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Tilottama Mangeshikar
Some time during life, most of us will suffer
from at least one episode of pain. The lucky ones will have the pain resolved within a few days with minor or no treatment. However, for some of the not-so-fortunate folks this pain will persist for months to years and for a few- rest of their lives . This type of pain, also called “chronic” pain is perhaps the most debilitating pain as impacts the quality of life for them as well as family members. Some of the sufferers will also exhibit signs of depression as the feeling of hopelessness takes over. This is generally because the unlike the “acute” or immediate type of pain, the treatment options for chronic pain are only a few and not so effective. This is especially true in India, where availability of pain medications is extremely limited and a lot of reliance is placed on non-conventional mode of treatment - which is mostly ineffective.
However, advances in medical field are slowly changing this situation. Specifically, injections of medications around the spinal column are being considered for a lot of pain sufferers. In some of the patients these types of treatments can substantially decrease pain and thus improve quality of life. There are other even more advanced techniques, such as radio-frequency ablations, implantation of electronic pumps and electric impulse generators. While these devices are extremely expensive now, the emerging science of interventional pain management in India is very likely to make these technologies cheaper and therefore more accessible to all in this country. Just like this country is offering advanced cardiac surgical options, soon we should see pain management centres in major cities.
Why Anaesthetists as pain management specialists? An anaesthetist’s function is mainly to provide a pain free state for a patient undergoing surgery, thus they know pain better than most other specialists. Besides, a lot of treatment options in chronic pain management involve inserting needles around the spinal cord. The anaesthetists by their training are already familiar with the spinal and epidural injections and thus inserting needles comes naturally to them. One may think that all the anaesthetists should be able to do that. The big difference is that it takes additional knowledge and training to learn about chronic pain and the injections are technically very precise. These injections - which are used for diagnosis and also treatment of back problems have to be placed at the exact point where the disease process is suspected and that requires use of sophisticated equipment including X-ray machines. An injection performed without use of proper equipment or adequate knowledge can perhaps do more harm than good.
Pain and inflammation go hand in hand. Whenever there is injury to any part of the body, a process called inflammation occurs. Essentially this is body’s natural response to protect and heal the injured area. While in acute pain, this process may be beneficial, in chronic pain, this process continues and results in ongoing pain and discomfort. Anti-inflammatory medications play an important role in treatment of chronic pain. Anti-inflammatory medication, such as Ibuprofen when taken by mouth will be distributed throughout the body and a small portion of the medication will reach the affected area. Besides taking such medication on a long-term basis can create other problems such as stomach ulcerations, kidney damage etc. For that reason, when a strong anti-inflammatory medication is injected right into the affected area, one would get the best results with least side effects. Steroids are the most potent anti-inflammatory medication available. This medication when injected at the correct place, should have the best outcome. Injection of long acting steroids (depo-steroids) is one of the major tool of these new breed of specialists, called Interventional Pain Management Specialists.
While steroids in correct amount and placed at the affected site can be useful, indiscriminate use of such medication - such as excessive injections and improper placement of medication can actually harm someone. Steroids placed inside the spinal cord can cause nerve damage and excessive steroids can cause weight gain and worsen diabetes if present already. A trained physician would be expected to know this and would be expected to treat one’s problems in an ethical and scientifically accepted way. In most of the world there is increasing talk about “evidenced based medicine” - which essentially establishes the guidelines for practicing medicine. These guidelines are based on reviews of thousands of studies around the world and then coming to conclusions regarding what works and what does not, thus guiding physicians to the best treatment options to offer to their patients.
The patient population that may benefit most include are
Back pain- All types esp Post Laminectomy Pain syndromes
Post thoracotomy pain syndromes
Post herpetic neuralgias
Reflex sympathetic dystrophy, Sympathetic maintained pain/CRPS
Craniofacial Pain, Migraine and Atypical Headaches
Cancer Pain
Chronic intractable non cancer pain
There are professionally trained pain physicians available to perform comprehensive evaluations and invasive treatment procedures such as facet joint injections, epidural steroid blocks (lumbar, thoracic, cervical, caudal , transforaminal), bursa injections, sacroiliac joint injections, selective nerve root blocks, lumbar sympathetic blocks, stellate ganglion blocks, etc. The treatment options also include medication management, physiotherapy, laser therapy, acupuncture , TENS, coping techniques and surgical referral where applicable.
The treatments offerred should be evidence based and peer-reviewed medicine using an approach which results in the best possible outcome (such as transforaminal epidurals for lumbar radiculopathy). These are tailored to provide relief for every patient’s specific disease process. All blocks are performed under fluoroscopic guidance for precision delivery of medication on target and every patient are re-evaluated before further procedures are performed.
While we may not be able to help every patient with chronic pain, we believe that there are many who will see their quality of life improve dramatically. Please note that this is just the beginning in the new era of pain management.
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