Pain Management: Routes to Relief-- Lori Schmitt, RN and Ayman Basali, MD -- 02/18/04

WebMD Live Events Transcript

When pain controls your life, and drugs and physical therapy aren't enough, there are other options. As part of the WebMD Body Electric Cyberconference we discussed device therapies that help control pain, including implantable nerve stimulators, radio frequency ablation, and intrathecal drug delivery system implants, with our guests, Lori Schmitt, RN, and Ayman Basali, MD. 

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: All of the devices we will be talking about today are for the management of chronic pain. How do you define pain as "chronic?"

Schmitt: There are really two types of chronic pain:

• Chronic nonmalignant pain 
• Chronic malignant pain

The malignant pain is the cancer pain, the pain that has no end in sight. Chronic nonmalignant pain is back pain, arthritic pain, postherpetic neuralgia, fibromyalgia, or peripheral neuropathy. It's different from the acute pain that people usually experience following injury or surgery, which has an end in sight.

Moderator: So do these various devices work best on one type of chronic pain?

Schmitt: The implants and the implantable nerve stimulators work on both types of chronic pain. They've had good success with both of them.

Moderator: Can you explain how implantable nerve stimulators work?

Schmitt: The spinal cord stimulators work by interrupting the pain signal. In order to have a spinal cord stimulator the patient comes in and undergoes a trial stimulation. Spinal cord stimulation involves the selected use of painless electrical stimulation of large efferent fibers in the dorsal columns of the spinal cord to inhibit transmission of painful stimuli to the brain.

Member question: Is there usually a hospital stay while having the implant implanted?

Schmitt: Yes. It's a brief stay, and it also may include physical therapy and psychological intervention, as well.

Moderator: Is that the case also for implantation of intrathecal drug delivery systems?

Schmitt: Yes. Before both of these are done, they do have the patient come in to have the trial implants.

Moderator: Dr. Basali, when is the use of implantable nerve stimulators, radio frequency ablation, and intrathecal drug delivery system implants warranted?

Basali: Those are three different modalities. They're very different. Let's talk about the neurostimulators, or spinal cord stimulators. Basically you implant an electrical system that gives the nerves that transmit the pain sensation an electric stimulation in order to override or change the pain signals. For example, post laminectomy syndromes, failed back syndromes, a patient with chronic lesional pain syndrome, which used to be the RSD (reflex sympathetic dystrophy), are probably the most common indications for these systems. They can be used for the intractable lower extremities, upper extremities, or chest wall pain.

The implantation process is in two phases:

1. The trial period where we put a temporary lead for the patient to try for one week and if that proves beneficial to the patient we go ahead and implant the permanent system. Prior to implantation, there should be a complete evaluation for the patient by a chronic pain team consisting of a pain specialist, a surgeon, as well as a psychiatrist. It's a whole team evaluation and decision rather than one person.
2. After the patient is deemed appropriate, and did the stimulation and felt the pain controlled with this as satisfactory, then we proceed with the permanent part.

Member question: What is the success rate?

Basali: The success rate depends on the reason for the pain. Some judge it by adequate pain control or going back to normal activity. It ranges from 30% to 80%, but it depends on what you consider success. In the pain area we judge the success by several things. For example: 

• A decrease in the requirement for narcotic pain medications
• Improved activities of daily living, such as walking, standing, sleeping, and going back to work
• Improved pain control

Member question: Are these devices ever indicated for chronic head pain?

Basali: No. They're not for head or neck type of pain.

Member question: I've heard they are less successful in eliminating back pain.

Basali: Again it depends on the reason for the back pain. We cannot lump sum the condition of back pain. These implants are for patients that have tried every different pain modality and have failed.

Member question: How about fibromyalgia?

Basali: Maybe an intrathecal pump. If you reach a point where you are on high doses of narcotics, maybe the intrathecal pumps might be beneficial, but definitely not the spinal cord stimulator.

Moderator: Can you explain when you might use intrathecal pump systems?

Basali: An intrathecal pump is basically a method of delivering the pain medications into our bodies, straight into the space around the nerves and the spinal cord. That's where most of the pain receptors are. Instead of swallowing it or taking injectable formats, we can deliver it straight to where the problem is.

The advantage of doing that is you can tremendously cut into the amount of pain medication you're taking. A rough estimate: if you're taking 100 milligrams of morphine pills you probably would be able to get the same amount of pain control with 1 milligram in this pump. Another advantage is you can use some other medications that are not available in pill forms.

Moderator: But for those patients who are drug resistant or drug intolerant can this be used?

Basali: Even if they have drug intolerance we go through a trial phase; we put in a temporary catheter and we can trial different types of medications in the hospital, under supervision, until we reach a level of patient comfort and would be able to make a decision regarding whether this was a proper modality for the patient or not.

Moderator: Radio frequency ablation -- how does that work?

Basali: In radio frequency ablation we use radio frequency waves in order to produce heat that can destruct or innervate the tiny nerve endings that are causing the pain. Back pain is the most common use for radio frequency. For the patient who has facet joint problems (these are the little joints that give the mobility of the spine), we go into the facet joints, into the small nerves that give them the pain sensation and use the radio frequency waves to heat it or destruct it. This is called neuroablation.

Member question: What would be the determining factor in deciding between neural ablation and implantable nerve stimulators?

Basali: We decide on the evaluation of the patient and evaluate the cause for the pain and the distribution or location of the pain. If the patient has mostly back pain with rotation-type movement that's probably a facet-type problem. If you have a patient with low back pain after surgery radiating down the legs, that's more a candidate for spinal nerve stimulation. So one needs a thorough evaluation before deciding which way to go.

Member question: I am approved for a neurostimulator implant. I really want to know if it will do anything for my lower back pain from a herniated disk. I know it will work on the RSD in my leg.

Basali: It probably will not for the disk. It is a good modality for the RSD but for the herniated disk I would need to know more to comment more.

Member question: My mother-in-law suffers from chronic pain in the hip caused by deterioration and arthritis. Biofeedback, painkillers, and injections haven't eliminated or reduced the pain, which has caused very limited standing or walking abilities for more than 10-15 minutes. Are there any prerequisites for a doctor to suggest this type of therapy, or is it relatively too new for doctors to suggest?

Basali: It would be very difficult to recommend this type of modality. She needs to have an orthopaedic evaluation. She may need surgery. If she is on high doses of medication, the intrathecal pump might be an option.

Member question: if a patient is told that they have to have at least 50% pain improvement when given a nerve block, and they were not allowed to take any medications prior to the procedure, how can they really give an accurate answer to the question? I had a bilateral bundle branch block done on my lower spine. Prior to getting the block that morning I was in excruciating pain. I did receive a great deal of relief at that moment in time; now I cannot answer the MD's question truthfully so he cancelled my radio frequency ablation procedure. Any advice?

Basali: Communicate with your physician. I can see the physician wants some kind of communication and guidance from you, whether you responded to the injection or not. Even if you responded for two or three hours he needs to know that. Based on that he can make a recommendation. You're the only one who can answer that question, whether you got any response to the injection or not.

Member question: How quickly do the procedures provide relief? How long do these devices last in the body?

Basali: It depends on which device you're talking about. For the spinal cord stimulator, most people would need a battery change from three to five years, depending on how much it's used. 

As far as the radio frequency, most patients start feeling the difference in about a week and it should last somewhere between six months to a year.

Moderator: Do you have any final comments for us?

Basali: Yes, I do. There is no reason that patients should suffer or live in pain. Pain specialty is growing. Patients should have access to good pain service and pain specialists all over the country right now.

Schmitt: For more information, visit clevelandclinic.org/painmanagement. Our direct number to the pain clinic is 1-800-392-3353.

Moderator: Our thanks to Lori Schmitt, RN, and Ayman Basali, MD, of The Cleveland Clinic pain management department. For more information on these options for pain management and other chronic pain issues, be sure to visit our message boards, including Pain Management, with Indie Cooper-Guzman, RN, where you can post our questions and concerns for our in-house expert and find support and helpful advice from fellow WebMD members.

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