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 Breivik et al., EJP 2006;10:287-333.

Interventional Therapies Diagnostic blocks Epidural steroids Radiofrequency technigues Neurostimulation techniques Neuroaxial medication ADJUVANT ANALGESICS + PATIENTS EDUCATION

INTERVENTIONAL TECHNIQUES IN THE MANAGEMENT OF CHRONIC PAIN MINIMALLY INVASIVE PROCEDURES 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 EFNS guidelines on neurostimulation therapy for neuropathic pain. Cruccu et all. Eur J Neurology 2007;14:952-70. 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 Evidence-based guidelines for interventional pain medicine according to clinical diagnoses. Van Kleef et al. Pain Practice 2009;9:247-51. Evidence based medicine. Trigeminal neuralgia. Van Kleef et al. Pain Practice 2009;9:252-9. 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 Chemical neuromodulation: neuraxial delivery of medication

WHICH PATIENTS FOR NEUROSTIMULATION AND WHEN? confirmed diagnosis of NP chronic disease with intractable pain in spite of pharmacological/physical treatment unresponsible for conventional treatment at least 1 month for each modality psychological evaluation positive response to trial (50% and more pain reduction)

INDICATIONS FOR NEUROSTIMULATION AND ITDD

SCS MECHANISMS IN NEUROPATHIC PAIN

SCS SUCESS RATE FBS 50%-70% PNP 60%-80% CRPS, DPN PVD 70%-80% IAP > 80%

SCS POSITION IN THERAPEUTIC STAIRCASE EVENTUAL LESIONAL TECHNIQUES MORE INVASIVE NEUROMODULATION TECHNIQUES OPIOIDS SCS ANTICONVULSIVES ANTIDEPRESANTS TENS

safety/complications, 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 staff and time knowledge and expierence policies

COST EFFECTIVENESS OF SCS Kumar et al.Neurosurgery 2002;51:106-16.

QUALITY SYSTEM FOR NEUROMODULATORY TECHNIQUES The development of a quality system for neuromodulation in the Netherlands. Neuromodulation 2005;8:28-35. TREATMENT PROTOCOL Intake of patients trial stimulation or administration of drugs implantation of permanent system control phase QUALITY INDICATORS 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 RF beginnings in eighties but did not develop decennia of ITB last 5 years SCS and DBS recent efforts for other ITDD and RF Main problems: cost knowledge and licenced stuff health policy Consilium on Neuromodulation in Slovenia, 2008 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.

INTERVENTIONAL TECHNIQUES IN PAIN MANAGEMENT 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 implementation should be guided by the best avaliable evidence on efficacy and safety with respect to the diagnosis of the individual patient need for correct application, good theoretical knowledge and practical expierence implementation of quality system will contribute to acceptance in national health policy and better management of chronic pain