Pain Clinic at Tata Motors Hospital; Past Present and Future –A report

Dr Ashok Jadon, MD DNB MNAMS

Aesculap fellowship of interventional pain management

Chief Consultant & HOD

Department of Anaesthesia

Tata Motors Hospital, Jamshedpur

Pain clinic or pain relief service at Tata Motors Hospital was available since

beginning of the hospital under the auspices of Anaesthesia department. However,

initially, very few patients were treated and basic techniques like acupuncture and

TENS (Trans cutaneous nerve stimulation) were used. Epidural steroid injections

to treat acute or chronic spinal pain were started in 2005 and 16 patients were

treated during yr 2005 & 2006.

Work of pain clinic has grown-up exponentially after yr 2007. Keeping up-

breasted approach to acquire current knowledge in management of pain, newer

techniques were introduced and Interventional pain management techniques which

were only available in few selected centers in India became main stay of

management. However, practice of basic techniques like trigger point injections,

TENS, muscle and joint manipulation, counseling and advice for exercise along

with appropriate medications continued as before. These techniques work as

adjunct or complimentary to interventional techniques and are essential to provide

comprehensive approach to patients suffering from pain.

Since yr.2008 onwards, every year, 75 to 100 new patients are treated with

approximately 100 to 200 interventional procedures.

Chronology of Landmarks in the progress of pain clinic:

Year 2008: Fluoroscopy was introduced for interventional pain procedures. Facet

intra articular injections and piriformis injections were started. First, caudal

adhesinolysis was done with indigenous technique by using tunneled epidural

catheter and continuous infusion of saline in a case of failed back surgery. Epidural

blood patch was introduced to treat post spinal headache. During this year thirty

five patients were treated and total 40 interventional procedures were done.

Year 2009: This year was a breakthrough year for pain clinic. As water soluble

contrast was available, more advanced procedures were included like stellate

ganglion block (to treat CRPS of upper limbs), Transforaminal injections and

Sacro iliac joint injection. On September 15, first cervical epidural injection was

given under fluoroscopic contrast control to treat cervical root pain. Few

interesting and resistant cases like headache after aneurismal clipping and scrotal

pain were treated successfully. Medial branch blocks for facet arthropathy and

intercostal block for intercostal neuralgias were introduced. A new gadget an

Ozone generator was procured and Intradiscal ozone for treatment of Discogenic

pain due to prolapsed intervertebral disc or IDD (internal disc disruption) was

introduced. This year 100 patients were treated and more than 200 procedures

were done and 5 new procedures were introduced.

Year 2010: With continuous efforts and study progress, two breakthrough events

happened this year. Firstly Radio-frequency generator was procured which is back

bone for any advanced pain clinic and secondly a new minimally invasive surgery

for disc prolapse (Percutaneous Discectomy) was started. Two Percutaneous

Discectomies were done this year with excellent results. Radio-frequency

procedures for medial branches, discs, and stellate ganglion were introduced. This

year 80 patients were treated and 110 procedures were done.

Year 2011: With better understanding of radiofrequency techniques a new

procedure DRG (dorsal root ganglion) pulsed radiofrequency treatment was

introduced for neuropathic back pain. This year was devoted to improve technical

competence for procedures like trans-foraminal injections cervical epidurals and

epidural adhesinolysis. One Percutaneous Discectomy was done. Cervical

epidurals numbers were increased. Many successful stellate ganglion blocks were

given and a study on the results was published in indexed journal. We also got

nerve stimulator which helped us to locate nerves and preformed stimulator guided

procedures for piriformis, lumbar plexus, sciatic, femoral and brachial plexus

blocks. Two studies on lumbar plexus block were published in indexed journals.

This year 90 new cases were treated and 125 procedures were performed.

Year 2012: This whole year many new techniques were introduced. Lumbar

sympathetic block for CRPS of lower limbs, grey ramus block for # vertebra pain,

cervical transforaminal (very advanced procedure requires extremely high

precision) were introduced. Few techniques were modified to get better results and

to ease the difficulty of performer like lateral or Para-central approach to inter-

laminar epidural, oblique view approach to cervical epidural and Kambin’s

approach to lumbar transforaminal injections. Radiofrequency for stellate ganglion

was introduced. This year 95 new cases were treated and 130 procedures done.

Year 2013: Only 4 months have passed this year and, as usual keeping good track

record, five new techniques are already introduced and used successfully. Ganglion

Impar block for rectal pain due to prostate malignancy, nerve stimulator guided

and fluoroscopic guided supra-scapular nerve block to manage frozen shoulder

pain and nerve stimulator guided and fluoroscopic guided Pudendal nerve block to

provide intraoperative anaesthesia and rectal or perineal pain due to malignancy or

other causes are already used on many patients successfully.

Success Vs. Failures: In the world of pain physicians, the criteria for successful

pain management is “50% or more reduction in symptoms up to reasonable

duration i.e. more than 6wks”. To this definition our results are comparable and

our customer satisfaction is very high. In the beginning we also had failures and

technical difficulties to target the pathology, however; with persistence and

training we could overcome those hurdles. We had three complications (diagnosed

on time and no further consequences) out of >500 procedure (0.6%) during these

years.

Future; way forward: Pain management is advancing leaps and bounds and newer

technology is being introduced every day. Over the time, as our resources would

permit, we would like to adopt those techniques for our patients also. As we

already have infrastructure for radiofrequency, treatment for Trigeminal Neuralgia

and Glossopharyngeal Neuralgia by radiofrequency is our next target. Later on, we

can adopt more advanced techniques like implantable pumps and spinal cord

stimulator for nociceptive and neuropathic pain at our pain clinic of Tata Motors

Hospital. Future is very promising indeed………!