CRPS.com :- Pain Management Clinic India

PAIN MEDICINE

Identifying a pain specialist

Dr Tariq Ahmad Tramboo MD. FIPP

Pain: An unpleasant sensation that can range from mild, localized discomfort to agony. Pain has both physical and emotional components. The physical part of pain results from nerve stimulation. Pain may be contained to a discrete area, as in an injury, or it can be more diffuse, as in disorders like fibromayalgia. Pain is mediated by specific nerve fibers that carry the pain impulses to the brain where their conscious appreciation may be modified by many factors.

 

 

Pain medicine is a new specialty of medicine that deals with the evaluation and treatment of people with acute or chronic pain. Acute pain usually follows surgery or injury and resolves as the body heals itself. Pain is chronic when it persists after healing has taken place. Disk prolapsed and certain degenerative diseases such as arthritis can also cause chronic pain.

All doctors and most health professionals are involved in treating pain but should have   formal training in pain management. A pain specialist may have several specialties, such as anesthesiology, neurology, neurosurgery, or physiatry. He or she has received at least a year of additional training specifically in pain management. Treating pain usually involves a team approach to manage not only the pain itself but such factors as anxiety, depression, family issues and quality of sleep—all of which can affect how we feel pain. A comprehensive treatment plan for treating pain may include medications, injections, psychological counseling, exercise programs, chiropractic treatment, physical therapy, massage and many other modalities.

Often, patients are not referred to a pain center until they have suffered needlessly for many months or years with pain. It is a goal of pain specialists and the Delaware Pain Initiative to educate patients and their health care providers that pain should be managed early and aggressively.  Early referral to a pain center that offers comprehensive evaluation and treatment of pain, not just injections, is the best way to minimize the suffering and disability often associated with undertreated pain.

Management of pain involves conservative treatment and minimally invasive treatment

Minimally Invasive Techniques

Minimally invasive techniques are very effective and safe. They prevent patients from going into chronic stage of pain. And they can save patients from undergoing major procedure like surgery.

These procedures are being routinely done here through relief interventional pain clinic. And many national and international doctors receive training here at our center and thousands of patients are saved from mutilating surgeries.

Procedures done routinely for chronic pain through our center in J&K, Dehli, Rajisthan, Gujrat and Mumbai are

Facet rhizotomy
In some low back pain programs, if three facet block injections provide good but temporary relief of the patient’s pain, a facet rhizotomy injection may be recommended. The purpose of a facet rhizotomy injection is to provide lasting low back pain relief by disabling the sensory nerve that goes to the facet joint.

Facet joint injections
Facet joint injections are performed for facet joint pain. Facet joints can be injected with long acting local anaesthetic and anti-inflammatory steroids, which can alleviate facet joint pain for long periods.

Facet joint denervation
This is a straightforward procedure that is normally carried out if you have had a successful result from facet joint injections. Special needles are carefully placed under continuous fluoroscopy so that their tips lie exactly on the nerves that carry pain signals from the facet joints. Radiofrequency energy is then passed through the needles so that that tissue at the tip is heated to about 80 degrees C for about a minute. This coagulates and inactivates the nerves.

Pulsed radiofrequency treatment
Passing alternating radiofrequecy energy through tissues without significantly heating it can selectively inactivate pain-carrying nerve fibres, which tend to be smaller in diameter than the fibres that control muscles and allow normal sensation. Conventional radiofrequency treatment results in the coagulation of all tissues at the tip of the needle, including all nerve tissue. In most situations this does not matter, but in some situations it is important to maintain as much normal nerve function as possible.

Discography
Discography involves the insertion of a thin needle into one or more discs. Then either saline is injected into the disc to see if it is painful, or radio-opaque contrast dye is injected and x-rays will be taken to show the internal structure of the disc.

Epidural steroid injection
The word ‘epidural’ simply refers to a layer of supporting tissue outside the spinal cord. In an epidural a solution of long acting local anaesthetic, long acting anti-inflammatory steroid, and sometimes other pain modifying drugs is injected into the epidural space in the spine.

Transforaminal epidural injection
This is an important adjunct to epidural steroid injection and the two are normally done together. If you have lumbar radiculopathy or cervical radiculopathy, you will probably also have one or more transforaminal epidural injections.

Sacrolliac joint steroid injection
In the first instance a solution of long-acting local anaesthetic, long acting anti-inflammatory steroid, and sometimes other pain modifying drugs is injected into one or both joints. If this is successful the joint can then be denervated in a similar way to facet joint denervation.

Selective nerve root block (SNRB) for diagnosis and back pain management
Another common injection, a selective nerve root block (SNRB), is primarily used to diagnose the specific source of nerve root pain and, secondarily, for therapeutic relief of low back pain and/or leg pain.

Lumbar sympathetic block
Injection needles will be positioned and then there are three main ways to produce the block: injection of a long acting local anaesthetic to produce a diagnostic block to safely see if your pain can be treated this way; injection of a neurolytic substance such as phenol or alcohol to destroy the lumbar sympathetic nerves; and the use of radiofrequency energy to similarly destroy the nerves in a highly controlled way.

Stellate ganglion block
The stellate ganglion is a collection of autonomic sympathetic nerves, which lies in front of the spine at the level of your larynx. It can be a site where pain signals from the face, heart, or arm are processed. It can therefore sometimes be useful to block it.

Dekompressor discectomy
The Stryker Dekompressor is a relatively new technique for the decompression of contained lumbar herniated discs. A special device the size of a needle is inserted into the affected disc. This then rotates like a drill removing some of the nucleus of the damaged disc, thus decompressing it and allowing the bulge to reduce. This in turn reduces the pain from both the disc and the nerve root.

Percutaneous disc nucleoplasty
This is a relatively new technique for the decompression of contained lumbar herniated discs. A special device the size of a needle is inserted into the affected disc. This probe has radiofrequency electrodes at its tip and is slightly angled. It is moved around inside the disc vapourising a very controlled amount of disc nucleus, typically 1 – 2 ml.

Vertebroplasty
It involves the injection of bone cement into the crushed vertebral body, which stabilises it and reduces pain by reducing movement at the fracture site. It is well established and straightforward to perform, usually as a day-case procedure. A newer alternative treatment is Kyphoplasty.

Kyphoplasty
It involves the insertion of needles into the damaged vertebral body, through which balloons are passed. These are inflated under high pressure, which expands the VCF and corrects the deformity. Once corrected, liquid bone cement is injected into the vertebra to permanently fix the restored shape.

Spinal cord stimulation
Spinal cord stimulation can be very effective at treating nerve pain (neuropathic pain) and dysfunction from a number of different conditions. It has been shown to be particularly effective at relieving resistant nerve pain such as lumbar radiculopathy following spinal surgery. It involves the implantation of a wire and a device the size of a matchbox.

Sacral nerve root stimulation
This is a new and effective treatment for a number of loosely related bladder and bowel control problems. The other main treatment alternative is spinal cord stimulation. The main risk is infection, which can occur in up to 5% of patients.

Intrathecal pump implant
Intrathecal drug delivery devices are advanced pain management systems for patients whose pain cannot be adequately be controlled by conventional oral or systemic analgesics. Delivery of strong painkillers such as morphine directly into the cerebrospinal fluid can avoid many of the unpleasant side effects of conventional drug delivery.

Mixter and Barr in their hallmark studies in 1934 first drew the widespread attention in herniated disc or nucleus pulposus as one of the important cause of low back pain and leg lain. (1) Apart from conservative therapy all other forms of treatment aim at decompressing the nerve roots. These can be done by taking the disc out by surgery or by decompressing the foramen and disc by different interventions. The various treatment options have confused clinicians due to significant failure rate associated with different kinds of surgeries as well as with different interventions.
Outcome studies of lumber disc surgeries document a success rate between 49% to 95%. (2) Reasons for this failure are: 1)dural fibrosis, 2)arachnoidal adhesions, 3)muscle & fascial fibrosis 4) mechanical instability resulting from the partial removal of bony and ligamentous structures required for surgical exposure and decompression leading to facet & sacro-iliac joint dysfunctions, 5) radiculopathy, 6)recurrent disc herniation. (3-5) There has been surge of interest in search of safer alternative method of decompressing the nerve roots maintaining the structural stability. Epidural steroid injection, transforaminal epidural procedures has a high success rate (up to 84%) but chances of recurrences are also high. (6-8) Chemonucleolysis using chymopapain has moderate success rate (approximately 66% at one year). (9,10) It has also the chances of anaphylaxis following intradiscal chymopapain injection. Injection of ozone for discogenic radiculopathy (low back pain with radiation to legs) has developed as an alternative to chemonucleolysis and disc surgery popularly called ozone therapy for slip disc. Owing to its high success rate, less invasiveness, fewer chances of recurrences and remarkably fewer side effects ozone therapy for slip disc is becoming very p[opular. (11-14)
Muto suggested intradiscal injection of ozone for disc hernia in 1998 under CT guidance. Leonardi popularized fluoroscopy guided ozone injection into the intervertebral disc. After that, successful outcomes of ozone therapy have been reported from various European centers. It is very important to note from those reports that complications of ozone therapy are remarkably few.
How does ozone therapy work? The action of ozone therapy is due to the active oxygen atom liberated from breaking down of ozone molecule. When ozone is injected into the disc the active oxygen atom called the singlet oxygen or the free radicle attaches with the proteo-glycan bridges in the jelly-like material or nuceus pulposus. They are broken down and they no longer capable of holding water. As a result disc shrinks and mummified and there is decompression of nerve roots. It is almost equivalent to surgical discectomy and so the procedure is called ozone discectomy or ozonucleolysis or popularly ozone therapy for slip disc. Besides, it has an anti-inflammatory action due to inhibitions of formation of inflammation producing substances, tissue oxygenation is increased due to increased 2,3 diphosphoglycerate level in the red blood cells. All these leads to decompression of nerve roots, decreased inflammation of nerve roots, increased oxygenation to the diseased tissue for repair work. (11, 13)

Ozone Nucleolysis (Ozone therapy for slip disc): Indications

Ozone nucleolysis may be done in most kinds of disc related pain.
1. It can be done in degenerated disc without any prolapse and nerve root irritation. This category is called discogenic back pain or back pain due to internal disc disruption. Axial dull ache in the low back increasing with flexion of spine is the main clinical feature. Leg pain is either nil of minimum without any dermatomal pattern of radiation. Provocative discogram should be performed. Positive discogram (provocation of similar pain more than 7/10 at a pressure below 15 psi) proves the presence of sensitized nociceptors and ozone therapy is indicated.
2. It can be done in contained disc prolapse or disc bulge with root irritation.
3. It may be done in non-contained disc (extruded or sequestrated disc) as well.

Procedure:

The patient is taken to the operation theater lying on prone position with a pillow under lower abdomen. The area is prepared and draped in sterile manner. It is done usually under local anaesthesia with intravenous sedation (midazolam and fentanyl). Intravenous antibiotic like ceftriaxone 1G should be given prior to procedure. The procedure should be done under C-arm guidance. Though may be done under CT guidance. C-arm first should be focused to a pure anterior-posterior view to view the diseased disc. Then C-arm is cranially/caudally to abolish any double end-plates and thereby getting widest possible view of disc space. Then C-arm is rotated obliquely away from vertebral column such that facet joint come at the center of the end plates. Now the needle entry point is just lateral to the superior pars/articular pillar exactly at the center of the disc. (fig1-2) 20 or 22 G needle is introduced into the diseased disc using tunnel vision (end on view, so that needle is seen almost as a single point.) under fluoroscopic guidance. (fig-3) The position of needle tip may be confirmed by complete AP & lateral view. (fig 4-6) Some small amount of radio-opaque dye (omnipaque) may be injected for discogram which is optional.(fig-7) Then some 3-10 cc of oxygen-ozone mixture (at a concentration of 29-40 microgram/ml.) is injected into the disc. Ozone at this concentration is not all harmful for the surrounded tissue. So if ozone spreads to the surrounded tissues including spinal cord, there is no harm. Ozone molecule is not stable. It has a half-life of 20 minutes only. So, within 20 minutes only half of the original ozone remains, the rest becomes oxygen. Increase in temperature decreases its half-life. For injection it is always freshly prepared on site (from an ozone generator) for immediate administration. Only Ozone resistant syringes can be used for injecting it. While needle with the syringe is taken out some amount of oxygen-ozone mixture is also injected into the paraspinal muscle and para-radicular soft tissue to reduce nerve root inflammation and increased oxygenation of the para-spinal muscles.

Contraindications:

There are few conditions when ozone therapy should not be performed. They are active bleeding from any site, pregnancy, G6PD deficiency, active hyperthyroidism, loss of control of urination & defecation, and progressive sensory & motor loss.

Complications:

Complications of ozone therapy are very rare. They include post-procedural muscle spasm & burning pain (these are transient) & discitis (very rare due to the bactericidal effect of ozone). Other complications are similar to discographic procedure.
Ozonucleolysis or ozone discectomy (Ozone therapy for slip disc) has a success rate of about 80%. On the other hand surgical discectomy has much higher side effects compared to remarkably few side effects of ozone discectomy. Ozone therapy is usually a day care procedure and general anaesthesia is not usually required. Ozone therapy is gaining popularity in different countries including India due to low cost, less hospital stay, fewer post-procedural discomfort & morbidity and very few side effects.

References:

1. Mixter WJ, Barr JS. Rupture of the intervertebral disc with involvement of the spinal canal. N Eng J Med 1934; 211:210-215.
2. Vijay S. Kumar: Total clinical and radiological resolution of acute, massive lumber disc prolapse by ozonucleolysis. Rivista Italiana di Ossigeno-ozonoterapia 4: 2005
3. Shah RV, Everett CR, McKenzie-Brown AM, Sehgal N. Discography as a diagnostic test for spinal pain: A systematic and narrative review. Pain Physician 2005; 8:187-209.
4. Schofferman J, Reynolds J, Herzog R, Covington E, Dreyfuss P, O’Neill C. Failed back surgery: etiology and diagnostic evaluation. Spine J 2003; 3:400-403. 5. Slipman CW, Shin CH, Patel RK, Isaac Z, Huston CW, Lipetz JS, Lenrow DA, Braverman DL, Vresilovic EJ Jr. Etiologies of failed back surgery syndrome. Pain Med 2002; 3:200-214.
6. Vad VB, Bhat AL, Lutz GE, Cammisa F. Transforaminal epidural steroid injections in lumbosacral radiculopathy; A prospective randomized study. Spine
7. Riew KD, Park JB, Cho YS, Gilula L, Patel A, Lenke LG, Bridwell KH. Nerve root blocks in the treatment of lumbar radicular pain. A minimum five-year followup. J Bone Joint Surg Am 2006; 88:1722-1725.
8. Ng LC, Sell P. Outcomes of a prospective cohort study on peri-radicular infiltration for radicular pain in patients with lumbar disc herniation and spinal stenosis. Eur Spine J 2004; 13:325-329.
9. Krugluger J, Knahr K. Chemonucleolysis and automated percutaneous discectomy–a prospective randomized comparison. Int Orthop 2000; 24:167-169.
10. Revel M, Payan C, Vallee C, Laredo JD, Lassale B, Roux C, Carter H, Salomon C, Delmas E, Roucoules J. Automated percutaneous lumbar discectomy versus chemonucleolysis in the treatment of sciatica. A randomized multicenter trial. Spine 1993; 18:1-7
11. Muto M, Andreula C, Leonardi M Treatment of herniated lumbar disc by intradiscal and intraforaminal oxygen-ozone (O2-O3) injection. J Neuroradiol. 2004 Jun;31(3):183-9.
12. Lehnert T, Mundackatharappel S, Schwarz W, Bisdas S, Wetter A, Herzog C, Balzer JO, Mack MG, Vogl TJ. Nucleolysis in the herniated disk. Radiologe. 2006 May 13.
13. Buric J, Molino Lova R. Ozone chemonucleolysis in non-contained lumbar disc herniations: a pilot study with 12 months follow-up. Acta Neurochir Suppl. 2005;92:93-7.
14. Andreula CF, Simonetti L, De Santis Fet al: Minimally invasive oxygen ozone therapy for lumber disc herniation. American Journal of Neuroradiology 2003; 24: 996-1000.
15. Gautam Das, S. Ray, S. Iswarari, M. Roy, P. Ghosh; Ozone Nucleolysis for Management of Pain and Disability in Prolapsed Lumber Intervertebral Disc: A Prospective Cohort Study; Interventional Neuroradiology 15: 330-334, 2009
We are doing ozone injectios since 2002 here at Relief pain center with average success rate of 85%.

We can be approached through our website www.nucleotomy.com , www.ozonediscectomy.com .  email : taria363@yahoo.com

STUDY DONE AT THE UNIVERSITY OF TORONTO.

Ozone Injections Relieve Pain in Herniated Lower Back Disks
by Michael on Mar 10, 2009 • 12:00 am 1 CommentScientists at the University of Toronto have conducted a study that indicates that injections of ozone gas into the spine helps relieve pain stemming from herniated disks. The researchers believe these findings may lead to fewer surgeries because some low back pain cases could be dealt with O3 injections.
From a statement by the Society of Interventional Radiology: Researchers conducted a meta-analysis of various results published for oxygen/ozone treatment in regards to pain relief, reduction of disability and risk of complications. More than 8,000 patients from multiple centers in multiple locations were included in the study. The estimated mean improvement for patients after treatment based on the 10-point visual analog scale (VAS), a standard tool for rating the disabling effects of back pain, was a change of 3.9 (with 0 being no pain and 10 representing worst pain experienced). The estimated mean improvement was 25.7 percent for the Oswestry Disability Index (ODI), which measures one’s ability to manage everyday life—such as washing, dressing or standing (with 61 percent or higher representing back pain that has an impact on all aspects of daily living. The improvement scores for VAS and ODI outcomes are well above both the minimum clinically important difference and the minimum (statistically significant) detectable change, indicating that the improvement in pain and function is a real change that can be felt by the patient. Much research in oxygen/ozone treatments has been done by interventional radiologists in Italy, said Murphy, indicating that as many as 14,000 individuals have received this treatment abroad over the past five years.
The mechanism of action in relieving low back pain is complex; however, the primary effect is a volume reduction due to ozone oxidation. Researchers discovered that a simple incompressible fluid model predicted that reducing disk volume by 0.6 percent results in an intradiscal pressure reduction of 1 psi (pounds per square inch). Thus a very small change in volume creates a large change in disc pressure, which reduces the applied pressure on the nerve and relieves pain. This model confirmed that a minimalistic alternative to a diskectomy, such as oxygen/ozone treatment, is capable of relieving the pain caused by a herniated disk without causing irreparable damage.

Below is a talk given at Society of Interventional Radiology’s 34th Annual Scientific Meeting by Kieran J. Murphy, M.D., interventional neuroradiologist

THE WASHINGTON TIMES 2009/27TH MAY

Ozone Injections Relieve Pain of Herniated Discs

 

A non-surgical, radiologically guided injection of oxygen and ozone into bulging or herniated discs results in just as much pain relief and restoration of function as back surgery but with fewer complications and shorter recovery time, two recent studies revealed.

The groundbreaking therapy involves injecting a gaseous mixture of oxygen and ozone into a damaged spinal disc, using an imaging machine to guide the needle. The ozone causes a slight shrinkage of the disc, which relieves internal disc pressure and lessens back pain considerably. Researchers at the Society of Interventional Radiology predict this therapy will become standard in the United States in the next few years.

One study was an analysis of the data from a number of previous studies. It was done by Kieran J. Murphy, an interventional neuroradiologist and vice chair and chief of medical imaging at the University of Toronto in Toronto, Ontario. The studies involved more than 8,000 back-pain patients who received the oxygen/ozone treatment.

Murphy found that the therapy reduced patients’ self-rating on a standard 10-point pain scale by a mean score of 3.9 points – a large drop. The treatment also improved the participants’ self-evaluation of their ability to manage everyday life in areas such as washing, dressing and standing by a mean score of 25.7 percent.

“The estimated improvement in pain and function is impressive when we looked at patients who ranged in age from 13 to 94 years with all types of disc herniations,” Murphy explained. “Equally important, pain and function outcomes are similar to the outcomes for lumbar discs treated with surgical discectomy, but the complication rate is much less – less than 0.1 percent. In addition, the recovery time is significantly shorter for the oxygen/ozone injection than for the discectomy.”

In Murphy’s second study, the research team discovered that the main element in the oxygen/ozone therapy’s complex mechanism of action in relieving low back pain is a volume reduction in the disc as a result of ozone oxidation. They found that reducing disc volume by 0.6 percent (a very small change) reduces pressure within the disc by 1 pound per square inch (a very large change). This diminishes pressure on the nerve, relieving pain.

“Having a herniated disk can affect how you perform everyday activities and can cause severe pain that influences almost everything you do; however, you don’t have to undergo invasive surgery,” said Murphy.

“The spine is a stunningly beautiful piece of engineering, or, as our engineers say, the spine is like a complex electromechanical system,” he continued. “And the interventional radiology oxygen/ozone treatment takes a minimalist approach. It’s all about being gentle.”

Source: http://www.eurekalert.org/pub_releases/2009-03/soir-oma022709.php