Pain physician
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Radiofrequency ablation (RFA) is a safe and effective pain therapy used to create sensory dysfunction in appropriate nerves via thermal damage. While commonly viewed as a simple process, RF heating is actually quite complex from an electrical engineering standpoint, and it is difficult for the non-electrical engineer to achieve a thorough understanding of the events that occur. RFA is highly influenced by the configuration and properties of the peri-electrode tissues. ⋯ A new paradigm for heating target tissue may be of value. Foremost in developing best practices for this procedure is avoiding pitfalls. Good RF heating and medial branch lesioning are the rewards for understanding how the process functions, attention to detail, and meticulous attention to electrode positioning.
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Propofol is a common induction agent that is utilized worldwide in the field of anesthesiology. In recent years, its potential therapeutic role in a variety of patient states has been demonstrated. Controversy exists regarding Propofol mediated analgesic and antihyperalgesic properties. ⋯ This clinical case demonstrates that Propofol could possibly have antihyperalgesic effects on opioid induced hyperalgesia caused by high-doses of chronic opioids and worsened by fentanyl. We postulate that a probable mechanism of complete pain relief after the procedure could be the inhibition of activity of the N-Methyl-D- Aspartate receptor by Propofol because it was the only agent the patient received during the procedure, causing a break of the cycle of opioid induced hyperalgesia. Additional research is required to clarify Propofol mediated or modulated analgesic properties in humans.
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Although there are several studies of systemic corticosteroid therapies in various doses and various durations in complex regional pain syndrome (CRPS), the outcome measurement parameters are limited to the range of motion measurements, edema, and symptoms of CRPS. ⋯ A short-term oral prednisolone therapy significantly reduced the symptoms and signs of CRPS, and improved the functional abilities and quality of life.
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Case Reports
Posttraumatic and postsurgical neuropathic pain responsive to treatment with capsaicin 8% topical patch.
Capsaicin 8% patch (Qutenza) is mainly used to treat postherpetic neuralgia and human immunodeficiency virus-associated neuropathy. However, evidence of the efficacy of Qutenza in other forms of neuropathic pain is lacking. A 24-year old Libyan man, with no previous medical history, sustained multiple wounds in the right side of the chest and back after a bomb explosion. ⋯ Interestingly, the most important finding was that capsaicin 8% patch showed a more than 80% reduction of the area of allodynia associated with the pain, when other treatments failed. Moreover, although recent data showed that in patients who respond to Qutenza, analgesia starts within a few days of treatment and lasts on average 5 months, our patient showed an initial response within 7 days of treatment but a longer duration of more than 18 months. Although further controlled studies are needed to explore the efficacy of the capsaicin 8% patch in patients who experience posttraumatic neuropathic pain, we encourage clinicians to try the capsaicin 8% patch when alternative treatments fail.
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Image guided intercostal blocks are commonly performed and considered relatively safe. Chemical denervation is commonly used in clinical practice for treatment of chronic non-cancer associated pain. ⋯ This case offers several lessons for a pain specialist including 1) the potential for a neurologic catastrophe (spinal cord injury) from aqueous neurolytic intercostal blocks despite "safe" contrast spread; 2) potential mechanisms of neurogenic injury with intercostal blocks; 3) review of modifiable factors to decrease the risk of neurogenic injury; and 4) review of potential interventions (steroids, lumbar drain) to improve outcome in the setting of iatrogenic procedural related spinal cord injury.