Pain physician
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Postdural puncture headache (PDPH) is a known complication of diagnostic lumbar puncture. Multiple factors including needle size, type, and needle bevel orientation, have been postulated to contribute to the development of PDPH. The presentation of PDPH tends to have classic symptoms that include a postural headache, nausea, vomiting, tinnitus, and ocular disturbances. Conservative treatment measures include bed rest, intravenous hydration or caffeine, and analgesics. Resistant cases might require an epidural blood patch (EBP). Though complications are rare, cases of immediate post-procedural pain and subdural epidural hematoma have been reported. Here we present a case of PDPH treated with sequential EBPs that resulted in delayed radicular pain. ⋯ Although EBP is typically a safe procedure, complications might occur. An inflammatory response, secondary to the injection of blood, or mechanical compression, due to the total volume of blood injection, are highlighted as possible causative agents in the development of this complication. The role of fluoroscopic imaging, particularly in patients who have failed an initial EBP, must also be examined. Given the rates of false loss of resistance (17-30%) reported in the literature, the use of real-time imaging to ensure proper needle placement and subsequent injectate spread should be considered.
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The synthetic opioid methadone is a promising analgesic for the management of chronic neuropathic pain. Methadone therapy is increasing as its advantages are being realized over other opioids. Methadone's lack of known active metabolites, high oral bioavailability, low cost, and its additional receptor activity as an antagonist of N-methyl-D-aspartate receptors make it an attractive analgesic. ⋯ The majority of survey responders (90%) prescribed methadone in their pain practice, but on a very limited basis; 59% state <20% of their patients are on methadone. Three times a day dosing schedule was the most typical regimen (57%) while 77% prefer to titrate up on the dosage. It seems interesting that many clinicians do not prescribe methadone as a primary analgesic. One reason for this is due to the social stigma of its use in treatment of heroin addicts. Also, a lack of widely recognized treatment algorithms or guidelines to assist clinicians with opioid conversions and maintenance might be playing a role. The role of stigma as a barrier to adequate treatment of chronic pain among pain physicians prescribing practices is a fundamental, yet unexplored issue.