Knowing the basics of interventional pain management
When should a primary care physician refer a patient?
That really depends on the comfort level of the primary care provider and the complexity of the patient. At times, we receive referrals to endorse an ongoing treatment strategy created by another physician, while at other times we evaluate a patient for a new or refractory diagnosis.
How do you evaluate a patient?
Almost universally, patients will tell us, “pain is pain,” but in fact, it is much more complex. We work through the pain complaint often using a physician-directed history to understand the nuances and reach a diagnosis. Once we have a diagnosis, we discuss treatment options, some of which can continue back in the primary care provider’s office.
What types of interventional treatments are available?
While epidural steroid injections are well known, there are a much broader range of spinal and non-spinal injections, as well as minimally invasive surgical procedures and a growing number of implantable devices now available. Pain physicians select from a variety of approaches or techniques and tailor treatment based on each patient’s unique pain condition.
Should every patient receive an injection?
In general, interventional pain procedures are reserved for relatively focal pain areas like a particular joint rather than diffuse polyarthralgias. Studies have largely disproven the effectiveness of interventional treatments (such as trigger point injections) for widespread pain conditions like fibromyalgia. Treatment should always be tailored to a diagnosis, and some pain conditions are better treated with noninterventional approaches.
Acute, Chronic, or Acute-on-Chronic Pain: No One Size Fits All
A variety of acute pain conditions are amenable to treatment by the interventional pain physician. Epidural steroid injections administered for acute disc herniations provide superior efficacy when compared to treating these same radiculopathies if present for decades. Conversely, implanted pain therapies, such as spinal cord stimulation, are reserved for chronic or subacute pain pathologies that have proven refractory to more conservative interventional approaches. When obtaining a history and conducting a physical examination of a patient with pain, assessment of chronicity of symptoms enables the pain physician to identify a treatment course.
Sorting through acute-on-chronic pain can be particularly challenging since some patients are unable to differentiate new-onset pain from their chronic pain condition. To a patient, “pain is pain,” and sorting through a complex pain history often requires a physician-directed history to define these nuances.
Bleeding Risk During Interventional Pain Procedures
Though bleeding complications rarely occur following interventional pain procedures, pain physicians are paying closer attention to an expanding list of anticoagulants in contemporary use. Pain physicians are tasked with considering newer anticoagulant agents with heterogeneous half-lives and diverse mechanisms of action. Of late, barely a year elapses without the introduction of one or more anticoagulant agents that each warrant specific consideration prior to spinal injections.
Though established guidelines exist indicating the duration and settings for discontinuation of anticoagulant therapy, these general statements often neglect patient-specific variables: most notably the indication for therapy and the potential risks posed with interrupting therapy. As a result, interventionalists collaborate with PCPs to weigh the risk-benefit ratio of moving forward or abstaining from select pain procedures that require a period of abstinence from anticoagulants prior to neuraxial injections.
What is interventional pain management?
Interventional pain management is a discipline in pain management that is rooted in the goal to help patients relieve their pain. These specialized pain doctors look beyond medication to help someone deal with pain. They rely instead on a vast array of therapies to help diagnose, reduce, and if possible, completely relieve a person’s pain. The ultimate goal is to help a patient get back to their best life. Often, doctors do this by helping patients return to their normal activities as quickly as possible.
Interventional pain management clinics often have multiple types of practitioners on hand. They all tackle various portions of the patient’s problem. For example:
- A chiropractor for spine issues
- An acupuncturist for alternative measures
- Pain doctors who perform minimally-invasive procedures or injections
- Chiropractors or physical therapists to resolve muscular issues
- Mental health therapists to treat often comorbid symptoms of depression and anxiety
By having multiple specialists on the staff, a patient has the best possible chance of getting the treatment they need. It also encourages collaboration between these different specialists to find all of the options a patient may have for reducing pain.
When someone is in pain, they’ll look for any possible method to get relief. A pain specialist who practices these techniques has the ability to first diagnose the problem to determine what the issue is, then treat the pain accordingly. In an interventional pain management practice, the issue causing the pain is taken care of via a procedure or treatment, and if it cannot be handled in just one session, then that’s where the management side of things comes into play. By working with a dedicated pain management team, a patient can receive an overall treatment regimen that will make sure that their pain levels are as tolerable as possible.
Below are some of the most commonly used interventional pain management techniques.
Using x-ray guidance and a needle with an electrode at the tip that gets heated, radiofrequency rhizotomy temporarily turns off a nerve’s ability to send pain messages to your brain.
Other names for radiofrequency rhizotomy are radiofrequency ablation and neuroablation.
For many patients, this procedure can provide pain relief for 6 to 12 months. During these pain-free months, however, your doctor will most likely recommend physical therapy. A physical therapist can help you address underlying physical problems that are causing pain.
Intrathecal Pump Implants
Intrathecal pump implants, also known as pain pumps, provide potent medications straight to the source of your pain. They’re a type of neuromodulation—a treatment that interrupts pain signals to your brain.
Pain pumps are commonly used for cancer pain and failed back or neck surgery. With this procedure, a small device—called a pump—gets implanted under your skin. Your doctor programs the pump to deliver a specific amount of medication, and he or she will need to refill the pump every few months. The main benefits of pain pumps are that they provide consistent pain relief, and if you’re taking oral medications, you don’t have to rely on them as much. Because this is a more invasive procedure than an injection, a pain pump is typically used only if other treatments have been unsuccessful.
Electrical stimulation is another type of neuromodulation. Similar to a pain pump, something gets implanted in your body with electrical stimulation. But with this procedure, a stimulator is implanted along with an electrical lead to send electrical pulses directly to the area that’s causing pain—the spinal cord, nerves, or brain, for instance.
Electrical stimulation can be used for certain spine conditions as well as conditions that affect your brain or nerves, such as Parkinson’s disease, epilepsy, and diabetic peripheral neuropathy. You can have spinal cord stimulation or deep brain stimulation, for example. Instead of pain, some people feel a tingling sensation with this treatment.