Last two decades have seen tremendous advances in our understanding of mechanisms that underlie in causation of pain and the treatment of patients with acute and chronic pain. This has resulted chiefly due to an extensive experimental and clinical research being undertaken to understand the pathophysiology of pain.The concept of a Pain Clinic was first advocated by Bonica in 1950s and further enriched by inputs from Fordyce and Sternbach in 1970s. It is now widely agreed that Pain Clinics have an important role to play in the health care systems of the developing countries and cater to a very large number of chronic pain patients including those with intractable cancer pain. The pain clinicians in these countries have the dilemma of providing the best pain treatment but within the resources available for the purpose. Keeping pace with the technological advances in pain management worldwide, pain clinics in developing countries are also employing newer methods of pain assessment, pain imaging and advanced interventional strategies for managing patients with chronic pain.

Because chronic pain is so complex, there are often multiple treatment goals. These goals may include more comfort (being "pain-free" is often not possible when pain has become chronic), better physical functioning, improved coping and less distress, getting back to work, helping the family cope, and other positive outcomes. To accomplish these goals, chronic pain often is best managed using what is called a "multimodality" approach. A multimodality approach to chronic pain includes a combination of therapies selected from eight broad categories:

• Drug therapies
• Psychological therapies
• Rehabilitative therapies
• Interventional therapies
• Neurostimulatory therapies
• Surgical therapies
• Complementary and Alternative medicine therapies
In many cases, a multimodality strategy requires the involvement of several types of health care professionals -the interdisciplinary team. Effective pain management is therefore collaborative in nature, involving good communication among the patient, family, and the practitioners involved in the care

Interventional Pain Management in India
Today pain management in India is a rapidly growing super-specialty. Though there are very few pain consultants but in recent years many Anesthesiologists have shown inclination towards this specialty. Unfortunately awareness about pain management among medical professionals is very limited. In contrast to USA and other developed countries Indian medical community is not aware of interventional pain management techniques which can be helpful for many patients suffering from intractable chronic pain.

Efforts are being made by arranging CME’s for general practitioners, medical consultants and other related specialties to spread the knowledge among our colleagues. Another important aspect would be to increase general public awareness by organizing pain camps, lectures or supplying pain treatment information booklets. This will definitely help the specialty to grow faster.

Interventional pain management involves special procedures to treat and manage pain. "Interventional" procedures might include an injection of an anesthetic medicine or steroid around nerves, tendons, joints or muscles; spinal cord stimulation; insertion of a drug delivery system; or a procedure with radio-frequency ablation or cryoablation to stop a nerve from working for a long period of time. Patients needing interventional pain management services suffer distress and discomfort caused by a variety of conditions and disorders, including:

These Guidelines are intended for use by anesthesiologists and health care personnel who deliver care under the direct supervision of anesthesiologists. The Guidelines do not compare the relative effectiveness of different interventions. They are not intended to provide treatment algorithms for specific pain syndromes. Complementary therapies are beyond the scope of these Guidelines

• Chronic low back and neck pain
• Chronic reflex sympathetic dystrophy (RSD) or complex regional pain syndrome
• Chronic head, mouth and face pain
• Postsurgical procedures
• Malignancy
• Post-traumatic pain syndrome
• Muscle and/or bone pain

The interventional pain management provides the most sophisticated and complex treatments available, including :
• Epidural /Transforaminal injections (cervical, thoracic, lumbar and caudal)
• Selective epidural and root blocks (cervical, thoracic, lumbar and sacral)
• Facet injections and medical branch blocks (cervical, thoracic and lumbar)
• Sympathetic blocks (stellate ganglion, thoracic, lumbar and hypogastric)
• Discography
• Percutaneous Nucleoplasty
• Epiduroscopy
• Ozone discectomy
• Peripheral nerve blocks
• Radiofrequency denervation
• Spinal cord stimulation
• Neurolytics of celiac plexus and cancer pain
• Intrathecal and epidural infusion systems

Equipment required for Interventional pain management
• Radiofrequency generator machine - Radiofrequency (RF) lesioning is a safe, proven means of treating chronic pain. Continuous radiofrequency current is used to heat a small volume of nerve tissue, thereby disrupting pain signals from that specific area. This procedure has a selective effect on nerve fibres, reducing pain in target areas, but leaving other sensory capabilities intact.
• RF cannula and electrodes of different sizes.
• C – Arm – helps in performing all procedures under direct radiological guidance.
• C-Arm compatible O T table.
• Implantable opiate pumps and equipped operation theater to perform these procedures
• Epiduroscope
• Cryoneurolysis machines
• Spinal cord stimulation equipment
• Infusion pumps etc
Equipment used to perform various pain procedures are quite expensive. Radiofrequency generator used in many RF neuroablation machine costs anywhere between Rs 14-25 lacs depending on the model chosen. Each disposable RF cannula costs between Rs 2000 – Rs 4000 (we might need to use 2-8 cannula’s per procedure as required. Very few companies manufacturing these RF machines have there base in India. C-Arm with compatible O T table costs approximately 12-15 lacs. Epiduroscope costs approximately 8 lacs. I feel the cost will go down in next few years as demand increases. What we need to do is to make doctors, industry people and patients aware about treatment options available with us. This will increase the turnover and ultimately reduce the cost.

In the Indian scenario,we can initiate interventional pain management with few essential equipments and then add on other equipment as per our needs and patient profile.I feel the basic requirements for initiating interventions are:

• C – Arm – for performing all procedures under direct radiological guidance.
• C-Arm compatible O T table.
• Infusion Pumps/Disposable infusion pumps for continuous infusion therapy
• Cryoneurolysis machine
• Nerve Locator/Special insulated needle
• Disposables for Epidural/spinal/continuous plexus block

Training in Interventional Pain Techniques
As of today training in pain management is available only abroad or very few centres in India. Many of Interventional pain specialists are trained abroad. There are efforts made by few of the interventional pain physicians to conduct training programmes for anaesthesiologists. National and International pain conferences, cadaveric hands on training and live demonstration of various pain procedures are conducted for this purpose.

With the advancement of technology and science, we have unveiled many aspects of the pain and its treatment. We have to work hard to spread the knowledge of interventional pain techniques among anaesthesiologists, colleagues from other specialty, patients (general public) and industry people. Our goal is to help people suffering from pain, make them productive human being for the society and increase their self esteem so that they can live life as normal individuals.