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Treating pain is important. Unrelieved pain can cause anxiety, depression, feelings for helplessness, as well as disruptions in daily activities, appetite, and sleep.

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Interventional Approaches
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For patients with chronic pain who get no relief from conservative therapies, an interventional therapy might be helpful. The simpler of these approaches include trigger point injections (injecting local anesthetic and/or steroid into myofascial trigger points), epidural steroid injections and joint injections. The more complex include nerve blocks, spinal cord stimulation, and intraspinal drug administration. These more sophisticated procedures are typically provided by anesthesiologists with advanced training in pain management.

Injections

Injections are commonly administered for both acute and chronic pain. Injection of a steroid or a local anesthetic, or both, into painful joints or varied trigger points are commonly used to treat joint pain and pain that originates in muscle or connective tissue. Sometimes, these types of injections allow patients an opportunity to participate in physical therapy, or reduce the pain long enough for a drug treatment to work. Sometimes they provide longer lasting pain relief by themselves.

A controversial injection therapy still considered to be unconventional is called prolotherapy. Prolotherapy is also known as nonsurgical ligament reconstruction, and is used for many different types of musculoskeletal pain. The treatment is intended to cause the growth of new connective tissue in areas where ligaments or tendons have become weak. The technique involves injecting a substance, like dextrose (sugar water), into a ligament or a tendon where it attaches to the bone. The purpose is to cause local inflammation in the hope that this will increase the blood supply and stimulate the tissue to repair itself. This technique is unproven and controversial. Because it involves injection of a substance into the body, it is not without risks, and the long-term effects are unknown.

Spinal Cord Stimulation

Spinal cord stimulation (also called dorsal column stimulation) provides low-voltage electrical current inside the spinal cord and may block or decrease the pain signals going to the brain. It requires implantation of a stimulator under the skin, which is connected to a wire that is placed inside the spine. Electrical impulses block the pain signal traveling to the brain, providing lasting pain relief. Patients have the ability to control the stimulation by turning the device on or off, and to modulate pain relief as needed based on their pain or activity. This technique has been used to treat chronic low back pain, chronic sciatica, and complex regional pain syndrome (reflex sympathetic dystrophy), among other conditions.

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View the video, Spinal Cord Stimulators


The ideal candidate for spinal cord stimulation is someone who suffers from chronic pain that has not responded to medications, therapies, or surgery. Once evaluated by a qualified pain specialist, an appropriate patient can undergo an outpatient trial to experience spinal cord stimulation and determine if the relief is significant enough to proceed to a longer-lasting treatment.

Neuraxial Infusion

Neuraxial infusion involves the implantation of a device that is used to deliver low doses of analgesic drugs through a catheter inserted directly into the space surrounding the nerves in the spine. By delivering medication so close to the nervous system, effects can be achieved with very tiny doses. Neuraxial infusion is now well-accepted by pain specialists and is usually tried when other, more conservative therapies have not worked.
There are many ways to deliver medication into the spine. Implantation into the body of a self-contained pump is preferred if the patient has chronic pain and is expected to live for at least a period of months. A number of medications can be delivered in this way. The ones used most commonly include morphine and other opioids; local anesthetics such as bupivacaine, clonidine (an adjuvant analgesic that is on the market to treat hypertension); and baclofen (usually used in this way to treat severe spasticity). Neuraxial Infusion is used often to manage cancer pain and refractory nonmalignant pain.




Practice Guidelines for Chronic Pain Management

Anesthesiology, April 2010, Vol 112, Issue 4, pp 810-33 - free full-text and .pdf available
(American Society of Anesthesiologists and American Society of Regional Anesthesia and Pain Medicine)



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