PAIN MEDICINE

Occipital Neuralgia

Headache is in the back of head and may be on one or both sides.

There has been great success with peripheral nerve stimulators, where electrodes are placed under the skin, near affected Occipital nerve and stimulated with an external generator for 5-7 days for trial. If successful the generator is implanted in the body like a pacemaker.

Migraine Headache

When Migraine headache is not controlled with medications, the best option is Botox injection.

Low backache is one most common pain conditions today. Most back pain resolves with painkillers, rest, physiotherapy and correction of posture. However, painkillers should not be taken frequently as it may cause more damage to your body than the cause of your pain.

If pain doesn't resolve in 3-6 weeks, you will need thorough physical examination and may be few investigations.

Common causes of backache are muscular, facet joint arthropathy, Sacroiliac joint arthropathy. Muscular/myofascial pain is usually due to wrong sitting/ walking/standing posture; which causes muscle strain, leading to thickening of muscles called Trigger points. These are felt as nodules/bands and are painful with deep pressure and pain can be felt far away too. Medications taken by mouth,do not reach these hard fibrous trigger points because of poor blood supply and need to be injected directly.

Muscular/Myofascial pain

Muscular/myofascial pain is usually due to wrong sitting/ walking/standing posture; which causes muscle strain, leading to thickening of muscles called Trigger points.

These are felt as nodules/bands and are painful with deep pressure and pain can be felt far away too.

Medications taken by mouth, do not reach these hard fibrous trigger points because of poor blood supply and need to be injected directly.

Facet joint arthropathy

Facet joint are two small joints which connect vertebrae above and below and are responsible for movement of spine.

When these joints are effected, it causes back pain on movement and tenderness to feel. Medications taken by mouth, do not reach these hard fibrous trigger points because of poor blood supply and need to be injected directly. These joints are located under an image intensifier/fluoroscopy ( continuous X- ray)and injected with local anaesthetic to confirm diagnosis.

These joints may sometimes have degenerated to an extent that they can't be pierced, in which case the nerve supply to the joint( Median branch to facet joint) is numbed.

Once diagnosis is confirmed, these small nerves can be destroyed with Radiofrequency lesioning. These are safe procedures, performed under local anaesthesia and do not involve surgical cutting. Facet joint arthropathy-Radiofrequency

Sacroiliac joint arthropathy

Sacroiliac (SI) joints are formed by the connection of the sacrum and iliac bones.

The sacrum is the triangular-shaped bone in the lower portion of the spine, below the lumbar spine.

While most of the bones (vertebrae) of the spine are mobile, the sacrum is made up of five vertebrae that are fused together and do not move.

The iliac bones are the two large bones that make up the pelvis. As a result, the SI joints connect the spine to the pelvis.

The sacrum and the iliac bones (ileum) are held together by a collection of strong ligaments. There is relatively little motion at the SI joints. There are normally less than 4 degrees of rotation and 2 mm of translation at these joints.

Most of the motion in the area of the pelvis occurs either at the hips or the lumbar spine. These joints do need to support the entire weight of the upper body when we are erect, which places a large amount of stress across them.

This can lead to wearing of the cartilage of the SI joints and arthritis and an important cause of low back and leg pain.

Another common cause of SI joint dysfunction is pregnancy. During pregnancy, hormones are released in the woman's body that allows ligaments to relax. This prepares the body for childbirth. Relaxation of the ligaments holding the SI joints together allows for increased motion in the joints and can lead to increased stresses and abnormal wear. The additional weight and walking pattern (altered gait) associated with pregnancy also places additional stress on the SI joints.

Patients often experience pain in the lower back or the back of the hips. Pain may also be present in the groin and thighs. The pain is typically worse with standing and walking and improved when lying down. Inflammation and arthritis in the SI joint can also cause stiffness and a burning sensation in the pelvis.

Anti-inflammatory medications and Ultrasonic over the joints are usually helpful. Those who do not respond to conservative treatment, will benefit from an injection of anti-inflammatory medications into the affected joints. Radiofrequency denervation of the joint is performed for lasting pain relief.

Disc prolapse leading to Sciatica/Radiculopathy

The spinal discs are composed of a tough spongiform ring of cartilage ("annulus fibrosus") with a more malleable center ("nucleus pulposus").

The discs separate the vertebrae, thereby allowing room for the nerve roots to properly exit through the spaces between the vertebrae.

The discs cushion the spine from compressive forces but are weak to pressure applied during rotational movements.

That is why a person who bends to one side, at a bad angle to pick something up, may more likely herniate a spinal disc than a person jumping from a ladder and landing on their feet.

Sciatica is generally caused by irritation of of lumbar nerves L3, L4, or L5 or sacral nerves as a result of a spinal disc bulge or herniation.

The nucleus pulposus, a jelly like substance, may extrude through the tear in the annulus and produce chemical inflammation reaction around exiting nerve roots. In a inflammatory response, local body chemicals like substance P & Prostaglandin E are produced and produce irritation and cause further compression of the nerve root in the confined space in the spinal canal.

MRI/Nerve Conduction Velocity (NCV)/EMG/X-ray help to support diagnosis but clinical presentation clinches the diagnosis.

In doubtful cases a diagnostic block with local anaesthetic is performed.

A potent anti-inflammatory medication is deposited around the nerve, using fluroscopy and contrast guidance, under local anaesthesia, to reduce /treat inflammation and ease pain.

The treatment is targeted at the source of pain, which is in this case is a tiny fraction of the whole body and rest of the body is spared. Orally taken medications circulate in the whole body and is responsible for many serious side effects like gastritis, kidney/ liver dysfunction etc.

The procedures are called selective spinal root block/ transformational epidural, depending on where the drug is deposited in the path of affected spinal nerve root.

They are performed as out-patient daycare procedures and are safe in the hands of experienced Interventional Pain Specialists. They are performed in the operating theatre under strict aseptic conditions and close monitoring.

The main obvious function of the neck is to hold up the head.

The neck is very fragile and it can move in all sorts of directions because of the sensory organs like the eyes, ears and nose.

This is a disadvantage as the vertebrae can easily "disalign," or its joints can frequently get dislocated, due to whiplash, birth injuries, neck trauma, etc.

Moreover, stress, posture, and excessive computer use can stiffen the neck.

Because of excessive mobility of the neck and wrong postures, the muscles holding the head are subjected to constant strain, leading to muscle spasms and later develop muscle knotting and bands. These cause pain on movement.

When conservative treatment fails, these knots and bands in the muscles need direct treatment with trigger point injection.

A trigger point is defined as a hyperirritable area located in a palpable, taut band/nodule of muscle fibers.