1. MANAGEMENT OF PAIN
BY
DR. OFOEGBU J.I

2. INTRODUCTION
Pain is a warning that something is wrong.
It pre empts other signals.
Pain by Sherrington is “the physical adjunct
of an imperative protective reflex”.
It is a subjective term and can be defined as
a sensory and emotional experience

3. PHYSIOLOGIC
OVERVIEW
• The sense organs for pain are
the naked nerve endings found
in almost every tissue of the
body.
• The pain impules are
transmitted to the CNS by 2
fiber systems;
• Small myelinated Ad fibers {fast
pain fibers}

4. PHYSIOLOGIC OVERVIEW
CONTD
• The neurotransmitters for both
include glutamate and
Substance P respectively.
• Both fibers terminate on the
dorsal horn.Some of the axons
of the dorsal horn neurons end
in the spinal cord and brainstem
while others ascend in the
lateral spinothalamic tract and

5. PHYSIOLOGIC OVERVIEW
CONTD
• The lateral spinothalamic tract
fibers project to the ventral
posterior nuclei of the
thalamus.
• From here to the cerebral
cortex. As such, pain activates
cortical areas( post central
gyrus) on the side opposite the
stimulus.

7. MANAGEMENT
• The key to accurate diagnosis
is a comprehensive history and
detailed physical examination.
HISTORY
a) Explore the pain
b) Review the systems
c) PMH and SH
d) Drug history

8. HISTORY CONTD
e) Family and Social history
EXAMINATION
General Physical Examination
Systemic Examination

9. INVESTIGATIONS
1) Diagnostic Imaging
• a) Plain film radiology
• b) Fluoroscopy
• c) Computed Tomography Scan
• d) Magnetic Resonance imaging
• e) Myelography
• f) Bone Scans

10. INVESTIGATIONS
CONTD
• 2) Urinalysis
• 3) S E/U/C
• 4) FBC + ESR

11. TREATMEMT
a) Pharmcologic
b) Neurosurgical Intervention
c) Other non-conventional
methods

12. PHARMACOLOGIC:
CLASSES OF PAIN
MEDICATIONS
1) Non Steroidal Anti inflammatory
drugs[NSAIDS]
E.g Aspirin, Diclofenac, Apazone,
Ibuprofen, Celecoxib e.t.c
MECHANISM OF ACTION
• Inhibition of biosythesis of
prostaglandins by inhibiting cyclo-
oxygenase isoforms
• Inhibition of Chemotaxis
• Downregulation of IL-1 production
• Decreased production of free radicals
and superoxide
• Interference with calcium mediated

14. INDICATIONS
• Acute pains;inflammatory
conditions like tendonitis,
bursitis and arthritis.
• Pain from bone metastases in
cancer patients.
• Others are rheumatic fever,
transient ischaemic
attack,coronary artery
thrombosis

15. SIDE EFFECTS
• Gastric upsets, peptic ulcer
disease,Elevated liver enzymes
and Hepatitis e.t.c

16. 2) Acetaminophen
MECHANISM OF ACTION
• Weak inhibitor of Cox-1 and
Cox-2 in peripheral tissues
• Has no significant anti
inflammatory effects
• Has antipyretic activity

17. INDICATIONS
• Mild to moderate pains as in
headache, myalgia
SIDE EFFECTS
Dizziness, Hepatotoxicity with
high doses etc

18. 3) Opioids
• E.g Morphine, Codeine,
Methadone, Fentanyl,
Pentazocin, e.t.c
MECHANISM OF ACTION
Bind to specific G-proteins
coupled receptors in the brain
and spinal cord regions involved
in transmission and modulation
of pain.

19. INDICATIONS
Pains associated with
cancer
SIDE EFFECTS
Behavioural restlessness,
respiratory depression, nausea,
vomiting, constipation e.t.c

20. 4) Corticosteroids
• E.g Prednisolone, Cortisone etc
MECHANISM OF ACTION
Phospholipase inhibitor
INDICATIONS
Acute pain and flare-ups of
chronic inflammatory conditions
like vasculitis, SLE, Sarcoidosis
etc

21. SIDE EFFECTS
Insomnia, behavioural
changes, acute pancreatitis etc
5) Anticonvulsants
E.g Neurontin (Gabapentin),
Lyrica (Pregabalin)
INDICATIONS
Neuropathic pain, Fibromyalgia

22. Local anaesthetics
• A) Nerve blocks
• B) Epidural anaesthesia ;
Patient controlled Epidural
anaesthesia (PCEA)

23. NEUROSURGICAL
INTERVENTONS
• A) ABLATIVE PROCEDURES
• a) Peripheral neurectomy
• b) Myelotomy
• c) Cordotomy
• d) Sympathectomy
• e) Dorsal root ganglionectomy

24. B) AUGMENTATION
PROCEDURES
• a) Peripheral nerve stimulation
• b) Spinal cord stimulation
• c) Deep brain stimulation
• d) Implantable infusion systems

25. OTHER METHODS
• Radiotherapy
• Acupuncture
• Use of ice
• Rest
• Elevation

26. Follow up
• Chronic pain can be managed
but not cured; the majority of
patients will require careful and
regular follow up indefinitely.
Periodic review of medications
and careful evaluation of the
progression of any underlying
disease are important.

27. CONCLUSION
• It is natural to have pains.
Medications are a key part of
recovery and can speed healing
and lead to fewer
complications.