Pain physician
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Instituting drug holidays for chronic opioid using patients is becoming commonplace for pain practitioners initiating procedures such as intrathecal pump or spinal cord stimulator trials. As such, pain practitioners need to be adept in their management of acute opioid withdrawal. Successfully weaning an opioid dependent patient off of chronic opioids requires a thorough knowledge of the available adjuvants to assist in this process. ⋯ We present a case in which refractory muscle spasms secondary to opioid withdrawal were successfully treated with an over-the-counter supplement that is not typically used for the attenuation of opioid withdrawal symptoms. In a patient intolerant to the side effects of clonidine, we were able to successfully wean chronic opiates by treating refractory muscle spasms with the serotonin precursor, 5-hydroxytryptophan (5-HTP). We hypothesize that our success with this medication gives further credence to the role of serotonin in opioid withdrawal somatic symptomatology, and supports the need for future research to clarify the role of serotonin precursors or serotonin modulating drugs as potential alternatives in those unable to follow standard treatment protocols.
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Although pharmacological therapy is the primary treatment modality for trigeminal neuralgia associated pain, ineffective analgesia and dose limiting side effects often prompt patients to seek alternative pharmacological solutions such as interventional nerve blockade. Blockade of the Gasserian ganglion or its branches is an effective analgesic procedure for trigeminal neuralgia, traditionally performed using fluoroscopy or CT imaging. Ultrasonography allows point of care and real time visualization of needle placement within the surrounding anatomical structures. ⋯ The decision was made that the patient was a suitable candidate for pulsed radiofrequency application in the pterygopalatine fossa. We successfully used an alternative approach through the pterygopalatine fossa to treat trigeminal neuralgia using ultrasound guidance in an office setting. Our case demonstrates the utility of ultrasound-guidance pulsed radiofrequency treatment in the pterygopalatine fossa as a potential alternative to other percutaneous techniques for patients with medical refractory trigeminal neuralgia.
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Psychological factors are recognised as influencing the outcome of spinal cord stimulation (SCS) although there is currently no consensus as to which factors impact upon SCS efficacy. ⋯ This study demonstrates that psychological aspects such as depression and autonomous coping may impact SCS treatment. Addressing these issues prior to SCS implantation may improve SCS long-term outcome.