Greg Vigna, MD, JD: Spinal Cord Injury Pain Requires Individualized Therapy

03/28/2013 // Concord, CA, USA // LifeCare123 // Greg A. Vigna M.D., J.D. // (press release)

Medical Perspective of Life Care Solutions Group:

Chronic pain in a spinal cord injury is very common, occurring in nearly 2 out of every three patients. In a majority of these patients, they are classified as severe. This is devastating to a patient faced with the physical, mental, social, and vocational loss following a spinal cord injury. Management of chronic pain in a spinal cord injured patient requires a knowledgeable physician who is well versed in spinal cord injury pain and who can implement a multidisciplinary approach to the patient’s treatment, which may include neurosurgery procedures, anesthesia injections, implantable pain devices, physical therapy, psychologic services, and pharmacologic management.

Spinal cord injured patients with pain at the location of the injury may be related to an inadequate fusion, torn soft tissues including muscles, tendons, ligaments, and joints (facets) above or below the level of the fusion. Often the patient’s symptoms will be worse with activity. The pain is often at or near the spine, and is often described as “aching” type of pain. Proper medical evaluation should rule out inadequate fusion. A trial of physical therapy should include modalities such as heat, ultrasound, electrical stimulation, and active exercises. Medication management may include anti-inflammatory medication, muscle relaxers, and narcotic pain medicines. Patients with continued pain should be evaluated for therapeutic injections by either a physiatrist or a pain management physician. Therapeutic injections may include Botox, trigger point injections, and facet injections. Based upon my training, education and treating many different spine injured patients, it is my opinion that chronic mechanical related pain is more common and is often overlooked and treated as central pain syndrome with chronic high dose narcotics, which unfortunately, may have significant long term detrimental effects on a spinal cord patient.

Spinal cord injured patients with pain at the level of injury may be radicular (e.g. pain that radiates down a limb), that is from the direct compression of the nerves as they leave the spine by fracture fragments, herniated discs, or scar tissue following surgical procedures. Patients will often complain of pain referred in a distribution directly related to the level of injury. Patients require evaluation of ongoing compression of the nerves by way of imaging studies, and diagnostic injections directly on the compressed nerve. Treatments may include medication management, surgical decompression, implantable devices, and therapeutic injections. Medications include anti-inflammatories, seizure and antidepressant medications used in pain management, and narcotic medications. Based upon my training, education and after treating many different spine injured patients, it is my opinion that spinal cord injured patients radicular pain will often be overlooked and treated as a central pain syndrome with high dose narcotics and it has been my experience that patients have had significant improvement following decompression after many years of pain that was originally blamed on central pain syndrome. It my opinion that spinal cord stimulators are very effective in appropriate patients and allow for improved function and decreased medications when utilized.

Based upon my training, education and after treating hundreds of spinal cord injured patients, it is my opinion that central pain following a spinal cord injury is the most debilitating pain syndrome in spinal cord injured patients. These injuries are the most poorly understood, and are they are commonly inadequately treated. Central pain symptoms are described as lancing, stabbing, and aching below the level of the lesion, and they are not in any particular order or nerve distribution. Patients with central pain following spinal cord injury require individualized therapies and multiple types of treatments to help control the pain. High dose narcotic pain medicines have been proven to benefit these patients. Patients need to be closely monitored for maximum therapeutic benefit as well as for patient compliance. I believe that patients must be screened by a psychologist trained in pain management to learn coping mechanisms, biofeedback techniques to decrease pain, and to follow depressive issues going forward. I also believe that patient compliance regarding a pain management contract is essential and must be followed long term to monitor these medications; failure to do so is the most likely reason for long-term failure of this treatment option. Multiple medications used together including antidepressants, anti-seizure, and muscle relaxers used together may add to the therapeutic effect of narcotic pain medications.

Life Care Planner Perspective:

A life care planner must consider all future care necessary and appropriate that is related to a spinal cord injury. That would include chronic spinal cord related pain. A life care planner must know all options, including physical therapy, exercise equipment, injection therapy, implantable devices, medications, laboratory tests, imaging studies, psychological services, physician needs, as well as the potential need for inpatient chronic pain management in the future. A failure to provide for this will lead to patient complications such as depression, self-neglect, pressure ulcers, maladapted behaviors, and poor functional outcomes.

Lawyer Perspective:

A competent serious injury lawyer must prove to the jury all future medical costs that are directly related to the spinal cord injury. Future management of chronic pain related to a spinal cord injury over the projected lifetime of the injured patient is typically a significant amount. A catastrophically injured client will need an outcome that will fairly compensate him for his future medical needs, and often times, the biggest challenge is finding enough insurance coverage or deep pockets that can adequately satisfy a significant damages award. Also, pain and suffering would be a large component of an award. Future planned treatment of a patient’s pain, as well as testimony by the patient, family members, friends and loved ones are the types of evidence that a jury would consider when awarding a significant pain and suffering award.

Media Information:

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