by: Dr. Michael A. Castillo
Dr. Castillo’s thoughts about intrathecal pain pump management for treating back pain after surgeries. Intrathecal pain pump management is a proven safe and effective therapy for managing chronic pain.
I send a lot of patients for surgery (We are working to heal the spine with our regenerative medicine practice. That is a different topic for a different Sunday.) There are patients in danger of hurting a nerve in their spine which allows them to function. The purpose of surgery is to fix a problem with the spine and stabilize the spine. Some people have no back pain after surgery, and we don’t talk about these outcomes. A lot of people are not so lucky. I tell all my patients, “Surgery is to fix pathology. Surgery is not to fix pain”. Most spine surgeons now warn patients before surgery there is a great possibility of pain after surgery. Many times, spine surgeons do not have a plan to deal with the pain.
Intrathecal Pain Pump Management (IPPM) is an underutilized therapy in America. It is usually considered the last-ditch hope for controlling pain after: 1) deal with the pain, 2) oral opioids and other medications, and 3) Spinal Cord Stimulation. Hear is my take on each:
Deal With It: It is not as common now, but it is still there. The surgeon states there is no problem with the surgery (And there probably wasn’t a surgical problem). The pain will get better. It will take three months. It will take six months. It will take a year. There is nothing else I can do. You need to work with a pain physician. In most Workman Compensation Cases a patient is allowed to see a pain physician four times a year to get pain medications. Pain is not that simple. Each patient is different. Your pain is your pain. If it affects your life it is a medical problem and, “deal with it,” is not a proper response.
Oral Opioids and other medications: A lot of patients are on at least one medication, an opioid like morphine. Pain can effect blood pressure and diabetes medications. Most patients require additional medications. These can be muscle relaxants, nerve meds (gabapentin or pregabalin), anxiety meds, and sleep meds. Some people need all these. Some patients are suffering because there are new limitations put on by our government (Federal and State) because of the opioid crisis. The question is do these medications have side effects? They do. They all work on the brain to sedate parts of the brains so patients can cope with their pain, but not relieve it. What doctors don’t know are the long-term effects on the brain and the body. We wean all patients of medications; everyone states they didn’t know the extent of the fog they were living in.
Spinal Cord Stimulation (SCS): Every pain physician and stimulator company can show a study where SCS works for a year. A number of years ago, we did a study for the office. We tapered patients off their meds and trialed patients on SCS and IPPM. We were going to do ten. We could have stopped at five, but we stopped at eight. All eight choose IPPM. SCS physicians stated SCS was never supposed to be a stand-alone therapy; it was meant to help oral opioids and other medications.
IPPM is not just another way to give opioids. IPPM therapy manages pain at the spinal cord. The only side effect is like oral opioids in it may depress breathing at night. It is not a perfect pain control system, but the perfect system does not exist. With IPPM therapy the goal is to get the patient to a manageable pain. That means to some patients being able to go out to eat, travel, or do outdoor activities. A one week trial tells us if IPPM can be a possible treatment option. IPPM works in over 80% of our patients. I think it needs to be discussed before some spine surgeries.