PAIN

MANAGEMENT
Dr.Sarvesh B MD FIPM
 Definition of PAIN

Pain is "an unpleasant sensory and emotional

experience associated with actual or potential tissue
damage, or described in terms of such
damage"
( IASP : 1979).
 Types of Pain
• Acute Pain • Chronic Pain
/Physiological Pain /Pathological Pain
• Nociceptive • Neuropathic
• Symptom of a disease • A disease itself, a
• Treatment of diseases disease of nervous
cures pain & it is self- system.
limiting. • Difficult to treat &
sustaining.
 What is Chronic Pain?
• American chronic pain association defines it as Pain
that continues a month or more beyond the usual
recovery period.
• Some has described chronic pain as pain persisting
more than 3 month as by three months pain itself
becomes a disease.
• All pain is acute pain till it becomes chronic pain.
Interventional Pain
Management
 Treatment of Pain
Recovery
Operation
Strong
opioids
Weak
opioids +/-
non-
Non- opioids +/-
opioids adjuvant
Non-pharmacological
methods(CBT,Physio)
 Treatment of Pain
Recovery
Operation
Strong
opioids
Weak
opioids +/-
non-
Non- opioids
opioids World of Misery
Non-pharmacological
methods
 Treatment of Pain
Recovery
Operation
Strong
opioids
Weak
opioids +/-
non-
Non- opioids
opioids
Non-pharmacological
methods
•Interventional Pain Management are some minimally
invasive procedures which gives permanent/long term pain
relief by stopping nociceptive inputs or correcting
neuropathy.
•It fills the gap between pharmacologic management of
pain & more invasive operative procedure.
 INDICATIONS
• Chronic pain not responding to pharmacotherapy.
• Undiagnosed pain with normal imaging study or imaging
abnormality not corresponding to patients symptom.
• Neuralgias (eg: Trigeminal, Glossopharyngeal,
Sphenopalatine, Intercostal etc)
• Pain with un-treatable cause – like cancer pain, degenerative
arthritis, diabetic neuropathy.
• Acute painful conditions – here pain management is used in
conjunction with other specific therapy.
COMMON PAIN
CONDITIONS
TREATED WITH IPM
LOW BACK PAIN
TREATMENT OPTIONS IN IPM
 SLIPPED DISC OR DISC
PROLAPSE

• Treatment – ozone discectomy/ percutaneous disc

decompression/ epidural steroid injection / surgical discectomy
MRI OF DISC PROLAPSE
 INTERNAL DISC DISRUPTION
• Discogenic back pain or back pain due to internal disc
disruption.
• Axial dull ache in the low back increasing with flexion of
spine is the main clinical feature.
• Leg pain is either nil or minimum without any
dermatomal pattern of radiation.
• Provocative discogram should be performed.
• Positive discogram (provocation of similar pain more
than 7/10 at a pressure below 15 psi).
• Management: Rami communicans nerve block and RF
of rami communicans , Caudal epidural injection
 FACET JOINT ARTHOPATHY
• Facet joints - True joints of the vertebral column.
• Prone to degeneration with advances in age.
• Local tenderness over a facet joint,
• To evaluate chronic low back pain with or without radiation
but without any radiographic clue
• Back pain with radiographic evidence of disc disease and facet
arthritis,
• Post-laminectomy syndrome/Failed back surgery syndrome
 Management of Facet joint pain

• Diagnostic intra articular steroid injection

• RF ablation of medial branch of dorsal primary rami
of spinal nerve at two levels
 SI JOINT ARTHOPATHY

• SI joint is located in the lower spine above the

tailbone.
• Inflammation of the sacroiliac joint can cause low
back and buttock pain.
• Treatment -
• Sacroiliac Joint Injection
• SI joint radiofrequency procedure
 FAILED BACK SURGERY SYNDROME
• Right surgery in wrong
patients.
• Wrong surgery in right • Incidence of Failed Back
patients. Surgery varies from 5%-
• Right surgery in right 50%, more with passage of
patients, but .... time
• Facet Joint Syndrome, • Treatment -
• SI Joint pain,
• Dural Fibrosis, •Epiduroscopic adhesionolysisis
best for Dural fibrosis.
• Discogenic pain, •Radio-Frequency procedure is
• CRPS best for Facet and SI Joint Pain.
• Recurrence of pathology •Spinal Cord Stimulation is best
for Neuropathic pain conditions like
CRPS.
 KNEE PAIN
• Osteoarthritis is commonest cause of knee pain.
• 80% of general population of radiologic evidence of osteoarthritis by 65 yrs of
age
• Treatment –
• Non-pharmacological therapy
• Pharmacological therapy
• Surgery
• Interventions –
• Intra-articular injections
• Prolotherapy and Prolozone Therapy
• Pulsed Radio-Frquency Procedure (PRF) of genicular nerves
 TRIGEMINAL NEURALGIA
• EXCRUCIATING, ELECTRIC SHOCK
LIKE, SHOOTING/STABBING PAIN IN
THE FACE
• Treatment –
• Pharmacotherapy
• Gasserian ganglion block
• Radio Frequency procedure of Gasserian
Ganglion
 FIBROMYALGIA
• Complex, chronic condition -
widespread pain and fatigue as well as a
variety of other symptoms.
• Mostly affects females.
• Treatment –
• Pharmacotherapy
• Systemic desensitisation
• Trigger point injection.
 ACUTE HERPES ZOSTER
(SHINGLES) & POST- HERPETIC
NEURALGIA.
• Acute Herpes Zoster (Shingles):
• Pharmacotherapy
• Respective nerve block (including epidural block) -when pain is severe.
• Post- herpetic neuralgia (PNH):
• PHARMACOTHERAPY
• Interventional Pain Management procedures like intercostal nerve
block, stellate ganglion block, thoracic or lumber sympathetic block
and paravertebral block give excellent and permanent/long lasting
pain relief.
 MIGRAINE
• Botulinum Toxin in the scalp prevent migraine
attack for prolonged period.

• Spheno-palatine Ganglion block - abort acute

attack of migraine.
• Spheno-palatine Ganglion Radio frequency
procedure – for long term relief.
MYOFASCIAL PAIN SYNDROME
• Myofascial pain syndrome - localized muscle spasm and
pain
• Pathognomonic feature - TRIGGER POINTS in
certain areas
• Commonly affects the persons with sedentary life style
– (IT Professionals), or persons having un-accustomed
exercise.
• Treatment –
• Pharmacotherapy
• Trigger point injections.
• Botox injection.
 CRPS
• NOCICEPTIVE IMPULSES ARE CARRIED BY
SYMPATHETIC NERVES IN AN EXAGGERATED WAY
• Type-I or reflex sympathetic dystrophy -injury occurs to the skin,
bones, joints or tissue.
• Type-II or causalgia -injury to major nerves
• Treatment -
• SYMPATHETIC BLOCKADE:
• INTRAVENOUS REGIONAL SYMPATHETIC BLOCKADE:
• SIPINAL CORD STIMULATION
• INTRATHECAL DRUG DELIVERY SYSTEM
 POST-SURGICAL NEURALGIC
PAIN

• Following surgery or other trauma

patient may experience neuropathic
pain.
• Pharmacotherapy
• Nerve block –according to the area of
pain.
 COCCYDYNIA
• A number of different conditions can cause
pain in the general area of the coccyx
• TRAUMATIC VERSUS NON-TRAUMATIC
• In many cases the exact cause is not known
(called idiopathic coccydynia).
• Treatment –
• Pharmacotherapy
• Peri coccygeal injections
• Ganglion impar block
CANCER PAIN
 CANCER PAIN

• 10 lakh new cancer patients are diagnosed every year in India.

• 60% are diagnosed in advanced stage, so require only pain
management and palliative care.
• 30% -50% have pain at the time of diagnosis.
• 70% to 90% have severe pain.
• 40% die with severe pain.
• 60%-80% complains of inadequate pain relief.
• 30% - not relieved by drug treatment alone, so require
interventional pain management.
• More than 90% cancer pain can be adequately controlled.
 INTERVENTIONAL PAIN
MANAGEMENT FOR CANCER PAIN
– RF OR NEUROLYSIS

• SPHENO PALATINE GANGLION BLOCK & STELLATE

GANGLION BLOCK – FOR HEAD AND NECK
• THORACIC SYMPATHETIC BLOCK
• SPLANCHNIC NERVE AND COELIAC PLEXUS BLOCK –
FOR ABDOMINAL CANCER
• LUMBER SYMPATHETIC BLOCK AND SUPERIOR
HYPOGASTRIC PLEXUS BLOCK – PELVIC CANCER
• GANGLION IMPAR BLOCK – FOR PERINEAL CANCER
Other Common Pain Conditions

• Tennis elbow, golfer’s elbow

• Bursitis
• Tendo Achilles pain
• Plantar fasciitis
• Shoulder pain due to rotator cuff tendinitis,
subacromial bursitis
• Carpel tunnel syndrome
• Spondyloarthropathy
 TREATMENT
MODALITIES IN
IPM
 OZONE NUCLEOLYSIS
(OZONE THERAPY FOR SLIP
DISC):
• The first ozone generators - developed by
Werner von Siemens in Germany in 1857
• O3 generated – from O2
• Strong anti inflammatory action
• When injected in disc - disc shrinks becomes
mummified – thus reduces the volume.
Ozone generator
 OZONE NUCLEOLYSIS
(OZONE THERAPY FOR SLIP
DISC): INDICATIONS
• It can be done in degenerated disc without any
prolapse and nerve root irritation.
• It can be done in contained disc prolapse or disc
bulge with root irritation.
• It may be done in non-contained disc (extruded or
sequestrated disc) as well.
• Outcome studies of lumber disc surgeries document
a success rate upto 95%.
 How does Ozone works??
Oxygen free radical liberated from ozone binds to
proteoglycan bridges in nucleus pulposus

Bridges will be broken down , so they no longer can hold

the water molecules

Disc shrinks and mummified , nerve root will be

decompressed

Besides this ozone is anti-inflammatory and increases

tissue oxygenation , there by promoting healing
 EPIDURAL BLOCK
• Most common technique to relieve chronic spinal pain.
• It may be transforaminal Lumber Epidural Block, Caudal
Epidural Block, Cervical Epidural Block or Thoracic Epidural
Block depending on the site of intervention.
Transforaminal epidural injection
 STELLATE GANGLION
BLOCK
• It is useful in the treatment of the following conditions :
• Raynaud’s diseases
• Arterial embolism in arm .
• CRPS I , CRPS II
• Any sympathetatically mediated or maintained pain of hand
and head,neck
It has been utilized both as
diagnostic as well as theurapeutic
intervention .
 LUMBAR SYMPATHETIC
BLOCK
• Sympathetic dystrophy may be the cause of pain in a
significant number of cases.
• Neurolysis of Lumber sympathetic chain using
alcohol/ phenol or RF ablation gives relief in
Complex Regional Pain Syndrome/ causalgia/
Sympathetic dystrophy etc.
 RADIOFREQUENCY PROCEDURE

• HIGH FREQUENCY ALTERNATING CURRENT IS PASSED

(AT 300 KHZ) THE CHARGED IONS MOVES TO & FRO.
• DUE TO THIS ELECTRO-MECHANICAL FRICTION HEAT IS
GENERATED.
 • RADIO FROQUENCY
PROCEDURES BLOCKS THE
PAIN SIGNAL GENERATED AND
CARRIED BY THE DISEASED
NERVE FOR LONG
CONVENTIONAL AND PULSED RF
• In the conventional type the nerves
are regenerated in future & average
pain-free period varies for type of
nerve. In a properly performed
lesion pain free period is 3-4 years.
• In the pulsed RF the nerve is
repaired. Average pain free period
is 4-24 months.
 PROLOTHERAPY AND
PROLOZONE THERAPY
• Prolotherapy is the procedure where tissue proliferant
are injected into the damaged tissue (ligament, tendon or
cartilage) to induce tissue growth.
• Prolotherapy = Proliferation therapy.
• As the damaged tissue is healed the pain is reduced.
Different types of tissue proliferants had been used with
success.
• When ozone and oxygen mixture is injected as
proliferant it is called Prolozone therapy.
• Common indication – OA knee
 SPINAL CORD
STIMULATION
• Although electricity has been used for centuries to treat pain &
many other ailments, stimulation of dorsal column of spinal
cord was first used by Shealy & his colleagues in 1967.
• Their study was based on the ‘Gate control theory of pain’ by
Melzack and Walls introduced in 1965.
• Initially they termed the procedure as dorsal column stimulation
as they believed that stimulation is effective only at dorsal horn
of spinal cord.
• As it is now known that electrical stimulation is effective in
suppression of nociception when applied in almost anywhere
of the spinal cord, so the better and more acceptable term is
spinal “cord stimulation” by spinal cord stimulator.
Spinal cord stimulator
LET US JOIN OUR HANDS TO MAKE THIS
SOCIETY PAIN FREE

NATIONAL HOSPITAL, IG ROAD,CALICUT

PAIN CLINIC : Monday
Wednesday
Friday

TIMINGS : 3 PM to 5 PM
THANK YOU