Transcript INVASIVE PAIN MANAGEMENT METHODS FOR CHRONIC NONCANCER …

INVASIVE PAIN MANAGEMENT
METHODS FOR CHRONIC
NONCANCER PAIN
Nevenka Krcevski Skvarc
University Clinical Centre Maribor,
Maribor, Slovenia
INADEQUATE CHRONIC PAIN TREATMENT
Percentage of chronic pain suffers who reported
that their pain is inadequately controlled in 16 countries
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Breivik et al., EJP 2006;10:287-333.
Interventional Therapies
Neuroaxial
medication
Neurostimulation
techniques
Diagnostic blocks
Epidural steroids
Radiofrequency technigues
ADJUVANT ANALGESICS + PATIENTS EDUCATION
INTERVENTIONAL TECHNIQUES IN
THE MANAGEMENT OF CHRONIC PAIN
MINIMALLY INVASIVE PROCEDURES
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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
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EFNS guidelines on neurostimulation therapy for neuropathic pain.
Cruccu et all. Eur J Neurology 2007;14:952-70.
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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
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Evidence-based guidelines for interventional pain medicine according to
clinical diagnoses.
Van Kleef et al. Pain Practice 2009;9:247-51.
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Evidence based medicine. Trigeminal neuralgia.
Van Kleef et al. Pain Practice 2009;9:252-9.
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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
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Chemical neuromodulation:
neuraxial delivery of medication
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WHICH PATIENTS FOR
NEUROSTIMULATION AND WHEN?
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confirmed diagnosis of NP
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chronic disease with intractable pain in spite of
pharmacological/physical treatment
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unresponsible for conventional treatment at least
1 month for each modality
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psychological evaluation
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positive response to trial
(50% and more pain reduction)
INDICATIONS FOR
NEUROSTIMULATION AND ITDD
SCS MECHANISMS IN NEUROPATHIC
PAIN
SCS SUCESS RATE
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FBS
50%-70%
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PNP
60%-80%
CRPS, DPN
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PVD
70%-80%
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IAP
> 80%
SCS POSITION IN THERAPEUTIC
STAIRCASE
EVENTUAL
LESIONAL
TECHNIQUES
MORE INVASIVE
NEUROMODULATION
TECHNIQUES
OPIOIDS
SCS
ANTICONVULSIVES
ANTIDEPRESANTS
TENS
ITDD INDICATIONS
malignant pain (1982)
nonmalignant pain (1997-8)
opioid dose limiting side effects
OIH 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
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staff and time
knowledge and expierence
 policies
COST EFFECTIVENESS OF SCS
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Kumar et al.Neurosurgery 2002;51:106-16.
QUALITY SYSTEM FOR
NEUROMODULATORY TECHNIQUES
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The development of a quality system for neuromodulation in the
Netherlands. Neuromodulation 2005;8:28-35.
TREATMENT PROTOCOL
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Intake of patients
trial stimulation or administration of drugs
implantation of permanent system
control phase
QUALITY INDICATORS
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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
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RF beginnings in eighties but did not develop
decennia of ITB
last 5 years SCS and DBS
recent efforts for other ITDD and RF
Consilium on Neuromodulation in Slovenia, 2008
Main problems:
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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.
cost
knowledge and licenced stuff
health policy
INTERVENTIONAL TECHNIQUES IN
PAIN MANAGEMENT
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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
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implementation should be guided by the best avaliable
evidence on efficacy and safety with respect to the
diagnosis of the individual patient
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need for correct application, good theoretical knowledge
and practical expierence
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implementation of quality system will contribute to
acceptance in national health policy and better
management of chronic pain