Am I a Candidate for Nerve Pain Treatments?

Injections, blocks, and ablation can relieve pain and delay or prevent surgery.

There are many treatments for nerve pain—anywhere from aspirin to invasive surgery. In between these extremes are interventional treatments such as joint injections, nerve blocks, and ablations, which can provide at least 50% pain relief for months at a time and help many people avoid surgery. They are performed by specialists who have training in interventional pain medicine.

When Should I Consider Nerve Treatments?

People who have had nerve pain for three months and have tried conservative treatments like physical therapy, over-the-counter pain relievers, and prescription medications, such as gabapentin, pregabalin, or duloxetine, may be candidates for interventional nerve treatments, says Corey Hunter, MD, founder and executive director of the Ainsworth Institute for Pain Management in New York.

The best candidates, says Dr. Hunter, are those who are motivated, who understand that in many cases the exact cause of the pain may never be identified, and who are willing to undergo trial-and-error to ascertain which nerve(s) is/are communicating the pain. Perhaps most important is that the patient has realistic expectations and goals for treatment. Average success for these treatments is a 50% reduction in pain that lasts for at least six months and improvement in overall function.

“In an ideal world, patients would come to us eight to 12 weeks after the onset of their pain,” says Dr. Hunter, “but they often don’t seek interventional treatment for two to three years.”

Unfortunately, many patients don’t know about interventional pain management and only find out about it after they’ve already been exposed to narcotics by other physicians who simply don’t know any better,” he says (see “Opioids Are Not for Nerve Pain” below).

Editor’s note: While most pain management physicians are familiar with interventional treatments and can make a referral based on your case, or even offer interventional treatments as part of a pain management clinic, not every provider may understand the benefits of or options around interventional medicine.

Your doctor can offer the best insight and determine which nerve treatment may be the best fit for you. (Image: iStockPhoto)

What Are Nerve Treatments?

Nerve treatments target the suspected nerve or bundles of nerves that are believed to be causing and/or communicating your pain. The three basic types of nerve treatments are:

  • Injections—these deliver anti-inflammatory medication, such as a corticosteroid, to the nerve in an attempt to reduce swelling in or around the nerve
  • Blocks—these deliver local anesthetic to the nerve to block pain signals in an attempt to localize the nerve(s) involved in the condition
  • Ablationthis procedure intentionally damages or disables a nerve so that it is no longer able to send pain signals to the brain. Ablation may also be called rhizotomy, neurolysis, or neurectomy.

Injections

Yes, injections involve a needle, which some patients would rather avoid. Fortunately, the procedure is quick. Injections have different names based on the part of the body they are treating. For instance, cervical epidural injections treat neck pain while lumbar epidural injections treat low back pain and/or sciatica.

“These injections are usually the starting point for many conditions and often required by insurance companies before more sophisticated treatments can be initiated,” says Dr. Hunter. “In some cases, injections can be definitive treatments—reduce the inflammation or swelling and the pain is gone for good.”

In most cases, however, whatever is causing the inflammation to begin with will still be present and simply create more once the effects of the cortisone are gone. “Ideally, an injection with corticosteroid (cortisone) will last for three to four months, at which point it can be repeated again,” says Dr. Hunter. The general rule is that three cortisone injections can be given to a certain area within 12 months.

Probably the most recognized nerve injection is the epidural, which is often performed during childbirth. Dr. Hunter notes an important distinction: “The ‘epidural’ performed for childbirth is meant to block all sensation below the waist to dull the pain from the passage of the baby, whereas an epidural for pain simply reduces inflammation without affecting sensation or movement.”

Nerve Blocks

Nerve blocks, which are also a type of injection, are frequently used in the field of pain management as a diagnostic tool, much the way one would use an x-ray or electrocardiogram, to localize the source of pain or determine how the pain is getting to the brain, says Dr. Hunter.

Ideally, a nerve block will consist only of a local anesthetic such as lidocaine (lasts 45 to 60 minutes) or bupivacaine (lasts six to eight hours). Many times, physicians will include a small amount of a corticosteroid called dexamethasone in an attempt to prolong the effects of the anesthetic for several more hours. A bonus to adding this medication is that, if there is local swelling, the procedure can become therapeutic as well.

Nerve blocks are outpatient procedures that take about 30 minutes. They follow this basic process:

  1. The skin around the injection site is cleaned, and then numbed with an anesthetic.
  2. Using imaging—either ultrasound, fluoroscopy, or CT—as a guide, the doctor inserts the needle and injects the medication.
  3. If the block is being performed for diagnostic purposes the doctor will ask if it has reduced your pain and for how long.
  4. You’ll have a short recovery period before going home.

Pain originating from different areas of the body require different nerve blocks. Examples include:

  • Celiac plexus block for abdomen, flank, and cancer-related pain
  • Cervical medial branch block for neck pain
  • Ganglion of impar block for pelvic and buttock pain, pudendal/genital neuralgia
  • Hypogastric plexus block for pelvic, genital, and rectal pain
  • Intercostal nerve block for chest wall pain, post-surgical pain, post-herpetic neuralgia
  • Lumbar medial block for back pain
  • Sympathetic block for complex regional pain syndrome (CRPS)
  • Occipital nerve block for migraine headaches, cluster headaches, and headaches
  • Sphenopalatine ganglion block for facial pain, trigeminal neuralgia, and headaches
  • Stellate ganglion block for pain in the head, neck, and upper extremities

Dr. Hunter says that the block he most often performs is the medial branch block. The medial nerves convey pain from the facet joints in the spine, which are the joints you feel when you crack your neck or crack your back. “These nerves are very easy to treat, and by blocking them you can block the pain signals coming from those joints and largely decrease back pain or spine pain,” he says.

The medial block is usually followed by an ablation (read more below), which can extend the pain-relieving benefit up to 18 months, Dr. Hunter says.

Nerve block injections essentially "turn off" a pain signal in nerves, reducing inflammation. (Image: iStockPhoto)

Ablation

A nerve ablation involves the destruction or disabling of a nerve or portion of a nerve to prevent it from transmitting pain signals. Once the affected nerve has been pinpointed by the nerve block procedure (describe above), what typically follows is an attempt to extend the relief created by the block, says Dr. Hunter. This trial can be accomplished in a number of ways: cryoablation (ice), thermal ablation (heat), pulsed ablation, alcohol or phenol (to chemically destroy the nerve). Pain relief can last for several months and help patients avoid surgery.

An ablated nerve will grow back over time at a rate of about 1 millimeter a day, says Dr. Hunter. When the nerve comes back, often the pain comes with it, at which point the ablation can be repeated. “A lot of patients are stable on these and will get an ablation about once a year,” he says. “It’s a good alternative to getting an invasive spine surgery like a fusion.”

Radiofrequency Ablation

Also known as RF, RFA, rhizotomy, or neurotomy, radiofrequency ablation is the most commonly used form of nerve ablation. Using a special needle called a canula, radiowave-based energy is delivered to the tip, which is converted to energy at the level of the target nerve. This energy causes friction in the tissue—if a nerve is caught within this area, it will then be stunned and rendered unable to transmit pain signals which in turn equals pain relief, says Dr. Hunter. The procedure steps are similar to the nerve block.

Radiofrequency ablation can be used to treat:

  • Back pain
  • Complex regional pain syndrome (CRPS)
  • Disc pain
  • Headaches and facial pain
  • Knee pain
  • Hip pain
  • Shoulder pain
  • Neck pain
  • Pelvic pain
  • Peripheral neuropathy
  • Sacroiliitis
  • Spondylosis (arthritis of the spine)
  • Trigeminal neuralgia

New Ablation Options for Knees, Hips, and Shoulders

Newer types of ablation procedures—genicular nerve ablation (knee), femoral/obturator ablation (hip), and suprascapular ablation (shoulder)—are being used to treat joint pain and in theory could delay or even take the place of knee, hip, or shoulder replacement surgery, says Dr. Hunter.

Genicular nerve ablation, also known as genicular neurotomy, is a minimally invasive procedure that targets the nerves in and around the knee that communicate pain. “You can do this procedure for someone who doesn’t want a knee replacement. You can do it for a person who’s had a knee replacement and still has pain,” says Dr. Hunter.

Similarly, a hip ablation is performed on the sensory articular branches of the femoral and obturator nerves to treat hip joint pain. Another easy nerve to access and ablate is the suprascapular nerve which, among other things, transmits pain signals from the shoulder.

These treatments are welcome options for patients who do not wish to undergo joint replacement surgery or simply may not be candidates for it due to morbid obesity, diabetes, or severe heart disease.

The beauty of the knee and hip ablations is that they ablate the nerves that control pain only. The shoulder, or suprascapular, ablation is somewhat trickier because this nerve also controls motor function, Dr. Hunter says.

The pain relief typically lasts for a year to 18 months.

Be a Partner in Your Pain Treatment

As noted, these treatments work best on patients who are motivated and participate in their health care. Dr. Hunter adds that interventional treatments should be part of a multidisciplinary, multimodal plan. He gives the example of a patient who receives an epidural injection for back pain. “I’ve gotten rid of your pain for now, but I want you to take care of yourself. I want you to do yoga and pilates and make your core better so it doesn’t come back.”

Your nerve pain may require combining a nerve treatment with physical therapy, prescribed exercises, and perhaps mental or behavioral therapies and medications.

Have a conversation with your doctor about your pain and whether an interventional nerve procedure will work for you.

Opioids Are Not for Nerve Pain

Pain specialists do not advocate using opioids for nerve pain, notes Dr. Hunter.“Opioids don’t work for neuropathic pain. They work for what we call nociceptive pain,” he says.

Nociceptive pain comes from an injury outside the nervous system to things like bones, tendons, muscles, ligaments, and joints. This pain can be described as aching or throbbing. “This is the pain you have from a car accident, bruise, or broken bone—opioids work on that,” Dr. Hunter explains.

Neuropathic pain, or nerve pain, comes from an injury to a nerve, the spinal cord, or even the brain itself. Nerves are responsible for transmitting signals from the body to the brain. When a nerve is damaged or not working properly, its ability to transmit that signal becomes hindered—much like static on a phone line due to a frayed telephone cord, Dr. Hunter says. The brain does not know how to interpret this static so it may be perceived as numbness and tingling in mild cases or pain in more severe cases.

Nerve pain feels very different from nociceptive pain. People will typically describe the pain as burning, stinging, or shooting. The pain may radiate from one part of the body to another along the path of the injured nerve, and it may be accompanied by numbness and tingling.

The most commonly used medications for neuropathic pain are membrane stabilizers and anti-depressants. The membrane stabilizers include medications like gabapentin and pregabalin, which are technically anti-convulsant medications (although they are not used for this purpose). Damaged nerves have the tendency to send irregular signals and “fire” excessively; these medications slow this excess firing down and stabilize the nerve, explains Dr. Hunter. Duloxetine and tricyclic antidepressants (TCAs) are known to affect the levels of serotonin and norepinephrine, which have been proving to be effective for nerve pain, he adds.

The Problems with Opioids and Nerve Pain

In the long term, current research does not show whether opioids are better than placebo for neuropathic pain. One reason some individuals may experience benefits from opioids for neuropathic pain is because the medications are euphoric. A patient may “feel so good from the opioid that the pain just doesn’t bother them as much,” explains Dr. Hunter.

In addition to opioids’ known adverse reactions and potential for addiction, “Studies have shown that people who are on opioids do not respond as well to certain pain treatments,” says Dr. Hunter. “Once a patient develops an addiction or dependency on the opioids, it’s no longer clear whom you are treating—the patient in pain or a potential addict who needs more medication to fuel a growing habit.” Opioids should not be considered in neuropathic pain until all other conservative treatments have failed, he concludes.

Updated on: 06/04/20
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Regenerative Medicine for Joint Pain and Injuries
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