Today, thousands of people suffer from chronic pain every day. Unrelieved chronic pain triggers a series of emotional, physical and social consequences, making it a real problem.
The economic burden associated with disability due to pain, multiple appointments with different specialists and different treatments, difficulties in interpersonal relationship shown by the patient and the ever-deteriorating health associated with even greater suffering mean that chronic pain is now a serious public health problem.
Over recent years, we have seen a spectacular advance in diagnostic and therapeutic techniques for chronic pain and pain management has emerged as a new sub-specialty with the involvement of many professionals and medical specialties.
The barnaclínic+ Pain Clinic has been created to provide an effective multi-disciplinary service to treat pain conditions that are not easily resolved with common therapies. We have a select group of specialists who have extensive experience in pain management and also use the latest therapeutic techniques for relieving pain. Our aim is to improve the quality of life of our patients by restoring their physical, social and emotional well-being.
I. MOST COMMON CONDITIONS TREATED BY OUR CLINIC
- Chronic lower back pain
- Orofacial pain syndrome
- Myofascial pain
- Chronic post-surgical pain
- Postherpetic neuralgia
- Complex regional pain syndrome
- Chronic post-amputation pain
II. SOME TREATMENTS OFFERED BY OUR PAIN CLINIC
- Drug treatment
- Peripheral nerve blocks
- Epidural steroid injections
- Facet joint injections
- TENS or transcutaneous electrical nerve stimulation
- Radiofrequency of nerve roots
- Trigger point injections
- Regional sympathetic blocks
- Implantable nerve stimulators
- Implantable drug delivery systems
- Botulinum toxin injections
CHRONIC LOWER BACK PAIN
Lower back pain, lumbago or lumbalgia is the most common cause of disability in young adults and is caused by a wide variety of factors. In order to treat this condition correctly, an accurate diagnosis is required. The most common cause of chronic low back pain is intervertebral disc or facet joint degeneration. Below is a summary of the most prevalent low back pain syndromes:
Pain of disc origin: the intervertebral disc is a structure located between the spinal vertebrae, comprising an internal gelatinous nucleus and a fibrous outer ring. The disc allows flexion and extension movements of the spine and act as shock absorbers for the different activities of everyday life. Disc herniation occurs when part of the contents of the nucleus pulposus escapes through the fibrous ring and pain symptoms occur when this compresses or affects surrounding anatomical structures.
Facet joint syndrome: Facet joints (zygoapophyseal joints) are responsible for interconnecting the vertebrae. With aging, trauma and repeated use, these joints, like all other joints of the body, can suffer excess wear resulting in facet joint degeneration, which causes a very distinctive pain. This pain is generally at the level of the affected joint and, if the lumbar spine is affected, can affect both the buttocks and the thighs, but it does not usually radiate beyond the knee.
Foraminal stenosis: This is the narrowing of the channels through which the spinal nerve roots exit the spinal canal. There are numerous causes of this reduction in size, including disc herniation, osteophytes and spondylolisthesis (displacement of one vertebra over another), and the symptoms depend on the nerve root involved.
Chronic post-surgical lower back pain: also known as failed back surgery syndrome or post-laminectomy syndrome, this is characterized by an intense, hard-to-treat pain that starts after surgery, generally for a spinal disc herniation. The most common provable causes are recurrent disc herniation and epidural fibrosis.
Sacroiliac joint pain: Sacroiliac joint pain is responsible for up to 15-20% of patients complaining of chronic low back pain. This joint is located at the junction of the spine and the pelvis and causes a generally unilateral low back pain that may radiate to the buttocks and back of the thigh.
Other causes of chronic low back pain: Pain syndromes of the muscle groups in the lumbar region are also a common cause of lower back pain, including piriformis syndrome, quadratus lumborum syndrome or iliopsoas syndrome.
OROFACIAL PAIN SYNDROME
This refers to pain conditions affecting the face and mouth region. It is classified as:
Neuropathic orofacial pain: The most characteristic condition is TRIGEMINAL NEURALGIA, also known as 'tic douloureux', which is characterized by a unilateral, sudden, very intense, recurrent and short-lived pain involving the area innervated by one or more branches of the trigeminal nerve, i.e. the face and 'surface of the eye', and is typically precipitated by lightly touching the area. This group of conditions also includes Ramsay Hunt syndrome, glossopharyngeal, hypoglossal and geniculate neuralgias and Tolosa-Hunt syndrome, among others.
Non-neuropathic extra-oral pain syndromes: Syndromes are divided into extra-oral syndromes, including temporomandibular joint disorders and masticatory muscle pain, and intra-oral pain syndromes, including glossodynia (pain in the tongue area), atypical odontalgia (unusual tooth pain) and cracked tooth syndrome.
This is a regional pain of muscular origin, characterized by the appearance of muscles with taut bands and trigger points. Taut bands are muscle groups of increased hardness that are painful to the touch and trigger points are sensitive areas within the taut bands that cause pain to a distant region, either spontaneously or upon compression.
This is a syndrome characterized by chronic, widespread pain in multiple muscle groups, joints and other soft tissues. It is typically accompanied by fatigue, morning stiffness, sleep disturbances, psychiatric symptoms such as depression and anxiety and sensitive tender points or trigger points.
CHRONIC POST-SURGICAL PAIN
Neuropathic pain can sometimes occur after a surgical procedure in the surgical area. The most common surgeries associated with this phenomenon are thoracotomy (chest surgery), post-mastectomy surgery (breast resection) or inguinal hernia repair surgery.
This is a very intense pain generally accompanied by increased sensitivity of the area (hyperesthesia) and even painful sensitivity to stimuli that do not normally cause pain (allodynia). It occurs in patients who have suffered from herpes zoster or varicella virus infection.
COMPLEX REGIONAL PAIN SYNDROME
Also known as reflex sympathetic dystrophy or causalgia, this is a chronic pain syndrome characterized by changes in color and temperature of the limb or affected region accompanied by painful sensitivity, sweating and inflammation. Its exact cause is unclear but it is thought to be linked to a peripheral sympathetic nervous system disorder that responds anomalously to tissue injury with (complex regional pain syndrome type 2) or without evidence of nerve injury.
CHRONIC POST-AMPUTATION PAIN
Patients who have lost a limb may develop post-amputation pain. Several pain conditions have been described, such as phantom limb syndrome, which is the perception of pain in the area of the limb when the limb is no longer there, and stump pain, which is pain localized in the distal area of the amputated limb.
NON-INVASIVE DRUG TREATMENT
Our specialists have extensive knowledge regarding the different drugs used to treat pain and their various forms of prescription. They will be able to offer you the most appropriate medications to treat your pain syndrome and warn you about possible side effects and how to avoid or treat them.
PERIPHERAL NERVE BLOCKS
Pain is transmitted via the nerves located in the different parts of our body. A nerve block involves administering drugs around the nerves involved in the pain process to 'numb' or prevent these pain signals from reaching the central nervous system. The drugs used are usually local anesthetics. Different techniques are used and combined to correctly locate the nerve and/or nerve plexus, including nerve stimulation (by stimulating the nerve with electricity, a motor response is achieved that helps accurately locate the structure to be blocked), ultrasound or X-rays.
EPIDURAL STEROID INJECTIONS
This is especially indicated for radicular pain due to irritation or inflammation of a nerve root. It is a widely used procedure that involves placing steroids (anti-inflammatory drug) into the epidural space, often with local anesthetics. It can be performed using the classic blind technique or guided by continuous imaging, which allows the drug to be placed accurately next to the nerve root causing the pain, increasing the chances of success.
FACET JOINT INJECTIONS
Used to diagnose and treat back pain originating from the facet joints, the technique is based on locating the joints using continuous imaging guidance (fluoroscopy) and administering local anesthetics and steroids either into the joint (intra-articular block) or close to the nerve causing the painful joint sensitivity (medial branch block). If the technique is effective, radiofrequency may then be considered.
TENS OR TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION
This involves administering an electrical current through electrodes placed on the skin over the affected area. This current selectively stimulates certain peripheral nerve fibers that can block transmission of pain impulses to the brain (Entry Point Theory). It is a non-invasive, easy-to-use technique with few side effects.
This involves using direct current to improve the absorption of ionizable substances that are used to treat pain, typically anti-inflammatory steroids and local anesthetics. It is a painless, safe treatment that can be useful in some chronic pain syndromes, such as lumbalgia and osteoarthritis.
TRIGGER POINT INJECTIONS
This procedure involves locating the trigger points related to musculoskeletal pain syndromes, such as myofascial pain and fibromyalgia, and injecting local anesthetics +/- steroids, which allows the pain stimulus to be blocked and the muscle to elongate (relaxation of tight muscle groups).
This is based on passing a low-energy, high-frequency electrical current through two electrodes. One of the electrodes has insulating material along its entire length, except at the tip (active electrode), and we will use this over the area to be treated, and the other electrode (dispersive electrode) is a conductive material plate with a much larger area than the uninsulated area (tip) of the active electrode. Passing current through this circuit generates heat at the tip of the active electrode, enabling treatment. There are two types of radiofrequency according to how this heat is administered: Traditional radiofrequency, which uses temperatures above 67ºC, lesioning the neurons involved in the pain process, and pulsed radiofrequency, which uses temperatures below 45ºC, inducing changes throughout the neuronal membrane and/or production of chemical mediators that block the pain stimulus without causing cellular damage. Depending on the location and type of pain, one of these techniques will be used.
Radiofrequency has various indications, including treatment of trigeminal neuralgia, pain caused by lower back conditions, especially facet joint syndrome, cervical syndrome (cervicogenic headache, facet joint syndrome, cervicobrachialgia), intercostal neuralgia, untreatable cancer pain, lumbar sympathectomy and radiofrequency of peripheral nerves to treat pain syndromes in determined areas (occipital nerves, suprascapular nerve, femoral cutaneous nerve, intercostal nerve, etc.).
REGIONAL SYMPATHETIC BLOCKS
Certain diseases, such as pain, are mediated by the sympathetic nervous system. In these cases, it is necessary to block these nerves to control the pain. This is usually done using continuous imaging and local anesthetics. Sometimes, to ensure long-term pain control, the affected nerve is destroyed using either drugs (chemical neurolysis) or temperature (radiofrequency thermocoagulation). The most common sympathetic blocks are: Stellate ganglion block, celiac plexus block, hypogastric plexus block and ganglion impar block, among others.
IMPLANTABLE DRUG DELIVERY SYSTEMS
In certain patients with chronic pain who have shown a good response to analgesic drugs but in whom side effects mean that administration of the drugs via the usual routes (oral, transdermal) is intolerable, the dose can be minimized by placing these drugs right next to the treatment site. This is achieved by inserting a small device during a minor surgical procedure that will act as a pump-reservoir connected to a catheter (small, thin, flexible tube) that is inserted into the area surrounding the spinal cord (intrathecal space), which is where the nerves transmitting pain signals are located. Placing the drugs right at the treatment site allows for spectacular dose reduction (e.g. intrathecal morphine is 300 times more potent than oral morphine), which allows pain to be controlled while preventing undesirable effects.
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IMPLANTABLE NERVE STIMULATORS
In certain patients with chronic pain that is difficult to treat, or in patients with intolerable side effects from the drugs used, Implantable Nerve Stimulators are a good alternative for pain management. This treatment involves placing a device under the skin via a small surgical incision that will emit electrical signals to an electrode placed right in the area where the nerves transmitting the pain signal are located, thereby blocking pain impulses and relieving pain.
The main indications for such nerve stimulators are failed back surgery syndrome, complex regional pain syndrome, untreatable angina pectoris, etc.
For further information, please see:
BOTULINUM TOXIN INJECTIONS
Botulinum toxin is a neurotoxin produced by a bacterium called Clostridium botulinum. It is used in medicine as a result of its ability to block the release of a substance called acetylcholine, which is necessary for muscle contraction. Due to preventing muscle contraction, it is useful for treating myofascial pain syndromes such as piriformis syndrome or iliopsoas syndrome.