PAIN MANAGEMENT: A NEW SUPERSPECIALITY
DR.NEERAJ JAIN M.D., FIMSA, FIPP (USA)
“Pain is real &treatable - There is no merit in suffering!”
“For all the happiness mancan gain, is not in pleasure but freedom from pain”.
“ON GLOBAL DAY AGAINST PAIN”
NONSURGICAL TREATMENT FOR LOW BACK PAIN AND SLIP DISCWITH SCIATICA
A young lady came to me with disabling back pain forlast 5 years which made her leave the job. She is not marrying due to sameproblem.
A schoolgirl of 12th class is not able tofocus on studies since past 6 months because of back pain which she relates todance competition preparation 7 months back. She has her board exams comingmaking her & family all the more worried.
“Because of my back pain I can’t play with my childrenor sleep comfortably.” Said a patient.
A patient had to change his job because he could notcommute distances due to back pain.
I keep getting this neck pain as & when I have tospend extra hour on my computer at duty in the bank.
A patient requested me to get rid of her worseningback pain as her daughter was getting married in two months.
“Help me doctor, my married life is getting ruined”said a young back pain patient.
For all these and many like them Dr. Neeraj Jain`smassage is “pain is real and treatable- there is no merit in suffering, as so manygood and effective treatments are now available at specialty pain clinics”. Youmust see a pain specialist if you still suffer from pain after a month ofconservative treatment. Sooner your pain is managed better are the overallresults.
Low back pain has 15-20% incidence in the population.Almost 80% of us are ought to suffer from nagging back pain at some time inlife. “Do not take your back for guaranteed” says Dr. Jain who isheading pain clinic at Sri Balaji Action Medical Institute and Sant ParmanandHospital in New Delhi.
One can avoid back pain with spine care and avoidingrisk factors like osteoporosis, obesity, smoking, prolonged driving, sedentarylifestyle, too heavy or too little exercise, bad spine postures and wrong wayof pushing or lifting heavy objects.
While spinal arthritis is the common reason of youngage back pain at prime of their carriers including some bollywood celebrities,disc diseases including slip disc is prevalent in all age groups, in young agedue to trauma & in old age due to degeneration.
With interventional pain management patients aregetting back to life. It has both diagnostic and treatment value, as sometimesall investigations put together do not give the exact diagnosis.
Newer technologies like ozone injection &nonsurgical disc decompression cures most of the patients of slip disc &sciatica, as ozone’s nascent oxygen atom shrinks the disc so taking awaypressure from pain sensitive nerves. It is a non surgical, outpatient proceduredone under local anesthesia not requiring bed rest for more than day or two& prolonged absence from work realizing the importance of time, at muchlower cost with almost no complications. This procedure is done underradiological guidance for precise needle targeting and best results. Thereafter patient is given advice for spine care & healthy habits. Thistechnology is latest & many people including medical caregivers don’t knowabout it. It has benefited millions in developed world and is now available inIndia also.
This novel treatment avoids the use of surgery in 80%of those who needed it. If despite the ozone therapy thesymptoms persist, percutaneous Drill Discectomy/ Laser or coblation Discectomyare good alternatives before open disc surgery.
Dekompressor:  A mechanical percutaneous nucleotome cuts& drills out the disc material somewhat like morcirator debulking the discreducing nerve compression.
Intrathecal (Spinal) Pump Implants:   Opted when oral narcotics provideinsufficient pain relief or side effects are troublesome in intractable cancer& chronic pain patients. It delivers drug via an implanted catheterdirectly into CSF needing a very small dose (1/300 of oral dose). Theprogrammable pump is implanted in ant. lower abdomen. It delivers the drug asper the patients needs. More powerful analgesia & spasticity control isachieved using lower doses, constant relief & fewer side effects as withoral doses e.g. Somnolence, mental clouding, constipation, euphoria withdecreased chances of drug addiction or misuse.
Neuromodulation Techniques: Spinal Cord Stimulation(SCS) Implants:    Done for FBSS (failedback surgery syndrome) & CRPS (complex regional pain syndromes) in USA. InEurope it is done for chronic intractable angina & pain of peripheralvascular diseases (PVD). The indications are expanding further in chronic painstates. A set of electrodes is placed in epidural space & connected to apulse generator (like a cardiac pacing device) that is implanted in upperbuttock. Low level of electric impulses replaces pain signals to the brain withmild tingling sensation. Trial stimulation is done before permanent SCS leadimplant.
Percutaneous Vertebroplasty / Kyphoplasty:  A Newer Approach to Management of VertebralBody Fractures:    As life expectancy isincreasing so is the incidence of vertebral body (VB) # now being the commonest# of the body. PVP is an established interventional technique in which PMMAbone cement is injected under L.A. via a needle into# VB with imaging guidanceproviding increased bone strength, stability, pain relief, decreasedanalgesics, increased mobility with improved QOL and early return to work.
CHRONIC PAIN: A MENACE
Pain is one of the most common reasons for patients toseek medical attention and one of the most prevalent medical complaints intoday’s world. Chronic pain has many causes and can affect any part of thebody. Conditions most associated with pain include arthritis, headache, neckand back problems, cancer, neuropathies eg. Diabetic, chronic regional painsyndromes (CRPS), pelvic pain disorders, fibromyalgia, myofacial pains, herpesand trigeminal neuralgias.
Chronic pain can lead to depression, anxiety, marital& interpersonal problems, decreased productivity, unemployment, compromisedsocial roles, isolation, financial burden, dependence, prolonged analgesicsusage, decreased self esteem with behavioral changes adversely affecting mentaland physical abilities, activities of daily living  & ruining quality of life
Pain still remains inappropriate & inadequatelytreated. Although tremendous scientific & technological advances have beenmade, the knowledge & techniques are highly underutilized. Untreated paindestroys people’s lives. I have had patients come in who couldn’t work or sleepor play with their children. Good pain management gave them their lives back.It is cruel to deny people in pain access to effective pain treatment. Peopleshould not be suffering needlessly.
Thus, pain clinics are specialized areas that are nowassuming the role of an essential service as they meet a need unmet by anypreviously existing medical facility. They help by simultaneously treating thephysical, emotional, cognitive, behavioral, vocational and social aspects ofchronic pain cost-effectively.
Our ultimate goal is to cure & care peoplesuffering from pain, make them productive human beings for the society andincrease their self esteem so that they can live life as normal individuals.
Interventionalpain procedures scores over both medicine and surgery, as they do not have sideeffects like medicines. Surgeries for pain, have now limited indications &usually as a last resort. The interventional pain procedures produce immediate painrelief, can be performed with ease by pain physicians without anesthesia asoutpatient or daycare basis and adequate duration of pain relief obtained andsuitable for surgically unfit & debilitated patients & procedure can berepeated safely if required.
In the absence of proper education among health careprofessionals and lack of awareness in the public mind in India, there ismisuse of painkillers resulting in high incidence of complications likegastritis, kidney failure, bone marrow depression and bleeding from gut whichcan be catastrophic.
The Indian health care scene has a curious mix ofparadoxes. Advances in cardiovascular surgery or high-tech investigativefacilities in India are on par with any advanced country, at least in somecities. Though skills, advanced equipments are available, still pain relief isnot available to majority of needy population. At least a million people inIndia suffer unrelieved cancer pain. The number of people suffering otherchronic pain conditions is anyone’s guess. Paradoxically, India stands highchance to become the health destination for pain management for the world, byusing interventional pain therapies and very effective traditional therapiesunique to India.
Pain is a major symptom of cancer andoccurs at all stages of the disease. In addition, pain is usually a hallmark ofprogression or metastatic spread, and 65 to 85 percent of people with cancerhave pain when they develop advanced disease. In 10 to 20 percent of cancercases, pain is difficult to treat, frustrating, and poorly controlled.Currently, opioid pharmacotherapy is the principal weapon in the fight againstcancer pain but when less invasive treatments are unsuccessful, invasiveinterventions should be added to optimize pain relief. Interventional painprocedures target neural and non-neural pain generators and neural blockadetechniques provide excellent pain relief for neuropathic, sympathetic,nociceptive somatic, or visceral pain. Neural blockade techniques are broadlycategorized into non-neurolytic and neurolytic blocks.
The management of patients withcancer pain can be a challenging task, even for physicians trained in cancerpain management Effectively relieving pain in cancer patients requires a rangeof treatment alternatives, including neural blockade when the patient’s pain nolonger responds to opioid analgesia. The type of neural block selected isdetermined by the location and mechanism of the pain, the physical status ofthe patient, the extent of tumor spread, and the technical skill and experienceof the person performing the intervention. Non-neurolytic blocks can providesafe and effective analgesia for the less serious conditions indicated above.Neurolytic blocks, with their potential for complications, are reserved forselect patients who are unresponsive to standard analgesic pharmacotherapyand/or are at a more advanced stage of disease. However, few would questionthat aggressive intervention is often appropriate. Neurolytic nerve blocksoffer an excellent option for the physician in the fight to control cancerpain. Such blocks can be easily utilized to help provide cancer pain relief inmost of patients at the utmost needed times.
DR. NEERAJ JAIN  M.D., FIMSA, FIPP. (USA)
Senior Consultant Spine & Pain Specialist
Spine & Pain Clinics, RU-23 & LD-122Pitampura, NewDelhi-110088
& HOD Spine & Pain Clinic, Max Hospital,Pitampura,
& Sri Balaji Action Medical Institute
& Action Cancer Hospital
98100 33800 (M),  27341685 (C)
Email – firstname.lastname@example.org
REMEMBER: NO ONEDIES OF PAIN BUT MANY DIE IN PAIN
AND EVEN MORE LIVE WITH PAIN!
Advanced Pain Management doneat Pain Clinics for:-
Chronic Intractable Pain Syndromes
Back Pain / Leg Pain (Discogenic/Spinal CanalStenosis)
Facet Joint Syndrome/Spinal Arthritis
Spine (Axial) Pain (Cervical/Lumbosacral/Thoracic)
Sacroilitis / Strain & Coccydynia
Disc Diseases (Hernia/Prolapse/Rupture/Slipped)
Rediculopathy / Sciatica
Neuralgic Pains / Plexopathies
Herpes Zoster Pain /Neuralgia (PHN)
Trigeminal / Cranial Neuralgias
Spastic Cerebral/Spinal Palsy
Fracture Spine (Compression # of Vertebra)
Reflex Sympathetic Dystrophies (RSD)
Complex Regional Pain Syndromes (CRPS 1 & 2)
Failed Back Surgery Syndromes (FBSS)
Musculoskeletal / Myofascial Pain Syndromes
Vasospastic Ischemic Pains
Cervicogenic / Tension/Cluster Headaches
Post Surgical / Post Traumatic / Sports Injury Pains
Central Pain States
Cancer Pain/ End of Life Pain / AIDS Pains
Chronic Visceral / Pelvic Pain Syndromes
Osteoporosis / Metastatic / Paget`s Disease Bone Pains
Hyperhidrosis (Wet Hands/Underarms/Feet)
Non Surgical Techniques of Specialized
Percutaneous Interventional Pain Procedures
For Diagnostic/Therapeutic/Neurolysis of:-
Diagnostic Epidurography Followed by
Transforaminal / Interlamminar Epidural Medication at
Cervical / Thoracic / Lumbar / Sacral / Caudal Levels
Selective Nerve Root Sheath Block (SNRB)
Provocative Discography & IntradiscalInterventions
Lumbar/Cervicothoracic Sympathetic Blocks / Neurolysis
Percutaneous Vertebroplasty (PVP)
Facet Joint/ Sacroiliac Joint / Piriformis Blocks
Decompressive Neuroplasty / Epidural Adenolysis
Intrathecal Opiate/Baclofen Pump Implants
Spinal Cord Stimulator/Neuromodulation Implants
Cranial Nerves Blocks / Neuroablations
Somatic Nerve / Myofascial / Myoneural Blocks
Trigger Point Injections WithSteroids/Botox/Neurolytics
Stellate/Celiac Plexus/Hypogastric/Impar Neurolysis
Interpleural Catheter /Splanchnic Blocks
Paravertebral / Psoas Compartment Blocks
Shoulder & Knee Joints Blocks
Nerve Sheath & Plexus Catheterisation & Medication
Laser Lessioning / Radiofrequency (RF) Neuroablations