Minor Procedures Can Make Major Difference in Chronic Pain
Sixth in a series
As the dangers of taking long-term opioids have become more apparent, doctors increasingly have sought alternative options for patients with chronic pain. Three minor procedures available at Einstein and MossRehab may provide longer-term relief for those who have tried injections and similar treatments.
Those procedures include radiofrequency ablation, and implantation of a nerve stimulator or medication pump. They can help relieve pain for months or longer, allowing some patients to postpone or avoid major surgery such as a knee replacement or spine surgery.
“My goal is to keep it as minimally invasive as possible and try to keep people off the surgical table,” says Alyssa Marulli, MD, a physical medicine and rehabilitation specialist at MossRehab and the Einstein Spine Institute.
These procedures target specific nerves that are causing the pain. They have allowed some patients to stop or minimize the use of opioids, doctors say. Often, they will taper the amount of drugs prescribed over time or suggest that patients start by simply taking fewer pills.
Although more invasive than a simple injection, ablation and implantation of a nerve stimulator are usually done on an outpatient basis. Implantation of a medication pump requires an overnight stay in a hospital.
“Compared with injections or a nerve block, they are slightly more involved, require more patient education, and involve more time and more skills,” says Jasmeet Oberoi, MD, Medical Director of the Einstein Pain Institute.
Three types of procedures are available:
- Radiofrequency ablation
- Electrical stimulation
- Intrathecal medication pump
In this procedure, the doctor uses X-rays to guide a specialized needle to the nerve that is causing the pain. The needle is heated and used to burn the nerve so it can no longer transmit pain signals to the brain. Ablation takes about 40 minutes.
“At the Pain Institute, the majority of ablation procedures are done for arthritic spinal pain, especially neck and lower back pain,” Dr. Oberoi says.
Dr. Marulli does ablation procedures on the spine and other joints. “This technology is currently approved for the knee, the shoulder and the hip,” she says.
“We target the nerves that that supply these joints,” Dr. Marulli explains. “So the joint remains arthritic, but it can no longer send pain signals up to the brain. It is a really good non-operative, minimally invasive way of treating chronic joint pain.”
A typical patient, she says, is someone who is no longer gaining enough relief from steroid injections but doesn’t want to have surgery or is not a good candidate for surgery.
“The literature shows that usually about 60% of people will have greater than 50% relief from pain at the six-month mark after ablation,” Dr. Marulli says.
Sometimes nerves grow back, but slowly. The procedure can be repeated if pain returns, she says.
Electrical nerve stimulation
For spinal cord stimulation, wires called electrodes are inserted through an incision in the lower back. The doctor guides the wire tips to a spot in the epidural space inside the spine where the nerves causing pain are located.
A battery pack, implanted under the skin of the lower back or abdomen, sends electrical signals through the electrodes to block pain messages between the nerves and the brain. The patient controls the implanted device using an external remote.
“We’ve had probably an 80% success rate with spinal cord stimulation, which I would describe as like having a pacemaker for the nerves,” Dr. Oberoi says. “It can reduce the patient’s perception and the intensity of the pain.”
The patient first goes through a trial period of wearing the pack outside the body to see how well it works. The procedure to implant the pack lasts one to two hours.
Spinal cord stimulation is used for several types of conditions:
- Spinal pain that is not relieved by other treatments, including surgery
- Nerve-related pain in other areas of the body, such as traveling down the leg or arm
- Reflex sympathetic dystrophy, a pain syndrome that begins after an injury or surgery but continues or gets worse even after the body heals
- Pain that can persist after chest surgery
Dr. Oberoi says most patients who receive a spinal stimulator
- have back pain that is not relieved by other treatments such as nerve blocks
- are not likely to benefit from surgery.
“It is an implanted device, so not everybody is suitable for it,” he says. “But with good patient selection and patient education, it does work long term.”
Dr. Marulli performs a similar procedure implanting a device for stimulation of peripheral nerves. Patients receiving this device also go through a trial period before implantation.
“These are people with chronic pain that’s localized to a specific area – maybe one leg, maybe an arm or shoulder,” she says. “The sciatic nerve is a common target for pain in the lower leg. It has also been successful for amputee patients with phantom limb leg pain.”
The 60-day trial itself sometimes will stop the pain permanently, Dr. Marulli says. “The stimulation algorithm for this device is thought to act to ‘rewire’ the nerve, so when you remove it, you still have ongoing relief.”
Intrathecal medication pump
A tiny device is implanted under the skin to pump pain medication through a tiny tube called a catheter directly into the spinal fluid.
“When we put it in the spinal fluid, it’s in direct proximity to the nerves and the other spinal structures, so we can get away with a minuscule amount of medication,” Dr. Oberoi says.
The pump is used primarily in patients with chronic pain who have not found relief from other treatments, Dr. Oberoi says. It is more invasive than some other pain procedures and requires an overnight stay in the hospital.
“There’s a recurrent need to refill the pump with medication, and it’s something the patients have to learn to handle because they can feel it every day,” Dr. Oberoi says. “So we really have to have the correct situation with a particular patient to be able to say, this is the right thing for you.”
As people’s pain improves, Dr. Oberoi says, they are better able to take the steps that will lead to long-term health and mobility.
“It’s important for them to understand that they need to put in their effort now, improve their lifestyle and start moving around more. It becomes a partnership between the patient and the physician.”