WebMD Live Events Transcript
More than 75 million Americans suffer from chronic, debilitating pain, according to the National Pain Foundation. Chronic pain accounts for more than 80% of all physician visits. We observed Pain Awareness Month on August 9, 2005. Our guest was interventional pain specialist John Oakley, MD.
The opinions expressed herein are the guests' 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.
Welcome to WebMD Live. Our guest today is interventional pain specialist John Oakley, MD. He is here to talk with us about pain management. Welcome Dr. Oakley. Can you please explain what "interventional" pain management is?
Interventional pain management is anything that goes beyond the traditional conservative approaches to pain management. It's better to explain the conservative approaches, which include medication, physical therapies and functional restoration programs, as well as psychological behavioral interventions.
Once we get beyond those approaches we begin to talk about trying to identify the pain generator, that is, what anatomical structure is generating the pain and trying to provide interventions which take away the pain from the pain generator, so all of the procedures that we do, which intervene anatomically in the body, can be interventional pain management techniques.
There are two different areas of interventional pain management:
- Diagnostic techniques, which are designed to identify what is generating the pain.
- Therapeutic techniques, which are designed to relieve the pain for shorter or longer periods of time.
What kinds things are you looking for when using diagnostic interventional pain techniques?
The diagnostic pain intervention techniques are designed to place local anesthetics on the nerves leading to the structure we assume is generating the pain.
For example, it could be a joint in the low back or the neck, it could be a nerve itself, it could be a disk in the back, or any one of a number of structures which can be involved in the pain process.
Once the local anesthetic has been placed on the nerve or nerve pathway that's involved, we try to determine if that relieves the pain. If it does we can then say that the nerve or the structure that the nerve goes to is involved in generating the problem.
|"There are therapeutic techniques designed to affect many different nerves all at one time."|
Once you've identified the structure involved, what's the next step?
Then we identify the techniques we have available to produce long-term relief of the pain, mediated by the structure that was anesthetized.
For example, we may use some type of long-term blockade of the nerve. We could use a chemical on the nerve to give a long-term decrease or permanent decrease in the function of the nerve and thereby give long-term pain relief. Or we may use techniques such as applying electrical stimulation to a nerve to block the perception of pain in the area where the nerve goes.
There are other therapeutic techniques designed to affect many different nerves all at one time when a single nerve or structure cannot be identified. One example is someone who has had multiple surgeries on the lower back and has persistent back and leg pain which more than likely comes from multiple nerves; there we use techniques such as electrical stimulation or drug- administration pumps which are designed to cover many nerves or larger territories that are involved in generating the pain.
Is this type of investigation and pain management usually administered by a pain specialist?
Yes. The diagnostic and therapeutic applications of interventional pain techniques are administered in general by what now are termed in the U.S. pain managers.
These may be specialists in:
- Anesthesiology neurosurgery
- Physical medicine
- Other specialties where physicians have developed an interest in interventional pain management.
Traditionally we're talking about all kinds of pain, because almost all kinds of pain can be addressed with one or more of the interventional pain techniques.
There are a lot of pain diagnoses that are considered to be more traditionally and perhaps optimally treated with noninterventional treatments; one of those would be fibromyalgia, which is better treated perhaps with medicines and behavioral management and physical therapy techniques.
I have had 19 surgeries due to connective tissue disorders. Being allergic to all traditional pain medications, my surgeons are at a loss on how to help with post-op pain. Are there options to managing my case better?
These are particularly difficult problems but there are some new approaches to this. One particularly interesting approach is at the incision area where the surgery has been performed is to place a small catheter under the skin and then to use a small pump, which delivers local anesthetic directly to the incision area.
|"For people who are very allergic to many of the pain-controlling medications, there are interventional techniques."|
What is available to people who are highly allergic to pain medications?
For people that are very allergic to many of the pain-controlling medications, there are interventional techniques which can occasionally be applied to give relief.
This would be totally dependent on the type of pain and how the pain is mediated. For example, pain which is related to nerve injury (we call that neuropathic pain), can often be treated with techniques of electrical stimulation, and with a substantially high success rate. Seven times out of 10 patients with neuropathic pain can have good control of the pain using a type of electrical stimulation.
There can be techniques that use heating of the nerve structure, such as what's called radiofrequency lesion generation, where the heat shuts down the nerve. The nerves can be heated to the point where they are completely ablated or destroyed. But there are techniques that preserve the nerve as well and these can occasionally be applied to patients with allergies.
Can you explain what is involved in electrical stimulation?
In patients with nerve-related pain it was determined many years ago, in the 1960s and before, if an electrical signal could be applied in the area of pain on the nerves that go to the area of pain, that often there is a relief of the pain during the stimulation. There are numerous ways in which electrical stimulation is applied to give relief.
Probably the most common and one of the oldest is stimulation of the spinal cord, a technique which goes back to the 1960s. In these cases, patients with nerve-related pain in the legs, for example (perhaps they have had prior back surgery and have persisting leg pain), an electrode can be placed into the epidural space -- the space between the covering over the spinal cord and the bone -- and the electrode can be activated to produce a tingling sensation in the lower extremity in the area where the pain is located.
The patient can then experience a control of the pain. You should notice I'm not saying a cure of the pain, because these techniques give, in general, relief of the symptom pain; when the stimulator is turned off the pain will recur, so they need to use the stimulator to control the pain and improve the quality of their life and ability of function and it can allow for a decrease in pain medication, as well.
The electrical stimulators can be used for pain of nerve origin almost anywhere in the body. Perhaps the most exotic pain stimulator is called motor cortex stimulator in which an electrode is placed on the motor part of the brain itself and relieves nerve-related pain of the face and upper extremities.
Electrical stimulation has also been applied in structures within the brain itself with some success at relieving some kinds of pain and has certainly been applied in what is known as peripheral nerves for relief of pain.
|"When might you use radio frequency lesion generation?"|
A newer application of electrical stimulation is the placement of electrodes underneath the skin in the distribution of a peripheral nerve that has been injured.
An example would be a bone graft donor site over the hip area that has been used to do a fusion. This is where the bone would be harvested or taken for a spinal fusion; the pain that can be seen due to injuries to small nerves there can be controlled by a stimulator placed under the skin where the skin was taken. This is called a subcutaneous stimulator.
The area of electrical stimulation for treatment of pain continues to expand to areas of control such as control of migraine headache; probably the future for electrical stimulation for pain control is quite large. Many applications are yet to be discovered for electrical stimulation, the advantages being no drugs and very few risks and side effects.
When might you use radio frequency lesion generation?
Radio frequency is used to shut down the nerves to joints in the back particularly, or the neck. So if a so-called facet joint, or a joint which joins two vertebrae together, can be determined to be the source of the pain, then using the radio frequency to heat the nerve or nerves to the joint can eliminate the pain coming to the joint.
This would be the most common application of radio frequency, although it can also be used in a special form called pulsed radio frequency, which can be used to pulse heat into a nerve, which causes the pained nerve fibers, or the portion of the nerve which signals pain, to be temporarily shut down.
The pulsed radio frequency techniques do not destroy the nerve but preserve the nerve. Later the pain nerves will start to function again, but one can expect anywhere from months to a year of relief with that type of a block, if it's very successful.
The third technique you mentioned was intrathecal medication pumps. Can you explain how they work and when they may be used?
The use of drug-administration pumps is based on an observation that ordinary pain medicine, such as morphine, can be placed directly into the spinal fluid that surrounds the spinal cord roots that go into the spinal cord; it markedly increases the potency of the drug to relieve pain.
The estimate is that a milligram of morphine applied to the spinal fluid with the use of a drug pump is about 300 times more potent in relieving pain than is oral morphine. 300 milligrams of oral morphine would be equal to 1 milligram given over 24 hours in the pump.
So given this observation, pumps have been developed that can be implanted in the body to relieve all types of pain. Morphine would be the standard used in the pump but there are other medications used, too. Some of these are called additive -- additional drugs added to the morphine; these would be local anesthetics, in one case a blood pressure medication.
These are primarily to relieve nerve-related pain where the morphine relieves pain from scarred bone and ligaments. That kind of pain is called "no susceptive pain" or "receptor mediative pain," as opposed to the nerve injury pain or neuropathic pain that we spoke of earlier.
The pumps often contain more than one medication for the reason of addressing both the receptor pain and the nerve-related pain; therefore the pumps can be used for a wide range of pain. The most common applications are, however, for patients with a multiple-operated spine that has been left with severe and intractable pain of a mixed variety, nerve and receptor-related and also as a very common application with cancer-related pain.
A pain management doctor would be the one to see about this electrical stimulation?
|"If there is an area of numbness on the skin...there may be nerve damage involved."|
Yes, the person to contact regarding electrical stimulation would be an interventional pain management specialist in your community.
How do you find out if you suffer from nerve damage?
The characteristics of nerve-injury pain are a good place to start. Nerve-injury pain has some characteristic findings. It's usually associated with a feeling of:
It may have an electrical shock like feel to it, and pressure along nerves going to this area can often produce a tingling or a burning sensation or a shooting pain in the area where the nerve goes. If there is an area of numbness on the skin or if there's an area where there's weakness in the movement of the muscles there may be nerve damage involved, particularly if these findings are in the area of the nerve.
I have degenerative disc disease and have had back problems for 30 years. I've had all the treatments you are talking about. I've been going to a pain clinic for 18 months, but my pain doctor said my treatments are done and has released me back to my family doctor who doesn't treat chronic pain. What can I do?
I would suggest you do a little of your own research. I would suggest you log on to the web site for the National Pain Foundation -- www.nationalpainfoundation.org or painconnection.org -- and you will find in this a tremendous variety of resources which the providers in your community may not have explored.
You can use the web resources from the National Pain Foundation to verify the various things available for your pain. You can chat with other people with the same pain and that can provide a tremendous support and resource for managing your pain, as well, and you may find there are things that the specialists you've seen have not offered or didn't think of, that could be available even in nearby communities.
What about pain relief associated with interstitial cystitis.
Interstitial cystitis is a terrible problem. It is hard to imagine a more horrible type of pain. The pain is very much nerve-related and involves the bladder. It is also associated, in cases of true interstitial cystitis, with very small bladder volumes and the need to urinate up to 60-100 times a day.
Each time you go to the bathroom it is one of the worst pains you can imagine. In fact, there is a treatment for this which has been used more frequently in the last 7 or 8 years and this is a special application of a spinal cord stimulation. The stimulator electrodes are actually placed over the nerves which go to the bladder.
In a high percentage of cases the pain relief will be rather immediate. It is also associated in true cases of what we call IC with an enlargement of bladder volume and a decrease in the need to urinate to a more normal frequency, and when successful, can be almost like a miracle cure for the pain of interstitial cystitis. So electrical stimulation is definitely something which should be considered for that diagnosis.
This can produce relief of the incision pain for two or three days as the tissue settles down, making it more tolerable to go through various procedures.
What is out on the horizon for lupus sufferers?
The pain from lupus has a multitude of potential sources, anything from inflammatory disease to vascular disease and there are a lot of things which can be done with lupus-related pain, depending on the source of the pain.
So, with lupus it's very important to determine what structure is causing the pain and how we should intervene to relieve the pain due to the structure we've identified. The difficulty is there can be many sources of the pain.
|"What are your thoughts on magnetic therapy?"|
Sometimes if the pain is widespread throughout the body using a shotgun approach, such as a drug administration system, can give total-body control of the pain without having to identify a multitude of different sources.
What are your thoughts on magnetic therapy?
There are as many people who believe in this as don't do not believe in this. There is no science. There is an area which is beginning to generate interest in the scientific community in generating magnetic fields which interact with nerves to give pain relief.
So I would not completely rule out the possibility that even the commercially available magnets, such as wristbands, necklaces, pillows and bedliners could have some therapeutic effect, it's just not been demonstrated scientifically.
I've had dental implants removed on both sides of my lower jaw. I'm in constant pain and am told nerves were damaged. What pain management would you suggest for someone who will not take pain killers?
Dental pain or pain due to nerve injury in the area of the teeth is generally an injury to branches of the trigeminal nerve, and there have been successful cases of electrical stimulation applied to the nerve which have helped to relieve the pain due to the nerve injury.
There has also been the use of radio frequency blocks of the peripheral nerves which go to these areas which can help also to take the pain out of the area where the teeth were removed or where the nerve damage has occurred.
These types of things require a good physical examination and understanding of where exactly the pain is occurring before one could apply such techniques as electrical stimulators. These stimulators are very difficult to obtain long-term relief.
How can you tell the difference between nerve pain caused by something like a subluxation and something like rheumatoid arthritis?
Pain due to instability in the spine generally can be correlated with the structure on X-ray studies which is seen to be unstable. The pain can often be confirmed as coming from the unstable structure with a block of the nerve using anesthetic.
The pain due to rheumatoid arthritis is inflammatory and can come from joints. But it should also be said that many with rheumatoid arthritis have subluxations due to the disease and one needs to investigate the stability of the spine using X-ray techniques and then use block techniques to determine whether it's just inflammatory pain from the rheumatoid disease or whether they're actually pinching a nerve because of the instability. A good history and good physical examination can also be very helpful.
Dr. Oakley, do you have any final comments for us?
I'd like to thank everyone for tuning in to WebMD and joining in the conversation. It is very clear that a large percentage of Americans are suffering from chronic, debilitating pain.
One of the most effective techniques for beginning to deal with pain is to get as much information about your pain as you possibly can. There are a number of web sites which are available to explore to learn about your pain. One I highly recommend is the National Pain Foundation web site -- www.nationalpainfoundation.org or painconnection.org. This is designed as a patient- education tool and also a tool for physicians to learn more about pain.
By going to nationalpainfoundation.org you can become a member for free and explore numerous links to many very, very useful web sites regarding pain and take advantage of the many sections concerning specific pain, diagnoses that are available on the site.
Web sites such as this can also provide the latest advances in pain-relieving techniques, but the important message to take away is that in order to deal with your pain, information is empowering. It gives you the ability to know what's available, know what to expect, and know who to seek out to get the appropriate treatment.
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