Analgesic Medication Adjustments
Medications are frequently the first line of treatment for pain. Finding an effective medication and dosage takes a trial-and-error approach. Many times, a combination of different types of medicines are required.
Medications for nerve injury (neuropathic) pain:
• Antidepressants or tricyclic antidepressants (TCA's), such as Amitriptyline and Nortriptilne
• Anticonvulsants such as gabapentin, Gabatril orTopomax are useful for pain related to nerve damage
• Local anesthetics, such as intravenous application of lidocaine, tocainide or mexiletine can often provide relief
• Muscle relaxants: This is a group of different drugs that have an overall sedative effect on the body. They do not act directly on the muscles; rather, they act centrally (in the brain) and are more of a total body relaxant.
• Non-steriodal Anti-inflammatory drugs (NSAID's): This is a large class of drugs with many different options. Most episodes of back pain have an inflammatory component; NSAID's work like aspirin by limiting the formation of inflammation but have fewer gastrointestinal side effects (like gastritis or ulcers). Ibuprofen (Advil, Nuprin, Motrin) was one of the original NSAID's and is now available without a prescription.
• Other non-narcotic pain medications: There is a relatively new type of non-narcotic oral pain medication – Tramadol (Ultram) acts centrally (in the brain) to modulate the sensation of pain and has no anti-inflammatory effect.
• Opioid Pain Medications: For severe episodes of low back pain; opioid agents are strong and potentially addictive forms of medication. They are not recommended as sole therapy to treat chronic, non-malignant pain, but are often combined with non-opioid analgesics.
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Epidural Steroid Injections
The epidural space surrounds the cover of the spinal sac and spinal nerves. Usually used for herniated discs, an injection is done under fluoroscopic guidance to the area in question. The steroid reduces the inflammation around the nerves, and decreases the pain. Generally, a series of three injections is done for a course of treatment.
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Facet Joint Injections
Facet joints connect two adjacent vertebrae. Pain caused by the facet joints, usually as a result of arthritis, can occur in the cervical, thoracic or lumbar spine. Typically, more than one level is injected, under fluoroscopic guidance.
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Intradiscal Electrothermal Therapy (IDET)
This is for lower back pain associated with degeneration tears of a lumbar disc. Under X-ray control, the doctor introduces a hollow needle into the disc. An electrothermal catheter is passed through the needle to the damaged area and slowly heated to 90 degrees C. The collagen fibers of the disc will contract and thicken with the heat, closing any tears in the disc and cauterizing nerve endings.
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Pain Pumps and Spinal Cord Stimulators (Implantable systems)
When oral medications and/or nerve blocks do not sufficiently control the pain, implantable systems interrupt the transmission of pain signals from the spinal cord to the brain.
• Spinal Cord Stimulation (SCS) introduces low levels of electrical current to the dorsal portion of the spinal cord. It is implanted with a surgical procedure, and may require an external power source. Current medical literature indicates that 50-60% of patients will get a 50% or better pain relief, and this can last up to 20 years post-implant.
• Spinal Pumps (Pain Pumps) deliver pain medication (typically morphine) directly to the space around the spinal cord via an implanted pump, and may be used to manage pain from failed back surgery or painful spasticity as seen in multiple sclerosis.
• See more at medtronic.com
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Neurolytic Injection
This is injecting Phenol or Alcohol into a nerve, completely destroying its function and blocking the transmission of pain.
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Radiofrequency Ablation (RFTC)
When a needle is placed with great precision into the proximity of a nerve, then heated in a controlled fashion to disrupt the nerve and stop transmission of pain. Common conditions treated with RFTC include Facet Arthropathy, intercostals neuralgia, and some Intradiscal conditions. A similar technique, Pulsed Radiofrequency, can also be used to treat pain from peripheral nerve damage, spinal root damage, and sympathetic nerve damage.
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Sympathetic Nerve Blocks
The sympathetic nerves run in chains down the spine and branch out to whatever organ they'll affect, and are important for the regulation of blood flow, sweating, and glandular function. They can be a source of chronic pain. Blocks are done at different locations, depending on the site of pain. They can be either diagnostic or therapeutic. If there is relief, usually a series of six blocks is done.
• Stellate Ganglion Block: A local anesthetic is injected in the front of the neck. This helps end pain in the face, arms and hands.
• Lumbar Sympathetic Block: An injection into the nerves in front of the spine, in the lower back. This helps with pain in the legs and feet.
• Celiac Plexus Block: Blocking this plexus brings relief from major pain in the abdomen. This block is usually done under CT guidance.
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Trigger Point Injection
Injections into spasmed muscles helps relieve the spasm. They are particularly effective in patients with fibromyalgia and myofascial syndrome.
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Kyphoplasty and Vertebroplasty
Reserved for vertebral compression fractures that fail to respond to conventional medical therapy, or when there is no pain relief with analgesics (or their side effects are intolerable), Vertebroplasty is a non-surgical procedure utilizing fluoroscopy (X-ray) to inject medical bone cement into a fractured vertebrae. It usually improves back pain within hours of the procedure.
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