The Three R’s Of Chronic Nerve Pain Management

March 22, 2023 / Thomas Cohn, MD

Chronic nerve pain can range from mildly annoying to downright debilitating, and it’s not an issue that should be ignored. When working to treat an underlying nerve issue, your pain management specialist will likely pursue one of three treatment paths. Those three paths all begin with the letter “R,” and they stand for Release, Repair and Remove.

In today’s blog, we take a closer look at each of these three treatments options as they pertain to chronic nerve pain.

Release, Repair And Remove

If you are dealing with chronic nerve pain, your doctor will likely work to determine the root cause of your issue before recommending a treatment plan. Here’s a closer look at the three forms of treatment they will usually pursue:

Release – Release is almost always the first type of treatment plan for nerve pain. The goal of this type of treatment is to release the nerve from whatever impingement is causing it to relay a pain signal to the brain. Oftentimes this involves a combination of conservative treatments that aim to strengthen an area, calm inflammation or take pressure off the nerve root. Common release techniques include stretching, exercise, physical therapy, anti-inflammatory medications, posture improvements and weight management. If the nerve cannot be released with conservative methods, a surgical decompression may be performed.

Repair – If you have suffered an acute injury, or your nerve discomfort begins in the wake of a surgical procedure, there is the possibility that a nerve has been severed or damaged. A surgeon can help to repair a severed nerve by sewing the broken ends back together, or by conducting a nerve transfer if the ends are too damaged to be sewn back together. Once the nerve is surgically repaired, the body will begin to adapt to this restored connection and pain sensations should fade over time, but additional conservative techniques may be pursed as well for best results.

Remove – Finally, if the nerve is damaged and it has not responded to release techniques and it cannot be repaired or it’s unlikely to respond to a repair operation, your doctor may recommend that the nerve be excised. Removing the damaged nerve will stop it from sending pain signals to your brain, but you may notice some numbness or a lack or sensation in that location once the nerve is removed. Nerves can repair and grow back, so your doctor will monitor the area over the next few months and years to see if symptoms remain controlled or if they begin to return.

The good news is that most nerve issues respond well to conservative or operative release techniques, so all you may need are a few small adjustments to get back to a life without nerve pain. If you’re experiencing nerve pain and you want to talk to a pain management specialist about your options, reach out to Dr. Cohn and his team today at (952) 738-4580.

New Technologies For Pain Management

August 19, 2019 / Thomas Cohn, MD

Medicine is evolving as electronic technology invades all aspects of medical care, and pain management is no exception. The areas that have changed the most are imaging technology and implantable devices. What is interesting to patients is how imaging can improve care and implantable devices may help when nothing else is working. The improved imaging makes diagnostic and treatment decisions easier and also makes interventions more precise when tied to management by an astute clinician. No matter how good the technology is, without the skill of a good clinician to understand the medical problem, no solution would be helpful.

The new implantable technology available is peripheral nerve stimulation. This is designed for treatment of pain that is related to damage to a peripheral nerve, such as in the arm or leg. Pain can often be traced to an isolated nerve and preventing that nerve from propagating the pain signals helps to control the problem. These pain issues arise sometimes after amputations with phantom pains, and can be seen after trauma when nerves are damaged. These problems can also occur with surgeries like joint replacements, orthopedic interventions, spinal operations and some fractures. When the pain is not resolving and an isolated set of nerves can be found and successfully blocked with local anesthetic, then nerve stimulation may be appropriate. This is a treatment to consider when simpler interventions like medications, physical therapy, and injections have not been successful.

Nerve Stimulation For Pain Management

The idea of peripheral stimulation has been around for a long time. In the distant past, traditional spinal cord stimulators were used for peripheral nerve stimulation. Unfortunately, at some point this began being abused and since those systems were extremely expensive, this process stopped. In the last two years, new systems have been designed specifically for peripheral nerve stimulation that are very technologically advanced and effective.

One example is electrode stimulation. The electrode is a very thin wire coated in silicone that can be delivered to the right place along the specific nerve with a needle guided by ultrasound imaging. The wire contains a special signal receiver that can be used to help stimulate the nerve and drown out pain signals. Most importantly, the signal generator is now a very small rechargeable unit that is placed on the skin over the end of the electrode. In the near future the electrode may connect even further from the generator such that it may be able to be carried in a pocket or other safe place.

The new technology is FDA approved for peripheral nerve pain from any type of nerve injury. The easiest insurance approval is Medicare, but other providers are starting to approve of such treatments when proven simpler treatments have failed. There currently are at least two manufacturers of equipment, the difference appears to be mainly in the generator’s ability to deliver a variety of signals that may effectively block pain signals and not be uncomfortable to the patient. From experience developed in spinal cord stimulation, the electrical signals can be varied such that the nerve pain is blocked but the patient does not feel any other odd sensations. The net effect is that one can perform activities that were once painful without the ongoing sense of pain.

For pain patients, this new technology is nice since the only thing implanted into the body is a thin wire to the appropriate location. Testing prior to implant is first by a local nerve block with a long lasting anesthetic. If that is successful, than a trial implant can be done for a week or longer to determine if a final implant would be indicated. The permanent implant is a brief outpatient procedure and can be easily removed in the future if necessary.

Pain patients who may benefit from peripheral nerve stimulators include those where pain symptoms have a definite peripheral nerve origin and the pain can be extinguished by blocking just one or possibly two nerves that are nearby each other in the body. The first problems that have been treated have been pain related to shoulder injuries that do not resolve with surgery. Other common orthopedic problems include knee and foot pain after trauma or other surgery with nerve damage or nerve pain afterwards. Amputation phantom limb pain and complex regional pain syndrome are other pain problems that may benefit from this technology. An interventional pain specialist who does implants should be able to help determine if the pain problem may be helped with such treatment. Not all pain problems can be helped and if the pain is coming from multiple pain generators or is centrally generated in the brain, this treatment is less likely to be helpful.

Can You Just Cut Those Painful Nerves?

February 19, 2018 / Thomas Cohn, MD

A common question from patients with pain is whether someone can just cut the nerves that are causing pain or otherwise destroy them. There are a few cases where this is done, but it is limited since most nerves in the body carry motor and sensory functions and cutting them would leave a person weak wherever that nerve controls a muscle.

The loss of muscles would also produce pain or sometimes the nerve then short-circuits and becomes even more painful. This is common in amputations where the nerves that are cut cause odd pains and phantom sensations. However, there are some special situations where we can damage the ends of sensory nerves in isolation to treat certain types of pain.

Nerve Control and Pain

The most common times where nerve endings are purposefully destroyed are for facet joint pain. On each side of the spine at every level there is a joint between the bones known as the facet joint. In the cervical and lumbar levels they are very mobile, but they also support a significant amount of weight from our head and bodies. These joints are almost identical to your finger joints in size and function but they have significantly more weight going through them. Pain from these joints in the neck have well defined patterns for head, neck and upper back pain. This is also the typical pain seen in a whiplash type injury.

In the low back, the pain is usually just along the spine or into the buttock area. The thoracic region rarely produces joint pain due to the ribcage providing support and restricting motion. When facet pain is unresponsive to other conservative treatments like medications and physical therapy, blocking the medial branch nerve to the joint with anesthetic will determine if the joint is the cause of the symptoms. If it is successful, we can use a special needle and machine to create a microwave signal at the tip of a needle and cut the very end of the nerve away from the joint to relieve pain for about a year. Since this is the terminal end of the nerve and not its cell body, the nerve ending will regrow and re-innervate the joint.

In the rest of the body there are very few safe places that only a sensory nerve travels separately from a motor nerve. For example, the knee joint is another place where doctors are trying to sever the sensory nerves. The technique is similar to the one used for the facet joints but the locations of the appropriate nerves are somewhat variable and a much larger lesion is needed to be successful, and it often only works for six months. There are other techniques for knee pain including the use of specialized hyaluronidase (rooster cone); a compound that stimulates joints to produce their own fluid. Another possible better treatment in the future will be the use of stem cell injections, since this may allow the joint to regrow more normal joint tissue. At this time it is not covered by insurance, is somewhat costly ($5,000/treatment) and is successful about 50% of the time.

Cutting Sensory Nerves

There are very limited other places and times when sensory nerves are attempted to be cut. Sometimes for rib pain or pelvic pain that does not respond to any other simpler management, the nerves can be frozen using a special machine. Localizing the nerves that cause this pain may be very difficult, and the success is around 50 percent. Pain relief again is about six months. In a few special circumstances, nerves are cut as part of surgery, like during amputation or certain reconstructive surgeries, especially after trauma. The problem with cutting nerves in amputations is phantom pain, where pain is felt by the brain in an area where a person no longer has an extremity.

Pain is a complex process that occurs in the body. Simply cutting a nerve to rid the body of pain usually causes more problems with pain and additional possibility of loss of muscle function. Nerves sometimes can be cut for certain types of spine joint pain, but there are very few other places in the body where a similar technique can be used successfully. If pain is a significant problem, asking a pain physician about the variety of options available for a particular issue may be the best plan.