Gabor B. Racz

Sphenopalatine Ganglion Pulsed Radiofrequency Treatment in 30 Patients Suffering from Chronic Face and Head Pain

Abstract:  This study evaluated the efficacy of sphenopalatine ganglion pulsed radiofrequency (SPG‐PRF) treatment in patients suffering from chronic head and face pain. Thirty patients were observed from 4 to 52 months after PRF treatment. The primary efficacy measures were the reduction in oral medication use, including opioids, time‐to‐next‐treatment modality for presenting symptoms, duration of pain relief, and the presence of residual symptoms. Secondary objectives included the evaluation of adverse effects and complications. All data were derived from patient charts, phone conversations, and clinical follow‐up visits. Fourteen percent of respondents reported no pain relief, 21% had complete pain relief, and 65% of the patients reported mild to moderate pain relief from SPG‐PRF treatment. Sixty‐five percent of the respondents reported mild to moderate reduction in oral opioids. None of the patients developed significant infection, bleeding, hematoma formation, dysesthesia, or numbness of palate, maxilla, or posterior pharynx. A large‐scale study of SPG‐PRF for the treatment of face and head pain has not been previously reported. Our results suggest that a prospective, randomized, controlled trial study to confirm efficacy and safety of this novel treatment for chronic head and face pain is justified.

Lumbar and thoracic sympathetic radiofrequency lesioning in complex regional pain syndrome.

If complex regional pain syndrome is defined in terms of the consensus paper, 1 most cases are preceded by a noxious event and are associated with both spontaneous pain or touch evoked pain, including hyperalgesia and/or allodynia that is both disproportionate and not limited to a single nerve territory. Associated vasomotor changes include abnormalities of temperature, sweating, and edema in the affected region. Sympathetically maintained pain as defined by Merskey and Bogduk 2 is pain associated with the sympathetic nervous system and/or circulating catecholamines that can be demonstrated by a regional anesthetic sympathetic block. Therefore, patients whose symptoms, both continuous pain and touch evoked pain, are largely relieved by a stellate ganglion or dorsal sympathetic block and are potential subjects for a prolonged sympatholysis using radiofrequency (RF). This technique should be considered in the context of guidelines that have been published for therapy of complex regional pain syndrome and is but one method of providing analgesia to help a patient regain function by physiotherapeutic methods. 3 RF Sympatholysis

Hypertonic Saline and Corticosteroid Injected Epidurally for Pain Control

Pain is a symptom with many etiologies. In a number of cases, pain persists after the initial cause is removed because the initial insult sets up a selfperpetuating cycle of events (figure 7–1). For instance, an injury can cause severe pain that produces muscle spasm, inflammation, and edema formation that produces pressure upon nerves. The pressure causes the nerves to discharge, producing pain or altered sensory perception.

DOSE EFFECTIVENESS AND SAFETY OF BUTORPHANOL IN ACUTE MIGRAINE HEADACHE

This study was undertaken to compare the effectiveness and safety of three dosage levels of butorphanol in 52 patients with acute, severe migraine headache. After baseline evaluation, patients were given a dose of butorphanol 1.0, 2.0, or 3.0 mg intramuscularly on a double‐blind basis. Assessments of pain intensity and pain relief using 100 mm linear analog scales (LAS), vital signs, and medication side effects were made at 15, 30, 45, and 60 minutes after the dose. All three treatment groups were similar in baseline characteristics. Each dose of butorphanol demonstrated a significant decrease in pain intensity LAS compared to baseline and increase in pain relief LAS over the observation period. The majority of analgesic response was observed at the first (i.e., 15‐min) assessment. Doses of 2.0 and 3.0 mg produced significantly greater analgesia than did 1.0 mg at all posttreatment evaluations. No significant difference was apparent between the 2.0‐ and 3.0‐mg doses. Adverse cardiovascular and respiratory depressant effects were not observed. An analgesic response to butorphanol 2.0 and 3.0 mg is clearly and rapidly evident and near maximum 30–45 minutes after administration. We conclude that in these doses butorphanol provides effective and safe analgesia for patients with acute migraine headache.

Repeat Epidural Phenol Injections in Chronic Pain and Spasticity

Since the introduction of phenol as a neurolytic agent by Maher (1955, 1957, 1960), extensive experience has been gained—primarily in its use as subarachnoid single dose injections for the treatment of the chronic pain of malignancy. A recent review by Wood (1978) leads to better understanding of the use of phenol for pain control and suggests that epidural administration of phenol for pain therapy needs to be further explored.

Peripheral Nerve Stimulator Implant for Treatment of RSD

Injury to peripheral nerves may produce causalgia as described in detail in preceding chapters. Sweet and Wepsic (1,2) utilized electrical stimulation to treat causalgia involving the median and ulnar nerves, to produce a pleasant “tingling” and loss of the burning pain in many cases.

Gross and Microscopic Lesions Produced by Phenol Neurolytic Procedures

The primary purpose of this brief discourse is to show, in pictorial form, the morphological changes that occur when phenol is applied to neural structures. According to Katz and Joseph [1], most studies on morphologic changes caused by neurolytic agents have been done with phenol. It generally is accepted that the primary neurolytic effect is a result of protein denaturation. When concentrations of 5% or more in water are applied directly to tissue, protein coagulation and necrosis occur. However, phenol has been suggested to have a greater affinity for vascular tissue than for neuronal tissue, thereby tending to cause neural lesions via interference with blood flow [2, 3]. When we [4] compared morphological changes that occurred following epidural and subarachnoid injection of phenol, no spinal cord damage was noted in the former case (see figure 12–3). In contrast, massive neural tissue damage occurred following subarachnoid injection. Blood vessels with normal morphology were present in areas of spinal cord destruction (see figure 12–4), illustrating a direct neurotoxic effect of phenol rather than an effect secondary to vascular destruction.

Medico-legal Aspects of Pain Medicine

Deviation from an acceptable standard of care is one of the central issues in a lawyer’s mind in any malpractice lawsuit. However, the trigger for a lawsuit is the occurrence of a compli‐ cation. That is, intense scrutiny of a doctor’ practice usually only occurs once harm has occurred to a patient. Thus avoiding complications is the maxim to follow. Understanding the situations in which complications leading to law suits may arise is most important. Not all complications will lead to law suits depending on how they are handled and, for example non negligent complications and side-effects may be successfully defended if appropriately consented. The trend towards more accreditation may reduce rare but serious complications. Many Boards (in the USA) and Faculty of Pain Medicine (in the UK) amongst others and international organizations such as World Institute of Pain (WIP) have introduced standards of training in an attempt to reduce complications rates. If you are sued, remember no one is going to care more about the result than you do. Pick the best lawyer and experts to defend you.