Pain – a common symptom
Pain is the most common symptom that we have in life.
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Pain is also the most common symptom seen by a Neurosurgeon, and pain can occur for a whole host of reasons. Despite that, pain is also very difficult to assess in any one patient.
A painful stimulus that is identical will be perceived differently by two different people. That is due to a number of reasons, including mood, fatigue, time of the day, factors specific to that patient, and the presence or absence of other pain. The same painful stimulus can be perceived differently in one individual, depending on when that stimulus is applied. Thus, various scales have been validated to try to gauge what that pain means to that person. Such scales are many, but generally a visual or conceptual estimation is made of how bad a pain is gauged between no pain at all and the worst pain imaginable or experienced.
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Pain Management Surgery
In the main, pain is treated through two ways, firstly the avoidance or removal of the painful stimulus. In Neurosurgery, that could be removal of a disc protrusion that is pushing on a nerve for instance. The other option generally utilised is pain relief and medications. These medications are many and varied and can be relatively non-harmful all the way through to extremely addictive medications, often of a narcotic nature. The side effects of such medications have to be weighed up in the treatment of any painful stimulus.
There are other methods of improving pain. These can be education and how to deal with it, improvement in an individual’s psychological wellbeing, distraction techniques, or physical therapies that alleviate part of the pain, but not all of it. Other treatments can be those provided by a pain physician such as guided injections, radiofrequency ablation (the disconnection of fine sensory nerves to a joint), and pulse radiofrequency.
When other methods of pain relief have failed and there is no reversible cause surgically of the pain that is arising, then other methods may need to be considered. These methods do not just have to deal with pain coming from the neurological system itself, but can come from pain in an organ, such as intractable angina. Another consideration for surgical management of pain is in malignancy. If a tumour and its subsequent treatment cause severe local and referred pain, it may not be sufficient to control the pain through simply analgesia.
In instances where surgical pain procedures are considered, a pain physician has usually seen the patient, they have usually been seen by a specialist relevant to the specialty where the pain is arising, and all other options have failed or are inappropriate for some clinical reason. The surgeries that can be performed include peripheral nerve stimulation, dorsal column stimulation and pain pumps in the main. There are other lesser procedures that will not be covered here.
Peripheral Nerve Stimulator/Dorsal Column Stimulator
Stimulating devices are electrical implantable devices. In the case of dorsal column stimulation, they are placed over the spinal cord, usually in the thoracic spine or neck depending on the distribution of pain or over the peripheral nerve itself in the case of peripheral nerve stimulation. Generally speaking, a trial is performed where a device is placed temporarily and taken out through the skin. A technician then goes through a number of programming stimulations, which often, but not always, provide a non-painful sensory perception instead of the pain. If it is seen that the device works well and that the sensory stimulus that replaces the pain is acceptable to the patient, then a second stage procedure is performed. That second stage procedure internalises the entire device, inclusive of a pulse generator and battery. That pulse generator and battery can be recharged through the skin, once the wound has healed. The battery life is roughly ten years.
The device can then be controlled remotely, used at different amplitudes and frequencies and different patterns according to the individual to provide pain relief. Most patients still require analgesics, though some do not and in the main, therefore, it is seen as something that helps with pain management rather than completely relieving it.
There are various risks and complications that can arise from placing such a device, which would need to be discussed with your treating Neurosurgeon. The one given is that the battery has a finite lifespan. When the battery does fail, it does require replacement and that is a subsequent surgical procedure, though not a particular onerous one.
In summary, peripheral and dorsal column, stimulating devices are used when intractable pain is unresponsive to other measures and a trial has been performed and found to be successful. It is usually the case that treatment is shared between a pain physician and the treating Neurosurgeon in the implantation of these devices.
Pain pumps can be placed surgically in a limited number of required situations. In essence, a pain pump is a small tube that is placed in the spinal canal. It is then tunnelled to a reservoir device that holds a medication that is then slowly instilled around the nerves to provide pain relief. The reservoir needs to be filled episodically to allow continued use. The amount of medication required when pain relief is administered in this way is considerably less than even that required for the same pain relief when given intravenously and substantially less than that required for oral analgesics. The down side with these such devices is the requirement to access the reservoir episodically and the risk, therefore, of infection.
There is another type of pain pump where the device is external and the tubing goes through the skin and to the area of interest. These devices cannot be used for all that long based on infection concerns, but can certainly be considered in particular in end stage malignant pain.
On occasion pain relief is required to be instilled directly into the brain. This portal of instillation of pain relief can also be used for chemotherapy when required for disease processes such as lymphoma. Finally, and very rarely, it can be used for the instillation of antibiotics, for rare intracranial infection. In essence, this is a half sphere device placed under the scalp with a connected tube running through a small burr hole in the skull then into the fluid cavities of the brain. Medication regardless of its type, but in this instance pain relief, can be injected directly through the skin in a sterile fashion to access the port and to instil the required dosage. Whilst this is a relatively straightforward procedure, it is not often called for and usually means that the patient requiring it is significantly unwell.
Radiofrequency Ablation (RFA), or Radiofrequency Neurotomy (RFN) as it is also known, is a minimally invasive procedure that can be utilised in the spine and aims to reduce pain by interrupting the transmission of pain signals that are carried into the spine and to the brain. In the spine, it is performed on the very small nerves on the facet joints. Facet joints are the joints at the back of either side of the spine that connect one vertebra to another above or below it. The facet joints may be subject to inflammation or arthritis, or mechanical pain. RFA can also be considered to treat Sacro-Iliac joint (SIJ) pain for similar reasons.
A clinical assessment and diagnostic process is conducted by the treating Clinician to determine if RFA is an option for a particular individual. It is performed using X-ray (Fluoroscopic) guidance in a theatre setting to locate the target and usually under a mild sedation and using local anaesthetic. RFA procedures are day cases meaning that the patient will go home on the same day. It is expected that the pain relief benefit from RFA will last for months or even years, and the procedure can be repeated in the future.