DARADIA: The Pain Clinic, Kolkata, India

2010-04-22T07:29:00.000-07:00

Cancer Pain Management-Beyond WHO Ladder

2010-03-15T07:35:00.000-07:00

Pain is one of the most feared and major complain by cancer patients, particularly by those who are suffering from advanced cancer. Recent studies on the prevalence ofpain in cancer patients show figures that vary from24% to 60% in patients on active anticancer treatment or early cancer (1-4)and 62%–86% in patients with advanced cancer (5-10). Many of the cancer patients are really afraid of pain (11) than impending death.

Types of cancer pain:

In general pain may be of two types. It may be a warning signal from damaged tissue, or it may be due to dysfunction of nerves. In phantom limb pain a person is feeling pain from the limb, which is already amputed. Here the person is feeling pain because the nerves which was taking signals from that limb is till there in brain and spine and are producing abnormal pain signals that is felt as pain coming from that limb which is no longer there. Here pain is not due to tissue damage as there is no question of any tissue in the amputed limb. This type of pain is called neuropathic pain and is due to dysfunction of nerve (anatomical or physiological or both) and there are many such examples. In cancer nearly 30% patients suffer from such kind of neuropathic pain. The other type of pain is due to tissue damage called nociceptive pain.

Treatment of cancer pain with WHO Ladder:

World Health Organisation (WHO) introduced a painladder (12) in 1986 that has been accepted worldwide. Combinedwith appropriate dosage guidelines, it should be able to providetools for adequate pain relief in 70%–90% of the patients(13–18).

Prevalence of cancer pain:

Types of cancer pain:

Treatment of cancer pain with WHO Ladder:

Under-treatment of cancer pain:

There are several pain management indices (PMI) to assess the adequacy of pain control in cancer patients. (19) With these indices under-treatment is well documented and it can involveup to 40% of patients (20) even in centers with availability of opioids (21).

With the above data it is clear that under-treatment of cancer pain is very common and it may involve upto 40% of patients. It is also noted that even with following WHO ladder only 70% patients are getting adequate pain relief. (22)

Barriers in cancer pain management:

Several factors are attributed for inadequate pain relief like:

I. Inadequate use of opioids.

Several barriers are identified like system barrier, physician barrier, and patient barrier etc. (23)

1. System barriers are represented by low priority given to cancerpain treatment and by legal and regulatory obstacles to theuse of opioids for cancer pain.

2. Physician barriers to correct cancerpain management consist of the following:

Use of a ‘disease-based’rather than a ‘symptom-based’ model of care;
Lackof physician education and failure to follow existing guidelines;
Lack of priority given to symptom management;
Analgesia levelon the basis of prognosis rather than severity of pain; fearof patient addiction and analgesic tolerance;
Poor assessmentof pain and lack of proactive questioning about the symptom;
Insufficient experience of pain management (poor knowledge ofopioid pharmacology, conversion, equianalgesia, rotation, doses,and ratio for breakthrough pain drugs);
Failure to use adjuvants;concern about and failure to treat opioid side-effects;
Failureto document information on drugs used, dosages given, timing,breakthrough pain, and laxatives administered; and
Failure tofollow-up.

3. Patient barriers have been identified as follows:

Reluctanceto report pain because of the conviction that health professionalsmust not be distracted from dealing with the main problem, i.e.the tumor, that pain is innately related to the cancer and assuch cannot be eliminated, and that the acknowledgement of ahigher level of pain indicates awareness of disease progression;
Fear of not being considered a ‘good patient’;
Reluctancein taking pain medications due to the well-known ‘mythsabout opioids’, represented by fear of addiction and/orof being thought of as an addict, fear of analgesic tolerance,and fear of side-effects. All these factors culminate in a ‘willingnessto put up with pain’ and in a determination to take asfew medications as possible, prolonging the ‘use as needed’strategy and refusing an ‘around the clock’ typeof administration

II. Inadequate assessment of pain.

a. In a 1997 randomized clinical trial, Trowbridgeet al. (24) found that standardized painassessment alone improvedcancer pain management and reduced patient-reported pain severity.

III. Lack of institutional protocol for cancer pain management.

a. Du Pen andcolleagues (25) found that the institutional use of a simpleprotocol for cancer pain management reduced pain severity.

IV. Criticism of WHO ladder.

a. Treatment is based on severity and not on physio-pathological mechanisms ofthe pain itself. (23)

b. Interventional pain management procedures also were not included in WHO ladder. To overcome this drawback and failure to obtain acceptable pain or symptom relief prompted the inclusion of a fourth step to the WHO analgesic ladder, which includes interventional approaches. (26, 27) So, in addition to the original three-step WHO ladder, inclusion of interventional pain management procedures as fourth step has been well accepted in many centers.

Modalities of Cancer Pain Management:

Cancer pain has been described as ‘total pain’ presentingphysical, psychological, social, and spiritual components,and can thus be defined as a ‘bio-psychosocial experience’. It is very difficult to identify the specific ‘percentage’of each of these components for a given value in a numericalscale of pain assessment although it has been reported thatemotional and cognitive components seem to be proportionallymore important in cancer pain than in non-cancer pain. Ascancer pain is a multi-factorial experience and is present togetherwith numerous other symptoms,pain management within the contextof palliative care plays an important role in the systematiccontrol of symptoms (23).

Keeping all these in mind modalities of cancer pain management may be classified as follows:

Classification of Cancer Pain Management:

I. Pharmacological therapy

1. Opioids

a. Weak opioids e.g. Codeine, Tramadol etc.

b. Strong Opioids e.g. Morphine, Methadone etc.

2. Non-opioids

a. Paracetamol

b. NSAIDs e.g. Ibuprofen, Diclofenac etc.

3. Adjutants and others

a. Anticonvulsants e.g. Pregabalin, Carbamazepine etc.

b. Antidepressants e.g. TCA etc.

c. Bisphosphonates e.g. Pamidronate, Ibandronate etc.

d. Steroids e.g. Betamethasone etc.

e. Sympatholytics e.g. Clonidine etc.

II. Psychological interventions

1. Cognitive Behavioral Therapy

2. Coping techniques etc.

III. Interventional Pain Management procedures

IV. Alternative therapy and others

1. Homeopathy

2. Acupuncture

3. Music therapy etc.

Interventional Pain Management:

The use of neurolytic substances has been used for many decades but has found a niche in the treatment of pain related to abdominal and pelvic cancers. Simple, percutaneous injections of alcohol or phenol can provide much needed pain relief for patients with pancreatic, colon, or gynecologic cancers. The percutaneous placement of catheters for the chronic infusion of spinal analgesics can provide pain relief for virtually any part of the body. Internal or external infusion pumps can be well managed at home, improving quality of life. The physician treating the pain should be aware of these and other interventional pain management techniques to provide alternative therapies to patients with refractory cancer pain. (28)

There are a variety of techniques used by interventional pain physicians, which may be grossly divided into modalities affecting the spinal canal (e.g., intrathecal or epidural space), called neuraxial techniques and those that target individual nerves or nerve bundles, termed neurolytic techniques. (29)

It has been proved undoubtedly in recent times that interventional pain management is a very important component of pain management services for cancer pain, particularly when non-invasive pharmacotherapy fails to give adequate pain relief. (28-32) But, can it be administered without a trial of WHO analgesic protocol? There are debates, controversies and differences in opinion. Some recent publications are proving that in some situations like upper abdominal malignancies interventional pain management is better in terms of quality of life and amount of pain relief. (33)

These situations where interventions might be administered at first going beyond WHO ladder may be summarized as follows:

Well-localized pain.
Nociceptive pain.
No distant metastasis.
Adequate survival possibility in months.
Good pain relief with diagnostic local anaesthetic block.
Non-availability of morphine.
Certain types of malignancies like pancreatic cancer.

If these criterions are fulfilled one should think beyond WHO ladder and interventional pain management procedures may be the better alternative to opioids.

Classification of Interventional Pain Management procedures in cancer:

1. Neurolytic block (Neurolysis)

· Peripheral nerve block

· Sympathetic nerve block

2. Central (neuroaxial) nerve block

Neurolysis in Interventional Pain Management:

It is a procedure by which nerve fibre carrying nociception (pain sensation) is irreversibly destroyed to obtain permanent pain relief.

Methods of neurolysis:

I. Using neurolytic agents:

phenol,
alcohol,
hypertonic saline,
glycerin,
butamben,
ammonium sulfate,
chlorocresol etc.

II. Other methods:

cryoneurolysis,
radiofrequency ablation,
surgical neurectomy.

Advantages of neurolysis:

1. Longer duration of pain relief.

2. Instruments and drugs are inexpensive

3. Repeated visits to pain clinic or hospital is not required.

4. Prolonged hospital stay is not required.

5. Patients can remain at home pain free even where medical help is scarce.

Disadvantages of neurolysis:

1. Blocks are occasionally unpredictable

2. Motor loss, loss of control bladder & bowel may occur in 5% of cases

3. Blocks may have to be repeated 8 to 12 weeks intervals

4. Failure to obtain pain relief in 30%

5. Preferably patients to be kept in hospital for 1/2 days

Diagnostic local anaesthetic block:

Diagnostic local anaesthetic block should be performed before neurolytic block.

· Distinguishes pain of somatic, sympathetic or of psychological origin.

· Have a predictive value of subsequent neurolytic block.

· Should always be done before neurolytic blocks

· Should be done on subsequent day

Specific interventional pain management procedures in cancer:

1. Peripheral nerve block (for head & neck pain):

· Trigeminal nerve at Gasserian ganglion or at its branches for facial pain.

· Glossopharyngeal and/or vagus nerve block in case of pain from base of tongue, pharynx, throat.

· Para-vertebral block of 2nd or 3rd cervical nerve root can be done in pain in angle of the jaw or neck.

· Phrenic nerve block for intractable hiccup when conservative measure has failed.

2. Peripheral nerve block (for chest & abdominal wall pain):

· Intercostal nerve block or thoracic/lumber paravertebral nerve block can be done in pain of chest and abdominal wall pain or from pleura/peritoneum.

3. Peripheral nerve block (for upper and lower extremity):

· Brachial plexus and its branch blocked for pain of upper extremity.

· Nerves of lower extremity or root block can be done for pain of lower extremity .

Problems of peripheral neurolysis:

· Some degree motor loss and numbness is common with chemical neurolysis. So it should only be done when patient is ready to accept these in exchange of pain.

· Pulsed radio-frequency is a better choice to avoid motor/sensory loss.

· Local anaesthetic block should be done before neurolysis to assess the benefits of neurolysis.

· Precise localization of the nerve should be done with the help of nerve stimulator and imaging.

Sympathetic nerve block

· Considered in visceral pain and in dysesthetic neuropathic pain (causalgia) of the limbs.

· Not associated with sensory or motor loss.

· Long lasting benefit than somatic nerve block

· Can be done with LA & depo-steroid also.

Stellate ganglion block

· Sympathetically mediated pain of face, neck and upper extremity.

· Examples: post-mastectomy pain and edema of hand; carcinoma of larynx, pharynx, base of tongue.

· May done with alcohol, phenol or repeated block with LA & steroid.

Coeliac plexus block

· Relieves pain from malignancies of foregut and its derivatives i.e. stomach, liver (primary & secondary), pancreas, gall bladder etc.

· Though less effective may be tried in other abdominal malignancies.

Superior hypogastric nerve block

· Effective in the treatment of pain due malignancies of lower abdomen and pelvis.

· Examples: carcinoma of vagina, cervix, uterus, prostate, U. bladder, rectum, perineum and vulva.

Ganglion Impar block

· Relatively easier technique.

· Effectively relieves pain of carcinoma of perineum, vulva, and anus.

Lumber sympathetic block

· Sympathetically mediated pain and causalgia of lower extremity.

Neuroaxial block:

· Intrathecal or subarachnoid block using phenol or alcohol does not require any radiologic guidance and can be done as a day care procedure.

· Epidural phenol neurolysis can also be performed depending on the area of pain.

Problems of neuroaxial block:

· Loss of other somatic nerve leading to muscle weakness and numbness.

· Loss of bowel and bladder control.

· Failure to obtain pain relief.

· Repetition of block within three month.

· Complications in judicially administered block is less than 5%.

References:

1. Pignon T, Fernandez L, Ayasso S, et al. Impact of radiation oncology practice on pain: a cross-sectional survey. Int J Radiat Oncol Biol Phys (2004) 60:1204–1210.

2. Puts MT, Versloot J, Muller MJ, et al. The opinion on care of patients with cancer undergoing palliative treatment in day care. Ned Tijdschr Geneeskd (2004) 148:277–280.

3. Rietman J, Dijkstra P, Debreczeni R, et al. Impairments, disabilities and health related quality of life after treatment for breast cancer: a follow-up study 2.7 years after surgery. Disabil Rehabil (2004) 26:78–84.

4. Taylor KO. Morbidity associated with axillary surgery for breast cancer. ANZ J Surg (2004) 74:314–317.

5. Bradley N, Davis L, Chow E. Symptom distress in patients attending an outpatient palliative radiotherapy clinic. J Pain Symptom Manage (2005) 30:123–131.

6. Di Maio M, Gridelli C, Gallo C, et al. Prevalence and management of pain in Italian patients with advanced non-small-cell lung cancer. Br J Cancer (2004) 90:2288–2296.

7. Wilson KG, Graham ID, Viola RA, et al. Structured interview assessment of symptoms and concerns in palliative care. Can J Psychiatry (2004) 49:350–358.

8. Hwang SS, Chang VT, Cogswell J, et al. Study of unmet needs in symptomatic veterans with advanced cancer: incidence, independent predictors and unmet needs outcome model. J Pain Symptom Manage (2004) 28:421–432.

9. Stromgren AS, Groenvold M, Petersen MA, et al. Pain characteristics and treatment outcome for advanced cancer patients during the first week of specialized palliative care. J Pain Symptom Manage (2004) 27:104–113.

10. Lin MH, Wu PY, Tsai ST, et al. Hospice palliative care for patients with hepatocellular carcinoma in Taiwan. Palliat Med (2004) 18:93–99.

11. Wootton M. Morphine is not the only analgesic in palliative care: literature review. J Adv Nurs (2004) 45:527 –532.

12. WHO. Cancer Pain Relief (1998) Geneva, Switzerland: World Health Organisation.

13. Ventafridda VOE, Caraceni A. A retrospective study on the use of oral morphine in cancer pain. J Pain Symptom Manage (1987) 2:77–82.

14. Walker VA, Hoskin PJ, Hanks GW, et al. Evaluation of WHO analgesic guidelines for cancer pain in a hospital-based palliative care unit. J Pain Symptom Manage (1988) 3:145–149.

15. Goisis A, Gorini M, Ratti R, et al. Application of a WHO protocol on medical therapy for oncologic pain in an internal medicine hospital. Tumori (1989) 75:470–472.

16. Caraceni A, Martini C, Zecca E, et al. Breakthrough pain characteristics and syndromes in patients with cancer pain. An international survey. Palliat Med (2004) 18:177–183.

17. Zech DF, Grond S, Lynch J, et al. Validation of World Health Organization guidelines for cancer pain relief: a 10-year prospective study. Pain (1995) 63:65–76.

18. Mercadante S. Pain treatment and outcomes for patients with advanced cancer who receive follow-up care at home. Cancer (1999) 85:1849–1858.

19. Cleeland CS, Gonin R, Hatfield AK, et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med (1994) 330:592–596.

20. Cohen MZ, Easley MK, Ellis C, et al, for the JCAHO. Cancer pain management and the JCAHO's Pain Standards. An institutional challenge. J Pain Symptom Manage (2003) 25:519–527.

21. Jadad AR, Browman GP. The WHO analgesic ladder for cancer pain management Stepping up the quality of its evaluation. JAMA (1995) 274:1870–1873.

22. Meuser T, Pietruck C, Radbruch L, et al. Symptoms during cancer pain treatment following WHO-guidelines: a longitudinal follow-up study of symptom prevalence, severity and etiology. Pain (2001) 93:247–257.

23. Maltoni M. Opioids, pain, and fear. Ann Oncol (2008) 19:5–7

24. Trowbridge R, Dugan W, Jay SJ et al. Determining the effectiveness of a clinical-practice intervention in improving the control of pain in outpatients with cancer. Acad Med 1997; 72: 798–800

25. Du Pen SL, Du Pen AR, Polissar N et al. Implementing guidelines for cancer pain management: results of a randomized controlled clinical trial. J Clin Oncol 1999; 17: 361–370.

26. Christo PJ, Mazloomdoost D. Interventional pain treatments for cancer pain. Ann N Y Acad Sci. 2008 Sep;1138:299-328.

27. Miguel R. Interventional treatment of cancer pain: the fourth step in the World Health Organization analgesic ladder? Cancer Control. 2000 Mar-Apr;7(2):149-56.

28. Sloan PA. The evolving role of interventional pain management in oncology. J Support Oncol. 2004 Nov-Dec;2(6):491-500, 503.

29. Christo PJ, Mazloomdoost D. Interventional pain treatments for cancer pain. Ann N Y Acad Sci. 2008 Sep;1138:299-328.

30. Christo PJ, Mazloomdoost D. Interventional pain treatments for cancer pain. Ann N Y Acad Sci. 2008 Sep;1138:299-328.

31. Cherny NI, Foley KM. Current approaches to the management of cancer pain: a review.Ann Acad Med Singapore. 1994 Mar;23(2):139-59.

32. Zuurmond WW, Perez RS, Loer SA. New aspects in performing interventional techniques for chronic pain. Curr Opin Support Palliat Care. 2007 Aug;1(2):132-6.

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PAIN MANAGEMENT, KOLKATA, INDIA: INTERVENTIONAL PAIN MANAGEMENT IN LOW BACK PAIN

2008-07-30T10:38:00.000-07:00

PAIN MANAGEMENT, KOLKATA, INDIA: INTERVENTIONAL PAIN MANAGEMENT IN LOW BACK PAIN

INTERVENTIONAL PAIN MANAGEMENT IN LOW BACK PAIN

2007-11-01T10:51:00.000-07:00

Introduction Interventional Pain Management (IPM) is defined as the discipline of medicine devoted to the diagnosis and treatment of pain and related disorders by the application of interventional techniques in managing subacute, chronic, persistent, and intractable pain, independently or in conjunction with other modalities of treatments.(1) Low back pain is a common & complex problem affecting about 40% to 80% of general population in life time and point prevalence being 14 to 20% (2-6) About one fourth of U.S. adults report low back pain in the past 3 months. (7) Back pain is associated with significant economic, societal, and health impact (8-10). Estimates and patterns of direct healthcare expenditures among individuals with back pain in the United States have reached $90.7 billion for the year 1998 (9). Before availability of diagnostic IPM procedures etiology remained unclear in most situations (85-90%) even with CT/MRI. In one prospective evaluation (11), consecutive adult patients with intractable low back pain (who had failed conservative therapy) of undetermined etiology (by medical history, physical examination, x-ray, CT, MRI, EMG/NCV) had pain from facet joint(s) in 24%, combined lumbar nerve root and facet disease in 24%, combined facet(s) and sacroiliac joint(s) in 4%, lumbar nerve root irritation in 20%, internal disc disorder in 7%, sacroiliac joint in 6%, and sympathetic dystrophy in 2%. No cause was identified in 13% of patients. In another similar study, 40% of the patients were shown to have facet joint pain, 26% discogenic pain, 2% sacroiliac joint pain, 13% segmental dural/ nerve root pain and no cause was identified in 19% of the patients (12). Thus diagnostic IPM procedures like diagnostic facet joint block, provocative discography, epidurogram, selective nerve root block, SI joint block etc. can unmask diagnosis in most situations. Similarly therapeutic IPM procedures which include facet joint interventions encompassing intra-articular injections, medial branch blocks, and medial branch neurotomy; sacroiliac joint interventions, including sacroiliac joint blocks, and radiofrequency neurotomy; epidural injections including caudal epidural injections, interlaminar epidural injections, and transforaminal epidural injections; epidural adhesiolysis including percutaneous adhesiolysis, and spinal endoscopic adhesiolysis; intradiscal therapies including percutaneous micro-discectomy/ disc decompression, nucleolysis and implantable therapies, which include spinal cord stimulation and intrathecal drug administration systems give permanent/long-term relief. Many of these procedures are done in Kolkata & are discussed briefly below. Trigger point injection Trigger point injection with local anaesthetic, depo-steroid, ozone gas, or even dry needling gives pain relief in Myofascial Pain Syndrome and Fibromyalgia. These are very simple procedures, repeated in a course of 3-7 injections and gives permanent/ long-term relief in properly selected cases. (13-14) Epidural steroid injection It reduces inflammation, blocks transmission of nociceptive C-fibre input and prevents ectopic discharge from axon & dorsal root ganglion. Immediate relief is more than 85% but long-term relief is nearly 50%. Earlier it is done long-term relief is more. It may be done through Lumber or Caudal approach, later being slightly more effective. (15-19) Most of the studies showed positive results for short-term and long-term pain relief. Best results are obtained in disc herniation with poor outcome in non-specific neck/back pain. Selective nerve root/ Transforaminal epidural block Transforaminal epidural injection (modern nomenclature) or a selective nerve root block (old nomenclature) consists of injection of contrast, local anesthetic, or other substances around spinal nerves under fluoroscopy (20-21). These are used for diagnostic as well as therapeutic purpose. The reported sensitivity of a diagnostic selective nerve root block ranges from 45% to 100% (22-23). Therapeutically it is more effective than simple Lumber or Caudal epidural steroid injection as we are installing the drug more anteriorly right at the target. Drug dose is also much less. (10-20mg vs. 40-80 mg in lumber/caudal epidural.) (24-26) If there is epidural scar like in failed back surgery syndrome it is the only root to inject epidural steroids. Epidurogram Here non-ionic water-soluble radio-opaque dye is injected in the epidural space under fluoroscopy and distribution of dye is noted. Normal Epidurogram looks like an inverted Christmas tree where dye enters into the dural extension of each nerve root. In cases of nerve root oedema/inflammation or epidural fibrosis the dye does not enter into the root / filling defect in epidural spread of dye. Epidural fibrosis is better diagnosed with Epidurogram than CT/MRI. Epidural fibrosis may account for as much as 20% to 36% of all cases of failed back surgery syndrome (FBSS) (27-29). Epidurolysis Epidurolysis/ epidural adhesiolysis/ neuroplasty is done in epidural fibrosis with normal saline/hypertonic saline with/without hyaluronidase. It may be done with Racz catheter after performing an Epidurogram. Epidural fibrosis is seen in failed back surgery syndrome or in post-inflammatory adhesion following extrusion/ sequestration of nucleus pulposus. (30-32) Provocative discography Discography literally means the opacification of the nucleus pulposus of an intervertebral disc to render it visible under radiographs (33). The commonly practiced technical and evaluative components of discography include: sterile needle placement into the center of the IVD (nucleus pulposus), radio-opaque contrast instillation to provoke pain, radiological assessment of disc morphology, and clinical assessment of the intensity and concordancy of evoked pain in relation to baseline pain. Discogenic pain may contribute up to 26% of spinal pain. (12) Percutaneous Disc Decompression/Discectomy It is done for contained disc prolapse & discogenic pain. (34-35) Here a 17G needle introduced into the diseased disc under C-arm guidance. Then a special motorized probe is introduced through this needle & then operated. It breaks the nucleus pulposus into fine particles and sucks it out. Success rate is nearly 80%. The advantages are: No cut, scar, epidural fibrosis & instability of normal anatomical structure. Hospital stay is less and less costly. Ozone Nucleolysis It is done for both contained & non-contained disc prolapse & discogenic pain. (36-38) Here also a needle introduced into the diseased disc & ozone gas (2-10ml.) is injected. It causes some chemical changes so that the nucleus pulposus is dehydrated & it shrinks in size. Extruded & sequestrated disc also absorbs ozone and have the fate. Ozone has powerful anti-inflammatory action & thus nerve roots are not only mechanically decompressed, the chemical irritations are also taken care. It is also less costly and needs minimal hospital stay. Success rate is more than 80%. Facet joint block/ radiofrequency (RF) neurotomy of medial branch Based on controlled diagnostic blocks of facet joints, in accordance with the criteria established by the International Association for the Study of Pain (IASP) (39), facet joints have been implicated as responsible for spinal pain in 15% to 45% of patients with low back pain 54% to 67% of patients with neck pain, and 42% to 48% of patients with thoracic pain (40-44) pain and mostly remains undiagnosed even with CT/MRI. Diagnostic block is the procedure that confirms it. Therapeutic facet joint injection with steroid/ RF ablation of medial branch of dorsal rami gives long-term relief. Open, controlled and uncontrolled clinical studies that evaluated the long term relief of back and leg pain from intra-articular facet joint injections are abundant (45-47). Sacro-iliac (SI) joint steroid injection/RF neurotomy SI joint may be the source of low back pain in about 15 % cases. Utilizing single diagnostic blocks, the prevalence of sacroiliac pain would appear to be at least 13% and perhaps as high as 30% in the United States (48). Percutaneous radiofrequency neurotomy of sacroiliac joints or steroid injection into SI joint has been reported to provide long-term relief (49-50). Percutaneous Vertebroplasty It is done for vertebral compression fracture (osteoporosis, cancer with metastasis, haemangioma of vertebral body etc.) with severe pain. (51-56) Here, an 11G needle is introduced through pedicle under C-arm guidance. Then low viscosity bone cement is introduced into the fractured bone. Caution should be taken so that bone cement does not come in contact with nerves in the epidural space/foramen. It stabilizes the spine and gives immediate pain relief. Lumber sympathetic block Sympathetic dystrophy may be the cause of pain in a significant number of cases. (11,57) Neurolysis of Lumber sympathetic chain using alcohol/ phenol or RF ablation gives relief in Complex Regional Pain Syndrome/ causalgia/ Sympathetic dystrophy etc. (57-58) Similarly Neurolysis/ RF ablation of ganglion Impar and superior hypogastric plexus gives pain relief in low back, buttock and perineal area due malignancy of pelvic organs or in non-cancer chronic pain. (59-61) There are different choices of IPM procedures for similar type of problem. Before choosing a particular procedure, diagnostic intervention is advisable to assess the outcome of therapeutic procedure. In short IPM procedures have revolutionized the management of spinal pain. References: 1.Manchikanti L, Staats PS, Singh V, Schultz DM, Vilims BD, Jasper JF, Kloth DS, Trescot AM, Hansen HC, Falasca TD, Racz GB, Deer T, Burton AW, Helm S, Lou L, Bakhit CE, Dunbar EE, Atluri SL, Calodney AK, Hassenbusch S, Feler CA. Evidence-based practice guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician 2003; 6:3-80. 2.Ihlebaek C, Hansson TH, Laerum E, Brage S, Eriksen HR, Holm SH, Svendsrod R, Indahl A. Prevalence of low back pain and sickness absence: a "borderline" study in Norway and Sweden. Scand J Public Health. 2006;34(5):555-8. 3.Oksuz E. Prevalence, risk factors, and preference-based health states of low back pain in a Turkish population. Spine. 2006 Dec 1;31(25):E968-72. Gilgil E, Kacar C, Butun B, Tuncer T, Urhan S, Yildirim C, Sunbuloglu G, Arikan V, Tekeoglu I, Oksuz MC, Dundar U. Prevalence of low back pain in a developing urban setting. Spine. 2005 May 1;30(9):1093-8. 4.Barrero LH, Hsu YH, Terwedow H, Perry MJ, Dennerlein JT, Brain JD, Xu X. Prevalence and physical determinants of low back pain in a rural Chinese population. 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