Chronic pain interventions avoid surgery, drugs.

SAN FRANCISCO -- A number of interventions offer patients with chronic pain something more than medications but less than surgery, Dr. Barbara S. Mallett said at a joint conference of the American Society on Aging and the National Council on the Aging.

"It's like 'Goldilocks and the Three Bears.' For some patients, it's juuuuust right," said Dr. Mallett of Southwest Washington Medical Center, Vancouver, Wash.

For patients with chronic neuraxial pain who fail conservative management, are losing function, and want to avoid surgery, consider referring them to a pain specialist who may employ an epidural steroid injection, a facet block, radiofrequency ablation, disk decompression, or other interventional pain management techniques.

"You don't have to memorize all these things, but just get the idea that there are options out there," Dr. Mallett said. She described some of the most commonly used pain intervention techniques:

* Epidural steroid injection. An injection of cortisone or other steroid into the epidural space treats inflammation of the spinal nerve roots resulting from disk compression or spinal stenosis. Physicians use fluoroscopy to guide the injections, often with the patient under conscious sedation.

Many patients get 6 months to 2 years of pain relief from this procedure, although the duration of action varies widely depending on the physical problem and personal characteristics. "I see a lot of people chronically off and on," for epidural steroid injections, she said. If their pain worsens between treatments, or every year or two if there's no change in pain levels between treatments, she recommends that they see a surgeon to discuss surgical options.

"Injections are not a fix, but they make some patients more functional and provide some relief," she said. This procedure may be helpful especially for patients with pain radiating down a leg due to nerve compression by a spinal disk, sometimes accompanied by back pain. Injections also can be used to treat neck pain.

* Radiofrequency ablation. For patients with low back pain only, or back and leg pain who fail treatment with epidural steroid injection, the newer technique of radiofrequency ablation may be helpful.

For a patient with facet joint pain, for example, Dr. Mallett injects local anesthetic as a diagnostic block of particular nerves affecting the joints in question. If the patient expresses relief and approves treatment, she inserts a needle that's insulated except at the tip, which delivers low-dose electricity to the nerves. High doses cause high temperatures that destroy nerves; pulsed or intermittent radiofrequency produces less heat that makes nerves less sensitive to pain impulses.

The treatment may relieve pain for 2 years. Radiofrequency also can be used to treat neck pain.

* Disk decompression. If a bulging spinal disk that's pressing on a nerve root causes pain, inserting a needle and delivering heat into the middle of the disk can shrink the disk through a procedure called nucleoplasty. Tears in the wall of a disk, which promote inflammatory chemicals that cause pain, can be scaled by threading a heat-generating probe along the disk fibers.

* Peripheral nerve blocks. Patients with severe headaches unresponsive to medications or who can't tolerate pain medications may be helped by an occipital nerve bock. Many people report persistent pain after hernia surgery; blocks of the iliohypogastric, ilioinguinal, or genitofemoral nerves may help, she said.

Nerve blocks can be especially helpful in cancer patients, for instance by blocking the ganglion impar for patients with pelvic pain. If there's pain all over, however, the patient needs medication all over--systemic treatment.

These interventional pain management techniques can help many patients significantly reduce their use of high-dose narcotics and thus avoid development of drug tolerance, preserving narcotics as an option for later use if they develop more diffuse pain, Dr. Mallett said.

BY SHERRY BOSCHERT

San Francisco Bureau