The use of topical pain medications for the treatment of chronic pain is widely adopted due to the lack of systemic effects of many of these preparations. Many painful conditions can be treated in this manner. Topical formulations of non-steroidal anti-inflammatory medications (NSAIDS) are often used. Voltaren gel and Pennsaid are a topical formulation of diclofenac, a NSAID. Capsaicin is a topically applied, over-the-counter pain medication that initially causes burning due to the release of substance P, followed by pain relief in the area. Local anesthetics such as lidocaine can also be applied topically. These can come as patches, liquids or gels. Care must be taken as these agents can also be absorbed systemically and reach toxic levels. Always follow the manufacturer’s guidelines to avoid problems. Some other medications such as anticonvulsants, anti-depressants and NMDA antagonists such as ketamine have also been used. Compounding pharmacies can produce a variety of these medications in different formulations depending on the intended target. Many types of painful conditions can be treated such as musculoskeletal pain, bursitis, osteoarthritis, complex regional pain syndrome, diabetic neuropathy and other types of neuropathy. The use of electricity (iontophoresis) and ultrasound (phonophoresis) can enhance the effectiveness of these preparations. Medications applied topically can often be used safely when compared to the same medications when given orally. Many of these medications’ side effects can be avoided when they are given topically. Of course, there are always complications and side effects that can occur. The use of topical medications should always be guided by discussion with your pain management physician.
The question of when do epidural steroids work for low back pain is complicated. Not all types of back pain are responsive to epidural steroids. Back pain can be radicular, meaning that it is due to nerve root irritation from a bulging or herniated disc. Back pain can also be axial, meaning that there is no radiation into the legs. This may be due to disease in the facet joints of the spine. Muscle spasm and sacroiliac joint disease may also produce pain in the back which is similar to the above two mechanisms.
Additionally, an epidural steroid injection may be administered in several ways. These include caudal ( at the bottom of the spine), interlaminar ( through the midline of the back), and transforaminal ( through the hole which the nerve root exits). Each of these methods target a particular area of the spinal chord and nerves and may be specific for a certain set of symptoms.
The studies analyzing the efficacy of epidural steroid injections are complicated by the previously discussed issues. Many studies do in fact find that there are improvements in the severity of pain from epidural steroid injections, especially in the short term. Additionally, different types of steroids may be injected into the epidural space. These including particulate steroids versus non-particulate steroids. There are some suggestions that particulate steroids may be more effective than non-particulate steroids. Particulate steroids, however, come at an additional risk over non-particulate steroids. These additional risks must be weighed against the benefits.
Additionally, the issue of multiple epidural steroid containing injections must be addressed. There are several studies suggesting that additional (more than one) injections may provide a synergistic effect on pain relief. Many providers limit the number of injections containing a steroid to three within a six month period. The injection of steroids is not without risk, including elevated blood sugar, weight gain, muscle weakness and other issues. The performance of multiple injections must be weighed against their additive risk.
Finally, in spite of conflicting evidence, there are some conclusions that we can draw. In general, epidural steroid injections are effective for decreasing radicular pain due to bulging or herniated discs. Epidural steroid injections are also effective for reducing pain due to spinal stenosis, a narrowing of the bony spinal canal. There are other non-invasive modalities that may be useful including physical therapy and non-steroidal anti-inflammatory medications. The risks and benefits of any intervention should be discussed with your pain management provider and an individualized protocol should be designed for each patient.
Most people are familiar with Botulinum Toxin, or BoTox, for cosmetic surgery but many are not aware of its application for the management of chronic pain. It can be used for migraine as well as cervical dystonia among others. We know that botulinum toxin prevents the release of acetylcholine from the presynaptic vesicles at the neuromuscular junction. This accounts for its ability to decrease wrinkles. Its mechanism for the treatment of chronic pain is not so well elucidated.
Cervical dystonia, or spasmodic torticollis, is a disorder of the muscles of the neck and shoulders. The injection of botox into these muscles will weaken the muscle and diminish abnormal muscle movements and contractions.
Chronic migraine is another painful condition that is often difficult to treat. Studies have shown that botox type A can decrease headache, both in frequency and severity.
There are other painful conditions that can be treated with botox, but for which the evidence is not so strong. These include myofascial pain, temporomandibular dysfunction (TMJ), pyriformis syndrome, lateral epicondylitis ( tennis elbow), plantar fasciitis, chronic pelvic pain, interstitial cystitis, trigeminal neuralgia, post herpetic neuralgia and others.
The use of botulinum toxin for chronic pain management is not without risk. These risks include infection, swelling, redness, allergic reaction and muscle weakness. This muscle weakness can including trouble swallowing, blurred vision, drooping eyebrows, dry mouth among others. The consideration of the use of botox should be made with the consultation of your pain management professional.
Spinal Cord stimulation for the treatment of chronic pain is useful for those patients who have failed conservative management. It involves the implantation of a stimulation catheter near the spine. Patients with neuropathic pain, or pain caused by damaged nerves, are the ideal candidates for this procedure.
The mechanism by which spinal cord stimulation works is not well understood, but is best explained by the “Gate Theory” of pain. This theory proposes that stimulation of large nerves by electricity can close the gate for pain impulses to reach the spine.
During placement of this catheter, the electrodes are placed into the epidural space at a level in the spine close to where the pain impulses enter the spinal cord. Patients experience paresthesia, or tingling, in the area of pain. This can substantially reduce the perception of pain by the patients.
Usually, a patient is given a trial of stimulation to assess how well it works. It the trial is successful, then the spinal cord stimulator is implanted permanently. Usually a 50% or greater reduction in pain from the trial is needed in order to justify the permanent stimulator implant.
Complications can occur during the trial or permanent placement of the stimulator. Hardware malfunction, lead migration, and breakage are among some of the issues. Infection is always a concern when implanting any object.
Finally, spinal cord stimulation for the treatment of chronic pain is a useful modality of treatment. It is only used after all other conservative modalities of treatment have failed. It has the potential to alleviate pain where all other modalities have failed. It is not without risk and should be undertaken only by a trained pain management professional.
Stem cells and Platelet Rich Plasma (PRP) are a new and innovative modality for the treatment of chronic pain. A short blog will not do the subject justice. However, I will try to communicate the basics.
Stem cells are the progenitor cell for almost every cell in the body. They are derived from bone marrow and can become almost any cell in the body. They are responsible for everyday tissue remodeling and turnover.
The majority of cells in the blood are red blood cells, white blood cells and platelets. Platelet rich plasma (PRP) is plasma with a high concentration of platelets. Although platelets are known for their effect on clotting, they also contain hundreds of proteins called growth factors which aid in healing.
Both stem cells and PRP are used to promote healing. Stem cells are usually taken from an area of high concentration, like your hip bone, and injected into an area where healing is occurring from an injury. PRP is derived from the blood, which is taken from a vein, put through a centrifuge to concentrate the platelets, and injected into the area of pain and injury.
Both stem cells and PRP promote healing. PRP contains many growth factors that can promote healing and decrease pain. Stem cells may have the ability to generate healthy cells to replace diseased cells.
Although this is a new and exciting area, many of these stem cell and PRP therapies are not covered by insurance. Many uses of stem cells are unproven and may be unsafe if used inappropriately. It is important to do your own research before undertaking this therapy.
What kinds of problems can be treated with stem cells and PRP? There are many including back pain, achilles tendon tear, shoulder rotator cuff tear, hip osteoarthritis, sacroiliac disease. It may take 3 weeks to 3 months after this therapy to see the full result. There is research ongoing as to the uses of stem cell and PRP. No guarantee can be given as to how effective this is. As with any procedure, the results are variable and depend on the patient and the severity of injury.