Uncategorized Facts and Solutions

Peripheral Neuropathy

Tuesday, February 24th, 2009

Peripheral neuropathy is a common cause of chronic pain.  Causes of peripheral nerve damage include diabetes, autoimmune disorders, nutritional deficiencies, alcohol abuse, inherited diseases, and toxic drug exposure.  Approximately 15% of diabetics experience some form of peripheral neuropathy.

Initially, patients develop numbness and/or weakness in the hands or feet.  Early on, this involves the fingers and toes, but can work its way up the limbs.  Patients experience burning pain in the extremities – most commonly involving the feet.

Treatment is centered on the underlying disease.  Pain therapy involves medication management centered on neuropathic pain medications. In some cases, Spinal Cord Stimulation can be an effective long-term therapy.

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Neuropathic Pain Medications

Tuesday, February 24th, 2009

The treatment of neuropathic pain can be very difficult.  It is often necessary to conduct trials of multiple medications before finding the best regimen.  It is important to be patient as effective medications for one individual may be different than others.   These medications include:

Anti-epileptic (anti-seizure) medication – gabapentin, pregabalin, carbamazapine, etc.

Antidepressant medication  - tricyclics (e.g. amitriptyline), SSRIs (e.g. duloxetine)

Topicals – Local anesthetic preparations (creams, gels, patches), other compounded creams


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Post-Amputation Pain

Tuesday, February 24th, 2009

After limb amputation, chronic pain can be a major issue.  Pain at the stump site can be a nagging problem due to recurrent infection, skin breakdown, pressure ulcers from prosthetic devices, etc.  Neuromas (abnormal overgrowth of nerve fibers) can also form at the site of amputation and can cause severe neuropathic pain.

After amputation, patients often have phantom limb sensation.  They sense the feeling of the body part that is no longer there.  Normal sensation is generally not a problem, but occasionally these can be painful (Phantom Limb Pain).  Patients experience severe shooting and burning pain in the limb that was already amputated.

Treatment initially involves medication management centered on neuropathic pain medications.  Psychological / cognitive behavioral therapy is also very important.  Spinal Cord Stimulation has been shown to be a very effective long-term therapy.

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Medial Branch Nerve Blocks

Tuesday, November 11th, 2008

Medial branch nerve blocks are a diagnostic test for facet joint arthropathy.  This test can be done in the cervical, thoracic, and lumbar spines.  I perform this procedure under intermittent X-ray guidance to localize the exact area of the nerve.  Each facet joint has two nerves that supply it.  By performing a local anesthetic block, facet arthropathy can be diagnosed or excluded.  After the injection, facet-loading maneuvers are performed.  In the low back, I have the patient bend back at the waist and to the affected side.  In the neck, this is done by the patient laterally flexing the neck (touching the ear to the shoulder).  If the pain is absent after the block, a diagnosis can be made.  This normally will only result in short-term relief.  However, with this information, radiofrequency ablation of these nerves can now be performed.  That will result in long-term relief.

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Facet Joint Arthropathy

Tuesday, November 11th, 2008

Facet arthropathy can affect the cervical, thoracic, and/or lumbar spine.  These small joints, also known as z-joints or zygapophysial joints, can be affected acutely or damaged from chronic wear and tear.  In the low back, these joints can be loaded or stressed by extension and lateral rotation (bending back at the waist and to one side).  If your usual pain is reproduced when making this motion without any leg pain, this is likely pain from your facet joints.  Pain can sometimes radiate to the buttocks and/or thigh, but rarely below the knee. 


In the neck, facet pain is reproduced when laterally flexing the neck (trying to touch your ear to your shoulder), as well as extending the neck (looking upwards).


Each individual joint has two nerves that supply it called medial branches.  These nerves are important in the treatment of facet-mediated pain.  This treatment involves medial branch nerve blocks and radiofrequency nerve ablation.


X-rays and MRIs can sometimes be helpful in diagnosing facet pain, but physical exam and diagnostic medial branch nerve blocks are most accurate.

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