There are three kinds of people,

the scholars,

the seekers of knowledge

and

all the others are a waste of humanity.

Jafar AlSadiq

Dr. Nasir Imran ZaidiConsultant Anaesthetist, Railway General Hospital

Assistant Professor, Islamic International Medical College

Rawalpindi

doctornasir@yahoo.com

This presentation and its relevant material can be obtained by sending an email to doctornasir@yahoo.com

Available to all those who take part in propagation of the knowledge

Chronic Pain Chronic Pain

Chronic Pain define as:

Pain persists beyond either the course of an

acute disease or reasonable time for an injury to

heal

Pain is associated with chronic pathological

process

Pain that recurs at interval of months or year

Chronic Pain SyndromeChronic Pain Syndrome

I Malignant

Cancer pain syndrome

II Non-Malignant

Nociceptive

Neuropathic

Psychogenic

Nociceptive Low back pain Myofacial pain Visceral pain Headache and facial pain Neck and shoulder pain

Neuropathic pain Sympathetically mediated pain Post herpetic neuralgia Trigeminal neuralgia Phantom pain

Modalities of Pain Management Modalities of Pain Management

I Pharmacological

II Anaesthesiologic

III Special technique

* Facet Blocks

* Acupuncture (Gate control theory)

* Cryolysis

* Ablative technique

* Radio frequency

* Physical therapy

PharmacologicalPharmacological

Analgesic

Paracetamol

NSAID Opioids

Co-analgesics

Anti-depressant Anti-convulsant

Contd...

Anesthisiologic Central nerve blocks

○ Spinal ○ Epidural

Peripheral nerve blocks ○ Femoral ○ ICN ○ Others

Autonomic Nerve blocks○ Stellete ganglion ○ Lumber Sympathectomy

Contd...

Special Technique Special Technique Facet block for back pain

Cryolysis for nerve damage

Radio frequency for facet joint / nerve damage

Acupuncture 361 classical acupuncture points lie along specific

pathway or meridians

Ablative neuro-surgical procedure - interrupt

sensory pathways to the brain or in the brain

and brain stem.

Contd...

Low Back PainLow Back Pain

Most common condition seen in the pain clinic

Major causes: Prolapse inter-vertebral disc Facet joint degeneration Sacroiliac joint arthritis Musculoskeletal disorder Miscellaneous

Prolapsed Intervertebral Disk

Management of Low Management of Low Back PainBack Pain

Do not miss a treatable cause of pain in

the rush to treat the symptoms

Pain alone may not justify

decompression surgery like

laminectomy or micro-discectomy

Treatment OptionsTreatment Options

Drug therapy vs nerve block procedure drug therapy NSAID, week opioids & other

support therapyLow morbidity out patient

○ Epidural steroid

○ Facet joint steroid injection

○ Sacroiliac steroid injection

As a first line of treatment

Myofacial Pain Syndrome Pathogenesis

The likely has a central mechanism, with peripheral clinical manifestations.

CausesAbnormal stresses on the muscles from sudden stress on

shortened muscles, leg-length discrepancies, or skeletal asymmetry

Poor posture, static position for a prolonged period of time Chronic infections and sleep deprivation

Anemia and low levels of calcium, potassium, iron, and vitamins C, B-1, B-6, and B-12 are believed to play a role

radiculopathy, visceral diseases, depression, Hypothyroidism, hyperuricemia, and hypoglycemia

Complex Regional Pain Syndrome : CRPS

Recently the sub-committee on taxonomy of IASP has

replaced the terms RSD and Causalgia to Chronic

regional pain syndrome (CRPS)

RSD - CRPS I

Causalgia - CRPS II

Sympathetically Mediated Pain (SMP)

Reflex sympathetic dystrophy (RSD) and causalgia

RSD

A group of condition associated with extremity pain and

autonomic dysfunction

Causalgia

Specific syndrome of burning pain and autonomic

dysfunction associated with major nerve trunk injury.

SMP / SIP

SMP (sympathetically mediated pain) SIP (sympathetically independent pain)

Majority of CRPS are associated with SMP but fewer cases are found to be SIP.

Treatment Options of CRPSTreatment Options of CRPS Drug therapyDrug therapy

Antidepressant Anti convulsant Narcotic analgesic Oral nifedipine Adrenergic blocking agents

Nerve BlockNerve Block Chemical sympathectomy Intravenous regional block (Bier’s Block)

Physical therapyPhysical therapy Tens therapy

Post-herpetic Post-herpetic neuralgia neuralgia Pain in the distribution of a nerve It follows an acute herpetic attack (shingles)

Incidence: 3-4 per 1000

Clinically: Burning pain constant deepache crawling or scratching pain stabbing or shooting

ManagementManagement

Drug therapy (main stay)

Anticovulsant

Anti depressant

Nerve block

Little role

Trigeminal NeuralgiaTrigeminal Neuralgia

Conditions occur more often in Female middle aged

Strictly unilateral, however in 2% it may be bilateral

Pain in the face is characterized by sharp, severe (paroxysmal) and brief lasting no more then a few seconds.

Management of Trigeminal Management of Trigeminal

Neuralgia Neuralgia

Drug Therapy

Anti-convulsant

Anti depressant

Nerve block

Cryo-analgesia

Radio-frequency

Malignant Pain Malignant Pain SyndromeSyndrome

Incidence

70% of cancer patients suffer

from pain as a symptoms

Management Strategies Pharmacological methods

Interventional pain management

neurolytic blocks

Intraspinal drug delivery system

Others

physical therapy

Tens therapy

Pharmacologic therapy Pharmacologic therapy

“Analgesic staircase”“Analgesic staircase”

Strong opioids +/- adjuvant

Weak opioids +/- adjuvant

Non-opioids NSAID +/- adjuvant

Invasive ProceduresInvasive Procedures When pain or side effects persist despite

comprehensive trials of pharmacologic therapy

I Neurolytic blocks

○ Coeliac plexus

○ Hypogastric plexus

II Intra-spinal drug delivery

○ short terms – intrathecal or epidural infusion

○ long term – implants

CONCLUSIONCONCLUSION

Control of pain in chronic pain syndrome can be

achieved in most patients by the application of a

carefully individualized, flexible programme of :

analgesic drugs

Interventional pain management

Certainly, knowledge is a lock and its key is the

question

Quote by: Ja'far al-Sadiqas

The teacher of Jabir ibn Hayyan,

an astronomer, alchemist, Islamic scholar, Islamic theologian, writer,

philosopher, physician, physicist and scientist.