Pain Treatment | Dr. Prem Pillay, Singapore
Introduction and Diagnosis
The most important part of the pain treatment is the correct diagnosis of it. For acute pain problems this is usually straightforward. Acute pain in the limbs, joints and the spine is often related to a sprain consequent to an injury. In severe cases, a muscle, tendon or ligament tear is the reason. In some patients an acute limb pain is from a sudden slipped disc compressing nerve roots.
It is in chronic pain that the diagnosis may be more difficult. Proper assessment by a specialist preferably a neurosurgeon or neuro-spine specialist can help determine the root causes.
Adjuncts to the physical examination include MRI (Magnetic resonance Imaging) scans, EMG (ElectroMyography) , NCS (Nerve Conduction Studies) and selected blood tests.
Pain can be treated symptomatically with pain medications. In general, these fall into two categories : Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Narcotic or Narctoic like drugs. NSAIDs include aspirin, ibuprofen, voltaren and equivalents. New generation NSAIDs include arcoxia and others which are COX-2 inhibitors and have less side-effects like gastric irritation. Narcotics include panadeine, codeine, morphine and pethidine. Intermediate drugs with narcotic like actions but less side effects include tramadol (ultracet). It is usually preferable to start with the mildest analgesics like paracetamol before progressing to stronger medications.
Neuralgic pain can be treated by anti-epileptic medications such as phenytoin, tegretol, valproate, and gabapentin. Pergabilin (lyrica) is one of the newer medications available.
There are specific pain treatment options for specific syndromes that often respond well to specific drugs. Migraine for instance can respond well to anti-migraine medications like imigran. Trigeminal neuralgia often responds to carbamazepine (tegretol).
If back and neck pain treatment is required for a significant slipped or herniated disc, bony spur, spinal or foraminal stenosis, facet degeneration, spinal instability, osteoporotic vertebral body fracture, spine injury or spinal tumor that has not responded to conservative treatment or may potentially cause nerve damage, then a surgical intervention may be necessary. This decision needs to be made by an experienced and qualified neurosurgeon in collaboration with a well informed patient.
Minimally Invasive spine treatments for pain relief include (this is not an exhaustive list) epidural steroid and analgesic blocks, facet blocks, nerve root blocks, spinal cord stimulation, nerve root stimulation, laser therapy, nucleoplasty, vertebroplasty, kyphoplasty and others. In general though these pain relief procedures do not cure the root of the problem which is often spine degeneration. A proper physiotherapy program to strengthen the spine after pain relief is strongly recommended. Multiple pain procedures may be required in some patients. Some patients may be better off treating the root cause of the problem rather than having multiple pain procedures and/or ending up with permanent nerve damage from the root cause of the problem . For example a patient with sciatica and foot weakness from a sequestrated disc herniation may be a better candidate for Microsurgical/Endoscopic microdisectomy than pain relief treatment such as a root block or nucleoplasty.
Trigeminal Neuraliga that does not respond to or where the patient cannot tolerate medications can be treated by minimally invasive options that include Radiosurgery (eg Gamma Knife), balloon decompression, Radiofrequency rhizotomy, or Glycerol ganglion injection. MicroVascular Decompression (MVD) is a specific microsurgical procedure to remove a vascular compression from the Vth cranial nerve which is often the cause of Trigeminal Neuralgia.
Post-Herpetic Neuralgia that is not relieved by medical therapy can be treated by a microsurgical procedure on the spinal cord called DREZ lesioning. Neuropathic pain syndromes are difficult to treat medically. Brain procedures such as Motor Cortex stimulation, Deep Brain Stimulation (DBS) and others have been used with varying degrees of success.