Criticare - A special feature on Anaesthesiology

Interventional pain management for chronic pain

Dr Kailash Kothari

Pain is one of the most common reasons for patients to seek medical attention and one of the most prevalent medical complaints in today’s world. In a 1999, Gallup survey, 9 out of 10 Americans aged 18 or older reported suffering pain at least once a month, and 42 per cent of adults reported experiencing pain every day. Women, minority groups, elderly persons (especially nursing home residents) and individuals with cancer are at appreciable risk of suboptimal pain assessment and treatment. Effective pain management presents a significant challenge for physicians, other healthcare professionals, and their patients.

Some 75 million Americans experience persistent pain and at least nine per cent of the US adult population is estimated to suffer from moderate to severe non-malignant pain. Patients with chronic (or “persistent”) pain can be especially difficult to treat. In one survey conducted for the American Pain Society, 47 per cent of those with moderate, severe or very severe pain had challenged physicians at least once since their initial visit for pain relief. When asked why, they cited continued suffering (42 per cent), the physician’s lack of knowledge (31 per cent), not taking the pain seriously enough (29 per cent), and unwillingness to treat it aggressively (27 per cent) as reasons for the change. Situation in India is not very different from this one.

One of the difficulties in treating pain is in distinguishing between acute pain and chronic pain. In acute pain, there is an identifiable injury (or illness), an appropriate treatment, and a satisfactory resolution, usually within days or weeks.

In chronic pain (or illness) the cause of the pain (or symptom) is less clear, identifying appropriate therapy is difficult, and there is no resolution to the case. Chronic pain, simply put, is pain that persists beyond the natural healing period.

A problem arises when chronic pain feels like acute pain, is described to (and is accepted by) physicians and therapists as acute pain, and is then treated as acute pain. When this happens results are apt to be disappointing to both the patient and the physician and both may end up feeling quite frustrated. To both recover from, and to treat, chronic pain requires taking a different approach.

However, most professionals, such as physicians, nurses, and physiotherapists, who are well trained in treating acute problems, are not well trained in treating chronic problems. It will be up to patients to find the appropriate professionals who do treat chronic conditions.

Why are anesthesiologists involved in pain management?

By virtue of their knowledge of anaesthesia, they are specialists in relieving pain as is done in surgical situations. Techniques used to make surgery painless can be used to relieve other types of pain. Present day anesthesiologists complete undergraduate college and medical college prior to attending three years of residency training in anaesthesiology. Pain management anesthesiologists obtain further training in pain management during or after residency in a fellowship or pain clinic.

How we can help?

We can perform following procedures for chronic pain patients, these are minimally invasive and most of them are day care procedures requiring about two-three hours of hospital stay:

• Stellate ganglion blocks and radiofrequency lesioning
• Lumbar sympathetic blocks, neurolysis, and radiofrequency lesioning
• Epidural lysis of adhesions with rac catheters
• Epiduroscopy
• Celiac plexus blocks and neurolysis
• Superior hypogastric plexus blocks, continuous catheter placement, and neurolysis
• Facet joint blocks and radiofrequency lesioning
• Sacroiliac joint injections and radiofrequency lesioning
• Sphenopal-atine, trigeminal, supraorbital, occipital nerve blocks, and mental nerve blocks
• Trigger point injections
• Dorsal column spinal cord stimulators
• Implantable opiate pumps
• Cervical, thoracic, lumbar, and caudal epidural steroid injections
• Local anesthetic infusion challenge
• Peripheral nerve blocks and cryoneurolysis

Conditions treated at pain clinics

• Headache
• Trigeminal neuralgia and other orofacial pain
• Neck Pain
• Myofacial pain syndromes
• Reflex sympathetic dystrophies / causalgias
• Vascular pain syndromes
• Herpes zoster pain
• Abdominal pain – ca pancreas or any other visceral cancer or
• chronic pancreatitis
• Low Back Pain (LBP)
• Painful diabetic neuropathy
• Generalized chronic pain not responding to other therapy
• Sacroilitis
• Phantom limb pain – pain after amputation of the limbs
• Pain in aids
• Central pain states
• Peripheral neuropathies

Mission and philosophy

Help people to manage their pain and resume more normal, productive lives. Philosophy of pain clinic is that chronic pain is a disease not a symptom.

Equipment

• Radiofrequency generator machine - Radiofrequency (RF) lesioning is a safe, proven means of treating chronic pain. Continuous radiofrequency current is used to heat a small volume of nerve tissue, thereby disrupting pain signals from that specific area. This procedure has a selective effect on nerve fibres, reducing pain in target areas, but leaving other sensory capabilities intact.
• RF cannula and electrodes of different sizes.
• C – Arm – helps in performing all procedures under direct radiological guidance.
• C-Arm compatible O T table.
• Implantable opiate pumps and equipped operation theater to perform these procedures
• Epiduroscope
• Cryoneurolysis machines
• Spinal cord stimulation equipment
• Infusion pumps etc

Pain management in India

Today pain management in India is a rapidly growing super-specialty. Though there are very few pain consultants but in recent years many anaesthesiologists have shown inclination towards this specialty. I would like to share my view on few of the issues which are important for the specialty.

Awareness

Unfortunately awareness about pain management among medical professionals is very limited. In contrast to USA and other developed countries Indian medical community is not aware of interventional pain management techniques which can be helpful for many patients suffering from intractable chronic pain.

Efforts are being made by arranging CME’s for general practitioners, medical consultants and other related specialties by Indian society for study of pain (ISSP), Pain foundation of India (PFI), North East Mumbai Anesthesiologist’s association (NEMAA), and many other organisations.

I think we need to be more aggressive to spread the knowledge among our colleagues. Another important aspect would be to increase general public awareness by organising pain camps, lectures or supplying pain treatment information booklets. This will definitely help the specialty to grow faster.

Equipment: Equipment used to perform various pain procedures are quite expensive. Radiofrequency generator used in many RF neuroablation machine costs anywhere between Rs 14-25 lacs depending on the model chosen. Each disposable RF cannula costs between Rs 2000 – Rs 4000 (we might need to use 2-8 cannula’s per procedure as required. Very few companies manufacturing these RF machines have there base in India. C-Arm with compatible O T table costs approximately 12-15 lacs. Epiduroscope costs approximately 8 lacs. I feel the cost will go down in next few years as demand increases. What we need to do is to make doctors, industry people and patients aware about treatment options available with us. This will increase the turnover and ultimately reduce the cost.

Training: As of today training in pain management is available only abroad or very few centres in India. Many of Interventional pain specialists are trained abroad. There are efforts made by ISSP, PFI, NEMAA and other pain associations to conduct training programmes for anaesthesiologists. National and International pain conferences, cadaveric hands on training and live demonstration of various pain procedures are conducted for this purpose.

With the advancement of technology and science, we have unveiled many aspects of the pain and its treatment. We have to work hard to spread the knowledge of interventional pain techniques among anaesthesiologists, colleagues from other specialty, patients (general public) and industry people. Our goal is to help people suffering from pain, make them productive human being for the society and increase their self esteem so that they can live life as normal individuals.

The writer is Anaesthesiologist and Interventional pain management specialist, Swastik Hospital, Mumbai.