Previous columns have discussed chronic pain and some of the first steps that sufferers, guided by their physicians, should explore to seek relief.
Exercise, physical therapy, cold and heat, massage, acupuncture, Transcutaneous Electrical Nerve Stimulation, chiropractic manipulation, or non-opioid medications such as ibuprofen and other NSAIDS can make pain levels tolerable for many.
For others, however, the relief from these measures is inadequate. If you have "tried everything and nothing has worked,” it might be time to ask your physician if Interventional Pain Management would be a suitable avenue to explore.
Most specialists in this field are anesthesiologists, but some additionally have fellowship training in image-guided spine intervention.
Several local pain management clinics and practitioners offer these interventions. Your primary care physician should be able to help you determine if you are a good candidate for these procedures and to make a referral to the practitioner whose training and expertise is best suited to your needs.
There are various treatment options that can be performed by interventional pain management specialists.
While initially the placement of injections was based mostly on educated guesswork, the more recent use of fluoroscopy to guide precise needle placement has allowed much higher success rates.
Fluoroscopy is a type of medical imaging that shows a continuous X-ray image on a monitor, much like an X-ray movie, so a needle or wire can be guided to exactly the right spot.
Different interventions treat different types and locations of pain and have varying lengths of effectiveness.
Facet joint injections
These treat pain in the facet joints which support the spinal column and allow it to flex, extend, and rotate.
In older adults trauma and arthritic changes can contribute to the development of facet syndrome. Frequently a deep, dull aching pain is referred to the groin, buttocks, hip, or side and back of the thighs.
Facet point injections have two purposes. Diagnostically they can pinpoint the location of structures causing pain. The small amount of local anesthetic and steroid is injected directly into the facet joint.
If the pain is improved, then a longer-lasting procedure like radiofrequency ablation can be performed for longer-acting relief. The short-term relief facet joint injections can provide also can make a patient comfortable enough to participate in restorative physical therapy.
Epidural steroid injections
These can be given in the neck (cervical), mid-spine (thoracic) or low back (lumbar) sections of the spine. They can also be used for diagnosis as well as short-term pain relief.
To reduce inflammation and pain in the nerves as they exit the spine, a mix of local anesthetic and steroid is injected into the epidural space, just outside the membrane that covers the spinal cord. Without the use of fluoroscopic x-ray for precise placement, 25 percent of procedures will result in incorrect placements.
Sometimes one or two more injections are needed, every three or four months apart. They can provide temporary relief in about 50 percent of patients for back pain, sciatica, and neck pain with shooting arm pain.
Epidurals are a common treatment option for many forms of low back pain and leg pain. Fifteen percent of the U.S. population suffers from low back pain and incidence increases with age.
While the pain relief effects are temporary — a week to a year — injections early in an acute attack can be very beneficial in preventing chronic pain.
Sacro-iliac joint injections
These deliver anesthetic and steroid to the place where the pelvic and tailbone meet, resulting in increased mobility and less pain. Some pain management practitioners feel that combining the S-I joint injections with rehabilitative exercise and chiropractic release of the joint yields the best result.
This can be used for longer-term relief of neck pain, back pain, and headaches from facet joint arthritis. Using fluoroscopic x-ray, heat generated by radiofrequency waves can be delivered precisely to damage small nerves, disturbing the transmission of pain signals from the spinal column to the brain. The effects usually last several months.
Pain intervention techniques
Muscle as well as joint pain can be treated in this way. Trigger points — tender, irritable spots in muscles that are painful to the touch — can be treated by injecting a mix of cortisone and a local anesthetic such as lidocaine or bupivacaine into painful muscle tissue, usually in the neck or back.
Spinal cord stimulators
These are somewhat like an implanted Transcutaneous Electrical Nerve Stimulation unit. The SCS is indicated for those who have chronic neuropathic pain and are not candidates for surgery but for whom other treatments and injections have not been effective.
Initially wires are implanted to the affected area with the generator for the electrical current worn externally. If this treatment helps to lessen pain, the SCS can be implanted by a surgeon.
Intrathecal pain pump implantation
This allows targeted drug delivery to help with intractable chronic pain. Since medication is delivered directly to the intrathecal area surrounding the spinal cord, a smaller dose can be used than if it were given by other means, there are fewer side effects such as sleepiness, upset stomach and constipation, as when medication is taken orally, and the pain relief is often dramatic.
If a trial shows a pain improvement of 50 percent or greater, the patient may be considered a candidate for implantation.
These interventions are definitely not appropriate for everyone, but if the more conventional methods of pain relief are not working, they should be discussed and considered.
For more information on treating chronic pain, contact Comprehensive Pain Management in Franklin, MA.