State of Pain

HEAD-ACHE

Everyone has suffered from headache in their lifetime. For most people, headache is a minor issue and can fade away with no need for medication. However, there is a group of pain types, where the pain is caused by a tumor, inflammation, bleeding or vascular abnormalities. To rule out these causes, it is desirable to consult with a neurologist first. In certain types of headache, such as trigeminal neuralgia, interventional treatment may be of help.

Trigeminal neuralgia
• Trigeminal neuralgia or a painful trigeminal nerve disease is described as one-sided, short-term (lasting for a few seconds), strong, sharp, shooting pain in the area of the jaw or cheek, similar to an electric shock. It may be triggered by eating, washing, shaving, cold, warmth or draft.

Cluster headache
• The patients suffering from the so-called “cluster headache” know it as very strong and severe pain in the eye and temple areas. The pain is often accompanied by same-sided signs of conjunctiva blood-repletion, nasal congestion or even contraction of pupils. In the most typical form, there will be periods of episodic headaches (clusters), lasting from a few weeks to months, whereby the attack frequency can vary from one every 2 days to eight per day. The attacks appear in the same time-frame during the day. After such a period, the patients often experience a longer period of time without attacks, followed by another attack period.

Cervicogenic Headache
• Cervicogenic headache, the source of which lies in the cervical spine, is usually unilateral but can also occur bilaterally. The pain usually begins in the neck area and radiates toward the eye area. This type of headache seems to be “delving” into the depths and is of a non-pulsing character. It comes in attacks, the duration of which cannot be predicted (hours to days). The pain is triggered by neck movements and usually accompanies the history of traumatic cervical-spine damage.

Whiplash
• “Whiplash” is an official term for associated symptoms related to the neck area, where the trigger is an injury with a quick movement of the head in the forward-backward direction (the so-called “whiplash”). The typical symptoms include: pain in the neck, shoulders, and possibly also in the arms, headache, particularly in the occipital area, sometimes radiating to the forehead and both eyes. Immediately after the injury, stiffness of the neck occurs, followed by its restricted mobility. “Whiplash” may also manifest itself in dizziness, visual impairments, nausea, tinnitus, deafness, spasms and post-traumatic stress disorder (depression).

Occipital Neuralgia
• Occipital neuralgia is a shooting or stabbing, short-lasting pain that originates in the sub-occipital area and radiates over the vertex to frontal region. In its character, it is very similar to trigeminal neuralgia. The pain may be accompanied by decreased sensitivity in the affected area. Pressing on the occipital nerve alleviates the pain. The stiffness and the triggering spot are located in the surrounding muscles. If conventional therapy does not succeed, diagnostic nerve blocks, which confirm the source of the pain, may be of help.

Diagnostic procedures:

Selective peripheral-nerve block
Medial branch blocks

Therapeutic procedures:

Thermal radio-frequency ablation
Pulsed radio-frequency)

BACK PAIN

Cervical spine

Pain coming from facet joints
Facet joints are small joints connecting vertebrae. They allow our spine to tilt and bend. The symptoms coming from facet joints in the cervical area include pain in the neck area, headache, pain in the shoulders, the area above and in the shoulder-blade and also pain in the upper limbs. The movement of the neck is constricted, the pain worsens in a backward bend and improves slightly in a forward bend.

To confirm that the facet joints are the real source of pain, it is necessary to perform the so-called diagnostic medial branch block, which innervates the facet joints. During this procedure, an anesthetic is administered to the proximity of these nerves. In case of significant alleviation of pain following this procedure, we can proceed with a treatment with a more long-term effect – the radio-frequency ablation of these nerves. This procedure applies heat to the respective nerves, thus interrupting their ability to carry pain signals to the brain.

Diagnostic procedures:

Medial branch blocks

Therapeutic procedures:

Thermal radio-frequency ablation

Pain coming from the disc
The intervertebral fibrocartilages or discs are flexible pads, which are located between individual vertebrae. They allow the spine to bend and rotate. If the disc is damaged, its inner part presses outward and may irritate spinal nerves. Pain coming from the discs is typically linked to activities that increase the pressure on its interior, like prolonged seated posture, especially in a prolonged forward bend. Frequent changes in posture may result in partial relief.

To confirm the diagnosis, a test called provocation discography is used. During this procedure, a contrast dye is administered to the affected disc, which shows the structure of the disc and also allows us to provoke pain in the patient’s body. It may be followed by intradiscal electrothermal therapy, i. e. application of heat to the tissue of the damaged disc using a special needle.

Diagnostic procedures:

Provocation discography

Therapeutic procedures:

Thermal radio-frequency ablation

Pain caused by nerve-root irritation
Pain that manifests itself in the arm area comes from cervical nerves. The pain sensation may radiate over the shoulders towards the fingers. Even combinations of pain in the neck and arms are not unusual. The treatment options include an injection into the epidural range in the area of the damaged nerves or a targeted injection into canal to the actual damaged nerve. Another treatment option is the pulsed radio-frequency therapy – application of moderate heat and intermittent electric current.

Diagnostic procedures:

Nerve-root block

Therapeutic procedures:

Pulsed radio-frequency

Thoracic spine

Pain coming from facet joints
The pain is localized in the upper and central part of the back with possible radiation towards the chest or ribs. It is blunt, deep, hard to describe. A forward bend, like when tying your shoelaces, worsens it. Morning stiffness is quite common and so is pain along the sides of the back, which may be accompanied by muscle spasms.

To confirm that the facet joints are the real source of pain, it is necessary to perform the so-called diagnostic medial branch block. During this procedure, an anesthetic is administered to the proximity of these nerves. In case of significant alleviation of pain following this procedure, we can proceed with a treatment with a more long-term effect – the radio-frequency ablation of these nerves. This procedure applies heat to respective nerves, thus interrupting their ability to carry pain signals to the brain.

Diagnostic procedures:

Medial branch blocks

Therapeutic procedures:

Thermal radio-frequency ablation

Pain coming from the disc
The intervertebral fibrocartilage or discs are flexible pads, which are located between individual vertebrae. They allow the spine to bend and rotate. If the disc is damaged, its inner part presses outward and may irritate spinal nerves. The pain coming from the disc is usually linked to activities which increase the pressure on its interior, like sitting, bending forward, coughing or sneezing. Discogenic pain may be accompanied by leg pain, caused by the irritation of surrounding nerves, especially when sitting, getting up or walking. Back pain is generally permanent, day-to-day, as opposed to root pain, which changes its character.

To confirm the diagnosis, a test called provocation discography is used. During this procedure, a contrast dye is administered to the affected disc, which shows the structure of the disc and also allows us to provoke pain in the patient’s body. It may be followed by intradiscal electrothermal therapy, i. e. application of heat to the tissue of the damaged disc using a special needle.

Diagnostic procedures:

rovocation discography

Therapeutic procedures:

Thermal radio-frequency ablation

Pain caused by nerve-root irritation
Pain coming from the nerves in the lumbar area generally radiates as far as below the knee. Back pain may be localized between the last ribs and above the sciatic muscle. Even back and leg pain is common, in case of the folk term “ischias”, the leg pain is greater than the back pain. The treatment options include an injection into the epidural range in the area of the damaged nerves or a targeted injection into canal to the actual damaged nerve. Another treatment option is the pulsed radio-frequency therapy – application of moderate heat and intermittent electric current.

Diagnostic procedures:

Nerve-root block

Therapeutic procedures:

Pulsed radio-frequency

Lumbar spine

Pain coming from facet joints
The pain comes from the lower-back area and may radiate towards buttocks, groin and legs, usually no further than the knee. The pain is blunt, deep and hard to describe. The backward bend and side bend worsen it, usually bending forward does not pose a problem. The symptoms worsen with prolonged sitting or standing, moderate exercise may alleviate the pain. Morning stiffness is quite common and so is pain along the sides of the back, which may be accompanied by muscle spasms.

To confirm that the facet joints are the real source of pain, it is necessary to perform the so-called diagnostic medial branch block. During this procedure, an anesthetic is administered to the proximity of these nerves. In case of significant alleviation of pain following this procedure, we can proceed with a treatment with a more long-term effect – the radio-frequency ablation of these nerves. This procedure applies heat to the respective nerves, thus interrupting their ability to carry pain signals to the brain.

Diagnostic procedures:

Medial branch blocks

Therapeutic procedures:

Thermal radio-frequency ablation

Pain coming from the disc
The intervertebral fibrocartilages or discs are flexible pads, which are located between individual vertebrae. They allow the spine to bend and rotate. If the disc is damaged, its inner part presses outward and may irritate spinal nerves. The pain coming from the disc is usually linked to activities which increase the pressure on its interior, like sitting, bending forward, coughing or sneezing. Discogenic pain may be accompanied by leg pain, caused by the irritation of surrounding nerves, especially when sitting, getting up or walking. Back pain is generally permanent, day-to-day, as opposed to root pain, which changes its character.

To confirm the diagnosis, a test called provocation discography is used. During this procedure, a contrast dye is administered to the affected disc, which shows the structure of the disc and also allows us to provoke pain in the patient’s body. It may be followed by intradiscal electrothermal therapy, i. e. application of heat to the tissue of the damaged disc using a special needle.

Diagnostic procedures:

Provocation discography

Therapeutic procedures:

Disc FX
Thermal radio-frequency ablation
Epiduroscopy

Pain caused by nerve-root irritation
Pain coming from the nerves in the lumbar area generally radiates as far as below the knee. Back pain may be localized between the last ribs and above the sciatic muscle. Even back and leg pain is common, in case of the folk term “ischias”, the leg pain is greater than the back pain. The treatment options include an injection into the epidural range in the area of the damaged nerves or a targeted injection into canal to the actual damaged nerve. Another treatment option is the pulsed radio-frequency therapy – application of moderate heat and intermittent electric current.

Diagnostic procedures:

Nerve-root block

Therapeutic procedures:

Pulsed radio-frequency
Epiduroscopy

Pain coming from the sacroiliac joint
The sacroiliac joint (or the SI joint) is an issue by itself in the lower-back area pain. This joint connects the sacral and pelvic bones. The pain worsens when sitting, bending forward, or prolonged sitting as a guest passenger in the car. Standing or walking may result in pain-alleviation. The pain is most commonly localized in the back part of the joint and in the central area of buttocks and it may radiate towards the groin, back part of the thigh and sometimes even as far as below the knee. It is often caused by lifting a heavy object while rotated or when misstepping on a curb.

To confirm this type of pain, an anesthetic and anti-inflammatory drug is injected in the joint. The recommended therapeutic procedure is the radio-frequency ablation of the nerve supplying the joint.

Diagnostic procedures:

SI-joint block
This block is performed by administering a local anesthetic to confirm or disconfirm the possibility that the sacroiliac joint is the source of the pain condition. Above all, it is a diagnostic test, where the pain alleviation depends on the duration of the effect of the anesthetic.

Therapeutic procedures:

Thermal radio-frequency ablation

VISCERAL PAIN

Pain in the chest and abdominal area
• Visceral (pancreatic) pain is caused by the activation of pain receptors in visceral organs. The pain is usually described as permanent, griping, or cramping. It cannot be easily localized and it radiates in all directions. Chronic pancreatic pain responds very well to the block procedure affecting the nerves connected to the pancreas.

Diagnostic procedures:

Peripheral-nerve block

Therapeutic procedures:

Thermal radio-frequency ablation
Chemical neurolytic block
◦ The administration of a neurolytic agent (a substance destroying nerves) is used for a long-term destruction of nerves, which were confirmed to be the source of the pain by a previously performed diagnostic procedure.

Pelvic pain
• Patients suffering from pelvic pain localize it in the area of the bladder, large intestine, for women in the area of uterus and ovaries, for men in the prostate and testicles. Chronic pelvic pain is often diagnosed by gastroenterologists, urologists, and internists. For many patients suffering from this type of pain, the source is never discovered. It is important to realize that the pain in these patients is not just a symptom but that they suffer from a chronic pelvic pain syndrome. To confirm the source of the pain, diagnostic nerve blocks are used. Neurolytic blocks or thermal radio-frequency ablation are performed to achieve a long-lasting pain relief.

Diagnostic procedures:

Peripheral-nerve block

Therapeutic procedures:

Thermal radio-frequency ablation
Chemical neurolytic block

NEUROPHATIC PAIN

Neuropathic pain is usually a result of peripheral-nerve damage or compression. The nerve can be damaged during surgery, after a trauma or as a result of degenerative changes in the body. Neuropathic pain has a specific quality to it – patients usually describe it as burning, tingling or “electric-like”. The pain is typically limited to the area, where the affected nerve normally collects the sensory input. The most common diagnoses for patients suffering from neuropathic pain that we encounter at our clinic are:

  • disc herniation with nerve-root compression
  • postlaminectiomy syndrome – scar-tissue formation in epidural space as a result of spinal surgery
  • carpal channel syndrome – median-nerve entrapment
  • certain types of headache – occipital-nerve entrapment
  • trigeminal neuralgia – painful unilateral disease of the face, sometimes of unknown cause
  • postherpetic neuralgia – pain persisting after a herpes-zoster recovery

Neuropathic pain can co-exist with other types of pain, which is typical for the lower-back pain, or can lead to a complex regional pain syndrome.

Diagnostic procedures:

Peripheral-nerve block

Therapeutic procedures:

Thermal radio-frequency ablation)
Pulsed radio-frequency
Neuromodulation
Neuromodulation is used to alter the activity of the nervous system using an implantable device. A small device (stimulator or a drug pump) is implanted in the hypodermis, which then, using small doses of medication or weak electric current, affects pain perception. This procedure is fully reversible and with the correct indication also very effective, returning patients back to active life.
Qutenza – Capsaicin 8 %
The application of warming capsaicin plaster. Capsaicin is a vegetable alkaloid present in chili peppers, where it adds the hot taste. It is also used in the neuropathic-pain treatment for its analgesic properties.

COMPLEX REGIONAL PAIN SYNDROME

CRPS is a less common disease – the word “complex” describes a complicated interplay between various systems in the human body that give rise to the disease as well as for the multitude of symptoms that a patient with CRPS can experience. The disease usually affects upper or lower extremities. CRPS is usually triggered by a minimal trauma to the limb (Type I CRPS) or by nerve damage (Type II CRPS). Besides the pain, CRPS manifests itself in some very specific symptoms, mostly perceptible in the fingers:

  • normal touch or pressure causes burning pain
  • abnormal sweating
  • changes in the skin and nail quality
  • osteoporosis

In its more severe forms, CPRS also affects the central nervous system, leading to muscle weakness in the limb or even loss of limb perception as a part of one’s body. Peripheral-nerve blocks are preformed to confirm the source of the pain. Among the therapeutic procedures, neurolytic nerve blocks, thermal radio-frequency ablation, peripheral or spinal-cord stimulation are performed.

Diagnostic procedures:

Peripheral-nerve block

Therapeutic procedures:

Thermal radio-frequency ablation
Pulsed radio-frequency
Neuromodulation
Qutenza – Capsaicin 8 %