1. There are three kinds of people, the scholars, the seekers of knowledge and all the others are a waste of humanity. Jafar AlSadiq

2. Dr. Nasir Imran Zaidi Consultant Anaesthetist, Railway General Hospital Assistant Professor, Islamic International Medical College Rawalpindi

3. doctornasir@yahoo.com  This presentation and its relevant material can be obtained by sending an email to doctornasir@yahoo.com doctornasir@yahoo.com  Available to all those who take part in propagation of the knowledge

4. 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

5. Chronic Pain Syndrome IMalignant Cancer pain syndrome II Non-Malignant Nociceptive Neuropathic Psychogenic

6.  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

7. Modalities of Pain Management IPharmacological IIAnaesthesiologic IIISpecial technique * Facet Blocks * Acupuncture (Gate control theory) * Cryolysis * Ablative technique * Radio frequency * Physical therapy

8. Pharmacological  Analgesic Paracetamol NSAID Opioids  Co-analgesics Anti-depressant Anti-convulsant Contd...

9. Anesthisiologic  Central nerve blocks ○ Spinal ○ Epidural  Peripheral nerve blocks ○ Femoral ○ ICN ○ Others  Autonomic Nerve blocks ○ Stellete ganglion ○ Lumber Sympathectomy Contd...

10. Special Technique Special Technique  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. Contd...

11. 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

12. Prolapsed Intervertebral Disk

15. Management of Low Back Pain  Do not miss a treatable cause of pain in the rush to treat the symptoms  Pain alone may not justify decompression surgery like laminectomy or micro-discectomy

16. 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

17. 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 Anemiacalciumpotassiumiron radiculopathy, visceral diseases, depression, Hypothyroidism, hyperuricemia, and hypoglycemia radiculopathydepression Hypothyroidismhyperuricemiahypoglycemia

18. Complex Regional Pain Syndrome : CRPS Recently the sub-committee on taxonomy of IASP has replaced the terms RSD and Causalgia to Chronic regional pain syndrome (CRPS) RSD-CRPS I Causalgia -CRPS II

19. 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.

20. 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.

21. 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

22. 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

23. Management  Drug therapy (main stay) Anticovulsant Anti depressant  Nerve block Little role

24. 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.

25. Management of Trigeminal Neuralgia  Drug Therapy Anti-convulsant Anti depressant  Nerve block Cryo-analgesia Radio-frequency

26. Malignant Pain Syndrome Incidence 70% of cancer patients suffer from pain as a symptoms

27. Management Strategies  Pharmacological methods  Interventional pain management neurolytic blocks Intraspinal drug delivery system  Others physical therapy Tens therapy

28. Pharmacologic therapy “Analgesic staircase” Strong opioids +/- adjuvant Weak opioids +/- adjuvant Non-opioids NSAID +/- adjuvant

29. Invasive Procedures  When pain or side effects persist despite comprehensive trials of pharmacologic therapy INeurolytic blocks ○ Coeliac plexus ○ Hypogastric plexus IIIntra-spinal drug delivery ○ short terms – intrathecal or epidural infusion ○ long term – implants

30. 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

31. Certainly, knowledge is a lock and its key is the question Quote by: Ja'far al-Sadiq as The teacher of Jabir ibn Hayyan, an astronomer, alchemist, Islamic scholar, Islamic theologian, writer, philosopher, physician, physicist and scientist.