and strategies are emphasized in a Pain Management Program

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Aims
At least
50% less pain 50% reduction in analgesic consumption 50% improvement in physical functioning

Reduce frequent GP / hospital attendances Increase education about the pain management techniques Teach coping strategies / self management Reduce behavioural problems like fear avoidance, catastrophising etc Work integration, work hardening etc
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Strategies
Pain camps outpatient vs. inpatient Cognitive behavioural therapy
Behaviour is dependant upon your belief system Remodel beliefs

Rehabilitation with physio / occupational therapy Medical input to help treatable conditions Social - Family + work involvement
reduce secondary gain / abnormal reinforcements Improve job satisfaction
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List the indications and contra-indications for contraTENS ? What does the patient need to know when using a TENS machine ?

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Indications
Pain management
Acute vs. chronic Mainly musculoskeletal Help reduce analgesic consumption

Not much evidence it helps at all

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ContraContra-indications
Physical
Frail elderly, rheumatoid fingers, cant reach

Mental
Low IQ, dementia / confusion

Communication
Lack of interpreter

Anatomical
Not over the heart or carotid arteries Painful area difficult to adhere to withpads

Neuropathic pain area

too sensitive

Numb skin
prevents large A fibre input

Allergy to self adhesive pads

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What does the patient need to know ?

Where to put / not to put the pads
Dermatomes 2 pads versus 4 pads

How to look after the self-adhesive pads Where to buy more pads How to connect the leads How to switch it on / change the battery How long to keep it on for
not overnight and not whilst driving for amplitude / frequency / pulse width see next slide

Initial settings Telephone number of who to contact for advice / repair

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TENS Settings
Parameter Use Frequency Range Pulse Width Sensory Nerves Stimulated Mechanism of Action Stimulation Intensity Reversed By Naloxone Duration of analgesia Traditional (Hi-TENS) General Pain Relief 90 130 Hz Start at 100 us A beta Gate Theory Present but not uncomfortable No Short
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Acupuncture (Lo-TENS) Muscle Pain 2 5 Hz 200 250 us A delta Endorphin Release Strong Sensation Yes Long

Describe 2 assessment tools for the measurement of acute pain in adults Describe the McGill pain questionnaire used to assess chronic pain Include the strengths and weakness of each above Why do assessment tools used in acute and chronic pain differ

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Acute pain assessment tools

Visual Analogue Score
0 100 mm

Verbal Rating Score

None / Mild Moderate / Severe

Numeric Rating Sore

0 10

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McGill Pain Questionnaire

Sensory, Affective, Evaluative, Miscellaneous Pain Patterns Present pain intensity
None, Mild, Discomforting, Distressing, Horrible, Excruciating

Pain Diagram http://www.painclinic.org/articles/CoventryPainCl inicQuestionnaire.doc

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Strengths and Weaknesses

VAS
Strengths
Simple bedside tool, continuous scale

Weaknesses
Comprehension, confusional states Good at looking at pain changes in an individual not across a range of individuals

VRS
Strengths
Simple bedside tool

Weaknesses
discontinuous, limited by choice of words

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Strengths and Weaknesses

MPQ
Strengths
Validated for pain research Useful for cancer pain

Weaknesses
More complex to administer Requires greater comprehension

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Difference between acute / chronic pain

Acute pain
short lived acute physiological derangements expect to recover

Chronic pain
Long term pain > 3 -6 months Associated psychological / socioeconomic changes

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A patient presents to the pain clinic with low back pain. List the indications (red flags) that would alert you to the possibility of serious pathology. In their absence what is the early management of simple mechanical low back pain ?

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Back Pain Red Flags

Spinal Nerve Root Compromise
Limb numbness, weakness, saddle sensation, incontinence / anal tone Progressive neurological deficit involving more than one spinal nerve root

Spinal Abscess / TB
PUO, progressive paralysis, upper motor neurone signs

Spinal Tumour
Constant and progressive night pain, +ve spring test, weight loss, known primary, limb neurology changes

Consider retroperitoneal, renal, gynae tumours, AAA

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Acute LBP Management

Biopsychosocial assessment for risk factors
Bio = Diagnostic triage for red flags Psycho = beliefs, pain avoidance Social = secondary gain, job satisfaction

Analgesia
Paracetamol + codeine + nsaid Diazepam (1week), Morphine (1 week)

Reassurance (90% better in 2 weeks without treatment) Stay active within the limits of the pain Limit bed rest to less than 3 days Evidence for exercises and manipulation

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Chronic LBP Risk Factors

Previous history of LBP Total absence from work over the last 12 months Radiating leg pain (sciatica) Reduced straight leg raising (positive sciatic nerve irritation test) Signs of nerve root involvement Reduced trunk strength and endurance Poor physical fitness Poor self-rated health Heavy smoking Psychological distress and depressive symptoms Disproportionate illness behaviour Low job satisfaction Personal problems (alcohol, marital, financial) Adversarial medico-legal proceedings
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 What safety features should be incorporated into a patient controlled analgesia (PCA) system and what is the purpose of each? What instructions would you give to the nursing staff, having set up the PCA?

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PCA Safety Features

Nursing familiarity / training / PCA guidelines Quality control drugs and sterility Tamper proof lock box / non-return filling ports Lockout time = 5 6 min negative feedback loop 4 hour limit (electronic devices only) Bolus / background dose settings Programming errors electronic vs. mechanical Separate IV line or non return valve Air in line / over pressure alarm
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Nursing Instructions
Patient Observations
Hourly P / BP / RR / SpO2 for 24 hours

Device Observations
Hourly volume infused / remaining / pump settings

PCA not NCA or RCA (except paediatrics) Supplemental O2 x 24 hours No other opioids except
IV rescue bolus by anaesthetist / pain nurse Chronic pain / addicts allowed background opioids
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How would you provide optimal pain relief for a 60 year old man undergoing shoulder replacement?

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Acute Pain Options

Multimodal oral / parenteral analgesics
Paracetamol / NSAIDs / Opioids

IV PCA LA wound infusion system Single shot suprascapular nerve block Single shot interscalene brachial plexus block Brachial plexus infusion

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