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Anaesthesia and Chronic Pain

Symptom Oriented Chronic Pain Management - An Update

DK Baheti

Introduction
Chronic pain is a disease by itself. It affects each and every system of the body and its manifestations are many fold. The emotion and psychological make up of each patient varies and so the presentation of the symptom.
The International Association for Study of Pain and other International pain bodies have strongly recommended that pain should be monitored along with other vital signs.
Pain should be considered as fifth vital sign along with pulse, blood pressure, respiration and temperature. Monitoring of pain along with these signs is mandatory at many institutes and this practice is gaining momentum.
Chronic pain results in loss of millions of working hours and professionals work out put and proficiency is affected. It ultimately has long term effects on the health care system of any nation.
Pain Management clinics are becoming popular amongst anaesthesiologist and other specialists. As importance of pain management is understood by medical fraternity hence many more pain clinics are being established.
Following is the protocol for the Interventional procedures for management of pain:-
1. Admission to hospital day care or for few hours.
2. Inform consent is mandatory.
3. Blood investigations- Bleeding time, clotting time.
4. Done in operation theatre or procedure room with monitoring of vital signs and stand by resuscitation trolly.
5. Procedure should be done under fluoroscopy or CT guided and documentation with print out.
6. Post procedure monitoring of vital signs.

Types of Patients Visit Pain Management Clinic

  • Headache
  • Neck Pain-cervical Spondylosis, Torticollis
  • Backache, Failed Back Surgery Syndrome
  • Cancer Pain
  • Ischaemic Pain- Peripheral Vascular Disease, Berger's Disease, Raynauds Phenomenon
  • Neuropathic Pain
  • Trigeminal Neuralgia
  • Post Herpetic Neuralgia
  • Myofascial Pain

Headache
Chronic headache is one of the common health problems, and is one of the major cause to the loss of million working hours and has major impact on finances of the society and ultimately to country.
The management options are as follows:-
1. Medications- Tryptans, beta blockers.
Interventional procedures
Supra orbital nerve block, Pulse radio frequency of the affected nerve root.

Neck Pain-cervical Spondylosis, Torticollis
Medications
  • Analgesics- such as NSAIDs, narcotic analgesic,
  • Anticonvulsants such as carba-mazepine, gabapentin, pregablin.
  • Anxiolytics- Tab. Amitryptiline, Nortryptiline, Duloxetine
  • Calcium and Vit D3 supplements.
  • Duragesic Patch-Transdermal patches of Fentanyl- 25, 50, 100 ug

Interventional Procedure- Cervical epidural block, Cervical facet jt. Block, Pulse radiofrequency of the affected nerve.
Backache
Backache is another common cause of loss of millions of working hours and financial burden to the health care system.
Here prevention by providing knowledge amongst the offices, factories and workplace will help in reducing incidence of backache and absenteeism.

Epidural Corticosteroids and Voumetric Adhesiolysis
Caudal epidural- The cocktail of Bupivacaine 0.125% 10 ml + Inj. Hylase 100 I.U. diluted in 20 ml of Normal Saline + Inj. Kenacort 80 mg.
Transforaminal Lumbar Epidural block- Inj. Kenacort 20 mg +Inj Bupivacaine 0.125% 1 ml injected at the affected nerve root.

Racz Adhesiolysis or Percutaneous Adhesiolysis
Racz catheter is manoeuvred through the adhesions under fluoroscopy and it can reach near the affected lumbar nerve root. The catheter is kept in situ for two to three days and inj. normal saline is injected at regular intervals. This is one of effective methods.

Facet Joint Injection
Degenerative disease of facet joint is important cause of low back pain with radiation to the knee level in FBSS. Facet joint injection with local anaesthetic and corticosteroid provides good pain relief. Trigger point injection with physical therapy is helpful during rehabilitation programme.

Median Branch Block
Selective median branch block can be done under fluoroscopy with Inj. Kenacort 40 mg + Inj. Bupivacaine 0.125% 2 ml.

Epiduroscopy
The indications are Chronic Low Backache, Resistant to Epidural Injection, Myofascial Pain, Intractable Facet Syndrome, Post Laminectomy Syndrome, and Persistent Radiculitis.
This is three dimensional, procedures, where adhesions around nerve root are visualized and adhesiolysis can be done with excellent pain relief. After the adhesiolysis Inj. Kenacort 80 mg is injected in to the affected area.

Spinal Cord Stimulation (SCS)
The gate control theory by Melzack and Wall and central inhibitory mechanisms evoked by A beta stimulation are commonly accepted mechanism of analgesia brought on by SCS. Long term studies have a success rate of 50%-70% for FBSS at 5 years. Dual lead placement in patients with backache allows for more.

Intradiscal Electrothermal Therapy (IDET)
Patient suffering from FBSS due to internal disruption of disc will be benefited with this technique. Studies evaluating IDET for patients with discogenic pain as suggested by history, physical examination, and discography have generated mixed results. However improved patient selection, psychological testing and better technique will probably offer a select patient a non operative solution to discogenic pain.

Implantable Pumps (Central Neuraxial Infusions)
Recently the use of implantable pump for nonmalignant pain in particular intrathecal opiates for FBSS is increasing. It can reduce pain score by 25%-50% and improves coping skills in FBSS.

Myofascial Pain
  • Persistent muscular pain can be because of injury, sprain, professional hazard and commonly seen in sportsman.
  • The treatment modalities are as follows
  • Analgesics, Muscle relaxants- Myoril,
  • Anxiolytics- Amitryptiline, Nortryptiline,
  • Vapo-coolent spray, Ointment, gel.
  • Botulinum toxin
  • TENS
  • Trigger point injection. Inj. Kenacort 10 mg/ trigger points
  • Dry needling.
  • Hot or cold therapy
  • Cryotherapy,
  • SWD, Laser
  • Exercises (active passive), mobilisation, manipulation stretching

Bone Pain
This is mainly due to metastasis or bone destruction due to disease or osteoporosis
  • Analgesics- such as NSAIDs, narcotic analgesic,
  • Anticonvulsants such as carbamazepine, gabapentin, pregablin.
  • Anxiolytics- Tab. Amitryptiline, Nortryptiline, Duloxetine
  • Laxatives, anti emetics. Calcium and Vit D3 supplements.
  • Duragesic Patch-Trans dermal patches of Fentanyl- 25, 50, 100 ug
  • I.T.D.D.S.-(IMPLANTABLE DEVICES)- Inj. Morphine is used.
  • Vertebroplasty- to provide stability of spine in case of osteoporosis
  • Spinal Fusion- in case of destruction of vertebrae due to secondaries.

Upper Abdominal Pain
Chronic intractable upper abdominal pain due to malignancy of pancreas, liver, gall bladder, kidney, retroperitoneal tumours, stomach; chronic alcoholic pancreatitis and any chronic pain can be treated well with following protocol.
Medications
  • Analgesics- such as NSAIDs, narcotic analgesic,
  • Antispasmodics- Spasmo proxyvon,
  • Anxiolytics- Amitryptiline, Nortryptiline, Duloxetine
  • Anti emetics
  • Laxatives
    • Interventional Procedures Neurolytic Coeliac plexus block- with Inj Alcohol 50% 40 ml Radio frequency lesioning of coeliac plexus.

Urogenital Pain
Intractable pelvic pain and pain in urogenital area is too much bothering to patients. The causes are pelvic tumour, interstitial cystitis, neurogenic bladder, prostate cancer. This can be effectively treated by combination of following modalities. The pain can be due to pressure of tumour, neuropathic type.
  • Analgesics- such as NSAIDs, narcotic analgesic,
  • Anticonvulsants such as carbamazepine, gabapentin, pregablin.
  • Anxiolytics- Amitryptiline, Nortryptiline, Duloxetine
  • Superior hypo gastric plexus block with Inj. Phenol 6-10% 10 ml is advised
  • Ganglion of impar block with Inj. Phenol- 6-10% 2-3 ml is advised.
  • Spinal Cord Stimulation- for interstitial cystitis.
  • Implantable devices- for intractable pain in prostate cancer.

Colo Rectal Pain
The components of pain can be due to pressure of tumour, neuropathic type.
  • Analgesics- such as NSAIDs, narcotic analgesic,
  • Anticonvulsants such as carbamazepine, gabapentin, pregablin.
  • Anxiolytics- Amitryptiline, Nortryptiline, Duloxetine
  • Superior hypo gastric plexus block with Inj. Phenol 6-10% 10 cc is advised..,
  • Ganglion of impar block with Inj. Phenol- 6-10% 2-3 ml is advised.
  • Implantable devices- for intractable pain in prostate cancer.

Head and Neck Cancer
MEDICATIONS
  • Analgesics- such as NSAIDs, narcotic analgesic,
  • Anticonvulsants such as carbamazepine, gabapentin, pregablin.
  • Anxiolytics- Tab. Amitryptiline, Nortryptiline, Duloxetine
  • Laxatives, anti emetics.

Interventional procedures
  • Nerve block-Trigeminal with local anaesthetic followed by Radio frequency lesioning
  • Hypoglossal nerve block
  • supportive therapy- nutritional,
    • /

Trigeminal Neuralgia
Medications
  • Analgesics- such as NSAIDS, narcotic analgesic,
  • Anticonvulsants such as carbamazepine, gabapentin, pregablin.
  • Anxiolytics- Tab. Amitryptiline, Nortryptiline, Duloxetine

Interventional procedures
  • Nerve blocks- Trigeminal nerve block with Local Anaesthetic + Inj. Kenacort
  • Radiofrequency lesioning either with single division, Trigeminal nerve or ganglion.
    • Neurolytic block with Alcohol can produce anaethesia dolorosa, so Inj. Glycerol is preferred.


Herpes Zoster and Post Herpetic Neuralgia (PHN)
PHN is most challenging pain problem for pain physician.
  • Analgesics- such as NSAIDs, narcotic analgesic,
  • Anticonvulsants such as carbamazepine, gabapentin, pregablin.
  • Anxiolytics- Tab. Amitryptiline, Nortryptiline, Duloxetine
  • Laxatives, anti emetics.
  • Ointments- EMLA cream, lacto calamine lotion, roffgel, mix. of aspirin chloroform,
  • capsaicin oint
    • Interventional procedures
  • Nerve block- inter costal, nerve to affected area
  • Pulse Radio frequency lesioning.

Neuropathic Pain
This is commonly seen in diabetic neuropathy, nutritional, failed back surgery syndrome and cancer patients.
The treatment and control of basic disease effectively is important key to the pain problem. The management strategy is as follows
Medications
  • Analgesics- such as NSAIDs, narcotic analgesic,
  • Anticonvulsants such as carbamazepine, gabapentin, pregablin.
  • Anxiolytics- Tab. Amitryptiline, Nortryptiline, Duloxetine
    • Interventional procedures
  • Nerve blocks
  • Sympathetic block- as diagnostic cum therapeutic block- Lumbar sympathectomy
  • Spinal cord stimulation-diabetic neuropathy

Phantom Limb Pain
  • Analgesics- such as NSAIDs, narcotic analgesic,
  • Anticonvulsants such as carbamazepine, gabapentin, pregablin.
  • Anxiolytics- Tab. Amitryptiline, Nortryptiline, Duloxetine
  • Laxatives, anti emetics.
Interventional procedures
  • Nerve blocks
  • Sympathetic block- as diagnostic cum therapeutic block- Lumbar sympathectomy
  • Spinal cord stimulation

Peripheral Vascular Diseases
The pain is due to spasm of vessels, compromised blood supply in diabetes, trauma; early gangrenous changes, peripheral vascular diseases
Interventional procedures
  • Sympathetic-stellate ganglion block, lumbar sympathetic block
  • Radio frequency ablation
    • Spinal cord stimulation

Role of Psychologist
Clinical psychologist can identify confounding behavioural problems that will continue to foster poor response to the treatment. He can also be helpful in evaluating the chronic pain and patient will be assessed for psychotherapy, biofeedback, relaxation techniques, psychopharmaco-therapy, and mind body chronic pain programmes.

Role of Physiotherapy
The structural symmetries, reconditioning, on going pain and attitude of the patient of backache is a suitable candidate for rehabilitation. The goals of physiotherapy are to improve range of motion, enhance strength, increase daily activities, improve ergonomics, and prevent or decrease musculoskeletal injuries. In FBSS there is loss of normal lumbar lordosis, chronic muscle spasm of para vertebral muscles, tightening and shortening of gluteal, hamstring and calf muscle groups. The rehabilitation process is slow and challenging requires continuous education and reinforcement.
Bombay hospital has an active Pain Management Clinic for last fifteen years.
Pain management clinic of Bombay hospital is first to perform epiduroscopy in India, it has reported largest series of Neurolytic coeliac plexus block from India and introduced blunt tip needle for sympathetic block.
More than 5000 patient have visited the clinic and more than 1000 interventional pain procedures performed with minimum morbidity and no mortality
That day is not far when we will have specialty pain hospital, which will have fellowship programmes in pain management in various universities of India.
 

ETHNICITY AND ADVERSE DRUG REACTIONS

Personalised drug treatment is getting closer but will not relapse good clinical judgment
Ethnic differences in drug response might originate from cultural or environmental factors.
McDowell and colleagues systematically reviewed the literature and summarised consistent findings about ethnicity and adverse drug reactions to cardiovascular drugs. They found, among other interesting results, a threefold higher risk of angioedema in black compared to non-black patients when taking angiotensin converting enzyme inhibitors as well as a doubled risk of intracranial bleeding from thrombolytic therapy.
Finding genetic markers for severe adverse drug reactions would help to identify patients at high risk before the start of specific treatment.
Han Chinese population between the human leucocyte antigen HLA-B*1502 and induction of Stevens-Johnson syndrome (a severe skin reaction) by the anticonvulsant carbamazepine.
“Personalised” drug treatment will continue, therefore, to rely on good clinical judgment. The meta-analysis by McDowell and colleagues is one more important piece of information to consider in the clinical assessment of the benefits and risks of specific cardiovascular drugs.

Erik Eliasson, BMJ, 2006; 332 : 1163-64.

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