Category: Treatments

While surgery and surgical procedures have become specialized and involve as little tissue damage as possible, they nonetheless involve the cutting, removing and suturing of skin, muscles, nerves and other structures. Therefore, some surgical procedures can cause chronic pain due to the trauma of the procedure. Post mastectomy pain syndrome is an example of the pain associated with the surgical procedure. The discomfort begins immediately or soon after the mastectomy or lumpectomy. The pain usually affects the front or sides of the chest in the area of the surgery and sometimes involves the upper arm. Patients with post mastectomy pain often describe their pain as burning and intensified by light touch or pressure. The pain can sometimes result in a disruption of the person’s daily life style. The pain in post mastectomy pain syndrome usually results from irritation of one or more of the nerves in the chest wall, which may have been entrapped by scar tissue or cut during surgery. In some cases a neuroma or painful bundle of nerves grows at the stump of a nerve that has been cut. For some patients with post mastectomy pain, the muscles of the chest, shoulder or arm can also contribute to the pain.

Diagnosis

Doctors perform a physical examination to confirm a painful, sensitive area near the surgical scar and to map the area of irritation. CT scans are sometimes used to determine if a recurrent tumor may be causing the symptoms. Doctors may use a kind of nerve block or injection of anesthetic around the painful structures or along the path of the nerves involved to help confirm the diagnosis.

Treatment

Some patients benefit from the use of oral non-steroidal anti-inflammatory medications with additional pain medications or special medications used to treat nerve pain. The use of topical ointments can sometimes reduce this pain as well. Research shows long- term relief can often be obtained with the use of therapeutic nerve block injections containing anesthetic medication with anti-inflammatory medications. These can be given into a neuroma or along the path of the nerves involved in post mastectomy pain syndrome.  Nerve block treatments usually occur in a short series that can be repeated intermittently as needed. Nerve stimulation procedures can sometimes help with chest wall pain that persists. Physical therapy exercises are used to help regain normal daily activity for those who find the pain interferes with their physical functionality.

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The spinal column is composed of a series of 24 bones called vertebrae that are separated from each other by a disk. Spondylolysis is defined as a condition that occurs when all or part of one vertebra has slipped onto another vertebra. This most often occurs in the lower back and can cause a person to experience low back pain that may spread into the back part of the thigh or lower leg.

It is unlikely that the disorder is the result of a single incident, but rather it develops gradually over time. Patients are likely to note the pain improves with extension, or straightening, of the spine and is made worse by flexing, or bending forward, at the waist. The pain can be present most of the time, however, occasionally rest may improve the symptoms.  Unfortunately, severe flare-ups may strike at any time.

Diagnosis

During a physical examination, doctors may find an unnatural curve to the lower back along with changes over the involved vertebra. Doctors may feel tightness in the muscles of the lower back overlying or adjacent to the vertebra involved. The patient’s range of motion at the waist is limited and associated with increased pain. In most cases, X-rays of the lower back will confirm the condition and locate the source of the slippage. A bone scan can be helpful in finding small fractures that may not appear on plain X-rays, or to evaluate whether infections or tumors in the spine may be causing the pain. If a pinched nerve is suspected, a MRI examination may be performed. Doctors may also use certain kinds of nerve block procedures, which involve the injection of anesthetic medicine around painful structures in the spine. These injections can help confirm the diagnosis and determine if further nerve block treatments will benefit the patient.

Treatment

Some patients find benefit from the use of nonsteroidal anti-inflammatory medications in addition to pain medications. Many patients find nerve block treatments to be extremely effective in helping to reduce the pain from spondylolysis over longer periods of time. These injections may reduce pain caused by irritation at the nerve root, which is where the spinal cord starts to branch out. This can help reduce the spread of pain to adjacent structures. Other injections around the joints of the lower back can help reduce pain associated with movement.

For other patients who have a strong degree of muscle irritation or spasm associated with their spondylolysis, injections of nerve branches in the muscles adjacent to the spine can help relieve symptoms. Doctors may suggest the use of therapeutic exercises to improve strength and flexibility, and assist in improving the patient’s abilities to perform more of their daily life activities with less discomfort. Occasionally a corset can help during strenuous activity.

Doctors usually reserve surgery for the most extreme cases and if needed, they will fuse the vertebra if all else fails.

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Nearly 40 million Americans experience chronic headaches. The problem is severe and sometimes disabling for half of these people. There are only a few structures in the head that hurt. These consist of the skin, the muscles and the blood vessels. The brain itself lacks pain sensitive nerve fibers. Most chronic headaches come from the muscles or the blood vessels. Headaches can be an early warning symptom that something serious is wrong such as a tumor or brain infection.

Diagnosis

When a patient first sees a doctor complaining of a headache, it is the doctor’s responsibility to make sure nothing serious is going on. The doctor will take a careful history and do a thorough physical and neurologic evaluation. If there is some doubt as to the nature of the headaches, the doctor may order blood work and X-ray studies. A test called an encephalogram (EEG) can be used to measure brain activity and rule out the possibility of epilepsy. The primary X-rays used in evaluating the head are the CAT scan and the MRI. Sometimes dye is injected through the vein prior to a CAT scan or MRI to enhance the pictures further. On the basis of the history, physical examination and radiographic tests, the physicians are almost always able to determine abnormalities in the brain. The vast majority of patients will not have headaches secondary to tumor, infection, etc. These patients will have what is referred to as chronic benign headaches. There are two primary types of benign headaches: migraines which are vascular headaches, and muscle tension headaches.

Migraine Headaches

The most common vascular headache. They are usually characterized by:

• A so-called aura prior to the migraine 
• Confusion
• Eyes  experience  flashing  lights  or zigzagging lines
• Nausea
• Occasional disturbed vision 
• Sensitivity to light 
• Severe pain on one or both sides of head
• Speech difficulty
• Temporary loss of vision
• Tingling of the face or hands
• Vomiting
• Weakness in the arms or legs

It is during this phase the blood vessels supplying the brain are believed to be constricting. Because of the low blood flow, neurological findings described above develop. This can occasionally be confused with a stroke-type process.  The difference is the symptoms remain in a stroke while symptoms quickly dissipate over a period of 30 to 60 minutes with a migraine. Migraine headaches can come at almost any time and with any frequency. However, most patients suffer severe migraines one to two times a week or less.

Migraine Progress: There is some debate as to the precise cause of migraine headaches, but it is: mainly believed the blood vessels constrict and get very tight due to various triggers. When this happens, blood elements called platelets clump together and release a drug called serotonin. Serotonin causes the blood vessels to further tighten and reduces the supply of blood to the brain. This can give rise to the distorted speech or vision commonly seen with migraines. Ultimately, the same blood vessels that are constricting, dilate and widen in order to re-establish proper blood flow to the brain.  Because the brain has been deprived of blood for a period of time, the blood vessels open extra wide in order to make up for the blood flow that was initially denied. It is during this dilation process the pain is experienced. Additionally, during this phase, chemicals that cause irritation and swelling are also released, resulting in the throbbing headache. Migraine headaches can begin anywhere between the age of 5 and 35 and are more common in women. Women may also suffer from menstrual migraines, which are headaches that appear around the time of their menstrual period and may disappear with pregnancy.

There may be numerous triggers to a migraine headache such as:

• Alcohol in any form
• Certain foods (foods high in tyramine should be avoided)
• Changes in the weather
• Fatigue
• Flickering lights
• Genetic predisposition
• Stress

Treatment: The classic treatment for migraine headaches is drug therapy. There are two approaches to the medications:  

• Prevent  the  headaches
• Relieve  the symptoms.  For infrequent migraines, drugs can be taken at the first sign of a headache to help ease the pain and stop the attack. These include:
  • Anti-inflammatory drugs such as aspirin or Naprosyn Vasoconstrictive drugs such as ergot alkaloids and sumatriptan
• If the headaches are occurring frequently, that is three or more times a month, preventative treatment is usually recommended. Drugs to prevent the classic migraine include:
  • High blood pressure medications, which help reverse constriction of the blood vessels (beta blockers and calcium channel blockers)
  • Anti-depressants (amitriptyline)

New drugs for migraines are being released all the time and your doctor will be aware of them.

Muscle Contraction Headaches

These are generally related to stress, which induces muscle tension. However, other studies now suggest muscle tension and vascular headaches may be one and the same. Chronic muscle contraction headaches, unlike migraines, can last weeks, months or sometimes years. These headaches are described as a tight band around the head with pain that is steady and is usually felt on both sides of the head. The muscles of the head are frequently painful to light touch; combing the hair can even be painful.

Treatment: Treatment of muscle contraction headaches is similar to migraines. The first consideration is to try to relieve the headache with anti-inflammatory drugs. In addition, preventing the headaches with the same medications used for migraine patients is reasonable. Non-drug therapy for chronic muscle contraction headaches includes biofeedback, relaxation training and counseling. Biofeedback is a technique that gives people better control over their body functions, such as blood pressure, heart rate, muscle tension and brain waves. By learning this technique, patients are able to  reduce stress and relax the muscles in the head and even open up blood vessels. This technique is ideal because it does not require the use of any medications and has no side effects. Patients can practice it at any time and when they feel a headache starting. In order to learn biofeedback, the patient must see an experienced biofeedback practitioner and practice at home with a portable monitor. Biofeedback is helpful for both types of headaches. Sometimes headaches may respond to  hot showers or moist heat placed to the back of the head or neck. In certain patients, ice may be more effective. Physical therapy, massage and gentle exercise of the neck may also be helpful. Ultimately, patients who have chronic headaches can live normal, active lives. Working with the doctor, a good program of medications, behavioral interventions and proper diet to reduce the frequency, severity and duration of headaches can be developed.

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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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