Pain physician
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Case Reports
Fluoroscopically Guided C2 Percutaneous Vertebroplasty: A Surgical Technique Note on an Anterior Ascending Approach.
C2 vertebroplasty is more challenging than transpedicular percutaneous vertebroplasty in the thoracic and lumbar spine. ⋯ Vertebroplasty, pain, axis, cement leak, metastases, palliative medicine, spine, fracture.
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Opioid overdose continues to be a significant and growing cause of preventable mortality and morbidity. Studies suggest that unintentional, non-fatal overdose from prescription opioid analgesics constitutes a large portion of total overdose events. The societal burden associated with these events is a frequently overlooked public health concern. ⋯ Prescription, opioid, accidental drug overdose, unintentional overdose, drug poisoning, fentanyl, oxycodone, hydrocodone, methadone, oxymorphone, hydromorphone.
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Pudendal neuropathy is a tunnel syndrome characterized by pelvic pain and may include bowel, bladder, or sexual dysfunction or a combination of these. One treatment method, pudendal nerve perineural injections (PNPIs), uses infiltration of bupivacaine and corticosteroid around the nerve to provide symptom relief. Bupivacaine also anesthetizes the skin in the receptive field of the nerve that is injected. Bupivacaine offers rapid pain relief for several hours while corticosteroid provides delayed pain control often lasting 3 to 5 weeks. Not all pudendal nerve blocks may provide complete pain relief but long-term pain control from the steroid appears to be associated with immediate response to bupivacaine. We offer a method of evaluating the quality of a pudendal block on the day it is performed using pinprick sensation evaluation. ⋯ Pudendal neuralgia, chronic perineal pain, pudendal nerve block, sensory examination, neurologic examination, pain management, chronic pelvic pain syndrome.
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Case Reports
Novel Single Puncture Approach for Simplicity 3 Sacral Plexus Radiofrequency Ablation: Technical Note.
Radiofrequency (RF) ablation of the lateral sacral plexus has been used for the treatment of sacroiliac joint pain including as an adjunct to other palliative therapies for the treatment of painful osseous metastasis. The treatment goal is targeted ablation of the dorsal lateral branches of S1-S4. Though several techniques have been described, the Simplicity III (Neurotherm, Middleton, MA) system allows for ablation to be achieved with a single RF probe by utilizing a multi-electrode curved RF probe to create a continuous ablation line across all sacral nerves. In the standard approach, there is sequential introduction of a spinal needle along the desired ablation tract for local anesthesia followed by separate placement of the ablation probe. Though fluoroscopic guidance is utilized, multiple needle passes increase the risk of complication such as bowel perforation or probe insertion through a neural foramen. It may also extend procedure time and increase radiation dose. We illustrate a technique for Simplicity III RF ablation of the dorsal sacral plexus using a modified Seldinger approach for treatment of a patient with sacroiliac joint pain due to osseous renal cell carcinoma metastasis. The desired ablation tract is initially anesthetized via a hollow micropuncture needle. The needle is then exchanged for a peelaway sheath. The RF probe is inserted through the peelaway sheath thus ensuring the probe is placed precisely along the previously anesthetized tract allowing the procedure to be completed using a single percutaneous puncture. We believe that this approach decreases the risks of bowel perforation, patient discomfort as a result of multiple percutaneous punctures, and procedure time. ⋯ Simplicity 3, sacral plexus ablation, image-guided approach, modified Seldinger, chronic sacral pain, thin wall introducer needle.
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A cluster headache (CH) is an excruciating pain centered on the periorbital region and is accompanied by autonomic symptoms. Despite the best currently available medical therapy, many patients still suffer from these headaches. Some patients also experience CH with side shift of attacks, which makes treatment more difficult. In light of the pathophysiological mechanism of CH, the sphenopalatine ganglion (SPG) is a promising therapeutic target for its management. SPG ablation and non-ablation techniques have been the preferred treatment for CH in recent decades. However, few articles have reported the effectiveness of acute SPG stimulation for CH, and no studies have demonstrated the safety and efficacy of bilateral continuous SPG stimulation for CH. In this article, we report on a 59-year-old chronic cluster headache (CCH) patient who had side shifts of attacks and was treated with bilateral continuous SPG stimulation. The patient suffered from CCH for 9 years, and the intensity of pain and the frequency of attacks had gradually increased over time. At the time of admission, he experienced daily attacks. Medical therapy and SPG blocks were offered, but he only achieved transient pain relief. After a careful preoperative examination and discussion with the patient, we provided bilateral SPG stimulation. The electrode was implanted under C-arm fluoroscopic guidance. After continuous stimulation, the patient experienced significant reductions in headache severity. The frequency of attacks was reduced from daily to less than once per week. He also discontinued all of the related drugs that he was taking. This is the first report of bilateral continuous SPG stimulation for CCH. This report indicates that continuous SPG stimulation is a feasible therapeutic option for CCH. However, large-scale and long-term studies are required to elucidate the efficacy of SPG stimulation. ⋯ Cluster headache, sphenopalatine ganglion, SPG, neuromodulation, side shift, stimulation.