CHRONIC PAIN

MANAGEMENT
Dr. Rowena Sarah B. Ramos
PGI Chong Hua Hospital
Definition by The International Association
for the Study of Pain (IASP)
▪Pain:
▫an unpleasant sensory and emotional experience
associated with actual or potential tissue damage,
or described in terms of such damage
▫Chronic Pain
▪pain without apparent biological value that has
persisted beyond the normal tissue healing time
usually taken to be 3 months.
Classification of Chronic Pain
▪Nociceptive
▪Neuropathic
Nociceptive Pain
▪pain in which activity in peripheral pain neurons
▪due to on going tissue injury is present
▪Example : Osteoarthritis pain
Nociceptive Pain
abnormal function of the nervous system causes
ongoing pain
▪Associated with signs and symptoms of abnormal
nerve function (burning or shooting pain
accompanied with hyperalgesia and allodynia
▪Example: Post herpetic neuralgia, painful diabetic
peripheral neuropathy
Common Pain Syndromes
▪Low Back Pain
▫refers to pain centered over
the lumbosacral junction.
▪Pain can be differentiated
primarily over the axis of the
spinal column from that which
refers primarily to the leg
Low Back Pain
▪Lumbar Spinal Pain
▪Pain inferior to the tip of the twelfth thoracic spinous
process and superior to the tip of the first sacral spinous
process.
▪Sacral spinal pain
▪ is inferior to the first sacral spinous process and superior
to the sacrococcygeal
joint.
Lumbosacral spinal pain
is pain in either or both regions and constitutes “low back
pain.”
Sciatica
pain predominantly localized in the leg.
Radicular pain
Low Back Pain
▪Epidemiology
▪most common problems leading people to seek medical attention
▪Majority of acute low back pain resolve without treatment
▪60-70% recover by 6 weeks
▪80-90% recover by 12 weeks
▪Low back pain is frequently recurrent
▪Risk factors of chronic low back pain:
▫Age, gender, socioeconomic status, education level, BMI, tabacco
use, perceived general health status, physical activity, repetitive
tasks etc.
Low Back Pain
Pathophysiology
▪ Synovitis- Earliest change in the lumbar facet joint
▪ Progress to degradation of the articular surfaces, capsular
laxity and subluxation, enlargement of the articular
process
▪ Progressive degeneration within the intervertebral disc
starts with loss of hydration of the nucleus pulposus
followed by appearance of circumferential or radial tears
within the annulus fibrosis (internal disk disruption)
Lumboscaral Pain
Pathophysiology
▪ With internal disruption of the annulus,
some of the gelatinous central nucleus
pulposus can extend beyond the disk margin,
as a disk herniation (herniated nucleus
pulposus, or HNP).
▪ When HNP extends to the region adjacent to
the spinal nerve, it incites an intense
inflammatory reaction. Patients with HNP
typically present with acute radicular pain.
Lumboscaral Pain
Pathophysiology
▪ Hypertrophy of the facet joints and
calcification of the ligamentous structures
can reduce the size of the intervertebral
foramina and central spinal canal (spinal
stenosis), with onset of radicular pain and
neurogenic claudication.
Initial Evaluation and Treatment of
Low Back Pain
▪History
▫New onset of worsening low back pain after trauma,
infection, or previous cancer.
▫Patients with progressive neurologic deficits (typically
worsening numbness or weakness)
▫Bowel or bladder dysfunction
▪Location and duration of symptoms,
▪Acute vs Chronic
▫Acute-for less than 3 months, Chronic- more than 3 months
▪Radicular vs Lumbosacral
Acute Radicular Pain
▪HNP typically causes acute radicular pain, with or without
radiculopathy ( numbness, weakness ,loss of DTR)
▪Narrowing of one or more intervertebral foramina can occur
in elderly patient and with extensive lumbar spondylosis
▪Management:
▪Symptomatic
▪Symptoms resolve without specific treatment in 90%
▪Lumbar Diskectomy- for patients with persistent pain after
HNP
Chronic Radicular Pain
▪Occur in patients with disk herniation with or
without subsequent surgery
▪Search for reversible cause of nerve root
compression in warranted
▪MRI –scarring around the nerve root at the
operative site
▪Management: consist of pharmacologic treatment
for neuropathic pain
 Chronic Lumbosacral Pain
▪Structures most commonly implicated include the
sacroiliac joint, lumbar facets and lumbar intervertebral
disks.
▪The incidence of internal disk disruption has
been estimated to be 39%, facet joint pain 15%, and
sacroiliac joint pain 15%.
▪The gold standard for diagnosing sacroiliac
▪and facet joint pain is injection of local anesthetic at the
▪site.
Neuropathic Pain
▪Characteristics:
▪ Spontaneous pain- no stimulus
▪ Hyperalgesia- response to mildly noxious stimuly
▪ Allodynia- painful response to a non noxious stimuli
▪Believed to arise when the normal protective physiologic systems of
the nervous system that produce sensitization of the peripheral and
central nervous systems (sensitization that affords protection during
the healing process) persist after the injured tissue has healed.
▪Common forms: postherpetic neuralgia, painful diabetic neuropathy,
and complex regional pain syndrome.
Postherpetic Neuralgia
▪Varicella-Zoster Virus- lies dormant in the dorsal root
ganglia following resolution of the primary infection
▪Shingles- occurs in immunosuppressed individuals or with
aging of the immune system
▪Virus travels from the ganglia along the spinal nerves
erupting in an acute vesicular rash limited to 1 or 2
dermatomes on once side of the body
▪Leads to damage of small unmyelinated nerve fibers and can
lead to severe and persistent pain
Acute Lumbosacral Pain
▪Patients without radicular symptoms have no
obvious abnormal physical findings
▪May be caused by traumatic sprain of the muscles
and ligaments of the lumbar spine or the
zygapophyseal joints and early internal disk
disruption
▪Symptomatic management
Postherpetic Neuralgia
▪Episodic lancinating pain and severe allodynia in the affected
dermatome.
▪Acyclovir, famcyclovir, valacyclovir reduce incidence of PHN
▪Incidence increases to 3.9-11.8/1000 among >65 yrs old.
▪Topical lidocaine can reduce pain with marked allodynia
▪TCA and anticonvulsants remain as primary treatment
Painful Diabetic Peripheral Neuropathy
▪Most common cause- Diabetes mellitus
▪Result in painless sensory loss or painful neuropathy
▪Begins with symmetrical numbness in the toes associated
with paresthesias, dysesthesias and pain.
▪Pain characterized as burning and deep aching pain
▪Progresses slowly over many years
▪Incidence of painful DPN related to glycemic control
▪Modest improvement with TCA and anticonvulsants
Complex Regional Pain Syndrome
▪refers to a constellation of signs and symptoms that emerge
in a subset of patients with injury to peripheral nerves
▪Begin with a traumatic event, most often involving an
extremity
▪With healing, patient is left with in persistent pain that is
neuropathic associated with symptoms of sympathetic
nervous system dysfunction (swelling, edema, erythema ,
temperature asymmetry )
Complex Regional Pain Syndrome
▪Types
▪CRPS type 1 (formerly called reflex sympathetic dystrophy)
▫present when persistent pain accompanied by sympathetic dysfunction
occurs without an identifiable nerve injury
▫Example: severe ankle sprain

▪ CRPS type2 (formerly called causalgia) is present when the same

symptoms following an identifiable nerve injury
▪Example: gunshot wound to the brachial plexus.
Complex Regional Pain Syndrome
▪Managed with maintenance and restoration of
function through aggressive physical therapy
▪TCA and andticonvulsants- first line analgesics
▪ Sympathetic nerve blocks-rarely useful in long
term management
▪Spinal cord stimulation- effective long term
management
 Cancer Related Pain
▪Most common presenting symptom in
undiagnosed malignancy
▪Due to direct invasion of the malignancy or
result from cancer treatment
▪Primary focus: direct treatment of
malignancy
▪more common nerve blocks that has been
used to successfully treat patients with pain
associated with abdominal malignancy is
the neurolytic celiac plexus block.
Pharmacologic
Management of
Chronic Pain
Pharmacologic Management
▪Acetaminophen and NSAIDs
▪ Cyclooxygenase inhibitors- decrease prostglandins
▪First step in the WHO analgesic ladder as initial drugs for treatment of mild to
moderate cancer related pain
▪COX 2 inhibitors- less GI complications, but slight increase in thromboembolic
events in long term therapy

▪Antidepressants
▪TCAs and SNRIs effective treatment of neuropathic pain including PHN and
painful DPN
▪Secondary amine TCA( nortriptyline and desipramine)- better tolerated then
tertiary Tcas ( nortriptyline and desipramine)
▪Common side effects- dry mouth, urinary retention, TCA worsen heartblock
▪Anticonvulsants
▪Antiepileptic drugs ( gabapentin, pregabalin)- well tolerated in
neuropathic pain management
▪Side effects include dizziness, somnolence and peripheral edema

▪Chronic Opioid Therapy

▪Long term management of non cancer related pain
▪Improve function of patient with chronic painful conditions
▪Overt addiction is unusual
▪Chronic opioid use can worsen pain by inducing hyperalgesia
▪Patients are given a long acting opioid for continuous analgesia,
short acting opioid may cause fluctuations in pain control
▪Decision to use short- or long-acting drugs alone or in combination
should be tailored to the individual patient’s pattern of pain.
Interventional Pain Therapies
▪Refers to a group of targeted treatments used for specific spine
disorders ranging from epidural infection of steroids to
percutaneous intradiscal techniques
▪When these treatment techniques are used for the disorders they
are most likely to benefit can be highly effective; however, when
used haphazardly, they are unlikely to be helpful and may cause
harm.
Epidural injection of Steroids
▪Combat the inflammatory response that is associated with acute
disk herniation.
▪In acute radicular pain with HNP, epidural steroids reduce severity
and duration of leg pain if given between 3 and 6 wks after onset
▪Beyond 3 months from treatment, there are no long term
reductions in pain or improvements in function
▪Epidural injections may be given by interlaminar or transfemoral
route.
▪Transfemoral route is to place steroid in high concentration directly
adjacent to the spinal nerve close to the site of inflammation, more
effective than interlaminar.
 Facet Blocks and Radiofrequency
Treatment
▪Patients are identified based on typical patterns of referred pain,
with maximal pain located directly over the facet joints and patient
report of pain on palpation over the facts
▪The intra-articular injection of anesthetics and corticosteroids
may lead to intermediate term pain relief (1-3 mos)
▪Radiofrequency denervation delivers energy through insulated,
small diameter needle positioned adjacent to the sensory nerve to
the facet joint, creating a small area of tissue coagulation that
denervates the facet joint.
Facet Blocks and Radiofrequency
Treatment
▪Radiofrequency denervation provide better pain
relief
▪Pain typically returns in 6 to 12 mos after
treatment and denervation can be repeated
without lessening of efficacy
Lumbar Diskography and Intradiscal
Treatments
▪Involved in 29% to 49%
▪Series of needles placed in the central portion of the intervertebral
disks
▪Small volume of saline or contrast is introduced to reproduce the
pain to determine the offending disk
▪This test is done to select patients for surgical fusion.
▪Intradiscal Electrothermal Therapy (IDET) used to treat discogenic
chronic lumbosacral pain.
▪IDET- thermal energy is applied to destroy nociceptive fibers and
change the cross linking GAGs, stiffening intervertebral disk
 Lumbar Diskography and Intradiscal
Treatments
▪Percutaneous plasma disk decompression- minimally
invasive, removes a portion of the central nucleus
pulposus to treat radicular pain associated with focal disk
bulges
▪Reduces pain and increases long term functional status
in <3mm disk bulges
 Sympathetic blocks
▪Blockade of sympathetic nerve fibers can produce pain relief in
specific pain syndromes, including complex regional pain
syndromes and ischemic pain produced by microvascular
insufficiency referred as sympathetically maintained pain because
they share the characteristic pain relief following blockade of
regional sympathetic ganglia
▪Little evidence in reduction of pain in sympathetic blocks,
however use of neurolytic celiac plexus block for treatment of pain
assoc with abdominal malignancies can extend over weeks to
mos after treatment
Stellate Ganglion Block
▪For diagnosis and treatment of sympathetically maintained
pain of the head, neck and upper extremity.
▪Most common stellate ganglion block is in the anterior
paratracheal approach at C6 using surface landmarks
▪Performing the block at C6 reduces the likelihood of
pneumothorax, anterior tubercle of the transverse process of
C6 (Chassaignac’s tubercle) is readily palpable in most
individuals.
Stellate Ganglion Block

▪To perform the block without radiographic guidance,

the operator palpates the cricoid cartilage, and then
slides a finger laterally into the groove between the
trachea and the sternocleidomastoid muscle, retracting
the muscle and adjacent carotid and jugular vessels
laterally
▪Once the tubercle has been identified, a needle is
advanced through the skin and seated on the tubercle,
where local anesthetic is injected.
Stellate Ganglion Block
▪The local anesthetic spreads along the
prevertebral fascia in a caudal direction to
anesthetize the stellate ganglion, which lies just
inferior to the point of injection in the same plane.
Stellate Ganglion Block
▪Signs of successful stellate ganglion block include the appearance of
Horner’s syndrome (miosis [pupillary constriction]); ptosis (drooping of
the upper eyelid); and enophthalmos (recession of the
▪globe within the orbit).
▪Other signs of successful block
▪include anhidrosis (lack of sweating), nasal congestion,
▪venodilation in the hand and forearm, and increase in
▪temperature of the blocked limb by at least 1 degree Celsius
Stellate Ganglion Block
▪A simple modification of technique in which the needle is
directed medially toward the base of the transverse process
using radiographic guidance is a safe and simple means of
improving the reliability of stellate ganglion block
▪Other neuropathic pain syndromes, including ischemic
neuropathies, herpes zoster (shingles), early postherpetic
neuralgia, and postradiation neuritis may also respond to
stellate ganglion block
Stellate Ganglion Block
▪Blockade of the stellate ganglion has also proved successful
in reducing pain and improving blood flow in vascular
insufficiency conditions such as intractable angina pectoris,
Raynaud’s disease, frostbite, vasospasm, and occlusive and
embolic vascular disease.
Stellate Ganglion Block
▪Finally, the sympathetic fibers control sweating;
thus, stellate ganglion block can be quite effective in
controlling hyperhidrosis (recurrent and uncontrollable
sweating of the hands).
▪Diffusion of local anesthetic can block the adjacent recurrent
laryngeal nerve. Leading to hoarseness, and a subjective
feeling of shortness of breath and difficulty swallowing.
Stellate Ganglion Block
▪Bilateral stellate ganglion block should not be performed
because bilateral recurrent laryngeal nerve blocks may well lead
to loss of laryngeal reflexes and respiratory compromise.
▪ The phrenic nerve is also commonly blocked by direct spread
of local anesthetic and will lead to unilateral diaphragmatic
paresis.
▪Diffusion of local anesthetic as well as direct placement of
local anesthetic adjacent to the posterior tubercle will result in
somatic block of the upper extremity.
Celiac Plexus Block

▪Neurolytic celiac plexus block is the most widely applicable

of all neurolytic blocks.
▪Has long lasting benefit of 70-90% of pancreatic and intra
abdominal malignancies.
▪Classic technique employs a percutaneous posterior
approach using surface and bony landmarks to position
needles in the vicinity of the plexus.
Celiac Plexus Block

▪Celiac plexus block using a transcrural approach places the

local anesthetic or neurolytic solution directly on the celiac
ganglion anterolateral to the aorta.
▪Needles pass directly through the crura of the diaphragm en
route to the celiac plexus.
 Celiac Plexus Block
▪Splanchnic nerve block avoids the risk of penetrating the aorta,
uses small volumes of solution and the success is unlikely to be
affected by autonomic distortion caused by extensive tumor or
adenopathy within the pancreas
▪Celiac and splanchnic nerve block are used to control pain
arising from intra abdominal structures.
▪Most common application is to treat pain associated with intra
abdominal malignancy, particularly pain associated with
pancreas cancer
Celiac Plexus Block

▪Complications of celiac plexus and splanchnic nerve block include

hematuria, intracascular injection, and pneumothorax.
▪Intravascular injection of 30ml of 100% ethanol will result in a
blood ethanol level well above the legal limit of intoxication, but
below severe alcohol toxicity.
▪Intravascular injection of phenol is associated with clinical
manifestations similar to local anesthetic toxicity: CNS excitation
followed by seizure and extreme toxicity, cardiovascular collapse
Celiac Plexus Block
▪The most devastating complication associated with
neurolytic celiac plexus block using either alcohol or phenol is
paraplegia due to spread of solution toward aorta to
surroinding spinal arteries, the solution causes spasm or
necrolysis and occlusion of Adamkiewicz leading to paralysis
Lumbar Sympathetic Block
▪Used extensively in the treatment of sympathetically maintained
pain syndromes of the lower extremities.
▪Most common of these are the CRPS type 1 (reflex sympathetic
dystrophy) and type 2 (causalgia)
▪Can produce marked pain relief of long duration, and is part of a
comprehensive treatment plan to provide analgesia and facilitate
functional restoration
▪Can improve microcirculation and reduce ischemic pain in small
vessel occlusion.
▪.
Lumbar Sympathetic Block
▪Reduces pain in acute herpes zoster and early post herpetic
neuralgia (if beyond 6 mos, rarely helpful)
▪Hematuria can follow direct needle placement through the
kidney
▪Nerve root, epidural and intrathecal injection can arise when
needle is advanced through the intervertebral foramen
Spinal cord stimulation
▪direct activation of the ascending fibers within the dorsal
columns of the spinal cord that transmit nonpainful stimuli is
used to treat chronic back pain
▪Make use of pacemaker-like, implanted pulse generators
connected to a small electrode array positioned within the
dorsal epidural space of the spinal column.
▪Spinal cord stimulation is less expensive and more effective
than reoperation in the management of persistent
postoperative radicular pain. SCS has the most favorable
outcomes in unilateral radicular pain; significant reduction in
long-term pain occurs in patients with CRPS treated with
spinal cord stimulation.
Intrathecal Drug Delivery
▪Intrathecal opioids, the most common being morphine, are now
widely used in treating acute and chronic pain. Some nonopioid
drugs with spinal selectivity also show promise, including ziconotide,
a selective N-type calcium channel blocker
▪usually reserved for patients with severe pain that does not
respond to conservative management
▪Morphine is currently the only opioid that is approved for
intrathecal use by the Food and Drug Administration,
Intrathecal Drug Delivery
▪Ziconotide delivered intrathecally demonstrated
significant analgesia in patients with severe chronic
pain, but side effects were common, the most
common being CNS side effects.