INTERVENTIONS FOR CHRONIC PAIN : MISCONCEPTION AND MANAGEMENT
Pain was defined as " an unpleasant sensory and emotional experience associated with actual and potential tissue damage , or described in terms of such damage". Please note that this definition talks about " potential tissue damage" and therefore excludes the possibility of a decisive objective test as a gold standard.

Chronic pain persists beyond the normal time of healing.

While acute pain is merely a physiological response to obvious tissue damage with an array of sympathetic responses, CHRONIC PAIN involves psychological and behavioral mechanisms in addition to physiological mechanisms. These three components may coexist together with or without a link between them.

Although it is difficult to quantify, the prevalence of chronic pain ranges between 10% to 55 %. The prevalence of chronic pain in the elderly ranges between 23.7 % to 50.2 %.

The economic and social impact of chronic pain in the society is enormous. During 1996, direct medical costs for persons with disabilities were 260 billion dollars.

There is very little teaching and education in the medical school and residency programs about the complex nature of chronic pain. Despite this, a big leap has been made in the past 20 years towards understanding and treating these painful conditions through cognitive, behavioral and interventional techniques. The biopsychosocial approach for pain therapies, essentially negates the proprietary role of the "block shop" .

The interventional pain management specialist emerges not only as a healer but also as a diagnostician. With implementation of precision blocks performed under direct visualization, a diagnosis of chronic spinal pain can be made in at least 50 % of the cases. These diagnostic techniques include facet blocks, nerve root and dorsal ganglion blocks, sacroiliac joint injections, sympathetic blocks and provocative discography.

Without these tools, while utilizing ONLY physical examination , psychological evaluation, computed tomography ( CT) , magnetic resonance imaging (MRI), a cause for low back pain can only be found in 15 % of the patients !

Often patients do memorize a few lines off the MRI report as an explanation for their pain . Many times there is no connection between the real source of pain and these MRI findings, as the sensitivity of these findings is extremely low. The overall inaccurate or incomplete diagnosis for patients referred to pain centers has been described as ranging from 40 % to 67 %.

The National Uniform Claim Committee defined interventional pain management as : " The discipline of medicine devoted to the diagnosis and treatment of pain and related disorders with the application of interventional techniques in managing subacute , chronic, persistent and intractable pain , independently or in conjunction with other modalities of treatment". These treatment modalities include, but are not limited to acupuncture, yoga, hypnosis, reiki ,massage therapy and biofeedback. Spinal injections are modalities implementing more conservative approaches such as exercises and physical therapy. Steroid medications are used for some of these interventions as a mean to decrease the local tissue inflammation. Alternatively, radiofrequency ablation can be used in certain situations in order to achieve a more lasting effect.

Some unfortunate patients may fail to respond to conservative measures altogether.

Implantable devices are now available for a sub group of patients who pass a standard psychological evaluation. These devices are not designed for every single chronic painful condition. A basic understanding of the mechanisms of disease and pathology is helping us choosing the proper candidates for such interventions. Patients should also have a clear understanding of all possible complications and risks involved with these sophisticated procedures.

Fundamental to modern interventional pain management are precision diagnosis and interventional techniques, applied judiciously to improve the health and well-being of patients.