In understanding pain it is important to realize that what appears to be quite simple is in fact a complex, multifactorial experience which has at least two distinct and separate components. The first or "acute pain" or "functional" pain perception is originating from pain receptors located throughout the body as a response to a noxious experience and generally has a protective "warning" function indicating that part of the body is damaged or injured and that it requires medical attention.
The so called chronic or dysfunctional pain, which sometimes follows the acute pain even if healing of the injured tissue has been completed, on the other hand results from activation of poorly understood neural connections long after the initial insult has subsided and it no longer has any protective function. The constant barrage of the useless pain messages, however, reaches various brain centers and creates the emotional experience best described as "suffering". This process results in a widespread disturbances in control of emotions, sleep-wake cycle, appetite, depression and sexual drive and thus deeply affect the lifestyle of patients with chronic pain. Although there is no good definition of chronic pain "musculoskeletal pain" and "neurogenic pain" are general terms often used in describing chronic pain disorders, although several similarly poorly described subgroups such as fibromyalgia, reflex sympathetic dystrophy (RSD), central pain and others have been recently recognized.Since there is no objective way to measure pain or suffering, dealing with chronic pain can be a difficult endeavor. Conceptually it is helpful to divide patients into two main groups.
- I. An anatomical substrate such as for instance, a lumbar herniated disc is identified as the cause of pain. In this group successful surgery restores a pain free experience. In the second group
- II. The origin of pain has no demonstrable anatomical substrate (on studies available with present day technology) and it is often called physiologic with a presumed musculo-fascial or neurological etiology. This is the most difficult group to manage because given our current state of knowledge, it is impossible to distinguish between abnormal pain response originating from diseased tissues such as in, for instance, a fibromyalgia, versus disturbance in the function of the central neurotransmitters.
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Experience has shown that the choice of treatment and the expected
response to it is best related to these categories.
Thus, the likelihood of success of appropriate
operations is high in Group I whereas it is much
less so in Group II. In this latter group, major
surgical procedures should be avoided except in most unusual circumstances
while minor procedures have a much greater chance for success as in
myofascial syndromes or RSD. The treatment should consist of various
forms of physical therapy, minor pain procedures, judicious use of drugs
to improve sleep patterns and alleviate depression. Recent experience
indicates that careful use of long term narcotic medications in carefully
selected patients may return them into productive activity without problems
normally associated with addiction. The psychological treatment is sometimes
very helpful and depends on the type of pain and the patient's personality.
It is essential to recognize that supportive treatment for chronic pain
is a life-long process which requires a maintenance program that follows
the conclusion of active medical treatment. While
clear goals and an end point of the acute phase of the therapy need
to be defined before the pain program is started, stress on self motivation
and post therapy maintenance program is a critical part of any pain
program.
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As part of the largest health care delivery system in the State of New Jersey, the Pain Institute treats patients with pain related to acute and chronic conditions. Uniting the expertise of anesthesiologists, physiatrists, orthopedists, rheumatologists and neurosurgeons, we are dedicated to determining the source of pain and designing individualized solutions for each patient's pain problems. Patients are frequently referred to the Pain Institute by orthopedic surgeons, neurosurgeons or internists. They may have continued pain despite surgery or have developed pain after initial improvement with surgery. Many patients have seen multiple physicians and had multiple workups without relief. The comprehensive team approach that is the hallmark at the Pain Institute provides a directed effort to provide pain control.Innovative techniques and advanced technology are being used to help control pain. These include implantable infusion pumps, radio frequency rhizotomy, cryoablation, spinal cord stimulation and epiduroscopy. Specific procedures available at the Institute include:
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Spinal Cord Stimulation
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Implantable Infusion Pumps
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Radio frequency Rhizotomies
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Cryoablation
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Epiduroscopy
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Infusion Procedures
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Block - under fluoroscopy
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Acupuncture
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Trigger Point Injections
Each of these procedures is indicated for certain pain syndromes.Over the years, these techniques have been devised to selectively destroy nervous tissue in the body in an effort to relieve pain. Two techniques commonly used at the Pain Institute are radio frequency rhizotomies and cryoblation. Acupuncture takes advantage of a pain relief afforded in some patients following the traditional Chinese procedure, the mechanism of which remains poorly understood.
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Cryoanalgesia therapy has widespread and diverse application in the fields of pain management and neurosurgery. Cryoanalgesia is a technique in which low temperatures are used to produce pain relief. Cryoanalgesia is best suited for those clinical situations in which analgesia is required for weeks to months. Because the injured axons regenerate, the analgesia is not permanent. The median duration of pain relief is from 2 weeks to 5 months and can be of benefit in several postoperative circumstances. Cryoanalgesia therapy is most appropriate for painful conditions originating from small, well-localized lesions of peripheral nerves, for sample, neuromas and entrapment neuropathies. Longer than expected benefit is often obtained in Biomechanics, pain syndromes (ie: facet joint arthropathy). Cryoablative procedures can be performed either open or percutaneously, depending on the clinical setting. Percutaneous cryoablative procedure is the technique of choice for outpatient chronic pain management.Cryoanalgesia can provide improvement of symptoms and enable better participation in physiotherapy. Cryoanalgesia for chronic pain syndromes should always be preceded by diagnostic prognostic local anesthetic injections. Cryoanalgesia has the advantage of easy application with few complications. The most common applications of cryanalgesia include intercostal neuralgia, painful neuroma, post-thoracotomy pain, post- herniorrhaphy pain, biomechanical spinal pain, and cranial and facial pain.
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The role of radiofrequency lesion generation for the purpose of making therapeutic lesions in the nervous system has been quite successful. Radiofrequency rhizotomy involves the passage of current through an electrode to generate heat and produce a lesion. The radiofrequency lesion generating procedure has certain advantages over other techniques for making discrete therapeutic or functional lesions with temperature control: Quantifiable lesions could be made consistently from one patient to another with avoiding unwanted and uncontrolled side effects because of the very nature of the radiofrequency electrode.It is amenable to stimulations, impedance monitoring and recouping and which enhances the ability of the physician to know that the electrode is at the appropriate target for generating a lesion. In the peripheral nervous system, the accurate and highly selective destruction of pain carrying nerve fibers is one of the most promising aspects of radiofrequency rhizotomies.Clinical applications of radiofrequency lesions include Biomechanics/spinal disorders of the cervical, thoracic and lumbar region, sacroiliac joint pain, components of the sympathetic nervous system, intercostal nerve grafts and peripheral neuropathies. Radiofrequency rhizotomy offers the patient a safe, highly precise and long term benefit up to 1 year as a modality for the treatment of both acute and chronic pain conditions.
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The use of neurolytic agents, such as alcohol, phenol and glycerol in various concentrations and at various sites in the body have the ideal ability of achieving adequate analgesia without serious side effects. One of the primary indications for neurolytic blockade is for cancer pain management.
Chronic low back pain is one of the most common problems treated by pain management specialists. The treatment of acute low back pain includes rest, nsaids, physiotherapy from a few days up to about one week. If the pain is not relived and there is persist radiculopathy, a trial of lumbar epidural steroids may be indicated following a complete evaluation. Epidural injections of steroid are most effective in lumbosacral radiculopathy associated with disc herniation, bulging, or degeneration. The success rate is better for patients who have not undergone prior operations and who have been experiencing pain for less than 6 months. Epidural steroid injections are performed as an outpatient procedure under fluoroscopic guidance that confirms accurate placement. A series of up to three injections are performed at 1-2 week intervals. This allows full assessment of the effect of the injections. Complications or side effects are rarely seen with this modality.
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Spinal cord stimulation and intraspinal morphine infusions are examples of implantable pain therapies.Spinal cord stimulation is indicated for treatment of chronic, intractable pain of the trunk or limbs. Indications for use may be chronic lumbar or cervical radiculopathy, intercostal neuralgia, peripheral vascular disease, failed back syndrome, arachnoiditis, causalgia, reflex sympathetic dystrophy, phantom limb pain, post-herpetic neuralgia, spinal cord injury, and neuropathies. When conservative therapies and corrective surgeries are ineffective and the patient has side effects to pain medications, a spinal cord stimulator trial may be indicated. A trial consists of placing a percutaneous electrode lead into the epidural space under monitored anesthesia care and IV sedation. The patient then determines if the stimulation is successful at reducing his/her overall pain pattern. If successful, the system consisting of a pulse generator, extension and lead is placed.Some types of intractable pain respond best to intraspinal morphine infusion. Indications for intraspinal morphine consist of diffuse cancer pain, failed back syndrome, axial sanatic pain, osteoporosis, RSD, arachnoiditis, painful neuropathies and spinal cord injury. Based on a full evaluation of the patient's pain pattern and type of pain, he/she may be a candidate for intraspinal morphine therapy or spinal cord stimulation.
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The Pain Institute also provides therapies for cancer patients whose pain control is inadequate with oral narcotics. Often, oncologists request neurolytic blocks, long acting but temporary blocks for cancer pain. These blocks decrease the amount of pain the patient experiences during the last months of their life.
The Pain Institute provides a variety of advanced pain control techniques in a caring and compassionate environment. Understanding the causes and effects, as well as the patient's perception of pain, their lifestyle and their individual needs for pain control are all considered in the design of an effective and efficient program for pain control.
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