Chronic Pain Disorders
Chronic Pain Disorders

Common Pain Management Modalities

Transcutaneous electrical nerve stimulation (TENS) has been used with varying degrees of success in the management of chronic pain. Electrodes are applied to either side of a pain site. The TENS machine then administers an electrical stimulus across the nerves in the area. The electrical stimulation reduces the capacity of nerves to transmit pain signals. Treatment can be repeated as required depending upon how long the relief lasts.

Cryotherapy is destruction of nerves with an ice ball produced by intense cold at the end of a probe. The pain relief is temporary and may last up to two weeks.

Epidural steroid injection is injection of long lasting steroid medication into the epidural space surrounding the spinal cord and the nerve roots. The steroid reduces nerve inflammation, which in turn reduces pain, numbness, and other symptoms caused by nerve irritation or swelling. The injection consists of a mixture of local anesthetic (like lidocaine or bupivacaine) and a steroid medication (triamcinolone or methylprednisolone). The immediate effect is usually from the local anesthetic injected. This wears off in a few hours. The cortisone starts working in about 3 to 5 days and its effect can last for several days to a few months. A series of three injections at three to four week intervals is a common treatment course.

Facet joint injection is an injection of long lasting steroid into the facet joints of the vertebrae. The steroid reduces the inflammation of tissue in the joint space, which in turn reduces pain and other symptoms caused by irritation of the joint and surrounding structures. Like epidural steroid injections, the solution injected is composed of a mixture of local anesthetic and steroid medication. The procedure is performed with the patient either lying on the stomach or sitting (for cervical injections) under x-ray control.

Sacroiliac joint injection is an injection of long lasting steroid into the sacroiliac joints located on either side of the low back area. The steroid reduces the inflammation of the joint space tissue, which reduces pain due to inflammation of the joint and surrounding structures. The injection consists of a mixture of local anesthetic and steroid medication. It is done with the patient lying on the stomach under x-ray control.

Epidurolysis (RACZ) procedure is done to dissolve scar tissue from entrapped nerves in the epidural space of the spine so that medications can reach inflamed, painful areas. Scarring is most commonly caused from bleeding into the epidural space following back surgery and the subsequent healing process. Sometimes scarring can occur when a disk ruptures and its contents leak out.

The procedure requires a series of three injections. First, under fluoroscopic guidance, a catheter is inserted in the epidural space up to the area of scarring. The first injection of medications is made via this catheter. The second injection is done the following day. On the third day, the catheter is injected and then removed. The injection consists of a mixture of local anesthetic and steroid as well as x-ray contrast dye to visualize the scarred space, and hyaluronidase – and concentrated sterile salt solution to soften scar tissue.

Radio frequency lesioning is a procedure using a specialized machine to interrupt nerve conduction and reduce pain on a semi-permanent to permanent basis. A needle is placed under x-ray guidance and a local anesthetic is injected. After confirmation of the needle tip position, a second needle is inserted. The tissues surrounding the needle tip are heated when electric current is passed using the radio frequency machine for a few seconds. This procedure effectively "burns" the nerves and destroys the pain pathways.

Dorsal column spinal cord stimulator therapy employs a specialized device to stimulate nerves with tiny electrical impulses via small electrical wires placed on the spinal cord. It is a treatment modality for patients with chronic severe pain due to nerve tissue damage who have not responded to conservative treatments. The procedure is done in two stages. First, temporary wires are placed and an external generator is used by the patient to generate electrical current. If this trial is successful in relieving pain, then the permanent generator is placed under the skin. Wires are placed along the spinal cord under x-ray guidance. For the pain involving lower back and lower extremities, the wires are inserted in the midline at the lower back.

Spinal myeloscopy is a relatively new procedure performed to release scar tissue around spinal nerve roots. A miniature fiberoptic scope is placed into the epidural space of the spine after local anesthesia has been applied to the skin. The space in the lower back is then examined, scar tissue released, and a combination of local anesthetic and steroid is injected directly onto inflamed nerves. Spinal myeloscopy is usually performed after routine epidural steroid injections have failed to relieve pain.

Occipital nerve stimulation is a new treatment for patients who suffer from occipital neuralgia. Using tiny electrodes placed just beneath the skin, the occipital nerve is stimulated and pain is replaced with a minor tingling sensation to which the patient becomes accustomed. The electrodes and battery-operated generator, which are smaller than a cardiac pacemaker, are then completely implanted under the skin. The procedure is reversible and initial results have been positive.

Nerve blocks are injections of anesthesia sometimes in conjunction with steroid medication to reduce nerve inflammation and block pain. Nerve blocks are administered in various sites depending upon the nature and location of the pain under treatment. Some of the most common nerve blocks are:

Occipital nerve blocks are injections of anesthesia into the back of the neck in order to treat pain going up the back of the head. By injecting the peripheral nerves in the neck which relate to damaged structures, impulses to the trigeminal nerve are blocked and cervicogenic headache is relieved.

Stellate ganglion blocks are used to relieve upper extremity pain syndromes. The stellate ganglion is a collection of sympathetic nerves in the upper neck on either side of the larynx. It is the nerve center for the hands, arms and shoulders. A local anesthetic is injected into the ganglion. Epinephrine may be added to prolong the beneficial effects of the injection. The injection permits increased blood flow to the area and can often decrease or stop the pain. A series of three to six injections is usually performed over a period of two to three weeks. The number of injections depends upon the severity and duration of the extremity pain.

Intercostal nerve blocks are used to relieve severe pain caused by rib fractures, or chest pain associated with pleurisy, acute herpes zoster, and post herpetic neuralgia. Intercostal nerve blocks are injections of long-acting local anesthetic and sometimes a steroid around the nerves of the ribcage. The injection interrupts the signals sent along the intercostal nerves, reduces pain and inflammation, and promotes healing and function. It may be necessary to perform intercostal nerve blocks on a weekly basis until significant improvement occurs.

Lumbar sympathetic blocks are injections of local anesthetic into the sympathetic nerve tissue located on the either side of spine. The injection blocks the sympathetic nerves to reduce pain, swelling, redness and sweating changes in the lower extremity. The injection consists of a local anesthetic (like lidocaine or bupivacaine). Epinephrine or Clonidine may be added to prolong the effects of the injection. It is done either with the patient lying on stomach under fluoroscopic x-ray guidance.

Neurolysis is the destruction of a nerve by injection of ethanol, phenol, or other neurolytic agents at sites of chronic intractable pain.