Interventional pain management or interventional pain medicine is a medical subspecialty defined by the National Uniforms Claims Committee (NUCC) as " invasive interventions such as the discipline of medicine devoted to the diagnosis and treatment of pain related disorders principally with the application of interventional techniques in managing sub acute, chronic, persistent, and intractable pain, independently or in conjunction with other modalities of treatment".

Medicare Payment Advisory Commission The Medicare Payment Advisory Commission (MedPAC) is an independent, non-partisan legislative branch agency headquartered in Washington, D.C. MedPAC was established by the Balanced Budget Act of 1997 (P.L. 105–33). The BBA formed MedPAC by mer ...

(MedPAC) defined interventional techniques as "minimally invasive procedures including, percutaneous precision needle placement, with placement of drugs in targeted areas or ablation of targeted nerves; and some surgical techniques such as laser or endoscopic

diskectomy A discectomy (also called open discectomy, if done through a 1/2 inch or larger skin opening) is the surgical removal of abnormal disc material that presses on a nerve root or the spinal cord. The procedure involves removing a portion of an int ...

, intrathecal infusion pumps and

spinal cord stimulator A spinal cord stimulator (SCS) or dorsal column stimulator (DCS) is a type of implantable neuromodulation device (sometimes called a "pain pacemaker") that is used to send electrical signals to select areas of the spinal cord (dorsal columns) for ...

s, for the diagnosis and management of chronic, persistent or intractable pain". Minimally invasive interventions, such as

facet joint injection Facet joint injections are used to alleviate symptoms of Facet syndrome. The procedure is an outpatient surgery, so that the patient can go home on the same day. It usually takes 10–20 minutes, but may take up to 30 minutes if the patient needs ...

nerve block Nerve block or regional nerve blockade is any deliberate interruption of signals traveling along a nerve, often for the purpose of pain relief. #Local anesthetic nerve block, Local anesthetic nerve block (sometimes referred to as simply "nerve b ...

s (interrupting the flow of pain signals along specific nerve pathways), neuroaugmentation (including

spinal cord stimulation A spinal cord stimulator (SCS) or dorsal column stimulator (DCS) is a type of implantable neuromodulation device (sometimes called a "pain pacemaker") that is used to send electrical signals to select areas of the spinal cord (dorsal columns) for ...

and peripheral nerve stimulation),

vertebroplasty Vertebral augmentation, including vertebroplasty and kyphoplasty, refers to similar percutaneous spinal procedures in which bone cement is injected through a small hole in the skin into a fractured vertebra in order to relieve back pain caused b ...

kyphoplasty Vertebral augmentation, including vertebroplasty and kyphoplasty, refers to similar percutaneous spinal procedures in which bone cement is injected through a small hole in the skin into a fractured vertebra in order to relieve back pain caused ...

, nucleoplasty,

endoscopic An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are insert ...

discectomy, and implantable drug delivery systems are utilized in managing subacute or chronic pain.Winnie AP Preface. In: Interventional Pain Management SD Waldman and AP Winnie (eds) WB Saunders 1996.American Society of Interventional Pain Physicians (ASIPP.org) Website

History

Early efforts at interventional pain management date back to the origins of regional analgesia and

s, and gradually evolved into a distinct specialty. Tuffer described the first therapeutic nerve block for pain management in 1899. Von Gaza developed diagnostic blockade in pain management, using

procaine Procaine is a local anesthetic drug of the amino ester group. It is most commonly used in dental procedures to numb the area around a tooth and is also used to reduce the pain of intramuscular injection of penicillin. Owing to the ubiquity of ...

for determining the pain's pathways. Modern day contributors include Bonica, Winnie, Raj, Racz, Bogduk, and others. The term "interventional pain management" was first used by pain management specialist Steven D. Waldman in 1996 to define the emerging specialty.Atlas of Interventional Pain Management 3rd ed. S.D. Waldman (ed) Elsevier Philadelphia 2010. The subspecialty of interventional pain management has received a specific specialty designation by the United States

National Uniform Billing Committee The National Uniform Billing Committee (NUBC) is the governing body for forms and codes use in medical claims billing in the United States for institutional providers like hospitals, nursing homes, hospice, home health agencies, and other provid ...

to allow its practitioners to bill Federal healthcare programs including Medicare and

Medicaid Medicaid is a government program in the United States that provides health insurance for adults and children with limited income and resources. The program is partially funded and primarily managed by U.S. state, state governments, which also h ...

. Physicians who practice interventional pain management are represented by a variety of pain management organizations including the American Society of Interventional Pain Physicians (ASIPP) founded by Laxmaiah Manchikanti, MD, in 1998, which solely represents interventional pain management professionals.

Radiation

Radiotherapy Radiation therapy or radiotherapy (RT, RTx, or XRT) is a treatment using ionizing radiation, generally provided as part of cancer therapy to either kill or control the growth of malignant cells. It is normally delivered by a linear particle ...

is used when drug treatment is failing to control the pain of a growing tumor, such as in bone metastasis (most commonly), penetration of soft tissue, or compression of sensory nerves. Often, low doses are adequate to produce analgesia, thought to be due to reduction in pressure or, possibly, interference with the tumor's production of pain-promoting chemicals.

Radiopharmaceutical Radiopharmaceuticals, or medicinal radiocompounds, are a group of pharmaceutical drugs containing radioactive isotopes. Radiopharmaceuticals can be used as diagnostic and therapeutic agents. Radiopharmaceuticals emit radiation themselves, which ...

s that target specific tumors have been used to treat the pain of metastatic illnesses. Relief may occur within a week of treatment and may last from two to four months.

Neurolytic block

A neurolytic block is the deliberate injury of a nerve by the application of chemicals (in which case the procedure is called "

neurolysis Neurolysis is the application of physical or chemical agents to a nerve in order to cause a temporary degeneration of targeted nerve fibers. When the nerve fibers degenerate, an interruption in the transmission of nerve signals occurs. In the medica ...

") or physical agents such as freezing or heating ("

neurotomy Neurolysis is the application of physical or chemical agents to a nerve in order to cause a temporary degeneration of targeted nerve fibers. When the nerve fibers degenerate, an interruption in the transmission of nerve signals occurs. In the medica ...

"). These interventions cause degeneration of the nerve's fibers and temporary interference with the transmission of pain signals. In these procedures, the thin protective layer around the nerve fiber, the

basal lamina The basal lamina is a layer of extracellular matrix secreted by the epithelial cells, on which the epithelium sits. It is often incorrectly referred to as the basement membrane, though it does constitute a portion of the basement membrane. The b ...

, is preserved so that, as a damaged fiber regrows, it travels within its basal lamina tube and connects with the correct loose end, and function may be restored. Surgically cutting a nerve severs these basal lamina tubes, and without them to channel the regrowing fibers to their lost connections, a painful

neuroma A neuroma (; plural: neuromata or neuromas) is a growth or tumor of nerve tissue. Neuromas tend to be benign (i.e. not cancerous); many nerve tumors, including those that are commonly malignant, are nowadays referred to by other terms. Neuromas ...

or deafferentation pain may develop. This is why the neurolytic is preferred over the surgical block.

Cutting or destruction of nervous tissue

Surgical cutting or destruction of

peripheral A peripheral device, or simply peripheral, is an auxiliary hardware device that a computer uses to transfer information externally. A peripheral is a hardware component that is accessible to and controlled by a computer but is not a core compo ...

or central nervous tissue is now rarely used in the treatment of pain. Procedures include neurectomy, cordotomy, dorsal root entry zone lesioning, and cingulotomy.

Neurectomy A neurectomy, or nerve resection is a neurosurgical procedure in which a peripheral nerve is cut or removed to alleviate neuropathic pain or permanently disable some function of a nerve. The nerve is not intended to grow back. For chronic pain it ...

involves cutting a nerve, and is (rarely) used in patients with short life expectancy who are unsuitable for drug therapy due to ineffectiveness or intolerance. The

dorsal root The dorsal root of spinal nerve (or posterior root of spinal nerve or sensory root) is one of two "roots" which emerge from the spinal cord. It emerges directly from the spinal cord, and travels to the dorsal root ganglion. Nerve fibres with the v ...

dorsal root ganglion A dorsal root ganglion (or spinal ganglion; also known as a posterior root ganglion) is a cluster of neurons (a ganglion) in a dorsal root of a spinal nerve. The cell bodies of sensory neurons known as first-order neurons are located in the do ...

(that carry mostly sensory signals) may be usefully targeted (called

rhizotomy A selective dorsal rhizotomy (SDR), also known as a rhizotomy, dorsal rhizotomy, or a selective posterior rhizotomy, is a neurosurgical procedure that selectively cuts problematic nerve roots in the spinal cord. This procedure has been well-esta ...

); with the dorsal root ganglion possibly the more effective target because some sensory fibers enter the spinal cord from the dorsal root ganglion via the ''ventral'' (motor) root, and these would not be interrupted by dorsal root neurectomy. Because nerves often carry both sensory and motor fibers, motor impairment is a possible side effect of neurectomy. A common result of this procedure is "deafferentation pain" where, 6–9 months after surgery, pain returns at greater intensity.

Cordotomy Cordotomy (or chordotomy) is a surgical procedure that disables selected pain-conducting tracts in the spinal cord, in order to achieve loss of pain and temperature perception. This procedure is commonly performed on patients experiencing severe p ...

involves cutting into the

spinothalamic tract The spinothalamic tract is a nerve tract in the anterolateral system in the spinal cord. This tract is an ascending sensory pathway to the thalamus. From the ventral posterolateral nucleus in the thalamus, sensory information is relayed upwar ...

s, which run up the front/side (anterolateral) quadrant of the spinal cord, carrying heat and pain signals to the brain.

Pancoast tumor A Pancoast tumor is a tumor of the apex of the lung. It is a type of lung cancer defined primarily by its location situated at the top end of either the right or left lung. It typically spreads to nearby tissues such as the ribs and vertebrae. Most ...

pain has been effectively treated with dorsal root entry zone (DREZ) lesioning – damaging a region of the spinal cord where peripheral pain signals cross to spinal cord fibers. This is major surgery, carrying the risk of significant neurological side effects.

Cingulotomy Bilateral cingulotomy is a form of psychosurgery, introduced in 1948 as an alternative to lobotomy. Today, it is mainly used in the treatment of depression and obsessive-compulsive disorder. In the early years of the twenty-first century, it wa ...

involves cutting the fibers that carry signals directly from the

cingulate gyrus The cingulate cortex is a part of the brain situated in the medial aspect of the cerebral cortex. The cingulate cortex includes the entire cingulate gyrus, which lies immediately above the corpus callosum, and the continuation of this in the cin ...

to the

entorhinal cortex The entorhinal cortex (EC) is an area of the brain's allocortex, located in the medial temporal lobe, whose functions include being a widespread network hub for memory, navigation, and the perception of time.Integrating time from experience in t ...

in the brain. It reduces the unpleasantness of pain (without affecting its intensity), but may have

cognitive Cognition is the "mental action or process of acquiring knowledge and understanding through thought, experience, and the senses". It encompasses all aspects of intellectual functions and processes such as: perception, attention, thought, ...

side effects.

Intrathecal infusion

Delivery of an opioid such as

morphine Morphine, formerly also called morphia, is an opiate that is found naturally in opium, a dark brown resin produced by drying the latex of opium poppies (''Papaver somniferum''). It is mainly used as an analgesic (pain medication). There are ...

hydromorphone Hydromorphone, also known as dihydromorphinone, and sold under the brand name Dilaudid among others, is a morphinan opioid used to treat moderate to severe pain. Typically, long-term use is only recommended for pain due to cancer. It may b ...

fentanyl Fentanyl is a highly potent synthetic piperidine opioid primarily used as an analgesic (pain medication). It is 30 to 50 times more Potency (pharmacology), potent than heroin and 50 to 100 times more potent than morphine. Its primary Medici ...

, sufentanyl or

meperidine Pethidine, also known as meperidine and sold under the brand name Demerol among others, is a fully synthetic opioid pain medication of the phenylpiperidine class. Synthesized in 1938 as a potential anticholinergic agent by the German chemist Ot ...

directly into the subarachnoid cavity (the space between the spinal cord's inner, waterproof sheath and its outer protective sheaths) provides enhanced analgesia with reduced systemic side effects, and has reduced the level of pain in otherwise intractable cases. The anxiolytic

clonidine Clonidine, sold under the brand name Catapres among others, is an α2A-adrenergic receptor agonist medication used to treat high blood pressure, attention deficit hyperactivity disorder (ADHD), drug withdrawal (e.g., alcohol, opioids, or nic ...

, or the nonopioid analgesic

ziconotide Ziconotide, sold under the brand name Prialt, also called intrathecal ziconotide (ITZ) because of its administration route, is an atypical analgesic agent for the amelioration of severe and chronic pain. Derived from '' Conus magus'', a cone sn ...

, and local anesthetics such as

bupivacaine Bupivacaine, marketed under the brand name Marcaine among others, is a medication used to decrease sensation in a specific small area. In nerve blocks, it is injected around a nerve that supplies the area, or into the spinal canal's epidural ...

ropivacaine Ropivacaine (International Nonproprietary Name, rINN) is a local anaesthetic drug belonging to the amino amide group. The name ropivacaine refers to both the racemate and the marketed ''S''-enantiomer. Ropivacaine hydrochloride is commonly mark ...

tetracaine Tetracaine, also known as amethocaine, is an ester local anesthetic used to numb the eyes, nose, or throat. It may also be applied to the skin before starting intravenous therapy to decrease pain from the procedure. Typically it is applied as a l ...

may also be infused along with the opioid.

Epidural infusion

The outermost, protective sheath surrounding the spinal cord is called the dura mater. Between this and the surrounding

vertebra Each vertebra (: vertebrae) is an irregular bone with a complex structure composed of bone and some hyaline cartilage, that make up the vertebral column or spine, of vertebrates. The proportions of the vertebrae differ according to their spina ...

e is the

epidural space In anatomy, the epidural space is the potential space between the dura mater and vertebrae ( spine). The anatomy term "epidural space" has its origin in the Ancient Greek language; , "on, upon" + dura mater also known as "epidural cavity", "e ...

, filled with connective tissue, fat and blood vessels, and crossed by the

spinal nerve A spinal nerve is a mixed nerve, which carries Motor neuron, motor, Sensory neuron, sensory, and Autonomic nervous system, autonomic signals between the spinal cord and the body. In the human body there are 31 pairs of spinal nerves, one on each s ...

roots A root is the part of a plant, generally underground, that anchors the plant body, and absorbs and stores water and nutrients. Root or roots may also refer to: Art, entertainment, and media * ''The Root'' (magazine), an online magazine focusin ...

. A

catheter In medicine, a catheter ( ) is a thin tubing (material), tube made from medical grade materials serving a broad range of functions. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgical procedure. ...

may be inserted into this space for three to six months, to deliver anesthetics or analgesics. The line carrying the drug may be threaded under the skin to emerge at the front of the patient, a process called tunneling. This is recommended with long term use so as to reduce the chance of any infection at the exit site reaching the epidural space.

Spinal cord stimulation

Electrical stimulation of the

dorsal columns The dorsal column nuclei are a pair of nuclei in the dorsal columns of the dorsal column–medial lemniscus pathway (DCML) in the brainstem. The name refers collectively to the cuneate nucleus and gracile nucleus, which are situated at the lo ...

of the spinal cord can produce analgesia. First, the leads are implanted, guided by the patient's report and

fluoroscopy Fluoroscopy (), informally referred to as "fluoro", is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of medical imaging, a fluoroscope () allows a surgeon to see t ...

, and the generator is worn externally for several days to assess efficacy. If pain is reduced by more than half, the therapy is deemed to be suitable. A small pocket is cut into the tissue beneath the skin of the upper buttocks, chest wall or abdomen and the leads are threaded under the skin from the stimulation site to the pocket, where they are attached to the snugly-fitting generator. It seems to be more helpful with

neuropathic Peripheral neuropathy, often shortened to neuropathy, refers to damage or disease affecting the nerves. Damage to nerves may impair sensation, movement, gland function, and/or organ function depending on which nerve fibers are affected. Neuropa ...

and

ischemic Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive). Ischemia is generally caused by problems ...

pain than

nociceptive pain Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated wit ...

, and is not often used in the treatment of cancer pain.

Deep brain stimulation

Ongoing electrical stimulation of structures deep within the brain – the

periaqueductal gray The periaqueductal gray (PAG), also known as the central gray, is a brain region that plays a critical role in autonomic function, motivated behavior and behavioural responses to threatening stimuli. PAG is also the primary control center for ...

and periventricular gray for nociceptive pain, and the

internal capsule The internal capsule is a paired white matter structure, as a two-way nerve tract, tract, carrying afferent nerve fiber, ascending and efferent nerve fiber, descending axon, fibers, to and from the cerebral cortex. The internal capsule is situate ...

ventral posterolateral nucleus The ventral posterolateral nucleus (VPL) is one of the subdivisions of the ventral posterior nucleus in the ventral nuclear group of the thalamus. It relays sensory information from the second-order neurons of the neospinothalamic tract and me ...

and

ventral posteromedial nucleus The ventral posteromedial nucleus (VPM) is a nucleus within the ventral posterior nucleus of the thalamus and serves an analogous somatosensory relay role for the ascending trigeminothalamic tracts as its lateral neighbour the ventral posterolat ...

for neuropathic pain – has produced impressive results with some patients but results vary and appropriate patient selection is important. One study of seventeen patients with intractable cancer pain found that thirteen were virtually painless and only four required opioid analgesics on release from hospital after the intervention. Most ultimately did resort to opioids, usually in the last few weeks of life.

Hypophysectomy

Hypophysectomy Hypophysectomy is the surgical removal of the hypophysis (pituitary gland). It is most commonly performed to treat tumors, especially craniopharyngioma tumors. Sometimes it is used to treat Cushing's syndrome due to pituitary adenoma or Simmond' ...

is the destruction of the

pituitary gland The pituitary gland or hypophysis is an endocrine gland in vertebrates. In humans, the pituitary gland is located at the base of the human brain, brain, protruding off the bottom of the hypothalamus. The pituitary gland and the hypothalamus contr ...

, and has been used successfully on metastatic breast and prostate cancer pain.

References

{{Reflist Pain management