from The Richeimer Pain Institute
September 2000


After multiple surgeries, Michelle G. had so much back pain that she was taking 300 milligrams of morphine per day to obtain relief. While the pain was finally bearable, Michelle suffered from loss of appetite, nausea, constipation, and severe lethargy. Ten years ago, Michelle had very little choice but to suffer with the side effects. Not so today. Michelle is a new person thanks to the amazing technology now available to us. Michelle is taking only 1 milligram of morphine per day with the improved pain relief, no side effects, and she leads a normal, happy life. Here's how:

Medicines taken orally get diffused throughout the entire body which means that a great deal of medication must be ingested in order to get the appropriate quantities to the place it is needed most to ease pain: the spinal cord. Now we have the ability to get that medicine to exactly where it's needed. By surgically implanting a pump under the skin of a person's abdomen, and running a catheter to the precise location in the spine where the pain is, we can pump medication directly into the spinal fluid, allowing for a much more potent effect on the spinal cord. This drastically cuts down the dose of medication that is needed, and the medication often provides even better pain relief with much fewer side effects.

Maintenance of the pump is fairly routine. The pump is refilled every 1-3 months by inserting a needle through the skin and through a diaphragm on the surface of the pump. Several different medications can be administered this way, and even combinations of drugs might be used. Because the whole system is under the skin, the risk of infection is minimized and the patient can be fully mobile and active.

Obviously, this technique should only be considered when more standard (and less expensive) treatments have not been effective or have caused intolerable side effects, but this is clearly a technological advance that can directly improve the quality of life.

Another new advance for pain relief is electric stimulators. For reasons that are not well understood, electric pulses on the surface of the spinal cord often dramatically reduce pain. The stimulators are similar to pumps in that they are surgically implanted under the skin, of the chest, upper buttock, or the abdomen, but they differ in that electric signals, rather than medication, is used to ease pain.

Electric signals are passed through the tip of the catheter, at the precise location near the involved segment of the spinal cord, producing a tingling over the painful area which eases the pain. Current theory is that the electrical input alters the spinal processing of the pain so that the patient's pain is reduced.

The patient is able to control the stimulator by holding a magnetic pulsing device over the skin on top of the implanted generator disk. The stimulator appears to be effective for patients with back and leg pain who did not get better with spinal surgery. There is data that shows that these patients will do better with the placement of a stimulator than they will with repeat surgery. Patients with RSD (reflex sympathetic dystrophy) can also respond well to this treatment. The response rates of patients with peripheral neuropathies or with phantom limb pain are lower, but a temporary screening trial with a stimulator is still worthwhile if the pain has not responded to other treatments.

Although far from panaceas, pumps and stimulators have proven to be very effective with carefully selected patients whose severe pain persists despite prior treatment efforts. Pumps and stimulators are expensive, and should only be used when extensive efforts at less invasive treatments have failed.

If this point is reached, and if an implant is being considered, a psychological assessment can help to determine the patient's emotional readiness for such technology. Only then should a trial treatment phase be implemented during which a pump or stimulator is tried on a short-term basis. If the desired benefit is achieved without significant side-effects, then the team can proceed with a permanent implant.

And by the way, research on new medications for the pump is currently underway, so perhaps these tools will soon become even more effective. They must be carefully administered, but clearly they are valuable weapons in the fight against severe, persistent pain.

Until next time…Steven Richeimer, M.D.

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Steven Richeimer, MD
Copyright © 2000. All rights reserved.
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