Neurosurgery

Diseases & Conditions

About Pain

The Neurosurgery Pain Group at the Boston Medical Center offers a variety of treatments to patients whose pain cannot be controlled through standard medical pain management.

For example, a surgical procedure known as a decompressive laminectomy can provide relief from pain due to a “pinched nerve” or sciatica. Similarly, open or endoscopic decompression surgery can help alleviate pain from carpal tunnel syndrome and a procedure called microvascular decompression can help relieve the pain of trigeminal neuralgia, an inflammation of the trigeminal nerve in the face. In addition, an implantable spinal infusion morphine pump or an implantable spinal cord stimulator can bring relief from some types of pain.

What is Pain?

Pain is a sensation of physical discomfort that can range from a minor nuisance to extreme and usually results from tissue damage. Most acute pain goes away after the tissue has healed. Pain is considered chronic when it continues after the tissue has healed and persists for more than six months. Inadequate treatment of pain can cause unnecessary suffering, disruption of life style, loss of income and loss of self-esteem.

Pain can be divided into two categories:

• Neuropathic pain 
  Pain caused by damage to nerve tissue. It may be described as tingling, burning, shooting, like an electric shock or stabbing pain. Examples include pain caused by a “pinched nerve,” carpal tunnel syndrome and peripheral neuropathy.
  
  
• Nociceptive pain 
  Pain that arises from an injury or disorder outside the nervous system that results in activation of specialized pain receptors called nociceptors. These receptors are present in skin, muscles, bone, joints, bowel and other tissues. The pain is typically described as aching, throbbing or less often, sharp. This type of pain can occur from arthritis, osteoporosis or loss of circulation, among other causes.

Mixed pain consists of a combination of neuropathic and nociceptive pain. This may be seen in migraine or cancer. About 70% of patients with advanced cancer have pain and about 25% die without adequate relief.

What is the standard treatment for Pain?

The World Health Organization’s (WHO) three-step "analgesic ladder" is an excellent guide for appropriate treatment of pain based on its intensity.

Step 1
Mild Pain: Nonopioid analgesics
Recommended drugs: Aspirin (ASA), Acetaminophen (Acet), and non-steroidal anti-inflammatory drugs ( NSAIDs)
± Adjuvants

Step 2 
Moderate Pain: Mild opioids used in combination with ASA, Acet, or NSAIDs
Recommended: Codeine, Hydrocodone, Oxycodone, Tramadol
± Adjuvants

Step 3
Severe Pain: Strong opioids
Recommended: Morphine, Hydromorphone, Oxydocone, Methadone, Fentanyl
± Nonopioid analgesics
± Adjuvants

Most nociceptive pain is opioid-responsive, but effective doses may produce intolerable side effects. Neuropathic pain is usually opioid-resistant. Many patients require the addition of adjuvant analgesics such as antidepressants and anticonvulsants.

Patients who do not respond to the three-step analgesic ladder should be considered for treatment in a comprehensive multi-disciplinary pain clinic. Transcutaneous electrical nerve stimulation (TENS), nerve blocks and epidural steroid injections are commonly used, depending on the cause of the pain.

The Neurosurgery Pain Group offers a variety of treatments to patients who have failed standard medical pain management.