Pain Treatments

Pain is defined as the unpleasant physical and emotional feeling that often occurs when the body's tissue is damaged. Sometimes pain can become chronic and lasts longer than normal. Pain is also characterized as nociceptive or neuropathic. Nociceptive pain is typically normal, acute, and time-limited; however, some nociceptive pain can become chronic and may be caused by conditions such as lower back problems or arthritis. Neuropathic pain is chronic and is typically the result of damage to, or dysfunction in, the nervous system, such as that caused by uncontrolled diabetes mellitus, stroke, or trauma. Neuropathic pain can manifest in a variety of conditions, including carpal tunnel syndrome, peripheral neuropathy, and postherpetic neuralgia.

There are many treatments for pain, and more than one treatment may be used. Options include medications, nerve blocks, neurostimulation, and ablative surgery.

WHEN IS IT INDICATED?

Medications, physical therapy, and lifestyle approaches are typically the first treatments for pain. Nerve blocks, neurostimulation, or surgery are usually recommended when noninvasive treatments do not provide sufficient pain relief or when a patient experiences severe side effects from medication.

WHO IS ELIGIBLE?

Medications. People with a known allergy or sensitivity to a drug are ineligible to take certain medications.

Nerve blocks. People who have an active infection near the proposed injection site should not receive nerve blocks.

Neurostimulation. People with a compromised immune system, bleeding problem, or an existing stimulating device may be ineligible for neurostimulation.

Surgery. Patients may be ineligible for surgery if they have certain underlying medical conditions.

PRE-TREATMENT GUIDELINES

Medications. The patient should report all medications that he or she is taking to a physician prior to undergoing medication treatment for pain.

Nerve blocks. People who take warfarin (Coumadin) or another anticoagulant medication should discuss this with their physician in advance.

Surgery and Neurostimulation. Before any surgical procedure or neurostimulation, the physician may perform a computed tomography (CT) scan or magnetic resonance imaging (MRI).

WHAT TO EXPECT

Medications. Physicians typically recommend medications as a first treatment for pain. Medications used to treat pain include nonsteroidal anti-inflammatory drugs, opioid drugs, and tricyclic antidepressants.

Nerve blocks. A nerve block is a type of injection that uses drugs or chemicals to interrupt pain signals in the nervous system. Most nerve blocks typically contain anesthetics or anti-inflammatory medications. The epidural steroid injection (ESI) is one of the most commonly used nerve blocks, and is usually recommended for neck or back pain. First, the patient's back is numbed with a local anesthetic. The physician inserts a needle into the patient's neck or lower back, then injects another numbing medication and a steroid drug into the epidural space.

Neurostimulation. Most neurostimulation therapies involve the implantation of a small, pacemaker-like device (stimulator) under the patient's skin. The procedure takes place in 2 stages, with the first stage being a trial placement before the stimulator is more permanently implanted.

One popular neurostimulation therapy is spinal cord stimulation (SCS). For SCS, the physician makes an incision in the patient's neck or back and exposes the spinal cord by removing a small piece of bone. The surgeon then attaches an electrode to the back of the spinal cord; the wires from the electrode lead to the stimulator. The patient wears the stimulator on the outside of his or her body and gauges his or her level of pain. Once the patient and physician have determined the amount of stimulation necessary to provide pain relief, the simulator is implanted under the skin.

Ablative surgery. Ablative therapies destroy nerve tissue responsible for the transmission of pain signals. These therapies may use heat or chemicals to destroy certain nerves in or near the spinal cord, or the nerves may be severed surgically. The details of each procedure differ based on the specific treatment.

Decompression surgery. For patients with pain from nerve compression, failure to respond to conservative measures may necessitate surgery to relieve pressure on nerves. For example, patients with severe arm (cervical) or leg (lumbar) pain can undergo surgery to remove the offending disk and gain significant pain relief.

POST-TREATMENT GUIDELINES

Nerve blocks. Once the local anesthesia used during an ESI wears off, pain usually returns. It may take a few days to feel the effects of the steroid injection, although it can provide significant pain relief that may last for weeks or months.

Neurostimulation. After implantation of a spinal cord stimulator, the patient is given a remote control to turn the stimulator on and off and adjust its intensity. During a follow-up appointment, the physician will ensure that the stimulator is working properly and providing sufficient pain relief.

Surgery. Following a surgical procedure, patients may be kept overnight in the intensive care unit and are monitored for any signs of problems. Patients may be instructed not to shower for the first week and to keep incisions covered by bandages. The stitches may be removed at a follow-up visit with the physician.

POSSIBLE COMPLICATIONS

Nerve blocks. Complications from ESIs are rare when a skilled physician administers them, but can include paralysis, bleeding, and infection.

ESIs may also temporarily raise blood sugar levels, so people with diabetes should carefully monitor their blood sugar within a few days of receiving an ESI.

Neurostimulation. Possible complications of SCS include infection, leakage of spinal cord fluid, and bleeding. Rare risks include increased pain, impotence, and death.

Surgery. As with all types of surgery, ablative therapies can have risks. While rare, they include stroke and death.

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