Pain physician
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Deafferentation pain secondary to brachial plexus avulsion, spinal cord injury, and other peripheral nerve injuries is often refractory to conventional treatments. Stimulation of the primary motor cortex (M1) has been proven to be an effective treatment for intractable deafferentation pain. The mechanisms underlying the attenuation of deafferentation pain by motor cortex stimulation remain hypothetical. ⋯ This study implies that a single session of 20 Hz rTMS over the motor cortex could reduce the pain level in patients suffering from long-term, intractable deafferentation pain. The stimulation of the M1 induces deactivation in the ACC, insula, and caudate nucleus. The changes in these pain-related regions may mirror an adaptive mechanism to pain relief after rTMS treatment.
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Case Reports
Resolution of long standing tinnitus following radiofrequency ablation of C2-C3 medial branches--a case report.
Tinnitus is described as an auditory phantom perception analogous to central neuropathic pain. Despite the high prevalence of this debilitating symptom, no intervention is recognized that reliably eliminates tinnitus symptoms; a cause has yet to be determined. A 65-year-old healthy man presented with a 3 year history of left-sided tinnitus. ⋯ Upper cervical nerve (C2) electrical stimulation evokes potentials in the DCN, eliciting strong patterns of inhibition and weak excitation of the DCN principal cells. New evidence demonstrated successful transcutaneous electrical nerve stimulation (TENS) of upper cervical nerve (C2) for treatment of somatic tinnitus in 240 patients. This case indicates that C2-C3 facet arthropathy may cause tinnitus and radiofrequency ablation of C2-C3 medial branches can provide an effective approach not previously considered.
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Transforaminal epidural steroid injections (TFESI) are a mainstay in the treatment of spine pain. Though this commonly performed procedure is generally felt to be safe, devastating complications following inadvertent intra-arterial injections of particulate steroid have been reported. The use of digital subtraction angiography (DSA) has been suggested as a means of detecting intra-arterial needle placements prior to medication injection. ⋯ DSA detected additional 5.26% intravascular needle placements following traditional methods. Our findings also support other studies that conclude TFESI are generally a safe procedure. We recommend that special attention should be paid to the sacral injections as vascular penetration was statistically higher than at other levels.
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Prescription drug abuse is the fastest growing drug problem in the United States, and the increase in unintentional drug overdose deaths has been driven by the increase in opioid analgesic use. Given the epidemic of non-medical prescription pain reliever use and the current medico-legal climate, it is increasingly important for the prescriber to monitor for medication compliance. ⋯ The limitations include the study was performed in a single academic center in an urban community. Also, there is a paucity of literature regarding windows of detection for OF analysis compared to urine. IRB: APPROVED - Allegheny-Singer Research Institute West Penn Allegheny Heath System (ASRI-WPAHS) - IRB Study #FWA00015120.
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Management of pain from skeletal metastases is notoriously difficult. Case reports and case series have described radiofrequency ablation of the obturator nerve branches to the femoral head for treatment of intractable hip pain. Ablation of the obturator branches to the femoral head is technically difficult because of bony and vascular anatomy, including close proximity of the femoral vessels. ⋯ Real-time ultrasound guidance was used to avoid vascular puncture. Thermal radiofrequency ablation resulted in sustained pain relief, and resumption in the ability of the patient to ambulate. From this case we suggest that an anterior approach to the obturator nerve branches to the femoral head may be technically feasible using combined ultrasound and fluoroscopic guidance to avoid vascular puncture.