Comprehensive Care: Chronic Pain as a Complex Syndrome

By | November 19, 2012

Pain can be treated at any point from the periphery to the spinal cord and up into the brain, but the efficacy and side effects will be different.

In our search for the best pain clinic in Los Angeles we have spoken about comprehensive care a number of times, but we have never looked at why it may be more important in the treatment of pain than in other conditions. That pain is a multifaceted problem seems almost to simple to be worth mentioning, but in fact, it is the critical starting point. Because pain signals can be generated by almost any organ in the body and by the central nervous system itself, it should be obvious that any single approach is unlikely to be universally applicable. Once generated these pain signals must be transmitted to higher centers where they are interpreted. The treatment of pain can occur at any of these steps and in general the earlier the pain signal is treated, the more successful the treatment will be and the fewer the side effects. As an example let’s look at the possible treatments of the pain from lumbar spinal stenosis. Here pain signals are generated by the nerve roots within the spinal canal in response to direct compression. The simplest approach is the injection of corticosteroids to decrease inflammation at the site of the nerve root (lumbar epidural steroid injection, LESI) stopping the generation of pain signals altogether, however in cases of severe spinal stenosis the injections of steroids may be helpful, but inadequate. The most direct and effective treatment is surgical decompression of the lumbar spine via lumbar laminectomy or other procedure, but many patients are not candidates for this surgery due to age and poor general health. When direct treatment fails, relief can often be obtained via neuromodulation using either an intrathecal drug delivery system (IDDS) or a spinal cord stimulator (SCS). Here the goal is to decrease or modulate the transmission of painful impulses up through the spinal cord. The main drawbacks of this approach are that while highly effective in mild to moderate cases, in cases of critical spinal stenosis they may prove inadequate and that while less invasive than lumbar decompression, they still require the surgical implantation of a pain pump or stimulator. Finally we can modulate the interpretation of painful stimuli in the brain, using a variety of drugs, such as narcotics, antiepileptics and antidepressants. It is important to remember that we are not really treating the pain, but rather the patient’s response to it. If these patients are questioned carefully they will almost always report that the pain is still there, but it bothers them less. While completely noninvasive treating pain at the level of the brain usually has the greatest number and severity of side effects. It should be clear that the best pain clinic in LA would consider all of these options and more and that any clinic that can’t is clearly inadequate.  At Schlesinger Pain Centers our commitment to comprehensive care is unconditional.


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