Hello, I'm Paul Evans and welcome to Airing Pain, a programme brought to you by Pain Concern, the UK charity providing information and support for those of us living with pain and healthcare professionals. This edition's been funded by Pfizer. Now, back pain accounts for half of all chronic pain in the UK. Initially, a GP may recommend exercise or acupuncture, pain relief, medication and self-management advice. A lot further down the line, it may be considered necessary for you to see a specialist in interventional pain management. Dr Ron Cooper is a consultant in pain medicine and anaesthesia in Causeway Hospital, Coleraine, Northern Ireland.
He has a special interest in interventional pain management. That's the use of invasive techniques or operations. Over a year, he sees around 1,200 new patients and performs around 600 procedures. 70% of the patients that are referred to me have back pain, lumbar sacral pain. About 15% of the patients may have neck pain. And then the rest are a mixed bag. The mixed bag are the ones that have things like neuralgia, tridermine neuralgia, which can be effectively treated at the pain clinic by intervention, or post-traumatic pain or people with...
neuropathic pains which are more difficult to treat neuropathic pains can range anywhere in the body such as post-surgical pain but back pain is the biggest feature yeah there's no doubt about that a significant number of these patients really are here because they just want reassurance and often doing a scan will reassure them and a scan is fairly harmless that can be done an examination to exclude any red flags and that's what you want to look at very few will have significant pathology and that's a fact but you have to see them to know Dr Ron Cooper now he and some of the dozen patients he saw at one of his clinics in Causeway Hospital Coleraine were willing for me to sit in on and recall their consultations But before we join them, don't forget pain concerns usual words of caution that whilst we believe the information and opinions on airing pain are accurate and sound based on the best judgements available, you should always consult your health professional on any matter relating to your health and wellbeing. He or she is the only person who knows you and your circumstances and therefore the appropriate action to take on your behalf.
Dr Cooper's first patient was suffering from neck pain. The pains come from the spine, from the very top of my neck, down to probably maybe brass flap area, which would be the pain to me that feels. It feels when I'm just actually walking or sitting, that it's grinding. It feels like a hacksaw. And then it seems to annoy, obviously, the muscles. To me, my mind annoys the muscles, and it flares up. And I think when they flare up, it's putting pressure on my head, because I've had a CT that's cast on my head then, because of the vomiting and whatever. And it's come back absolutely clear. So we're trying to rule out.
Other things that are causing the headache, it's not a headache, it's a pain in the head, but I think it still seems to be coming back to the muscles of the neck. Can I just check your neck again, because that's important. And just go into the shoulder as well. It goes into these muscles. Yeah, but not down the arm. And it's mainly on the right side. Both sides. Both sides, yeah. The right's the worst. There? That's sore there? Yeah. Okay, never hurt your neck at all, no?
No, they just say it's wear and tear. I think the first x-ray I had for it was about 20 years ago. The muscles are quite tense. But that's nothing. Today's a good day. Well, what I'd said to you was that we would try the tablets to see, and if the tablets didn't work, we could try some injections to see if that could identify any cause in the pain. It's possible you've got what's called a cervicogenic headache. That just means that your headache, we think, is coming from the neck. Cervicogenic is the cause of it, we think. Now, in order to try and see if that's right, we can do what's called diagnostic injections in the neck to see if that affects it.
And that's done in the theatre, with the x-rays, with some care, taken in precise needle location to try and find it out. There is, however, some risk with it, you should understand. There's a risk of flaring up the pain, in other words, which can happen any time. There's a risk of producing some numbness in your neck. There's a risk of injury, permanent injury. It's just something go wrong. You could even have a fit or a convulsion. That's very rare, but I think it's something that you have to bear in mind. I think it's a reasonable thing to do, and I think it's obviously worth a try. And if it does help it, then it may allow us to do some other treatments. If the injections don't help it and not likely to prove that, then it may be a case of trying to work and relax the tension by doing maybe injections into the muscles, such as Botox.
with physiotherapy, with stretching exercise and they help it, that's the possibility. Is there a cure for it? Probably not, but hopefully we can make it easier. So how do you feel about that? It's getting to a stage where you are the last port of call. If you can't help me, I might as well. I think it's worth a try. Can you come up tomorrow to have it done? Any questions? No, I'm fine. There's no guarantees with this. It's worth a try to see. It's more of a diagnostic thing than a treatment thing. See you tomorrow then. Half past one day.
20 years is a long time to have pain like that. And she said, no, this is last chance saloon. How do you feel about that? I don't think that's quite true. I think, you know, she's probably told the other doctor she saw as well. I think she is searching for a cause too much. I think that, you know, at some point she may need to have some multidisciplinary approach where she has some help in trying to cope with her symptoms and deal with them. And hopefully straight relaxation and manage that. But I think before that, I would like to see if I can just exclude a cause in her neck and survive. It can easily help by some radiofrequency treatment. But yes, it's a long time. But that's often the nature of people with chronic pain with no physical findings as such.
Often the search for a cause can be a thing, really, and sometimes they just need to be able to say, no, there's nothing we can find, or they just have to try and manage her differently. I mean, she's not a suicidal person, she's not something like that, and she's well-adjusted and not overly depressed either. I just think that she's not been able to identify. 2010. Now you say double, you mean both sides or two sides in one? Both sides. Right and left. Oh, right together. That's unusual. They just want to get over it. They want you to sleep for the operation. Did they do it with mesh? Yes. After I started getting this pain down near the groin. Left groin. It was like the pain that started with a hernia. So then my own doctor, I told him about it and he says, right, I'll get you in to see asbestos. And he says, no, the mesh, no. You're worried in case there's a hernia again. Yes, I thought it was that.
And then I kind of got worried in case there was something else. They checked me out. And they checked out the stress and the scrotum. Yes. No lumps or bumps. No lumps or bumps. And there was nothing like cancer. Were you always worried about that? I thought we'd be frustrated or something. Yeah, you saw the TV campaigns and things like that. It was scary. So they put it down to that this pain here was coming off my back. You've had a bad back for a number of years. Oh, so that's why I'm referring to you now. Have you still got the pain in the groin? Can you tell me a bit about it? Was it there all the time or what's it like?
A burning thing and it will be there all the time. Would it be like shooting pain as well or sore to touch? Would your clothes, underpants make it sore if you touched it gently? No, it would be. So it's really burning is the main thing? It's burning and after you've pushed, you know. Where the scar tissue is? Yes. And lower back is very sore. Is this pain different than the pain you had before you had operation? No, it wasn't burning before you had operation, no. Okay, so it's a different sort of pain. And when you pass water, does it affect it? Sometimes. Does anything else you do affect it make it worse or make it easier? No.
Okay, now you say you have back trouble as well. You get the back pain when you get that as well. Aye, I have back pain most of the time. Yeah I know, it's there for years, but I've done many treatments with you. That's what's still... Still trouble? Still trouble. Okay, let's have a look at your back and then we'll have a look down below. No problem. You slip off your jacket there. So what's the home situation now? Who's at home with you? Ah, the other half. No problem. How do you think at home? Ah, just normal, just don't need very much. No, there's a big scar on the back there from the surgery. Now I'm going to, it's the left side mainly, isn't that correct? Ah, yes.
Sorry about that. You've had treatment for the shoulder, didn't you? I'm going now to the pain. I think I'd actually suggested to your doctor a few years ago about the pain management program and I think he got around to send you to it now. I think that's the best thing for you to help manage the pain. The pain you're describing is likely to be nerve pain, which could well be coming from the back. But you've had back pain now 10, 12, 15 years. And it's never going to go away, you know that. Injections can manage it for a good while and help it. I just think the way things are at the minute, I don't think that's the best thing for you.
you know I'm not saying we'll never do it I'm saying it's not the best thing at the minute I think the best thing to do is to the medication you're on is probably stay on what you're on but I'll write your doctor about that rather than don't change anything yet I think the best thing is the pain management program and I'd recommend you go there it's not going to be a cure but I hope they'll help you manage it because you need to be very stiff at the minute generally you need to get a little bit they'll come One thing I noticed, Ron, was his movement. He's exhibiting a lot of what we call pain behaviour. A lot of it is really to, if you like, demonstrate to others that he has pain. He has pain, but he has got a lot of pain behaviours. Movement was, it's not a pathological movement. Some layman would say it's putting on things, but what he's doing is emphasising how he feels to show the kind of attention-seeking behaviour it is. And you'll find that a lot of patients that have a...
large psychological component of their pain as opposed to a physical component actually to exhibit this and he's got multiple visits to GP and to other specialists and he really is going to the best case a pain management programme. That's not going to cure him by any means but hopefully it'll help him identify how he is see how things are and help cope with his pain and try a lot of self-help and it needs to be helped. And he needs some psychological help as well. He's not mad at any means he's a sensible person but he's in this situation where he's one of these patients that's susceptible to any sort of pain he gets pain post-operatively after any operation he's had multiple operations in the past by surging people and always getting problems. Often there is some...
non-physical problem at the root of this. But I can't address that in my clinic. I'm an interventional pain physician mainly. And the important thing for me is not to stick needles in or not to change drugs drastically where I think they're not going to help. You have to be honest with patients.
Dr Ron Cooper's next patient at Causeway Hospital in Coleraine has had back and leg pain for some years. She's had various interventional treatments including nerve blocks and more recently a spinal cord stimulator. This works by sending small electrical pulses to the spinal cord from a battery-powered device which is implanted in the buttock or abdomen. You have what's called a scoliosis in your spine, a twist in your spine. You can see it there in your rectra and you can see the stimulator in place. There's the wire there in your back. It's a stimulator. There's eight electrodes there.
and you would say that that has helped the leg pain not the back pain that's always been the case and it helps the leg pain by good you reckon about 60% better than it was so you'd miss it if it wasn't there because remember we talked about turning it off to sea and you tried that and you found it did help so really this is what you've got on your back How long has it been? How many years? It's only three years ago since it's passed. And it's giving you stimulation in there. That's into the skin. So it's the size of a cigarette box. It's a bigger one. Now we have different ones that go in. So basically it's working satisfactory to doing what it can do. But at the time when we put it in, remember we said that it won't take away the pain totally and it probably won't help it back. And I think that was true. But at least it's helping some of it, which is better than nothing, would you agree? The medication, I think you still will require it. I think it's important to keep doing the activity as you do and keep as active as you can. And basically, whenever the battery would stop working.
wears out then we can replace it and we can maybe replace it with one of the rechargeable ones because the less operations you have the better. Because I'm actually waiting now to get my gallbladder out as well. Well that affects the... Yeah you'll need to tell them but what you need to do is you need to tell them and in fact what I will do is I will write to your doctor and I will write a letter to you to take to the surgeon because what it means is you need two things when you go into the hospital to have the gallbladder out they need to know because you need to have antibiotics which you'll get anyway from the surgery you'll get that but you'll also need to know there's a special thing they use called diathermy which is a thing they use to stop any bleeding when they do the operation whenever they cut their blood vessels they have to... stop them bleeding and they put electric current to them. There's a certain type of therapy that they should not use and they need to know this before they do it. Most of the surgeons know that but I will send a letter to you to take with you when you go in to say look and show that to the surgeon and make sure they know that. Otherwise if they used the wrong one it could wipe out the stimulator and it would stop working. If your stimulator changes after the surgery sometimes you need to reset after the surgery so what you should do is when you go in the hospital switch it off when you're in hospital you can use it after the surgery okay after the operation but before the surgery it's best to switch it off in case you forget to switch it off because if it's switched off then it's much safer.
all right but really people have a big operation there's no bother as long as I remember those two things and you can take the thing in with you but switch it off before you go to theatre all right that's my advice and if you have problems with it after you come out contact Joyce again we'll see you again and we'll get readjusted if not maybe about two out of ten people may get readjusted but you just have to wait and see anyway good luck anyway What's the principle behind the spinal cord stimulation? Well, the basic answer is no one knows how it works, but the initial theory was that it worked in the gate theory where you stimulated the spine and you blocked out the impulses coming from the painful leg and it blocked them out. And that was a simple theory, first but forwarded by Mel, second wall. It's not thought to be the case now. It's thought to work on chemicals in the blood, chemicals produced in the spinal cord, which go to the brain, and endorphins are affected, inflammation is affected, sympathetic activities, in fact, inhibitory, no one knows, but we know that it has complex effects and we know that it can help certain types of pain in the neuropathic pain and the patient can turn on and turn off as necessary.
but it's a system that we have the benefit of doing a trial a trial to see is it going to work because if it doesn't go to work then we shouldn't do it and by putting in a temporary lead which comes out through the body and the patient tries it for anything from a week to four weeks and they know is it working in their home environment this is done they go home and if it helps significantly and I am convinced it helps them then we go ahead and do an implant if the patient is not convinced or doesn't want to be bothered with it and I'm not sure then we take it out if there's any doubt we don't do it and those it works for it works well it works very well for it pain in the leg, a single leg, a single arm, a single limb. It works for other types of pain, more complex pain, where they have CRPS, which is associated with swelling of the leg. It's also useful for amputation stump pain, but not phantom pain. It's useful for pain after angina, which hasn't responded to cardiac surgery or failed back surgery. It's used for conditions such as abdominal pain, conditions such as pelvic pain. It's also used for painful bladder syndrome, where it can also control the urgency and the frequency of running the toilet. It can also be used to control faecal incontinence, in certain cases, for the lower of the sacrum. So it's a lot of uses.
I'm Dr. Cooper and the physiotherapist asked me to see you because you had back pain for a year or so. And you've been to your doctor and he had got you to go to the ICATS physiotherapist. That's a specialist physiotherapist who decides do you need to have an operation or not. And they did a scan of your back. And have you seen the scan? No. That's your bones in the spine. We call it the vertebrae. There's the discs, those little black things, the shock absorbers. And there's the spinal cord where the nerves are. And if you look down there, that's nice and healthy.
The first thing I tell you is you don't need an operation. That's good. Do you understand that? Yeah. And that's good. I'm glad that you said that. If you look down here...
See the way it's a little bit wider? That shows there's some inflammation there and possibly where the pain is down at that level. Possibly. Now, the discs are starting to bulge a little bit. You can see a little bulge. See there. That's okay. A lot of people have bulging discs and it doesn't mean anything. If the disc was to go right out and get prolapsed, then you'd need an operation like anybody. You don't need that. At the back of the spine, we're looking at the muscles there. And the muscles are a wee bit thin there. You haven't been, you know, because the pain's bad, you probably haven't been doing too much. No, because I can't. You know the way when you go into a plaster of Paris, your muscles go weak? That's the muscles in the back getting thin there. That's the normal muscle. That's the muscles getting thin.
and that's why it gets a vicious circle. There's the joints at the back there, see there? We call those the facet joints, and that's those joints there. You see the way they're thickened there and they're black? That shows that there's some wear and tear there, or hypertrophy. It's not a disease, but it's really just possibly, and the word I use is possibly a source of pain. Not definitely, because we can't tell from scans is the structure causing pain or not. We can just say it may be. It's difficult to know the exact source of the pain without doing any more tests. The ways of managing this are you can obviously take painkillers, you can rest and exercise and do those things, which you can do. I think because you've had it for so long,
a couple of years now and that it's not improved. I think the reasonable thing to do would be to try some form of injection to see if we can find exactly where the pain is coming from. It might be that the pain is coming from some of these joints down here that we saw on the scan that are tender when I examine over them. The only way to find that out is to do what's called a nerve block, where you put in needles into the back here, to where the nerves are, the vastest joints, around there, and you freeze it a bit like a dentist looking for a bad tooth. Try and find out which one's sore. We think it's down here somewhere, see if that helps it, and give an indication that the pain comes from there. That may help it for a short time, or it may help it longer, or it may not help it at all. If it doesn't help at all, and it's been done right, then we can assume the pain has not come from here. If it's not coming here, then there are other causes that we can look at. But that's the simplest thing.
And if we do find this company there, there's some treatment that we might be able to do to help it, or we do radio frequency treatment, which may be a benefit. The idea on this treatment is not to cure the pain, but to relieve it, to allow you to get more active, to get the muscles built up again, to do the exercise, and get the weight down, and just get more fit again. So it shouldn't be seen as a treatment on its own. It should be seen in conjunction with, we call it rehab, or it's really just more activity and targeted therapy. The one I would do would be done fairly precisely in the theatre, where you go to the day theatre, and you lie on the operating table, and we take x-rays of your back, and we try and find...
where the structures are. We can't see the nerves, but we use the exercise to help us guide the little fine needle where the nerve should be at the joint. And then we usually put two or three injections with you awake to tell us what you feel, to test it, and then see if that helps or not. It's a very tiny amount of anaesthetic in a controlled manner to see if that can precisely find if the pain's coming there or not. And if it is, then there might be something we can do to help it. Well, that's great as long as I can get. Okay. Any questions? No, that'd be great. Okay, so that's fine. Okay, well, hopefully we'll get some benefit. That's great. Okay, bye-bye. Okay, that's good.
The nerve block injections, they are there purely to identify? Purely diagnostic. They do sometimes have a therapeutic benefit. We're not sure why they have a prolonged benefit. It could be because they are reducing the vicious circle, reducing the pain, reducing the spasm and allowing the patient to do more, and that could be what it is. It's unlikely, however, but the point is that I do them in a controlled manner. The patient goes to theatre, they have it done with fluoroscopy guidance to identify the targets of the bone, where the nerve should be, and a small, tiny, precise amount of anaesthetic, usually about 0.5 a mil, a tiny drop, is placed where the nerve should be. And if that helps it, then we consider it a positive result. If it doesn't, it's a negative result. And then we will repeat that sometime, repeat it to see.
if it gets a different result with a different type of anesthetic. And if that helps, then we can say to the patient, we're fairly sure, not 100%, fairly sure this is where your pain is coming from. And if it's coming from there, the fact that we identified a source of pain will help a lot of people. But then we can offer another treatment where we do radiofrequency, where we simply re-ablate the nerve or cauterise or burn the nerve with radiofrequency treatment in the same manner. And that should give a longer term result. However, it's important that the patient realises that this is part of a rehabilitation strategy where you don't just do the procedure and go away. They have to work at it. They have to improve their function and build up their muscles and change their lifestyle a bit, lose weight, build up the muscle tone at the front of their abdomen and hopefully reduce their analgesics.
and keep more active. And that's important to get that emphasis on. People call them facet joint ejections, but they're precisely called medial branch nerve blocks. The joint ejection is not something that we normally do. Now back pain is a major problem. Major problem, in all age groups. But you're seeing extreme cases. Yes, yes, I must emphasise that. I am seeing patients who have had pain for at least a year, in some cases much longer. I generally do not see patients that have had pain less than six, several months. It would be the exception. Invariably all of them have treatment, conservative treatment elsewhere. They've all seen a GP, a physiotherapy treatment, majority of physiotherapy treatment. They've all had some sort of exercise programme and they've had several analgesics and maybe seen other specialists as well. I do think, however, that...
we probably should be seeing patients earlier to try and prevent some of this chronicity by doing earlier intervention, whether that be in the form of more active physical therapy, active rehabilitation, or more earlier interventions, diagnostic interventions and treatments to do that. I think that we probably should be seeing them earlier, but you're right, I'm seeing the tip of the iceberg. But it's important for people with back pain, including me, including just about everybody I know, not to get on your list and get operated on. I agree entirely, because I don't want to be doing procedures on patients. I want patients to manage their pain, to get better themselves without this.
They have tried that. I do encourage them to try again before they do this, and if there's any doubt, they'll not do an intervention. The risks of the interventions are very low, depending on which we do, but obviously it's better not to interfere if you don't have to. Dr Ron Cooper's final patient has had back pain following a car crash. We did radio frequency treatment where we did nerve blocks and burned the nerves, and you found that helpful? That is absolutely fantastic. That's exactly what I was looking for. You had actually come looking for this treatment anyway. I had done my own research and found out from someone. Google's brilliant. I was speaking to that person who said to me, I think the general...
to be safe, the guarantee is like a year, but he was well in his fifth, sixth year and knew somebody else who was in their eighth year, pain-free, spasm-free. Tell us about how you find the procedure in terms of discomfort, the actual doing the procedure. The procedure, I don't know, from the girls' faces, a bit of feedback at the time. A few words, a few words. Yeah, it was a big bear hug on the thing, but it was so at the time, but it was like, say, an hour, an hour and a half of pain and discomfort, but it's only seen, hopefully, you know, any gods in it. It's worse than the dentist, or what's the same than the dentist?
It doesn't really bother me at all. I have quite a good pain threshold, you know, but it's just, you know, someone's sticking a needle into the sore part of your body. Do you understand that we had to find the sore bit? Oh yeah, I fully understand the whole thing, but I think it's the fact that I get six nerves done. Yeah, you were unusual, you went to have both sides done it once. Normally I would only do one side, and the reason I do one side is because it is uncomfortable. But you wanted to get over with them and go, and you did that, and you were wise. And how soon after did you notice pain relief? Pain relief?
You've seen about a dozen patients today and I've been privileged to sit in on it. there have been some very, very good results, and some that perhaps need a little more help. You have to realise in this field that you will not help all of the patients all of the time, and you will help some of the patients some of the time, and you really have to just be prepared to accept your own treatment, if you like, failures, but try and always offer the patient an alternative or refer them elsewhere for a different approach. And just remember that you shouldn't use the same things in everybody, and just because you can't do that doesn't mean it can't be done. The patient should be prepared on as well. And there are other ways to tackle problems. And my advice is for interventionists, always use the least invasive, least risky procedure first, after other interventions have been tried.
and it's not going to be all and all, but it does help some patients fantastically well. as opposed to the non-interventional approach. Some people seem to think the only way to treat conditions are by using needles or injections or burning or frying nerves. And the others seem to think that there's no role for that at all. And it is only for psychology is all in the mind and behavioural exercise rehab. Most people that I know...
are somewhere in between and that one can't really exist without the other and all the patients I intervene on I tell them that they must have some form of rehabilitation some other way to back it up and I think there's room and in fact it's essential that we work together and the British PN Society while it has all its different special interest groups namely the interventional PN Society which I was the past chairman off they're the psychology group they're a multidisciplinary society and we must have multidisciplinary working and that's essential regardless of how much intervention we do we all have a role to play and we need more joined up working.