Interventional Pain Management
One of the definitions for pain is "an unpleasant sensory and emotional experience associated with actual and potential tissue damage, or described in terms of such damage." Note that this definition talks about "potential tissue damage" and therefore excludes the possibility of a decisive objective test as a gold standard.
Chronic pain is defined as the persistence of painful sensations beyond the normal time of healing.
While acute pain is a physiological response to obvious tissue damage with an array of sympathetic responses, CHRONIC PAIN involves psychological and behavioral mechanisms in addition to physiological mechanisms. These three components may coexist together with or without a link between them.
Although it is difficult to quantify, the prevalence of chronic pain ranges between 10% - 55 %. In the elderly, the prevalence of chronic pain ranges between 24 % - 50 %.
Over time the trend shows an ongoing increased medical expenditure for the treatment of chronic pain and disabilities.
There is very little teaching and education in medical schools and residency programs about the complex nature of chronic pain. Meanwhile, a big leap has been made in the past 20 years towards understanding and treating painful conditions through cognitive, behavioral and interventional techniques. The interventional pain management specialist emerges not only as a healer but also as a diagnostician. Direct fluoroscopic (X ray) visualization of various spinal structures enables the practitioner to make an accurate diagnosis in at least 50% of the cases which were previously considered as " nonspecific back or neck pain." Various nerve blocks, provocative tests or joint injections are frequently utilized to make a correct diagnosis. These include medial branch blocks, nerve root blocks, sacroiliac joint injections, sympathetic blocks and provocative discography.
When combining physical examination with computed tomography (CT) and/or magnetic resonance imaging (MRI), a cause for low back pain can be diagnosed in only 15 % of patients.
Many times there is no correlation between the real source of pain and MRI findings, as the sensitivity of these tests can be extremely low. The overall rate of inaccurate or incomplete diagnosis for patients referred to pain centers has been described as ranging between 40 % and 67 %.
The National Uniform Claim Committee defined interventional pain management as: "The discipline of medicine devoted to the diagnosis and treatment of pain and related disorders with the application of interventional techniques in managing subacute, chronic, persistent and intractable pain, independently or in conjunction with other modalities of treatment."
These other treatment modalities include, but are not limited to acupuncture, homeopathy, yoga, hypnosis, reiki, massage therapy, physical therapy and biofeedback.
Fundamental to modern interventional pain management are precision diagnosis and interventional techniques, applied judiciously to improve the health and well being of patients.
When performing spinal injections, various pharmacological agents are used with the purpose to decrease the inflammation and restore the nervous cell function. These agents might include a variety of steroid preparations, local anesthetics and hypertonic saline. Radiofrequency ablation represents another treatment alternative designed to destroy small nerve fibers and thus achieve a longer effect without compromising motor function.
Some patients may not respond to nerve blocks. Instead, they may be candidates for more invasive modalities such as surgery and implantation of spinal cord stimulators or morphine pumps (implantable devices).
Implantable devices are now available for a sub group of patients who pass a standard psychological evaluation. These devices are not designed for every single chronic painful condition. A thorough understanding of the mechanisms of disease and pathology helps us in choosing the proper candidates for such interventions. Patients should also have a clear understanding of all possible complications and risks involved with these sophisticated procedures.
Meet our pain management specialists Dr Julien Vaisman, Dr Joe Ordia, Dr Ben Kripke, Leslie Levitan NP, Karen Little NP
