Pain Management Center - Managing Back Pain : An Update

Dr Tan Kian Hian, Director, Pain Management Center

Discogenic back pain accounts for up to 40% of all causes of chronic back pain.¹ Intradiscal biacuplasty (IDB) is a novel bipolar cooled radiofrequency system for the treatment of degenerative disc disease leading to back pain. Patients with chronic low back pain for more than 6 months, back pain exceeding leg pain, concordant pain on provocative discography, disc height more than 50% of control, and evidence of single- or two-level degenerative disc disease without evidence of additional changes on magnetic resonance imaging will benefit from the procedure. IDB is performed under fluoroscopy using two radiofrequency probes positioned bilaterally in the intervertebral disc. This delivers thermal energy to the posterior aspect of the disc resulting in collagen formation thereby “sealing” the disc as well as reducing aberrant nerve growth in the disc. A study done by Kapural et al in 2008 showed that patients displayed improvements in several pain assessment measures after undergoing IDB for discogenic pain.²

Sacroiliac joint disorders are also common causes of lower back pain and the incidence can be up to 27%.³ Therapeutic solutions include intra-articular injections with short-term pain relief. Radiofrequency (RF) of the joint capsule or lateral branches has been previously reported with variable successes. The new procedure involved using a new radiofrequency technology, which by cooling tissue adjacent to the electrode increases the radius of lesion. The cooled RF is performed on the S1, S2, and S3 lateral branches and of dorsal ramus L5 following two diagnostic SI joint blocks (>50% of pain relief ). A case series showed that the majority of patients with chronic SI joint pain experienced a clinically relevant degree of pain relief and improved function following cooled RF of sacral lateral branches and DR of L5 at 3-4 months follow-up.⁴

Pain Management Center – A One Year Retrospective

The Pain Management Centre at the Singapore General Hospital was officially opened in January 2008. It is the first and largest referral centre in Singapore for patients with persistent and disabling pain disorders. The one-stop centre consists of specialist outpatient clinics, acupuncture services, procedure room with X-ray facilities and recovery room for interventional pain treatment.

On top of providing advanced cutting-edge clinical service to our patients, several milestones were achieved during the past year. It became a multidisciplinary centre with the involvement of a Psychologist running clinics in the centre. We continued to organise well-attended Continuous Medical Education Programs for the General Practitioners on persistent pain, involving Orthopaedic surgeons as well in the interactive sessions. Strong collaborations with the Pain Association of Singapore resulted in a successful cadaveric workshop on interventional pain procedures that attracted specialists from around the world. The Pain Management Centre also became the first centre outside of Australia and New Zealand to be accredited towards the Fellowship of Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists. As a result, we continue to attract specialists from around the region who are interested in Pain Management, to join our training programme and research activity. In order to continue with our endeavor to be a leading centre for interventional pain procedures in the region, new procedures were constantly evaluated and offered to our patients in the past year.

As part of the Pain Management Center’s plan to extend its range of services, the Centre established “Pacing” as one of the Centre’s chronic pain management programme. “Pacing” is a multidisciplinary programme involving the pain doctors, physiotherapists, psychologists and nurses to help patients self-manage pain and improve their activity levels. We were the first to implement the Pacing programme in Singapore in October 2008. It aims to educate patients about their pain, how to pace their activities during the day so that activity is regular and consistent; as well as teach patients psychological skills on how to interpret pain and improve their coping abilities. The Pacing programme offers patients with persistent pain a multidisciplinary approach to help increase their activity levels. The inaugural programme has been very well-received by our patients.

As we look forward to the next lap ahead, the Pain Management Center will continue to adopt a 3-pronged approach in our direction, consisting of clinical services, research and education. With this firmly in place, we will continue to strive to provide latest quality and evidence-based management to our patients.

Reference:

1. Schwarzer AC, Aprill CN, Derby R etc. The relative contributions of the disc and zygapophyseal joint in chronic low back pain. Spine 1994;19(7):801-6.
2. Kapural L, Ng A, Dalton J et al. Intervertebral disc biaculoplasty for the treatment of lumbar discogenic pain: results of a six-month follow-up. Pain Med 2008;9(1):60-7.
3. Hansen HC, McKenzie-Brown AM, Cohen SP et al. Sacroiliac joint interventions: A systemic review. Pain Physician 2007 10(1):165-84.
4. Kapural L, Nageeb F, Kapural M et al. Cooled radiofrequency system for the treatment of chronic pain from sacroilitis: the first case-series.
   Pain Pract 2008;8(5):348-54.