Category: Painful Conditions

Reflex sympathetic dystrophy is a syndrome that may develop when the body has been injured. This injury can result from a motor vehicle accident, a gunshot wound, an accident around the house or even after surgery. Any sort of wound can result in reflex sympathetic dystrophy. Normally, the nerve signals pain when the body is injured. This causes a reflex, which makes the body pull away from the painful stimulus. The blood vessels will then protect the body by constricting to reduce blood loss. In patients without reflex sympathetic dystrophy, these responses gradually disappear, blood vessels open up, the fear and suffering decreases and the body takes appropriate actions to heal the wound. In patients with reflex sympathetic dystrophy, however, the body never gets quite back to normal. The nerves stay hyperactive causing increased pain because of continual blood vessel spasms. This tightening of the blood vessels causes swelling of the limb, discoloration and increased pain.  This pain from the reduced blood flow keeps the nerves excited, which then keeps the blood vessels tight and continues in a cycle. Increased pain and reduced blood flow are the hallmark of this disorder.

Diagnosis

The patient will note hypersensitivity. Patients with reflex sympathetic dystrophy do not like the limb being touched at all and will seek to protect it from even casual encounters or the wind. The slightest touch can be interpreted as pain. The doctor will note objective changes in the limb such as discoloration and increased sweating. The limb will feel two degrees cooler, the pain will increase in cold weather, and there may be alterations in the appearance of the hair on the limb. In addition, the skin becomes shiny, the bones lose their calcium and nail growth may change in appearance. X-rays and bone scans can help demonstrate reduction in blood flow and reduction of calcium in the bones. Overall, the limb may appear to be wasting away. This wasting is called dystrophy and develops as a consequence of low blood flow. In late stages of RSD, the hand or foot becomes withered and nonfunctional, virtually a useless appendage.

Treatment

Reflex sympathetic dystrophy is divided into three stages. Stage one is the least severe and three is the most severe. Depending on the stage, the treatment will vary.

Stage One: There may be some slight swelling, hypersensitivity and occasional discoloration following an injury. The skin will appear normal and there will be a minimal loss of calcium from the bones. Patients in this stage are very treatable with a combination of medications, injections and physical therapy. Neurontin is the medication of choice given to decrease activity in the overactive nerves. Other medications may be used as well to help open the blood vessels. Physical therapy is important to keep the limb from wasting away and also to decrease the sensitivity in the limb. A skilled physical therapist can design a program to help the limb recover. It is important that the nervous system returns to normal. This can be done with a sequence of nerve blocks that can help treat the underlying condition by interrupting the reflex arc of pain in the nervous system. The nerves are temporarily put to sleep with a local anesthetic causing them to forget the memory of the injury. Usually nerve blocks are given as a sequence of 3 to 10 injections.

Two: Significant wasting of the limb occurs. Calcium is very low in the bones, the skin is shinny and the blood vessels are in significant spasm all the time. Surgery becomes an option to permanently interrupt the nerves so the blood vessels can open and nourish the limb. The nerves can also be injected with drugs to permanently disrupt their function. Another alternative is the placement of a spinal stimulating device. This can interrupt the nerves without destroying them and help reverse the changes of stage two sympathetic dystrophy. In addition, another alternative is the placement of a morphine or local anesthetic pump for temporary or permanent use in order to decrease activity in the nerves.

Three: The tendons and muscles have wasted away and the limb cannot be used at all. The bones are virtually demineralized and the skin is very shinny. Unfortunately, in stage three, there is no treatment. Cutting the nerves or treating the patient with spinal narcotic infusion or with spinal stimulation will not cause the limb to regenerate. Fortunately, in this day and age, with the development of advanced pain management centers, few patients progress to stage three.

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Certain areas of the musculoskeletal system experience significant stress from everyday living. Fluid filled sacs, called bursae (bursa) cushion the bones, tendons and muscles near your joints. Unfortunately bursae can become inflamed and irritated and this is call bursitis. Bursitis often occurs near joints that perform frequent repetitive motion. The most common sites for this to occur are the hips knees, shoulders and elbows.

Diagnosis

The patient with bursitis will complain of well-localized pain in the shoulder, hips or other joints. The pain may travel from one of these areas into the arm or thigh. When the doctor examines the patient, he or she will look for swelling and tenderness over the locations of the bursa.  Doctor can often diagnose bursitis based on the medical history and physical exam. If further testing is needed, the doctor my order x-rays. X ray images can’t positively establish the diagnosis of bursitis but they can help to exclude other cause of your discomfort. The bulk of bursa inflammation occurs in the soft tissue, which cannot be seen on X-ray.

Treatment

There are many treatment for bursitis. In the early stages, an anti-inflammatory drug will frequently help the problem. Ice should can also be applied over the inflamed area several times during the day to assist with swelling.  It is important to rest the affected area. For example, avoid elbow pressure by not leaning on the elbow or if the right hip is affected, try to sleep on the left side.  If these treatment strategies fail to work, the doctor may inject an anti-inflammatory drug and /or corticosteroid directly and into the bursa. These drugs are very useful for the relief of inflammation. These drugs generally bring rapid pain relief and in many cases, one injection is all you need. Although if more than one injection is needed, these medications can only be used a few times each year. Physical therapy may be ordered to strengthen the muscles in the affected area to ease pain and prevent recurrence. The physical therapist may use ultrasound and soft tissue manipulation that can sometimes be helpful. Sometimes an inflamed bursa must be surgically drained.

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Peripheral neuropathy is a burning or aching pain due to nerve diseases. The pain can either be constant or intermittent and most often occurs in the arms or legs; however, it has been known to occur in the trunk, abdomen, head and neck. The pain can occur from irritation of one nerve or from several nerves. Generally, peripheral neuropathies are a consequence of diabetes, alcoholism or other neurological diseases.

Diagnosis

Doctors will use a physical examination to confirm the area involved. Neurological examinations can sometimes reveal loss of sensation to pinprick or to hot and cold temperatures. Weakness is sometimes noted in the affected extremity. Reflexes may be affected and there may be changes in the skin over the region. Evaluations of peripheral neuropathies usually involve tests appropriate for the primary disease, which doctors suspect is causing the problem such as diabetes. Evidence of nerve damage can sometimes be demonstrated with electrical nerve testing. Doctors who treat the pain as peripheral neuropathy will often use a nerve block procedure to help diagnose the problem.

Treatment

For some patients with peripheral neuropathy, the use of oral non-steroidal anti- inflammatory medications along with traditional pain medications can be helpful. For others, special medications help directly with nerve pain. These medications are often started at low doses and gradually increased until the desired affects are reached. Long-term relief can often be obtained with the use of therapeutic nerve blocks. These include injections of anesthetic medications along with anti-inflammatory medication around the painful nerves. The injections are usually performed in a short series over several weeks until symptoms subside or a plateau is reached in the treatment. If helpful, these injections can be repeated at appropriate intervals.

Nerve stimulation techniques can be helpful in certain types of peripheral neuropathy. Stimulation can either occur on the skin over the affected region, or in some cases, with stimulator electrodes placed surgically around the nerves or in the spine at the origin of the affected nerves. Although physical therapy is not usually helpful in relieving the pain from peripheral neuropathy, therapeutic exercises can help restore loss of function and allow patients to lead more active lives. In addition, behavioral modification techniques or biofeedback training with muscle relaxation exercises can help patients be less sensitive to the irritation from the affected nerves.

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This disorder is a type of headache with discomfort noted at the back of the head, beginning at the base of the skull and radiating upward toward the top of the head. The symptoms can occur on either side of the head, or it can include both sides. The symptoms can be sharp, spasm-like pains that occur at different intervals. It is caused from irritation of the occipital nerves, which begin at the back of the head and extend to the top of the head. Occipital neuralgia is caused by inflammation or injury to these nerves. It can also be caused by excessive muscle tension in the muscles at the back of the head through which these nerves pass.

Diagnosis

A physical examination will usually show signs of increased tenderness in the tissues at the base of the skull and at the top of the spine. Doctors can use X-rays to determine whether there is any narrowing of the vertebra at the top of the spine, where the occipital nerves pass to the back of the head. The best test to confirm occipital neuralgia is an injection of anesthetic, called a nerve block, given at the base of the skull around the occipital nerve itself. If blocking the occipital nerve results in resolution of the symptoms, the diagnosis of occipital neuralgia is usually confirmed.

Treatment

One of the greatest concerns to doctors treating this problem is to make sure that these symptoms do not indicate an increase in intracranial pressure within the skull, which could signal a vascular, infectious or other significant problem. Some patients will find temporary relief from the pain with the use of non-steroidal anti-inflammatory drugs and muscle relaxants. Physical therapy exercises will also provide some limited effectiveness. Doctors believe the best approach for long-term relief is the use of nerve block treatments. In some cases, an injection of local anesthetic combined with medication to reduce inflammation can result in long-term relief following a series of treatments. At times, the pain at the base of the skull is related to other disorders or arthritis in the joints of the upper portion of the spine. Doctors may use nerve block injections around these structures to help in the treatment of occipital neuralgia. Surgery can sometimes provide relief for several months, but most patients find the pain may return. Surgery is usually reserved as a last option. Some patients will find additional help through a combination of muscle relaxation techniques, known as biofeedback, in conjunction with physical therapy that focuses on manual therapy to the muscles at the back of the neck and head.    Newer block treatments at the occipital nerves can also be utilized for long-term treatment at appropriate intervals.

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