Clinical Report: Interventional Pain Services in a Large African Teaching Hospital

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Introduction

Chronic pain affects approximately 10% to 20% of patients in primary care and is among the most personally compelling reasons for seeking medical attention. Worldwide, about one-half of patients with chronic pain report low back pain, among other conditions, one-fifth report widespread pain and one third report shoulder pain. People seek health care for pain not only for diagnostic evaluation and symptom relief, but also because pain interferes with daily activities, causes worry, emotional distress and undermines confidence in one’s health. When pain persists for weeks or months, its broader effects on well-being can be profound. Psychological health and performance of social responsibilities in work and family life can be significantly impaired. Delays in treatment and/or lack of appropriate facilities for treating chronic pain conditions are particularly damaging. In a systematic review, patients with chronic pain who had to wait 6 months from the time of referral until treatment had significant deterioration in health-related quality of life (QOL) and psychological well-being.  In older adults, these issues are especially common, as undertreated pain can lead to reduced QOL, decreased socialization, depression, and sleep disturbances.  Higher levels of comorbidity are associated with reports of more severe pain, more depressive symptoms, reduced activity, and greater physical impact from pain.  Numerous clinical conditions are associated with chronic pain, typically identified by the site of injury (e.g., low back, carpal tunnel, head, neck, viscera) or type of injury (e.g arthritic, cancer, diabetic, myofascial, neuropathic).  Among the most common is chronic low back pain, which has an annual prevalence rate of 15% to 45%.8  Osteoarthritis affects nearly 27 million US adults, and fibromyalgia affects 5 million.

In most African hospitals, treatments of chronic pain do not go beyond prescription  of  oral  and systemic medications (paracetamol and nonsteroidal anti-inflammatory drugs), low-potency opioids (tramadol and pentazocine), bed rest with or without spinal traction, and some sessions of physiotherapy. The scope of this multidisciplinary treatment approach can be expanded with better outcomes if appropriate interventional pain therapies can  be employed in the management plan. The limitation of this desired broadened conservative treatment is lack of the technical skills and appropriate equipment in most tertiary health centers in Africa. In the 500-bed hospital in this report, there is only one C-arm machine for the orthopedic, cardiothoracic, and spine procedures  in the hospital. This scenario often produces competition for use among these professionals. Additionally, there is a lack of expertise in interventional pain medicine.

Due to the limitations of the available treatment modalities in this African practice environment, the decision was made to seek further training and assis- tance. A  visit  to  the  Departments of Palliative  Care, Rehabilitation Medicine, and Pain Medicine in 2009 ignited my passion to learn the clinical art, science, skills and techniques of interventional pain management, which are virtually nonexistent in any of the Central and Sub-Saharan African countries.

The challenges ahead included the acquisition of necessary pain materials, strong and formidable mentors in the field of pain medicine, mandatory attendance of courses and workshops on interventional pain manage- ment, acquisition of pain equipment and consumables, adaption to African environment, the provision of the interventional pain management services, and the huge number of patients suffering from varied chronic pain conditions.

The experience began in 2009 with a visit to the Department of Pain Medicine, University of Texas, MD Anderson Cancer Center, Houston. Evidence-based interventional techniques were observed for the treat- ment of chronic pain conditions in the United States, as opposed to therapies used for similar conditions in Nigeria. The comparative rapidity of pain relief in many patients treated with interventional techniques was encouraging.

With help of the WIP foundation, I was able to attend various meetings and workshops for more training. Dr. Gabor Racz donated teaching materials including textbooks, DVDs of various techniques, and other educational items. Having realized that specific pain therapies and treatment can only be learned from a firsthand exposure, I sought for a month clinical placement in Houston Pain Associates, Houston, Texas and Pain Medicine Department, MD Anderson Cancer Center, Houston, to help further my knowledge of treating cancer pain and other chronic pain conditions. While in Houston, I learned firsthand and observed various interventional pain therapies for different chronic pain conditions. This experience helped me to put the knowledge I had gained from various international pain workshops and conferences into proper perspective.

Just as I was finishing my visit at the Houston Pain Associates, Drs. Gabor Racz and Philip Finch donated a used radiofrequency (RF) machine. This would allow me to manage patients with trigeminal neuralgia and facet joints pain. With the fulfillment of basic require- ments including acquisition of associated risk manage- ment skills, the availability of a C-arm in my hospital, a few necessary consumables, and the RF machine, the ground was set for the initiation of a pain service that included image-guided interventional pain therapies in our hospital. With the help of my colleagues in the Anaesthesia department, I was able to introduce inter- ventional pain procedures at the Illorin Teaching Hos- pital, and report here the first cases.

Read Full Clinical Report: Suleiman et al 2013

Zakari Suleiman, MBBS, FWACS; Allen W. Burton, MD, FIPP
Department of Anaesthesia, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria; Houston Pain Associates, PLLC, Houston, Texas, U.S.A