Chronic Pain Management : Non Pharmacological Methods

Dr (Prof) G P Dureja
Director
Delhi Pain Management Centre
New Delhi 110029

Last two decades have seen tremendous advances' in our understanding of

mechanisms that underlie in causation of pain and the treatment of patients with
acute and chronic pain. This has resulted chiefly due to an extensive
experimental and clinical research being undertaken to understand the
pathophysiology of pain..The concept of a Pain Clinic was first advocated by
Bonica in 1950s and further enriched by inputs from Fordyce and Sternbach in
1970s 1,2. It is now widely agreed that Pain Clinics have an important role to play
in the health care systems of the developing countries and cater to a very large
number of chronic pain patients including those with intractable cancer pain. The
pain clinicians in these countries have the dilemma of providing the best pain
treatment but within the resources available for the purpose. Keeping pace with
the technological advances in pain management worldwide, pain clinics in
developing countries are also employing newer methods of pain assessment,
pain imaging and advanced interventional strategies for managing patients with
chronic pain.

Because chronic pain is so complex, there are often multiple treatment goals.
These goals may include more comfort (being "pain-free" is often not possible
when pain has become chronic), better physical functioning, improved coping
and less distress, getting back to work, helping the family cope, and other
positive outcomes. To accomplish these goals, chronic pain often is best
managed using what is called a "multimodality" approach. A multimodality
approach to chronic pain includes a combination of therapies selected from eight
broad categories:

• Drug therapies
• Psychological therapies
• Rehabilitative therapies
• Anesthesiological therapies
• Neurostimulatory therapies
• Surgical therapies
• Lifestyle changes
• Complementary and Alternative medicine therapies
In many cases, a multimodality strategy requires the involvement of several types
of health care professionals -the interdisciplinary team. Effective pain
management is therefore collaborative in nature, involving good communication
among the patient, family, and the practitioners involved in the care.

Pain Management by Rehabilitative Approaches

Some types of pain therapies have been classified as rehabilitative because they
are performed or directed by physiatrists (physicians who specialize in
rehabilitation medicine) or by physical or occupational therapists, or because
they have the specific goal of improving function as well as relieving pain.

Physical therapy (PT)

PT can be an important part of the treatment strategy. PT techniques are useful

in teaching patients to control pain, to move in safe and structurally correct ways,
to improve range of motion, and to increase flexibility, strength and endurance.
“Active" and "Passive" modalities can both be used, but active modalities, such
as therapeutic exercise, are particularly important when the goal is to improve
both comfort and function.

Bed Rest

The use of prolonged bed rest in the treatment of patients with neck and low back
pain and associated disorders is without any significant scientific merit. Bed rest
supports immobilization with its deleterious effects on bone, connective tissue,
muscle, and psychosocial well-being. For severe radicular symptoms, limited bed
rest of less than 48 hours may be beneficial to allow for reduction of significant
muscle spasm brought on with upright activity. Patients should be instructed to
avoid resting with the head in a hyperflexed or extended position. Two days of
bed rest is commonly cited as the appropriate duration for the individual with low
back pain, and though no literature exists to support the use of bed rest in neck
pain disorders, 48 hours would be considered the window for bed rest in
individuals with these conditions, as well.3

Bracing

Immobilization has been used for thousands of years to treat injuries to the
human body. Unfortunately, immobilization may lead to deleterious effects that
may compromise treatment outcome, such as muscle fiber atrophy, decreased
proprioception, and loss of cervical and lumbar range of motion (ROM).4 This loss
may be a clinically significant problem in an individual who already has
compromised muscle function. McPartland et al5 demonstrated atrophy of the
suboccipital muscles along with fatty infiltration in patients with chronic neck pain
as compared with healthy control subjects.

In acute neck pain secondary to whiplash injury, Gennis et al 6 demonstrated no

advantage of a cervical collar in the treatment of patients with soft tissue injury
with respect to the duration or degree of persistent pain as compared with
matched control subjects treated without use of a cervical collar. Existing
literature has failed to demonstrate the efficacy of lumbar bracing as a means to
prevent low back injury in the workplace.7,8

Manipulation & Mobilisation

Manipulative treatment is commonly used in the treatment of patients with neck

pain and associated disorders. Many different types of manual treatment exist,
including soft tissue myofascial release, muscle energy/contract-relax, and high-
velocity low-amplitude manipulation. Soft tissue myofascial release may include
various techniques, including effleurage, pétrissage, friction, and tapotement. It
has been shown to improve flexibility, decrease the perception of pain, and
decrease the levels of stress hormones.9-12

Manipulation and mobilization have gained support in the treatment of patients

with acute low back pain.13 Although several studies have demonstrated the
efficacy of manipulation and soft tissue mobilization in the treatment of patients
with acute low back pain, some have not been found to be effective.14-16 The
current literature is confounded by poor study design, execution, and poorly
quantifiable objective measures. The consensus of the Agency for Health Care
Policy and Research (AHCPR) guidelines13 was that manual medicine techniques
can relieve acute pain and reduce symptoms in the initial 1 to 4 weeks of
treatment..

Traction

Cervical traction is a therapeutic modality that can be administered with the

patient in the supine or seated position. Traction may reduce neck pain and
works through a number of mechanisms including passive stretching of
myofascial elements, gapping of facet joints, improving neural foraminal opening,
and reducing cervical disc herniation.17-18 It has been found to reduce radicular
symptoms in individuals with confirmed radiculopathy and localized neck pain in
individuals with cervicogenic pain and spondylosis.19-20 Cervical traction may be
initiated during physical therapy with the patient properly instructed in home use.
It is not a stand-alone treatment modality and should be done in conjunction with
range-of-motion (ROM) exercises, appropriate strengthening, and correction of
postural issues.

Transcutaneous Electrical Nerve Stimulation

Transcutaneous electrical nerve stimulation (TENS) has been used to treat

patients with various pain conditions, including neck and low back pain. Success
may be dictated by many factors, including electrode placement, chronicity of the
problem, and previous modes of treatment.21 TENS is generally used in chronic
pain conditions and not indicated in the initial management of acute cervical or
lumbar spine pain.22-23 Overall, research is limited in regard to the isolated use of
TENS in the treatment of patients with acute cervical and lumbar spine disorders,
though it has been used in combination with ROM exercises, spray and stretch,
and myofascial release.24,25

Thermal Modalities

Thermal modalities include a variety of methods that produce heating and cooling
of the tissues to manage acute and chronic musculoskeletal pain. Superficial
heat, such as moist hot packs, increases skin and joint temperature and blood
flow, and may decrease joint stiffness and muscle spasms.

Diathermy

Diathermy involves the use of high-frequency oscillating current and ultrasound

(inaudible sound wave vibrations) to create deep heating. The deep heating may
reduce the perception of pain. It is believed to promote healing and decrease
inflammation. While there has not been a great deal of research on the
effectiveness of diathermy and ultrasound for pain relief, it appears that there are
short-term beneficial effects with the use of diathermy and significant
improvement in pain relief with ultrasound, as with other heating modalities

Ultrasound
Ultrasound is a deep-heating modality that is most effective in heating structures
such as the hip joint, which superficial heat cannot reach. It has been found to be
helpful in improving the distensibility of connective tissue which facilitates
stretching.26-29 It is not indicated in acute inflammatory conditions where it may
serve to exacerbate the inflammatory response and typically provides only short-
term benefit when used in isolation. It is perhaps best used in the region of the
upper trapezius or lumbar paraspinals to facilitate active stretching and
strengthening.
Cryotherapy

Cryotherapy can be achieved through the use of ice, ice packs, or continuously
via adjustable cuffs attached to cold water dispensers. Intramuscular
temperatures can be reduced by between 3 °C and 7 °C, which functions to
reduce local metabolism, inflammation, and pain. Cryotherapy works by
decreasing nerve conduction velocity, termed cold-induced neuropraxia, along
pain fibers with a reduction of the muscle spindle activity responsible for
mediating local muscle tone.30-31.

Exercise

Correction of posture may be the simplest technique to relieve symptoms in

patients with nonspecific neck or low back pain, though it is extremely difficult to
change habits. The physician should instruct patients to assume their worst
postural "slump position" with forward protrusion of the head, flexion of the neck,
rounding of the shoulders, and increased thoracic kyphosis and reversed lumbar
lordosis while sitting.

Pearson et al32demonstrated in a trial of repeated neck retractions that ROM was

not affected, but resting posture was significantly improved. Black et al33
demonstrated the effects of sitting posture on neck positioning with increased
lumbar kyphosis resulting in neck extension, whereas sitting erect resulted in
relative neck flexion. Range of motion exercises should be done in a pain-free
range in all four planes of motion (flexion/extension, sidebending, and rotation) on
a daily basis. .

Conflicting literature exists on the efficacy of strengthening exercises in the

treatment of patients with acute and chronic low back pain.34-38 Some of this
conflicting literature is due to poor study design, difficulty in randomization, and
the lack of specific diagnosis in most studies.39-40 There has also been debate
over the merits of flexion versus extension exercises for the treatment of patients
with various low back conditions.40-41 Some studies have shown that flexion
exercises are helpful in patients with posterior element dysfunction, such as
spondylolysis and spondylolisthesis.42
Psychological/Mind-Body Therapies for Chronic Pain Management

Psychological factors are important contributors to the intensity of pain and to the
disability associated with chronic pain. Pain and stress are intimately related.
There may be a vicious cycle in which pain causes stress, and stress, in turn,
causes more pain. Mind/body approaches address these issues and provide a
variety of benefits, including a greater sense of control, improved coping skills,
decreased pain intensity and distress, changes in the way pain is perceived and
understood, and increased sense of well being and relaxation. These
approaches may be very valuable for adults and children with pain

Cognitive-Behavioral Therapy (CBT)

CBT has proven to be effective in reducing pain and disability when it is used as
part of a therapeutic strategy for chronic pain. CBT addresses the psychological
component of pain, including attitudes and feelings, coping skills, and a sense of
control over one's condition. It can provide educational information and diffuse
feelings of fear and helplessness. CBT may include training in various types of
relaxation approaches, which can help people in chronic pain lower their overall
level of arousal, decrease muscle tension, control distress, and decrease pain,
depression and disability43.

CBT has been found to be effective as part of a treatment regimen for a variety of
pain conditions including episodic migraine and chronic daily headache, chronic
musculoskeletal pain, pain in the well elderly, chronic cancer pain, rheumatoid
arthritis and osteoarthritis, fibromyalgia, myofascial temporomandibular
disorders, chronic low back pain, carpal tunnel syndrome pain, and chronic pelvic
pain 44-51 It has been suggested to benefit patients with chronic fatigue syndrome,
irritable bowel syndrome, and anxiety 52-53. Although research into the use of
CBT in children is in the early stages, it holds promise for reducing pain-related
distress in children 54.

Biofeedback

Biofeedback is the use of electronic monitoring instruments to provide patients

with immediate feedback on heart rate, blood pressure, muscle tension, or brain
wave activity. This allows the patient to learn how to influence these bodily
responses through conscious control and regulation. Electromyographic (EMG)
biofeedback, for example, can teach patients how to relax a particular muscle or
how to achieve more generalized relaxation for stress reduction. Biofeedback
has been shown to be effective in the management of migraine headaches,
fibromyalgia, temporomandibular disorders, and rheumatoid arthritis, Raynaud's
disease, tension headaches, headaches in children and the pain associated with
irritable bowel syndrome 43,55-61
.

Advanced Interventional Pain Management

Continuous delivery of opioids by an implanted intrathecal pump provides

excellent pain relief even in refractory cancer pain. Radio frequency lesioning of
sympathetic plexus in patients with peripheral vascular disease and those with
sympathetically maintained pain has simplified the management of these
disorders to a great extent. Intradiscal electrothermal therapy (IDET) is a new,
minimally invasive approach for the treatmentof discogenic Low back pain. Initial
results with this treatment are encouraging, but more clinical studies are needed
to prove its efficacy. It involves percutaneously threading a flexible catheter
(SpineCath) into the disc tissue with fluoroscopic guidance. The catheter is
composed to thermal resistive coil enabling heating its distal part to the desired
temperature Botulinum toxin type A (BTX-A) has been used clinically for relief of
pain in number of disorders believed to be due to overactive striated or smooth
muscles, such as cervical dystonia, spasticity, rectal sphincter spasm with
fissure, achalasia and myofacial pain syndrome. Pain relief is achieved by
reducing muscle hyperactivity and spasm. Thus, based on the needs of the
community, these advanced interventional pain modalities are integral part of
management options offered in the pain clinics across the world.

Radio Frequency Lesioning in Pain Management

Over the years, many techniques have been used to selectively destroy
nervous tissue in the spinal axis, brain and other locations in the body. Of the
various techniques that have been used, the radiofrequency (RF) technique
has proven itself to be the most effective and is certainly the most widely
used(Table 1 ) 62-63.
_______________________________________________________________
Table 1.Advantages of Radiofrequency Ablation

- A new perspective in the management of Acute and Chronic Pain

- Great advantage over conventional neurodestructive procedures

- Provides prolonged and complete Pain relief

- Significantly better Outcome as compared to Neurolysis with alcohol

Radiofrequency (RF) is an alternating electric field with oscillating frequency of

500,000 Hz.Heat is produced around the electrode leading to neuro
destruction. RF is a widely used method for lesioning nervous tissue. The basic
principle of radiofrequency lesions involves the placement of an insulated electrode shaft with
an uninsulated tip into nervous tissue. If an electrical generator source is connected
to this shaft, the electrical impedance of the surrounding tissue will allow a current to
flow from the generator source into the tissue itself. Regardless of current
frequency, when that current flows through a source of resistance heat is
generated in the tissue. Since the current spreads into the tissue as it leaves the
tip of the electrode, the greater density of treatment, as well as the hottest part
of the lesion, will be in the tissue directly adjacent to the tip of the electrode
.With this technique, a very high frequency current is passed down a
thermocouple probe which is inserted through special cannula, fully insulated
except for its tip. When t he current is passed down the thermocouple probe it heats the
surrounding tissues to a temperature which can be totally controlled by the
operator. Thus the nerve can first be located by passing stimulating current down
the thermocouple probe and then a well circumscribed lesion can be produced64

Since myelinated fibres are more resistant to heat than unmyelinated fibres,
differential effects can be produced.
Indications of RF Neuroablation

Radiofrequency neuroablation is frequently carried out for following

conditions :
- Lumbar RF sympathectomy for peripheral vascular disorders and
complex regional pain syndrome (CRPS) of lower extremity
- RF ablation of Gasserian Ganglion or of individual branches for
- trigeminal neuralgia
- Cervical, thoracic, lumbar facet joint RF denervation
- Stellate ganglion lesioning for CRPS of upper extremity
- Cervical thoracic lumbar, sacral rhizolysis
- Sacroiliac joint denervation
- Intervertebral disc annuloplasty in intervertebral disc prolapse

Procedure

RF ablation are carried out in operation theatre (OT) setup under strict aseptic
conditions and in presence of all resuscitation facilities.

The cannula is placed in close proximity to the nerve in question under

fluoroscopic control. The stylet is removed from the cannula and replaced by
thermocouple probe. The operator then attempts to find the nerve by low voltage
stimulation at a frequency 50-100 Hz, strongest possible sensory stimulation at the
lowest possible voltage. If the cannula is actually resting on the nerve, the
minimum stimulation required to produce a discharge is 0.5 mA o r approximately
0.25 V for a standard 500 ohms tissue impedence. Cannula should be within 3
mm of the nerve in order to create adequate lesion indicated by maximum
stimulation level around 0.6V. To ensure that the cannula is not dangerously
close to any motor nerve, low frequency stimulation of 2Hz is given and muscle
twitching is noted. When the operator is satisfied that the needle is safely in
position a radiofrequency current is passed through the thermocouple probe. The
current heats up the surrounding tissues and produces a lesion in the nerve which
has been targeted. The lesion will grow until a steady state is reached. To
ensure adequate lesioning desired temperature of 90°C is required for 60-120
seconds.

The modern thermocouple electrodes are small, quite accurate at measuring

temperature and impedance as well as generating the RF lesion. Newer lesion
generators such as RFG-3C, allow for accurate measurement of impedance,
a broad range of electrical stimulation, highly accurate temperature
monitoring and control of lesion duration. Thus it is an excellent method for
controlling the size of the coagulative lesion. Since the size of the lesion
depends upon the temperature of the lesion itself and since modern cannula
tips are equipped with electrodes that accurately measure temperature.
.

Radiofrequency Ablation vs. Chemical Neurolysis

The advantages of radiofrequency techniques versus other neurodestructive

methods are that 65:

- The lesion size can be adequately controlled.

- Good monitoring of the lesion temperature can be performed with a
thermal coupled electrode.
- Good placement of electrode is facilitated with electrical stimulation and
impedance monitoring.
- Ability to utilize the same radiofrequency cannula for different types of
spinal axis lesions.
- Can be performed under local anaesthesia or sedation.
- Rapid recovery.
- Low morbidity and mortality.
- Ability to repeat radiofrequency lesions if the neural pathway
regenerates.

SPINAL CORD STIMULATION FOR MANAGEMENT OF CHRONIC

INTRACTABLE PAIN

Electrical stimulation for treatment of pain was first documented in 600 B.C.,
utilizing electrical power from the torpedo fish. In 1967 Spinal cord stimulation
was introduced by Shealy and associates66. Their work was based on the “gate
control” theory of pain proposed by Melzack and Wall. With recent advances in
technology, the SCS has become a part of minimally invasive treatment for
controlling intractable chronic pain syndromes. The stimulating electrodes are
placed in the epidural space percutaneously in similar manner as an epidural
catheter is placed. Improvements in hardware design and selection criteria have
enhanced the efficacy of SCS, and success rates of 50% to 70% have been
reported in different series67.

Mechanism of action

The Melzack and Wall “gate control” theory of pain was the foundation for the
first SCS trials. It was based on the idea that stimulation of A-beta fibers closes
the dorsal horn “gate” and reduces the nociceptive input from the periphery.
However it seems that other mechanisms like increased dorsal horn inhibitory
action of neurotransmitters such as alpha-aminobutyric acid (GABA) and
adenosine A-1, the potential activation of descending analgesia pathways by
serotonin and norepinephrine are another explanations for SCS action 68-69

Possible Mechanisms of action of SCS are

- Segmental, antidromic activation of A-beta afferent (gate control
theory)
- Blocking of transmission in the spinothalamic tract
- Supraspinal pain inhibition
- Activation of central inhibitory mechanisms influencing
sympathetic efferent neurons
- Activation of putative neurotransmitters or neuromodulators
The probable mechanism for pain relief in ischemic heart disease is redistribution
of the coronary blood flow from regions with normal perfusion to regions with
impaired perfusion 70.

Patient selection, indications and contraindications

When patient symptoms and sequel of pain can not be controlled satisfactorily
with conventional modes of treatment like non-steroidal anti-inflammatory drugs
(NSAID), weak and strong opioids, physical and occupational therapies and
cognitive and behavioral therapies or side effects of high doses of opioid are
intolerable, then he should be given a trial of SCS. Before SCS implantation, a
psychological evaluation of the patient is recommended.

Patient Selection Criteria

• Most conservative therapies have failed

• An observable pathology exists that is concordant with the pain complaint
• Further surgical intervention is not indicated
• No serious untreated drug habituation exists
• Psychological evaluation and clearance for implantation has been
obtained
• No contraindications such as sepsis,coagulopathy implantation exist. Trial
screening has been successful

Indications of SCS

Failed Back Syndrome

Complex Regional Pain Syndrome of lower extremity

Nerve injuries causing causalgia

Peripheral vascular diseases

Phantom limb syndrome

Chronic intractable angina
1. Patients with complex regional pain syndrome (CRPS) or with neuropathic
pain symptoms of upper or lower extremities are the best candidates for SCS
trial.
2. Patients with failed back surgery syndrome (FBSS) may respond well to SCS.
It has been documented that patients with FBSS respond better to SCS than to
reoperation. This applies in particular to low back pain (LBP) with a radiating
component to the leg. In these patients, the chance of long-term success with
SCS varies from 12% to 88%, with an average efficacy of 59% as indicated by a
systematic review of the literature 71 In addition, 25% of patients may return to
work, 61% show an improvement in activities of daily living, and 40% to 84%
decrease their consumption of analgesics
3 . Diabetic neuropathy may respond well to SCS, but the infection risks in these
patients are higher than in the nondiabetic population.
4. The use of SCS in postherpetic neuralgia is controversial.
5. Phantom limb pain is another indication of SCS
6 Severe peripheral vascular disease is also an indication for SCS. Patients with
advanced peripheral vascular disease who are not fit for surgical management
respond well to SCS, with reported efficacy rates ranging from 60% to 100%.
Besides providing pain relief, SCS promotes ulcer healing and potentially
contributes to limb salvage
7 Ischemic heart disease refractory to pharmacologic and surgical treatments
may respond well to SCS, with reported efficacy rates of 60% to 80% several
years after implantation. These patients have demonstrated a reduction in
anginal pain, decreased use of short-acting nitrates, and increased exercise
capacity72

Advantages of SCS

• Effective alternative for chronic, intractable pain

• Effective alternative to back re-operation
• Reversible alternative to neuroablation
• Cost effective

Contraindications

Infection, drug abuse, and severe psychiatric disease are major contraindications
for SCS implantation.

SCS trial

Before proceeding with permanent SCS implantation, a stimulation trial is

warranted. The trial allows patients to evaluate the SCS analgesic activity in
patients everyday surroundings. The criteria for a successful trial include at least
a 50% pain reduction, a decrease in analgesic intake, and a significant functional
improvement. The SCS trial is a minimally invasive procedure (similar to placing
an epidural catheter), and it can positively predict a long-term outcome in 50% to
70% of cases.
Minimal trial time should be 24 hours, although many centers perform 3- to 7-day
trials. The trial begins in the hospital with proper SCS adjustment, after which the
patient is discharged for several days of home trial. In cases of equivocal results,
the trial time can be extended.

Choice of SCS hardware

The permanent SCS hardware consists of the SCS lead, an extension cable, a
power source, and a pulse generator. The number of electrodes in the lead
varies from four to eight . There are two types of pulse generators :

• the completely implantable pulse generator containing a battery, and

• an Implantable pulse generator supplied by external power through the
radiofrequency antenna applied to the skin.
The implanted pulse generator is more convenient to use and can be easily
adjusted by the patient using a small telemetry device. Patients can turn the
stimulator on and off, and they can control the stimulation amplitude, frequency,
and pulse width..

Implantation technique\

Strict aseptic conditions are paramount for

implantation procedure. For lumbar lead placement,
the patient is placed in the prone position, and for
cervical placement both prone and lateral decubitus
positions are used. Both trial and permanent
implantations are performed under local anesthesia
with light intravenous (IV) sedation. The most
common entry sites are the T 12-L 1 and L1-L2 spinal
inter- spaces for the lumbar area and C7-T1 for the
cervical area (Fig 2 ).

Fig 2 -- Lead Placement & Pulse generator

implantation.

For the percutaneous SCS trial, the Tuohy needle

entry site is at the level of the spinous process below
the desired interspace. It is important to achieve a
shallow entry angle The needle tip should stay close
to midline during insertion. As the needle is advanced
loss-of-resistance technique is used to identify the
epidural space. At this point, the SCS lead is inserted
into the epidural space under continuous fluoroscopic guidance. The curved
stylet, or curved lead tip, allows lead steering. The lead tip during insertion and at
final position should lie at the lateral border of the spinous process on the
ipsilateral side of the pain.
Once adequate lead position is obtained, the trial stimulation is performed. It is
important that stimulation paresthesias provide 70% to 80% overlap with the
patient's pain location. Adequate patient feedback during this stage is important.

The SCS topographic coverage depends on the spinal level at which the SCS
lead tip is positioned. The following landmarks are for orientation only; the
variance can be very high in individual patients. Careful intraoperative mapping is
needed for optimal coverage ("sweet spot placement"). The SCS electrode
placement for various sites of pain is as follows:
Upper extremity: Between C2 and C5. The shoulder area can be difficult to
cover.
Foot: between T11 and L1.
Lower extremity: At the T9-10 level.
Low back: A level between T8 and T10; parallel leads can be used.
Chest: At the Tl-2 level.
Occipital neuralgia: At C1-C2 levels.
Pelvic pain: At S2 to S4, leads may be placed retrogradely.

Complications

The most common encountered complications of SCS are

• hardware failure
• lead migration
• infection
• skin irritation at the IPG site, and
• failure to provide pain relief.

CONTINUOUS INTRATHECAL DRUG DELIVERY SYSTEMS FOR CANCER

AND NONMALIGNANT PAIN

Intrathecal drug delivery has gained its popularity since the discovery of opioid
receptors in the spinal cord 73. It provides targeted delivery of medications and
avoids side effects encountered by systemic administration of drugs. Opioids are
delivered to the intrathecal space via a surgically implanted subcutaneous pump
containing a reservoir for the medication. The pump is easily refilled with
medication every 2 to 4 months depending on the infusion rate

Medications other than opioids have been used recently for intrathecal delivery.
This includes local anesthetics, clonidine, midazolam and baclofen, given alone
or in combination with opioids. Because numerous receptors involved in
nociceptive transmission are located in the spinal cord, this approach seems to
be very promising. The efficacy of intrathecal drug delivery has been shown in
patients with malignant and nonmalignant pain74,75.

The completely implanted intrathecal system has many advantages over the
epidural drug delivery via an external catheter. The epidural route is more costly
because of the maintenance needed for the external system, and it is. frequently
more inconvenient for the patient; therefore, it should be reserved for short-term
use only (less than 3 months). The completely implanted intrathecal delivery is
preferred when treatment is expected to last longer than 3 to 6 months.

Patient selection

1. Cancer pain patients responds well to intrathecal therapy in carefully selected

patients. The following cancer patients might be considered for intrathecal trial:
Patients who develop intolerable side effects to opioids given by oral or
parenteral route (nausea, vomiting, sedation, constipation)
Patients who have a life expectancy of more than 3 months
Patients who have no obstruction in CSF flow
Patients who have neuropathic cancer pain that does not respond to oral
regimen and nerve blocks.

2 . Nonmalignant pain may respond to intrathecal therapy but it should be

considered as a last resort. In general, patients with cancer pain tend to respond
better to intrathecal therapy than patients with nonmalignant pain. Therefore, the
selection criteria for intrathecal therapy for nonmalignant pain should be very
strict. Only patients who have failed nerve blocks, oral medications, physical
therapy, and cognitive-behavioral programs and who have passed psychological
evaluation shou1d be considered for intrathecal trial.

Use of adjutants such as clonidine midazolam etc, intrathecally potentiates

analgesia in neuropathic pain76

Screening

Before considering implantation of intrathecal hardware, patients should undergo

a trial procedure to better assess the odds of a favorable outcome. The actual
trial procedure varies, and no consensus has been made on the best procedure.
Preceding the trial, oral opioids are either discontinued or decreased
substantially. It is important to monitor the patient for signs of respiratory
depression during the trial. The most common screening methods are the
following( Flowchart):
An intrathecal trial is performed by implanting the temporary intrathecal catheter.
Pediatric or standard epidural catheters can be used for this purpose. After
intrathecal placement, the catheter is taped to the skin. The medication bolus is
given first, followed by continuous infusion via an external infusion pump. The
intrathecal opioid dose starts at 1/300th of the usual oral daily dose. The patient
pain intensity score, functional status, and use of medications for breakthrough
pain are monitored during the trial period.
An epidural trial is performed in the same way as the intrathecal trial, except that
the catheter is placed in the epidural space. The administered epidural opioid
daily dose is higher than the intrathecal one, representing 1/30th of the usual
daily oral dose.
A one-time bolus is the simplest screening method. The intrathecal bolus of
medication is given and the patient is monitored for 24 hours. The pain intensity
score, functional status, and use of medications for breakthrough pain are
monitored. This method does not allow dose titration, as the other methods do,
but it can provide information on patient response to intrathecal opioids.

Hardware selection
Two kinds of pumps exist:
• battery powered externally programmable pumps , and
• nonprogrammable pumps, many of them gas driven.
The amount of medication delivered by nonprogrammable pumps is dependent
on drug concentration as infusion rate is fixed. Although externally programmable
pumps offer the great advantage of an adjustable infusion rates of different
combinations, fixed rate pumps can be used in patients requiring less frequent
rate adjustments.
Medication selection and dosage

All intrathecally administered medications should be preservative free. The most

commonly administered intrathecal medication is morphine. Other opioids include
fentanyl, sufentanil, hydromorphone, and meperidine.

Dose of Intraspinal Opioid

• Highly individualized and depends on pain intensity, age, disease

• 300mg Oral Morphine = 100mg
Parenteral Morphine = 10 mg epidural
Morphine = 1mg intrathecal morphine

To convert intrathecal doses to other routes of administration the following ratios

are used: (a) intrathecal to epidural, 1: 10; (b) intrathecal to Intravenous , 1: 100;
(c) intrathecal to oral, I: 300. In opioid- naive patients, morphine should be started
at 0.2 mg/day and gradually increased. In opioid-tolerant patients, the initial
intrathecal dose should be less than the conversion dose, and oral opioids
should be used for breakthrough pain. Gradually, the intrathecal dose should be
increased and breakthrough pain medications discontinued.
The addition of local anesthetics to intrathecal opioids may be used for cancer
and nonmalignant pain, with particular benefit to patients with a neuropathic
component of pain.. Alphadrenergic agonists (clonidine, epinephrine) can be
used in conjunction with opioids. Clonidine is now approved by the U .S. FDA for
epidural administration and its intrathecal-equivalent dosage is 50 to 900 mg/day.
It should be carefully titrated since it can cause significant hypotension (most
severe in dosage range of 400 to 570 mg/day)75-77.
.
Complications and side effects

Medication-Related Complications

Medication-related side effects and complications of neuraxial opiates include

respiratory depression, pruritus, nausea, vomiting, urinary retention, reduced
libido, edema with weight gain, and constipation. Respiratory depression can
occur immediately after opioid administration or with several hours' delay. It is
much more frequent in opioid naïve patients.. .
The incidence of urinary retention ranges from 40% to 80% and is not dose
dependent. Hormonal abnormalities are reported with intrathecal opioid
administration. Serum lipids, estrogens, androgens, insulin-like growth factor
(IGF-1), and 24-hour urinary cortisol should be monitored in these patients.
There is a 3% to 5% incidence of decreased libido in patients receiving
intrathecal opioid therapy, because of hormonal abnormalities.
Surgical complications :

Infection at the pump insertion site may require complete hardware removal..
Antibiotics should be started after wound cultures (by aspiration) are obtained.
Seroma at the insertion site is usually benign and does not require revision.
Necrosis and skin perforations can also occur and should be surgically treated.
Meningitis presents with stiff neck, fever, and meningeal signs. The CSF can be
obtained from the pump for cultures and cell count.

Surgical Approaches For Chronic Pain management

Surgery is usually performed to treat the underlying disorder. Rarely, a surgical
procedure may be suggested as a primary treatment to relieve pain. These
procedures involve specific lesions in the nervous system. They are usually
considered only for highly selected patients. For example, a patient who has a
painful neuroma developed after a nerve injury might be cured if the neuroma is
removed. Patients with so-called sympathetically-maintained pain are sometimes
offered surgery that cuts sympathetic nerves. Patients with cancer or other
serious diseases are occasionally offered a surgical technique in which a cut is
made in nerves or the spinal cord (Dorsal Rhizotomy) to try to block activity in the
nervous system that may be sustaining the pain. Presacral Neurectomy is also
performed surgically and can relieve pain in patients with terminal cancer of
cervix etc.All of these surgical approaches have some risks, and the availability
of new therapies, such as neuraxial infusion and spinal cord stimulation, has
steadily decreased their use.

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