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Friday July 28, 2017

Expanding Options for Pain Management in the Operating Room and Beyond

Expanding Options for Pain Management in the Operating Room and Beyond

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Advances in the use of regional anesthesia and other techniques at Robert Wood Johnson Medical School are helping patients recover faster and manage pain

Dr. Kiss with Patient
Photo: John Emerson
Ethel DeBari, left, credits her positive experience with total knee replacement surgery to the pain management that she received during and after the procedure from Geza Kiss, associate professor of anesthesiology and clinical director of acute pain and regional anesthesia.

'I did so well the therapists couldn’t believe it, and I honestly think it was because there was no pain involved. You are very hesitant in physical therapy when it hurts. I had no pain, so I was able to do all the exercises right from the beginning.'
 
– Ethel DeBari
 

Before undergoing total knee replacement surgery three years ago, East Brunswick resident Ethel DeBari had heard all the horror stories about intense pain and difficult recovery – even from physicians. But with a loss of cartilage in her right knee that caused bone-on-bone impact and resulting severe pain, DeBari had already tried other solutions, including cortisone shots, all to no avail.

Looking for relief from the pain and a return to full activity, she prepared herself for what the surgery might bring. “I put it in my head that if you expect to have surgery and not have pain, you’re crazy. So I thought, ‘OK, you’re going to have pain; hopefully they’ll be able to control it to a degree. I’ll just fight through it, and each day it will get a little better,’” DeBari recalls.

She wasn’t prepared, however, for her actual experience.

“Without a doubt, it was so much better than I expected. It can’t get any better than what I experienced,” she says. “I had zero pain after my surgery. I breezed through rehab. I did physical therapy without any problems, and I didn’t even rely on taking Percocet or anything like that!”

DeBari credits her positive experience in part to the type of implant used: a custom-fit knee replacement designed based on X-rays sent to the manufacturer and made to the specifications of her existing knee, so there was less trauma in adjusting to the hardware. But the major reason, she says, was the pain management during and after the procedure.

She had entrusted her orthopedic surgeon, David A. Harwood, clinical associate professor of surgery at Robert Wood Johnson Medical School, with determining the best course for her particular procedure. He consulted with Geza Kiss, associate professor of anesthesiology and clinical director of acute pain and regional anesthesia for the medical school, and they decided to use regional anesthesia for the procedure.

While local anesthetics numb only a small area of the body, and general anesthesia involves a total loss of consciousness and pain sensation, regional anesthesia is used to make a large area of the body insensate to painful stimuli, Kiss explains. It is achieved by injecting medication near a cluster of nerves to numb only the area that needs surgery, he adds.

DeBari received a femoral and sciatic nerve block, as well as a sedative to allow her to “sleep” comfortably during the surgery; the anesthesia was delivered through a catheter that was kept in for two more days to provide optimal pain relief. The day after the catheter was removed, she was discharged from the hospital and entered a Lawrenceville-based rehabilitation facility, from which she was able to go home far sooner than anticipated because she was doing so well. She experienced similar positive results in her outpatient physical therapy, she says.

“I did so well the therapists couldn’t believe it, and I honestly think it was because there was no pain involved,” DeBari says. “You are very hesitant in physical therapy when it hurts. I had no pain, so I was able to do all the exercises right from the beginning.”

A widow who takes care of all the responsibilities around her home, she is now very active and walks approximately three to five miles per day, including a tremendous amount of walking at work.

“Before the surgery, I said I want to get back to doing everything I could do before: I want to wear heels, I don’t want to walk with a limp, I don’t want to have to use a cane or a walker. I’m 70 years old, and I’m fine,” says DeBari, noting that her only issue is a little difficulty when she kneels on a hard surface to scrub the kitchen floor.

“I pray that anyone else who has to have this surgery has the kind of experience I did. I have told everyone that if you ever have to have a knee replacement, you must go to Robert Wood Johnson, you must see Harwood, and you must have Kiss as your anesthesiologist,” she says.

Controlling Pain

DeBari’s experience epitomizes the impact of effective pain control in recovery, as well as the increasing role of regional anesthesia techniques in pain management and patient satisfaction. Pain – now considered one of the vital signs – can adversely impact patients’ cardiovascular stress response, among other negative physical effects, if not properly controlled, says Scott J. Mellender, assistant professor of anesthesiology at Robert Wood Johnson Medical School and clinical director of the New Jersey Pain Institute at Robert Wood Johnson University Hospital. 

“You have a moral and ethical responsibility to control your patients’ pain, but you also want them to have a good level of satisfaction with their care,” he adds.

The medical school’s Department of Anesthesiology has been working to dramatically improve pain management and the patient’s experience, in and out of the operating room, says Christine H. Fratzola, associate professor and chair, Department of Anesthesiology. Many of those advances are taking place in the area of regional anesthesia, in which the department has specialists with a high level of skill and expertise, including the use of newer methods of ultrasound guidance and advanced, minimally invasive procedures for chronic pain, Fratzola says.

Today, regional anesthesia encompasses spinal and epidural anesthesia, as well as peripheral nerve blocks. It is frequently used for certain orthopedic, gynecologic, obstetric, and ophthalmologic surgeries. And it typically results in reduced side effects, including less post-operative pain, less nausea, lower incidence of blood clots, less blood loss, less of a stress response by the body, and earlier mobility.

For same-day surgeries, regional anesthesia can provide 18 to 24 hours of significant pain relief without narcotics, Kiss says. For some procedures, a single injection of long-acting anesthetic is all that is needed. With others – such as DeBari’s knee replacement – a catheter is inserted to allow the anesthetic to be delivered over a period of two to three days, he adds.

Evolving Techniques

Dr. Christine Fratzola
Photo: John Emerson
The medical school’s Department of Anesthesiology has been working to dramatically improve pain management in and out of the operating room, says Christine H. Fratzola, associate professor and chair, Department of Anesthesiology.
 
Despite the benefits, patients sometimes are concerned about the concept of being awake during surgery, afraid of hearing or otherwise being aware of what is going on, Kiss says. Different levels of sedation are available to help patients avoid that issue and doze through the surgery, he adds, without having the potential drawbacks of general anesthesia.

Advances in the field also have brought additional benefits. “Drugs, technology, and techniques have evolved,” Kiss says.

Much of the evolution in the area of regional anesthesia can be attributed in part to the shifting emphasis on reducing hospital lengths of stay, says Mellender, a fellowship-trained interventional pain medicine specialist who completed residency training in anesthesiology, as well as general surgery, at Robert Wood Johnson Medical School. The use of regional anesthesia techniques has helped turn what in some cases used to be a five-day hospital stay into a two-hour outpatient surgery, he says.

As medication and technologies continue to improve, more surgical procedures are involving the use of regional aneshesia, says Kiss. As a result, there is a much greater need and request for anesthesiologists who are skilled in these techniques. At Robert Wood Johnson Medical School, a dedicated regional anesthesia rotation has been in place since 2008.

The medical school’s anesthesiologists and residents have been encouraged to learn new techniques and even push the envelope, Kiss says. For example, Shaul Cohen, professor of anesthesia and a specialist in regional anesthesia, has been a pioneer in developing some of the techniques of obstetric anesthesia.

For the past year, members of the acute pain and regional anesthesia team also have been working more with placement of specific blocks and the use of balanced anesthesia (employing a combination of smaller doses of different medications, to minimize side effects and still yield the desired effect) for surgeries such as total knee replacement, to allow for pain relief to the area while enabling some muscle control.

The department also has been working extensively with ultrasound-guided regional anesthesia to help determine the best location for the injection, according to Fratzola. Certain blocks, such as the supraclavicular block, are done using ultrasound guidance because of the proximity of the lungs and the precision needed for safe, effective delivery of anesthesia. Use of ultrasound guidance can help improve the speed of the block, as well as provide enhanced opportunities for teaching purposes, says Kiss.

The regional anesthesia program takes a multi-modal approach, whether using nerve stimulation, ultrasound guidance, or both, depending on the circumstances of the surgery and what is best for the patient, Mellender says.

Expanding Options

Scott Mellender
Photo: John Emerson
The regional anesthesia program takes a multi-modal approach, whether using nerve stimulation, ultrasound guidance, or both, says Scott J. Mellender, assistant professor of anesthesiology, and clinical director of the New Jersey Pain Institute at Robert Wood Johnson University Hospital.
 
We give patients choices a lot of places can’t,” says Kiss. These options not only enhance care, but also help patients feel more empowered, he says.

“As surgeons are realizing that patients are having good experiences using these techniques, it reinforces the benefits of regional anesthesia, so now it’s actually being requested. In some cases, they are even insisting on it,” says Fratzola.

Requests for regional anesthesia also are coming from patients, she says: “There are a lot of educated patients who have been going online, becoming more informed about regional anesthesia, and now know more about the different options than they did in the past.”

Tackling Chronic Pain

Regional anesthesia techniques have expanded beyond the operating room, into outpatient uses at facilities such as the New Jersey Pain Institute, Mellender says – for example, using epidural spinal injections for back pain, easing pain experienced after hernia operations or with metastatic cancer, and helping people get back to work or sports after an injury. And advances continue to be made overall in management of chronic pain.

“It all goes back to quality of life,” Mellender says. “We try to improve quality of life in the operating room, but beyond as well. People think they may have to live with their chronic pain for the rest of their life. We can decrease it, in some cases by 80 percent, and they are able to become fully functioning.”

For Jeff Gorsak, these methods helped make everyday life bearable.

A traumatic accident on January 11, 2011, left Gorsak with severe neck and back injuries and marked the beginning of his daily battle, living every moment with excruciating pain. He was unable to walk, his movements were severely limited, and he went more than two years without a full night’s sleep.

“It was an extreme challenge just to get through every day,” says Gorsak. “I was on opiates for the pain, but I don’t like pills and didn’t want to be on that medication.”

That’s when his neurosurgeon, Michael G. Nosko, associate professor of surgery and chief, division of neurosurgery, suggested spinal cord stimulation (SCS). SCS uses a small pulse generator, similar to a pacemaker, that is implanted under the skin to send the spinal cord low-voltage electrical pulses that interfere with pain signals from the nerves. A handheld programmer allows individuals to adjust the level of stimulation based on their pain level and activity.

Gorsak’s initial procedure, which allowed for a trial of the device before permanent implantation, was done in June 2013 by Mellender.

The results were immediate, Gorsak says.

“When Mellender did the trial – you’re awake, because you have to give feedback – at one point, I said, ‘That’s it; you’re done! You got the spot,’” he recalls. “I could feel the difference right away.”

During the initial procedure, electrical leads are placed in the epidural space with the intention of finding the proper coverage for all areas of pain, Mellender explains. An external device that functions the same as the permanent stimulator is provided, and patients are able to make adjustments based on a number of different settings, he adds. After a trial period of several days to determine whether the device would provide adequate relief, Gorsak returned to Nosko for the surgery to implant the permanent device.

With SCS, Gorsak has seen dramatic changes in his quality of life. He’s able to walk short distances with a cane or even, on smooth surfaces, unassisted. Three toes that he was unable to move prior to the procedure now have restored motion. And the catnap-only nights are a thing of the past, he says: “If I get woken up at night, I just adjust the setting and go back to sleep.”

The device is “always running for me, because I’m never without pain, but this helps keep it in check,” he adds. “I honestly don’t know what I would have done without it.”

While SCS is not technically a regional anesthesia technique, pain management and regional anesthesia go hand in hand, says Kiss, who first became interested in regional anesthesia during fellowship training in pain management. “The skill set is essentially the same for both,” he says. “It’s a continuum – acute pain intraoperatively in one, while the other deals with chronic pain – and we are able to provide that full continuum for our patients.”


This article was originally published in Robert Wood Johnson Medicine, Summer 2014.

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