Interventional pain management

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Interventional pain management or interventional pain medicine is a medical subspecialty defined by the National Uniforms Claims Committee (NUCC) as, " invasive interventions such as the discipline of medicine devoted to the diagnosis and treatment of pain related disorders principally with the application of interventional techniques in managing sub acute, chronic, persistent, and intractable pain, independently or in conjunction with other modalities of treatment". [1] Medicare Payment Advisory Commission (MedPAC) defined interventional techniques as, "minimally invasive procedures including, percutaneous precision needle placement, with placement of drugs in targeted areas or ablation of targeted nerves; and some surgical techniques such as laser or endoscopic diskectomy, intrathecal infusion pumps and spinal cord stimulators, for the diagnosis and management of chronic, persistent or intractable pain". [2] Minimally invasive interventions such as facet joint injections, nerve blocks (interrupting the flow of pain signals along specific nervous system pathways), neuroaugmentation (including spinal cord stimulation and peripheral nerve stimulation), vertebroplasty, kyphoplasty, nucleoplasty, endoscopic discectomy, and implantable drug delivery systems are utilized in managing subacute or chronic pain. [3] [4]

Contents

History

Early efforts at interventional pain management date back to the origins of regional analgesia and nerve blocks, and gradually evolved into a distinct specialty. Tuffer described the first therapeutic nerve block for pain management in 1899. Von Gaza developed diagnostic blockade in pain management, using procaine for determining the pain's pathways. Modern day contributors include Bonica, Winnie, Raj, Racz, Bogduk, and others. [5] The term "interventional pain management" was first used by pain management specialist Steven D. Waldman in 1996 to define the emerging specialty. [3] [6] The subspecialty of interventional pain management has received a specific specialty designation by the United States National Uniform Billing Committee to allow its practitioners to bill Federal healthcare programs including Medicare and Medicaid. Physicians who practice interventional pain management are represented by a variety of pain management organizations including the American Society of Interventional Pain Physicians (ASIPP) founded by Laxmaiah Manchikanti, MD, in 1998, which solely represents interventional pain management professionals. [4]

Radiation

Radiotherapy is used when drug treatment is failing to control the pain of a growing tumor, such as in bone metastasis (most commonly), penetration of soft tissue, or compression of sensory nerves. Often, low doses are adequate to produce analgesia, thought to be due to reduction in pressure or, possibly, interference with the tumor's production of pain-promoting chemicals. [7] Radiopharmaceuticals that target specific tumors have been used to treat the pain of metastatic illnesses. Relief may occur within a week of treatment and may last from two to four months. [8]

Neurolytic block

Cross section of the spinal cord showing the subarachnoid cavity, and spinal nerve roots including the dorsal root ganglion Gray770-en.svg
Cross section of the spinal cord showing the subarachnoid cavity, and spinal nerve roots including the dorsal root ganglion

A neurolytic block is the deliberate injury of a nerve by the application of chemicals (in which case the procedure is called "neurolysis") or physical agents such as freezing or heating ("neurotomy"). [9] These interventions cause degeneration of the nerve's fibers and temporary interference with the transmission of pain signals. In these procedures, the thin protective layer around the nerve fiber, the basal lamina, is preserved so that, as a damaged fiber regrows, it travels within its basal lamina tube and connects with the correct loose end, and function may be restored. Surgically cutting a nerve severs these basal lamina tubes, and without them to channel the regrowing fibers to their lost connections, a painful neuroma or deafferentation pain may develop. This is why the neurolytic is preferred over the surgical block. [10]

Cutting or destruction of nervous tissue

Cross-section of the spinal cord showing the dorsal column and the anterolateral spinothalamic tracts Spinal cord tracts - English.svg
Cross-section of the spinal cord showing the dorsal column and the anterolateral spinothalamic tracts

Surgical cutting or destruction of peripheral or central nervous tissue is now rarely used in the treatment of pain. [8] Procedures include neurectomy, cordotomy, dorsal root entry zone lesioning, and cingulotomy.

Neurectomy involves cutting a nerve, and is (rarely) used in patients with short life expectancy who are unsuitable for drug therapy due to ineffectiveness or intolerance. The dorsal root or dorsal root ganglion (that carry mostly sensory signals) may be usefully targeted (called rhizotomy); with the dorsal root ganglion possibly the more effective target because some sensory fibers enter the spinal cord from the dorsal root ganglion via the ventral (motor) root, and these would not be interrupted by dorsal root neurectomy. Because nerves often carry both sensory and motor fibers, motor impairment is a possible side effect of neurectomy. A common result of this procedure is "deafferentation pain" where, 6–9 months after surgery, pain returns at greater intensity. [11]

Cordotomy involves cutting into the spinothalamic tracts, which run up the front/side (anterolateral) quadrant of the spinal cord, carrying heat and pain signals to the brain. [11]

Pancoast tumor pain has been effectively treated with dorsal root entry zone (DREZ) lesioning – damaging a region of the spinal cord where peripheral pain signals cross to spinal cord fibers. This is major surgery, carrying the risk of significant neurological side effects. [11]

Cingulotomy involves cutting the fibers that carry signals directly from the cingulate gyrus to the entorhinal cortex in the brain. It reduces the unpleasantness of pain (without affecting its intensity), but may have cognitive side effects. [11]

Intrathecal infusion

A patient-controlled analgesia infusion pump, configured for epidural administration of fentanyl and bupivacaine PCA-01.JPG
A patient-controlled analgesia infusion pump, configured for epidural administration of fentanyl and bupivacaine

Delivery of an opioid such as morphine, hydromorphone, fentanyl, sufentanyl or meperidine directly into the subarachnoid cavity (the space between the spinal cord's inner, waterproof sheath and its outer protective sheaths) provides enhanced analgesia with reduced systemic side effects, and has reduced the level of pain in otherwise intractable cases. The anxiolytic clonidine, or the nonopioid analgesic ziconotide, and local anesthetics such as bupivacaine, ropivacaine or tetracaine may also be infused along with the opioid. [8] [11]

Epidural infusion

The outermost, protective sheath surrounding the spinal cord is called the dura mater. Between this and the surrounding vertebrae is the epidural space, filled with connective tissue, fat and blood vessels, and crossed by the spinal nerve roots. A catheter may be inserted into this space for three to six months, to deliver anesthetics or analgesics. The line carrying the drug may be threaded under the skin to emerge at the front of the patient, a process called tunneling. This is recommended with long term use so as to reduce the chance of any infection at the exit site reaching the epidural space. [8]

Spinal cord stimulation

Electrical stimulation of the dorsal columns of the spinal cord can produce analgesia. First, the leads are implanted, guided by the patient's report and fluoroscopy, and the generator is worn externally for several days to assess efficacy. If pain is reduced by more than half, the therapy is deemed to be suitable. A small pocket is cut into the tissue beneath the skin of the upper buttocks, chest wall or abdomen and the leads are threaded under the skin from the stimulation site to the pocket, where they are attached to the snugly-fitting generator. [11] It seems to be more helpful with neuropathic and ischemic pain than nociceptive pain, and is not often used in the treatment of cancer pain. [12]

Deep brain stimulation

Ongoing electrical stimulation of structures deep within the brain – the periaqueductal gray and periventricular gray for nociceptive pain, and the internal capsule, ventral posterolateral nucleus and ventral posteromedial nucleus for neuropathic pain – has produced impressive results with some patients but results vary and appropriate patient selection is important. One study [13] of seventeen patients with intractable cancer pain found that thirteen were virtually painless and only four required opioid analgesics on release from hospital after the intervention. Most ultimately did resort to opioids, usually in the last few weeks of life. [12]

Hypophysectomy

Hypophysectomy is the destruction of the pituitary gland, and has been used successfully on metastatic breast and prostate cancer pain. [11]

Related Research Articles

Nociception is the sensory nervous system's process of encoding noxious stimuli. It deals with a series of events and processes required for an organism to receive a painful stimulus, convert it to a molecular signal, and recognize and characterize the signal in order to trigger an appropriate defense response.

Pain Type of distressing and unpleasant feeling

Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." In medical diagnosis, pain is regarded as a symptom of an underlying condition.

Trigeminal nerve Cranial nerve responsible for the faces senses and motor functions

In neuroanatomy, the trigeminal nerve, also known as the fifth cranial nerve, cranial nerve V, or simply CN V, is a cranial nerve responsible for sensation in the face and motor functions such as biting and chewing; it is the most complex of the cranial nerves. Its name ("trigeminal", from Latin tri- 'three', and -geminus 'twin') derives from each of the two nerves (one on each side of the pons) having three major branches: the ophthalmic nerve (V1), the maxillary nerve (V2), and the mandibular nerve (V3). The ophthalmic and maxillary nerves are purely sensory, whereas the mandibular nerve supplies motor as well as sensory (or "cutaneous") functions. Adding to the complexity of this nerve is that autonomic nerve fibers as well as special sensory fibers (taste) are contained within it.

Pain management Interdisciplinary approach for easing pain

Pain management is an aspect of medicine and health care involving relief of pain in various dimensions, from acute and simple to chronic and challenging. Most physicians and other health professionals provide some pain control in the normal course of their practice, and for the more complex instances of pain, they also call on additional help from a medical specialty devoted to pain, which is called pain medicine. Pain management often uses a multidisciplinary approach for easing the suffering and improving the quality of life of anyone experiencing pain, whether acute pain or chronic pain. Relief of pain in general (analgesia) is often an acute affair, whereas managing chronic pain requires additional dimensions. The typical pain management team includes medical practitioners, pharmacists, clinical psychologists, physiotherapists, occupational therapists, recreational therapists, physician assistants, nurses, and dentists. The team may also include other mental health specialists and massage therapists. Pain sometimes resolves quickly once the underlying trauma or pathology has healed, and is treated by one practitioner, with drugs such as pain relievers (analgesics) and occasionally also anxiolytics. Effective management of chronic (long-term) pain, however, frequently requires the coordinated efforts of the pain management team. Effective pain management does not always mean total eradication of all pain. Rather, it often means achieving adequate quality of life in the presence of pain, through any combination of lessening the pain and/or better understanding it and being able to live happily despite it.

Nociceptor Sensory neuron that detects pain

A nociceptor is a sensory neuron that responds to damaging or potentially damaging stimuli by sending "possible threat" signals to the spinal cord and the brain. The brain creates the sensation of pain to direct attention to the body part, so the threat can be mitigated; this process is called nociception.

Hyperalgesia Abnormally increased sensitivity to pain

Hyperalgesia is an abnormally increased sensitivity to pain, which may be caused by damage to nociceptors or peripheral nerves and can cause hypersensitivity to stimulus. Prostaglandins E and F are largely responsible for sensitizing the nociceptors. Temporary increased sensitivity to pain also occurs as part of sickness behavior, the evolved response to infection.

Bone pain is pain coming from a bone, and is caused by damaging stimuli. It occurs as a result of a wide range of diseases or physical conditions or both, and may severely impair the quality of life.

Nerve block Deliberate interruption of nerve signals

Nerve block or regional nerve blockade is any deliberate interruption of signals traveling along a nerve, often for the purpose of pain relief. Local anesthetic nerve block is a short-term block, usually lasting hours or days, involving the injection of an anesthetic, a corticosteroid, and other agents onto or near a nerve. Neurolytic block, the deliberate temporary degeneration of nerve fibers through the application of chemicals, heat, or freezing, produces a block that may persist for weeks, months, or indefinitely. Neurectomy, the cutting through or removal of a nerve or a section of a nerve, usually produces a permanent block. Because neurectomy of a sensory nerve is often followed, months later, by the emergence of new, more intense pain, sensory nerve neurectomy is rarely performed.

Dorsal root of spinal nerve

The dorsal root of spinal nerve is one of two "roots" which emerge from the spinal cord. It emerges directly from the spinal cord, and travels to the dorsal root ganglion. Nerve fibres with the ventral root then combine to form a spinal nerve. The dorsal root transmits sensory information, forming the afferent sensory root of a spinal nerve.

Substantia gelatinosa of Rolando

The apex of the posterior grey column, one of the three grey columns of the spinal cord, is capped by a V-shaped or crescentic mass of translucent, gelatinous neuroglia, termed the substantia gelatinosa of Rolando, which contains both neuroglia cells, and small nerve cells. The gelatinous appearance is due to a very low concentration of myelinated fibers. It extends the entire length of the spinal cord and into the medulla oblongata where it becomes the spinal nucleus of the trigeminal nerve.

Anesthesia dolorosa or anaesthesia dolorosa or deafferentation pain is pain felt in an area which is completely numb to touch. The pain is described as constant, burning, aching or severe. It can be a side effect of surgery involving any part of the trigeminal system, and occurs after 1–4% of peripheral surgery for trigeminal neuralgia. No effective medical therapy has yet been found. Several surgical techniques have been tried, with modest or mixed results. The value of surgical interventions is difficult to assess because published studies involve small numbers of mixed patient types and little long term follow-up.

General visceral afferent fiber Part of the visceral nervous system

The general visceral afferent (GVA) fibers conduct sensory impulses from the internal organs, glands, and blood vessels to the central nervous system. They are considered to be part of the visceral nervous system, which is closely related to the autonomic nervous system, but 'visceral nervous system' and 'autonomic nervous system' are not direct synonyms and care should be taken when using these terms. Unlike the efferent fibers of the autonomic nervous system, the afferent fibers are not classified as either sympathetic or parasympathetic.

Group C nerve fiber One of three classes of nerve fiber in the central nervous system and peripheral nervous system

Group C nerve fibers are one of three classes of nerve fiber in the central nervous system (CNS) and peripheral nervous system (PNS). The C group fibers are unmyelinated and have a small diameter and low conduction velocity, whereas Groups A and B are myelinated. Group C fibers include postganglionic fibers in the autonomic nervous system (ANS), and nerve fibers at the dorsal roots. These fibers carry sensory information.

Electroanalgesia is a form of analgesia, or pain relief, that uses electricity to ease pain. Electrical devices can be internal or external, at the site of pain (local) or delocalized throughout the whole body. It works by interfering with the electric currents of pain signals, inhibiting them from reaching the brain and inducing a response; different from traditional analgesics, such as opiates which mimic natural endorphins and NSAIDs that help relieve inflammation and stop pain at the source. Electroanalgesia has a lower addictive potential and poses less health threats to the general public, but can cause serious health problems, even death, in people with other electrical devices such as pacemakers or internal hearing aids, or with heart problems.

Tarlov cyst Medical condition

Tarlov cysts, are type II innervated meningeal cysts, cerebrospinal-fluid-filled (CSF) sacs most frequently located in the spinal canal of the sacral region of the spinal cord (S1–S5) and much less often in the cervical, thoracic or lumbar spine. They can be distinguished from other meningeal cysts by their nerve-fiber-filled walls. Tarlov cysts are defined as cysts formed within the nerve-root sheath at the dorsal root ganglion. The etiology of these cysts is not well understood; some current theories explaining this phenomenon have not yet been tested or challenged but include increased pressure in CSF, filling of congenital cysts with one-way valves, inflammation in response to trauma and disease. They are named for American neurosurgeon Isadore Tarlov, who described them in 1938.

Pain in cancer may arise from a tumor compressing or infiltrating nearby body parts; from treatments and diagnostic procedures; or from skin, nerve and other changes caused by a hormone imbalance or immune response. Most chronic (long-lasting) pain is caused by the illness and most acute (short-term) pain is caused by treatment or diagnostic procedures. However, radiotherapy, surgery and chemotherapy may produce painful conditions that persist long after treatment has ended.

Neuromodulation is "the alteration of nerve activity through targeted delivery of a stimulus, such as electrical stimulation or chemical agents, to specific neurological sites in the body". It is carried out to normalize – or modulate – nervous tissue function. Neuromodulation is an evolving therapy that can involve a range of electromagnetic stimuli such as a magnetic field (rTMS), an electric current, or a drug instilled directly in the subdural space. Emerging applications involve targeted introduction of genes or gene regulators and light (optogenetics), and by 2014, these had been at minimum demonstrated in mammalian models, or first-in-human data had been acquired. The most clinical experience has been with electrical stimulation.

Intractable pain is a severe, constant, relentless and debilitating pain that is not curable by any known means and which causes a house-bound or bed-bound state and early death if not adequately treated, usually with opioids and/or interventional procedures. It is not relieved by ordinary medical, surgical, nursing, or pharmaceutical measures. Unlike the more common chronic pain, it causes adverse biologic effects on the body's cardiovascular, hormone, and neurologic systems. Patients experience changes in testosterone, estrogen, cortisol, thyroid hormones, and/or pituitary hormones. Both men and women require testosterone, however many doctors neglect to test women for low testosterone. Untreated intractable pain can cause death.

Cancer pain can be caused by pressure on, or chemical stimulation of, specialised pain-signalling nerve endings called nociceptors, or by damage or illness affecting nerve fibers themselves.

Presacral neurectomy

Presacral neurectomy is one of the treatments for chronic pelvic pain and dysmenorrhea. Lapraroscopic presacral neurectomy is an initial surgical intervention for chronic pelvic pain when medical therapy fails.

References

  1. ↑ "The National Uniform Claims Committee. Specialty Designation for Interventional Pain Management- 09" (PDF). Retrieved 15 April 2021.
  2. ↑ "Medicare Payment Advisory Commission. Report to the Congress: Paying for interventional pain services in ambulatory settings. Washington, DC: MedPAC. December 2001" (PDF). Retrieved 15 April 2021.
  3. 1 2 Winnie AP Preface. In: Interventional Pain Management SD Waldman and AP Winnie (eds) WB Saunders 1996.
  4. 1 2 American Society of Interventional Pain Physicians (ASIPP.org) Website
  5. ↑ Manchikanti L, Boswell MV, Raj PP, Racz GB (October 2003). "Evolution of interventional pain management". Pain Physician. 6 (4): 485–494. PMID   16871301.
  6. ↑ Atlas of Interventional Pain Management 3rd ed. S.D. Waldman (ed) Elsevier Philadelphia 2010.
  7. ↑ Hoskin PJ (2008). "Radiotherapy". In Sykes N, Bennett MI, Yuan CS (eds.). Clinical pain management: Cancer pain (2nd ed.). London: Hodder Arnold. pp. 251–55. ISBN   978-0-340-94007-5.
  8. 1 2 3 4 Atallah JN (2011). "Management of cancer pain". In Vadivelu N, Urman RD, Hines RL (eds.). Essentials of pain management. New York: Springer. pp. 597–628. doi:10.1007/978-0-387-87579-8. ISBN   978-0-387-87578-1.
  9. ↑ Fishman S, Ballantyne J, Rathmell JP (January 2010). Bonica's Management of Pain. Lippincott Williams & Wilkins. p. 1458. ISBN   978-0-7817-6827-6 . Retrieved 15 August 2013.
  10. ↑ Williams JE (2008). "Nerve blocks: Chemical and physical neurolytic agents". In Sykes N, Bennett MI, Yuan CS (eds.). Clinical pain management: Cancer pain (2nd ed.). London: Hodder Arnold. pp. 225–35. ISBN   978-0-340-94007-5.
  11. 1 2 3 4 5 6 7 Cosgrove MA, Towns DK, Fanciullo GJ, Kaye AD (2011). "Interventional pain management". In Vadivelu N, Urman RD, Hines RL (eds.). Essentials of pain management. New York: Springer. pp. 237–299. doi:10.1007/978-0-387-87579-8. ISBN   978-0-387-87578-1.
  12. 1 2 Johnson MI, Oxberry SG, Robb K (2008). "Stimulation-induced analgesia". In Sykes N, Bennett MI, Yuan CS (eds.). Clinical pain management: Cancer pain (2nd ed.). London: Hodder Arnold. pp. 235–250. ISBN   978-0-340-94007-5.
  13. ↑ Young RF, Brechner T (March 1986). "Electrical stimulation of the brain for relief of intractable pain due to cancer". Cancer. 57 (6): 1266–1272. doi: 10.1002/1097-0142(19860315)57:6<1266::aid-cncr2820570634>3.0.co;2-q . PMID   3484665.
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