AUAA… Episode 32 – Pain Management – Penn State Health Milton S. Hershey Medical Center

>> From Penn State Health welcome to Ask Us
Anything about Pain Management. I’m Scott Gilbert. Chronic pain is the number one cause of long-term
disability in the U.S. and if chronic pain affects you you’re not alone. It affects some 100 million Americans. So we’re here to talk today about the causes
of chronic pain and perhaps even more importantly how it’s treated, some of the different treatment
options out there. And here to help us do that is Dr. Michael
Sather. He’s a neurosurgeon here at Penn State Health
Milton S. Hershey Medical Center. Thanks for your time today. I appreciate it. >> Thank you, Scott. >> I want to talk a little bit about what
defines chronic pain because it seems that we all experience pain at some point but it’s
typically transient, it’s not something that sticks around for a matter of months, right? >> That’s correct. So there’s acute pain, which is what all of
us have experienced. That’s if you stub your toe, cut your hand,
and then there’s chronic pain. So acute pain is sort of the short-term pain,
chronic pain is this long-term pain. So typically we define that as more than three
months of pain. >> And pain, people might think why is it
necessary, but it actually does serve a function, correct? In terms of maybe signaling a problem? >> The acute pain serves a function. The chronic pain is sort of this abnormal
cascade that you get that keeps that sort of pain continuing. But the acute pain is important because it
let’s us know that we’re doing something that’s harming our bodies such if we have our hand
on a hot stove, lets you to know that you need to take it away so you don’t burn your
hand. >> And so let’s talk about the chronic pain
component and what’s going on. I don’t want to get science here, but a little
bit. I want to look a little bit inside the body
and for you to tell us what’s happening inside the body, especially the brain. You know, it’s about signals and electricity
isn’t it? >> Yeah, that’s correct. So a metabolic study called a PET scan kind
of looks at the uptake of different substances in the brain and so it’s looking at active
areas in the brain. We know from those studies that acute pain
activates different areas in the brain than a chronic pain. There’s something about chronic pain where
this is an abnormal cascade between the nerves, the spinal cord, and the brain. >> You’re watching Ask Us Anything about Pain
Management from Penn State Health. I’m Scott Gilbert alongside Dr. Michael Sather. Throughout the course of this conversation
whether you’re watching it live or on playback we welcome your questions. Just add them to the comment field below this
Facebook post and we’ll make sure that we get an answer for you, again either during
this live interview or we’ll answer in the comment field for you. And if you like this content feel free to
share it so that more people — so we can reach more people with it. You know, Dr. Sather, I’m curious about the
most common causes of chronic pain because it really is a very broad category. I mean it can affect pretty much any part
of the body correct? >> Yeah, that’s correct. Probably the most common cause of chronic
pain is actually back pain and that’s certainly a lot of what I see in my practice. Then there’s nerve related pain, all kinds
of different nerve conditions that we’ll get into. Arthritis pain, so there’s lots of different
chronic pain syndromes. >> Sure, so a lot of different potential causes. I imagine a lot of different potential treatments,
right? >> That’s correct, yeah. I mean first and foremost is of course medical
treatment and then moving on forward to injections, physical therapy, things like that. And then surgical aspects of treatment is
sort of reserved for people to fail all those other treatments. >> So we think about pain as a physical condition,
but it also affects somebody’s mental well-being because knowing that you’re saddled with that
pain, that you can’t escape it. It follows you everywhere. I imagine that has mental health implications. >> Yes, it does. I mean there’s a big interplay of psychosocial
factors with chronic pain so we know a lot of patients with chronic pain suffer from
depression or anxiety that goes along with it and that’s very common. Also there’s stress on the family because
of stress at work, money concerns, divorce, things like that. >> So we’re doing an interview here that’s
going to run about 10 or 15 minutes. Obviously it’s hard to go into great depth
on anything in particular, but I do want to talk about some of those treatments that you
mentioned earlier. Medical treatment is one option for chronic
pain. When is medical treatment usually the right
option? >> It’s usually the first line there will
be after physical therapy. So you’re looking at anti-inflammatories,
you’re looking at medications that affect the nervous system like gabapentin or Neurontin,
Lyrica, medications that are directed towards trying to help the nerve pain that are non-narcotics
and then you’re getting into some narcotic medications as well. So that’s kind of — medication is sort of
one of the first line treatments. >> And so we are hearing a lot in the news
lately about opioids and that type of thing. Are there are concerns, do you hear concerns
and do physicians in general hear concerns about going on medication long term as a treatment? >> There’s concerns for a long term treatment
especially with narcotics because of the effects of narcotics especially with tolerance development
over time. And what we know for at least nerve related
pain is that narcotic medications often are not effective and so when narcotic pain medications
are used to treat neurologic conditions or nerve related pain, what we find is that there’s
this continued increase in pain medications trying to find this dose that works when actually
it’s just not effective. >> You’re watching Ask Us Anything about Pain
Management from Penn State Health. I’m Scott Gilbert alongside Dr. Michael Sather. He’s a neurosurgeon here at Penn State Health
and welcomes your questions again whether you’re watching the video live or on playback
just add them to the comment field and we’ll get you some answers here. And also feel free to share this video as
well. And we’re talking about treatment of pain,
especially chronic pain. We were just talking about medical treatment. Are there times when physicians feel like
they’ve exhausted all the options medically and need to look at procedures and kind of
go beyond the medicine? >> So yes, so then typically the next step
would be injections with a pain physician. And then moving on from there with failure
of injections it’s consideration for if it’s nerve related pain considering a procedure
to be called neuromodulation, which is using electrical stimulation either of the spinal
cord or of a nerve to story of modulate the effect of the chronic pain cascade to minimize
nerve related pain. >> And so spinal cord stimulation is a relatively
common approach in that regard, right? >> That’s correct. So spinal cord stimulation actually has been
around for about since the 1970s. Certainly more advances now compared to back
in the 1970s but initially it started around the 1970s. >> So tell me about what that involves. Does it involve actually implanting something
inside? >> So yes, so there’s two parts to this. There’s the electrical generator itself, which
is the battery pack. And then there’s the lead, which is basically
the electrical wire. It’s how the electrical signals get to the
spinal cord. So there’d be an electrical cable or lead
if you will that’s placed in the spinal canal. So if I show you a little model here. >> Sure. >> So typically for spinal cord stimulation
you’re looking at a spine model here and this is the back part of the spine here and you
can see that those back parts of the spine shingle. And there’s this little space in between at
each level. And up in here, inside here is the spinal
cord. We make a little opening in there and place
the lead in and then it gets connected to that battery pack. And so it’s delivering electrical signals
directly to the spinal cord. >> And what is the result then? What generally happens? Does it negate some of those electrical signals
or what’s happening inside the body there? >> Yeah, on average you can get about a 50
to 70 percent — in 50 to 70 percent of patients you get about a 50 percent reduction in pain. >> So it’s not 100 percent. >> So it’s not 100 percent correct. It’s not a cure for pain. It’s not going to make the pain go away completely. But it’s improving the quality of life to
mitigate some of those psychosocial aspects and it’s effect on the lifestyle and work. >> It’s certainly better than no treatment
and it doesn’t bring the complications of medicine and that type of thing over long
term. Again, you’re watching Ask Us Anything about
Pain Management from Penn State Health. I’m Scott Gilbert alongside Dr. Michael Sather. As we mentioned we welcome your questions
and we have a question here from Alex. She’s asking how to treat a shoulder injury? Well, sounds like — I’m sure there’s a wide
range of shoulder injuries but do you see a lot of shoulder pain in your clinic? >> I typically do not. I mean typically the first like of treatment
would obviously be going to the primary care physician, the family physician. Make sure that there’s not any severe injury,
obviously X-rays typically, depending on the severity of the injury. If there’s no fracture or rotator cuff tear,
you know you’re looking at physical therapy first, maybe some steroid injections to the
shoulder. If it persists then you need an MRI to further
delineate what’s going on with the ligaments and tendons. >> Right, a very complex, kind of a part of
the body up there in the shoulder, a lot going on up there. Again, we do welcome your questions here. Here’s a follow up question actually it looks
like from Alex asking how to treat pain from two massive tears in rotator cuff. She says, “The only treatment is a reverse
shoulder. I’m not up for that surgery. I’m not familiar with what reverse shoulder
is.” >> Well, that’s sort of — that’s an orthopedic
procedure really outside of my aspects in line of treatment. But certainly that’s, you know, surgery is
one alternative for those that are, you know, failing physical therapy and injections. >> And Alex what we’re going to do for you
is we’re going to put contact information for orthopedics here at Penn State Health
because I really feel that there’s a good chance that they could address some of those
good questions you have about shoulder pain. So thank you for that question. And we do welcome others as well. Now we were just talking about spinal cord
stimulation so it’s somewhat effective, it certainly is an answer for a lot of patients. There is a new therapy we want to talk about
though and we hinted at this in the Facebook post previewing this interview and that is
it’s called a DRG therapy. That stands for Dorsal Root Ganglion Stimulation
Therapy. We have some images behind us here so walk
us through a little bit about what DRG therapy is, especially how it’s different from spinal
cord stimulation as we were just talking about. And right up here on this image it looks like
this represents? >> That’s representative of the spinal cord
there so in the instance of a spinal cord stimulator that lead or that wire is going
along the back aspect of the spinal cord itself. >> And what are these things that are extending
off of the spinal cord? So this is a spinal nerve and you can see
at every level in the spine there’s a spinal nerve coming out. And there’s two components to it. There’s the motor component which allows for
movement and motion, so different muscle groups. And then there’s the sensory component, which
is this aspect that’s lit up here so that’s pain, sensation, light touch, that’s sensation. >> Motor and sensations. So obviously you target the sensation side
then with this therapy. And if this diagram were to continue here
would we see these lines branch off into a bunch of different nerves to different parts? >> Yeah, so if this was the — this was the
low back, you’d see these nerves branching out in a different — and then coming together
and forming different nerves that go down the legs to control the leg movement. >> OK. So when we talk about DRG therapy then why
the bright light there? What are we looking to do? We’re looking if that represents pain are
we looking to kind of zap that out? >> Yeah, so that is — this is lit up because
that’s the dorsal root ganglion. And so what the ganglion is, is it’s basically
the cell bodies of the nerve, o the axons, which are the cables that the electrical information
travels down. They’re going down here and they go up to
the cell body and so that’s a grouping or a conglomeration of different cell bodies
for that particular nerve. We know that aspect of that is where the pain
is actually organized. >> What part of the body is DRG therapy typically
used for? >> So it’s FDA approved for thoracic 10, T10
level to sacral 2, T10 to S2. >> In English? >> So what that means is the lower part of
the thoracic spine all the way down, so we’re trying to treat with that — abdominal pain,
pain in the groin, pain in the limbs, lower extremities. >> OK, so we’re talking about the lower part
of the body mainly, sure. And we’ll talk a little bit more about this. Jean is asking, “Is this the same as a spinal
cord stimulator?” That’s a really good question because it works
on some of the same principles but it’s very different. So let’s get into some of those details here
is to how DRG therapy has the ability to target specific parts of the body better than spinal
cord stimulation. How does that work? >> So what you’re seeing there is the reason
for that is because you are stimulating a particular nerve and where its distribution
is. So what we try and determine when we’re trying
to treat the pain is where in the lower part of the body is the pain. So for instance if the pain is on the top
of the foot that correlates to the lumbar 5 nerve, the L5 nerve, so we would treat the
fifth lumbar dorsal over ganglion. So it’s very focused treatment. >> Where as with spinal — >> Yeah, so stimulation to, you know, other
parts. >> And that’s what would happen with spinal
cord stimulations. So you’re targeting that particular nerve
on the foot of the spinal cord stimulation and it’s really not so targeted. >> So yeah, so if you have very focal pain
just on the top of one foot, this is a very focal treatment so that makes sense. If you’ve got pain all the way down both legs,
that involving a lot of nerves and spinal cord stimulation in that instance makes sense. >> We are going to get back to DRG therapy
in in moment. Here you’re watching Ask Us Anything about
Pain Management from Penn State Health. Dr. Michael Sather is a neurosurgeon here
and he’s taking your questions. So feel free to add those to the comment field
as Judy just did. She’s asking about the success rate for pain
pump implants. Apparently here daughter is going to be receiving
one pretty soon here and she says, “What’s the success rate for those?” And what is a pain pump implant, by the way? >> So a pain pump implant is there’s two parts
to that. There’s a lot of these devices that have two
parts. So there’s the actual reservoir itself and
what that means is there’s — it can hold about 40 ccs of fluid. And that fluid is usually a pain medication
so like morphine is a common medication that’s used. And then there’s a motor that actually delivers
the medication. So it’s pump basically, it’s delivering that
medication. There’s a catheter that’s attached to that
pump that goes around and is in near the spinal fluid. So it’s actually delivering medication in
the spinal fluid that’s around in bathing the spinal cord here. So what’s that doing is chemically blocking
and improving pain for patients that have pain syndromes that are very responsive to
narcotics but unfortunately have high doses of narcotic requirements or where there’s
lots of side effects. >> Chemically blocking the pain verses DRG
therapy and spinal cord stimulation where we’re talking about using electrical impulse. >> Electrical impulses. So when I talk to the patients I describe
this as basically this is like the electricity in your house for stimulation and the other
one is more like plumbing. >> Sounds good. And if we could jump to the other slide here
I think we’re going to get into a little more detail about DRG therapy. This shows kind of depiction of what it’s
like to have one of the devices implanted. You also have one here on the counter. And perhaps we could talk through a bit about
what the different components are. >> Yes. So there’s two parts. So as I mentioned this whole two part thing. So first is the battery pack itself. So you see here there’s a battery pack and
that’s delivering the electrical stimulation. And it has, the life of the battery is in
there. It’s about a five-year battery. It delivers the electrical stimulation. Now it’s attached to a wire, which you see
as the dotted line here and this is a small thin spaghetti-like wire. And on the end of it there’s four different
contacts. And I don’t know if you can see that but there’s
four different contacts on the end of it. It’s also depicted here on this blown up picture
where that — >> Those four right there. >> Yeah, where that’s sitting right over the
dorsal root ganglion itself. So I have to get into the spinal canal with
a needle and then I deliver that electrode right over the dorsal root ganglion. >> And then it stays in there? >> It stays in there. There’s sort of a two-part process. I mean the first thing is a trial so we — with
a needle going through the skin that wire is placed out and then it’s coming out of
the skin and there’s an external box outside the body where this is tested for about a
week. And if we get a 50 percent success that’s
what we’re looking for to be considered for placing the — placing everything inside and
that’s the battery pack and the wire all underneath the skin fully implanted. >> And this is a relatively emerging therapy. How long have we been doing this here at Penn
State Health? >> We’ve been doing this for about a year
here at Penn State Health. It’s been approved for about a year and a
half or two by the FDA. >> OK, and so Connie is asking, “Does insurance
cover DRG?” Is that — now of course coverages will vary
depending on somebody’s carrier but in general? >> In general it fits right along with spinal
cord stimulation. So if your insurance company covers spinal
cord stimulation it’s very similar. It’s stimulation inside the spinal canal so
it’s considered along that same spectrum. >> And so anybody watching now might think
I have chronic pain, I’m a candidate for this, but who are the best candidates for DRG therapy? Because it’s — I’m sure it’s for a lot of
people but maybe not for everybody. >> Yeah, so it has to be nerve related pain. Because of it’s arthritic pain, if it’s bone
type of pain it won’t work. This is working on the nerves. So it has to be a nerve related pain. The two conditions that this was tested on
for the study, for the FDA approval study are peripheral causalgia and complex regional
pain syndrome. So to tell you a little bit about that in
English peripheral causalgia is if you were to damage a particular nerve, its nerve related
that — or pain related to that nerve that’s injured. So if you were to go in for a hernia repair
and you had an injury to a nerve or it was injured in some fashion, you would have chronic
pain in the groin, a burning type of pain in the abdomen and groin from that nerve being
injured. That’s peripheral causalgia. It’s very effective treatment for that. The other is complex regional pain syndrome,
which is a complicated pain syndrome where it’s pain and intensity of pain and the time
of pain is out of proportion of what you would expect for the injury. So if you were to have a sprain of your ankle
or you to were fracture your ankle, you would expect acute pain. You would expect that you would have pain
for several weeks to several months but then that would subside. In complex regional pain syndrome it can go
on for years. It can be permanent. >> And the thoughts to be temporary is not? >> Correct. And it’s more of a like a burning electrical
shocking type of pain like feeling like the limb is on fire, really sensitive skin, swelling
associated with it, all things that you wouldn’t expect from a typical injury. >> Yeah, all things can really affect quality
of life, so obviously people want to get the best treatment possible. And we are going to put these images that
you see on the screen as well as some links to more information below including how you
can get in touch with Dr. Sather and his team over in in neurosurgery here at Penn State
Health, anything else to add as we wrap up here? Anything about DRG therapy or the topic of
pain management that we didn’t cover here? >> Well, I think as far as the success rate
is concerned and a little bit about the recovery of the surgical procedure, so this is fairly
mild surgical procedure. Obviously there’s this trial period before
hand to know if it had worked. So if it works in the trial period it should
work with a permanent implant. Typically it’s about a six-week recovery and
the pain is pretty mild with it. About 70 percent of patients that have a trial
have success. And again, success is about 50 percent. >> And 70 percent have success with this. That sounds like a higher success rate than
spinal stimulation. >> Yeah, spinal stimulation classically is
at around 50 to 60 percent. Patients get about 50 percent relief. So kind of following the 50/50 rule. So this a little bit better than that. And if you get the permanent implant, if it’s
worked for you and you get the permanent implant, then you have about an 85 percent chance of
getting that pain reduction. >> Sounds good. Dr. Michael Sather thanks so much for your
time today. >> Well thank you very much. I appreciate that. >> And Dr. Sather is a neurosurgeon here at
Penn State Health Milton S. Hershey Medical Center. Thank you so much for the great questions
during this interview. And again if you’re watching this interview
on playback now, feel free to add those in the comment field and we will get answers
for you from Dr. Sather and his team. And we’ll also of course put some contact
information down there so you know how you can learn even more about whether DRG therapy
or any of the courses of treatment we discussed today are right for you. Thanks again for watching Ask us Anything
About Pain Management from Penn State Health.

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