PAIN RELIEF: A MULTIDISCIPLINARY APPROACH

By: Frank Adipietro, MD

What was the worst pain you can remember? Was it childbirth? Kidney stone years ago? Or the time you scratched the cornea of your eye?

Unfortunately, it is unusual not to have experienced some sort of pain at some point in your life. Mercifully though, the relief always came. The stone passed. The baby was born. Doctors call these types of pain, acute pain.

The body sustains an injury and will likely heal itself. However, if the healing process is protracted or incomplete, the pain becomes chronic. Chronic pain is different. Chronic pain lingers. Pain signals in the nervous system fire for weeks, months or even years.

As with all chronic illness, long lasting pain will lead to depression, insomnia, isolation and hopelessness. The treatment of chronic pain requires a multidisciplinary coordination, the specialists often involved in this type of care include: the family practitioner, orthopedist, neurologist, neurosurgeon, psychiatrist, physical therapist, or for cancer related pain, a hematologist oncologist, as well as a pain management specialist.

Often, the family practitioner performs the initial evaluation on patients who first seek medical treatment for back pain, neck pain or shingle pain, for example. Eventually, there may be referrals to other specialists. Physicians must educate the patient and their family members to understand the disease process, prognosis, causes of pain as well as the numerous and varied steps taken to undo what pain has done. This is why a good patient/doctor relationship is critical to the overall success in these cases.

When pain is constant and does not subside, a patient may be referred to a physician who specializes in the management of pain. Frequently, these are medical doctors who practice anesthesiology as a primary specialty and have extensive fellowship training in pain management.

Prior to 1993, fellowship training was not a requirement. Now, however, subspecialty training is part of every residency program. A pain management specialist is integral to the treatment plan and ultimate disposition. The Pain Management Center at Eastern Long Island Hospital offers these sophisticated treatments for pain management services. Information about acute and chronic pain management may be obtained by calling (631) 477-5119

CHRONIC PAIN: TREATMENTS TO IMPROVE QUALITY OF LIFE
by Frank Adipietro, MD 

Low back pain is an extremely common problem seen in your local emergency room as well as a frequent cause for missed workdays, second only to the common cold. If you have ever experienced an acute episode of low back pain, you will appreciate how doing daily activities seems nearly impossible.

The good news is that most acute cases are not serious and respond to simple pain management treatments. Unfortunately, some pain can be severe and extremely debilitating. This pain can limit activity, reduce work capacity, and alter the quality of life.

What are the primary causes of back pain?
 Muscle strain often occurs when the muscles of the lower back are poorly conditioned and subsequently overused. Herniated discs, sciatica (pinched nerve), spinal stenosis (arthritic back) and age related degeneration of the discs (degenerative disc disease) are other reasons for chronic back pain. Muscle strain is most amenable to physical therapy or rehabilitation. A short period of rest and medication to diminish inflammation is usually the first treatment option. As the initial pain eases, a rehabilitation program will strengthen back and abdominal muscles, increase flexibility through stretching, and, in some cases, include a weight loss program. I

f the initial pain persists, or physical therapy proves to be too uncomfortable, further testing with a MRI or CT scan may be necessary. A consultation with an orthopedist or referral to a pain management center may also be indicated. A pain specialist may suggest epidural steroid injection (ESI) as a treatment option after evaluation. Epidural steroid injection is a safe treatment modality, successfully used for over 40 years for back pain. The injection contains a powerful anti-inflammatory agent, cortisone, which is placed into the epidural space, located around the spine. ESI is a common procedure, and because of low risk and low incidence of problems is a reasonable alternative after other conservative therapies have failed to provide any measurable relief.

ESI is performed as an outpatient procedure without sedation in about 5 to 10 minutes. It is usually no more uncomfortable than having blood drawn. The main goal is to shrink the swelling in herniated discs, around a pinched nerve, or diminish the inflammation associated with some forms of spinal stenosis. Improvement after the first treatment may be immediate or may take up to two weeks. Patients are advised to rest on the same postoperative day.

Gradually, normal activity should resume when coordinated with physical therapy. Physical therapy should be better tolerated after the injection. Generally, an accepted practice is to repeat the injections two more times over the next two months for an additive effect. Initially, weekly postoperative follow up will gauge clinical response as well as side effects. Adverse reactions and side effects are rare. Some include fluid retention, acne, headache, infection, and bleeding. Clinical response varies from partial to complete relief in a large number of patients to a small percentage with no real improvement. If the injections provide little or no relief, surgical evaluation may be the next option. If a surgeon has seen the patient prior to the pain specialist, frequently a trial of epidural injections will be prescribed as an alternative before surgery is seriously considered.

Similar pain management procedures are prescribed for head and neck pain, shingles, trigger point pain, and sacroiliac arthritis. These and other treatment modalities are available at the Pain Management Center at Eastern Long Island Hospital. For more information, call (631) 477-5119.

MINIMALLY INVASIVE RELIEF OF LOW BACK PAIN
By: Frank Adipietro, MD

Agonizing and sometimes debilitating, back pain can be experienced by people with contained herniated discs, an injury that strikes nearly one and a half-million Americans each year. Commonly referred to as a "thrown-out back" or "pinched nerve," this injury can be accompanied by intense pain in and around the affected disc as well as in surrounding areas of the lower back and legs.

A disc, sandwiched between the spinal vertebrae (back bones), is composed of two parts: a hard protective outer shell called the annulus, and soft, spongy tissue at the center called the nucleus. A healthy disc acts like the shock absorber of an automobile, providing a cushion against jolts caused by simple movements like running or jumping. If the annular ring, or the protective shell of the disc, is damaged by injury or weakened by normal aging processes, a portion of the shell can give way to pressure from the central spongy nucleus, causing an outward bulge. It is this unnatural bulge, or "herniation," that is often responsible for the patient's back or leg pain. Typically a bulge will put pressure on either an adjacent nerve root or on the spinal cord. It is this compression of the nerve pathway that causes the patient to feel pain in the parts of the body served by the nerves.

For example, when the spinal cord is compressed, pain is felt in the back, whereas nerve root compression is accompanied by pain in both the back and legs. A technique called percutaneous disc decompression works like letting air out of a bicycle tire. By removing tissue from the center of a disc there is a reduction of pressure within the disc. This then leads to a reduction in the pressure that the disc applies to nerve roots or the spinal cord. The disc decompression is performed through a minimally invasive catheter or thin needle. This type of procedure, performed through the skin, or 'percutaneously', minimizes trauma to the patient leading to shorter hospital stays and faster recovery compared to traditional open surgical techniques. Usually the patient is home 2 hours after the procedure. Percutaneous disc decompression has been used in the treatment of herniated discs for over 30 years and in over 500,000 patients.

A variety of techniques have been used to decompress discs, including chemical, mechanical, and thermal/heat (radio frequency and laser) methods. While the basic mechanism of percutaneous disc decompression has been well understood, each of the previous methods has had limitations.

No method has adequately addressed all of the issues inherent in disc decompression - until now. The Disc Nucleoplasty procedure is a recent and significant leap forward in minimally invasive disc decompression therapy. Disc Nucleoplasty is performed percutaneously through a small needle, resulting in minimal trauma and fast recovery times. Because of this, Disc Nucleoplasty disc decompression is performed while the patient is awake, requiring only local anesthesia and light sedation. The difference between Disc Nucleoplasty and other methods of percutaneous disc decompression is Coblation® technology. This enables the Interventional Pain Management Specialist to combine tissue removal with thermal treatment to achieve disc decompression quickly, efficiently and safely because the needle tip is kept at a lower temperature than other techniques.

Coblation technology has been used successfully in over 2 million other procedures since its introduction in 1995. Since it’s first application in July 2000, the Disc Nucleoplasty procedure has been used to treat over 20,000 patients. During this time a variety of peer reviewed and published studies have demonstrated both the safety and effectiveness of the procedure. It has quickly become a leading treatment for symptomatic patients with contained herniated discs. Accordingly, it has become a leading method for performing minimally invasive disc decompression, the choice of Interventional Pain Management Physicians across the USA and around the world.

The ideal patient for percutaneous disc decompression suffers from back and/or leg pain caused by a contained disc herniation. The procedure is much like having an epidural steroid injection. First you will be given a local anesthetic and light sedation. Then your Pain Management Physician will insert a needle into the center of the herniated disc. The needle emits radio waves that dissolve excess tissue, reducing the size of the bulge. This relieves the pressure inside the disc and also on the nerves. When the pressure is relieved, the symptoms are relieved. Recovery is rapid and usually occurs within 8-10 days. 80% of properly selected patients will have significant long-term relief of their symptoms.

For more information regarding this procedure call Eastern Long Island Hospital Pain Management and Spinal Diagnostics Center at 477-5119.

Frank Adipietro MD is a Diplomate of The American Board of Anesthesiologists and a Diplomate of The American Academy of Pain Management.