Taking pain treatments into a new dimension: the dimension of cure….

Pain –The Definition

“Pain is an unpleasant subjective symptom resulting from organic or psychological dysfunction or both.”

The Burden of Pain

“Only about one in four of the 23 million surgical operations done in the United States annually does the patient receive adequate relief of acute pain. In addition, Americans incur about 65 million traumatic injuries, including 2 million burns, each year, and millions more have diseases that produce acute pain.” (source: ‘JCAHO Pain Management Standards Are Unveiled’ p 428 JAMA, July 26, 2000—Vol 284, No. 4)

Pain…How well are we treating it?

“Of the 50 million people in this country with chronic pain, 4 in 10 with moderate-to severe pain cannot find adequate relief. More than 26 million people 20 to 64 years of age have frequent or persistent back pain, and 1 in 6 has painful arthritis. Only about 30% of all cancer patients with pain get adequate relief.” (source: ‘JCAHO Pain Management Standards Are Unveiled’ p 428 JAMA, July 26, 2000—Vol 284, No. 4)

The Burden of Pain

“Back pain accounts for more than $ 100 billion in annual US healthcare costs and is the second leading cause of physician visits and hospitalizations.” (source: ‘Archives of Internal Medicine /Vol164,Oct11,2004).

“Lost productive time from common pain conditions among active workers costs an estimated $61.2 billion per year” (source: Lost Productive Time and Cost Due to Common Pain Conditions in the US Workforce JAMA November12 2003—Vol 290 No.18)

Interventional Pain Treatments (Minimally invasive spine surgery)

Referral Patterns

ASA Recommends..

Narcotic medications be added to pain treatment regimen after all non narcotic options are maximized (Task Forceon Pain Management, Chronic Pain Section. Anesthesiology 1997 ;86:995-1004)

Physiotherapy

• Very uncomfortable for pain patients who have an untreated pain focus.
• Quickly fall out of sessions.
• May never want to go back to this useful modality of pain treatment.
• Most successful in patients who have had pain relief with invasive treatments.

Referring for Interventional Procedures

Success Rates: Pain Procedures

• ClinOrthopRelatRes. 1988 Mar;(228):270-2. A retrospective analysis of the efficacy of epidural steroid injections. Rosen CD, KahanovitzN, Bernstein R, Viola K.
• “Overall results were poor….. it appears that approximately 50% of patients with radicular symptoms may receive temporary relief with steroid injection. However, long-term relief occurs in less than 25% of patients.”
• Spine. 1993 Aug;18(10):1345-50.(study involving 35 patients) Bowman SJ, WedderburnL, Whaley A, Grahame R, Newman S. Outcome assessment after epidural corticosteroid injection for low back pain and sciatica.
• “43% had improvement lasting 3 months.”
• Ann Rheum Dis. 2003 Jul;62(7):639-43. (study involving 85 patients) ValatJP, GiraudeauB, RozenbergS, GoupilleP, Bourgeois P, Micheau-BeaugendreV, SoubrierM, Richard S, Thomas E. Epidural corticosteroid injections for sciatica: a randomized, double blind, controlled clinical trial.
• “22/43 (51%) in the steroid group SG (p=0.15) were considered as success”

Success Rates: Open Surgery

• Neurosurgical Treatments: Cingulotomy, Interruption of Spinothalamictracts etc.,
• Neurosurgical treatments of pain involving open surgical manipulation of the brain and spinal cord have an overall success rate of only 50% for pain conditions. The Neurosurgical Treatment of Pain Cole A. Giller, PhD, MD Archneurol/Vol60, Nov2003
• Spinal Fusion, posterior fixation, insertion of spinal rods, artificial discs.
• Results variable, usually around 50%
• Failed back surgery syndrome very common
• Percutaneous Diskectomy
• Beneficial only in cases where the pain symptoms are due to the herniated disc

Success Rates: Pain Practice (2004-2005)

Success Rates: Pain Practice (2006 to 2009)

• Nearly 1200 New patients treated
• More than 5000 procedures performed
• 18-19 Pts receive sustained pain relief out of 20 (> 90%)
• A number of Pts with decades of pain problems resolved in 4-6 weeks.

Success Rates: Pain Practice

• JAMA Nov 22/29, 2006 Vol296 pp 2451-2459 Spine Patient Outcomes Research Trail (SPORT)
• Surgical treatments provided immediate pain relief.
• By 2 years, pain in both surgical and non surgical group improved.
• Epidural steroid injection was used in 38% of the non surgical group and was the only intervention used.
• Pain Physician Jan 2007; 10:185-212. ISSN 1533-3159
• SalahadinAbdiet al.,Epidural Steroid Injections in the Management of Chronic Pain: A Systemic Review
• Compares numerous studies showing success rates ranging from as high as 93% to total failure of treatments.
• Wide discrepancy in how interventional pain treatments are practiced.

Key to Successful Pain Treatments

• Individualized Pain Treatments
• Treatments based on pain focused neurological clinical examination
• Independent Assessment of MRI and CT films
• Ethical Practice of Interventional Pain Treatments
• Emphasis on Smoking Cessation

Interventional Pain Treatments: A Bridge between Medical and Surgical Options. “Extreme Cases”

Patient has had:

• Abdominal Aortic Aneurysm surgery.
• Two strokes.
• Both carotids operated
• A popliteal artery graft placed for leg pain.
• The popliteal graft got blocked resulting in severe leg pain.
• Barely can walk to mail box because of excruciating pain.
• Couldn’t bear to bedsheetsto touch her feet as they caused severe pain.

ONE TREATMENT RESULTED IN PERMANENT PAIN RELIEF.

• Immediate relief after the procedure, patient walked 60 feet no pain.
• Was followed up after 7 months, still remained pain free
• Patient notes the treatment to be a miracle! (Advanced Interventional Pain Center notes this to be intelligent application of medical science)

Patient has had:

• Severe back pain
• MRI showed a spinal cyst.
• Neurosurgeon’s comment: “Pain condition will never go away without surgery”
• Spinal cyst was aspirated and injected under CT guidance.
• R SI joint was injected after 2 weeks.
• Final Diagnosis: “SI joint Pain!!!

Patient was pain free at 1 year after the treatments.

Other Examples

• 36 yr/o fireman is able to work 36 hours non stop during a local fire after getting his back pain treated
• 70 yr/o lady with severe scoliosis get 100% pain relief from back pain
• 220 lb lady gets 100% pain relief from back pain
• Complete 100% pain relief in cases of CRPS where there was no initial nerve injury

Cost Savings in Work Comp Patients

One stop diagnosis and treatment of Pain Conditions:

• Comprehensive Pain Focused Neurological Clinical Examination
• Avoids the use of a Neurologist to arrive at a diagnosis.
• Assessment of Pain conditions in the context of a neurology assessment.
• Interpretation of Radiology Reports in the Clinical Context
• Expensive radiology examinations such as the MRI is avoided if not needed.
• Interpretation of MRI films independently without the radiology report in light of the clinical exam.
• Distinguish abnormal findings that are benign from abnormal findings that cause pain.
• Highly Individualized, Minimally Invasive Treatments
• Avoids the use of narcotics.
• Avoids or postpones unnecessary surgery.
• Reduces disability time and leave of absence.
• Increases worker productivity.
• Referral to other specialists is generally not needed.

Comparative Costs And Outcome

END RESULT: HEALTHCARE COST SAVINGS IN THOUSANDS OF DOLLARS!

Referring for Interventional Procedures

• Wide range of focal pain conditions can be treated in workers.
• Consider Advanced Interventional Pain Center as your 1stline of defense.
• Injured workers who have no fractures or those with treated fractures should first be referred to Advanced Interventional Pain Center for maximum benefit and early return to work.
• All consult and treatment records are electronic and are transmitted by e-mail within 1 week
• Close cases with MMI/PI ratings around 0-5%.

A Single Non surgical Treatment Provides
Permanent Relief from Vascular Pain,
Improves Blood Flow, Reverses Ischemia
and Early Necrosis

Taking pain treatments into to new dimension: the dimension of cure….

Pattanam Srinivasan, MD