1. INVASIVE PAIN MANAGEMENT METHODS FOR CHRONIC NONCANCER PAIN
Nevenka Krcevski Skvarc
University Clinical Centre Maribor,
Maribor, Slovenia

2. INADEQUATE CHRONIC PAIN TREATMENT
Percentage of chronic pain suffers who reported
that their pain is inadequately controlled in 16 countries
Breivik et al., EJP 2006;10:

3. Interventional Therapies
Diagnostic blocks
Epidural steroids
Radiofrequency technigues
Neurostimulation
techniques
Neuroaxial
medication
ADJUVANT ANALGESICS + PATIENTS EDUCATION

4. INTERVENTIONAL TECHNIQUES IN THE MANAGEMENT OF CHRONIC PAIN
MINIMALLY INVASIVE PROCEDURES
injections of drugs to target areas
ablation of targeted nerves
implantation of intrathecal infusion pumps
implantation of spinal cord stimulators
some surgical techniques (IDET, annuloplasty, nucleoplasty)

5. EVIDENCE BASED GUIDELINES FOR INTERVENTIONAL PAIN MEDICINE
EFNS guidelines on neurostimulation therapy for neuropathic pain.
Cruccu et all. Eur J Neurology 2007;14:
Polyanalgesic consensus conference 2007: recommendations for the management of pain by intathecal (intraspinal) drug delivery: Report of an interdisciplinary expert panel.
Deer et al. neuromodulation 2007;10:
Evidence-based guidelines for interventional pain medicine according to clinical diagnoses.
Van Kleef et al. Pain Practice 2009;9:
Evidence based medicine. Trigeminal neuralgia.
Van Kleef et al. Pain Practice 2009;9:252-9.
Comprehensive evidence-based guidelines for interventional techniques in the management of chronic pain.
Manchikanti et al. Pain Physician 2009;12: 699 (in press).

6. RADIOFREQUENCY TECHNIQUES
The use of high frequency electric current
to produce controlled thermocoagulation
Sweet and Wepsic, 1974 (Gasserian ganglion)
Shealy, 1975 (spinal pain)
Sluijter and Mehta, 1981 (needles)
Sluijter, 1998 (pulsed radiofrequency) RF

7. NEUROMODULATION TECHNIQUES
neurostimulation with “electicty”:
SCS, PNS, ONS, DBS, MCS
Chemical neuromodulation:
neuraxial delivery of medication

8. WHICH PATIENTS FOR NEUROSTIMULATION AND WHEN?
confirmed diagnosis of NP
chronic disease with intractable pain in spite of pharmacological/physical treatment
unresponsible for conventional treatment at least 1 month for each modality
psychological evaluation
positive response to trial (50% and more pain reduction)

9. INDICATIONS FOR NEUROSTIMULATION AND ITDD

10. SCS MECHANISMS IN NEUROPATHIC PAIN

11. SCS SUCESS RATE FBS 50%-70% PNP 60%-80% CRPS, DPN PVD 70%-80%
IAP > 80%

12. SCS POSITION IN THERAPEUTIC STAIRCASE
EVENTUAL
LESIONAL
TECHNIQUES
MORE INVASIVE
NEUROMODULATION
TECHNIQUES
OPIOIDS
SCS
ANTICONVULSIVES
ANTIDEPRESANTS
TENS

13. safety/complications,
ITDD INDICATIONS
malignant pain (1982)
nonmalignant pain (1997-8)
opioid dose limiting side effects
OIH and narcotic tolerance ?
improvement of function ?
Drug choice:
knowledge on:
the mode of action,toxicity,
clinical data on:
safety/complications,
efficacy,
dosing,
co-administration
Knowledge of neurophysiology

15. LIMITATIONS FOR THE USE OF INERVENTIONAL TECHNIQUES
resources
staff and time
knowledge and expierence
policies

16. COST EFFECTIVENESS OF SCS
Kumar et al.Neurosurgery 2002;51:

17. QUALITY SYSTEM FOR NEUROMODULATORY TECHNIQUES
The development of a quality system for neuromodulation in the Netherlands. Neuromodulation 2005;8:28-35.
TREATMENT PROTOCOL
Intake of patients
trial stimulation or administration of drugs
implantation of permanent system
control phase
QUALITY INDICATORS
pain reduction
complication registration
adverse events registration
number of revisions
battery life
functionality scale
dropouts
quality of life
patient satisfaction

18. INTERVENTIONAL PAIN MEDICINE IN SLOVENIA
RF beginnings in eighties but did not develop
decennia of ITB
last 5 years SCS and DBS
recent efforts for other ITDD and RF
Main problems:
cost
knowledge and licenced stuff
health policy
Consilium on Neuromodulation in Slovenia, 2008
Prof.dr. Milan Gregorič, dr. med.,
Asist. mag. Nevenka Krčevski Škvarč, dr.med.,
Prof. dr. Roman Bošnjak, dr. med., Asist. dr. Aleš Pražnikar, dr. med.,
Prof. dr. Tadej Strojnik, dr. med., Asist. mag. Klemen Grabljevec, dr. med.

20. INTERVENTIONAL TECHNIQUES IN PAIN MANAGEMENT
interventional pain management techniques have undergone a rapid evolution over the last decennia and have gained a definite place in the management of chronic pain syndromes
implementation should be guided by the best avaliable evidence on efficacy and safety with respect to the diagnosis of the individual patient
need for correct application, good theoretical knowledge and practical expierence
implementation of quality system will contribute to acceptance in national health policy and better management of chronic pain