Multimodal Approach to Pain Management
Clinical Connections – Summer 2017
A Newfoundland suffering from recurrent neck pain, due to nerve root compression, was helped by a multimodal approach involving the RVC’s Anaesthesia and Analgesia Service, Diagnostic imaging, Neurology and Neurosurgery and Physiotherapy and Rehabilitation services.
Sky presented to RVC Small Animal Referrals in September 2015, aged eight, as a result of episodic neck pain. She was diagnosed with a left-sided C5/6 nerve root compression, most likely the result of osteoarthritis or joint hypertrophy.
Upon discharge, she was prescribed oral analgesics and a controlled exercise regime. The owners were encouraged to ensure Sky was walked on a body harness rather than neck leads and collars that would pull on her neck. They were also advised to ensure Sky avoided running, jumping and using stairs.
Sky responded well initially but in January 2016 started to yelp in pain. She was treated at her regular veterinary practice with gabapentin, NSAIDs and codeine but did not respond to analgesia and so was re-referred to the RVC.
Neurological examination in February 2016 was largely unremarkable, with the exception of cervical hyperaesthesia and resentment of dorsiflexion and left lateroflexion of the neck. Differential diagnoses were discussed with the owner, including a recurrence of signs related to the C5/6 nerve root compression.
MRI scans revealed a mild increase in the severity of the narrowing of the left intervertebral foramen. Due to the recurrence of clinical signs following conservative management, further treatment options were discussed. These included ultrasound-guided administration of local anaesthesia and steroids offered by the RVC’s Sport Medicine Osteoarthritis and Pain Clinic (SMOAP) and Surgical Decompression.
The owner elected to try ultrasound-guided administration of local anaesthesia and a steroid. The procedure was performed jointly by Jaime Viscasillas of the Anaesthesia and Analgesia Service and members of the Diagnostic Imaging team. Sky responded well to treatment. These injections are meant to diminish clinical signs between three months to a year. She also started receiving acupuncture from Kata Veres-Nyeki, Lecturer in Anaesthesia, as a complementary treatment and began hydrotherapy at the RVC to increase her exercise and help control her weight.
Sky has been regularly evaluated in the Sport Medicine Osteoarthritis and Pain Clinic by Sandra Sanchis-Mora, whose doctoral research is concerned with improving diagnosis and treatment of neuropathic pain with the use of quantitative sensory testing (QST). The QST devices enable the clinicians to measure pain thresholds and location in an objective manner. Sky’s owner completed pain questionnaires at each visit to track improvement. Veterinary Physiotherapist Emily Cowderoy assessed Sky’s mobility and gait by getting her to walk on a pressure sensing mat. Sky’s owner was satisfied that medication could be reduced with an alternative mechanism-based therapy.
In August last year, Sky was presented with remission of her neck pain and additional lumbosacral pain. Ultrasound-guided administration of local anaesthetic and steroids was repeated with a good effect. An epidural injection with the same medication was performed to provide analgesia of the lumbosacral region. She was discharged with the advice of continued analgesic management along with controlled exercise. She is maintaining her exercise levels and returns to the RVC for regular pain assessment and acupuncture.
Commenting on the value of a multimodal and transdisciplinary approach, Kata Veres-Nyeki, Lecturer in Anaesthesia, said: “We can now provide more advanced approaches and these procedures can make a real difference to our patients suffering from pain. The RVC offers a multimodal approach with different techniques used such as interventional analgesia, physiotherapy, hydrotherapy and acupuncture.”
Sandra Sanchis Mora, leader of the pain clinic, added: “We do a thorough pain assessment with the aid of objective measurements, such as quantitative sensory testing, activity collars and pressure mat. With these tools we establish individualised mechanism-based treatments for each patient.”
To make a referral, contact RVC Small Animal Referrals 01707 666 365 or email firstname.lastname@example.org
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