Home

 

      

Pain Syndromes:

Abdominal pain: virtually any organ and structure within the abdomen may be a cause of pain. Paramount is to make a proper diagnosis and treat early potentially lethal disease. Abdominal pain that lasts for weeks requires detective work. Systematically addressing every possible organ and structure.  Gallblader, pancreas, liver, esophagus, kidneys, intestines need to be evaluated. Muscles covering the abdomen have also been implicated in abdominal pain. Prior abdominal surgery may cause internal adhesions and scar tissue leading to pain. At times, abdominal scars may trigger pain in certain individuals. Broken or injured ribs, need to be evaluated as possible causes. Irritable bowel syndrome, ulcerative colitis and Chron's disease are conditions involving the intestines. All may present with abdominal pain. Abdominal masses and cancer should be ruled out. Antineuropathics and opioids may be used to help with pain. Your doctor may recommend certain procedures that may help with diagnosis. If pain improves after injecting the sympathetic chain with local anesthetics  then pain is assumed to be of sympathetic origin. Further therapy will planned after.

Anal rectal pain: rectal and anal pain could be devastating for patients. Pain may be due to several causes, including trauma, infections, hemorrhoids, surgery and colonoscopies. At times after exhaustive work-up, no reason is found.  Medications, acupuncture and nerve blocks could be used to treat pain. 

 

Ankylosing spondylitis:

Anterior Cutaneous nerve entrapment syndrome

Arachnoiditis:

Arachnoiditis describes a pain disorder caused by the inflammation of the arachnoid, one of the membranes that surround and protect the nerves of the spinal cord.  The arachnoid can become inflamed because of an irritation from chemicals, infection from bacteria or viruses, as the result of direct injury to the spine, chronic compression of spinal nerves, or complications from spinal surgery or other invasive spinal procedures.  Inflammation can sometimes lead to the formation of scar tissue and adhesions, which cause the spinal nerves to “stick” together. If arachnoiditis begins to interfere with the function of one or more of these nerves, it can cause a number of symptoms, including numbness, tingling, and a characteristic stinging and burning pain in the lower back or legs.  Some people with arachnoiditis will have debilitating muscle cramps, twitches, or spasms.  It may also affect bladder, bowel, and sexual function.  In severe cases, arachnoiditis may cause paralysis of the lower limbs.
Arachnoiditis remains a difficult condition to treat, and long-term outcomes are unpredictable.  Most treatments for arachnoiditis are focused on pain relief and the improvement of symptoms that impair daily function.  A regimen of pain management, physiotheraphy, exercise, and psychotheraphy is often recommended.  Surgical intervention is controversial since the outcomes are generally poor and provide only short-term relief.  Clinical trials of steroid injections and electrical stimulation are needed to determine the efficacy of these treatments.
Arachnoiditis appears to be a disorder that causes chronic pain and neurological deficits and does not improve significantly with treatment.  Surgery may only provide temporary relief.  Aging and pre-existing spinal disorders can make an accurate prognosis problematic.   The outlook for someone with arachnoiditis is complicated by the fact that the disorder has no predictable pattern or severity of symptoms.
 

Arthritis: Rheumatoid arthritis is disease that affects the joints. It causes pain, swelling, and stiffness. If one knee or hand has rheumatoid arthritis, usually the other does too. This disease often occurs in more than one joint and can affect any joint in the body. People with this disease may feel sick and tired, and they sometimes get fevers.

Some people have this disease for only a few months, or a year or two. Then it goes away without causing damage. Other people have times when the symptoms get worse (flares), and times when they get better (remissions). Others have a severe form of the disease that can last for many years or a lifetime. This form of the disease can cause serious joint damage.

Doctors don't know the exact cause of rheumatoid arthritis. They know that with this arthritis, a person's immune system attacks his or her own body tissues. Researchers are learning many things about why and how this happens.

RA is treated by a rheumathologist. If pain is severe, then NSAID's and  opioids may be of help. At times, selected joint injections, nerve blocks and epidurals may be indicated.

 

Cancer pain: cancer may be painful for several reasons. The tumor itself, growth into nearby nerves, organs and tissue may all be responsible. Cancer may also destroy the tissues after invading them, particularly painful when involving bones and nerves. Tumor spread or metastases could be painful for the same reasons explained. As a tumor grows, it may put pressure on nerves, bones or other organs, causing pain.

Cancer therapy — such as chemotherapy, radiation and surgery — may leave painful sequelae. After surgery, recovery may be slow and painful. Radiation may burn skin and other tissues. Chemotherapy can cause many potentially painful side effects, including mouth sores, diarrhea and nerve damage. Peripheral neuropathy after chemotherapy could be difficult to treat.      
There are many different ways to treat cancer pain. Pain medications can usually control the pain. Most commonly used are NSAIDs, such as ibuprofen (Advil), opioid medications, such as codeine, morphine, oxycodone, fentanyl or methadone.

Severe cases may need nerve blocks, epidurals and morphine pumps. We may recommend a continuous delivery of medication (epidural, spinal or intravenous), and arrangements could be made to receive these at home, hospice or hospital.

Central Cord Syndrome:

Central cord syndrome is a form of incomplete spinal cord injury (in which some of the signals from the brain to the body are not received), characterized by impairment in the arms and hands and, to a lesser extent, in the legs. The brain's ability to send and receive signals to and from parts of the body below the site of trauma is affected but not entirely blocked. This syndrome, usually the result of trauma, is associated with damage to the large nerve fibers that carry information directly from the cerebral cortex to the spinal cord. These nerves are particularly important for hand and arm function. Symptoms may include paralysis and/or loss of fine control of movements in the arms and hands, with relatively less impairment of leg movements. Sensory loss below the site of the spinal injury and loss of bladder control may also occur, with the overall amount and type of functional loss dependent on how severely the nerves of the spinal cord are damaged.
 
There is no cure, nor is there a standard course of treatment, for central cord syndrome. Drug therapy, surgery, and rest are often part of the treatment program.
 

The prognosis for individuals with central cord syndrome varies. Patients who receive medical intervention soon after their injury often have good outcomes. Many people with the disorder recover substantial function after their initial injury, and the ability to walk is recovered in most of the cases, although some impairment may remain.

Central pain syndrome:

Central pain syndrome is a neurological condition caused by damage to or dysfunction of the central nervous system (CNS), which includes the brain, brainstem, and spinal cord. This syndrome can be caused by stroke, multiple sclerosis, tumors, epilepsy, brain or spinal cord trauma, or Parkinson's disease. The character of the pain associated with this syndrome differs widely among individuals partly because of the variety of potential causes. Central pain syndrome may affect a large portion of the body or may be more restricted to specific areas, such as hands or feet. The extent of pain is usually related to the cause of the CNS injury or damage. Pain is typically constant, may be moderate to severe in intensity, and is often made worse by touch, movement, emotions, and temperature changes, usually cold temperatures. Individuals experience one or more types of pain sensations, the most prominent being burning. Mingled with the burning may be sensations of "pins and needles;" pressing, lacerating, or aching pain; and brief, intolerable bursts of sharp pain similar to the pain caused by a dental probe on an exposed nerve. Individuals may have numbness in the areas affected by the pain. The burning and loss of touch sensations are usually most severe on the distant parts of the body, such as the feet or hands. Central pain syndrome often begins shortly after the causative injury or damage, but may be delayed by months or even years, especially if it is related to post-stroke pain.
Pain medications often provide some reduction of pain, but not complete relief of pain, for those affected by central pain syndrome. Tricyclic antidepressants such as nortriptyline or anticonvulsants such as neurontin (gabapentin) can be useful. Lowering stress levels appears to reduce pain.

Information provided by www.ninds.nih.gov/disorders/central_pain/central_pain.htm
 

Cheiralgia paresthetica

Chronic Pain: While acute pain is a normal sensation triggered in the nervous system to alert you to possible injury and the need to take care of yourself, chronic pain is different. Chronic pain persists. Pain signals keep firing in the nervous system for weeks, months, even years. There may have been an initial mishap -- sprained back, serious infection, or there may be an ongoing cause of pain -- arthritis, cancer, ear infection, but some people suffer chronic pain in the absence of any past injury or evidence of body damage. Many chronic pain conditions affect older adults. Common chronic pain complaints include headache, low back pain, cancer pain, arthritis pain, neurogenic pain (pain resulting from damage to the peripheral nerves or to the central nervous system itself), psychogenic pain (pain not due to past disease or injury or any visible sign of damage inside or outside the nervous system).

 

CRPS: complex regional pain syndrome, formerly known as regional pain syndrome is a constellation of symptoms involving usually extremities. The hallmark of the condition is pain and inflammation that may progress  to  complete loss of function of the limb. May be cause by a minor injury like an ankle twist or more severe like bone fractures. Surgery, nerve injury, burns, intramuscular injection have been implicated with this condition. The initial injury may not be so small that it may not be remembered by the patients. CRPS could be difficult to diagnose and may go unrecognized until  evaluated by the trained  specialist. At times, it is confused with early infection and time is wasted with antibiotic therapy. Symptoms are exaggerated in relation to the suspected injury. Therapy can be equally challenging. Tryciclic antidepressants, anti-neuropathics are among  the initial medications used. To help with diagnosis, sympathetic blockade injections (neck or back) are given. If injections are effective, it helps support the diagnosis. If pain is difficult to control and medications and injections have failed to help, then further therapy may include  spinal cord stimulator and intrathecal pumps.

 

Diabetic peripheral neuropathy: progressive, painful condition of peripheral (usually arms and legs) nerves. High levels of circulating sugars in blood are thought to cause  injury to nerves. The most important treatment is to maintain normal levels of glucose in blood. Medications consider to be beneficial include anticonvulsant and  antidepressants. These include tricyclic antidepressant like amitryptilin, nortryptiline and desipramine. The most widely used anticonvulsant is gabapentin (Neurontin). These medication may have side effects including dizziness, difficulty concentrating, somnolence and loss of balance. This effects will subside with time.

   

Eye pain: several conditions may be associated with eye pain. Infections, trauma, surgery, cancer and unknown causes. Different structures within the eye may contribute  to pain including the  eye globe, eyelids, nerves, arteries and muscles. Identifying the cause of pain becomes paramount in treating the condition. Therapy is tailored to the cause. Your doctor may choose a regimen including medications that treat neuropathic and nerve pain, opioids or antidepressants. In selected cases injections may be of benefit. Stellate ganglia blocks, nerve blocks may be offered.

 

Face pain: Several conditions may be associated with face pain. Nerves, muscles, tendons an bone may be implicated. Infections, herpes, trauma, nerve damage, stroke and  surgery may be a cause. Identifying the problem will help delineate therapy. Your doctor may choose to trial antineuropathics, opioids, antidepressant. If medications fail some injections may be of benefit including stellate ganglia , trigger point, selected nerves (facial, trigeminal, supraoptical etc), epidurals, TMJ and facet joints.

 

Fibromyalgia: very complex medical condition, ignored by some; misunderstood by others. At times, patients are not diagnosed and suffer for years. Tender muscles, sleep disruption, morning fatigue and multiple other diffuse symptoms hallmark fibromyalgia.Diagnosis is based on tenderness over specific muscle areas and exclusion of other conditions. Therapy should be multidisciplinary including physical therapy, reconditioning of fatigued muscles, psychological support, control of depression and other associated psychiatric symptoms. Medications that may be useful include tryciclic antidepressants, antineuropathics, muscle relaxants, sleep aid and trigger point injections. In some instances opioids may be used, but rarely as a first option.

 

Headaches:

There are four types of headache:  vascular, muscle contraction (tension), traction, and inflammatory.  The most common type of vascular headache is migraine. Migraine headaches are usually characterized by severe pain on one or both sides of the head, an upset stomach, and, at times, disturbed vision.   Women are more likely than men to have migraine headaches.    After migraine, the most common type of vascular headache is the toxic headache produced by fever.  Other kinds of vascular headaches include "cluster” headaches, which cause repeated episodes of intense pain, and headaches resulting from high blood pressure.  Muscle contraction headaches appear to involve the tightening or tensing of facial and neck muscles.  Traction and inflammatory headaches are symptoms of other disorders, ranging from stroke to sinus infection.  Like other types of pain, headaches can serve as warning signals of more serious disorders. This is particularly true for headaches caused by inflammation, including those related to meningitis as well as those resulting from diseases of the sinuses, spine, neck, ears, and teeth.

Migraine

Moderate to severe pain — many migraine headache sufferers feel pain on only one side of their head, while some experience pain on both sides. Feels  pulsating or throbbing, may worsen with physical activity hindering  regular daily activities. Nausea with or without vomiting is common. Also, sensitivity to light and sound is present.

Chronic tension-type headache
Occasional tension-type headaches sometimes progress to daily attacks. The pain involves both sides of the head and the back of the head and neck. It's often described as a dull ache or a tight band of pressure around the head. The pain may fluctuate throughout the day or be steady for days, weeks or even years at a time.

New daily persistent headache
New daily persistent headaches begin abruptly in people without a history of headaches. Sometimes the headaches are triggered by an infection, surgery or stressful life event, but often there's no recognized trigger. The pain is often described as throbbing, dull, achy, stabbing or burning, or as pressure or tightness. The pain continues unabated throughout the day. Some new daily persistent headaches go away within several months. Others persist for years or even decades.

Hemicrania continua
Hemicrania continua is a relatively rare type of chronic daily headache. The pain occurs on one side of the head and varies in intensity without ever disappearing completely. The pain is usually moderate but may include jolts of severe pain that last less than a minute. The flare-ups of severe pain may be accompanied by tearing or redness of the eye on the affected side, swelling or drooping of the eyelid, and a stuffy or runny nose. You may experience nausea, vomiting and sensitivity to noise and light. Sometimes auras — such as blind spots or flashing lights in your visual field or sensations of numbness or tingling — are present as well.

The causes of chronic daily headaches are not well understood. For primary chronic daily headaches, possible factors may include:
  • Medication overuse (Tylenol, opioids)
  • Muscle tension or tissue inflammation.
  • Abnormal function of brain structures that suppress pain
  • Changes in the nervous system due to frequent headaches
  • Stimulation of the central nervous system due to stress, infection or trauma
  • Injury of the upper spine
  • Vasculitis
  • Tumors
  • Infection
  • Obstructive sleep apnea
Chronic daily headaches are more common in women than in men. Various factors may increase the chance of having headaches, including:
  • Anxiety
  • Depression
  • Sleep disturbances
  • Obesity
  • Snoring
  • Overuse of caffeine
  • Overuse of pain medication

When headaches occur three or more times a month, preventive treatment is usually recommended.  Drug therapy, biofeedback training, stress reduction, and elimination of certain foods from the diet are the most common methods of preventing and controlling migraine and other vascular headaches. Regular exercise, such as swimming or vigorous walking, can also reduce the frequency and severity of migraine headaches.  Drug therapy for migraine is often combined with biofeedback and relaxation training.  One of the most commonly used drugs for the relief of migraine symptoms is sumatriptan.  Drugs used to prevent migraine also include methysergide maleate, which counteracts blood vessel constriction; propranolol hydrochloride, which also reduces the frequency and severity of migraine headaches; ergotamine tartrate, a vasoconstrictor that helps counteract the painful dilation stage of the headache; amitriptyline, an antidepressant; valproic acid, an anticonvulsant; and verapamil, a calcium channel blocker. Another antidepressant — such as the selective serotonin reuptake inhibitor (SSRI) fluoxetine (Prozac) — may occasionally be an effective alternative for some people.   Muscle relaxants such as tizanidine (Zanaflex) may help some people manage chronic daily headaches.

Injections may be of benefit in certain conditions. Trigger point injections in tender muscles, nerve blocks (trigeminal, facial, supraorbital) or epidural steroid injections have been used effectively. Severe cases can be managed as in-patients in multidisciplinary clinics.

For more information link to http://www.ninds.nih.gov/disorders/headache/headache.htm

 

Low back pain: very generalized term to characterize a group of conditions that produce back pain. Several structures of the back may implicated in generating pain. These include muscles, tendon, joints, nerves and spinal discs. It is important to recognize the affected structure and minimize unnecessary testing and therapy. Treatment can be as easy as muscle relaxants and anti-inflammatory therapy. Well defined syndromes (and structures causing pain)  have been described: most commonly discogenic pain, facet arthritis, myofascial pain, herniated discs, sciatic neuralgia, sacro-iliitis, pirirformis syndrome and vertebral compression fractures.

  • Herniated disc: the intervertebral disc is a soft tissue, cushioning in between vertebral bones of the spine. Trauma, age and arthritis may cause it to herniated ( squeeze out of its capsule). Spinal nerves exit the spine in close proximity to the disc and can be pinched by the squeezed disc. This creates a local inflammation and irritation of the nerve. Spinal nerves give origin to the large nerves of the leg, the most talked about being the sciatic. From here derives the term “sciatica”. Treatment consists of alleviating pain while allowing the herniation to heal. Studies have shown that a disc herniation may resolve by   itself. Physical therapy, chiropractor care along with NSAID’s, muscle relaxants and antineuropathics may be of benefit. Some patients may need opioids. If this initial therapy fails the epidural steroid injection may be needed. Epidural injections will deliver anti-inflammatory medications very close to the nerve and in turn decreasing pain. Very severe cases may need surgery.

 

  • Sacro-iliitis: this joint is formed by the sacrum and pelvis. Pain in felt in the low back, legs an groins. Standing for too long and going from a sitting to a standing position usually triggers pain. Physical therapy, stretch exercises and chiropractor adjustments  may be beneficial. Muscle relaxants and NSAID’s are commonly used. Injection directed by fluoroscopy (x-rays) into the joint may help relief pain.

 

  • Discogenic pain: the vertebral disc cushions in between two spine vertebrae. Disruption of its normal anatomy may cause pain. Discomfort will be felt in the low back and occasionally legs. It is important to promptly diagnose discogenic pain to avoid unnecessary procedures and delay of treatment. Epidural injections may be tried, if not effective then your doctor may recommend a diagnostic procedure that consist of placing a needle inside the disc and directly assessing the status of the disc under fluoroscopy. Other therapies may include IDET and nucleoplasty. Both procedures are performed by a pain specialist and at times avoid surgery.  A needle is placed in the disc and small pieces are taken out or the disc is subjected to heat. Your doctor  will determine if you may be helped by these procedures. Ultimately, surgery may be the only option.

 

  • Piriformis Syndrome:   aching sore, shooting pain in the buttocks may be due to spasm of the piriformis muscle. The sciatic nerves runs trough the muscle and may be irritated by the muscle spasm. This condition may be confused with sciatica and spinal nerve/disc herniation. It is important that is properly diagnose to avoid unnecessary therapy, tests and pain. Pain specialists are trained to recognize this condition. Therapy consists of stretch exercises, muscle relaxants and injections into the muscle. The muscle is located deep in the buttocks and x-rays (fluoroscopy) should be used to confirm proper injection.

 

  • Facet arthropathy: facet joints help keep two vertebrae together. As other joints, the facets coordinate movement of the spine. Pain is achy, sore, tender and diffuse. May be worse in the morning, also presenting with stiffness. As the joints “warm up” pain decreases, by the end of the day after sitting and standing for too long, pain exacerbates. In certain cases, pain may be felt radiating to the front and  back of legs. This pattern may be confuse with sciatica, the importance of being evaluated by a trained pain specialist can not be stressed enough. Treatments is aimed to decrease inflammation of the joints, promote mobility and increase function. Physical therapy, coordinated exercise, NSAID’s and the new COX 2 inhibitors (celebrex)  are cornerstone of therapy. Severe cases may need  injections into the nerve and/or facet rhizotomy (RFA)

 

  • Vertebral fractures: caused by trauma or bone weakening from osteoporosis. Extremely painful, at times very difficult to treat. Potent opioids may be necessary to control the pain. A relative new procedure places a needle into the bone, and under close vigilance with fluoroscopy, cement is injected. When dry, the cement will act as a cast inside the bone. Also, by filling the vertebrae with cement, the normal  anatomy may be restored.

 

  • Myofascial pain: ilio-lumbaris, paravertebral, multifidus are some of the examples of muscles located on the low back. Spasm and injury of these and other muscles may be severe enough to send patients to emergency rooms and primary care doctors. Physical therapy, chiropractor adjustments, stretch exercise and muscle relaxants are part of treatment. It is important to be evaluated by trained pain MD’s  to avoid unnecessary tests and procedures.

 

Meralgia paresthetica:  condition associated with pain on the lateral aspect of the upper leg. It presents with numbness and burning, shooting pain. Injury to the lateral femoro-cutaneous nerve  is consider the cause of this syndrome. Obesity, wearing a heavy belt and trauma have been implicated in injuring the nerve.  Treatment include physical therapy, weight loss and NSAID’s. In selected cases injections to the nerve with local anesthetics and depo-medrol may be effective. If that fails, your doctor may recommend epidural injections.

 

Myofascial Pain: diffuse aching, sore and burning pain. May be throughout the body or confined to a small group of muscles. This condition may present by itself or associated with other syndromes like fibromyalgia and arthritis. Treatment consist of muscle relaxants, trigger point injections and physical therapy. Opioids are rarely effective.

 

Neck Pain: several structures may be responsible for neck pain. Nerves, discs, tendons, muscles and joints have all been reported as sources of pain. One or several structures may be a cause of pain, complicating diagnosis and treatment. Arthritis (facet joints), muscle spasm, disc herniations, prior surgery, nerve impingement, neuralgias of the occipital nerve, whiplash injuries, cancer, infection, spine trauma, vertebral compression fractures, misalignment (anterolysthesis) and bleeding may be possible etiologies.

Of paramount importance is to diagnose  infection, cancer, bleeding and fractures, as therapy may be more effective early. Red flags help your doctor rule our these conditions: pain worse at nights, fevers, chills, weight loss, loss of appetite, insomnia, pain not resolving at rest. Treatment is oriented towards its originating cause.  

Once the above conditions are ruled out, a systematic questioning and physical exam helps your doctor narrow the potential sources of pain.

  • Herniated discs may cause neck and arm pain. Numbness, loss of sensation and weakness may be present. Pain may be exacerbated with movement of the head, arms, coughing and sneezing. Usually improved with rest.

  • Facet joint pain causes pain in the neck with radiation to shoulders, posterior head and face. Much worse with movement, better at rest. Pain radiating outside of the neck confuses patients and doctors, focusing on mild disk disease. Often misdiagnosing this easily treated condition.

  • Muscles and tendons can be a significant source of pain. Spasm may occur after accidents, falls or poor positioning at work. At times muscle spasms occur as a response of the body to changes in posture when pain is present from other causes.

  • Nerve (non spinal) damage can occur after falls, whiplash injury and poor positioning. pain is diffuse, aching and burning. Difficult for patients to describe. Poor localization of pain is also common.

Herniated discs  could be treated initially conservatively with medications, chiropractor care, physical therapy, acupuncture and epidural injections. Contained disc  herniations may respond to decompression of the disc via a needle. Also called percutaneous discectomy.  Surgery may be indicated for severe cases, particularly those affecting mobility of arms, loss of sensation and increasing pain. Muscle and tendon pain respond well to muscle relaxants, myofascial release therapy, physical therapy, trigger points injections and acupuncture. For vertebral fracture treatment see:  vertebroplasty. Facet joint or arthritic pain is treated with NSAID's, Physical therapy, chiropractor care and acupuncture. Severe cases may respond to facet joint injections or ablation of the nerve feeding the joint. This procedure (See procedures for more information), may improve pain for up to one year. Neuralgias to specific nerves or group of nerves (occipital, superficial cervical plexus) responds to medications, injections and physical therapy.

Occipital Neuralgia: pain confined to posterior head. With a diffuse, throbbing, sharp and aching nature. Extreme tenderness upon palpation help with diagnosis. A simple injection performed in the office with local anesthetics into the nerve helps confirm the diagnosis. Therapy involves TCA's and antineuropathics. Further therapy include injecting with depo-medrol and sarapin.

Pancreatitis: inflammation of the pancreas. When acute, it should resolve on its own, and rarely pain medications are needed. Cancer and chronic disease may come with constant severe pain. Opioids and antineuropathics should initially help. If severe and not responding then epidural injections, sympathetic blocks may be needed. Lastly, if all fails spinal pumps and epidural catheters may be placed to provide with constant potent medications directly to the spine and near the pancreas.

Pelvic pain: very complicated condition affecting both men and women. An extensive list of conditions may be responsible for causing pain in the pelvic region. Cancer, tumors, endometriosis, dysmenorrhea, infections, nerve damage, trauma, surgery, psychological conditions, fibromyalgia, colo-rectal disease, menstrual period need all be evaluated as causes of pelvic pain. After no surgical or treatable cause is identified your pain doctor may recommend a medical regimen as initial therapy. Acupuncture may be effective in certain cases. Epidural injections, sympathetic blocks may also be tried. Some of these injections can be done in an office setting. If scars are present in the area they may need to be injected, as scars are a common source of pain. For severe, intractable cases more invasive therapies can be suggested by your pain doctor.

Peripheral neuropathy:

Peripheral neuropathy describes damage to the peripheral nervous system, which transmits information from the brain and spinal cord to every other part of the body. More than 100 types of peripheral neuropathy have been identified, each with its own characteristic set of symptoms, pattern of development, and prognosis. Impaired function and symptoms depend on the type of nerves -- motor, sensory, or autonomic -- that are damaged.  Some people may experience temporary numbness, tingling, and pricking sensations, sensitivity to touch, or muscle weakness. Others may suffer more extreme symptoms, including burning pain (especially at night), muscle wasting, paralysis, or organ or gland dysfunction. Peripheral neuropathy may be either inherited or acquired. Causes of acquired peripheral neuropathy include physical injury (trauma) to a nerve, tumors, toxins, autoimmune responses, nutritional deficiencies, alcoholism, and vascular and metabolic disorders. Acquired peripheral neuropathies are caused by systemic disease, trauma from external agents, or infections or autoimmune disorders affecting nerve tissue. Inherited forms of peripheral neuropathy are caused by inborn mistakes in the genetic code or by new genetic mutations.

 

No medical treatments exist that can cure inherited peripheral neuropathy. However, there are therapies for many other forms.  In general, adopting healthy habits -- such as maintaining optimal weight, avoiding exposure to toxins, following a physician-supervised exercise program, eating a balanced diet, correcting vitamin deficiencies, and limiting or avoiding alcohol consumption -- can reduce the physical and emotional effects of peripheral neuropathy.  Systemic diseases frequently require more complex treatments. Anti-neuropathics are commonly used as therapy. For severe cases, temporary relief may be achieved with epidural steroid injections. Some types of peripheral neuropathies respond to spinal cord stimulators and intrathecal pumps.

 

 

In acute neuropathies, such as Guillain-Barré syndrome, symptoms appear suddenly, progress rapidly, and resolve slowly as damaged nerves heal. In chronic forms, symptoms begin subtly and progress slowly. Some people may have periods of relief followed by relapse. Others may reach a plateau stage where symptoms stay the same for many months or years. Some chronic neuropathies worsen over time, but very few forms prove fatal unless complicated by other diseases. Occasionally the neuropathy is a symptom of another disorder.

Adapted from www.ninds.nih.gov/disorders/peripheralneuropathy/peripheralneuropathy.htm

Phantom pain: see post-amputation pain. Phanton limb syndrome is pain of an amputated limb (finger, toes, arms, legs).

Piriformis syndrome: aching sore, shooting pain in the buttocks may be due to spasm of the piriformis muscle. The sciatic nerves runs trough the muscle and may be irritated by the muscle spasm. This condition may be confused with sciatica and spinal nerve/disc herniation. It is important that is properly diagnose to avoid unnecessary therapy, tests and pain. Pain specialist are trained to recognize this condition. Therapy consist of stretch exercises, muscle relaxants and injections into the muscle. The muscle is locate deep in he buttocks and x-rays (fluoroscopy) should be used to confirm proper injection.

Plantar fasciitis:

Post-surgery knee pain: constant burning, shooting and aching pain after knee surgery may be the result of damage to saphenous and peroneal nerves. Therapy consists of antineuropathics and blocking the affected nerves. Opioids are rarely effective, but may be tried. Differentiating this pain from other common pain syndromes is key, other possible diagnosis may include CRPS, spinal nerve damage from a herniated disck or infections. It is important to be seen by a physician trained in recognizing these conditions.

Post-laminectomy pain syndrome: common term to refer to pain in the back and extremities after surgery. Pain may originate from screws and hardware placed in the spine, nerve damage after surgery, scar tissue surrounding nerves and free moving disc or bone fragments. It is paramount that a spine surgeon rules out a surgical cause for the pain. Although pain started after surgery, further surgery may be the only solution. Antineuropathics and judicious amounts of opioids may be prescribed. Acupuncture has shown to be effective in certain cases. Severe pain, not improving with conservative therapies, may necessitate intrathecal pumps or spinal cord stimulators.  

Post lumpectomy pain: see mastectomy pain syndrome.

Post herpetic neuralgia:

Shingles (herpes zoster) is an outbreak of rash or blisters on the skin that is caused by the same virus that causes chickenpox — the varicella-zoster virus. The first sign of shingles is often burning or tingling pain, or sometimes numbness or itch, in one particular location on only one side of the body. After several days or a week, a rash of fluid-filled blisters, similar to chickenpox, appears in one area on one side of the body. Shingles pain can be mild or intense.  Some people have mostly itching; some feel pain from the gentlest touch or breeze.  The most common location for shingles is a band, called a dermatome, spanning one side of the trunk around the waistline. Anyone who has had chickenpox is at risk for shingles.  Scientists think that in the original battle with the varicella-zoster virus, some of the virus particles leave the skin blisters and move into the nervous system.  When the varicella-zoster virus reactivates, the virus moves back down the long nerve fibers that extend from the sensory cell bodies to the skin.  The viruses multiply, the tell-tale rash erupts, and the person now has shingles.
 

The severity and duration of an attack of shingles can be significantly reduced by immediate treatment with antiviral drugs, which include acyclovir, valcyclovir, or famcyclovir. Antiviral drugs may also help stave off the painful after-effects of shingles known as postherpetic neuralgia. Other treatments for postherpetic neuralgia include steroids, antidepressants, anticonvulsants, and topical agents. When pain is severe, epidural injections may be effective. Intractable cases may necessitate further invasive therapy. Consult a fellowship trained pain physician

For more information check www.ninds.nih.gov

Post mastectomy pain: breast surgery may injure a local nerve, the intercosto-brachialis. Pain is felt around the breast, axilla and sometimes chest. Therapy consist of mainly antineuropathics. Opioids may betried in severe cases. Some blocks may be of benefit. If all fails, then spinal cord stimulator and spinal pumps may be tried.

Post radical neck dissection pain: radical neck dissection surgery may be necessary to remove cancer lesions from neck, face and throat. In the process, unfortunately a group of nerves called superficial cervical plexus may be injured. Pain is localized to the side of surgery. Usually burning an throbbing in nature. Medications may be tried initially, consisting of antineuropathic kind. Injecting the plexus may provide pain control. This is an easy, safe injection. May be performed in the office setting.

 

Post thoracothomy pain syndrome: after chest surgery (CABG, cancer, biopsy) the intercostals nerves may be injured. Pain slowly progresses after surgery and is localized on  the side of surgery. Early therapy with antineuropathics, intercostals injections and epidural may help worsening of symptoms. Delaying therapy makes it more difficult to treat this condition. In very severe cases spinal cord stimulator or a spinal pump may be the only option.

 

Post-amputation pain: pain may originate from the missing limb (AKA phantom limb pain) or from the stump. In both cases the origin of pain is nerve structures. Therapy consists of antineuropathics, injections into the affected nerves and epidurals. Severe cases may require a spinal pump or spinal cord srimulator.

Post-chemotherapy peripheral neuropathy: see peripheral neuropathy. Treatment of cancer with certain agents may injure peripheral nerves causing severe, burning, electrical type of pain. Treatment is described in peripheral neuropathy.

Post-stroke pain: see central pain.

Prostadynia

Pudendal neuralgia:

Painful condition involving the pudendal nerve affecting both men and women. The pudendal nerve runs through the pelvic region, including  genitals, urethra, anal, and perineum. Your perineum is the area between your anus and genitals. The condition is also known as pudendal neuropathy, pudendal nerve entrapment, cyclist's syndrome, pudendal canal syndrome, or Alcock’s syndrome.

Pudendal neuralgia can cause pain, especially when one sits. Men with pudendal neuralgia may have pain in the buttocks, scrotum, penis, and perineum. Women with pudendal neuralgia may have pain in their buttocks, vulva, urethra, and perineum.

If the pudendal nerve is entrapped, surgery may be needed to free the nerve. For other causes acupuncture, medications and  biofeedback often improve pain. Severe cases may need nerve injections, epidural injections or sympathetic blocks may be needed. Spinal cord stimulators have been used for intractable, debilitating pain.

Radiation enteritis

Raynaud’s syndrome: disease of the collagen system. Involves damage to arteries causing low flow of blood to hands. Lack of oxygen to nerves in hands may cause severe pain. Severe cases may improve with sympathetic nerve blocks and spinal cord stimulators.

RSD: see CRPS.

Scar neuroma: skin scars are thought to cause pain by entrapping small nerves within. Very simple therapy performed in the office may diagnose and at the same time treat the pain.

Slipping rib syndrome

Spinal cord injury pain: see Central Cord Syndrome.

Spondylolisthesis: term that defines the slippage of one vertebrae over the next one. All structures contained within will be strained with the movement of the two vertebrae. Early cases can be treated conservatively with chiropractor care, physical therapy and medications. More severe cases may need surgical repair. See back pain above.

Stump pain: pain originating after amputation. Usually results from scar neuromas or nerve pain. Pain that continues several weeks after surgery may need intervention. Medications, acupuncture, nerve blocks or sympathetic blocks may be recommended by  your doctor. Severe cases have responded in the past to spinal cord stimulators.

Temporal arteritis:

Vasculitis is an inflammation of the blood vessel system, which includes the veins, arteries, and capillaries. Vasculitis may affect blood vessels of any type, size, or location, and therefore can cause dysfunction in any organ system, including the central and peripheral nervous systems. The symptoms of vasculitis depend on which blood vessels are involved and what organs in the body are affected. The disorder may occur alone or with other disorders such as temporal arteritis. Temporal arteritis (also called cranial or giant cell arteritis) is an inflammation of the temporal artery (which runs over the temple, beside the eye). Symptoms of this disorder may include stiffness, muscle pain, fever, severe headaches, pain when chewing, and tenderness in the temple area. Other symptoms may include anemia, fatigue, weight loss, shaking, vision loss, and sweats.
 

Treatment for vasculitis depends on the severity of the disorder and the individual's general health. Treatment may include cortisone or cytotoxic drugs. Other treatments may include plasmapheresis (the removal and reinfusion of blood plasma), intravenous gammaglobulin, and cyclosporin. Some cases of vasculitis may not require treatment. Treatment for temporal arteritis and its associated symptoms generally includes corticosteroid therapy. Early detection of temporal arteritis and immediate treatment are essential to prevent vision loss.

 

The prognosis for individuals with vasculitis varies depending on the severity of the disorder. Mild cases of vasculitis are generally not life-threatening, while severe cases (involving major organ systems) may be permanently disabling or fatal. The prognosis for individuals with temporal arteritis is generally good. With treatment, most individuals achieve complete remission, however vision loss may be irreversible.

Tendinitis

Testicular pain

Torticollis

Trigeminal neuralgia

Trigeminal neuralgia (TN), also called tic douloureux, is a chronic pain condition that causes extreme, sporadic, sudden burning or shock-like face pain that lasts anywhere from a few seconds to as long as 2 minutes per episode.  The intensity of pain can be physically and mentally incapacitating. TN pain is typically felt on one side of the jaw or cheek. Episodes can last for days, weeks, or months at a time and then disappear for months or years.  In the days before an episode begins, some patients may experience a tingling or numbing sensation or a somewhat constant and aching pain.  The attacks often worsen over time, with fewer and shorter pain-free periods before they recur.  The intense flashes of pain can be triggered by vibration or contact with the cheek (such as when shaving, washing the face, or applying makeup), brushing teeth, eating, drinking, talking, or being exposed to the wind.  TN occurs most often in people over age 50, but it can occur at any age, and is more common in women than in men.  There is some evidence that the disorder runs in families, perhaps because of an inherited pattern of blood vessel formation. Although sometimes debilitating, the disorder is not life-threatening.

The presumed cause of TN is a blood vessel pressing on the trigeminal nerve in the head as it exits the brainstem. TN may be part of the normal aging process but in some cases it is the associated with another disorder, such as multiple sclerosis or other disorders characterized by damage to the myelin sheath that covers certain nerves.

 

Because there are a large number of conditions that can cause facial pain, TN can be difficult to diagnose.  But finding the cause of the pain is important as the treatments for different types of pain may differ.  Treatment options include medicines such as anticonvulsants and tricyclic antidepressants, surgery, and complementary approaches. Typical analgesics and opioids are not usually helpful in treating the sharp, recurring pain caused by TN.  If medication fails to relieve pain or produces intolerable side effects such as excess fatigue, surgical treatment may be recommended. Several neurosurgical procedures are available. Some are done on an outpatient basis, while others are more complex and require hospitalization. Some patients choose to manage TN using complementary techniques, usually in combination with drug treatment.  These techniques include acupuncture, biofeedback, vitamin therapy, nutritional therapy, and electrical stimulation of the nerves.

Trigger finger

Vaginal pain

Vascular Ischemic pain: lack of blood flow to extremities contributes pain in lower extremities. Pain is usually worse with walking and improves with rest. If surgery has failed to improve blood flow. Pain can be controlled with medications. Acupuncture may be tried. More invasive procedures could be indicated in severe cases. Placement of stimulators in the epidural space may increase the blood flow to lower extremities.

Vertebral fracture: caused by trauma or bone weakening from osteoporosis. Neck, upper and lower back may be affected. Extremely painful, at times very difficult to treat. Potent opioids may be necessary to control the pain. A relative new procedure places a needle into the bone, and under close vigilance with fluoroscopy, cement is injected. When dry, the cement will act as a cast inside the bone. Also, by filling the vertebrae with cement, the normal  anatomy may be restored.

Vulvodinia

Winged scapula syndrome