Interventional Pain Medicine - need more Neurologists

[doctorlarry]

Hey guys,

Having been on the forums over the years, there is not much talk about one subspecialty of Neurology, Pain Medicine. Now I know its not as sexy as interventional stroke like nearly everyone else on the forum seems to want to pursue, but there are certain advantages.

If you're on the forum, more than likely you're a med student interested in or a resident of Neurology. In my experience, most neurologists run away from pain patients, but in reality, if you're going to practice neurology (even if you subspecialize in stroke, epilepsy, neuromuscular, etc.) you're still likely to do a lot of general neurology, and at least 50% of your pts will be coming in for some kind of pain. So instead of shying away or turfing these patients, why not embrace it.

Strictly from an interventional standpoint, let me list some of the procedures that pain specialists are able to offer their patients, aside from prescribing neurontin or lyrica and calling it the day.

Epidural steroid injections
Medial branch blocks
Radiofrequency ablation
Intraarticular joint injections
Sacroiliiac joint injections
Sympathetic blocks
Stellate ganglion blocks
Spinal cord stimulation
Occipital nerve blocks
Occipital nerve stimulation
Intrathecal pump delivery
Intradiscal Electrothermal Therapy
Percutaneous disc nucleoplasty
Vertebroplasty
Kyphoplasty
Among others...

There will be more image-guided interventions to come on the horizon, including CT- and Ultrasound-guidance. These procedures are cutting edge guys. This adds so much more to your arsenal. No longer is it 'diagnosis and adios.'

Look we do EMG's and read MRI's, prescribe neurontin, but then what? Imagine being able to provide the majority of your clinic patients with more options. We, the neurologists, not just your fellow anesthesiologists or physiatrists, should be able to provide these modalities to OUR patients after careful selection.

Now I'm sure I'll get a lot of negative feedback about opioid addiction, drug-seekers, where is the evidence, etc., but there are many facets of neurology that have negatives as well, including lacking strong data (even with interventional stroke!).

Overall, I think this is a really cool, cutting edge, interventional field. At the moment, it only requires a one year fellowship, as opposed to 3 total additional years if you do interventional stroke (ESN), for example.

I don't think many neuro types are aware of this, so I hope some would find this intriguing. There is certainly a greater need for more neurologists to pursue interventional pain medicine.

I will be pursuing my pain fellowship at Hopkins for next year. So feel free to PM me if you are interested in learning more.

Thanks for listening.

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[GoodmanBrown]

Do you have to do a fellowship in Pain to be able to some of those things? Because in the Pain forum, I was reading that it's harder for neurologists to get into pain fellowships...

 

[bonran]

I considered it, but then pain was too painful......
Headache & facial pain still interests me as long as it is not a 23yo female with 2yrs of continuous HA.

 

[doctorlarry]

Do you have to do a fellowship in Pain to be able to some of those things? Because in the Pain forum, I was reading that it's harder for neurologists to get into pain fellowships...

It would be safer for your patients and for you (for litigation reasons) by doing an ACGME accredited fellowship. It IS harder for us, but more programs are opening up, due in part to ACGME influence/guidelines. I was pleased to find that many of the more progressive, big name programs consider neurologists, and in some instances, this can work in your favor. It felt like I was the only neurologist interviewing this year. So it is possible, just takes a little hard work and planning. PM me if you have questions...

 

[doctorlarry]

I considered it, but then pain was too painful......
Headache & facial pain still interests me as long as it is not a 23yo female with 2yrs of continuous HA.

I can understand...but 230am stroke codes are MUCH more painful for me. Different strokes I suppose...

 

[GoodmanBrown]

It would be safer for your patients and for you (for litigation reasons) by doing an ACGME accredited fellowship. It IS harder for us, but more programs are opening up, due in part to ACGME influence/guidelines. I was pleased to find that many of the more progressive, big name programs consider neurologists, and in some instances, this can work in your favor. It felt like I was the only neurologist interviewing this year. So it is possible, just takes a little hard work and planning. PM me if you have questions...

Very interesting, thanks! I'm about 8 years from having to think about fellowships, but as medicine is a second career, I'm trying to think further out this time.

As a neurology trained pain specialist, can you actually treat more pain than an anesthesiology or PM&R trained doctor? It seems like headache is out of bounds for those folks, but would still be in your realm of knowledge.

 

[drusso]

Very interesting, thanks! I'm about 8 years from having to think about fellowships, but as medicine is a second career, I'm trying to think further out this time.

As a neurology trained pain specialist, can you actually treat more pain than an anesthesiology or PM&R trained doctor? It seems like headache is out of bounds for those folks, but would still be in your realm of knowledge.

I'm a PM&R interventional pain physician and I do headache management...probably a rarity.

I find that most general neurologists do primary headache management very poorly beyond episodic migraine. I will usually involve my neurology colleauges if there is a question of secondary headache, but increasingly have gotten more comfortable with the work-up for these too.

As a pain physician, I have at my disposal several diagnostic and therapeutic modalities for primary headache disorders including occipital nerve blocks, cervical medial branch blocks and denervation, sphenopalatine blocks, botox, etc.

 

[GoodmanBrown]

Are blocks in headache the norm? I hadn't heard much about using blocks for headache.

 

[doctorlarry]

I know that the following pain programs have accepted neurologists for fellowship training:

Hopkins
Mayo Rochester
MGH
UPitt
USF
Stanford
NYU
Columbia

Any other pain-boarded neurologists out there want to add to the list?

I am sure there are more, but these come to mind. Just thought I'd share.

 

[neurorehab]

From the opinions of some fellow anesthesiologists and physiatrists, it seems like the future of pain is bleak. Within the next 5 to 10 years, interventional pain medicine will take a huge hit. Reimbursements are dropping and the lack of evidence based medicine put a damper on the field for me personally. Any neurologists have any opinions on the matter?

 

[doctorlarry]

From the opinions of some fellow anesthesiologists and physiatrists, it seems like the future of pain is bleak. Within the next 5 to 10 years, interventional pain medicine will take a huge hit. Reimbursements are dropping and the lack of evidence based medicine put a damper on the field for me personally. Any neurologists have any opinions on the matter?

Sure, glad to. Since you already asked me this question on private message.

One can be part of the problem or part of the solution. In the clinic, how is the bulk of chronic axonal lumbar radiculopathy managed, assuming they are not surgical candidates? Sure we get MRI's and EMG's, but what can we do from a therapeutic standpoint? PT? Not much...unless they have associated pain. Then its Neurontin, Lyrica or maybe Cymbalta. How often do these patients become refractory to "the evidence", either by lack of effectiveness or poor tolerability?

Once "evidence-based" medicine is exhausted for a given patient, are we to throw in the towel and not offer other interventions that carry positive data. The field is relatively young. Evidence does not just appear overnight. Trust me, we (those of us who are interested in advancing the field) are working on the evidence. Remember, lack of evidence does not necessarily mean lack of efficacy.

Neurologists in general are evidence-driven, at times to a point where we limit our patients to treatment. I think we need more interested and open-minded, "glass is half full" neurologists in academic pain to help push the field to the next level, using our expertise in designing strong clinical trials, etc. Did you know neurologists once owned the field but then threw it away? What a shame! I commend our anesthesiology colleagues for advancing the field as far as they have, and have still opened their arms to welcome other fields such as physiatry, neurology and psychiatry. The interventions are there and often times they work. It's just a matter of time to put some of these interventions into the evidence box.

One thing is constant, and that is that patients with pain will always be in demand, and will often exhaust the evidence. In this way, perhaps there will be more demand for interventional pain treatments.

Its interesting that you are so certain about the future based on your anecdotes, I don't think anyone really knows what the future holds at this point. If Pain medicine takes a hit, many other specialties (even neuro-IR) may take a hit for the same reasons.

Either way, I'm glad to hear you are not interested in Pain. I just realized you're looking for a PGY2 spot in neurology, are you leaving Rehab? At least 50% of neurology patients come into clinic for a pain problem, so you'll see a lot of it. Feel free to PM me again...

 

[narcotics999]

Very nice post. I am thinking of pain medicine too.

University of washington also accepts neurologists for its pain fellowship.

I know that the following pain programs have accepted neurologists for fellowship training:

Hopkins
Mayo Rochester
MGH
UPitt
USF
Stanford
NYU
Columbia

Any other pain-boarded neurologists out there want to add to the list?

I am sure there are more, but these come to mind. Just thought I'd share.

 

[pmasque]

Thanks for the info doctorlarry, and for helping to open doors to future neurology pain specialists.
Right now the interventional pain electives at my school are offered from anesthesia or PM&R. I'm wondering if taking one is better than the other.

 

[doctorlarry]

For those who are interested, in Neurology...

http://www.neurology.org/cgi/content/full/67/8/1522

 

[doctorlarry]

Thanks for the info doctorlarry, and for helping to open doors to future neurology pain specialists.
Right now the interventional pain electives at my school are offered from anesthesia or PM&R. I'm wondering if taking one is better than the other.

I don't think that one would be 'better' than the other. Both specialties would provide a wealth of experience (interventional/needle experience, acute pain, regional procedures with anes; musculoskeletal exam, exposure to ultrasound-guided interventions, etc. with PM&R). If you are considering Anes or PM&R for residency, then the answer is clear. If you are considering Neuro for residency (as it seems you are), then I would choose the one that has the strongest presence in Pain and from whom you can develop a working relationship. PM me if needed.

 

[BlackFrancis33]

I'm a PM&R interventional pain physician and I do headache management...probably a rarity.

I find that most general neurologists do primary headache management very poorly beyond episodic migraine. I will usually involve my neurology colleauges if there is a question of secondary headache, but increasingly have gotten more comfortable with the work-up for these too.

As a pain physician, I have at my disposal several diagnostic and therapeutic modalities for primary headache disorders including occipital nerve blocks, cervical medial branch blocks and denervation, sphenopalatine blocks, botox, etc.

Wait a minute. General neurologists do very poorly beyond episodic migraine? I need to stand up for my specialty a bit. Who are these neurologists who see episodic migraine? I sure don't. CDH, CDH, CDH, some rare headache disorders and secondary headaches. True episodic migraine is a rarity in mine and most neurology practices. I could quote clinic epidemiology literature if needed.

It would be nice to study these procedures in a systematic manner and on a larger scale. I am sure this has been to some degree beyond my current knowledge of the literature. Chronic headache patients are a difficult population, figuring out which of these patients may need interventional pain procedures would be welcome. Personally, I see those patients that continue to have headaches despite various surgical and interventional pain procedures which are sometimes done with questionable indication. I am glad to hear that you have better success than what I have observed. Medical management definitely is not enough for many chronic headache patients. I definitely agree that neurologists should pursue interventional pain management to help identify the role of interventional pain in the management of chronic headache.