Introduction to Pain and Pain Management
Pain management specialists, like neurosurgeons, are best equipped to treat pain. Pain specialists use traditional and alternative treatments, medications, injections, exercises, counseling, acupuncture and whatever else is needed to relieve suffering.
Pain is difficult to describe but is immediately obvious. It can be hot, sharp, dull, aching, or heavy. It can be slight or overwhelming.
Pain usually warns us when something is wrong. When it does not go away it can rob us of our productivity, well-being, and our very lives. Pain is perceived differently by every patient.
In 1931, Dr. Albert Schweitzer called pain "a more terrible lord of mankind than even death itself." The International Association for the Study of Pain defines pain as: "An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage."
Pain has become increasingly common and costly. It is a challenge for family, friends, and the doctors who care for pain sufferers.
Pain specialists systematically study pain. They identify the source of the pain, select the best therapies, and strive to help the patient return to a normal work and home life.
The Two Faces of Pain
Pain can be acute or chronic.
Acute means of "sudden onset" or "short duration." Acute pain is most often related to a trauma. The pain is usually sharp in quality and is caused by a disease or injury. Examples include broken bones, cuts, burns, surgery, dental work, and childbirth.
Acute pain may be mild in severity. It usually lasts just minutes or days. It can persist for as long as six months. If it is not relieved, it can become chronic.
Acute pain is often treated with simple pain medications. For mild acute pain, there are many drugs available without a prescription.
Chronic means of "long duration" or "frequently recurring. It is the opposite of "acute." Chronic pain can remain long after an injury has healed. Doctors define chronic pain as lasting longer than six months. For reasons still unclear, the nervous system continues to send pain signals for months or years after an injury. Physical problems including muscle tension, a lack of energy, and changes in appetite are common with chronic pain. Emotional problems such as depression, anger, anxiety, and fear of re-injury are also associated with chronic pain. Chronic pain can stop a person from returning to work and even to their hobbies and pastimes.
Headache, neck pain, arm pain, low back pain, arm pain, arthritis pain, cancer pain, and neurogenic pain (from damaged nerves) are common types of chronic pain.
Psychogenic pain (pain without evidence of injury) occurs occasionally. It is defined as pain which is present even though there has been no injury or damage.
Chronic pain is much more difficult to treat than acute pain and some people choose to live with the chronic pain rather than find treatment. Over 50,000,000 Americans suffer from chronic pain, so you are not alone and you have the same frequently asked questions about chronic pain management as they do.
The pain scale
The severity of one's pain is measured using something called the visual-analog scale (VAS). People are asked to rate pain from zero to ten.
Who to See for PainNeurosurgeons, neurologists, and anesthesiologists specialize in pain management. Some specialty-trained psychiatrists and physiatrists also help to manage pain.
Not all neurosurgeons, neurologists, anesthesiologists, psychiatrists and physiatrists specialize in pain. If you have pain, pick a doctor who specializes in pain, is a good listener, is patient, encourages questions, and is open to suggestions. The medications used for pain can be dangerous. Do not purchase medications "on the street" and do not take other people's pain medications. There is a tendency to see pain medications almost as "fast food." Do not assume that non-specialists can safely provide appropriate pain treatments any more than you might assume that McDonald's food is appropriate for those with special medical needs.
Finding the Cause of Pain
An accurate diagnosis is critical when treating pain. A careful history and a thorough physical examination may find the cause of the pain. If not, doctors are armed with a myriad of tests. Tests for pain include imaging studies (such as X-rays) to functional tests (like EMG) to selective blocks (which find a damaged and painful nerve) to provocative tests (that reproduce the pain).Imaging studies
Some medications can be used to find the source of the pain.
Treatments for Pain
There are many ways to treat pain. The best way to treat a pain depends on whether the pain is acute or chronic. It depends on the severity of the pain.Medications
Over-the-counter medications are for acute pain which is mild to moderate
OTC (or over-the-counter) pain relievers are those which can be purchased without a prescription. These include aspirin (Excedrin, Bayer, Bufferin, store brands of aspirin), acetaminophen (Tylenol, Aspirin Free Excedrin, store brands labeled "non-aspirin" or "aspirin free"), nonsteroidal anti-inflammatory drugs or NSAID's (Motrin, Aleve and Orudis KT, store brand NSAID's), topical corticosteroids (Cortaid and Cortisone), and other topical medications (Lidoderm Patch, Aspercreme, Ben-Gay, Icy Hot and Capzasin-P).
Aspirin controls pain from minor inflammation
Acetylsalicylic acid (ASA), the chemical name for aspirin, is a pain reliever and an anti- inflammatory medication. It is also used for fevers and to prevent blood clots. It acts on inflamed tissues by inhibiting the harmful effects of prostaglandins. The usual dose in adults is from 650 milligrams to 1000 milligrams (extra strength) every four to six hours. In some conditions, such as rheumatoid arthritis, higher doses may be appropriate. Aspirin is one of the safest medications known. Like all drugs, there are potential risks. Aspirin's main side effect is stomach upset. "Enteric coated" tablets, or preparations containing acid inhibitors called buffers, may prevent stomach upset. Do not use this medication with any nonsteroidal anti-inflammatory medications including Motrin. Aspirin may not be used in children with flu-like illnesses, those with allergies to aspirin or any other nonsteroidal, anyone on anticoagulants, anyone with peptic ulcers, or some who have other stomach conditions. Stop the medication and call the doctor if you develop abdominal pain, nausea, vomiting, ringing in the ears, a rash, itching, unusual tiredness, or weakness. Do not use aspirin if you might be pregnant or are breast feeding. Stop this medication at least one week before any surgery. A complete list of side effects and warnings will be found on the package insert.
Acetaminophen blocks "pain messages" in the brain
Acetaminophen, the chemical name for Tylenol, is also an analgesic. The usual dose in adults is from 650 milligrams to 1000 milligrams (extra strength) every four to six hours. It also can help fevers. Unlike aspirin, acetaminophen rarely upsets the stomach. It is also one of the safest medications know but does rarely cause problems. Overdoses of acetaminophen are extremely dangerous. The medication can cause liver disease. Acetaminophen is reported to be safe for short-term use in pregnancy and when breast feeding but check with your doctor first. The combination of alcohol and acetaminophen can be dangerous. A complete list of side effects and warnings will be found on the package insert.
Over-the-counter nonsteroidal medications are a stronger form of aspirin
NSAID's reduce inflammation. Pain caused by inflammation includes muscle aches and stiffness. NSAID's work by reducing the production of hormones called prostaglandins. Unchecked, these can cause pain. The OTC NSAID's are available in prescription strength and there are several stronger medications in this class which are available only by prescription. The risks of nonsteriodals are similar to those of aspirin. The most common problem is stomach upset. Do not use this medication with any aspirin containing medications. Nonsteriodals may not be used in those with allergies to aspirin or any other nonsteroidal, anyone on anticoagulants, anyone with peptic ulcers, or some who have other stomach conditions. Stop the medication and call the doctor if you develop abdominal pain, nausea, vomiting, ringing in the ears, a rash, itching, unusual tiredness, or weakness. Do not use these medications if you might be pregnant or are breast feeding. Stop this medication at least one week before any surgery. A complete list of side effects and warnings will be found on the package insert.
Topical corticosteroids relieve pain from some skin conditions
Hydrocortisone cream is used for skin irritations. It should not be used for prolonged periods. Side effects are rare but can include burning, dryness, irritation, itching, or redness of the skin. The long-term use of this medication can be dangerous and can cause an increased risk of infections, slow healing of wounds, acne, increased blood sugar, fluid retention. This medication may not be safe for pregnant women. A complete list of side effects and warnings will be found on the package insert.
Other creams and patches also help some forms of pain
A number of topical pain relievers are also available without a doctor's prescription. These include creams, lotions, gels, or sprays. They are applied to the skin in order and work locally. Aspercreme and similar aspirin containing topicals have the same mechanism of action as aspirin. Ben-Gay, Icy-Hots, and Tiger Balm act by heating or cooling the skin.
The use of marijuana for pain is controversial. Many people strongly advocate its use and it is claimed to be both safe and effective. It is generally smoked or baked into cookies, candies, or cakes.
Marijuana is very helpful for the nausea caused by AIDS or cancer chemotherapy. It has been studied and shown to be of benefit. Marijuana for medicinal purposes has been legalized in California. The Federal Government does not consider it to be legal and it is classified as a Class I drug (with heroine and cocaine). Doctors cannot easily prescribe marijuana. Prescribing that medication can result in their loss of prescribing privileges.
Marijuana purchased "on the street" may be dangerous. It is often tainted with other illegal drugs or chemicals which can be poisonous. Marijuana use before driving or operating dangerous equipment is not safe.
Caffeine, such as found in coffee or tea can help some pain. Caffeine is commonly added to over the counter pain preparations. If you are using caffeine for pain, make sure that you do not take too much. Using several caffeine containing pain medications together can be dangerous.
Opiate pain medications will almost always cause constipation. A laxative regimen can help you avoid these problems.A daily bowel regimen is as important as your other medical treatments. The overall goal is go have a bowel movement every one to three days. Responses vary. If you experience constipation, try using the guidelines below to find a regimen that works best for you. When pain medications are changed, the laxative regimen may also need to be revised.
Remember that the use of laxatives often must continue. Stopping the laxatives abruptly can cause very severe constipation.
Prescription medications are for moderate to severe pain
Pain relievers and related drugs are used at every stage of the medical treatment of back pain, from the initial onset of acute pain to facilitation of rehabilitation, treatment of chronic back pain and alleviation of pain in cases of failed back surgery.
Prescription non-steroidals are for acute and chronic pain which is moderate (NSAID’s)
Ibuprofen (Motrin) and naproxen (Naprosyn) are pain medications which are available over the counter in low doses. In higher doses they require a prescription. Etolodac (Lodine) and celecoxib (Celebrex) are some of the stronger non-steroidals which always require a prescription.
Non-steroidals are all relatives of aspirin and are very safe. These medications are not sedating and are not addictive. You may work or drive a car after taking these drugs. The most common side effect from non-steroidals is stomach upset. They can rarely affect the kidneys and liver. The recently introduced COX-2 inhibitors, including Vioxx, Celebrex, Mobic and Bextra, are controversial. They may be better for those patients with ulcers but increase the risk of stroke and heart disease. Vioxx has been withdrawn by the manufacturer at the request of the FDA. Celebrex now carries stern warnings. Celebrex should only be used when there is no alternative.
Short acting narcotics are for severe acute and chronic pain
Opioids (also called narcotics) are similar to our bodies’ own internal pain relieving hormones which are called endorphins. The first man-made opioids were derived from the opium poppy. There are now hundreds of these medications available. They all contain natural, synthetic or semi-synthetic opiates. Opioids are divided into two groups: short acting and long acting. The short acting opioids are most often used for acute pain, such as short-term pain after surgery.
The stronger drugs in this group work better but have more side effects. All are sedating and addictive. All cause constipation and some cause nausea. You cannot drink or drive or use machines after taking these drugs. All of these medications are addictive. On the other hand, they are extremely good at relieving pain. Codeine, Vicodin, Norco, Percocet, morphine and Dilaudid are all examples. Codeine is one of the least addictive and Dilaudid is one of the strongest but most addictive.
Long acting narcotics are for chronic pain
Long acting opioids (narcotics) often contain the same ingredients as their short acting cousins. The long acting versions are designed to provide a timed released dose over a longer period. The medications last for many hours or even several days. They are used for chronic pain. They have the same side effects as the short acting opioids with several exceptions. The most important problems with these drugs include excessive sedation, addiction potential, and a greater risk of dangerous overdose. Examples include Fentanyl, oxycodone (OxyContin), and MS Contin.
Muscle relaxants are used for muscle pain and spasm
Seizure medications help some types of chronic pain or nerve pain
Anticonvulsants are drugs used to treat seizure disorders. Some of these medications are effective in treating pain as well. The exact way in which these medicines control pain is unclear but it is thought that they minimize the effects of nerves that cause pain. Some examples include Tegretol, Neurontin and Lyrica. In general they are well tolerated. Side effects include drowsiness, dizziness, fatigue, nausea, and occasional other side effects.
Antidepressants treat chronic pain, especially when it causes depression
Antidepressants are drugs which are usually for emotional conditions caused by abnormal levels of by neurotransmitters (natural chemicals) in the brain. These medications can increase the availability these essential chemicals. The same medications can treat certain kinds chronic pain, especially neuropathic (“nerve”) pain, that does not respond to other treatments. These drugs work only if used consistently for several weeks. In general, antidepressants have fewer long-term side effects than other pain medicines. Generally, SSRI’s and SSNRI’s have fewer side effects than tricyclic antidepressants. They are typically non-sedating (with some exceptions) and do not interfere with work or driving. The most common side effects with antidepressants are blurry vision, constipation, difficulty urinating, dry mouth, fatigue, headache and nausea.Some antidepressant medications include:
Prescription corticosteroids inflammation and pain that is caused by swelling, redness, or itching. Corticosteroids are also used to treat allergies. When used to control pain they are generally given in the form of pills or injections. Examples include: Deltasone, Hydeltrasol and Solu-Medrol. These are strong medicines and may have side effects, including weight gain, upset stomach, headache, mood changes, trouble sleeping, and a weakened immune system. To minimize these potential side effects, corticosteroids are prescribed in the lowest dose possible for as short of a length of time as needed.
Specific medications for special problems
Certain medical problems can be treated for certain medical problems. For example, calcitonin can be used to treat bone pain due to cancer. Hormone therapy can relieve pain due to other tumors.
Other prescription pain medications
A great number of other medications are available for pain. For example, Lidoderm patches are used for local pain in an extremity or a small area of skin.
Several different medications may be combined
For example, non-steroidals, muscle relaxants, and short acting opioids are used together for acute back pain. For chronic pain, long acting opioids can be combined with antidepressants or anti-seizure medications. For neuropathic pain, seizure medications can be used in combination with non-steroidals. Cancer pain can be aided with long acting narcotics in combination with specific therapies targeting the tumor.
Noninvasive, non-drug techniques for pain management
There are many pain treatments which do not involve medications. Non-drug treatments can help headache, back, and neck pain. The most widely accepted include:
Needle Procedures for Pain Management
These procedures are pain treatments involving an injection or a minor surgical procedure. There are a multitude of options for neck and back pain. Some of the most popular include the following.
Most injection procedures involve placing local anesthetics (like Novocain, Lidocaine, or Marcaine) and steroids (like Solu-Medrol or Depo-Medrol) into a muscle, around a nerve or into a joint. These injections can only be performed three or four times a year because of the risks related to the steroid medications.
Trigger point injections
Trigger point injections involve the injection of medication into a painful muscle. They are usually used for muscle spasm that does not respond to medications. Most commonly these are used to decrease painful spasm in the muscles of the neck, shoulders or low back.
It is possible that a nerve (or group of nerves) can be so damaged as to cause pain. Nerve blocks -- injecting medications into the nerve -- can alleviate the pain. By injecting the nerve it is possible to kill the pain. One of the most common nerve injuries is an occipital nerve injury. The occipital nerve is often damaged when there is spasm in the neck. Occipital nerve injuries can cause headache. Injecting the nerve can give almost immediate relief of pain. Injections here can give long term or permanent relief.
These injections are used to treat neck and arm pain or back and leg pain. A needle is carefully placed in the space around the nerve roots and spinal cord in the neck or low back. The local anesthetic provides pain relief for the first several hours and the steroid then provides pain relief for weeks to months. The injection may not last forever but it can block the pain long enough to let the body heal completely.
Selective nerve root blocks
These are similar to epidural injections. Instead of placing the pain medicine in broad areas to cover many nerves, the medicine is precisely injected around just a few damaged nerve roots. For example, if there is a bad disc pinching the L5 and S1 nerves, it is possible to block just those two roots.
The sympathetic nerves are those which control basic bodily functions. Occasionally pain can be caused by abnormal sympathetic nerve function. It is possible to block the nerve ganglia in the neck or the abdomen to control pain deep within the body.
Facet joint blocks
The small joints of the spine can cause a great deal of pain. When arthritis or injury damages these small joints, pain in the midline, and pain in an arm or leg is not uncommon. By numbing the joint, it is possible to relieve the pain.
Other pain blocks for joints
Like the small joints of the spine, the larger joints in the arms and legs can be damaged by arthritis or trauma. When injured and painful, these joints can be helped by steroid injection. In addition to treating the pain, steroid injections can improve range of motion, strength, and even dexterity.
Other Minor Pain Procedures
Nerve blocks work for a period of weeks or months. When blocks are successful, but when the pain returns, it is possible to do something more long lasting. Permanently deadening the painful nerve with heat produced can give long term relief. The procedure is no more complex than a needle injection but can be far more gratifying and durable.
A nerve that is causing pain can and cannot be treated with medications or injections can be removed. Removing a small peripheral nerve is a minor procedure. In some cases a neurectomy can give permanent relief of pain.
Surgically implanted electrotherapy devices
TENS units can give relief on a temporary basis. When TENS units are helpful but are not enough, it is possible to use a permanent implantable stimulator. Implantable spinal cord stimulators (SCS) and implantable peripheral nerve stimulators are each designed to treat pain in specific ways. Each of the stimulators is programmable and each can be adjusted by the patient. The devices can be turned up when is pain is more severe and turned down when symptoms subside.
Implantable opioid infusion pumps
Long term opioids are often helpful for people who have chronic pain. The same medications can cause significantly side effects. For those whose pain can be treated with opioids, but who cannot tolerate the side effects, there is a possible alternative. It is possible to inject the pain medications and treat the pain without the side effects. Opioids can be injected into the space around the spinal cord. The pain is relieved. There are rarely side effects. A pump is implanted, can be adjusted, and can control the pain. The amount of pain medication is adjusted by the patient depending on the severity of complaints.
Spinal Cord Stimulation
Spinal cord stimulators are devices that block pain signals before they reach the brain. They do this by sending low-level electrical impulses to the space around the spinal cord.
In the procedure, a device like a transistor radio is inserted under the skin of the abdomen. It is connected to wires that also run under the skin. The wires go to the back where they block the pain.
Spinal cord stimulation is helpful when other treatments have fail and when surgery does not help.
Epidural lysis of adhesions
Arachnoidis, or scarring and inflammation of the nerve roots, may result from injury or surgery. It can cause pain, numbness or weakness. The scar tissue is often visible on MRI scan. Scar tissue can be seen by inserting an endoscope into the space around the nerve roots. Using the same instrument, it is possible to break up the scar tissue. This procedure, called a lysis of adhesions, is most often done using a Racz catheter. It can be of benefit but remains controversial. Many insurance companies consider it to be experimental.
Intradiscal electrothermal therapy (IDET)
Discs are the cushions between the vertebrae. Damaged discs cause pain. IDET uses a heating coil to strengthen the annulus or capsule of the disc. At the same time, painful nerves are blocked.
IDET is an outpatient procedure done under local anesthesia. It gives relief for six or more months when successful. Studies regarding long term results are ongoing. Many insurance companies do not pay for this procedure.
This newer procedure utilizes a high temperature radiofrequency needle. It is similar to IDET but also can partially decompress the center of the disc. It relieves the pain caused by a degenerate disc nucleus and may help in some cases of “pinched nerve.” Long term studies have not been completed. Like IDET, insurance companies often do not pay for this procedure.
More Major Pain Procedures
Peripheral nerve root decompression
Nerves can be compressed and damaged in a number of locations. The commonest sites are the carpal tunnel and the cubital tunnel. If conservative treatments, medications, and pain blocks do not work then it may be necessary to decompress the damaged nerve. There are numerous nerves which can be compressed, including nerves in the legs and occasionally nerves in other parts of the body. The decompression of a peripheral nerve is a relatively minor surgical procedure.
Spinal nerve root decompression
If the compressed nerve is in the neck or low back, it is possible to decompress the nerve without disturbing the other spinal nerves or normal discs. One can, using microsurgical techniques, remove the bone spurs or fragments compressing the nerve and causing pain in the neck or pain in the back. The decompression procedure typically takes approximately one hour.
Decompression for spinal stenosis
The X-stop is a device that allows some patients with spinal stenosis at one or two places to avoid invasive surgery. It can be done outpatient and with minimal anesthesia. The X-stop operation, unfortunately, cannot be done for those with problems at more than two levels or those with arthritis at the lowest (L5-S1) level.
Microdiscectomy (cervical or lumbar)
Pinched nerves in the neck and back are among the commonest causes of pain. When a broken disc is causing the pain, the bad piece of the disc can be removed through a tiny incision. It does involve surgery, but in most cases the procedure is done in an outpatient center. Patients may go home a few hours after microdiscectomy. The entire disc is not removed. “Bone-on-bone” pain is not a problem with this approach.
Discectomy (cervical, thoracic, or lumbar)
In cases where a disc is painful from severe damaged, or when the broken part is very large, more of the disc can be removed. A slightly larger skin incision may be needed but hospitalization is most often not required. “Bone-on-bone” pain is still not a problem.
Anterior discectomy (cervical)
Small painful discs in the neck can be removed from the back or from the front. The discectomy procedure from the back is called “posterior.” When done from the front, the procedure is called “anterior.” Anterior discectomy is less painful. It can be done with or without replacing the disc. By replacing the disc, the space between the bones is preserved and there are fewer problems. The disc can be replaced with either bone or an artificial disc. The bone replacement heals about as quickly as the artificial disc and has a proven track record of success. The artificial disc is new and still not entirely proven. Artificial discs may decrease the chance that other discs in the neck will need surgery in the future.
Anterior discectomy (thoracic)
Thoracic discs are uncommon. Surgery for discs in the middle of the spine is more risky than in other areas. If a thoracic disc surgery has been recommended, a second opinion would be a good idea. The surgery is done through the chest like a heart surgery. Although it can be done with endoscopes, it is still a major undertaking.
Anterior discectomy (lumbar)
Anterior lumbar discectomy for pain is most often used when a fusion is also needed or when there is a tumor. This more major approach, however, is best when there is instability. Where once it was necessary to do a very major operation from behind, instability can now be treated using this less invasive approach. The disc can be replaced. When a replacement is needed it is possible to use either bone or an artificial disc. Bone is best when there is instability. Artificial discs may be better when the disc is painful and degenerate but not unstable. Artificial discs are new. The risks remain uncertain. Artificial discs may decrease the chance that other surgery will be needed in the future.
Posterior fusion (cervical, thoracic, or lumbar)
Fusions are operations for unstable or “broken” areas of the spine. They are sometimes needed if a tumor is present. This is a more major operation but remains the “gold standard” for certain types of pain. When a disc is so badly damaged that it cannot be repaired or replaced, it is possible to reconstruct the entire area by removing the disc, inserting metal hardware, and allowing the two vertebra (on either side of the bad disc) to grow solidly together.
Anterior and posterior fusion (cervical, thoracic, or lumbar)
The most severely damaged discs sometimes require a two stage surgery where the front and back sides of the disc are repaired. The chance of a successful repair is greatest using this combination of approaches. Although more major than either anterior or posterior surgery alone, the risks are still low. Blood transfusions are extremely rare. The rate of success is higher.