There are three kinds of people,
the scholars,
the seekers of knowledge
and
all the others are a waste of humanity.
Jafar AlSadiq
Dr. Nasir Imran Zaidi
Consultant Anaesthetist, Railway General Hospital
Assistant Professor, Islamic International Medical College
Rawalpindi
doctornasir@yahoo.com
This presentation and its relevant material
can be obtained by sending an email to
doctornasir@yahoo.com
 Available to all those who take part in
propagation of the knowledge

Chronic Pain
Chronic Pain define as:

Pain persists beyond either the course of an
acute disease or reasonable time for an injury to
heal

Pain is associated with chronic pathological
process

Pain that recurs at interval of months or year
Chronic Pain Syndrome
I Malignant
 Cancer pain syndrome
II Non-Malignant
 Nociceptive

Neuropathic

Psychogenic

Nociceptive






Low back pain
Myofacial pain
Visceral pain
Headache and facial pain
Neck and shoulder pain
Neuropathic pain




Sympathetically mediated pain
Post herpetic neuralgia
Trigeminal neuralgia
Phantom pain
Modalities of Pain Management
I
Pharmacological
II
Anaesthesiologic
III
Special technique
* Facet Blocks
* Acupuncture (Gate control theory)
* Cryolysis
* Ablative technique
* Radio frequency
* Physical therapy
Contd...
Pharmacological

Analgesic
 Paracetamol
 NSAID
 Opioids

Co-analgesics
 Anti-depressant
 Anti-convulsant
Contd...
Anesthisiologic

Central nerve blocks
○ Spinal
○ Epidural

Peripheral nerve blocks
○ Femoral
○ ICN
○ Others

Autonomic Nerve blocks
○ Stellete ganglion
○ Lumber Sympathectomy
Special Technique
Contd...

Facet block for back pain

Cryolysis for nerve damage

Radio frequency for facet joint / nerve damage

Acupuncture
 361 classical acupuncture points lie along specific
pathway or meridians

Ablative neuro-surgical procedure - interrupt
sensory pathways to the brain or in the brain
and brain stem.
Low Back Pain
Most common condition seen in the pain clinic
Major causes:

Prolapse inter-vertebral disc

Facet joint degeneration

Sacroiliac joint arthritis

Musculoskeletal disorder

Miscellaneous
Prolapsed Intervertebral Disk
Management of Low Back Pain

Do not miss a treatable cause of pain in
the rush to treat the symptoms

Pain
alone
decompression
may
not
justify
surgery
like
laminectomy or micro-discectomy
Treatment Options
Drug therapy vs nerve block procedure
 drug therapy NSAID, week opioids & other
support therapy
 Low morbidity out patient
○ Epidural steroid
○ Facet joint steroid injection
○ Sacroiliac steroid injection
As a first line of treatment
Myofacial Pain Syndrome

Pathogenesis
 The likely has a central mechanism, with peripheral
clinical manifestations.

Causes
 Abnormal stresses on the muscles from sudden stress on
shortened muscles, leg-length discrepancies, or skeletal
asymmetry
 Poor posture, static position for a prolonged period of time
Chronic infections and sleep deprivation
 Anemia and low levels of calcium, potassium, iron, and
vitamins C, B-1, B-6, and B-12 are believed to play a role
 radiculopathy, visceral diseases, depression,
Hypothyroidism, hyperuricemia, and hypoglycemia
Complex Regional Pain Syndrome : CRPS
Recently the sub-committee on taxonomy of IASP has
replaced the terms RSD and Causalgia to
regional pain syndrome (CRPS)
RSD
-
CRPS I
Causalgia
-
CRPS II
Chronic
Sympathetically Mediated Pain (SMP)
Reflex sympathetic dystrophy (RSD) and causalgia
RSD
A group of condition associated with extremity pain and
autonomic dysfunction
Causalgia
Specific syndrome of burning pain and autonomic
dysfunction associated with major nerve trunk injury.
SMP / SIP
SMP
(sympathetically mediated pain)
SIP (sympathetically independent pain)
Majority of CRPS are associated with
SMP but fewer cases are found to be SIP.
Treatment Options of CRPS
Drug therapy
 Antidepressant
 Anti convulsant
 Narcotic analgesic
 Oral nifedipine
 Adrenergic blocking agents
 Nerve Block
 Chemical sympathectomy
 Intravenous regional block (Bier’s Block)
 Physical therapy
 Tens therapy

Post-herpetic neuralgia

Pain in the distribution of a nerve

It follows an acute herpetic attack (shingles)
Incidence:
3-4 per 1000
Clinically:
 Burning pain
 constant deepache
 crawling or scratching pain
 stabbing or shooting
Management
 Drug
therapy (main stay)
 Anticovulsant
 Anti depressant
 Nerve
block
 Little role
Trigeminal Neuralgia

Conditions occur more often in
 Female
 middle aged

Strictly unilateral, however in 2% it may be
bilateral

Pain in the face is characterized by sharp,
severe (paroxysmal) and brief lasting no more
then a few seconds.
Management of Trigeminal Neuralgia

Drug Therapy
 Anti-convulsant
 Anti depressant

Nerve block
 Cryo-analgesia
 Radio-frequency
Malignant Pain Syndrome
Incidence
70% of cancer patients suffer
from pain as a symptoms
Management Strategies

Pharmacological methods

Interventional pain management
 neurolytic blocks
 Intraspinal drug delivery system

Others
 physical therapy
 Tens therapy
Pharmacologic therapy “Analgesic staircase”
Strong opioids
+/- adjuvant
Weak opioids
+/- adjuvant
Non-opioids
NSAID +/adjuvant
Invasive Procedures

When pain or side effects persist despite
comprehensive trials of pharmacologic therapy
I
Neurolytic blocks
○ Coeliac plexus
○ Hypogastric plexus
II Intra-spinal drug delivery
○ short terms – intrathecal or epidural infusion
○ long term – implants
CONCLUSION

Control of pain in chronic pain syndrome can be
achieved in most patients by the application of a
carefully individualized, flexible programme of :
 analgesic drugs
 Interventional pain management
Certainly, knowledge is a lock and its key is the
question
Ja'far al-Sadiq
Quote by:
as
The teacher of Jabir ibn Hayyan,
an astronomer, alchemist, Islamic scholar, Islamic theologian, writer,
philosopher, physician, physicist and scientist.