Emile M. Hiesiger, MD

What is Pain Management?

Pain management is the area of medicine concerned with reducing or eliminating the level of pain experienced by patients. Pain is controlled by two means. First, the amount of pain signals that enter the spinal cord and subsequently reach the pain processing centers of the brain may be reduced. Second, the pain processing system within the spinal cord and brain may be made less effective. It then processes pain signals in an attenuated fashion, as if a “brake” is applied to a rapidly firing motor. These two pain reducing objectives may be reached through medication and some interventional procedures. Biofeedback and behavioral therapy may also help achieve the second objective

The main focus of pain management specialists is the treatment of chronic pain—that which continues for more than three months. Successful pain management should be a main goal of any physician, health care professional, or normal layman. It is not only humane but actually prevents brain damage. Untreated chronic pain causes nerve cells, in areas of the brain involved in suppressing pain, to “wear out” and shrink. However, once successful pain management is achieved, these areas may become partially restored to normal function and their cells regain normal size. Obviously, pain relief also is cost effective if instituted early. It keeps people functioning as psychologically intact, economically viable members of society.

The Pain Matrix

Pain is an unpleasant sensory or emotional experience not necessarily associated with bodily damage. (For example, not all headaches or muscle pain are associated with damage to tissues—at least as far as can be determined in careful study by modern scientific methods.) Pain is a vital physiological adaptation enhancing survival. It tells us that our body is being damaged. Pain is processed in the group of brain structures that process pain, the pain matrix, allowing you to characterize both the intellectual and emotional reactions to pain. The first is characterized by a precise, calm description of pain such as: “there is a small pin prick on my left thumb, creating pain of moderate severity—a scale of 4/10.” The second is exemplified by a patient screaming “don’t ask me what it feels like — just stop it. It hurts like hell.”

The matrix also is responsible for quantifying pain—for example, determining how your pain fits on a 1-10 scale. The matrix also allows us to do something quickly to stop the damage (running from a burning building), remember what caused the damage (fire), fear it, and develop strategies to avoid a specific pain inducing situation (don’t decorate your Christmas tree with real lit candles) in the future. Pain is divided into 1) musculoskeletal pain associated with damage to muscles, bones, joints, and ligaments; 2) visceral pain, resulting from distention or damage to inner organs (bowels, uterus, prostate); and 3) neuropathic pain.

Neuropathic pain is more complex. It is pain caused by stimulation of, damage to, or dysfunction of nerves in the peripheral or central nervous system. Stimulation of nerves may come in the form of a dental drill, hitting your “funny bone,” or a disc herniation pressing on a spinal nerve root. Damage may come from injuries like a cut with a chainsaw, a crush injury, a virus damaging nerves and causing “shingles,” scars within nerves due to surgery gone awry, diabetes, strokes, or multiple sclerosis. Dysfunction of the nervous system, as used in this context, involves production of pain in the absence of a painful stimulus. Bouts of burning or shock-like pain occurring and then fading seemingly without cause is characteristic of some conditions of neuropathic pain.(Diabetics with nocturnal burning feet, or patients still suffering two years after a bout of shingles, know this all to well.) This pattern of pain invariably suggests that the pain matrix is itself the source of pain. It has become dysfunctional and no longer helps us survive. In fact, a dysfunctional pain matrix, producing pain with no external stimulus, predictably may shorten survival.

Managing Pain

Pain can be “managed“ through analgesic or pain relieving medication or procedures or, preferably, elimination of the cause of pain. The former requires a thorough knowledge of medications and pain relieving procedures. Unfortunately, the management of many patients in chronic pain is far from robustly successful. The preferable alternative to “pain management”—treatment of the cause of pain– requires a vast body of knowledge enabling the correct diagnosis and treatment—assuming a cause is recognized and treatable. Removal of a herniated lumbar disc by an excellent surgeon is vastly preferable to a year of weakly effective medication, epidurals,and physical therapy, followed by unemployment or disability Regrettably, too much “pain management” focuses on ”management” rather than”elimination” of the pain or cure. In this manner patients become chronic pain sufferers and a burden to themselves and society—psychologically, socially, and economically.

This “speciality” is one for which there is no uniform formal training program. Anesthetists, neurosurgeons, physiatrists (rehabilitation doctors), rheumatologists, neurologists, radiologists, orthopedists, psychiatrists, and the non-medically trained psychologists, all may engage in “pain management.”

• Anesthetists

Anesthesiology, unlike most other medical specialties, was and is always devoted to analgesia or the relief of pain. Anesthetists dominate acute pain management—treating or preventing pain occurring from recent or ongoing surgery. However emergency ward physicians, general or specialized surgeons (orthopedists, neurosurgeons, gynecologists, urologists, ENT surgeons, oral surgeons), internists, neurologists, and dentists, for example, depending on the specialty, may treat acute pain due to injuries such as fractures, lacerations, burns, post-operative pain, superficial abscesses of the skin or tooth abscesses, severe ear or sinus infections, disc herniations, and sciatica, as well as painful disorders such as kidney stones, gall stones, gout, angina, severe menstrual cramps, labor, disabling nerve pain, and severe headache.

In the past, anesthetists played a major role in the management of chronic pain. . Anesthetists have a great wealth of knowledge of both 1) the properties and duration of action various local anesthetics and narcotics and 2) techniques of giving local anesthetic injections or “blocks.” The word “blocks” describes the action of injected local anesthetics blocking the transmission of nerve impulses in nerves throughout the body, rendering part of the body supplied by the blocked nerve temporarily weak, numb, tingling, possibly painless, covered by warm, blush colored skin, depending on the strength of the local anesthetic used. (Remember how you feel after receiving a local anesthetic when visiting the dentist.) However, the methods of relieving acute pain during and following surgery do not usually succeed in treating chronic pain on a long-term basis. Nor does knowledge of anesthesia prepare a physician for diagnosing painful conditions and reducing pain by treating its cause. (Anesthetic techniques can obliterate the pain of a broken leg completely. However the only sensible means of treating a broken leg in the long run is to set the bone and stabilize it until it heals.)

Today many other medical specialties are involved in the diagnosis and treatment of chronic pain, and a host of new medications and pain relieving procedures that are foreign to the operating room are widely used as well.

• Neurosurgeons

Neurosurgeons once used techniques to destroy or lesion, completely or in part, nerves carrying pain impulses to or within the spinal cord and brain. Lesions have been made made using either radiofrequency induced heat or freezing probes to injure nerves in a precise, focused manner. Lesions of the brain or cord are seldom used today. These cord or brain lesions have been supplanted because of better pain medication which blunts pain processing by the nervous system with less side effects, more available techniques of delivering pain medication to either the site of pain (local patches), or to the brain and spinal cord where pain is processed. Lesions of nerves outside the cord and brain were also developed by neurosurgeons. These were and still are used to control pain emanating from painful joints of the spine and other parts of the body, certain kinds of headaches emanating from the neck, and a particular form of debilitating facial pain. For cancer patients in pain, better chemotherapy, radiation therapy, and dedicated physicians recognizing and treating the cause of cancer pain have made a tremendous positive difference. These were and still are used to control pain emanating from painful joints of the spine and other parts of the body, certain kinds of headaches emanating from the neck, and a particular form of debilitating facial pain.

Today, certain anesthetists, physiatrists, and I, trained as a neurologist, expanded our pain relieving repertory to include some or all of the lesions discussed above. (I utilize all of them routinely.) Diagnostic and therapeutic blocks to identify sources of pain or provide short term relief are routinely performed more safely and accurately, using ultrasound, fluoroscopy, and CT guidance for needle placement and injection of medication deep into the body. Short term relief may be appropriate and sufficient especially in conditions which may heal over several months, such as a small disc herniation. Transient relief may also help a patient travel cross-country to a wedding in spite of sciatica due to a disc herniation or stenosis (arthritic narrowing of the spine) that may require surgery upon return from the trip. The above physicians obviously also use pain medication of various types in their treatment armamentarium.

Neurosurgeons later used devices (brain, spinal cord, or peripheral nerve stimulators) to stimulate pain suppressing pathways in the nervous system, treating intractable pain following nerve damage and failed back surgery, for example. They also implanted pumps which delivered medication into the covering of the spinal cord. This medication either reduced pain of various causes or, alternatively, painful tightness in muscles—spasticity—due to excessive signals from a damaged brain or spinal cord. (Trauma to the brain or spinal cord is a condition potentially causing spasticity, potentially relieved by pumps delivering anti-spasticity medication.) Some anesthetists also implant pumps and spinal cord stimulators. I have, but no longer do so, simply because my practice population doesn’t require this kind of treatment.

• Physiatrists

Physiatrists, or rehabilitation specialists, treat pain due to sports injuries, sore muscles, various spinal structures, painful sacroiliac joints, spasticity (often due to stroke or spinal cord injury), and recovery from joint replacements. They employ medication, physical therapy, biofeedback (a technique in which the patient learns to reduce pain due to migraines and other headaches, as well as other types of pain), injections into painful muscles and joints, and more recently, some of the pain relieving techniques described above.

• Rheumatologists

Rheumatologists often treat fibromyalgia, a disorder in which multiple sites in muscles are painful in spite of no evidence of muscle abnormality. They also treat painful tendons (structures which attach muscles to bones) and joints, with medication but, at times, with injections.

• Neurologists

Neurologists usually treat pain due to nerve (i.e. from diabetes or disc herniations pressing on spinal nerves) or spinal cord or brain injury (i.e. from accidents or strokes), muscle spasm following disc herniations, and various types of headaches—usually with medications or minor injections. Some neurologists are specially trained to treat cancer pain with medication. As a neurologist, I am the exception. Most of my practice focuses on the application of interventional procedures to evaluate and relieve pain (For more information, go to Discogenic Pain, Synovial Cyst Decompression, and Vertebroplasty under “Procedures.”),  I still depend heavily, however, on my knowledge and skill in using the full armamentarium of analgesic medication. I also routinely refer patients to appropriate specialists for physical therapy, psychotherapy, psychopharmacology, and other medical and surgical consultants where needed.

• Radiologists & Orthopedist

Radiologists and some orthopedists may treat pain due to broken bones from osteoporosis or cancer with injections of bone cement into the broken bones. ( I, a neurologist by training, was actually the first US physician to employ this technique to painful collapsed bones due to cancer, having learned it in the late 1990’s from French colleagues in Lyon and Amiens.) Some radiologists also perform discography or a discogram—a procedure to evaluate if a degenerated spinal disc causes pain (see “Discography” under “Discogenic Pain Procedures”). If the discogram reproduces the patient’s usual back pain, patients are often referred for either a procedure to heat up the disc and make it less painfulor for a spinal fusion. Radiologists and orthopedists may also perform blocks to relieve spinal pain.

• Psychiatrists & Psychologists

Psychiatrists and psychologists may help control the depression and anxiety which occurs due to chronic pain—emotions which in turn make the misery associated with pain greater.

Conclusion 

“Pain management” is an amalgam of poorly linked specialties, each one often viewing pain through its own specialty-colored spectacles. With most -not all- consultants, each one has its own hammer looking for its own nail. If you fit into the “specialty box” of one of the specialists above, and your treatment is reasonably successful, at least making your pain quite tolerable, then bravo. “Quite tolerable” means allowing you to continue your life with little, if any, diminution in its quality, while also allowing significantly more independence from a pain management practice. If not, then find a physician who can do so and don’t give up until you do. The vast majority of chronic pain can be successfully treated. Better yet, for some chronic pain patients—those with pain persisting beyond three months—a source of the pain exists that can be eliminated—usually by surgery. .Find a physician who not only can control your pain, but efficiently determine if it is caused by a curable problem and then carry out or facilitate its treatment.