Treatment of Acute & Chronic Pain
The field of pain management has progressed significantly in recent years. A better understanding of disease pathology and improved diagnostic procedures has resulted in safer medications, greater nerve blocking accuracy, and an improved quality of life for many patients.
The Pain Medicine Program At Maimonides
Maimonides Medical Center Practices state-of-the-art pain medicine and we recognize its important role in patient well-being. Whether after surgery, for greater comfort, fewer complications and faster recovery, or for chronic sufferers, to improve their quality of life, work and relationships, our goal is the elimination of pain or at the very least, to manage it effectively. The Maimonides Pain Medicine Program recognizes not only the physiological aspects of pain, but also the social and psychological dimensions, along with their implications in a patient's life. We utilize a multi-disciplinary team of anesthesiologists, neurologists, neurosurgeons, psychiatrists, surgeons and physical therapists to treat the following conditions:
- Accident pain
- Back, neck, abdominal, pelvic, hip, leg muscle and head pain
- Complex regional pain syndrome, Type I and II (RSD & causalgia)
- Diabetic neuropathy
- Facet pain
- Myofascial pain
- Post laminectomy / failed back surgery syndrome
- Spinal stenosis
- Trigeminal neuralgia
- Vertebral compression fractures
How Pain Affects the Body
By blocking the pain pathways, we work to prevent some of the harmful effects of pain. Untreated pain not only causes physical discomfort and mental distress, but can also lead to post-operative complications by stressing the body. Pain reduces the ability to take deep breaths and cough. This can cause lung problems (ie, pneumonia). Pain can also decrease appetite, disturb sleep and prolong the need for bed rest.
Pain stimulates the sympathetic nervous system, which can increase blood pressure, heart rate, and may place patients at a higher risk for heart problems. Pain can also increase the risk of blood clots. Additionally, the stress response from pain can also weaken the immune system and increase blood sugar. This may cause a higher infection rate and may be associated with a higher rate of tumor recurrence.
Eliminating as much pain as possible during and after your surgery is always our goal. Untreated pain not only causes physical discomfort and mental distress, but can also lead to post-operative complications. By treating and preventing pain, we work to avoid its harmful effects.
Pain control is an important component of your recovery. During your hospital stay, a specially trained physician-led team is available to coordinate your post-operative pain control. Our goal is to provide our surgical patients with safe and effective pain management. In addition to the usual medications, we utilize cutting-edge regional anesthetic techniques to help alleviate pain during and after surgery.
Local anesthetics are medications which 'block' nerve fibers and relieve pain. Regularly used anesthetics include lidocaine, bupivicaine and ropivicane. Local anesthetics are commonly used by dentists. The numbness they cause can relieve pain for several hours.
'Regional anesthesia' is a broad term that describes pain relief to a particular part of the body. Examples include spinals, epidurals and nerve blocks. This type of anesthesia uses an injection of local anesthetics to block the pain sensation in a specific part of the body both during and immediately after surgery. Regional anesthesia is often used to minimize or sometimes avoid the use of general anesthesia. In many cases, a nerve block will eliminate the need for inserting a breathing tube in the windpipe.
A spinal or epidural can be performed to numb the middle to lower half of the body for specific surgical operations. Spinal or epidural anesthetics can easily be performed while patients are sitting upright or lying on their side. Similarly, using state-of-the-art technologies, our anesthesiologists can locate a specific nerve and anesthetize a particular limb or body part. Maimonides Department of Anesthesiology employs the latest ultrasound-guided techniques to visualize nerves for regional nerve blocks.
Not only does regional anesthesia treat post-operative pain, but it also can decrease the amount of opiate required, which can reduce side effects such as nausea, vomiting and constipation. With adequate pain control and minimal side effects, patients may be discharged from the hospital earlier.
Deciding Which Anesthetic Technique is Best for You
Our anesthesiologists and pain medicine teams coordinate patient care, developing personalized pain plans. In the pre-operative area, a member of the team will discuss anesthesia options individually with patients.
The patient's medical history and pre-operative blood tests are reviewed. The benefits and risks of the techniques offered are clearly explained. It is important that patients review any medial conditions, current medications and herbal remedies that they are currently taking with their anesthesiologist. Known allergic reactions to medications, especially those prescribed for pain, must be communicated to the medical team by the patient, so that post-operative recovery can be planned with alternative medications.
Advanced Techniques and Technology
The Department of Anesthesiology employs the latest ultrasound-guided techniques to visualize nerves for regional nerve blocks. Ultrasound imaging utilizes the body's ability to reflect sound waves from a probe that is placed on the skin above the location where the nerve block will be performed. The probe receives these reflected waves and an image is created on a computer screen. This ensures correct placement of the block around the nerve. Anesthesiologists will likely administer medication to provide relaxation prior to numbing the area.
What to Expect During your Regional Block
Patients are positioned comfortably with oxygen and monitors. While vital signs are monitored prior to performing the block, an anesthesiologist will usually administer a small amount of sedation to help the patient relax. The skin over the area to be blocked will be cleaned with an antiseptic solution and numbed. The block is placed through the numbed skin, and the local anesthetic administered. Surgery begins only after the surgical site is numbed, and the patient is well sedated or sleeping. After surgery, sedation wears off and patients may notice that they are unable to move or feel the affected area. This is normal and may last several hours. The hospital staff will set up a medication schedule for to help with pain control once the surgical block wears off. In select patients, when indicated, an infusion of numbing medication may be connected to a catheter in order to help with pain control for a longer period of time after surgery.
What to Expect After a Nerve Block
Nurses with expertise in post-operative pain control closely monitor a patient's status and deliver pain control medications through specialized computer pain pumps. Many patients who stay in the hospital following surgery may have either continuous epidural or continuous peripheral nerve infusions. Our nursing staff monitors the pain levels using a scale of 0 to 10. When pain levels become unacceptable, a member of the pain team is consulted to plan a course of treatment to help alleviate pain.
Most patients who have received a nerve block have minimal pain, nausea or vomiting after surgery. Depending on the block and medication used, pain relief often lasts between 4 and 24 hours. Although the immediate post-operative period is usually the most painful, many patients require little to no pain medicine after receiving a regional pain block.
An anesthesiologist will discuss with patients how to care for a peripheral nerve catheter at home, if it is decided that this therapy is beneficial to your recovery. A family member should also be available to help with care at home and will be instructed by the physician accordingly. Occasionally, pain may persist after surgery or result from other chronic pain conditions. Pain may also be exacerbated from inactivity after surgery. If patients experience pain lasting longer than expected, they are advised to call their surgeon and consider seeing a pain specialist.
Health Benefits of Using a Nerve Block
In addition to pain control, nerve blocks may have specific medical benefits. Research suggests that spinal anesthesia decreases blood loss and blood clot formation, and enhances recovery of normal bowel function.
Some nerve blocks, such as paravertebral nerve blocks, have been associated with a decrease in cancer recurrence by blunting the immune-weakening stress response to surgery. This is particularly relevant in women with breast cancer, but could also be applicable to other cancers in the future.
Complications such as infection, bleeding and nerve damage from peripheral nerve blocks occur very rarely. We use ultrasound technology to view nerves and follow the spread of medication around targeted areas. This is a safer approach and should lower complication rates even further.
Spinal and epidural anesthesia have low incidence of complications and are not usually performed with ultrasound. One-half to one percent of patients may experience a bad headache. This is benign and can be addressed with simple bed rest and by drinking lots of fluids.
Nerve Blocks Used During Surgery and/or Post-Operative Pain Relief
Upper Extremity Surgery
- Interscalene: used for surgery of the shoulder or upper arm.
- Infraclavicular or supraclavicular: used for surgery of the lower shoulder or arm.
- Axillary: used for surgery of the arm to the hand.
Lower Extremity Surgery
- Femoral: used for surgery of the knee and upper leg.
- Sciatic: used for surgery of the leg, ankle and foot.
- Popliteal: used for surgery of the lower leg, ankle and foot.
- Ankle: used for surgery of the foot.
Breast, Chest and Lung Surgery
The breast and chest are supplied by intercostal nerves. Each arises from a different segment of the backbone and travel under a rib to your breast/chest wall. The following blocks may be used:
- Thoracic Paravertebral (TPV): blocks each nerve after it leaves the spinal canal, but before it goes under the rib.
- Intercostal: block each nerve under the rib.
- Indwelling epidural catheter: a continuous infusion which can be adjusted to meet a patient's needs.
Abdominal and Pelvic Surgery
Similar to the breast and chest wall, the abdomen and pelvis can be anesthetized by numbing the intercostal nerves using the following blocks:
- Transversus abdominis plane (TAP)
- Spinal or epidural