T

he most important thing in the treatment of pain is the correct diagnosis.

For acute pain problems, this is usually straightforward. Acute pain in the limbs, joints and the spine is often related to a sprain consequent to an injury. In severe cases, a muscle tendon or ligament tear is the reason. In some patients, an acute limb pain is from a sudden slipped disc compressing nerve roots.

It is when patients and doctors are confronted with chronic pain that a diagnosis may be more difficult. Proper assessment by a specialist '€” preferably a neurosurgeon or neuro-spine specialist '€” can help determine root causes.

Adjunct to a physical examination are diagnostic tools such as magnetic-resonance imaging (MRI) scans, electromyography (EMG) nerve conduction studies (NCS) and selected blood tests.

In general, however, pain relief procedures do not cure the root of the problem, which is often spine degeneration.

Pain can be treated symptomatically with pain medications. In general, these drugs fall into two categories '€” non-steroidal anti-inflammatory drugs (NSAIDs) and narcotic or narcotic-like drugs.

NSAIDs include aspirin, ibuprofen, voltaren and equivalents. New generation NSAIDs include arcoxia and others that are COX-2 inhibitors, and have lesser side effects, such as gastric irritation.

Narcotics include panadeine, codeine, morphine and pethidine. Intermediate drugs with narcotic-like actions with lesser side effects include tramadol (ultracet). It is usually preferable to start with the mildest analgesics like paracetamol before progressing to stronger medications.

Neuralgic pain can be treated by anti-epileptic medications such as phenytoin, tegretol, valproate, and gabapentin. Pergabilin (lyrica) is one of the newer medications available.

There are also specific pain syndromes that often respond well to specific drugs.

Migraines, for instance, can respond well to antimigraine medications like imigran, while trigeminal neuralgia often responds to carbamazepine (tegretol).

Surgical intervention may be necessary in cases where back or neck pain is from a significant slipped or a herniated disc, a bony spur or spinal or foraminal stenosis; facet degeneration; spinal instability; osteoporotic vertebral body fracture; spine injury or a spinal tumour that has not responded to conservative treatment or may potentially cause nerve damage.

This decision, however, needs to be made by an experienced and qualified neurosurgeon in collaboration with a well-informed patient.

Minimally invasive spine treatments for pain relief include epidural steroids and analgesic blocks, facet blocks, nerve root blocks, spinal cord stimulation, nerve root stimulation, laser therapy, nucleoplasty, vertebroplasty and kyphoplasty '€“ among many other treatments.

In general, though these pain relief procedures do not cure the root of the problem, which is often spine degeneration, thus a proper physiotherapy program to strengthen the spine after pain relief is recommended.

Multiple pain procedures may be required in some cases. Some patients may be better off treating the root cause of the problem rather than having multiple pain procedures or ending up with permanent nerve damage from the root cause of the problem.

For example, a patient with sciatica and foot weakness from a sequestrated disc herniation may be a better candidate for microsurgical/endoscopic icrodisectomy, as opposed to pain relief treatment, such as a root block or nucleoplasty.

Trigeminal neuraliga that does not respond to treatment or situations where the patient cannot tolerate medications can be treated by the minimally invasive options such as radiosurgery, e.g., the '€œgamma knife'€; balloon decompression; radiofrequency rhizotomy; or glycerol ganglion injection. Microvascular decompression (MVD) is a specific microsurgical procedure to remove a vascular compression from the Vth cranial nerve which is often the cause of trigeminal neuralgia.

Post-herpetic neuralgia that is not relieved by medical therapy can be treated by a microsurgical procedure on the spinal cord called DREZ lesioning.

Neuropathic pain syndromes are difficult to treat medically. Brain procedures such as motor cortex stimulation, deep brain stimulation (DBS) and others have been used with varying degrees of success.

The writer, a frequent commentator in the media on medical issues, is a senior consultant neurosurgeon at the Singapore Brain, Spine and Nerves Center at the Mount Elizabeth Medical Center in Singapore. Visit drprempillay.org or spine-neuro.org for more information.