INVASIVE PAIN MANAGEMENT METHODS

FOR CHRONIC NONCANCER PAIN

Nevenka Krcevski SkvarcUniversity Clinical Centre Maribor,

Maribor, Slovenia

INADEQUATE CHRONIC PAIN TREATMENT

Breivik et al., EJP 2006;10:287-333.

Percentage of chronic pain suffers who reported that their pain is inadequately controlled in 16 countries

Diagnostic blocksEpidural steroids

Radiofrequency technigues

Neurostimulationtechniques

Neuroaxial medication

Interventional Therapies

ADJUVANT ANALGESICS + PATIENTS EDUCATION

INTERVENTIONAL TECHNIQUES IN THE MANAGEMENT OF

CHRONIC PAIN

MINIMALLY INVASIVE PROCEDURES

injections of drugs to target areas ablation of targeted nerves implantation of intrathecal infusion pumps implantation of spinal cord stimulators some surgical techniques (IDET, annuloplasty, nucleoplasty)

EVIDENCE BASED GUIDELINES FOR INTERVENTIONAL PAIN

MEDICINE EFNS guidelines on neurostimulation therapy for neuropathic pain. Cruccu et all. Eur J Neurology 2007;14:952-70.

Polyanalgesic consensus conference 2007: recommendations for the management of pain by intathecal (intraspinal) drug delivery: Report of an interdisciplinary expert panel.

Deer et al. neuromodulation 2007;10:300-328

Evidence-based guidelines for interventional pain medicine according to clinical diagnoses.

Van Kleef et al. Pain Practice 2009;9:247-51.

Evidence based medicine. Trigeminal neuralgia. Van Kleef et al. Pain Practice 2009;9:252-9. Comprehensive evidence-based guidelines for interventional techniques in

the management of chronic pain. Manchikanti et al. Pain Physician 2009;12: 699 (in press).

RADIOFREQUENCY TECHNIQUES

The use of high frequency electric current to produce controlled thermocoagulation

Sweet and Wepsic, 1974 (Gasserian ganglion)Shealy, 1975 (spinal pain)

Sluijter and Mehta, 1981 (needles)Sluijter, 1998 (pulsed radiofrequency)

RF

NEUROMODULATION TECHNIQUES

neurostimulation with “electicty”:SCS, PNS, ONS, DBS, MCS

Chemical neuromodulation:neuraxial delivery of medication

WHICH PATIENTS FOR NEUROSTIMULATION AND

WHEN? confirmed diagnosis of NP

chronic disease with intractable pain in spite of pharmacological/physical treatment

unresponsible for conventional treatment at least 1 month for each modality

psychological evaluation

positive response to trial (50% and more pain reduction)

INDICATIONS FOR NEUROSTIMULATION AND ITDD

SCS MECHANISMS IN NEUROPATHIC PAIN

SCS SUCESS RATE

FBS 50%-70%

PNP 60%-80% CRPS, DPN

PVD 70%-80%

IAP > 80%

SCS POSITION IN THERAPEUTIC STAIRCASE

TENS

ANTIDEPRESANTS

ANTICONVULSIVES

OPIOIDS

MORE INVASIVE NEUROMODULATION

TECHNIQUES

EVENTUAL LESIONAL

TECHNIQUES

SCS

ITDD INDICATIONS

malignant pain (1982)nonmalignant pain (1997-8)

opioid dose limiting side effectsOIH and narcotic tolerance ?improvement of function ?

Drug choice:

knowledge on: the mode of action,toxicity,

clinical data on: safety/complications,

efficacy,dosing,

co-administration

Knowledge of neurophysiology

LIMITATIONS FOR THE USE OF INERVENTIONAL TECHNIQUES

resources staff and time knowledge and expierence

policies

COST EFFECTIVENESS OF SCS

Kumar et al.Neurosurgery 2002;51:106-16.

QUALITY SYSTEM FOR NEUROMODULATORY

TECHNIQUES The development of a quality system for neuromodulation in the

Netherlands. Neuromodulation 2005;8:28-35.

TREATMENT PROTOCOL

Intake of patients trial stimulation or administration of drugs implantation of permanent system control phase

QUALITY INDICATORS

pain reduction complication registration adverse events registration number of revisions battery life functionality scale dropouts quality of life patient satisfaction

INTERVENTIONAL PAIN MEDICINE IN SLOVENIA

RF beginnings in eighties but did not develop

decennia of ITB last 5 years SCS and DBS recent efforts for other ITDD and RF

Main problems:

cost knowledge and licenced stuff health policy

Consilium on Neuromodulation in Slovenia, 2008

Prof.dr. Milan Gregorič, dr. med., Asist. mag. Nevenka Krčevski Škvarč, dr.med.,

Prof. dr. Roman Bošnjak, dr. med., Asist. dr. Aleš Pražnikar, dr. med.,Prof. dr. Tadej Strojnik, dr. med., Asist. mag. Klemen Grabljevec, dr. med.

INTERVENTIONAL TECHNIQUES IN PAIN MANAGEMENT

interventional pain management techniques have undergone a rapid evolution over the last decennia and have gained a definite place in the management of chronic pain syndromes

implementation should be guided by the best avaliable evidence on efficacy and safety with respect to the diagnosis of the individual patient

need for correct application, good theoretical knowledge and practical expierence

implementation of quality system will contribute to acceptance in national health policy and better management of chronic pain