By Brenda Dickinson
Faculty of the Multidisciplinary Pain Center under the direction of Dr. Vildan Mullin have started admitting patients to the University Hospital for implantation of dorsal column stimulators and intrathecal morphine pumps. Dr. Jeffrey Rosenthal, Assistant Professor of Anesthesiology and a faculty member in the pain center, describes the new program.
 |
Dr. Jeffrey Rosenthal performs implantable pump |
“We have always worked closely with the Department of Neurosurgery, screening patients and subsequently referring them for implantation. What is new and exciting is that pain management fellows, under our supervision, will begin treating these patients independently, including operating room management,” Rosenthal said.
Intrathecal morphine pumps and spinal stimulators are two methods utilized in controlling chronic pain. They are near end-of-the-line therapy for very difficult pain problems. Delivery of morphine to the spinal space is a very potent and powerful method. The ratio of oral to spinal morphine is 300:1. A typical patient considered for a morphine pump, currently, has been diagnosed with cancer and is suffering excessive side effects, or incomplete pain relief from their opioid medication. Typical treatments have been tried and failed.
“In our pain clinic, the most common indicator, for dorsal column stimulation is treatment of chronic low back and leg pain. Most patients have undergone multiple spinal surgeries for complaints of back and leg pain, yet have failed to find relief. They have been through physical therapy, are taking drugs used for the long-term management of chronic back pain, have undergone injection therapy and, despite these measures, continue to complain of pain and seek treatment,” Rosenthal said.
Patients are brought into the hospital for an anticipated overnight admission. Dorsal column stimulation involves the placement of a neural stimulator electrode in the epidural space somewhere between the cervical and caudal region. The electrode is gently advanced under fluoroscopic guidance to a position overlying the spinal segments to be stimulated. The electrode is attached to a pulse generator, located externally during the trial phase, and then implanted subcutaneously following a successful trial.
While these two invasive and exciting therapies are not new, they are a new path in which the Chronic Pain Clinic is venturing. For the first time, Anesthesiologists at the U-M are admitting their own patients to the hospital and managing every aspect of their care, including surgical implantation in the Main University Hospital.
“We have sought and been granted the opportunity to admit our patients for whatever the need may be. This opportunity will be most commonly utilized for patients known to the Chronic Pain Clinic, however, if another situation arises that we feel warrants inpatient care, we have the privilege to admit and primarily manage in the Main University Hospital.
“Currently, the plan is to have Pain Clinic faculty and fellows responsible for coordinating admission, care, and discharge of inpatients admitted onto our service. This is not a service that will perform inpatient consults, which is a role of the acute pain service,” Rosenthal said.
For the first year, anesthesiologists anticipate a volume of one to two implants per month. Once the service has had some experience the volume is expected to grow steadily as the number of cancer pain patients who are referred from our Cancer Center continues to grow. The Medical Center has a world-renowned Cancer Center that evaluates over 43,000 outpatients each year. The Chronic Pain Clinic rounds on 6,000 inpatients per year. These patients are postoperative as well as hospitalized patients with chronic pain issues. Postoperative epidural management is provided to 1,200 patients per year. According to Rosenthal, the data indicates that one to five percent of all cancer patients are candidates for a neurolytic nerve block, and another two to six percent should be considered for neuraxial drug delivery, based upon failed pain control with simpler measures.
“It’s a direction in which we want to take the Multidisciplinary Pain Clinic because we feel there is enough data to support its efficacy,” Rosenthal said. “At this point in time it has been demonstrated that these surgically-based methods are safely performed in the hands of an anesthesiologist. The more complicated cases, requiring open surgical technique, will continue to be referred to Neurosurgery.
“A multidisciplinary approach for the management of chronic pain remains the gold standard in terms of outcome. We will continue to consult other services, when indicated, to provide the best overall care for our patients.”