Introduction to Advanced Pain Management Procedures
Current pain management is far different than a decade ago when primarily epidural steroids, narcotics, or trigger points injections were used as the only available treatments. Advancement in understanding of the physiology, anatomy, and microanatomy of pain coupled with advances in technology have brought about much needed changes in the field. The emergence of pain management as a full time specialty has also accelerated the pace of forward movement.
In general, pain management procedures are either diagnostic or therapeutic. Those that are solely diagnostic such as discography are not meant to have any long lasting effects other than localization of pain sources. Procedures that include steroid injections, such as trochanteric bursa injections or epidural steroids, may provide variable time periods of relief. Longer acting treatments consist of injection of neurotoxic agents such as Botox, 10% lidocaine, or phenol. Other long term treatments include cryotherapy, laser denervation, or radiofrequency rhizotomy. Curative treatments, such as vertebroplasty or discectomy may provide a lifetime of relief.
The most important factor in deciding on treatment is the localization of a pain source when possible. In many cases when pain has been present for years, the pain sources may be manifold. It is often possible to identify one pain generator and institute treatment on it, but other pain sources may subsequently become the primary pain problem. Diagnosis may require more than one diagnostic block for confirmation. Treatments that destroy nerves such as radiofrequency denervation require a high level of confidence that the diagnosis is correct before utilizing these advanced procedures. Following these diagnostic procedures, some patients will be asked to rate their pain on an hourly basis in order to help determine the proximity of the injection to the pain source. Others will have increased pain for a period of time, usually no more than a couple of days (eg. Discography).
Physical therapy, although initially painful, may be a vital part of the rehabilitation process since treatment of the pain generator alone may not long term be sufficient to maintain pain relief. Postural correction and eradication of biomechanical aberrations such as sacroiliac joint rotation may be necessary to maintain long term results. At times, the pain is so severe, it is not possible to perform physical therapy without the injections to calm down the pain to the degree necessary to withstand the mechanical changes induced by physical therapy. Finally, if we do not have the capability of determining the pain generator source, medication management of chronic pain is often an option. Financial constraints and insurance restrictions sometimes prevent the use of advanced interventional pain techniques. But even if correction of the primary pathology is not possible at this time, the advancements in technology are coming at an astonishing rate. Already, artificial disc technologies are being used to treat advanced spinal diseases. We look forward to the future in anticipation of continued rapid evolution in pain management.