OVERVIEW

The Department of Interventional Pain Medicine in our Institute is aimed at finding the cause for chronic pain due to any origin and treat the pain permanently. This department is equipped with an exclusive out patient block to see walking patients and referred cases from out stations throughout the day. The multi disciplinary approach with the surgical, medical and the rehabilitation department is the high light of our department.

Pain Interventions:

Traditionally  any chronic pain which hurts us for more than six months are diagnosed clinically and treated with conventional medications. The conditions which are not treated convincingly with the medicines and rehabilitations are subjected for surgical interventions. The modern medicine found an alternative to these treatment modalities as the medical treatment is not always successful and the surgical interventions are cumbersome. Pain interventions in practice are precise injections at the target site, modification of nerve pathways by ablative procedures intramuscular injections and joint manipulations. Many interventions are done as an outpatient procedures with a few hours observation prior to discharge. Major procedures like coeliac plexus blocks and lumbar sympathetic interventions may need admission and in house observations.


MEDICAL CONDITIONS

This is a condition where patients who have undergone back surgery experience pain. It really isn’t a syndrome but a term used to describe those suffering from pain after surgery. Technically a back surgery can only either decompress the pinched root of a nerve or stabilise a joint that is painful. Ir cannot however ‘cut out’ pain. Patients suffering from this usually have chronic pain in the back or leg after a laminectomy. It is sometimes referred to as ‘post-laminectomy syndrome’. There are a number of treatments for this such as physical therapy, microcurrent electrical neuromuscular stimulators, minor nerve blocks, spinal cord stimulation and so on.

It is a rare form which typically affects the arm or leg after an injury, stroke, surgery or heart attack. However, the pain experienced by the patient is completely out of proportion with the severity of the injury. Some of the symptoms of complex regional pain syndrome are:

  • continuous burning in the arm, hand, leg or foot
  • swelling in the are where there is pain
  • sensitivity to cold and touch
  • changes in the temperature of the kin
  • changes in the colour of skin
  • stiffness, damage and swelling of the joints
  • changes in the growth of nails and hair
  • weakness, atrophy and spams of the muscles
  • a reduction in mobility of the affected part

Angina is the debilitating pain in the chest caused by Coronary Artery Disease (CAD). A stable angina may only exhibit symptoms for a few minutes and may respond fairly easily to medication and rest. Chronic intractable angina or refractory angina is a much worse version of it. It is a form of angina that does not respond to medication. In fact, patients suffering from refractory angina may even respond badly to surgical procedures such as bypass surgery or angioplasty. The mortality rate of patients suffering from refractory angina is low, at 5%. However, they may suffer from advanced, long-term CAD. They are at much greater risk of heart attack and their physical activity is severely limited. Sadly, the increased risk of heart attack coupled with the limited physical activity actually adds to the levels of stress they suffer from. Which in turn leads to a heightened risk of heart attack. Refractory angina is a condition that predominantly affects men. Here at Sri Ramakrishna Hospital, we have had success treating refractory angina through spinal cord stimulation techniques.

The same trigeminal nerve is the source of probably among the most excruciatingly painful experiences we know of - trigeminal neuralgia. Commonly referred to as ‘tic doloreux’ the pain takes the form of stabbing shock-like jolts which occur in volleys lasting from seconds to two minutes. The whole attack can sometimes last up to two hours. Searing, burning, jolts, aches - trigeminal neuralgia can present a whole range of pain, all of which can cripple a person physically and mentally. While the physical aspect of it prevents the patient from pursuing any form of activity, the relentless pain and the inability to cure it can also be a cause of deep depression. Here at Sri Ramakrishna Hospital, we can offer patients suffering from trigeminal neuralgia a range of treatment options from medication to surgery to radio frequency ablation.

Cluster headaches are bouts of intensely painful headaches. Typically they begin at night, usually a couple of hours after the patient goes to sleep. More painful than migraines, they (thankfully) last for shorter periods of time. The attacks occur over extended time periods of weeks or months, hence the name. Between ‘clusters’ they can disappear for months or even years. They do however tend to be cyclical, occurring at the same times of the year. The root cause is unfortunately unknown but the pain is transmitted via a structure called the Sphenopalatine ganglion. This ganglion could be blocked or stunned to provide long-lasting pain relief.

The Department of Pain Management has had great success in helping patients overcome their debilitating pain through radio frequency ablation (RFA).

One side effect of paralysis is spasticity. It takes many forms and can vary from mild muscle stiffness to uncontrollable leg movements which are severe in nature. It can occur due to injury to the spinal cord, and multiple sclerosis. Damage to part of the brain or spinal cord which is responsible for voluntary movement causes spasticity. The normal flow of nerve messages are interrupted below the level of the injury and they might not reach the brain’s reflex control centre. The spinal cord, as a response, then tries to control or moderate the response of the body. Since it is not meant to do this, the signals are often exaggerated in muscle response or a jerking movement (known as spastic hypertonia). It can include strengthening of muscles, contractions which might be shock-like and abnormal muscle tone. The muscles that commonly go into spasm are the ones responsible for extending the leg or bending the elbow. Patients suffering from this may benefit from intrathecal pump placement.

  • Headache
  • Neck pain
  • Atypical facial pain
  • Trigeminal neuralgia
  • Brachial plexopathy
  • Complex regional pain syndromes(CRPS)
  • Thoracic and abdominal wall pain
  • Back pain
  • Sciatica of various origin
  • Sympathetic neuropathy
  • Facetogenic pain syndromes
  • Fibromyalgia
  • Cancer pain syndromes

FACILITIES & TECHNOLOGY

  • Day care pain interventions
  • Exclusive Headache Clinic
  • Neck & Back pain Interventions
  • Fluoroscopic guided procedures
  • Trigger point injections
  • Radio-frequency ablation
  • Neurolytic procedures
  • Interventions & Rehabilitation for cancer pain
  • Ultrasound guided interventions
  • Rehabilitation for chronic pain syndromes in elderly

TREATMENTS & PROCEDURES

This is an advanced treatment for the management of chronic pain. Spinal cord stimulation utilises an electric current (mild) i to block spinal nerve impulses.

It involves implanting an electrode in the body, along with wires leading to a battery pack. Given that it is an ‘interfering’ signal, different people experience different degrees of relief from it. Since it is difficult to gauge potential response of the body to such a treatment, a ‘trial’ is advised. Typically this trial runs for a week. During the trial, the wires connect the electrode to a battery pack that is carried outside the body. If the patient experiences more than a 50% reduction in pain, then a permanent Spinal Cord Stimulator (SCS) is recommended.

The procedure is very quick and is performed as an ‘outpatient’ procedure with patients being discharged home the very same day. The permanent implant is done under general anaesthesia and usually takes one to two hours.

They may be some soreness due to the implantation process but is about all the discomfort the patient should feel.

The implanted batteries may be rechargeable or they may last for as much as five years (without charging). When the battery drains out completely, another procedure surgery is required to replace it.

At Sri Ramakrishna Hospital we have had great success with this procedure in treating patients suffering from chronic pain due to post-laminectomy nerve damage, diabetic neuropathy, radiculopathy and reflex sympathetic dystrophy.

This is a method use to deliver medication directly to the spinal cord area. It makes use of a tiny pump which is placed under the abdominal skin through surgery. Medication is then delivered from it via a catheter to the region around the spinal cord. The space around the spinal cord is known as the intrathecal space and it is filled with cerebrospinal fluid (CS) into which the dosage is released.

Since the medication is targeted directly at the =spinal cord area, less of it is required and the side effects of taking too much of it (orally) are reduced. In fact a patient would need as little as a hundredth of his or her typical oral dose. The pump itself is small, about the size of the palm of the hand. It can be programmed in a number of ways. It can release the same medication over an extended period of time or can disperse different amounts of medication across different times of the day. The reservoir is the space in the pump where the medication is stored. It has a port through which it is filled. If the medication runs out, it can be topped up via the port using a needle.

Typically the pain pump is a last resort when all other traditional treatment options have been exhausted and the patient is still suffering. It is usually used to treat people suffering pain from failed back surgery syndrome, cancer pain, causalgia, reflex sympathetic dystrophy, arachnoiditis and chronic pancreatititis.

It can also help control spasms and muscle rigidity which may be caused by cerebral palsy, multiple sclerosis, brain injury, stroke or spinal cord injury.

Ablation simply means the removal of tissue. Radio Frequency Ablation (RFA) is a surgical technique wherein high frequency heat is aimed at different parts of the body in order to achieve a desired result. It may be used on tissue or tumour or, in this case, nerves. The last is used when patients suffer from chronic pain.

The trigeminal nerve is the centre of all heat and pain sensation in the face. Sometimes, medication is simply not enough to tackle the searing pain of cluster headaches and neuralgia . During the procedure, under sedation, a needle is inserted in the cheek to reach the trigeminal ganglion. The patient is then awakened and stimulated to ensure that the needle is at the correct location. High frequency heat is then aimed at the trigeminal nerve to ensure that it doesn’t communicate pain any more. This basically ‘injures’ the nerve enough to ensure it doesn’t communicate pain any more. There is a fairly high success rate for this procedure with nearly 80% of patients expressing relief from their overwhelming pain.

Radio frequency ablation is also performed to give patients relief from cluster headaches (sphenopalatine ganglion RFA) and neuropathic pain (peripheral nerve RFA).

A damaged disc or a bone spur can cause spinal nerves to become inflamed due to irritation. This can result in excruciating pain or other symptoms like tingling and numbness, depending on the location of the affected nerves.

A membrane known as the dura covers the roots of the nerves in the spine. Surrounding the dura is a region known as the epidural space. Nerves travel through the epidural space and on to the limbs and chest. An epidural injection injects medications into this space in order to reduce pain of the back, leg or any other which might be caused by irritation to the spinal nerves.

The chosen medicine will reduce inflammation which is usually the source of pain. The injection might also have a flushing effect which can remove inflammatory proteins around the pain-inducing structures. This is not a cure but more an intermediate measure which will help the patient return to rehabilitation. It is also an aid to natural healing.

A nerve block is a form of treatment where signals travelling along one or more nerves are interrupted. This is with a view to giving patients pain relief. Patients suffering from cancer in particular suffer from a host of pain-inducing conditions. A neurolytic block is a type of nerve block used in a number of specific situations. It involves the deliberate injury of a nerve through freezing or heating or chemicals. These cause the fibres of the nerve to degenerate thereby interfering with the transfer of signals. These blocks usually last about 6 months and are prescribed for terminal patients.

There are a number of types of neurolytic blocks and they are classified based on the region they target. Some of the ones which are more commonly performed here at Sri Ramakrishna Hospital are:

  • Celiac plexus neurolysis – for abdominal pain
  • Splanchnic neurolysis – for abdominal pain
  • Superior hypogastric plexus neurolysis – for pelvic pain
  •  Ganglion impar neurolysis – for perineal pain
  • Intrathecal and epidural neurolysis – for limb pain
  • Peripheral nerve neurolysis

SPECIALITY DOCTORS

Dr.M.Sekar
DA., MD.,(Anaes.)DNB.,
Consultant Pain Management & Interventional Pain Specialist