and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians AAFP the Arkansas Medical Society AMS the Arkansas State Medical Board ASMB the Arkansas Department of Health ADH and its Division of Substance Misuse and Injury Prevention ID: 780293
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Slide1
Supported
in part by Arkansas Blue Cross and Blue Shieldand the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP)
Continuing Education Credit: TEXT: 501-406-0076
E
vent
ID
:
30664-24581
Slide2Lumbar Radicular Pain.
Johnathan Goree, MDDirector of Chronic Pain DivisionAssistant Professor Department of Anesthesiology
University of Arkansas for Medical Sciences
Slide3Poll Everywhere
PhoneText JOHNATHANGOR491 to 37607 to respondComputerRespond at Pollev.com/johnathangor491
Slide4Disclosures
I have no financial interests to disclose related to this presentationI will present some non-FDA approved uses of medications which include steroids (dexamethasone) for lumbar epidural steroid injections and anti-convulsants/anti-depressants for the treatment of neuroinflammatory chronic pain. Both of these medications have been used for these indications for over 20 years.
Slide5Spine.
Slide6Grading of Disc D
isplacementBulge (out of round)Protrusion (pointed, but not thru all the fibers)Herniation (thru the fibers, leaks Nucleus
Pulposis
)
Extrusion (travels up or down the canal and starting to pinch off)
Free Fragment (a loose piece that can travel in the canal or nerve root)
Bulge
Protrusion
Herniation
Extrusion
Free
Fragment
Slide7Degenerative Disc Disease (DDD)
Disc Bulge - annular tissue projects beyond the margins of the adjacent vertebral bodies, over more than 90 degrees of circumference
Circumferential Bulge: involves the entire disc circumference
Asymmetric bulge: does not involving the entire circumference, but more than 90 degrees
Slide8Herniated Nucleus Pulposus (HNP)
Protrusion - <25% of Disc Circumference
Not Extending above or Below Vertebral Endplates
Bulge - >25% of Disc Circumference
Extrusion – Base narrower than dome
Sequestration – Separated from Disc
Slide9Disc Extrusion
Slide10Disc Sequestration
Slide11Lumbar Radiculopathy
“Sciatica”
Back and lower extremity pain
Compression spinal nerve roots
Pain, Sensory Deficits, Paresthesias in dermatomal distribution
Level
Sensory Deficits
Weakness
Reflexes
L3
Thigh
Hip flexion
L4
Shin
Ankle Dorsiflexors
Patellar
L5
Lateral Leg/Dorsum
of Foot
Extensor Hallucis Longus
S1
Lateral Foot
Gastrocnemius and Soleus
Ankle
Slide12Dermatome Map
Slide13X-ray
Bone Not discs Not nerves
Slide14MRI
Slide15Medication Treatments.
Slide16Slide17Gabapentinoids
Slide18Mathieson et al.
Slide19Slide20Gabapentinoids
Slide21Anti-Convulsants
“Interpretation: There is moderate- to high-quality evidence that anticonvulsants are ineffective for treatment of low back pain or lumbar radicular pain. There is high-quality evidence that gabapentinoids have a higher risk for adverse events.”
Slide22Tricyclic Antidepressants
55 patients underwent randomization 4 groups, 1) Tricyclics (25-100mg) 2
) Tricyclic + Morphine 3)
Morphine (15-90mg) 4
) Placebo
20 Week study
28 Study completers
14% pain score improvement with Nortriptyline
7% pain score improvement with Morphine
7% pain score improvement with Combo
Slide23Ibuprofen.
“Our
findings show very low-quality evidence that the efficacy of NSAIDs for pain reduction is comparable with that of
placebo”
Slide24Duloxetine (120mg daily)
Slide25Anti-Neuropathic Meds.
Slide26Do Lyrica and Gabapentin Have a Place?
Slide27Slide28Offer NSAIDs first line, if no contraindications
If inadequate response, consider anti-depressants
Encourage early treatment with non-drug treatments including group exercise or physical therapy
If patients have persistent sciatic at 6-8 weeks, refer to specialized care.
Slide29Questions? Discussion?
Johnathan H Goree MDTwitter: @DRJGoree
Slide30What is the Goal?
Slide31Pain v. Function.
Instead of pain score reduction…What if our goal is increased function? Quality of lifeWhat are you not able to do right now that would dramatically increase your quality of life?
Slide32Pain v. Function.
Slide33Supported
in part by Arkansas Blue Cross and Blue Shieldand the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP)
Continuing Education Credit: TEXT: 501-406-0076
E
vent
ID
:
30664-24581