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British Journal of Pain logoLink to British Journal of Pain
. 2012 Nov;6(4):170–173. doi: 10.1177/2049463712468056

Scientific Meeting of the Interventional Pain Special Interest Group of the British Pain Society: 8 September 2012 Radisson Blue Hotel, Manchester, UK

PMCID: PMC4590101

Survey of pain clinics in the north of England

M. Gupta1, R. Chawla1, M.L. Sharma1, S. Das2 and S. Gupta2

1Walton Centre NHS Foundation Trust, Liverpool, UK

2Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK

Background: Systemic reviews provide good evidence of efficacy for multidisciplinary pain treatment centres.1 It is also good practice to run condition-specific and joint pain clinics if the setup allows it. Consent is central to good medical practice and a fundamental part of clinical governance, and General Medical Council guidance should be considered.2 Validated pain clinic questionnaires are indispensable for the assessment of the multidimensional pain experience. Some pain clinics also request patients to complete a customised questionnaire for further details about their pain condition. Ultrasound is an imaging technique used increasingly in interventional pain management, with a potentially useful role for outpatient-based interventions. Spinal cord stimulation is a technique that has been approved by the National Institute for Health and Clinical Excellence for a variety of neuropathic pain conditions.3 There is also an increasing evidence base for the use of neuraxial analgesia for chronic non-malignant pain. Our aim through this short survey was to explore the current practice of the pain clinics in the north of England for the above.

Methods: The survey was distributed to 76 participants at the fourth annual meeting of the North England pain group. This meeting was attended by members of the multidisciplinary pain team (consultants, specialist registrars, specialist nurses, psychologists and physiotherapists) and provided a good forum for the members to discuss various topics in the area of pain management. Completed questionnaires were returned by 55 participants, yielding a response rate of 72.3%. All questions had either open or closed choices and the respondents could choose more than one response for the latter. The denominator for calculating the overall percentage response was the actual number of responses given to those questions, as all responders did not complete all questions. The survey consisted of 10 questions relating to the following: condition-specific pain clinics, pain questionnaires, intrathecal drug delivery service (ITDD), neuromodulation service, ultrasound-guided pain interventions, consent process, multidisciplinary teams and presence of anticoagulation guidelines for spinal interventions.

Results: The results were reflective of the fact that only 5% of the respondents were primary care pain physicians; about 25% worked in tertiary care and the remainder in a secondary care setup. A good proportion of clinics sent out validated pain questionnaires prior to clinic appointments; nearly half of the respondents also send out their own customised questionnaire. These cover most aspects of a typical pain history and are self-reported; two-thirds of these respondents think this also reduces time at the clinic. Condition-specific clinics, neuromodulation and ITDD are restricted to tertiary-level centres. Two-thirds of the respondents mentioned that they had a hospital-agreed anticoagulation guideline for spinal interventions. A good proportion of respondents continue to consent patients for interventions in theatres. Only very few centres have pre-printed consent forms that mention the risks and benefits of common interventions.

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Conclusion: This survey reflected that most centres in the north of England work in an evidence-based multidisciplinary setup. Neuromodulation, ITDD and management of complex cases remain the forte of tertiary-level centres, as commissioned. The consent process needs to be improved, and patients should be given sufficient information and time before the procedure. Ultrasound opens new perspectives in interventional pain medicine; however, it is limited because of operator inexperience and technical difficulties, and fluoroscopy remains the first choice. Customised questionnaires can possibly help to reduce clinic times; however, it is a time-consuming process and may suffer from poor patient compliance. The survey was limited by the fact that it was distributed only to the hospitals from which respondents attended, and therefore may not be a true reflection of the pain clinics in the whole of the north of England.

References

  • 1. Flora H, Fydrichc T, Turkd DC. Efficacy of multidisciplinary pain treatment centres: a meta-analytic review. Pain 1999; 49: 221–230. [DOI] [PubMed] [Google Scholar]
  • 2. General Medical Council. Consent: patients and doctors making decisions together. London: GMC, 2008. [Google Scholar]
  • 3. National Institute of Health and Clinical Excellence. Spinal cord stimulation for chronic pain of neuropathic or ischemic origin. NICE technology appraisal guidance 159. 2008. Available at: http://guidance.nice.org.uk/TA159/Guidance/pdf/English (accessed 16 November 2011).
Br J Pain. 2012 Nov;6(4):170–173.

Management of low back pain by applying the combination of facet radiofrequency and intradiscal ozone injection

Z. Elchami, A. R. Cooper, E. AbdElkarim, A. Mirambel and R. Massoud

Pain & Headache Management Center of Excellence (COE) International Medical Center, Jeddah, Saudi Arabia

Background: Back pain is one of the most common causes of pain and disability. There are many causes of back pain. Determining the source of pain can help guide treatment of this common problem. Common causes of back pain include back muscle strain, a herniated disc, spinal stenosis and other conditions. The purpose of this study is to evaluate the effectiveness of using the combined therapy of lumbar facet radiofrequency and intradiscal ozone injection in the treatment of low back pain (LBP) with lower limb pain, in patients for whom the role of radicular pain as a result of a bulging disc and facet involvement is significant.

Methods: Forty patients (30 males, 10 females, age range 38–65 years [mean 50 years]) with chronic LBP were evaluated at the Pain & Headache Center, International Medical Center, Jeddah, Saudi Arabia. Their chief complaint was predominantly axial LBP with a radicular component. Exclusions included pregnancy, children age under 16 years the presence of a pacemaker or a history of bleeding tendencies.

All patients underwent facet radiofrequency ablation and intradiscal ozone injection; 20 mL 40% ozone was injected intradiscally and periradicularly.

Radiofrequency treatment was applied to the lumbar medial branch nerves using the standard parameters of heating to 80oC for 60 s at three positions along the nerve using a curved 18 g radiofrequency electrode with a 10-mm exposed tip. Patients were reviewed independently in the clinic after 1 month and subsequently by telephone up to 24 months later.

Discussion: Radiofrequency ablation is a procedure used to reduce pain. An electrical current produced by a radio wave is used to heat up a small area of nerve tissue to 80oC for 60 s, thereby decreasing pain signals from that specific area after correct positioning of the radiofrequency electrode along the nerve.1

The action of ozone is due to the liberation of the active oxygen atom when ozone molecules are broken down. When ozone is injected into the disc, the active oxygen atom (called the singlet oxygen or the free radical) attaches to the proteoglycan bridges in the jelly-like material or nucleus pulposus. They are broken down and they are no longer capable of holding water. As a result, the disc becomes shrunken and mummified and there is decompression of nerve roots. It is almost equivalent to surgical discectomy, so the procedure is called ozone discectomy or ozonucleolysis. In addition to this, ozone has an anti-inflammatory action because it inhibits the formation of inflammation-producing substances. Tissue oxygenation is also increased because of increased levels of 2,3-diphosphoglycerate in the red blood cells. All of this leads to decompression of nerve roots, decreased inflammation of nerve roots and increased oxygenation to the diseased tissue for repair work.2

Results: An average improvement of 75%, according to the numerical pain scale, was seen in all patients. Results were sustained for a period of 18 months.

Conclusion: Patients with radicular LBP as a result of a bulging disc and significant facet involvement respond very well to the combined therapy, and the benefit lasts up to 18 months. Further study is require to determine whether it is the radiofrequency neurotomy or the ozone nucleolysis that is the predominant mechanism in patients with axial discogenic LBP, but this combination offers an easily applied therapy for this common condition.

References

Br J Pain. 2012 Nov;6(4):170–173.

A survey of lumbar radiofrequency for spinal pain

S. Das1, S. Gupta1, R. Chawla2, M.L. Sharma2 and M. Gupta2

1Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK

2Walton Centre NHS Foundation Trust, Liverpool, UK

Background: Forty per cent of patients with back pain have facet joint pain. Percutaneous radiofrequency lumbar median branch neurotomy is often employed to provide longer-lasting pain relief for patients diagnosed with facet joint pain. It uses high-frequency alternating current to coagulate the nervous tissue and block nociceptive transmission.

Although the technique was first used in spinal pain by Shealy in 1974,1 the efficacy was dubious. Later studies tried to address this through proper selection of subjects and by improving the technique. However, success rates varied, ranging from 13% to 80%. One study by Dreyfuss et al.2 used correct target points with parallel placement of electrodes and quoted 80% pain relief in 60% of patients and 60% pain relief in 80% of patients.

Several factors affect the outcome of radiofrequency treatment. The most important of these are the selection of patient population, the diagnostic method, the techniques of radiofrequency in terms of needle used, number of lesions and the angle at which the needle is placed in relation to the medial branch.

We therefore conducted a survey to understand the current practice in the north of England.

Methods: The survey was distributed to 76 participants at the fourth annual North England pain medicine group meeting in May 2012. This was combined with another survey on practice in pain clinics for ease of administration. The questions pertained mostly to the method of selection of patients for radiofrequency treatment, the needle used and the actual technique. The total responses were 55. There were 29 responses to the survey on radiofrequency treatment.

The candidate list identified 51 of the attendees as pain clinicians. At least three clinicians mentioned the lack of facilities as being the reason for not using the technique. Twenty-nine performed radiofrequency treatment and responded to the survey. Therefore, our response rate works out as 29 out of 48, which is 60.4%.

Results: The results reflected a wide variation in practice among clinicians. Clinicians were almost equally divided on the number of diagnostic blocks they would perform. Most (59%) would still use local anaesthetic with a steroid for diagnostic block rather than pure local anaesthetic. For the radiofrequency treatment, the 20-G needle seemed to be the popular choice (59%), although the 18-G needle is more likely to produce a larger lesion. Likewise, a good proportion of clinicians (48%) preferred the 5-mm rather than the 10-mm tip needle for radiofrequency treatment.

A large proportion (38%) of clinicians continue to practise perpendicular placement of the needle. A single lesion seemed to be more popular (59%), although multiple lesions are recommended for better results. Interestingly, 9 of the 11 clinicians who practised perpendicular placement of the needle also performed a single lesion and one clinician performed three lesions.

Conclusions: Our survey has shown that there is a wide variation not only in the method of selection of patient but also in the technique. A recent national survey last year involved 103 clinicians and showed similar results in most categories but differed markedly in the proportion of clinicians using the perpendicular approach (16.3% nationally vs. 38% in the north of England).

The International Spine Intervention Society has published practice guidelines,3 which recommends some aspects of the technique. Good practice guidelines by the British Pain Society are also due to be published. Clinicians must inform themselves on aspects that may improve the outcome of this treatment.

Although we had a reasonably good response rate, the survey was limited to the clinicians who attended the meeting, and hence may not accurately represent the whole of the north of England.

References

  • 1. Shealy CN. Percutaneous radiofrequency denervation of spinal facets. Treatment for chronic back pain and sciatica. J Neurosurg 1975; 43: 448–451. [DOI] [PubMed] [Google Scholar]
  • 2. Dreyfuss P, Halbrook B, Pauza K, et al. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine 2000; 25: 1270–1277. [DOI] [PubMed] [Google Scholar]
  • 3. Bogduk N. (ed.) Practice guidelines: spinal diagnostics and treatment procedures. San Francisco: International Spine Intervention Society, 2004. [Google Scholar]
  • 4. Townend R, Baranidharan G, Rajendram A, et al. Current UK practice in radiofrequency treatment. Pain News 2011; Autumn: 39–40. [Google Scholar]
Br J Pain. 2012 Nov;6(4):170–173.

Sphenopalatine ganglion pulsed radiofrequency for chronic facial pain

R. Nagaraja1, A. Ghazi2 and C. Gauci2

1Pain Fellow

2Whipps Cross University Hospital, London, UK

Abstract: We evaluated the efficacy of sphenopalatine ganglion (SPG) pulsed radiofrequency for chronic facial pain. Nine patients who had this procedure in the last 3 years were included in the study. We were looking primarily at the duration of pain relief, reduction of oral medication and presence of autonomic symptoms. We collected the data by reviewing patient notes and telephone calls. Sixty per cent of patients reported complete pain relief. The others reported no pain relief, although one patient reported relief for 1 day.

Introduction: SPG block has been performed since the early 1900s when cocaine was used to block the ganglion for various pain syndromes. SPG block is most commonly used for SPG neuralgia, trigeminal neuralgia, migraine headache, cluster headache and atypical facial pain.1 Sluijter and Racz first described the pulsed radiofrequency (PRF) technique, in which the generator output is interrupted to allow for the elimination of heat during the silent period between pulses. This novel approach has been recommended for treatment applied to peripheral nerves and trigger points where the application of heat carries a significant risk.2

Methods: Between January 2010 and May 2012, a total of nine patients were included in our audit to assess the efficacy of SPG block. A review of the case notes was carried out as well as a telephone review to assess the efficacy of the procedure.

Questions in the phone questionnaire were as follows:

  1. Has the procedure been effective?

  2. What was the duration of pain relief?

  3. Was there any reduction in pain medication?

  4. Was there any presence of autonomic symptoms?

Results: Nine patients received this procedure for chronic facial pain, atypical trigeminal neuralgia and atypical facial pain. These patients had symptoms lasting from 2 to 10 years.

Sixty per cent of patients reported good pain relief that lasted between 3 and 6 months. In one patient, the procedure needed to be repeated for recurrence of symptoms. There was a reduction in the use of medication in one patient and the remainder did not reduce medication use because of a fear of symptoms recurring.

Discussion: SPG PRF offers a variable period of pain relief in a select group of patients. This technique of PRF can be used when conventional radiofrequency is contraindicated because of the risk of neuritis. The procedure was repeated for one patient, which means the pain relief is not expected to last permanently. It is unclear as to how many times the procedure could be repeated and whether repetition would extend the duration and degree of pain relief. Complications include infection, epistaxis, haematoma, dysaesthesia and numbness of the palate, maxilla or pharynx. There are two reported cases of complications during radiofrequency lesioning of the SPG for headaches.3

This group of patients come to us after trying various other treatments. It would be worthwhile considering this technique as an option for providing pain relief.

References

  • 1. Klein RN, Burk DT, Chase PF. Anatomically and physiologically based guidelines for use of the sphenopalatine ganglion block versus the stellate ganglion block to reduce atypical facial pain. Cranio 2001; 19: 48–55. [DOI] [PubMed] [Google Scholar]
  • 2. Sluijter M, Racz GB. Technical aspects of radiofrequency. Pain Pract 2002; 2: 195–200. [DOI] [PubMed] [Google Scholar]
  • 3. Konen AA. Unexpected effects due to radiofrequency thermocoagulation of the sphenopalatine ganglion: two cases. Pain Digest 2000; 10: 30–33. [Google Scholar]

Articles from British Journal of Pain are provided here courtesy of SAGE Publications

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