Ask Us Anything About… Pain Management

Description – The video begins inside a meeting room at Penn State Health Milton S. Hershey Medical Center. Two males stand in front of a screen that shows a graphic view of the spinal nervous system. The two people standing in front of the projected screen include, from left to right is, Scott Gilbert and Dr. Michael Sather.

Scott Gilbert – 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.

Dr. Michael Sather  – Thank you, Scott.

Scott Gilbert – 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?

Dr. Michael Sather  – 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.

Scott Gilbert – And pain, people might think why is it necessary, but it actually does serve a function, correct? In terms of maybe signaling a problem?

Dr. Michael Sather  – 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.

Scott Gilbert – 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?

Dr. Michael Sather  – 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.

Scott Gilbert – 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?

Dr. Michael Sather  – 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.

Scott Gilbert – Sure, so a lot of different potential causes. I imagine a lot of different potential treatments, right?

Dr. Michael Sather  – 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.

Scott Gilbert – 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.

Dr. Michael Sather  – 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.

Scott Gilbert – 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?

Dr. Michael Sather  – 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.

Scott Gilbert – 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?

Dr. Michael Sather  – 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.

Scott Gilbert – 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?

Dr. Michael Sather  – 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.

Scott Gilbert – And so spinal cord stimulation is a relatively common approach in that regard, right?

Dr. Michael Sather  – 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.

Scott Gilbert – So tell me about what that involves. Does it involve actually implanting something inside?

Dr. Michael Sather  – 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.

Scott Gilbert – Sure.

[Dr. Michael Sather holds up a simulated spine and spinal cord model to explain.]

Dr. Michael Sather  – 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.

Scott Gilbert – 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?

Dr. Michael Sather  – 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.

Scott Gilbert – So it’s not 100 percent.

Dr. Michael Sather  – 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.

Scott Gilbert – 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?

Dr. Michael Sather  – 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.

Scott Gilbert – 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.”

Dr. Michael Sather  – 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.

Scott Gilbert – 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?

Scott Gilbert – 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.

Dr. Michael Sather  – 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.

Scott Gilbert – 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?

Dr. Michael Sather  – 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.

Scott Gilbert – 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?

[Dr. Michael Sather, points to the simulated image on the screen behind them.]

Dr. Michael Sather  – 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.

Scott Gilbert – What part of the body is DRG therapy typically used for?

Dr. Michael Sather  – So it’s FDA approved for thoracic 10, T10 level to sacral 2, T10 to S2.

Scott Gilbert – In English? [Dr. Sather and Scott smile]

Dr. Michael Sather  – 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.

Scott Gilbert – 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?

Dr. Michael Sather  – 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.

Scott Gilbert – Where as with spinal —

Dr. Michael Sather  – Yeah, so stimulation to, you know, other parts.

Scott Gilbert – 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.

Dr. Michael Sather  – 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.

Scott Gilbert – 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?

Dr. Michael Sather  – 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.

Scott Gilbert – Chemically blocking the pain verses DRG therapy and spinal cord stimulation where we’re talking about using electrical impulse.

Dr. Michael Sather  – 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.

Scott Gilbert – 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. [Scott Gilbert advances the image on the screen and points to a specific area on the simulated graphic that shows the implanted DRG device]

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.

Dr. Michael Sather  – 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 —

Scott Gilbert – Those four right there.

Dr. Michael Sather  – 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.

Scott Gilbert – And then it stays in there?

Dr. Michael Sather  – 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.

Scott Gilbert – And this is a relatively emerging therapy. How long have we been doing this here at Penn State Health?

Dr. Michael Sather  – 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.

Scott Gilbert – 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?

Dr. Michael Sather  – 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.

Scott Gilbert – 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.

Dr. Michael Sather  – 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.

Scott Gilbert – And the thoughts to be temporary is not?

Dr. Michael Sather  – 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.

Scott Gilbert – 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?

Dr. Michael Sather  – 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.

Scott Gilbert – And 70 percent have success with this. That sounds like a higher success rate than spinal stimulation.

Dr. Michael Sather  – 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.

Scott Gilbert – Sounds good. Dr. Michael Sather thanks so much for your time today.

Dr. Michael Sather  – Well thank you very much. I appreciate that.

Scott Gilbert – 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.