Management of Acute and Chronic Pain
Anesthesiologists also specialize in treatment of acute and chronic pain disorders. There are many types of acute and chronic pain disorders as well as many treatment regimens. A very common treatment for back and leg pain or neck and arm pain caused by herniated discs, spinal stenosis, or similar disorders is called an Epidural Steroid Injection. The following is a description of this procedure. Please see the links section for other articles on treatment of chronic and acute pain disorders.
Botulinum toxin injection is used to treat dystonia, a neuromuscular disorder that produces involuntary muscle contractions, or spasm, that affects muscles that control movement in the eyes, neck, face, voice box, or the smooth muscle in the bladder. The goal of the therapy is to reduce muscle spasm and pain.
This potent neurotoxin is produced by Clostridium botulinum, a bacterium that causes food poisoning (botulism). There are seven known types of C. botulinum toxin, but only types A (Botox) and B (Myobloc) are used as medical treatments.
Botulinum toxin has proven to be useful in the treatment of many forms of dystonia, including the following:
blepharospasm, forceful involuntary closure of the eyelids
strabismus, misalignment of the eyes hemifacial spasm, sudden contraction of the muscles on one side of the face spasmodic torticollis, or cervical dystonia, muscle spasm in the neck that causes the head to turn to one side, and sometimes forward or backward oromandibular dystonia, continuous spasms of the face, jaw, neck, tongue, larynx, and in severe cases, the respiratory system urinary retention, severe inability to urinate that requires catheterization spasmodic dysphonia, spasm of the vocal cords that causes sudden disruption of speech stuttering, repetitions of parts of words and whole words, long pauses, elongated sounds voice tremor, quavering vocalization.
Neurons generate new nerve endings that reactivate the dystonia, so improvement is not long lasting, and treatment is usually repeated every 3 to 4 months. Physical or occupational therapy usually is undertaken to stretch and restore normal muscle function. Some patients develop antibodies to the toxin over time, rendering the treatment ineffective.
Side Effects
This is a safe and effective treatment when given in very small amounts by a qualified neurologist. Some patients experience temporary weakness in the group of muscles being treated. For example, ptosis (drooping eyelid) can develop after treating blepharospasm. Flu-like symptoms develop in some, but rarely.
Overview
Epidural injection is the administration of medication into the epidural space. It is used to treat swelling, pain, and inflammation associated with neurological conditions that affect nerve roots, such as a herniated disk and radiculopathy.
Epidural injections may be painful and produce uncertain results. Studies show that epidural injection may provide short-term pain relief for patients when conservative treatments have failed.
Anatomy
The brain is covered by three membranes (dura, arachnoid, and pia), called the meninges that extend through the base of the skull and surround the entire spinal cord. The spinal cord travels down the entire length of the spinal column through the spinal canal. The epidural space is located between the dura and the interior surface of the spinal canal and contains veins, arteries, and fat. Epidural injection is the injection of medication into the epidural space.
Procedure
Epidural injection is usually given in an outpatient setting. An anesthesiologist usually administers the injection, but some neurosurgeons, orthopedic surgeons, and neurologists are also qualified to perform this procedure.
A mild sedative and a local anesthetic may be given prior to the procedure to relax the patient and numb the injection site. Medications, usually an anesthetic such as bupivacaine (Marcaine?) or a muscle relaxant, and a corticosteroid such as methylprednisolone (Medrol?), are injected directly into the epidural space. (The injection is commonly called a cortisone shot.)
Effectiveness
Approximately 30% to 70% of people who receive an epidural injection benefit from it. Some patients notice improvement within hours of the injection; others improve over a number of days; and others experience no improvement with the treatment. In some cases, two or three injections are given over weeks or months.
Complications
Complications resulting from an epidural injection are rare. Possible conditions that may develop following the procedure include infection (e.g., epidural abscess), bleeding into the epidural space, and headache caused by a cerebrospinal fluid leak. Approximately 2% of patients experience side effects from the corticosteroid, such as mild fluid retention.
Lumbar Epidural Steroid Injection:
Your physician may refer you for a procedure called an Lumbar Epidural Steroid Injection. This procedure is used to treat swollen and inflamed spinal nerve roots often referred to as a "pinched nerve." The spinal nerves come from the spinal cord and exit the backbone to provide sensation to different parts of the body. Occasionally something rubs or irritates these nerves where they exit the backbone causing them to be swollen and inflamed. The source of irritation may be a ruptured, herniated, or bulging disc. Another source may be Spinal Stenosis, where arthritis of the spine, bone growth, or hardening of the ligaments begins to close the openings in the spine through which these nerves exit. Common problems associated with this inflammation of the spinal nerves include:
Your symptoms may include some or all of the above problems. Your physician may treat these symptoms with oral medications and/or physical therapy or exercise. Another method for treating this condition is called an EPIDURAL STEROID INJECTION. This technique involves an injection of a steroid into an area of your lower back called the epidural space. The epidural space extends through the spinal canal from your head to your tailbone. The spinal nerves pass through the epidural space and are therefore bathed in this steroid (a solution of anti-inflammatory medicine). After the procedure you will be asked to reduce your activities at home for 24 to 48 hours to allow the medicine a chance to do its work. Within a few days after the injection, the medicine should reduce the swelling and inflammation of these nerves and thereby reduce your symptoms.
You will probably be asked to return two weeks after your first injection. If all of your pain or numbness has been relieved, you will not need another shot at that time. Most often, however, the first injection will relieve most, but not all of your pain or numbness. At that time (2 weeks after the first injection) we will suggest a second EPIDURAL STEROID INJECTION. Occasionally you may require a third injection two weeks after the second one. After a series of three injections, you should probably wait six months before starting another series of injections.
EPIDURAL STEROID INJECTIONS work very well for most people with the above problems. While it will not cure everyone, this procedure can be extremely helpful to relieve the pains caused by "pinched nerves".
If you have questions about this procedure, please discuss them with your anesthesiologist.
Here are some commonly asked questions and answers:
Although this procedure may give excellent pain relief, it will not fix the source of the "pinched nerve". However, by reducing the inflammation of the nerve and with the help of some exercises provided by your orthopedist or physical therapist, you should have months to years of freedom from pain. And although you may have to return for a repeat series of Epidural Steroid Injections in future years, many people prefer this treatment than having surgery to repair the defect.
Yes. This is the best and easiest approach to the Epidural Space. We do not inject anything directly into the spinal nerves or spinal cord. As stated above, by using the Epidural Space the medicine can soak into the nerves very easily without a direct injection into the nerve itself.
As stated, the nerves which supply feeling to your legs come from the spinal cord in your lower back. The site of irritation of this nerve is usually in the lower back where the nerve leaves the spinal canal or backbone. Your Doctor referred you for this treatment because he feels this may be the source of your problem.
As with any procedure, there are always certain risks involved with injections. Epidural Steroids have proven to work very well and carry very low risks of injury. However, anytime you receive a shot there is a minimal risk of complications. It is rare that these complications ever cause a significant problem. The following are some, but not all of the possible complications:
No. These steroids are anti-inflammatory agents, not the anabolic steroids like athletes use.
Cervical Epidural Steroid Injections:
Your physician may refer you for a procedure called a Cervical Epidural Steroid Injection. This procedure is used to treat swollen and inflamed spinal nerve roots often referred to as a "pinched nerve." The spinal nerves come from the spinal cord and exit the backbone to provide sensation to different parts of the body. Occasionally something rubs or irritates these nerves where they exit the backbone causing them to be swollen and inflamed. The source of irritation may be a ruptured, herniated, or bulging disc. Another source may be Spinal Stenosis, where arthritis of the spine, bone growth, or hardening of the ligaments begins to close the openings in the spine through which these nerves exit. Common problems associated with this inflammation of the spinal nerves in the neck or cervical spine include:
Your symptoms may include some or all of the above problems. Your physician may treat these symptoms with oral medications and/or physical therapy or exercise. Another method for treating this condition is called an EPIDURAL STEROID INJECTION. This technique involves an injection of a steroid into an area in the back of your neck called the epidural space. The epidural space extends through the spinal canal from your head to your tailbone. The spinal nerves pass through the epidural space and are therefore bathed in this steroid (a solution of anti-inflammatory medicine). After the procedure you will be asked to reduce your activities at home for 24 to 48 hours to allow the medicine a chance to do its work. Within a few days after the injection, the medicine should reduce the swelling and inflammation of these nerves and thereby reduce your symptoms.
You will probably be asked to return two weeks after your first injection. If all of your pain or numbness has been relieved, you will not need another shot at that time. Most often, however, the first injection will relieve most, but not all of your pain or numbness. At that time (2 weeks after the first injection) your anesthesiologist may suggest a second EPIDURAL STEROID INJECTION. Occasionally you may require a third injection two weeks after the second one. After a series of three injections, you should probably wait six months before starting another series of injections.
EPIDURAL STEROID INJECTIONS work very well for most people with the above problems. While it will not cure everyone, this procedure can be extremely helpful to relieve the pains caused by "pinched nerves".
If you have questions about this procedure, please discuss them with your anesthesiologist.
Here are some commonly asked questions and answers:
Although this procedure may give excellent pain relief, it will not fix the source of the "pinched nerve". However, by reducing the inflammation of the nerve and with the help of some exercises provided by your orthopedist or physical therapist, you should have months to years of freedom from pain. And although you may have to return for a repeat series of Epidural Steroid Injections in future years, many people prefer this treatment than having surgery to repair the defect.
Yes. As noted above, in this instance the nerves involved are located in the cervical spine. This is the best and easiest approach to the Cervical Epidural Space. We do not inject anything directly into the spinal nerves or spinal cord. By using the Epidural Space, the medicine can soak into the nerves very easily without a direct injection into the nerve itself.
As stated, the nerves which supply feeling to your arms and hands come from the spinal cord in your neck (the cervical spine). The site of irritation of this nerve is usually in the cervical spine where the nerve leaves the spinal canal or backbone. Your Doctor referred you to us because he feels this may be the source of your problem.
As with any procedure, there are always certain risks involved with injections. Epidural Steroids have proven to work very well and carry very low risks of injury. However, anytime you receive a shot there is a minimal risk of complications. It is rare that these complications ever cause a significant problem. The following are some, but not all of the possible complications:
No. These steroids are anti-inflammatory agents, not the anabolic steroids like athletes use.
What is a facet join injection?
The facet joints are joints between the vertebrae of your spine, much like the knuckles in your hand, that allow for proper stability and mobility of your spine. Many times these joints are inflamed by mechanical injury or arthritis, resulting in back pain. A facet injection is done to reduce inflammation and/or nerve irritability in the joint region and thereby reduce pain. These injections may also be diagnostic for certain surgical procedures.
What can I expect at the Pain Center?
A Pain Management Specialist at the clinic will assess your pain condition, take a medical history, and examine you to see if the procedure is a potentially beneficial option. At this time any precautions that need to be taken based on the status of your health may be discussed. Additional or alternative treatment options can be discussed. After this examination, the procedure can then be scheduled.
What should I do before the procedure?
Do not eat or drink non-clear liquids 6-8 hours prior to your procedure. You may drink a small amount (a few ounces) of clear liquid (water) up to 2-3 hours before your procedure. Take your routine medications the day of your procedure as you normally would with a small amount of water, unless instructed otherwise by the physician. If you take pain medications, do not take a dose 2 hours prior to your procedure time, unless otherwise instructed by the physician. If you take blood thinners (such as Coumadin), or you are a diabetic, you will need to follow special directions which the physician will give you prior to the procedure. It is mandatory that you arrange for someone to drive you home from the ambulatory surgical center after your procedure. Additional instructions may be given by the physician if necessary depending on your health status.
Where will the procedure be done?
In the ambulatory surgical center as an outpatient.
Will I be asleep for the procedure?
Monitored anesthesia care with light sedation may be medically indicated, based upon your health status, or to reduce unintentional movement during the procedure. Your physician will discuss this with you at the time of your appointment.
When will I have some relief of pain?
You may receive immediate pain relief after the procedure. However, it is more typical for pain relief to occur gradually over several days to weeks. If a patient receives partial improvement, then repeat injections or continuation of a short series of injections may be indicated. If the pain goes away then repeat injections are not needed.
Will I be able to drive afterward?
No, do not operate motorized vehicles/equipment (ie cars, lawn mowers, power tools, kitchen appliances, etc) until the day after your procedure, especially if you have received sedation.
Will I be able to resume my normal activities after the procedure?
Yes, the next day. Just maintain good body mechanics and posture and continue with physical therapy or your home exercise program.
What are the risks of the procedure?
A full discussion of the risks of the procedure will occur when you meet the Pain Specialist who will perform the injection. Overall, the risks are relatively low.
Back [Lumbar] Fusion Surgery for Pain, Sciatica & Stenosis
Short video presentation reviewing the current technology for dealing with back or leg pain with surgical treatment
An Intrathecal Pump ("Spinal Morphine Pump")? is a specialized device, which delivers concentrated amounts of medication(s) into spinal cord area via a small catheter (tubing).
Am I a candidate for Intrathecal Pump Implant
Currently at TPM, Intrathecal Pump is offered to patients with :
Chronic and severe pain, who have not adequately responded to other treatment modalities. Some of the examples are failed back syndrome, cancer pain, RSD. These patients receive infusion of painkillers such as Morphine or Dilaudid.
Spastic disorders such as Multiple Sclerosis, Spinal Cord Injury - associated with muscle spasms. These patients receive infusion of an antispasmodic medication called Baclofen.
What is the purpose of it?
This device delivers concentrated amounts of medication into spinal cord area allowing the patient to decrease or eliminate the need for oral medications. It delivers medication around the clock, thus eliminating or minimizing breakthrough pain and/or other symptoms.
How long does the procedure take?
It is done in two stages. In the first stage, a single injection is made to assess effectiveness and screen for unwanted side effects. If this trial is successful in relieving symptoms, then the permanent device is placed under the skin. The patients have to meet certain other screening criteria before implanting the pump.
Will the procedure hurt?
The procedure involves inserting a needle through skin and deeper tissues (like a "tetanus shot"). So, there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the needle. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easy to tolerate.
Will I be "put out" for this procedure?
The placement of the tubing is done under local anesthesia with patients mildly sedated. The amount of sedation given generally depends upon the patient tolerance.
For the pump placement, patients are given stronger intravenous sedation and analgesia.
How is the procedure performed?
It is done with the patient lying on the side. Sometimes the tubing is placed with the patient sitting up. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. The skin is cleaned with antiseptic solution and then the procedure is carried out. X-ray (fluoroscopy) is used to guide the needle for inserting the tubing.
Where is the tubing inserted? Where is the pump placed?
Tubing is inserted in the midline at the lower back. The pump is then placed on the side of the abdomen.
What should I expect after the procedure?
If the procedure is successful, you may feel that your pain may be controlled or quite less. The pump is adjusted electronically to deliver adequate amount of medication.
What should I do after the procedure?
This procedure is normally a day-procedure and patients are kept overnight for observation and pump adjustment.
How long will the pumps last?
The medication contained within the pump will last about 1 to 3 months depending upon the concentration and amount infused. It is then refilled via a tiny needle inserted into the pump chamber. This is done in the office or at your home and it takes only a few minutes.
The batteries in the pump may last 3 to 5 years depending upon the usage. The batteries can not be replaced or recharged. The pump is replaced at that time.
Will the Intrathecal Pump Implant ("Spinal Morphine Pump") help me?
It is very difficult to predict if the procedure will indeed help you or not. For that reason a trial is carried out to determine if a permanent device (pump) will be effective to relieve your pain or not.
What are the risks and side effects?
Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. Please discuss your concerns with your physician.
Who should not have this procedure?
If you are on a blood thinning medication (e.g. CoumadinÆ), or if you have an active infection going on, you should not have the procedure. The patients also have to meet certain other screening criteria before implanting the pump.
Additional information?
More detailed information is available from the manufacturer of this device. At the time of consultation you will receive a Synchromed™ Infusion System Patient Education Booklet. Additional information is also available at the Medtronics™ Web Site @ www.medtronics.com/neuro/apt/faq.html.
A lumbar laminectomy, or lumbar decompression, is performed to treat spinal stenosis, a narrowing of the spinal canal that puts pressure on the nerves in the lower back, which causes symptoms in nearly 500,000 Americans over the age of 50. Used to manage related conditions involving deformities of the vertebrae, such as spondylolisthesis or scoliosis, a transforaminal lumbar interbody fusion (TLIF) is an innovative, sometimes safer, more efficient alternative to other anterior and posterior-approach fusion procedures. Both conditions cause pain and weakness in the lower back and legs, leading to walking difficulty in many patients. The conditions occur as people age because ligaments around the spine thicken and the discs, or cushions, between the vertebrae start to deteriorate.
During the surgery, an incision will be made in the patient's back, but surgeons will approach the spine from the side, minimizing the nerve manipulation required to access the vertebrae, discs and nerves. They will remove bone and ligament from the spine to open the spinal canal and relieve pressure on the nerve roots which has been caused by stenosis.
Next, the surgeons will perform a TLIF to fuse the spine where one vertebra has slipped forward onto the vertebra below it. (This generally occurs with spondylolisthesis, but in the case of the webcast patient it has been caused by complications from scoliosis.) Some vertebral bone will be removed to reduce nerve exposure, and then the pain-causing disc will be taken out. A spacer and bone from the patient's extracted vertebra will then be manipulated to fuse the two surrounding vertebrae together. Finally, rods and screws will be put in place to support the spine over the next several months as bone generates and connects to the vertebra.
Most patients are out of bed and walking the morning after surgery, and typically spend three to five days in the hospital. After discharge, they require three to six months of outpatient rehabilitation, but are able to care for themselves at home with the exception of heavy lifting. Generally after six months, patients are able to do any type of activity excluding those that pose high physical risk
What is a lumbar sympathetic block?
A lumbar sympathetic block is a procedure which is used to diagnose and sometimes treat certain pain disorders of your leg or foot.
Special nerves, which control blood flow and which can be causing some of your pain or altered sensitivity, can be found at the side of your spinal column in your lower back. A lumbar sympathetic block interrupts the activity of these nerves. Depending on the success of the first injection, repeated injections may be necessary to help to treat your pain problem.
What can I expect at the Pain Center?
A Pain Management Specialist at the clinic will assess your pain condition, take a medical history, and examine you to see if the procedure is a potentially beneficial option. At this time any precautions that need to be taken based on the status of your health may be discussed. Additional or alternative treatment options can be discussed. After this examination, the procedure can then be scheduled.
What should I do before the procedure?
Do not eat or drink non-clear liquids 6-8 hours prior to your procedure. You may drink a small amount (a few ounces) of clear liquid (water) up to 2-3 hours before your procedure. Take your routine medications the day of your procedure as you normally would with a small amount of water, unless instructed otherwise by the physician. If you take pain medications, do not take a dose 2 hours prior to your procedure time, unless otherwise instructed by the physician. If you take blood thinners (such as Coumadin), or you are a diabetic, you will need to follow special directions which the physician will give you prior to the procedure. It is mandatory that you arrange for someone to drive you home from the ambulatory surgical center after your procedure. Additional instructions may be given by the physician if necessary depending on your health status.
Where will the procedure be done?
In the ambulatory surgical center as an outpatient.
Will I be asleep for the procedure?
Monitored anesthesia care with light sedation may be medically indicated, based upon your health status, or to reduce unintentional movement during the procedure. Your physician will discuss this with you at the time of your appointment.
When will I have some relief of pain?
You may receive immediate pain relief after the procedure. However, it is more typical for pain relief to occur gradually over several days to weeks. If a patient receives partial improvement, then repeat injections or continuation of a short series of injections may be indicated. If the pain goes away then repeat injections are not needed.
Will I be able to drive afterward?
No, do not operate motorized vehicles/equipment (ie cars, lawn mowers, power tools, kitchen appliances, etc) until the day after your procedure, especially if you have received sedation.
Will I be able to resume my normal activities after the procedure?
Yes, the next day. Just maintain good body mechanics and posture and continue with physical therapy or your home exercise program.
What are the risks of the procedure?
A full discussion of the risks of the procedure will occur when you meet the Pain Specialist who will perform the injection. Overall, the risks are relatively low.
ANALGESICS.
i) Non-steroidal anti-inflammatory drugs (NSAIDs) have been used for 150 years in Europe, and probably for a great deal longer in the East, in the form of willow bark extract. Useful when given appropriately, examination of the chronic pain population indicates that a very high number of patients are intolerant to these drugs because of gastrointestinal or other side-effects. There are two possible hypotheses for this. Firstly, chronic pain sufferers tend to be somewhat hypochondriacal and intolerant of body symptoms in general and thus less tolerant of real or perceived side-effects when taking medication. The second is that there may be a sub-group of patients whose pain is not managed well early on. NSAIDs may produce side-effects, limiting their use. With no pain relief, the patient fails to exercise. This hampering of their rehabilitation because of inadequate analgesia may contribute significantly towards the chronicity.
Recently COX2 antagonists have come on the scene, but the first wave of these have been disappointing in the UK, in that the side-effect profile does not appear to be particularly better than the present drugs (Meloxicam, Etodolac). The newer drugs, Vioxx and Celebrex, are now available in the USA and will soon become available in Europe. Their arrival is awaited with eager anticipation, but the results may prove to be disappointing. The products may not be as side-effect free as they first seem.
ii) The use of opioid drugs for the management of chronic non-malignant pain is fraught with difficulties, some real and some perceived. Morphine itself has tended not to be prescribed for chronic pain, because of a fear or stigma concerning Morphine. Physicians may fear dependence, tolerance and side-effects. There is a wide difference of opinion, which is still to be resolved; however, some patients can have their pain adequately controlled with opioids, without an unacceptable level of addiction problems. The potential risk of addiction remains a very real problem for a minority. Also, a significant number of patients with chronic pain complain of bothersome side-effects from medication. Mobility and distress must be monitored and benefits must accrue in both these parameters, as well as in reduction of pain.
iii) In the UK and in the USA, traditionally most patients with chronic pain receive an opioid derivative such as Codeine, Dihydrocodeine or Dextropropoxyphene. In the past Pentazocine and Buprenorphine enjoyed a passing vogue but are now little used. Pentazocine proved to have unacceptable side-effects, and Buprenorphine, originally thought to be non-addictive, was shown to have addictive potential and since being classified as a controlled drug has enjoyed little popularity. Nefopam has limited efficacy and popularity, and Meptazinol is short-acting, and often associated with an unacceptable level of side-effects.
Recent work suggests that Codeine and Dihydrocodeine are merely pro drugs for Morphine, and exert their action through metabolism to this compound. Given that a significant number of the population do not have the metabolic pathway to facilitate this, it is not surprising that there is a significant failure rate to produce any analgesia at all and that patients getting analgesia seem to get limited relief-hence possibly the popularity of these preparations being compounded with Paracetamol. There is good evidence that in some patients, much of the analgesic effect in these combined preparations lies with the Paracetamol itself, whilst many of the side-effects lie with the opioid.
v) Tramadol hydrochloride is an orally active, clinically effective, centrally-acting analgesic. It can produce analgesia that has been compared to Codeine or Dextropropoxyphene. It has been used in post-surgical pain, obstetric pain, cancer pain and chronic pain of mechanical and neurogenic origin. Analgesic tolerance is not a significant problem, and psychological dependence and euphoric effects are minimal. There are a significant number of patients in the chronic group who develop side-effects, but many of those who tolerate the drug get useful benefit in pain reduction. This slow-release formulation is an appropriate vehicle for chronic pain management.
Tramadol has an affinity, albeit relatively weak, for mu opioid receptors. It is also a neuronal uptake inhibitor. The monoamine neurotransmitters 5HT (Serotonin) and Noradrenaline (NA) are involved in the inhibition of spinal cord dorsal horn neurone responses to painful stimulation (i.e. closing the gate). Analgesia can result from activating the pain inhibitory pathways originating from higher CNS levels, and containing these neurotransmitters. Tramadol inhibits the uptake of 5HT and Noradrenaline but not Adenosine, Cyclic AMP, Dopamine, or Gaba.
Metanalysis by Moore and McQuay indicates an appropriate dose response curve for Tramadol, and suggests a reduced number needed to treat to show therapeutic efficacy as compared with Codeine, in doses of 75 to 150 mg. Nausea, vomiting and dizziness are greater than with Codeine, somnolence about the same and constipation much less. In the chronic pain situation nausea and vomiting are attenuated with usage, as is somnolence for both drugs, but constipation remains a particular problem with Codeine and Dihydrocodeine, and less of a problem with Tramadol.
Side-effects from Tramadol can be minimised by starting with a low dose and increasing gradually. There is evidence that this reduces the side-effects and improves tolerance. According to need, it can be started in a low dose of 50 mg daily or twice a day, and gradually titrated to reach 50 mg three times a day by day 3. Once a patient is established on a therapeutic dose, they can be put on the slow-release formulation to provide round-the-clock analgesia.
B. PSYCHOACTIVE DRUGS.
i) Anticonvulsants are well acknowledged as being effective in the management of shooting pain, for example: trigeminal neuralgia and the shooting element of neurogenic pain, such as post-herpetic neuralgia, diabetic neuropathy and similar conditions. Carbamazepine appears to be the most effective drug although there is a higher incidence of side-effects than with Sodium Valproate. Recently Gabapentin and Lamotrigine are enjoying popularity, either as "add on" drugs, or as sole agents. Further drug development of these types of agents might produce useful efficacy in the future.
ii) Tricyclic antidepressants are one of the most commonly used analgesics in pain clinics. This is not for the specific antidepressant action, but is more associated with the activation of pain inhibitory pathways. This appears to be less of a feature with the tetracyclic agents, and has meant that their usage in chronic pain has as yet remained unproven. This is of course is disappointing as the side-effect profile is significantly better. The sedative effect of Amitriptyline can be harnessed to good usage by giving the tablet one or two hours before retiring, and it should not be used during the day.
ANALGESIC PAIN MANAGEMENT
In general, patients with pain can be given a trial of Paracetamol. An appropriate non-steroidal can be used if there is an inflammatory process, and continued if these are effective and if side-effects are minimal. The next optimal step in the analgesic ladder will be the use of agents like Tramadol, Dextropropoxyphene, or Dihydrocodeine, with long-acting preparations being ideal for chronic pain. At present, slow-release Tramadol would appear to be the most effective drug in chronic pain for this group of patients. If side-effects preclude its usage, one of the other agents can be considered.
Finally a small group of patients might be suitable for the use of opioids themselves.
In conjunction with this ladder, anticonvulsants and tricyclic antidepressants can be considered, for their specific and appropriate actions on shooting and burning pain, usually of neurogenic origin.
by Phillip Kim. MD
Neurostimulation is the application of precise targeted electrical stimulation on nociceptive pathways. Electric stimulation has a long history in medicine for treating various ailments. Beyond the application of electrodes on the skin such as in transcutaneous electrical nerve stimulation (TENS), electrodes have been applied directly to nociceptive pathways.
The nociceptive pathways are made up of tracts in the central and peripheral nervous systems. The central nervous system includes nociceptive pathways in the spinal cord and brain, specifically the dorsal roots, dorsal ganglion, spinothalamic tracts, and all ascending neural tracts to the cerebrum. The peripheral nervous system includes pathways outside the spinal cord, specifically various plexuses and peripheral nerves.
Spinal cord stimulation involves the placement of an electrical system to block nociception. The system comprises the surgical placement of epidural electrodes, cables, and radiofrequency transmitter or battery. Much of this method has evolved from cardiac pacemaker technology. The minimal invasiveness and trialing has led to the success of this approach. Neurostimulation can be placed during an outpatient procedure, with local anesthesia and sedation. The patient experiences minimal discomfort when the system is placed and during the postoperative period.
continue reading on Medscape.com
http://www.medscape.com/viewarticle/473431
Whilst this has usually been attempted by the time a patient reaches a Pain Clinic, appropriate physiotherapy in the form of an exercise programme is almost always of benefit. A great deal of work needs to be done to validate conventional physiotherapy techniques; usage in acute pain appears to bring little benefit over the natural history of the condition, whilst in chronic pain it can often be of only short-term efficacy. However, functional rehabilitation programmes aimed at restoration of suppleness and muscle function do appear to be of very real benefit in the long term. Chiropractic manipulation has been shown to be effective in some studies, whilst ineffective in others. Again, patient selection and the technique of the manipulator are markedly variable and will alter efficacy a great deal.
Both acupuncture and TENS are exciting great controversy at the present time in the Western world; their long standing use for chronic pain is being questioned because (again) of the lack of evidence. This remains a controversial field, but both techniques appear to be relatively simple, fairly safe in appropriate hands and reasonably cheap. Acupuncture again is said to work on descending inhibitory pain pathways and also to stimulate endorphins (as well as the body's natural cortisone). Both positive and negative results have been shown in a bewildering variety of trials. There is certainly a powerful placebo effect, but there also seems to be a significant analgesic component, albeit this might last for only a very short period, and the benefits seen with many patients may be due to a reduction in distress and disability engendered by their interaction with the therapist.
Again it is difficult to find a wealth of hard evidence as to the efficacy of TENS, but a limited, albeit significant number of patients appear to get good benefit, and this appears in some studies to be better than placebo.
Dorsal column stimulation continues to excite interest. Clearly, this can be a useful therapy for moderate pain, especially if it encourages entry into a pain management programme-type approach.
Nonsurgical reconstructive therapy ó also referred to as "prolotherapy" or "proliferative therapy" ó evolved out of a treatment pioneered by H. I. Biegeleisen called "sclerotherapy," which was originally (and still is) used to treat varicose veins. Prolotherapy involves the injection of an "irritant" solution into the area where ligaments are weak and/or damaged. Over the next few days, cells called "macrophages," literally big eaters, are attracted into the area by the presence of this irritant solution. Once they arrive, these macrophages pick up the irritant solution and carry it away for disposal (they are the garbage men of the body). As the macrophages are finishing their job, the body sends in "fibroblasts," literally connective tissue builders, to lay down fibrous tissue wherever they detect damage to connective tissue such as ligaments.
Of course, prolotherapy can be used on any weakened ligament or tendon in the body. The determining factor is the doctor's skill in introducing the needle to exactly the right locaiton. Knees, hips, elbows, shoulders, in fact every joint in the body can develop problems which can be addressed with prolotherapy.
The doctor's job is to introduce the irritant solution into the places where ligaments are weak or damaged. If properly placed, this causes the repair of ligaments. This new supporting structure pulls the vertebrae back into close relationship with each other correcting instability and therefore putting an end to inflammation. When inflammation disappears, so does pain! Stability is restored along with mobility.
A single treatment with prolotherapy will cost around $200. Usually not more than ten to fifteen treatments are necessary to bring a typical back pain or neck pain syndrome under control.
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The term "prolotherapy" is a derivation of "proliferative injection therapy" and is also known as sclerotherapy. The practice of prolotherapy is used by doctors of osteopathy and other physicians to treat a number of different types of chronic pain. Prolotherapy consists of a series of intraligamentous and intratendinous injections of solutions in trigger points near the pained area to induce the proliferation of new cells.
Proponents of this treatment suggest that looseness in the supporting ligaments and tendons around the joints causes the pain, inducing the muscles to contract against the ligament and irritate the nerve endings. The physicians using this treatment method for low back pain believe the ligament laxity to be concentrated in the sacroiliac joint. During a physical examination a physician will identify trigger points generally in the muscles overlying the sacroiliac joint. The physician then may inject proliferant substances into the supporting ligament and tendon tissue.
The practice of sclerotherapy or prolotherapy to produce dense fibrous tissue in an effort to strengthen the attachment of ligaments and tendons is not new. Forms of this therapy apparently date back to Hippocrates, however, prolotherapy recently found favor with osteopaths following the teachings of George Hackett, MD, who in 1939 began using a local injectable irritant to initiate the healing process. It was Dr. Hackett who coined the term "prolotherapy" because sclerotherapy implied scar formation, which, according to Dr. Hackett, did not occur with prolotherapy. Nevertheless, both processes use trigger point injections to form new cells in an effort to support weakened muscles. Although the method has been in use for some time, to date there is no strong clinical evidence to support the efficacy of the treatment.
Prolotherapy injections are intended to mimic the natural healing process by causing an influx of fibroblasts that synthesize collagen at the injection site, leading to the formation of new ligament and tendon tissue. The newly produced collagen is intended to support the injured or loosened ligaments, creating a more stable and strong muscle base, in the process, alleviating pain.
There are three classes of proliferant solutions used to initiate inflammation: chemical irritants (e.g. phenol), osmotic shock agents (e.g. hypertonic dextrose and glycerin), and chemotactic agents (e.g. morrhuate sodium, a fatty acid derivative of cod liver oil). The two studies supplied by the requestor used a dextrose-glycerine-phenol solution.
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What is known about prolotherapy outcomes for back pain?
Reported success rates range from 80%-90% when performed by a physician trained in the prolotherapy procedure. Many of these reports are based on anecdotal evidence from the physicians themselves. Studies have not yet connected positive outcomes for back pain and healing to prolotherapy.
The anecdotal reports suggest improvements such as:
* Reduction or elimination of back pain
* Increased strength of the ligament, tendon or joint capsule
* Reduced recurrence of injury to the treated site
* Improved or return to normal function
Factors that may be key for a successful outcome include:
* Proper diagnosis of the location of the sprain or strain
* Willingness of the patient to complete follow-up therapy
* Clinical skill of the physician in performing the injection
Finally, it is important to note that nobody knows exactly what happens in prolotherapy. There is no objective medical evidence, and no histology has been published as to what goes on when injection is placed into the painful soft tissues.
Psychological techniques again need to be tailored to the individual patient and not offered piecemeal. Cognitive therapy is perhaps something that any good physician will do, in explaining to the patient the cause of the pain in less than the lurid terms sometimes adopted by a clinician. Knowledge of the natural history of conditions is essential. False promises lead to confusion and long-term disillusionment. Behavioural techniques are something adopted by any good therapist with rewards being given for re-establishment of function rather than expressions of pain and misery.
A skilled clinical psychologist is an invaluable and essential part of every Chronic Pain Unit, and a useful second opinion and source of help for any clinician who has any doubt as to the differential diagnosis and management of a particular patient. Techniques such as relaxation, hypnosis and bio-feedback have been shown to be effective, although again these can be time-consuming and therefore expensive, and long-term results can sometimes be disappointing.
It is quite clear that many patients improve a great deal on a multi-disciplinary pain management programme, with some getting a reduction in pain and others improving greatly on parameters of reduced distress and reduced disability.
What is a selective nerve root block?
A selective nerve root block is a procedure that is used diagnostically to identify whether a spinal nerve is the generator of pain. Additionally, coincident injections of corticosteroid along with the local anesthetic block can be therapeutic and relieve pain.
What can I expect at the Pain Center?
A Pain Management Specialist at the clinic will assess your pain condition, take a medical history, and examine you to see if the procedure is a potentially beneficial option. At this time any precautions that need to be taken based on the status of your health may be discussed. Additional or alternative treatment options can be discussed. After this examination, the procedure can then be scheduled.
What should I do before the procedure?
Do not eat or drink non-clear liquids 6-8 hours prior to your procedure. You may drink a small amount (a few ounces) of clear liquid (water) up to 2-3 hours before your procedure. Take your routine medications the day of your procedure as you normally would with a small amount of water, unless instructed otherwise by the physician. If you take pain medications, do not take a dose 2 hours prior to your procedure time, unless otherwise instructed by the physician. If you take blood thinners (such as Coumadin), or you are a diabetic, you will need to follow special directions which the physician will give you prior to the procedure. It is mandatory that you arrange for someone to drive you home from the ambulatory surgical center after your procedure. Additional instructions may be given by the physician if necessary depending on your health status.
Where will the procedure be done?
In the ambulatory surgical center as an outpatient.
Will I be asleep for the procedure?
Monitored anesthesia care with light sedation may be medically indicated, based upon your health status, or to reduce unintentional movement during the procedure. Your physician will discuss this with you at the time of your appointment.
When will I have some relief of pain?
You may receive immediate pain relief after the procedure. If a patient receives partial improvement, then repeat injections may be indicated.
Will I be able to drive afterward?
No, do not operate motorized vehicles/equipment (ie cars, lawn mowers, power tools, kitchen appliances, etc) until the day after your procedure, especially if you have received sedation.
Will I be able to resume my normal activities after the procedure?
Yes, the next day. Just maintain good body mechanics and posture and continue with physical therapy or your home exercise program.
What are the risks of the procedure?
A full discussion of the risks of the procedure will occur when you meet the Pain Specialist who will perform the injection. Overall, the risks are relatively low.
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The use of nerve blocks has also been criticised because of the lack of appropriate double-blind, randomised controlled trials. However, it must be appreciated that these are hard to carry out for non drug treatments, and in such a disparate group of patients as for instance those with low back pain and neurogenic pain. However, it is clear that trials are now being carried out and can show the efficacy of various treatments. On the whole I veer away from permanent lesions for patients with chronic non-malignant pain.
Facet joint denervations have been shown by Lord, Barnsley and Bogduk to be effective for both low back pain and neck pain resulting from whiplash injuries.
Efficacy and safety of epidural steroids have been investigated extensively and recent randomised controlled trials appear to show benefit for their use in limb pain and also in acute back pain or neck pain. It is essential for an appropriate dose to be used and for careful placement of the drug in the correct compartment. I would suggest the use of epidurography at least and the new technique of epiduroscopy is interesting, although as yet completely unproven.
It is understandable and tempting to think of a painful disc as the cause of a significant number of certain patients' symptoms, and the new technique of disc denervation is another therapy under review at present.
Pulsed radiofrequency has been recommended by Dutch authors, but as yet I fail to see the rationale or the scientific evidence which would lead me to embrace this technique. At least it appears to be side-effect free, although it is a potentially expensive treatment, especially if it is only a placebo!
The use of Botulinum Toxin for muscle spasm is also under investigation at the present time. Clearly the agent has a powerful muscle relaxant effect, which is present from two to six months. Also it appears a relatively safe drug. However a great deal of work needs to be done now to identify the appropriate patients for treatment with this fairly extensive compound.
What is a stellate ganglion block?
A stellate ganglion block is a procedure which is used to diagnose and sometimes to treat certain pain disorders involving your head, shoulder, or arm.
The stellate ganglion is a special structure in your neck, near your spine, where some of these special nerve fibers come together. By injecting local anesthetic medicine into that area we can alter the activity of these special nerve fibers to both find out more about your particular pain problem and/or to reduce your pain.
What can I expect at the Pain Center?
A Pain Management Specialist at the clinic will assess your pain condition, take a medical history, and examine you to see if the procedure is a potentially beneficial option. At this time any precautions that need to be taken based on the status of your health may be discussed. Additional or alternative treatment options can be discussed. After this examination, the procedure can then be scheduled.
What should I do before the procedure?
Do not eat or drink non-clear liquids 6-8 hours prior to your procedure. You may drink a small amount (a few ounces) of clear liquid (water) up to 2-3 hours before your procedure. Take your routine medications the day of your procedure as you normally would with a small amount of water, unless instructed otherwise by the physician. If you take pain medications, do not take a dose 2 hours prior to your procedure time, unless otherwise instructed by the physician. If you take blood thinners (such as Coumadin), or you are a diabetic, you will need to follow special directions which the physician will give you prior to the procedure. It is mandatory that you arrange for someone to drive you home from the ambulatory surgical center after your procedure. Additional instructions may be given by the physician if necessary depending on your health status.
Where will the procedure be done?
In the ambulatory surgical center as an outpatient.
Will I be asleep for the procedure?
Monitored anesthesia care with light sedation may be medically indicated, based upon your health status, or to reduce unintentional movement during the procedure. Your physician will discuss this with you at the time of your appointment.
When will I have some relief of pain?
You may receive immediate pain relief after the procedure. However, it is more typical for pain relief to occur gradually over several days to weeks. If a patient receives partial improvement, then repeat injections or continuation of a short series of injections may be indicated. If the pain goes away then repeat injections are not needed.
Will I be able to drive afterward?
No, do not operate motorized vehicles/equipment (ie cars, lawn mowers, power tools, kitchen appliances, etc) until the day after your procedure, especially if you have received sedation.
Will I be able to resume my normal activities after the procedure?
Yes, the next day. Just maintain good body mechanics and posture and continue with physical therapy or your home exercise program.
What are the risks of the procedure?
A full discussion of the risks of the procedure will occur when you meet the Pain Specialist who will perform the injection. Overall, the risks are relatively low.
Trigger point injection (TPI) is used to treat extremely painful areas of muscle. Normal muscle contracts and relaxes when it is active. A trigger point is a knot or tight, ropy band of muscle that forms when muscle fails to relax. The knot often can be felt under the skin and may twitch involuntarily when touched (called a jump sign).
The trigger point can trap or irritate surrounding nerves and cause referred pain - pain felt in another part of the body. Scar tissue, loss of range of motion, and weakness may develop over time.
TPI is used to alleviate myofascial pain syndrome (chronic pain involving tissue that surrounds muscle) that does not respond to other treatment, although there is some debate over its effectiveness. Many muscle groups, especially those in the arms, legs, lower back, and neck, are treated by this method. TPI also can be used to treat Fibromyalgia and tension headaches.
Procedure
Medical specialists such as an orthopedist, physiatrist, pain specialist, or neurologist can administer TPI. Injections are given in the physician's office and takes approximately 30 minutes. Before performing TPI, the physician may give the patient a nerve block to prevent pain from needle penetration.
A small needle is inserted into the trigger point and a local anesthetic (e.g., lidocaine, procaine) with or without a corticosteroid is injected. Injection of medication inactivates the trigger point and thus alleviates pain. Sustained relief usually is achieved with a brief course of treatment. The injection may cause a twitch or pain that lasts a few seconds to a few minutes.
Aftercare
Numbness from the anesthetic may last about an hour and a bruise may form at the injection site. Pain can be relieved by alternately applying moist heat and ice for a day or two. In most cases, stretching exercises and physical therapy are performed following TPI.
Complications
The patient should contact the physician if redness or swelling develops. There is some risk for puncturing a lung or the membrane that surrounds the lung (called the pleura), when a muscle near the ribcage receives a trigger point injection.
Vagus nerve stimulation involves the implantation of a generator that stimulates the vagus nerve and thus reduces seizure activity. The vagus nerve is one of 12 pairs of cranial nerves (i.e., nerves that originate in the brain). It has motor functions in the larynx (voice box), diaphragm, stomach, and heart, and sensory functions in the ears and tongue. It has both motor and sensory functions in the pharynx (sinuses) and esophagus. Stimulation of the vagus nerve is thought to affect some of its connections to areas in the brain that are prone to seizure activity.
Patients who suffer from complex partial seizures or generalized seizures where consciousness is lost, and who do not respond to anticonvulsant medication, and patients who cannot undergo brain surgery are considered good candidates for vagus nerve stimulation therapy. It also may be ecommended as a treatment for photosensitive epilepsy and epilepsy resulting from head injury.
Procedure
The procedure is performed under general anesthesia. A neurosurgeon implants the device, a generator about the size of a small tape measure, in the upper left area of the chest. A connecting wire is run under the skin from the device to the vagus nerve in the left side of the neck. Three small leads are then carefully attached to the nerve. Implantation is usually accomplished within 1 to 2 hours.
For a few days following the procedure, the generator is programmed to stimulate the vagus nerve at regular intervals (e.g., for 30 seconds every 5 minutes) at a frequency determined by the doctor and patient. The physician adjusts the frequency using a computer. If a seizure begins between intervals, the patient activates the stimulater by swiping a magnet over their chest at the location where the device is implanted.
Risks include possible surgical injury to the vagus nerve, carotid artery, and internal jugular vein.
Results
Many patients experience 50% reduction in seizure frequency, and seizures are less severe. Vagus nerve stimulation eliminates seizures in approximately 15% of patients, according to some studies, and a small number experience no improvement.
Complications include coughing, hoarseness, and swallowing difficulties resulting from injury to the vagus nerve. Infection, bleeding, and discomfort at the site can occur. There may be tingling in the neck, hoarseness, and a slight cough during nerve stimulation.