Supported in part by Arkansas Blue Cross and

Supported in part by Arkansas Blue Cross and Blue Shield 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 (Prescription Drug Monitoring Program—PDMP) Continuing Education Credit: TEXT: 501 -406 -0076 Event ID: 30664 -24581

Lumbar Radicular Pain. Johnathan Goree, MD Director of Chronic Pain Division Assistant Professor Department of Anesthesiology University of Arkansas for Medical Sciences

• Poll Everywhere – Phone • Text JOHNATHANGOR 491 to 37607 to respond – Computer • Respond at Pollev. com/johnathangor 491

Disclosures • • I have no financial interests to disclose related to this presentation I 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.

Spine.

Grading of Disc Displacement 1. Bulge (out of round) 2. Protrusion (pointed, but not thru all the fibers) 3. Herniation (thru the fibers, leaks Nucleus Pulposis) 4. Extrusion (travels up or down the canal and starting to pinch off) 5. Free Fragment (a loose piece that can travel in the canal or nerve root) Bulge Protrusion Herniation Extrusion Free Fragment

Degenerative 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

Herniated 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

Disc Extrusion

Disc Sequestration

Lumbar Radiculopathy • “Sciatica” • Back and lower extremity pain – Compression spinal nerve roots – Pain, Sensory Deficits, Paresthesias in dermatomal distribution Level Sensory Deficits Weakness Reflexes L 3 Thigh Hip flexion L 4 Shin Ankle Dorsiflexors Patellar L 5 Lateral Leg/Dorsum of Foot Extensor Hallucis Longus S 1 Lateral Foot Gastrocnemius and Soleus Ankle

Dermatome Map

X-ray Bone Not discs Not nerves

MRI

Medication Treatments.

Gabapentinoids

Mathieson et al.

Gabapentinoids

Anti-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. ”

Tricyclic Antidepressants 55 patients underwent randomization 4 groups, 1) Tricyclics (25 -100 mg) 2) Tricyclic + Morphine 3) Morphine (15 -90 mg) 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

Ibuprofen. “Our findings show very low-quality evidence that the efficacy of NSAIDs for pain reduction is comparable with that of placebo”

Duloxetine (120 mg daily)

Anti-Neuropathic Meds.

Do Lyrica and Gabapentin Have a Place?

1) 2) 3) 4) Offer 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.

Questions? Discussion? • Johnathan H Goree MD – Twitter: @DRJGoree

What is the Goal?

Pain v. Function. • Instead of pain score reduction…What if our goal is increased function? Quality of life • What are you not able to do right now that would dramatically increase your quality of life?

Pain v. Function.

Supported in part by Arkansas Blue Cross and Blue Shield 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 (Prescription Drug Monitoring Program—PDMP) Continuing Education Credit: TEXT: 501 -406 -0076 Event ID: 30664 -24581