Lessons from the Front
Questions for Lt. Col Chester C. Buckenmaier, III
In the February, 2005 issue of Wired, Lt. Col Chester
C. Buckenmaier, III talks about casualties in Iraq. He believes
the future of wartime pain control is a new form of
anesthesia called a continuous peripheral nerve block, which
takes a more targeted approach by switching off only the pain
signals coming from the injured limb, leaving patients' vital
signs and cortical functions unimpaired. Further in
the article, it says, Pioneered in experimental programs
at Duke University and St. Luke's-Roosevelt Hospital in New
York City, continuous peripheral nerve blocks could transform
civilian medicine in the next few years by reducing the incidence
of chronic pain
" Further, this technique "will
enable patients to take control of their own pain relief at
home, with less dependence on addictive pharmaceuticals.
We were intrigued by this, and asked Lt. Col Buckenmaier,
an acute pain specialist at Walter Reed Army Medical Center
(WRAMC), about this technique and its potential use for people
Q: Could physicians use regional anesthesia, continuous
peripheral nerve blocks, for peoples who have complex regional
Yes. It is a technique we use at WRAMC to provide patients
with a 'pain free interval.' We believe this temporary adjustment
in the afferent pain input from the affected CRPS area allows
the brain to 'reset,' often resulting in improvement in symptoms
when the block is resolved. Currently, this treatment is purely
investigational and has not been formally studies to my knowledge.
Again, it is a treatment option we employ at WRAMC.
Q: What about using it for other neuropathic pain syndromes?
Regional anesthesia blocks for a variety of chronic pain syndromes
are common in chronic pain practice. Though I practice chronic
pain medicine, my specialty is acute pain and perioperative
medicine. Chronic pain is a clinical, outpatient activity
while acute pain is an inpatient hospital activity. We have
a close working relationship with chronic pain but our focus
Q: Could this be used as a preventative measure, to keep
acute pain from becoming chronic pain?
We know that uncontrolled pain has a number of ill effects
on the body- depressed immune function, increased stress response
to surgery, up-regulation of inflammatory mediators, to name
just a few. We believe that true preemptive pain control (pain
management before, after, and long after the surgical insult)
has a positive impact on patient recovery and possibly limits
the development of chronic pain. You have essentially hit
on the fundamental question for regional anesthesia and advanced
pain control. Do we impact on morbidity and chronic pain states?
We are hoping our Regional Anesthesia Combat Casualty database
will help us begin to answer this question. We have the largest
cohort of wounded soldiers, many with amputation, who have
been exposed to regional anesthesia during their care. We
plan to compare these soldiers to other databases with soldiers
who did not receive this intervention. This is a fundamental
question that the Army Regional Anesthesia & Pain Management
Initiative is trying to answer.
Q: Is it appropriate for chronic pain patients? With any
It is appropriate for a variety of chronic pain patients as
one of a variety of therapies. Because it is an invasive technique,
it is usually reserved for the most difficult cases.
Q: Have any studies have been conducted on this procedure
for long-term pain relief? Studies are available that
have tried to define an impact of regional anesthesia on phantom
limb pain following amputation. Results have been mildly encouraging.
The biggest problem with these studies in the 'n' number (sample
size) of participants is usually very small. Considerable
work remains to be done in this field of study. I am hopeful
our database will help clarify some of these issues.
Q: Are you seeing many soldiers returning from the war
with symptoms of CRPS?
No, CRPS is a rare condition that strikes patients with a
variety of injuries. Some people with CRPS have the condition
begin with something as simple as an ankle strain. The use
of regional anesthesia for the management of CRPS is an interesting
footnote; it is not the focus of our organization. We are
specifically interested in how pain adversely affects recovery
from major surgery (an improvised explosive device that blows
off a soldier's leg for example) and how we can improve on
pain management in general after surgery. While regional anesthesia
is a focus of our organization because it is so effective,
it is just a slice of the whole pain management pie.
We are the Army Regional Anesthesia & Pain Management
Initiative, we are also interested in innovative uses of narcotics,
ketamine (and other NMDA receptor antagonists), new nanotechnology
pain medications on the horizon, NSAIDS, drug combinations,
and true multimodal pain therapy. We are working very hard
to improve the experience of our soldiers in the current war
to ease the strain of the very successful but difficult evacuation
realities facing them after wounding.
1. Silberman S. The Painful Truth. Wired Magazine.
2005 February;13(02). Available at http://www.wired.com/wired/archive/13.02/pain.html?pg=6