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Treatments

Pain is a complex medical problem that can have profound effects on your physical and mental well-being. Our goal is to help you decrease your level of pain and suffering, to return you to your maximum level of functioning and independence, and to help you restore your quality of life. Your physician may refer you to the Pain Management Center for evaluation, for one or more specific procedures, or for ongoing treatment.

Individualized treatment plan: The treatment plan developed by the Pain Management team will be specially tailored to your condition and degree of pain, your needs and your personal objectives. Your treatment plan may include a single approach, or a combination of different types of therapies: medical therapies, including both medications and special procedures; psychological therapies; and rehabilitation therapies.

 

Duration of care: The duration of the treatment plan will vary from patient to patient, depending on the particular complexity and combination of treatments prescribed. On average, most patients will be in treatment for a period of approximately three to six months. During this time, you may need to allocate approximately three hours per week for treatments at the Pain Management Center.

Throughout the duration of your treatment at the Pain Management Center, we will remain in contact with your primary physician to keep him/her apprised of your progress.

Treatment options  

Epidural steroid injections

Types of injections of corticosteroid medications into the area around the spinal nerves (epidural space) to reduce inflammation of the nerve and disc. Options include caudal epidural, interlaminar epidural, transforaminal epidural, and translaminar epidural.

What Is An Epidural Steroid Injection?

An epidural steroid injection is a nonsurgical procedure that delivers pain-killing medication into a small space in your back or neck.

This treatment is commonly used to relieve pain caused by irritation of nerves in the spine.  Conditions treated include:

Epidural steroid injections are very effective at alleviating arm or leg pain caused by a disc herniation.

How long will an epidural steroid injection relieve my pain?

The effects of an epidural steroid injection can vary greatly from person to person. Your results will depend on your specific condition and how your body responds to the medication. It may provide long-term relief, short-term relief, or no relief at all.

Safety of epidural steroid injections

Epidural steroid injections are very safe, but not entirely without risk. Much less than 1% of injections cause serious complications.

 

Intrathecal programmable pump placement

An implanted medical device to deliver medication directly into spinal fluid to provide relief from chronic pain, including severe spasticity of spinal cord origin.

What Is An Intrathecal Programmable Pump Placement?

The intrathecal programmable pump is an implanted medical device, which is used to deliver medication directly into the spinal fluid. The system consists of an infusion pump, a spinal catheter, and an external programmer.

This treatment has brought relief to many patients who suffer from chronic, severe pain from multiple causes and also from chronic, severe spasticity of spinal cord origin.

How Quickly Can I Expect Pain Relief?

The pump is programmed immediately upon placement, before leaving the surgical suite. The effect of the medication occurs within minutes to hours, depending on the choice of medication placed in the pump.

How Should I Prepare for the Procedure?

The intrathecal programmable pump is a safe medical procedure; but, as with any procedure, it has risks as well as benefits. The pump placement is a relatively minor surgery preformed under general anesthesia. To minimize the chance of complication, we ask that you follow a few simple guidelines:

  • Do not eat or drink anything for six hours prior to the procedure.
  • We require that you be accompanied to and from Stanford Health Care by a responsible adult driver. Following the procedure, you will be admitted to the hospital for an overnight stay for observation.

What Happens During the Procedure?

First, an intravenous line will be placed, generally in your hand. We will then bring you to the operating room and place several monitors on you, such as a heart, blood pressure and a pulse. These will enable us to monitor your vital signs throughout the procedure. Following placement of the monitors we will begin to give you some intravenous medication in order to decrease anxiety, as well as provide you with some pain relief.

You will be asked to lie on your side in the surgical suite. An x-ray is used to help guide the intrathecal catheter to the correct position. After cleaning your skin, the skin is anesthetized with local anesthetic to decrease any pain associated with performance of the procedure. By this point, you will already have received sedation by the anesthesiologist, as well.

The intrathecal catheter is placed through a small incision in your back. The programmable pump is placed under the skin in the right or left abdomen where there is sufficient skin and soft tissue to support the pump. A pocket is created underneath the skin to contain the pump. The catheter is tunneled from the back, underneath the skin to the abdomen where it is connected to the programmable pump. Both incisions are then closed with sutures. The pump is filled with the medication while you are in the surgical suite, and the programming is initiated. It will be functioning before you leave the surgical suite.

What Happens After the Procedure?

The pump is filled with the medication while you are in the surgical suite, and the programming is initiated. It will be functioning before you leave the surgical suite.

We will assess that the pump is functioning correctly by observing for signs of pain relief from the medications, as well as development of numbness from the local anesthetic. You will be monitored for 20 to 40 minutes by a Recovery Room nurse and a Pain Management physician.

If there are no signs of problems, you will be ready to leave the recovery area and be transferred to your room in the Ambulatory Treatment Unit for observation overnight. You will be monitored for correct functioning of the newly placed intrathecal pump, as well as for any complications related to the procedure and the anesthesia. If there are no signs of problems, you will be ready to leave by the next day.

You will need to return to the Pain Management Center for refills of the pump approximately every 30 days. Also, your pump can be reprogrammed at anytime by the Pain Management physicians using an external programmer. You will also be taught how to turn the pump on and off yourself while at home, using a magnet.

What should I expect from this procedure?

You will require a short period of recovery from this minor surgical procedure. You may notice soreness in the abdominal wall where the intrathecal pump is placed, and some soreness in the back where the catheter is inserted; this is usually quite minimal. There will be some bruising which may last up to a week, but will resolve. Your home nursing agency will assist in monitoring the two sites for any evidence of infection. Signs to monitor are redness and/or increased pain or swelling of the two incision sites. The stitches will be removed at the Pain Management Center in approximately one week, provided that the incisions are well healed.

Postprocedure instructions

These will be provided for you, in further detail, by the nurse, prior to your discharge from the hospital.

Signs to monitor are redness and/or increased pain or swelling of the two incision sites. The stitches will be removed at the Pain Management Center in approximately one week, provided that the incisions are well healed.

 

Temporary epidural catheter

A temporary tube placed into the epidural space in your spine, allowing for the injection of pain management medication for a defined period of time, typically less than two weeks.

What Is a Temporary Epidural Catheter?

An epidural catheter is a very fine plastic catheter (tube) that is placed through the skin into the epidural space in your spine. This temporary catheter is left in place for a defined period of time; normally less than two weeks. The catheter allows access to the epidural space to inject medication such as local anesthetics and/or narcotics for relief of pain.

Temporary epidural catheters are used for tempory treatment of painful conditions that require pain control for intensive physical therapy and/or joint mobilization. They are also used prognostically for trials of spinal medications prior to placement of permanent implanted ports or programmable pumps.

What Is a Temporary Epidural Catheter?

An epidural catheter is a very fine plastic catheter (tube) that is placed through the skin into the epidural space in your spine. This temporary catheter is left in place for a defined period of time; normally less than two weeks. The catheter allows access to the epidural space to inject medication such as local anesthetics and/or narcotics for relief of pain.

Temporary epidural catheters are used for tempory treatment of painful conditions that require pain control for intensive physical therapy and/or joint mobilization. They are also used prognostically for trials of spinal medications prior to placement of permanent implanted ports or programmable pumps.

How Should I Prepare for the Procedure?

The temporary epidural catheter placement is a safe medical procedure; but, as with any procedure, it has risks as well as benefits. To minimize the chance of complications, we ask that you follow a few simple guidelines:

  • Do not eat or drink anything for six hours prior to the procedure.
  • Following placement of the temporary epidural catheter you will be admitted to the hospital for approximately five days for observation.
  • It is required that you be accompanied to and from Stanford Hospital & Clinics by a responsible adult driver.
 

What Happens During the Procedure?

First, an intravenous line will be placed, generally in your hand. We will then bring you to the operating room and place several monitors on you, such as a heart, blood pressure and a pulse. These will enable us to monitor your vital signs throughout the procedure. Following placement of the monitors we will begin to give you some intravenous medication in order to decrease anxiety, as well as provide you with some pain relief.

You will then be asked to either sit or lie on your side on the bed. Sometimes, x-ray guidance aids in the appropriate placement of the catheter, and an x-ray may be used.

After cleaning a small patch of skin along your spine, a local anesthetic is injected into the skin to decrease any pain associated with the placement of the catheter. A small needle is then used to locate the epidural space, and the catheter is threaded through the needle. The needle is then withdrawn and a second patch of skin is anesthetized with local anesthetics.

A similar needle is placed in the second spot in order to bring the catheter from the middle of your back to the side. This allows the catheter to be tunneled underneath the skin for a distance of four to five inches in order to provide stability. Two or three stitches may be placed to secure the catheter. The catheter is then covered with sterile dressing and taped to the skin of your back. The procedure itself is very brief, and associated with minimal discomfort. 

What Happens After the Procedure?

Once the catheter is placed, it will be injected with medication, usually a local anesthetic and/or a narcotic. We will assess that the catheter is functioning correctly by observing for signs of pain relief from the medications, as well as development of numbness from the local anesthetic. You will be monitored for 20 to 40 minutes by a nurse and a Pain Management physician. If there are no signs of problems, you will be ready to leave the recovery area and return to your hospital room.

Your epidural catheter will be dosed with medications on either an intermittent or continuous basis based on the determination of the Pain Management physician. The catheter is designed for short term use only and is normally removed prior to discharge from the hospital. In some cases patients are discharged home with the catheter and are managed at home with the assistance of a home nursing agency.

If you have any questions after the procedure, the medical staff of the Pain Management Center is on call 24 hours a day, seven days a week. During normal business hours, you can reach either the nurse of physician by calling 650-723-6238. After hours, the physician on call can be reached by calling the Stanford Hospital page operator at 650-723-6661.

Postprocedure instructions

These will be provided for you, in further detail, by the nurse, prior to your discharge from the hospital. Before going home, the catheter will be removed and the insertion site will be dressed with a gauze dressing.

If you go home with the temporary epidural catheter in place, the catheter insertion site will be dressed with a clear plastic dressing. This allows you to be able to monitor the site for any signs of infection such as redness or swelling. Your home nursing agency will change the dressing as ordered and also inspect the site for any evidence of infection or problems.

 

How quickly can I expect pain relief?

With an epidural catheter, patients can obtain pain relief within minutes. It may, however, take a few days to adjust the dose for the optimal pain relief. The catheter gives your pain management physician the ability to adjust the medication and determine the appropriate dosage.

How quickly can I expect pain relief?

With an epidural catheter, patients can obtain pain relief within minutes. It may, however, take a few days to adjust the dose for the optimal pain relief. The catheter gives your pain management physician the ability to adjust the medication and determine the appropriate dosage.

Gasserian ganglion block

This procedure administers a dose of local anesthetics directly to the bundle of nerves that supply sensation to the face and scalp.

What Is a Gasserian Ganglion Block?

A gasserian ganglion block is a medical procedure using administration of a dose of local anesthetics directly to a bundle of nerves that supplies sensation to your face and scalp. This nerve block may bring relief to patients who suffer from trigeminal neuralgia and other syndromes of facial pain, as well as patients who suffer from pain caused by cancer.

In some instances, in patients who suffer from facial pain from cancer, a small dose of medication to kill the nerve going to the gasserian ganglion, can be used. This is not an option for patients who do not have cancer.

What Should I Expect from This Procedure?

This is usually a diagnostic procedure that allows us to pinpoint, more accurately, the location of the origin of your pain syndrome. Sometimes repeated gasserian ganglion blocks can be used to decrease certain types of facial pain syndromes. In general, nerve killing procedures are not performed or recommended except in certain instances of patients with cancer pain. Typically, local anesthetic is used to block the nerves that go to your pain.

You might have some numbness of your face and gums, and decreased ability to chew. This might last between six to twelve hours. When the numbness resolves, your pain might return or you might have pain control that extends beyond the duration of the local anesthetic. It will be important for you to tell your pain management doctor about your pain control, following the block.

How Should I Prepare for the Procedure?

The gasserian ganglion block is a safe medical procedure, but as with any procedure it has risks, as well as benefits. To minimize the chance of complications, we ask that you follow a few simple guidelines:

Do not eat or drink anything for six hours prior to the procedure. An exception is always made for routine scheduled medication, which you can take with a sip of water.

We ask that you be accompanied to and from the Ambulatory Surgery Center by a responsible adult driver. Pain Management physicians, or a nurse in the Ambulatory Surgical Center may offer a small dose of relaxing medication prior to the procedure, which could impair your driving ability.

Plan on spending approximately ninety minutes in the Ambulatory Surgical Center. This includes time for registration, preparation, performance of the procedure and observation period.

What Happens During the Procedure?

First, an intravenous line will be placed, generally in your hand or arm. We will initiate continuous monitoring of your heart, breathing and blood pressure. You will be asked to lie on the treatment table. X-ray guidance will be used to help with placement of the medication. Once the equipment has been positioned, you will be offered sedative medications to help you relax and minimize discomfort.

A patch of skin over your face will be cleaned, using an antiseptic solution, and local anesthetic injected into the skin to decrease any pain associated with performance of the procedure. A needle will be placed adjacent to the gasserian ganglion using X-ray guidance. The procedure takes approximately 10 to 15 minutes to perform once the monitors and X-ray machine are in place. Occasionally, because the gasserian ganglion is adjacent to blood vessels, swelling or bruising of the face may occur. Should this occur, we would recommend that you rest in a seated position and use an ice pack.

What Happens After the Procedure?

After the gasserian ganglion block has been performed, we will continue to monitor you for approximately thirty minutes. If there are no signs of problems, you will be ready to leave. We will provide your physician with a written record of the procedure, and will keep him/her informed of your progress during the entire course of treatment. You will be provided with a set of postprocedure instructions to help guide you following the procedure.

If you have any questions after your procedure, the medical staff of the Pain Management Center is on call twenty-four hours a day, seven days a week. During normal business hours, you can reach either the nurse or the physician by calling 0775250101.

For after hours, the on-call physician can be reached by calling the agrilar.az page operator at 0775250101.

Postprocedure instructions

Use Tylenol®, ice and apply to the facial region for several hours following the procedure. Try to keep your head elevated for several hours until you are sure that no significant swelling will occur. Non-steroidal medication, such as aspirin and Motrin®, is not recommended for the first twenty-four hours because this may increase swelling.

Please call the Pain Center at 0775250101 to report your total duration of pain relief tomorrow. If you do not have a follow up appointment, or a specific plan, then you need to discuss this with the pain management physician who has been taking care of you.

How quickly can I expect pain relief?

Relief is instantaneous, if the pain that you are experiencing is related only to the nerves which go to the gasserian ganglion. Total duration of pain relief will be six to twelve hours. If a nerve killing medication is used, maximum relief starts in one to two days, and may last up to three to six months.

What Possible Side Effects Might I See?

In general, the most frequent complication includes, facial swelling, bruising because of the proximity of blood vessels to the gasserian ganglion. This should be treated with ice and elevation, should it occur. In addition, other nerves are adjacent to the gasserian ganglion and can, in very rare circumstances, develop weakness from the local anesthetic medication. In general, this would be noticed in the recovery room. However, if you had difficulty with breathing or swallowing following the procedure, we would want you to inform one of the recovery room nurses or physicians.

Sometimes, despite the use of an X-ray machine, we are unable to place the medication in the appropriate space because of technical difficulty. Finally, while most patients get pain relief, in rare instances, sometimes there is an aggravation of the current pain symptoms. This is likely secondary to the facial swelling or bruising as stated, and is likely to last for several days.

What should I do if any problems develop after I leave the hospital?

Call the Pain Management Service at 0775250101, Monday through saturday, 9 a.m. - 5 p.m.

For after hours, dial the page operator at Stanford at 0775250101 and ask for the Pain Service physician on call.

IPsychological therapy

Pain can hinder a normal, productive life. Psychological evaluation and treatment can help individuals develop specific skills to cope pain and increase their quality of life.

Psychological Therapy

Chronic pain can have profound psychological effects, including feelings of hopelessness, anger, sadness, and even despair. These feelings can interfere with your ability to perform your job or your normal daily activities.

Psychological therapy can help you to cope with the effects of pain on you and those around you. There are also specific psychological techniques that can actually help to reduce pain.

Your treatment plan may include the following psychological therapies:

  • Individual and group counseling
  • Biofeedback
  • Relaxation techniques
  • Self-hypnosis
  • Visual imaging
  • Learning or conditioning techniques

What can a psychologist do for my physical pain?

Pain is a "whole person" experience. Most people experience pain physically, emotionally, socially and intellectually. Pain can inhibit a normal productive life: it can limit your ability to concentrate, participate in physical activities and enjoy social interactions. Psychological evaluation and treatment can help many individuals develop specific skills that relieve the suffering of pain and thus increase their quality of life.

What happens during a psychological evaluation?

During your psychological evaluation, we hope to gain an understanding of your situation so that we can provide you with some relief from the psychological consequences of your pain. A psychological evaluation is an efficient way of obtaining the necessary personal and historical information to assist you in getting effective medical care and pain relief.

As part of the initial consultation, you will be asked to complete several psychological tests and questionnaires. Combined with a personal interview, psychological testing helps you and your physician understand and plan the best possible multidisciplinary treatment.

Professional recommendations are normally made after the initial evaluation is completed. We will discuss with you the results of your psychological evaluation and your individualized treatment recommendations prior to your agreement to enter treatment at the Pain Management Center.

What psychological evaluation is not?

Some patients are concerned that the psychological evaluation might imply that their pain is imagined rather than felt; this is not the case. In fact, pain that is delusional cannot be alleviated through psychological treatments. Physical pain is normally recognized by the brain and, thus, has many effects on your well-being. It is these effects that we hope to identify during the psychological evaluation.

What psychological techniques are used?

Psychological therapy offered at the Pain Management Center addresses both the physical and the emotional suffering associated with pain. We offer psychotherapy in both individual and group settings. Specific techniques include:

Psychophysiological techniques

Biofeedback/Relaxation Training: Many patients benefit from learning how to control their responses to chronic pain. Biofeedback and relaxation training teach you how to release the tension and anxiety that often make painful physical conditions more excruciating.

Behavioral Techniques

Self-Monitoring: Most patients will be asked to keep a diary of their pain, observing how pain levels increase or decrease over time. By monitoring your pain, you can develop an appreciation of your ability to control and manage levels of pain using skills you have learned.

Paced Progressive Increases in Activity Levels: By encouraging the slow and steady introduction of or increase in activity, we can help patients start to feel an improvement in their quality of life. Pain can be very debilitating, and the Pain Management Center is committed to helping patients improve their social, occupational and recreational activity levels.

Cognitive Techniques

Self-Hypnosis and Visual Imagery: These techniques help you control pain that interferes with your occupational and sleep patterns. Through self-hypnosis, many patients report reduced levels of pain and an increased ability to concentrate on meaningful pursuits.

Emotional Management: Over time, pain can be very distressing, leading to depression, anxiety and social turmoil. Psychological therapy can assist you in reducing the emotional distress associated with chronic pain. By learning these techniques, your pain can be transformed and your suffering reduced.

Home Treatment Aids

Office visits also include many helpful self-aid materials that enable patients to maximize the effects of treatment in the shortest time possible. Professional materials instructing you in the self-management approach to chronic pain and professionally produced relaxation and self-hypnosis tapes are provided.

Are sessions with the psychologist confidential?

In almost all situations, you control who has access to the information disclosed during your interview sessions with your psychiatrist. There are some unusual exceptions to this rule, however, and you need to be aware of them. Information regarding child abuse, elder abuse or the need to protect you and others from physical harm or immediate danger must be reported to the appropriate persons by state law.

 

Physical therapy

Physical therapy may include a regimen of exercise, tissue manipulation, and other treatments focused on maximizing function in specific body parts to help relieve your pain.

Peripheral nerve block

Depending on the location of the pain, a nerve block is used to diagnose and/or manage pain for a variety of conditions.

Peripheral Nerve Block Overview

Peripheral nerve blocks may be indicated for a variety of pain conditions and may be performed for diagnostic and/or therapeutic effect. The area injected will depend on the location of your pain. It is not possible to predict how much help, if any, this procedure will be for your pain. Results vary with each person.

Nerves involved may include:

  • Trigeminal
  • Occipital
  • Axillary
  • Illioinguinal
  • Illiohypogastric
  • Sciatic
  • Interscalene
  • Infraclavicular
  • Femoral

What Happens During the Procedure?

With this procedure, an IV will be placed in your hand or arm and you will be given some intravenous medicine to help you relax and have less pain from the needle used for the procedure. You will not be asleep. An X-ray machine is used to locate the area(s) of the spine to be injected.

Your doctor will use a local anesthetic to numb the area(s) to be injected. You will feel a pinprick and then a burning feeling as the local anesthetic is injected. Once the area is numb, the spinal epidural needle will be placed and the steroid injected. 

What Should I Expect After the Procedure?

Initially, you may experience several hours of pain relief as a result of the local anesthetic. After that time the pain will return. If steroids are used, it may take 7 to 10 days for the anti-inflammatory effect of the steroid to be effective and for you to experience pain relief.

  • You may experience soreness or a feeling of fullness at the injection site.
  • You may experience muscle spasms.
  • You may experience a neck ache or backache.
  • Your blood pressure may decrease or increase.
  • You may feel increased warmth of the upper or lower extremity.
  • You may feel some numbness or tingling of the upper or lower extremity.
  • The affected area may be numb for a few hours and should be protected from injury.

Post-procedure instructions

These will be provided for you, in further detail, by the recovery room nurse prior to your discharge from the Ambulatory Surgery Center. These instructions should include; no driving or operating machinery for 24 hours after the procedure. This is recommended because the intravenous medication given during the procedure may impair your ability to safely perform tasks. A Pain Clinic follow up appointment should be scheduled.

What should I do if any problems develop after I leave the Surgery Center?

If you have any questions after the procedure, the medical staff of the Pain Management Clinic is on call 24 hours a day, seven days a week. During normal business hours you can reach either a physician or nurse by calling 0775250101

 

 

Occipital nerve block

An intravenous procedure to administer medication into the back of the head.

Hypogastric plexus block

The administration of pain killing medication near the collection of nerves located near the lower part of your abdomen, to relieve chronic pelvic pain.

Intrathecal catheter placement

An implanted device which allows pain medication to be delivered directly into the intrathecal space in the spine.

Implanted epidural portal

An implanted port, which allows pain medication to be injected into the epidural space of the spine over a longer-term, ongoing period.

Brachial plexus block

An injection of a dose of local anesthetic into the neck, above the collarbone or into the upper arm, for treatment of chronic arm and shoulder pain.

Spinal cord stimulation

A procedure that uses an electrical current to treat chronic pain in the back, arms or legs by sending electrical pulses to the spinal cord.

Medications

Medications are used to reduce the intensity of pain. The primary goal of medications is to help patients participate more fully in pain management, and to return to their personal, family, and social activities.

Occupational therapy 

Occupational therapy focuses on a range of techniques to enable you to return to work or a normal daily routine.