CHRONIC PAIN MANAGEMENT

1. RECENT ADVANCES IN
PAIN MANAGEMENT
DR.K.KISHORE

2. PAIN
• DEFINITION:
“An unpleasant sensory and emotional experience
associated with actual or potential damage” .
• PAIN IS SUBJECTIVE REACTION TO AN
OBJECTIVE STIMULUS.

3. DIFF. MODALITIES OF
TREATMENT

4. Multimodal analgesia:
• Different classes of analgesics using different routes
of administration such as iv and epidural are used to
produce fewer side effects of sedation,
nausea,vomiting, pruritis, constipation, and improved
pain relief.
• Multimodal analgesia also can produce opioid
sparing.
• Faster recovery, reduced hospital stay, and decreased
length of convalescence can occur if multimodal
analgesia is combined with a rehabilitation program
that is multidisciplinary and multimodal.

5. PAIN MANAGEMENT
• PHARMACOLOGICAL : >90%
• NONPHARMACOLOGICAL : <10%
INTERVENTIONAL
NONINTERVENTIONAL

6. WHO LADDER

7. Pain
Step 1
Nonopioid
 Adjuvant
Pain persisting or increasing
Step 2
Opioid for mild to moderate pain
Nonopioid  Adjuvant
Pain persisting or increasing
Pain persisting or increasing
Step 3
Opioid for moderate to severe pain
Nonopioid Adjuvant
Invasive treatments
Opioid Delivery
Quality of Life
MODIFIED WHO ANALGESIC
LADDER
Proposed 4th Step
The WHO
Ladder
Deer, et al., 1999

9. OPIOIDS
• Opioid use worldwide is increasing; in many countries opioid
availability is limited by legislation or circumstances .
• Data on long-term benefits are limited except for highly
selected patients, while risks of abuse, diversion and even
mortality are high .
• Multiple new formulations, aimed at increased speed of onset
or reduced risk of abuse and diversion, are or have been
recently developed.
• A large number of deaths have been reported with these
preparations if used inappropriately .
• Combinations with antagonists such as naloxone (in
buprenorphine or oxycodone preparations) and naltrexone
(in a morphine preparation) are also available or have been
investigated .

10. • TAPENTADOL:
• Centrally acting analgesic
• Dual mode of action as an agonist at the μ-opioid receptor
and as a norepinephrine reuptake inhibitor.
• Used in the treatment of moderate to severe chronic pain that
proves unresponsive to conventional non-narcotic
medications.
• 18-fold affinity for the μ opioid receptor in as compared to
morphine.
• 3 times less analgesic than morphine.
• Improved GI tolerability when compared to opioids.

11. • Dose adjustment for tapentadol is not needed in the presence
of renal impairment.
• No Hepatoxicity.
• Potency between Tramadol and Morphine.
• Contraindicated in severe bronchial asthma, paralytic ileus,
and patients on MAOI (serotonin syndrome).
• Risk of death - lower than from conventional opioids
• It is similar to tramadol, but differs in not being a racemic
mixture of two enantiomers with different pharmacological
effects, has no active metabolites (which are relevant for
tramadol’s mu opioid receptor agonism) and has only
minimal serotonin effects .

12. • Transmucosal immediate-release
formulations of fentanyl (TIRF) –
• Fentanyl -commonly used synthetic
phenylpiperidine derivative.
• Initially developed for parenteral administration,
with the oral route being of limited use due to high
first pass metabolism.
• High lipophilicity and high potency make it suitable
for both acute and chronic pain management .

13. • Oral transmucosal fentanyl citrate (OTFC) .
• Oral disintegrating tablets (ODT) of
fentanyl:
• mixture of carrier particles coated with fentanyl .
• These particles adhere to the oral mucosa through a
mucoadhesive agent aiming for rapid absorption and result
in good control of breakthrough pain .
• Fentanyl buccal tablets (FBT):
• an effervescent disintegrating tablet, which enhances early
systemic uptake by changing the mucosal pH to increase
unionized fentanyl concentration in the area of absorption .
• Fentanyl buccal soluble films (FBSF).

15. • Patient-controlled intranasal analgesia
(PCINA):
• Intranasal (IN) opioids in the form of a dry powder or water
or saline solution, are delivered using a syringe, nasal spray
or dropper, or nebulized inhaler.
• Needle-free administration
• bypass the hepatic first-pass effect
• excellent perfusion of the nasal mucosa
• rapid absorption and rise in plasma concentration.
• PCINA is efficacious, safe, non-invasive, and easy to
administer, but there are limited studies evaluating this route
of analgesic administration in the postoperative period .

16. • Patient-controlled transpulmonary
analgesia AeroLEF™(aerosolized liposome-
encapsulated Fentanyl):
• Inhalation formulation of free and liposome-encapsulated
fentanyl .
• AeroLEF™ is in development for the treatment of moderate to
severe pain, including cancer pain.
• AeroLEF™ has a simple and noninvasive route of
administration,
• rapid onset of action,
• sustained effect, and
• self-titratable dosing for the treatment of acute and
breakthrough pain.

17. • Extended-release epidural morphine (EREM)
called DepoDur:
• Single-dose
• Works locally to give long-lasting pain relief at the site of
surgical focus.
• Duration of action: 48 hrs
• Long-lasting analgesia in the absence of large systemic
concentrations of opioids as well as better patient activity
levels.
• For surgeries like- knee arthroplasty and cesarean section.
• Side effects of EREM-treated with opioid antagonists.
• Pruritis and respiratory depression common.
• Elderly sensitive to EREM, so close peri-operative monitoring
required.

18. • Patient-controlled fentanyl hydrochloride
iontophoretic transdermal system (fentanyl
ITS):
• Fentanyl ITS is an innovative, needlefree, self-contained, pre-
programmed drug delivery system that uses iontophoretic
technology to deliver fentanyl through the skin by application of a
low-intensity electrical field.
• Not approved by the U.S. FDA for current clinical use;
• Demonstrated to have efficacy and safety equivalent to morphine
IV-PCA in four RCT, and a meta-analysis.

20. • Adverse events - similar to those with IV opioid
administration, including nausea, vomiting, pruritis,
headache, and mild-to moderate dizziness.
• Disadv: as with all transdermal systems, skin
hypersensitivity, skin redness, and hyperpigmentation.
• Use with extreme caution for in-patients with severe hepatic
dysfunction, head injuries, sleep apnea, and impending
respiratory failure and in pts with increased ICP of any
etiology.

22. Analgesic adjuvants
• Adjuvants are compounds, which by themselves
have undesirable side effects or low potency, but in
combination with opioids allow a reduction of
narcotic dosing for postoperative pain control.
• Needed for postoperative pain management due to
s/e of opioid analgesics, which hinder recovery.

23. NON OPIOID ANALGESICS
• Acetaminophen (paracetamol)-
• One of the oldest and most used analgesics, the debate on its
mechanism of action continues.
• Mediated centrally and may involve direct and indirect
inhibition of central cyclo-oxygenases, but also the activation
of the endocannabinoid system and spinal serotonergic
pathways .
• Perioperative administration reduces postoperative nausea
and vomiting (PONV), in particular if given prophylactically
at induction of anesthesia .
• In therapeutic doses below 4 g/day, hepatotoxicity is very
unlikely to occur .
• Acetaminophen intake has been linked to increase INR with
warfarin treatment .

25. • Non-steroidal anti-inflammatory drugs
(NSAIDs) –
• Fast-acting preparations provide better analgesia than slow-
acting ones .
• There is no difference in analgesic efficacy between non-
selective NSAIDs (nsNSAIDs) and COX-2 selective NSAIDs
(Coxibs).
• With regard to gastrointestinal complications, in particular
bleeds, coxibs carry a lower risk than nsNSAIDs .
• Coxibs are safe in patients with aspirin-sensitive asthma .
• In the perioperative setting, coxibs- do not impair platelet
function , do not increase blood loss even after high-risk
surgery such as total knee joint replacement ; this is in
contrast to increased risk of bleeding with nNSAIDs .

27. • With regard to cardiovascular risk-with short-term use in
the acute setting parecoxib/valdecoxib is safe.
• No recent new substances in this class of analgesics.
• Ketorolac as nasal spray, recently approved by the FDA.
• Other developments are preparations, which permit use of
lower doses of NSAIDs in an attempt to reduce adverse
effects.
• Submicron particle NSAIDs (so called nano formulations);
diclofenac as well as indomethacin have been tested in such
formulations.
• A new formulation of injectable diclofenac sodium
solubilized with hydroxypropyl-beta-cyclodextrin similarly
showed efficacy at much reduced doses .

28. Alpha-2-delta modulators (gabapentin
and pregabalin)
• Gabapentin :
• Anti-epileptic drug
• Analgesic effect in DM neuropathy, post-herpetic neuralgia,
and neuropathic pain.
• Gabapentin does not bind to GABA A or GABA B receptor but
to the alpha-2 delta subunit of the presynaptic voltage gated-
calcium channels responsible for the inhibition of the
calcium influx.
• The inhibition of calcium release then prevents the release of
excitatory neurotransmitters involved in the pain pathways.
• Potential for perioperative use as an analgesic adjuvant and
anti-hyperalgesic agent when used in conjunction with
opioids.

29. • Pregabalin:
• Analgesic, Sedative, Anxiolytic, and Opioid-sparing effect
• Structural analog of GABA and a derivative of gabapentin,
used in various pain settings, including postoperative pain.
• Its MOA is similar to that of gabapentin .
• Efficacy in neuropathic pain conditions such as postherpetic
neuralgia, painful diabetic neuropathy, central neuropathic
pain, and fibromyalgia.

30. • Benefits-
• reducing opioid requirements,
• prevn and reduction of opioid tolerance,
• improvement of the quality of opioid analgesia,
• decreased respiratory depression,
• relief of anxiety, and
• gastric sparing.
• Also used in certain specific operations such as hysterectomy
and laminectomy.
• Currently no agreement on the ideal doses and treatment
duration for the indication of acute postoperative pain .

31. • Serotonin-norepinephrine reuptake inhibitors
(SNRIs) :
• MOA- related to the inhibitory effects on norepinephrine and
serotonin reuptake, thereby strengthening endogenous
descending pathways of pain control.
• In the management of chronic pain, with tricyclic
antidepressants (TCAs), in particular amitriptyline, commonly
being utilized in the treatment of neuropathic pain .
• For treatment of diabetic polyneuropathy, where both,
duloxetine and venlafaxine, show better efficacy and a better
benefit-risk balance than amitriptyline .
• Duloxetine and, to a lesser extent, milnacipran , are also
effective in fibromyalgia .
• Also for conditions like chronic low back pain and
osteoarthritis.

32. • Ketamine-
• Originally introduced into clinical practice as a dissociative
anaesthetic in 1963 .
• NMDA receptor antagonist.
• iv, sc, epidural, transdermal, and intra-articular.
• At low sub anesthetic doses (0.15–1 mg/kg), ketamine exerts
a specific NMDA blockade and, hence, modulates central
sensitization.
• Ketamine appears to reduce the level of sensitisation by
modulating the ‘wind up’ process.
• Ketamine also has a number of other sites of action including
nicotinic, muscarinic, opioid, AMPA and Kainate receptors. It
also inhibits serotonin and dopamine reuptake, and down
regulates certain ion channels

33. • Use of sub-anesthetic doses of ketamine as an adjunct to
provide postoperative pain relief in opioid-dependent
patients
• Prevents opioid-induced hyperalgesia in patients receiving
high doses of opioid for their postoperative pain relief.
• Adv effects- dizziness, blurred vision, nausea ,vomiting and
hallucinations.
• After burns injury, it reduces wind-up and secondary
hyperalgesia .

34. • CALCITONIN-
• a polypeptide hormone produced naturally by the para-
follicular cells of the thyroid gland .
• Uses-
• CRPS later stages.
• acute phantom limb pain after amputation.
• pain caused by vertebral compression fractures.

35. • Cannabinoids:
• Act upon the cannabinoid receptor
• Receptor proteins include the endocannabinoids such as
anandamide, the phytocannabinoids and synthetic
cannabinoids .
• Derivatives of the cannabis plant -used anecdotally to treat a
variety of ailments such as anorexia, insomnia, pain and
nausea .
• Primary active component is d-9-tetrahydrocannabinol
(THC).
• At least another eighty-five different cannabinoids exist.

36. • CB1 receptors are found mainly within the brain,
responsible for the analgesic, euphoric and
anticonvulsive effects;
• they are however absent from the medulla oblongata,
possibly explaining the lack of respiratory and cardiac
depressive effects.
• CB2 receptors are found primarily within the immune
system, modulate the cytokinin system and are believed
to have anti-inflammatory and immunosuppressive
effects.
• Dronabinol (a synthetic THC)-used as an antiemetic and
as an appetite stimulant in AIDS related weight loss,
• Nabilone, a synthetic THC analogue- used for
chemotherapy induced nausea and vomiting, with only
minimal analgesic benefits in neuropathic pain.

37. Local anaesthetics
• There are two approaches for prolongation of LA action:
• One is the use of novel delivery techniques for existing
drugs. Liposome or polymer encapsulation of LA are being
formulated.
• Second is the development of novel, extremely long-acting
LA.
• Liposomes are microscopic phospholipid- bilayered
vesicles that are biocompatible, biodegradable, and non-
immumnogenic.
• Recently, new drug delivery systems utilizing
nanoparticles, micro-particles composed of biodegradable
polymers are developed.
• They have some advantages over liposomes in terms of
stability both during storage and in vivo.

38. • Lidocaine plaster:
• amide local anesthetic.
• its effects are mediated by sodium channel block
• It has a potential to be a treatment for neuropathic
pain.
• the development of a plaster for topical
administration of lidocaine has resulted in a new
first-line treatment of localized neuropathic pain
with minimal systemic adverse effects .

39. • Lidocaine plaster 5%, is a 10 cm × 14 cm patch containing
around 700 mg lidocaine (50 mg/g of patch).
• The patch is placed directly over the painful area (intact skin
only) for a period of 12 hrs f/b 12 hrs patch free time.
• Only around 3% of the lidocaine dose from the patch is
absorbed.
• Used in diabetic neuropathy and post herpetic neuralgia
• Effective in the treatment of neuropathic pain and
accompanying allodynia with fewer adverse events than
pregabalin .

40. • Used in painful idiopathic sensory polyneuropathy,
CRPS, carpal tunnel syndrome, postsurgical and
posttraumatic pain.
• Also used in the elderly population and other high-
risk groups.
• Most common adverse effects are skin irritation in
the area of application.
• They can also be safely combined with systemic
medications as part of a multimodal approach to
pain management .

41. • Capsaicin:
• 8-methyl-N-vanillyl-6-nonenamide
• Non narcotic , acts peripherally.
• TRPV-1 agonist . Capsaicin binds to the transient
receptor potential vanilloid 1 (TRPV1) subunits.
• TRPV1 is a receptor present on unmyelinated C fiber
endings in the periphery. The activation of the TRPV
receptors releases substance P

42. • While exposure to capsaicin results initially in a
painful burning sensation due to substance P release,
multiple administration of low concentration or single
administration of high concentration capsaicin will
finally lead to reduced sensitization or even complete
desensitization.
• No effect on A delta and A alpha fibers and does not
affect the temperature and touch sensations. Capsaicin
cream contains capsaicin that is combined with
narcotic analgesics and NSAIDS .
• Used for back pain, arthritic jointpains, and strains
and sprains.
• Higher concentrations used for the treatment of the
neuropathic pain of post herpetic neuralgia.
• It can be used in the elderly as an adjuvant, as it has
opioid sparing effects.

43. • Injectable capsaicin is used for the control of post op
pain, such as after TKR,THR, hernia repair , shoulder
arthroscopy.
• Absolute contraind- Hypersensitivity.
• Relative contraindications-
age < 2 years,
pts with elevated liver enzymes,
pts on ACE inhibitors, and
pts with signs of septic arthritis and joint infections.

44. • Capsaicin in low concentrations (<1%) with repeat
administration has been used for a long time in an
attempt to treat neuropathic pain.
• High concentration (8%) capsaicin patch for single
administration
• In postherpetic neuralgia and HIV-related
neuropathy, low incidence of adverse effects.

45. • Dexmedetomidine :
• highly selective central alpha2 agonist.
• sedative, pro-anesthetic, and pro-analgesic effects at
0.5-2 micrograms/kg iv.
• Blunt the central sympathetic response .
• Also minimizes opioid-induced muscle rigidity, lessens
postop shivering, causes minimal respiratory
depression, and has hemodynamic stabilizing effects.
• When used as an adjunct, can reduce postoperative
morphine consumption.
• Addition of dexmedetomidine to IV PCA morphine
resulted in superior analgesia, significant morphine
sparing, and less morphine-induced nausea, and
devoid of additional sedation and untoward
hemodynamic changes.

46. Botulinum toxin
• ACTION-
• Inhibition of ach release,
• Inhibition of the release of glutamate, substanceP, and CGRP
• Reduced afferent input to the CNS through effects of the toxins
on muscle spindles
• INDICATIONS-
• Strabismus,
• Blepharospasm,
• Hemifacial spasm,
• Cervical dystonia ,
• Muskuloskeletal Pain

47. • SIDE EFFECTS-
• Pain, muscle weakness,
• Flulike syndrome
• Autonomic side effects appear to be commonly seen
with type B toxin
• CONTRAINDICATIONS –
• Pregnancy (category C),
• Concurrent use of aminoglycoside , Myasthenia
gravis, Eaton–Lambert .
• Known sensitivity to the toxins

48. NON PHARMACOLOGICAL
• Because medical treatments have limited effects on patients
with chronic pain, patients are twice as likely to commit
suicide and lifetime prevalence of suicide attempts is about
10%.
• Medication will likely affect not only the neural structures
responsible for sustaining pain, but also other brain regions
that can give rise to side-effects or render the interventions
less effective.

49. NON INTERVENTIONAL
• PHYSIOTHERAPY
• ELECTROTHERAPY-
COLD THERAPY,
HEAT THERAPY,
ULTRASOUND,
TENS
• MANIPULATIVE THERAPY-
MASSAGE,
SPINAL TRACTION,
PASSIVE STRETCHING,
ORTHOSES (CERVICAL COLLARS,
LUMBAR SUPPORTS)
• HYDROTHERAPY

50. NON INTERVENTIONAL
• MEDITATION,
• HYPNOSIS,
• BIOFEEDBACK, BEHAVIOURAL THERAPY
• POSTURE
• PHYSICAL EXERCISES
• DIET THERAPY

51. NON-INVASIVE BRAIN
STIMULATION TECHNIQUES
• Brain stimulation is a technique that can guide brain
plasticity and thus be suitable to treat chronic pain-a disorder
that is associated with substantial reorganisation of CNS
activity.
• Therefore, therapies that directly modulate brain activity in
specific neural networks might be particularly suited to
relieve chronic pain.
• Repetitive transcranial magnetic stimulation (TMS)
and Transcranial direct current stimulation (tDCS),
are particularly appealing as they can change
brain activity in a non-invasive, painless and safe
way.

52. TMS-TRANS CRANIAL MAGNETIC
STIMULATION
• Developed in 1985.
• It is based on a time-varying magnetic field that generates an
electric current inside the skull, where it can be focused and
restricted to small brain areas by appropriate stimulation coil
geometry and size.
• This current, if applied repetitively, repetitive TMS (rTMS),
induces a cortical modulation that lasts beyond the time of
stimulation.

53. tDCS –TRANS DIRECT CRANIAL
STIMULATION
• Induces similar modulatory effects.
• tDCS is based on the application of a weak direct current
to the scalp that flows between two relatively large
electrodes—anode and cathode electrodes.
• Some studies have shown that the efficacy of tDCS
depends critically on parameters such as electrode
position and current strength.
• Application of tDCS for 13 min to the motor cortex can
modulate cortical excitability for several hours.
• This technique can also be used to obtain
clinical gains in neuropsychiatric disorders
such as stroke, epilepsy, and tinnitus.

54. 1.high-frequency rTMS of the primary motor cortex .
2.low and high-frequency rTMS of dorsolateral
prefrontal cortex

55. 1. low-frequency rTMS of the secondary
somatosensory cortex
2. anodal tDCS of the primary motor cortex

56. • At the beginning of the 1990s, a new and less invasive
strategy of brain stimulation was developed, known as
epidural motor cortex stimulation,
• It showed substantial pain improvement and brought new life
to the concept of brain stimulation for the treatment of
chronic pain.
• Epidural cortical stimulation not only decreased the
neurosurgical risks of brain stimulation for chronic pain, but
also invited the exploration of non-invasive brain stimulation
techniques, tDCS and rTMS.

57. RESULTS
• FOR rTMS-
• Right and Left secondary somatosensory
cortex stimulation with 1 Hz, 20 Hz.
• The results showed that 1 Hz (of left and right
secondary somatosensory cortex) and right
somatosensory cortex (with 1 and 20 Hz)
stimulation led to a significant pain reduction.

58. RESULTS
• FOR tDCS
• Patients with chronic pain due to spinal cord injury were
randomised to receive active motor tDCS (2 mA for 20 min
for five consecutive days).
• There was a significant pain improvement after active anodal
stimulation of the motor cortex.
• tDCS has some advantages over rTMS-
• it has longer-lasting modulatory effects of cortical function.
• is less expensive.
• easy to administer.

59. INTERVENTIONAL
1. SPINAL & EPIDURAL OPIOID & STEROID
2. PNS,SCS & DBS
3. NEUROLYSIS-Chemical neurolysis,
Radiofrequency thermocoagulation
Cryoanalgesia
4.VERTEBROPLASTY & KYPHOPLASTY
5.DRY NEEDLING,INFILTRATION,PROLOTHERAPY,TPI
6.ACUPUNCTURE
7.RADIOTHERAPY
8.OZONETHERAPY
9. CAUDAL EPIDURAL DECOMPRESSIVE NEUROPLASTY (LYSIS
OF ADHESIONS)
10.PERCUTANEOUS MANAGEMENT OF
VISCERAL PAIN
11.NEUROSURGICAL PROCEDURES

60. EQUIPMENTS USED ARE
• FLUOROSCOPIC GUIDED
• ULTRASOUND GUIDED
• CT GUIDED
• MRI GUIDED

61. SPINAL CORD STIMULATION
• Relieves pain by applying sufficient electrical stimulation to cause
paresthesias covering or overlapping the area(s) of pain without discomfort
or motor effects
• MECHANISM OF ACTION- “gate control theory of pain,”

62. SPINAL CORD STIMULATION
• SCS is minimally invasive and reversible.
• A typical SCS system has four components.
1. A neurostimulator that generates an electrical pulse (or
receives radio frequency pulses) – this is surgically implanted
under the skin in the abdomen or in the buttock area.
2. An electrode(s) implanted near the spinal cord either
surgically or percutaneously (the latter via puncture, rather
than through an open surgical incision, of the skin).
3. A lead that connects the electrode(s) to the
neurostimulator.
4. A remote controller that is used to turn the
neurostimulator on or off and to adjust the level
of stimulation.

63. SPINAL CORD STIMULATION

64. INDICATIONS-
• Failed back surgery syndrome,
• Ischemic pain of peripheral vascular disease
• Postcordotomy dysesthesias,
• Reflex sympathetic dystrophy
• Phantom limb and stump pain.
CONTRAINDICATIONS-
• Coagulopathy, Sepsis,
• Serious drug behavior problems,
• Inability to cooperate or to control the device
• Demand cardiac pacemaker (without ECG monitoring
or changing the pacemaker mode to a fixed rate).

65. COMPLICATIONS-
• Electrode fatigue fracture, Electrode migration/malposition
• Exposure to electromagnetic fields (eg, diathermy,security
systems)
• Spinal cord or nerve injury,
• CSF leak
• Infection
• Bleeding

66. RADIOFREQUENCY ABLATION
• ACTION-
• Destruction of the nerves that signal pain
• The effect of RF on tissue depends on the temperature generated:
• >45°C, irreversible tissue injury occurs;
• Between 42 and 45°C, temporary neural blockade occurs.
• INDICATIONS-
• head and neck pain ,
• spine pain ,
• neuropathic pain

68. • COMPLICATIONS-
• Neurologic deficits from the intended target or nearby
neural structures,
• Deafferentation pain,
• Neuritis,
• Burn injury at breaks in the needle insulation,
• Hematoma
• Infection

69. CRYONEUROLYSIS
• Temporarily destroys a nerve through the application of
extreme cold.
• The extreme cold degenerates the nerve axons without
damaging surrounding connective tissue
• Larger myelinated fibers cease conduction at 10°C,
• At 0°C, all nerve fibers entrapped in the ice ball stop
conduction.
• Can be cooled upto -70 degrees
• Pain relief upto 3 months.

70. CRYONEUROLYSIS

71. CRYONEUROLYSIS
• INDICATIONS-
• POSTTHORACOTOMY PAIN, POSTHERNIORRHAPHY PAIN
• INTERCOSTAL NEURALGIA, PAINFUL NEUROMA
• CERVICAL AND LUMBAR FACET AND INTERSPINOUS
LIGAMENT PAIN
• COCCYDYNIA, PERINEAL PAIN
• ILIOINGUINAL, ILIOHYPOGASTRIC, AND GENITOFEMORAL
NEUROPATHIES
• SUPERIOR GLUTEAL NERVE NEURALGIA
• CRANIAL NEURALGIA, SUPRAORBITAL NERVE NEURALGIA
• INFRAORBITAL NEUROPATHY, MANDIBULAR
NEUROPATHY

72. VERTEBROPLASTY
L2
• Bone cement is injected
percutaneously into a
fractured vertebra with the goal of
relieving back pain caused by
vertebral compression fractures
• Recent research has demonstrated
that percutaneous vertebroplasty can
relieve pain from vertebral
compression fractures for up to
nearly three years following the
procedure.

73. CAUDAL EPIDURAL DECOMPRESSIVE
NEUROPLASTY (LYSIS OF ADHESIONS)
Indications-
• Failed back surgical
• Disc disruption
• Mets of spine compression fracture
• Multilevel degenerative arthritis
• Epidural scarring following infection or meningitis
• Pain unresponsive to spinal cord stimulation
• Pain unresponsive to spinal opioids
Contraindications-
• Sepsis
• Coagulopathy
• Local infection at the site of the procedure
• Patient refusal

74. CAUDAL EPIDURAL DECOMPRESSIVE
NEUROPLASTY (LYSIS OF ADHESIONS)
• Neuroplasty is done to repair nerve damage.
• It is a procedure that is used to break up scar tissue that has
formed around the nerve in the epidural space of the spine,
so medications such as the steroid can reach the affected
nerve/nerves so pain and other symptoms will lessen or go
away.
• The actual procedure is similar to a caudal steroid injection
in that a thin catheter is inserted from very low in the spine
and it runs up to the point where there is scarring.

75. CAUDAL EPIDURAL DECOMPRESSIVE
NEUROPLASTY (LYSIS OF ADHESIONS)
• Immediate
complications
• Bleeding in the epidural
space
• Bending of the tip of the
needle
• Penetration of the Dura
• Subdural insertion of the
catheter
• Shearing of the catheter
• Hypotension
• Late complications
• Penetration of the Dura
• Numbness in the
dermatomal distribution
• Temporal anesthesia
• Permanent paresthesias
• Bowel and bladder
dysfunction
• Sexual dysfunction
• Headache
• Infection at the site of
penetration
• Epidural abscess
• Arachnoiditis

76. COELIAC PLEXUS BLOCK
• INDICATIONS-
• To control pain of the epigastric viscera, especially due to
primary or metastatic upper abdominal cancers
• chronic pancreatitis
• for intraabdominal surgery.
• DRUGS UTILIZED-
• For a sensory block-
• 0.25% Bupivacaine with or without 1:200,000 epi.
• For a neurolytic block-
• 50% - 100% Alcohol diluted with sterile water or local
anesthetic.
• Total volume - no more than 15-20 ml for each injection.
• Overfilling the space may cause the alcohol to leak
and spread posteriorly, resulting in alcohol neuritis.

77. COELIAC PLEXUS BLOCK
• At the level of the T12 and L1 vertebrae
• Ganglia lie on each side of L1 (aorta lying posteriorly,
pancreas anteriorly and inferior vena cava laterally).
• Receive sympathetic fibers from the greater, lesser, and least
splanchnic nerves.
• Receives parasympathetic fibers from the vagus nerve.
• Retrocrural and Transcrural blocks-MOST COMMON
• Other techniques include-
Transaortic approach
Anterior approach
Paramedian approach at T-12
Transdiscal approach

78. COELIAC PLEXUS BLOCK
PROCEDURE-
• Prone position
• Lines are drawn connecting the spine of T12 with points 7-8
cm lateral at the edges of the 12th ribs
• Performed with a 15-cm, 20-22 G needle
• Advance the needle at a 45 angle from the horizontal plane
toward the body of T12 or L1 .
• Bony contact should be made at an average depth of 7-9 cm.
• Withdraw the needle and reinsert it at an increased angle of
5-10 degrees to allow the tip to slide off the vertebral body
anterolaterally.

79. COELIAC PLEXUS BLOCK
• Complications
• Related to needle insertion/technique
Pneumothorax
Needle placed too far cephalad
Puncture of surrounding structures, mainly kidneys
• Due to puncture of the aorta or vena cava- bleeding
• Related to sympathetic block/neurolytic agent
• Hypotension -MOST COMMON
• Systemic toxicity
• Transient mild diarrhea (lasting up to 2 weeks)
• Paraplegia (rare but most serious) - related to use of
alcohol damaging the artery of Adamkiewicz

80. • HYPOGASTRIC PLEXUS BLOCK
• Distal ureters, gonads, sigmoidcolon,
vagina, rectum, bladder, perineum, vulva,
prostate, uterus, and the major pelvic
blood vessels

81. OTHERS
• DRYNEEDLING,
• INFILTRATION,
• PROLOTHERAPY,
• ACUPUNCTURE
• RADIOTHERAPY
• OZONETHERAPY

82. Neurosurgical Pain Therapies
Ablative
•Neurectomy
•Sympathectomy
•Ganglionectomy
•Rhizotomy
•Spinal DREZ lesioning
•Cordotomy
•Myelotomy
•Nucleus caudalis DREZ lesioning
•Trigeminal tractotomy
•Mesencephalotomy
•Thalamotomy
•Cingulotomy
•Hypophysectomy
Augmentative
•Peripheral nerve
stimulation
•Spinal cord
stimulation
•Thalamus (PVG-PAG)
stimulation
•Motor cortex/deep
brain stimulation
•Intrathecal/epidural
drug infusion
•Intraventricular drug
infusion

83. Intrathecal Drug Delivery Systems
AKA: Pain pump
Mechanism of Action:
• Drug delivered directly to
the intrathecal space
Drugs:
• Morphine
• Baclofen
• Bupivacaine
• Clonidine
• Ketamine
http://www.medtronic.com/IN/images/intro_intrathecal1.
gif

84. Intrathecal Drug Delivery Systems
PROS
• Short reversible trial
• Delivery of drug
directly to the site of
action
• 1mg IT Morphine =
300 gm oral
Morphine
• Cancer Pain: pain,
toxicity, survival
6mo
CONS
• Short reversible trial
• opioid benefit with
time (40% failure
with time)
• Contraindications to
placement
• Complications
(granuloma)

85. SUMMARY
• Pharmacological management of pain will
continue to have to rely on a multimodal
approach with old medications finding new
uses and indications.
• Many factors must be considered before
deciding on the type of pain therapy to be
provided to the surgical patient

86. P atients
A re
I n
N eed