[Show abstract][Hide abstract] ABSTRACT: Transforaminal epidural steroid injections are provided frequently for patients with lumbar radiculopathy, having demonstrated efficacy and safety. We present a patient who developed methicillin-resistant Staphylococcus aureus epidural abscess 11 days after a transforaminal epidural steroid injection. The abscess required surgical intervention and intravenous vancomycin. Fortunately, the patient made a full recovery, and continues to do well one year later. The incidence, etiology and treatment of epidural injection-related infections are reviewed.
[Show abstract][Hide abstract] ABSTRACT: Setting: Tertiary care university hospital. Patient: A 48-year-old man with coccydynia. Case Description: The patient, who had multiple sclerosis, presented to our clinic with a 3-year history of coccygeal pain. Pain varied from 5 to 10 on a scale of 10 and was described as a sharp, knife-like, burning, stabbing, and achy pain. Walking, sitting, standing, and bending exacerbated pain. Alleviating factors included using topical capsaicin. The patient tried multiple medications without relief. Poor sleep parameters were noted. Strength was 2/5 on the left and 3/5 in the right lower extremity. Upper-extremity strength was normal. Assessment/Results: The patient was diagnosed with coccydynia. Fluoroscopically guided ganglion impar blocks were performed on February 4 and Feburary 8, 2002; the blocks resulted in 50% to 60% pain relief. A caudal epidural steroid injection, performed on March 4, 2002, under fluoroscopy, did not provide any relief. Pulsed radiofrequency denervation of the ganglion impar was performed under fluoroscopy on June 20, 2002, with good pain control noted. Discussion: Ganglion impar, also known as the ganglion of Walther, supplies some innervation for the pelvic and perineal regions, and it was initially blocked by Plancarte in 1990. To our knowledge, its effectiveness for coccydynia has not been published. We present 1 patient who experienced dramatic improvement in his coccygeal pain after blocking the ganglion impar under fluoroscopy. Successful pain control aids rehabilitation. The ganglion impar is the most caudal of the sympathetic prevertebral ganglion and supplies sympathetic fibers to the perineum. It is located anterior to the sacroccygeal junction. Blocking the ganglion impar has demonstrated considerable relief of intractable perineal and pelvic pain. Due to its location, bowel and bladder dysfunction are potential risks. Penetration of the rectum is a potential complication. Conclusions: Fluoroscopically guided ganglion impar block may offer a safe and effective way of improving coccygeal pain.
Archives of Physical Medicine and Rehabilitation 09/2003; 84(9). DOI:10.1016/S0003-9993(03)00653-1 · 2.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Transforaminal epidural steroid injections under fluoroscopy are an alternative treatment for lower back pain with radiculopathy. We followed 82 patients with a standardized telephone questionnaire at 2, 6, and 12 months after the first injection, in order to assess their effectiveness. Ninety-two patients with radiculopathic back pain due to spinal stenosis, herniated discs, spondylolisthesis, and degenerated discs, underwent transforaminal epidural steroid injections under fluoroscopy. Eighty-two patients were followed with a standardized telephone questionnaire. The population was divided into four groups: Group I, previous back surgery (16%); Group II, discogenic abnormalities: herniations, bulges, or degeneration, (42%); Group III, spinal stenosis (32%); Group IV, those without MRI (11%). Age ranged between 24 to 99 years, mean 64.5. Forty-seven were female, 35 male. Thirteen patients (16%) underwent one procedure, 27 patients (33%) two, 37 patients (45%) three, and five patients (6%) four, an average 2.4 procedures per patient. The pain scores for all patients improved significantly at all three time points (2, 6 and 12 months) compared to the initial mean pain score of 7.3 to mean pain scores of 3.4, 4.5 and 3.9 respectively. After one year, 36 patients did not take any pain medications. Greater than 50% improvement after one year was seen in 23% of Group I; 59% in Group II; 35% in Group III and 67% in Group IV. Transforaminal epidural steroid injections can offer significant pain reduction up to one year after initiation of treatment in patients with discogenic pain and possibly in patients with spinal stenosis.
[Show abstract][Hide abstract] ABSTRACT: Neuropathic pain is a challenge for clinicians because it is resistant to commonly prescribed analgesics, such as opioids and nonsteroidal antiinflammatory drugs. Fortunately, adjuvant analgesics, drugs not typically thought of as pain relievers, may be effective. It is helpful to classify adjuvant analgesics used to treat neuropathic pain into two broad categories: (1) membrane stabilizing agents, which inhibit ectopic discharges on damaged neural membranes, and (2) drugs that enhance dorsal horn inhibition, which may augment biogenic amine or GABAergic mechanisms in the dorsal horn of the spinal cord. Current evidence regarding efficacy generally does not support the use of one drug over another, and selection of a particular drug may depend on experience or expected side effects. The overall efficacy of tricyclic antidepressants for neuropathic pain is modest, and they may produce intolerable side effects. Based on current studies, gabapentin is a reasonable alternative to antidepressants, as initial monotherapy or add-on treatment, particularly for painful diabetic peripheral neuropathy and postherpetic neuralgia. From a practical standpoint, to optimize analgesia more than one drug may be necessary. Although polypharmacy is the result, this approach may improve therapy and minimize side effects. From a safety standpoint, medications generally should be started at low doses and titrated to effect. Although labor-intensive, this strategy can improve compliance and optimize patient care.
[Show abstract][Hide abstract] ABSTRACT: Superior hypogastric plexus block has been used to treat cancer pain of the pelvis.
A patient with severe chronic nonmalignant penile pain after transurethral resection of the prostate underwent a single superior hypogastric plexus block with local anesthetic and steroid. The patient was also started on medications that treat neuropathic pain a few hours after the procedure was finished.
The superior hypogastric plexus block resulted in complete pain relief immediately after the procedure. The pain relief continued at 1, 2, 4, and 8 months follow up.
In this case of severe penile pain the superior hypogastric plexus block was useful diagnostically and therapeutically.
Regional Anesthesia and Pain Medicine 11/1998; 23(6):618-20. DOI:10.1016/S1098-7339(98)90092-X · 2.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Neuropathic pain is common and may be resistant to usual doses of analgesic medications. However, an improved understanding of the pathophysiology of neuropathic pain and a growing number of adjuvant medications that are useful for the treatment of neuropathic pain provide renewed hope for clinicians and their patients. It is useful to classify adjuvant analgesic drugs into two broad categories. Membrane stabilizing agents, which include the anticonvulsants, antiarrhythmics and probably corticosteroids, may act by blocking sodium channels on damaged neural membranes. Medications that enhance dorsal horn inhibition, which include the antidepressants and some anticonvulsants, may augment biogenic amine or GABAergic mechanisms in the dorsal horn of the spinal cord. Current evidence regarding efficacy generally does not support the use of one agent over another and selection of a particular agent may depend in part on the expected side effects or experience with a given drug. For maximum analgesic effect, more than one agent may be necessary and to improve therapy and minimize side effects, medications generally should be started at lower doses and titrated slowly to effect. Although labor-intensive, this strategy may improve compliance and optimize patient care.
Journal of Back and Musculoskeletal Rehabilitation 01/1997; 9(3):247-54. DOI:10.3233/BMR-1997-9307 · 1.04 Impact Factor