Dr Sean White
MB ChB, FRCA
Consultant in Anaesthetics and Interventional Pain Management
Interventional Pain Relief
The treatments offered by pain specialists fit into an escalating ladder of treatments which are offered to people suffering from ongoing pain. Naturally it is appropriate to start with the most simple and least invasive measures such as the use of oral painkillers and rehabilitation techniques. Indeed osteopathy and physiotherapy provide the main stay of muscle condition and posture maintenance that reduce pain for the longer term. If these techniques are not the whole answer to the painful condition, then the next level up is the Pain Specialist.
The modern Pain Specialist has a range of analgesics at their disposal including an ever expanding new range of pain relieving drugs, as well as techniques involving the injection of analgesics and anti- inflammatories into specific areas guided by the use of ‘real time’ x-ray machines. It is often the case that either a single, or short course of such interventional injections can eliminate pain and allow the subject to return to the normal activities of daily living and enhance there ability to perform a suitable exercise programme. Moreover the techniques employed often give useful diagnostic information, and enhance the benefit of surgical techniques when structural abnormalities need to be corrected.
The painful conditions treated by the Pain Specialist fall into 3 broad categories:
1. Firstly pain mediated by the spinal column caused by both degenerative changes and inflammatory conditions such as painful joints and degenerative intervertebral discs.
2. The second broad category is nerve related pain, or ‘neuropathic pain’; pain related to diabetes, operation scars, facial pain or serious injuries that resulted in the destruction of nerves and even shingles fall into this category.
3. Finally, the last main category is associated with vascular problems where the pain is mediated by fluctuations in blood flow. Again this covers a very broad spectrum of pains including Migraine, Angina (heart pain) and pain resulting in poor circulation to the hands and feet.
In additional to these three broad categories there is a whole host of other difficult to diagnose and complex pains again which are the remit of a modern Pain Specialist.
Spinal Column Pain
Disc mediated, pain where the discs have degenerated over a period of time and are suffering from "wear and tear" changes or whether there is an acutely torn and inflamed disc then there are 2 main ways to provide relief.
1. An injection of anti-inflammatories into the epidural space, which contains the spinal cord and associated structures. Steroids can reduce inflammation and swelling from the disc and thus reduce pain.
2. Dorsal root ganglion blocks where the root of the nerve is inflamed exiting the spinal column then specific targeting of individual nerve trunks may reduce the swelling which is part of the mechanism for inducing pain that radiates out from the spine and down into the arm or the leg.
Neuropathic Pain (Nerve Related Pain)
There are a series of conditions were nerves can become damaged either physically or by abnormal function. The range of processes that damage nerves are very wide and a small list is outlined below;
1. Injuries causing cuts and lacerations to the skin
2. Surgical incisions
3. Diabetes
4. Poor circulation
5. Shingles
6. Prolonged immobilisation
7. Any painful condition of long duration
Treatment of this type of pain is broken into 2 main categories
1. Local infiltration of anti-infiltration of anti-inflammatory medications into the sensitive area
2. Tablet medication aimed at reducing sensitivity of these nerves and the frequency with which they send their "pain signals"
There are a whole range of drugs not primarily designed to treat pain, but which have been found by research to have significant effects on the levels of pain under such circumstances as listed above.
Altered Circulation of the Blood
There are many conditions where pain results from reduced blood supply to an organ. Many patients suffer from furring of their arteries either as a consequence of too high an intake of fatty foods or smoking or by some other disease process. This can result in painful ulceration of the legs in particular. Conversely some painful syndromes can affect the nerves that control the diameter of blood vessels and paradoxically cause alteration in the body circulation as a second effect. The group of nerve responsible for this effect are called the sympathetic nerves and normally have activities, which we are quite often not conscious. (These include blood pressure, heart rate, digestion, sweating etc). These nerves do not respond to traditional analgesics and often respond to nerve blocks or special medication designed to block these particular pathways. Below is a small list of some of the conditions where these nerves are active inappropriately.
1. Leg ulcers from poor circulation
2. Leg ulcers from diabetes
3. Raynaud’s disease
4. Hyper-hydrosis (excessive sweating)
5. Shingles
6. Reflex sympathetic dystrophy (chronic regional pain syndrome)
7. Chronic refractory angina
As you will see from the above list there is a wide range of situations where the Pain Specialist can become involved and this is an ever-increasing list of medications and techniques that come available to treat them.
For more information please contact sean.white@londonspineclinic.com