Exploring Interventional Pain Medicine: Moving Beyond Pills and Surgery

Welcome to another episode of the Kentucky Pain Reversal Show. In today's conversation, the focus is on redefining pain management by exploring the evolving field of interventional pain medicine. Instead of relying solely on pills or repeat surgeries, listeners are invited to discover a modern toolbox of targeted treatments such as nerve blocks, radiofrequency ablation, and peripheral nerve stimulation. The discussion delves into how advanced diagnostic approaches can identify the exact source of pain and provide personalized solutions that restore quality of life. Listeners will also hear stories that illuminate how these innovative options empower patients, replace long-held misconceptions, and, above all, offer hope—affirming that pain does not have to be a life sentence.

00:00 Understanding interventional pain management

04:53 Discussing chronic pain management

06:22 Discussing patient treatment options

09:42 Using local anesthetic for pain relief

15:57 Discussing neck pain treatment options

18:05 Discussing procedure risks with patients

22:52 Patient satisfaction and life improvement

25:25 Importance of Hope in Healing

Podcast Website - https://thekentuckypainreversal.com/

Dr. Ajith Nair Clinic - https://kentuckianapainspecialists.com/

Media Partner - https://tophealth.care/

Transcript

SPEAKER_01 0:00

Being prescribed pain pills is not necessarily a bad thing or a good thing. In fact, if a patient has chronic back pain and they take one to two pills a day, they're able to go do their day-to-day activities and they have a quality of life, I think that's fine. I don't think that the patient would require any further intervention.

SPEAKER_00 0:44

Over the last few episodes, Dr. Nyer has introduced us to some of the most advanced tools in modern pain medicine, from pain pumps to spinal cord stimulation, and shown us that there are alternatives to the traditional cycle of pills in repeat surgeries. But what many people don't realize is that those treatments are just part of a larger toolbox. So today we're exploring the world of interventional pain medicine, a field focused on identifying the source of pain and treating it with targeted precision-based procedures. If you've ever been told to simply live with your pain, or if you thought that your only options were pills or surgery, this episode may completely change how you think about what's possible. So let's continue. Dr. and I are over the past two episodes, we've talked about pain pumps and spinal cord stimulation. And today I'd love to zoom out a little bit more. So when people hear interventional pain medicine, what actually does that mean?

SPEAKER_01 1:40

That is a great question. Now, interventional pain management or pain medicine is the art of medicine where we can identify certain pain generators, and we are able to test and see whether that truly is a pain generator. And if so, we have methods to treat that pain. Very often, it is a definitive way to treat pain. So, just to give you an example, uh, and we did touch upon this before. Um, let's say a patient develops uh phantom limb pain from an amputation. Well, we know that it is a centrally oriented pain that the brain still recognizes the limb which has been amputated in being still there. So we know the mechanism of how that pain is generated, so then we institute a treatment program, an interventional treatment program, that will try and alleviate that pain. Um, another example would be: let's say a patient comes and complains about knee pain. Well, after a clinical examination is done, and let's say some radiological studies like X-rays show that arthritic changes in their knee, then what we know that that is the source of the pain, the arthritis. So we can introduce a small amount of cortisone into the knee through a knee injection, and we can now treat that. So we have a diagnostic part of the treatment and then a therapeutic part of the treatment. The key here is that we are able to precisely locate the generator of the pain. And I believe that is the uh cornerstone of interventional pain manager. I can give you yet another example. Let's say a patient who complains of chronic headaches. Now, there are many different causes of headaches, but some of the more uh treatable causes would be things like tension headaches or what is known as cervicogenic headaches. So cervicogenic headaches are headaches that occur when a patient has pathology, let's say degenerative disc disease in the neck. So this is where there's degenerative arthritis in the uh discs that are located in the cervical spine, which is the neck. That can manifest as headaches. So, how does one diagnose that? Well, when the patient comes in with complaints of headaches, it's important to understand the location of the headaches, the type of the headache, other associated symptoms with the headaches, and it is also important to examine the neck to make sure that that's not the source of this cervicogenic headaches. So, to summarize, interventional pain management is the clinical science of identifying the source of the pain, then to apply a test or a diagnostic tool to verify that that is a cause of the pain, and then to go after the pain and therapeutically control the pain. I hope that shed some light on interventional pain management.

SPEAKER_00 5:13

Yeah, absolutely. All right, so next question here. Many patients uh believe that their options are basically pills, physical therapy, or surgery, which we've talked about ad nauseum in our past episodes. Um, and you've educated us so much about the different treatment options. So, but what are they missing when they think about pain treatment in those specific ways?

SPEAKER_01 5:34

Well, I think that it is important when a patient who does develop chronic pain, and let's say they are taking pain pills to control their pain. Now, again, I think that being prescribed pain pills is not necessarily a bad thing or a good thing. In fact, I feel that if let's say a patient has chronic back pain and they take one to two pills a day and they're able to go do their day-to-day activities and they have a quality of life, I think that's fine. I don't think that the patient would require any further intervention. But I would say that the patient who takes 120 pain pills a month, who describes their pain as intractable, rates the pain at eight or nine out of ten, and has poor quality of life, well, those patients need to research what are the other ways to address their pain. And I think that's where a doctor like myself will be useful. Um, and if let's say I did have uh a patient like this, uh, which I did, by the way, uh earlier this week, you know, I think it's important to first educate the patient on how the patient developed this pain, whether taking pain medications would improve their activity levels or their abilities and their quality of life. And if the patient tells me that, well, you know, my quality of life is you know down the tubes, then that gives me some space to discuss other treatment options. So, again, as I said earlier on, I would try and identify the pain generation of alternative treatments that could also address the pain, discuss the risks and benefits with the patient, and then leave it up to the patient to see if that's something that they would like to explore further. And if so, I would be ready to give them whatever information they would need to help them make that decision. And at that point, providing the patient with more information, education, so that when they get into a decision to move forward with interventional pain management, that they understand what are the benefits, what are the risks, and what are the alternatives. So I believe empowering the patient with those tools will allow them to make a better decision about their own care. So that's where I would begin. And then from that point, if a patient requires diagnostic testing, and that can be in the form of x-rays, MRIs, uh EMG studies where they can locate nerve injury or muscle damage, undergoing the appropriate tests, evaluating those tests, discussing those test results with the patient so that the patient is very clear at every juncture what is being done, so that I feel those things will help the patient make a better decision.

SPEAKER_00 8:47

Excellent. Well, let's start uh with the nerve blocks. What exactly is a nerve block and how can uh temporarily blocking a nerve sometimes create that long-lasting relief?

SPEAKER_01 8:59

That is a great question, Jamie. So let me give you an example uh of a patient who is a 36-year-old uh male who is a landscaper and he has a task of resurfacing a wall. So he purchases six bags of uh uh concrete and he's carrying it into the workplace, and all of a sudden he develops a severe pain in his low back, radiating down the back of his leg, and he's got tingling and numbness. Now, as discussed earlier, the patient is gonna see the primary care doctor. Eventually, they will be referred to an orthopedic doctor who will get an MRI, which then reveals a herniated disc at the L5S1 disk. Now with this type of sciatica at that particular disc level, where I come into the picture is that I can do something known as a diagnostic block. What that diagnostic block is, is that I can identify the exact level where the disc herniation is causing the patient's symptoms. So what I would do is under X-ray guidance, I would place a special needle very close to the nerve root, which is affected by this herniated disc. I will only use local anesthetic. And once I do that, what I would expect the patient to tell me is that after the block, the pain that they were experiencing would have dissipated or gone away. Now, this reduction in pain is because I have placed local anesthetic specifically in the nerve that has been affected by this herniated disc. Now, you may ask, well, why would you want to do that? Well, very simple. Now we have actually identified the exact location and the exact cause of this patient's sciatica. The next step would be for me to do an epidural, which will contain some cortisone and local anesthetic, and I would inject that same area because I know that it is the disc that is irritating the nerve root at this particular area. So now, once I place in cortisone, the patient is going to get improvement in that pain that was going down the leg. The patient may require a second or possibly even a third epidural, but doing this, I can reduce the patient's sciatica by at least 60 to 80 percent, which will allow the patient to get back to work and uh uh not have that many uh uh sick days, and they can get back to their work and have their quality of life. So that would be an example of a diagnostic block. Um, another example would be: let's say some patients can develop low back pain emanating from a specific area called the facet joints. This facet joint, when it gets arthritic, it can cause severe back spasms. And you can have patients who won't be able to bend because their back is seized. Again, a diagnostic block can be done at the facet joint level, thereby blocking the nerve that causes the muscle spasm. When I do this diagnostic block, the patient's muscle spasm will come will will diminish or will reduce. And that tells me that that particular spot is where the pain generator is located, and then I can treat that by doing a procedure called radio frequency ablation, where I heat that nerve, inactivate the nerve, and thereby reduce or eliminate the back spasm. So this is yet another example of a diagnostic test.

SPEAKER_00 13:15

Are you done? Okay. I didn't know. Sometimes you do these really nice pauses, and I didn't I didn't know if you were uh finished here. Okay. All right. Um, Dr. Naris, 60 to 80 percent is tremendous. Um, another treatment also that many people have heard about is that radio frequency ablation. Tell us more about that um and how does it differ from a nerve block?

SPEAKER_01 13:41

Well, let's first talk about what is radio frequency ablation. Essentially, we are using radio frequency waves, which gets converted into heat, and that heat is applied at a sensory nerve. A sensory nerve is a nerve that only conducts sensations, and pain is a sensation. We make sure that we differentiate sensory nerves from motor nerves or mixed nerves, which is a combination of sensory and motor. We only want to target sensory nerves because that is where the pain is generated. So, as I mentioned earlier on, let's say um the nerve that's causing facet-related pain is the source of the pain and muscle spasm. We can then place a needle in close proximity to that nerve and apply radio frequency ablation. This process will heat the nerve and think of it like we are jolting the nerve to stop it from conducting painful information to the muscles, thereby stopping muscle spasm. So that's in a nutshell, radio frequency ablation.

SPEAKER_00 15:11

Excellent. So when a patient comes into your office with chronic back pain, neck pain, joint pain, how do you determine whether it's a nerve block, an ablation, a spinal cord stimulator, or a pain pump? Which one of those um is the right approach? How do you determine that?

SPEAKER_01 15:29

Now, I have been very conservative in the way I, you know, talk to patients about treatment options. I always try to do the least invasive thing that works for the patient. So let's say we had a patient that had uh a herniated disc, for example, in the neck, and they have a lot of stiffness in the trapezius muscles, and they have a very difficult hard time sitting up straight because the neck muscles are all in spasms. I would first suggest oral muscle relaxants. Very often that's all that's needed because it may not be uh anything more than just muscle spasm. I might even tell them, hey, get some Epsom salts, put it in some warm water and stick your feet in it. Sometimes the magnesium and the Epsom salt will act as a muscle relaxant and reduce the muscle spasm. I may even advocate simple trigger point injections into the muscles to see if that will alleviate the problem. Now, for a lot of patients, simple treatment options will do the trick. But for other patients that may have neck pain with radiation down their arm, maybe some weakness in the fingers, then these patients may require an epidural. Of course, we would first get an MRI to ascertain the cause of the pain before advocating an epidural. Now, there are some patients who will get conservative treatment and injection therapy, and still they may have pain, uh debilitating pain. And at that point, I have no problems in referring this patient to be evaluated by a surgeon. Now, if the surgeon feels that this patient has no other options than to uh have surgery, for example, like a diskectomy, you know, I would be supportive of the patient if that's what they decided to do. Now, thereafter, let's say the patient has a surgery, continues to have uh back pain, I will still be very supportive. I still would follow the path of advocating least invasive type of treatment. And if that still doesn't alleviate the patient's pain, that's when I would consider things like peripheral nerve stimulators, radio frequency ablation, um, maybe a spinal cord stimulation if that applies to this patient's pain. And if all else fails and the patient is still needing to take pain pills for a protracted period of time, then this patient may be a candidate for a pain pump at that point. But I'd like to underline that I try to advocate conservative treatments first before escalating uh to more involved procedures.

SPEAKER_00 18:29

Yes, that's something that you've always talked about in all of our episodes. Um, one of the misconceptions patients have is that these procedures are somehow extreme or risky. Uh, what does the reality actually look like for most patients? Is that true?

SPEAKER_01 18:46

Well, you know, to be perfectly honest, any procedure, even if it's a very simple uh removing a hangnail from a toe or a simple biopsy, it might sound like it is simple, but there are risks involved. Um, sometimes certain procedures have more significant risks over 100,000 of these epidurals. So for me, in addition to being experienced in doing it, I also will evaluate the patient to understand if this patient would be at a higher risk for having this procedure. And I make it a point to have those discussions with the patient so the patient understands what the what significant risks are they taking before doing the procedure. And again, as I said earlier on, I always discuss with the patient risks versus benefits. What would be in the patient's best interest? And how are the ways that we can minimize the risks? So to answer your question in a few words, there are risks to procedures, but I feel that very often it is a calculated risk that the patient will take, knowing full well what their options are.

SPEAKER_00 20:13

Absolutely. And there's risks with everything that we do in life, not just medical procedures. So um even getting in your car and going to driving to the store, right? Um, there's always a risk in everything we do. But when you're under the supervision of a medical professional who is so experienced like you are, um, that's where I would want to put my put my risk if there was any. Okay, so next question, Dr. Nyer, can you share examples of conditions where targeted interventions have dramatically improved uh a patient's quality of life without major surgery?

SPEAKER_01 20:50

Absolutely. I'll start with the fairly simple conditions. Um, I've had patients that have severe knee pain. Mostly it is osteoarthritic. There can be a multitude of reasons why the patient has developed uh inflammation or arthritis in the knee. I do believe that conservative treatments using anti-inflammatories, sometimes oral, sometimes topical, they are very effective. If let's say those things don't work, then I would advocate for the patient to have a simple steroid injection in the knee. Now that can sometimes give about maybe two, three, four months of pain relief. And if the patient needs to have a second injection, I think that's still reasonable. Now, let's say that doesn't help, and let's say the patient decided to have uh surgery, and the initial type of surgery that they would be uh offered would be things like an arthroscopy, where they the orthopedic doctor will go in and clean up the cartilage and any other debris that's in the knee. Hopefully. That will solve the patient's knee problem. But if the knee pain continues, then there's the option of radio frequency ablation. That's an option, a very realistic option that can help the patient control knee pain. Now, I've had patients who have eventually ended up getting a knee replacement and they still develop chronic pain. There's technology now available called peripheral nerve stimulation, where we can identify the nerve that is generating this pain after the knee replacement has been done, and we can stimulate that nerve to reduce pain, which has been very, very effective. I've done this for countless numbers of patients who were taking a whole bunch of pain pills, uh, who were status post uh knee replacement with continued knee pain, and they all have done very well. So my biggest advice to patients is never give up, even if you have chronic pain, there are treatment options that are available. I think that as I keep mentioning, careful evaluation, identifying pain generators, and then offering patients realistic treatment options, taking into consideration the risk-benefit ratio. And I think the patients will never go wrong when they go when they follow this path.

SPEAKER_00 23:25

I love it. Okay, so tell me now, what surprises patients the most after they experience successful interventional treatment?

SPEAKER_01 23:34

Oh, I think the the most common thing that I hear my patients say is, Doctor, I wish I knew about this 10 years ago. I would have done this procedure, then go through all of the various things, various medications, various procedures that I have gone through in the past 10 years. That's what I hear most of the time. But in addition to that, I think that it is what is not said by the patient, and that is the smile on their face, the feeling that now there is some meaning in their life, the feeling that they can now spend more time with their family. And very often patients don't come out and say it. You can literally see that on their face, and you can hear that in the stories that they tell me about how they were able to go for their family members' wedding, or spending time playing Nintendo with their grandchildren, or going for a vacation, which they weren't able to do. So it's very often not something that's said directly to me, but it is the things that they're able to do after they get successful treatment.

SPEAKER_00 24:41

I love hearing that. Oh, that has to be such a great feeling, like you mentioned, to see smiles on their faces and hearing stories of them being able to do things that they couldn't in so long. So um, it's so wonderful that you're able to give patients that not only the freedom, but uh a complete different mindset shift and an elevated state of being uh through different treatments uh to help with their pain.

SPEAKER_01 25:04

Thank you.

SPEAKER_00 25:05

Any last words, Dr. Naira, before we wrap up today's episode?

SPEAKER_01 25:09

You know, as I said earlier on, I often tell patients always abide by the hope principle. Hang on, pain ends. So let that be the parting words. H-O-P-E, hang on, pain ends. We actually have that sign hanging in my office. Hang on, hope ends. And I think that that is such an important part of the treatment. Because I I have now realized after doing this for nearly four decades, is that healing, an integral component of that is having hope. Because when you're in chronic pain, hope is in short supply. And patients tend to ruminate about their chronic pain condition, very little room for light, very little room for hope. And so it's it's a downward spiral. And I often tell patients who are successful in having their pain controlled after getting treatment. I also tell them the importance of getting enough sleep, eating healthy, sharing fellowship with their family and friends, you know, improving their quality of life by sharing good moments and being available for their friends and family during bad times. Because all of that gives the patient, you know, a sense of purpose and it gives them hope. Pain management is not just addressing the painful condition, but addressing the entire person. And very often, chronic pain is not just about a single physical issue, it's a combination of various things, their mindset, their self-esteem, their sense of pride, all of that has to be addressed, and all of that has to be talked about. A lot of patients have difficulty in opening up about those things, but I think that that's all part and parcel of the treatment of pain, of the way to reduce pills, of the way to reduce unnecessary procedures. So I truly believe in that. And uh, you know, I wish that patients will give some mind to what I'm saying.

SPEAKER_00 27:19

Oh, I love that. And an acronym to close us out. Hold on, pain ends. Hope. All right. Um, well, thank you all for joining us for episode eight of the Kentucky Pain Reversal Show. One of the biggest takeaways from today's conversation is that pain care is no longer limited to a few broad options. Modern medicine now offers highly targeted treatments designed to address specific pain pathways, specific nerves, and specific conditions. For many patients, the challenge isn't that solutions don't exist, it's that they've never been told about them. So we need to lower the pills, lower the surgeries, and stop the pain. Dr. Nyer and I will see you in episode nine.