Apollo Pain Clinic

Hello,

I am Dr. K J Choudhury, senior consultant in pain management. I am here to speak to you about pain management because the public is not aware of what do we do as a pain specialist. Pain is a very useful thing for the body without which the body is not protected. So pain is basically a warning signal for something is going wrong or is likely to go wrong in the body so that the body can take action. So, there are two types of pain basically chronic or acute pain. We will focus mainly on the chronic pain when the pain lasts for more than 3-6 months then you call it as chronic pain. Acute pain is following a surgery or an injury and the pain stops as the healing process is completed. Chronic pain can be a bothersome that affects the quality of an individual, his family and society as a whole and it is a major problem worldwide. So what is the cause of pain is the one where I am expected to find out what is causing the pain if your pain is there at any time then if you take a painkiller that stops the pain until the painkiller effect is there in the body. But when you take a painkiller by mouth it is absorbed in the body, it circulates and reaches the pain receptors where the pain is felt, which is in the spinal cord and the brain. Every part of the body has got sensors, called receptors, which carry the pain sensation through the nerves, through the spinal cord into the brain where it is perceived. We have to find out what is this place or what you call the pain generator. As a pain specialist we find out the exact cause of the pain, sometimes using equipments like MRI, x-rays, ultrasound and those ones, but clinical history like how it happened, how long it is happening, what is the tyle of the pain and on clinical examination we find something on the surface, will give the clue to what could be the cause of the pain. And the objective is not to keep on loading the body on pain killers which is the major cause of organ failures these days like kidney, liver and gastritis is the most common one, but to treat the source of the pain. And with this special skills that we are trained to do, we reach to the pain generator or that is causing the pain and deliver medication that will heal the pain and sometimes we give numbing agents and numbing agents can be converted to a long term sensory brocket with use of what you call the radio frequency ablation. So every part of the body has different types of pain.

Today I may discuss with you about a couple of them. So, one of the common causes is knee pain. It’s very confusing, people with knee pain what they should do, there is a lot of information in the newspaper, advertisements, don’t go for surgery, don’t do this, don’t do that. So what do we expect, knee pain, like this, is the model of the knee, this is the knee joint, and in a joint two bones join together but they don’t touch each other, and the joint is covered with a capsule which retains its identity, and inside the joint, there is jelly-like substance which is lubricant and that helps the joint to move. But again, as the bones do not touch each other, there will be jelly inside and in this case, there is miniscus that is soft bone and that stops from touching each other. So there are so many reasons that somebody will have knee pain or arthritis of the knee, commonest is osteoarthritis, which is age-related generally starts in the 60s and sometimes early in 50s, mostly it is a degenerated process, i.e aging process, sometimes aging starts early because of inactivity or less physical activity. So what happens in that case, the jelly inside the joints gets less and less and the bones start touching each other. That is the time we should intervene because the bones, ones it touches each other then they bruise each other, then linings inside the joints also get eroded, that is the time we should treat and avoid major interventions later in life. So there are different grades of osteoarthritis knee, the earliest symptom is the grade one and second, if it goes further, is 2, then there is grade three and 4 are normally requires to have surgery. But what can you do at this stage to treat your osteoarthritis pain, is number one, if you are overweight, you have to reduce your weight, if you are not physically active then start building up your activity, particularly for the joints, that means strengthening the muscles that control the joint movement in the knee. That is the quarter steps and the muscles and the back. So, by making those muscles strong, the major part of your problem is over.

Then you have to use some supplements which will replenish the gel inside the joint. There are ways also you can supplement with viscus injections, but they just don’t last long. Unfortunately, the viscus is not normally eaten in normal diet that can produce the jelly, so it has to be eaten. And also, later on, when there is a swelling, redness or severe pain, that means the internal linings are also getting eroded, in that case, you have to have medicines, supplements that can start healing. But to help heal faster there are injections that can be used inside that is called regenerative medicine we can take our own blood and center fuse and part of the components can be injected back which will help regenerate the lining of the joint or there is another intra-articular inside the joint that is ozone. Ozone is the safest medication in the world and it is injected in a sterile environment and repeated a couple of times along with your exercise, reducing the weight or other medical issues you can completely get rid of the progress of osteoarthritis of the knee. But if you have not done that and if your joint is bothering you, you may need surgery in the grade three and four where it is almost like touching each other and there is a deformity that means the knee is bent that is the real indication for surgery particularly for grade four. But many times in grade three just before this definitive injective surgery we have other means that is non-surgical technique because there are some patients not suitable for surgery because joint replacement is a major surgery and if there is severe medical conditions like heart disease, diabetes, and some people are afraid of failure of surgery for anything in the world there is a failure but in knee joint, if properly done the knee replacement can also fail because of lack of compliance strengthen the muscle that controls the joint, if you don’t do again that will fail or knee joint replacement still continues to pain there is another option today available that is called radio frequency ablation of genicular nerves. Genicular nerves, there are three main nerves that can carry the pain sensation from the joint from the main nerve to the brain and these are three ones we can locate them with the help of ultrasound, x-ray and nerve locator and if you use local anesthetic which gives them temporary numbing and if the pain is relieved we can permanently numb those nerves without any side effect and patient can be pain-free but knee joint condition remain the same. But if you want the improved and better quality of life then this is the best option available, we have done so many patients with genicular brands radio frequency ablations and nobody had any side effect. The only problem is that the nerves can regenerate after a few years then you can repeat the procedure. So this is the, of all the options that you have, you can not club every person, nobody needs any surgery, you can always treat that is also right. Your own effort to take care of your knee joint pain is very crucial, whether surgery or no surgery. Then there is another painful condition that I like to treat is something called Trigeminal neuralgia. Trigeminal neuralgia is a nerve disorder that affects the face. The trigeminal nerve originates from the brain it comes and supplies the part of the face. It has three divisions, one is in the forehead, one in the cheek area, and one in the chin area. So one or more of these branches, for some reason, usually a viral infection, attacks the nerve, do no physically damage, but make it irritable in severe pain. And the pain can be so severe that some people even commit suicide because the drugs also do not affect them.

There are some true stories, there are some people who are publically known, they have got the disease and they need definite treatment. But most of these conditions get controlled with medications. But when the medications stop to work or produces side effects, then the pain specialist is required to control his pain. What we do is that we numb that particular division of the trigeminal nerve and when comes out of the brain. It’s very very close to the hole, these nerves come from the brain, we selectively block those nerves to confirm that yes this is the trigeminal neuralgia and this is the specific division that needs to be treated. Then once it’s confirmed, just like explained for the knee joint, we can also do the radio frequency ablation where we enter through that canal through which the nerve comes out from the brain and enter into the nerve bundle and select that particular division, by stimulating for a second aggressive the pain and under suggestion or anesthesia we destroy the function of the nerve. There is no physical destruction but like you boil the egg and loses the function, similarly, that division of nerve can be made permanently numb and so relieve the pain. In some patients, there may be blood vessel, that may be sitting on the nerve inside the brain which can be diagnosed in MRI and we need to surgically intervene and do a brain surgery, enter that part of the brain where the blood vessel is thumbing on the trigeminal nerve With a specking and they treat the pain. Then there are other options also like radio surgery where radiation is focused on that division of trigeminal nerve and also destroys it. So I would like to finish by two major pain issues. Next time we can talk about other issues.

Thank You!

Pain management, pain medicine, pain control or algiatry, is a branch of medicine employing an interdisciplinary approach for easing the suffering and improving the quality of life of those living with chronic pain.

I am Dr. K J Choudhury, senior consultant in pain management and in charge of pain clinic in Indraprastha Apollo Hospital, New Delhi.

Many people don't know what pain management is about. Though people know that pain is the issue with every family. And I am sure, in every family, there must be a member who is suffering from pain from 2-3 months like joint pain, headache, neck & back pain. Generally, the treatment given for any pain or painkillers is given for a time period, and if they don't subside, they seek surgical opinion from an orthopedic or neurosurgeon. But every pain does not require the surgery. So, pain management, or as we call it interventional pain management, delivers the medications where the problem is without cutting.

The drugs you normally use by mouth, they circulate all over the body through blood. But the area that requires the treatment may be a 1 mm area, so the whole body is loaded with medications. If we misuse the painkillers, it becomes an important cause of kidney failure and liver failure.

What does a pain physician do? They look at the exact source of pain. They use the specialized technique to teat the pain. And they deliver the medications mostly through needles using specialized equipments like x-ray or ultrasound to reach to the target so as they stay where it is required. So, the rest of the body is safe from the ill effect of painkillers. But all the patients do not need any surgical interventions. It is not necessary that all the painkillers will work for every painful condition. So, the pain specialist also knows that what kind of painkillers or what exponents are required.

So, I will tell you about back pain. It is common today amongst those who are not physically fit and use wrong posture while using computers, bicycles. They stress on the muscles and that could be because of pain. But if it doesn't subside with medication and physiotherapy, you can go to a surgeon who will ask you for the MRI.

Now the question is whether the disc is the cause of the pain. So, what we do is, between the 2 vertebrae, it contains a gel. When the covering breaks down because of the poor body strength then these gel causes irritation of the nerves that are going down to the legs and it is called sciatica. The most common thing is that we enter into the place where the disc material is irritating the nerve and put the healing agents.

We don't have to treat inflammation with a surgical technique. But if the patient has the unstable spine or there is a tumor or there is the narrowing of the bony canal in the spinal cord then it needs a surgical intervention. My idea is to educate you that not every patient who fails medications, require surgery. There is a much safer procedure to take care of pain anywhere in the body. Thank you very much.