PAIN MANAGEMENT

Up to 4% of adults suffer from chronic headaches, mostly migraines.

Headache continues to be the most common pain complaint of patients presenting to general practitioners, internal medicine specialists, and neurologists. Although the various primary headache types (vascular: migraine and cluster; nonvascular: tension-type headache) may appear alone or in various combinations in the headache patient, cluster headache is felt by many experts to be the most debilitating. The diagnosis of headache is based on the case history and indications from the physical examination.

The primary treatment is medication, but in patients who are therapy resistant, interventional pain management can be considered.

Patients with neck and upper extremity pain and underlying multilevel cervical disc disease present special problems in the diagnosis and management of the primary pain generator. These lesions are routinely diagnosed on x-ray, computed tomography (CT), and magnetic resonance imaging (MRI) as degenerative, and not usually considered as a legitimate source for the patient’s pain complaints, resulting in undertreatment and delay in improving the baseline pain control. We present the most common spinal procedures utilized to diagnose and treat spinal pain. Minimally invasive interventional spine treatment involves discrete, well-controlled injection techniques directed at specific target sites in and around the spine, which usually involve the use of fluoroscopy and ultrasound to aid in the proper needle placement and in so doing, may help increase the accuracy and efficacy of the specific injection technique

The neuralgias involving the face are often misdiagnosed and seen initially by the dentist or otolaryngologist. Therefore, the ideal pain treatment is often delayed and patients may unnecessarily suffer from neuropathic pain until someone correctly recognizes the signs and refers the patient to a neurologist. The primary treatment is medication, however in patients who are treatment- resistant, interventional pain management in this area should only be carried out in specialized centers.

Low back pain doesn’t always come from the back. Physical diagnosis techniques exist to help differentiate back pain originating from other than the lumbar spine.

The etiologies of chronic low back pain are many, and sometimes diverse. While herniated disc, spinal stenosis, spondylosis, and facet arthropathy are often considered along with myofascial origins, myofascial trigger points have been shown as coexisting with the other commonly accepted causes. Therefore, myofascial trigger point injections are considered a significant treatment adjunct to low back pain. Additionally, prolotherapy, ultrasound guided injection or C-arm guided injection can be considered.

Diagnostic and Therapeutic Spinal Injections

Selective spinal injections are being performed with increasing frequency in the management of acute and chronic pain syndromes. A few of the most common indications for these diagnostic and therapeutic spinal procedures are noted as follows:

  • Spinal nerve radiculopathy
  • Spinal stenosis
  • Discogenic pain (i.e., symptomatic, internal disc disruption)
  • Contained, disc bulge, or protrusion vs. extruded or sequestered herniated disc
  • Multilevel degenerative disc disease
  • Facet joint arthropathy or associated facet joint nerve pain
  • Sacroiliac joint pain dysfunction
  • Failed back surgery syndrome (FBSS)
  • Epidural and/or perineural fibrosis/granulation with associated symptomatic pain
  • Complex regional pain syndrome (CRPS) (formerly known as reflex sympathetic dystrophy, RSD).

 

Although numerous interventional procedures are used to treat spinal-related pain conditions, a few of the most common types of diagnostic and therapeutic spinal injections are noted as follows:

  • Epidural steroid injections (translaminar, transforaminal, caudal)
  • Facet joint nerve blocks and facet joint intra-articular injections
  • Radiofrequency (RF) nerve ablation procedures
  • Sacroiliac joint and other intra-articular joint injections
  • Sympathetic ganglion nerve blocks
  • Diagnostic discographic injections
  • Epiduroscopic laser decompression

Shoulder pain represents a significant portion of musculoskeletal injuries, myofascial problems and Cervical radiculopathy etc. There are many risk factors including repetitive work, heavy work, age- related rotator cuff delamination (rotator cuff disease), shoulder joint problem, postural dysfunction, acromial hooking, degenerative disc disease and metabolic disease. The primary treatment is medication, but in patients who are therapy resistant, ultrasound guided injection or C-arm guided injection can be considered.

Elbow pain may involve the arm muscles, elbow ligaments and tendons, as well as the bones in the arm. Many elbow conditions are caused by overuse and sports injuries. Treatment varies, depending on the elbow disorder and symptoms you experience. Most elbow disorders require conservative treatment. Your treatment options include rest, non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, bracing or immobilization, steroid injections, elbow padding, prolotherapy and surgical treatments.

Hip pain is the general term for pain felt in or around the hip joint. It isn’t always felt in the hip itself but may instead be felt in the groin or thigh. While many causes of hip pain can arise from the joint itself, there are numerous structures surrounding the hip that can also be the source of pain. Trauma is often the cause of hip pain, but any source of inflammation may cause pain in the hip area.  The treatment of hip pain depends on the cause. The treatment typically involves bed rest, medications, and ultrasound guided injection or C-arm guided injection to relieve swelling and pain. Hip fractures, malformation of the hip, and some injuries may require surgical intervention to repair or replace the hip.

Treatments will vary, depending upon what exactly is causing your knee pain. Your doctor may prescribe medications to help relieve pain and to treat underlying conditions, such as rheumatoid arthritis or gout. Strengthening the muscles around your knee will make it more stable. Training is likely to focus on the muscles on the front of your thigh (quadriceps) and the muscles in the back of your thigh (hamstrings).  In certain conditions, different types of braces may be used to help protect and support the knee joint. In some cases, your doctor may suggest injecting medications or other substances directly into your joint. Examples include: Corticosteroids. Injections of a corticosteroid drug into your knee joint may help reduce the symptoms of an arthritis flare and provide pain relief that lasts a few months. These injections aren’t effective in all cases. Hyaluronic acid which is a thick fluid similar to the fluid that naturally lubricates joints, hyaluronic acid can be injected into your knee to improve mobility and ease pain. Although study results have been mixed about the effectiveness of this treatment, relief from one or a series of shots may last as long as six months. Platelet-rich plasma (PRP) contains a concentration of many different growth factors that appear to reduce inflammation and promote tissue healing. These types of injections tend to work better in younger people and in people with mild arthritis. Recently developed RF neurotomy of genicular nerves leads to significant pain reduction and functional improvement in a subset of elderly chronic knee OA pain.

Foot pain can occur due to certain lifestyle choices or a medical condition. Wearing high-heeled shoes can often cause foot pain because they place a great deal of pressure on the toes. You can also develop foot pain if you become injured during high-impact exercise or sports activities, such as jogging or intense aerobics. Various medical issues are closely associated with foot pain. Your feet are especially susceptible to the pain that occurs due to arthritis.  Diabetes can also cause complications and several disorders of the feet. People with diabetes are more prone to foot ulcers or sores and nerve damage in the feet. Other potential causes of foot pain include ingrown toe nails, neuromas, plantar fasciitis arthritis of the joints, and gout especially affecting the great toe. The treatment for your condition depends on the cause.

The initial aim of the evaluation of a patient with joint pain is to localize the source of the joint symptoms and to determine the type of pathophysiologic process responsible for their presence.

The differential diagnoses of joint pain are generated in large part from the history and physical examination. [1] Screening laboratory test results serve primarily to confirm clinical impressions. In patients with arthritis, the goals of treatment include relief of pain, restoration or maintenance of joint function, and prevention of joint damage. These goals are achieved with both pharmacologic and nonpharmacologic therapeutic modalities

Myofascial pain syndrome is a chronic pain disorder. In myofascial pain syndrome, pressure on sensitive points in your muscles (trigger points) causes pain in seemingly unrelated parts of your body. This is called referred pain. Myofascial pain syndrome typically occurs after a muscle has been contracted repetitively.

Treatment for myofascial pain syndrome typically includes medications, trigger point injections or physical therapy. In some people, just the act of inserting the needle into the trigger point helps break up the muscle tension. Called dry needling, this technique involves inserting a needle into several places in and around the trigger point.

Chronic post-surgical pain (CPSP) is one of the most common and serious complications after surgery. There is no universally agreed definition of CPSP. The incidence of CPSP varies from operation to operation and between studies, but what is clear is that it is common. Nerve injury during surgery has been implicated in the development of CPSP; some (but not all) patients with CPSP have neuropathic pain. Considering the multi-factorial pathogenesis of chronic pain is very important. Moreover, failed back surgery syndrome (also called FBSS, or failed back syndrome) is a misnomer, as it is not actually a syndrome – it is a very generalized term that is often used to describe the condition of patients who have not had a successful result with back surgery or spine surgery and have experienced continued pain after surgery. Spine surgery is basically able to accomplish only two things:

  1. Decompress a nerve root that is pinched, or
  2. Stabilize a painful joint.

Unfortunately, back surgery or spine surgery cannot literally cut out a patient’s pain. It is only able to change anatomy, and an anatomical lesion (injury) that is a probable cause of back pain must be identified prior to rather than after back surgery or spine surgery. The treatment for your condition depends on the cause.

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