Gulshan Doulatram

Alcohol neurolysis of the sciatic and femoral nerves to improve pressure ulcer healing.

Successful pressure ulcer treatment is challenging and is often plagued with prolonged hospitalizations, multiple surgeries, and high recurrence rates. Pressure ulcer secondary to spinal cord injury is further complicated by spasticity, which contributes to both ulcer continuance and healing. This report illustrates the use of neurolytic regional techniques for spasticity control and pressure ulcer healing. Case report: We present our experience with a paraplegic man who suffered from chronic right trochanteric and ischial pressure ulcers that failed to heal despite surgical and conservative treatment. We report the successful treatment of knee and hip flexor spasticity with a femoral and sciatic alcohol neuroablation technique. It was not until the successful control of his lower extremity spasticity that the pressure ulcers showed signs of healing. Neuroablation nay be considered for spasticity control when more conservative approaches fail or are not feasible.

Efficacy, Safety, and Feasibility of the Morphine Microdose Method in Community-Based Clinics

Objectives The goal of this study was to assess the success of the morphine microdose method in a community pain clinic setting by monitoring follow-up frequency, dose escalation, and monotherapy/polytherapy ratio. The morphine microdose method involves a pretrial reduction or elimination of systemic opioids followed by a period of abstinence. Intrathecal (IT) morphine is then started at doses of less than 0.2 mg per day. Systemic opioid abstinence is then continued after pump implant and IT morphine monotherapy. Design Retrospective review of medical records. Setting Private and academic pain clinic practices. Subjects Chronic noncancer pain patients. Methods We reviewed the charts of 60 patients who had completed a microdose regimen and had an IT pump implanted between June 11, 2008, and October 11, 2014. During IT therapy, dose change over time, pain scores, side effects, max dose, and duration were recorded. Results The majority of patients (35/60, 58%) were successfully managed solely on morphine microdose monotherapy. These patients did not require additional oral therapy. There was a significant reduction in mean pain scores, from 7.4 ± 0.32 before microdose therapy to 4.8 ± 0.3 after microdose therapy. Conclusions Microdose therapy achieved analgesia, improved safety, and avoided systemic side effects. The safety of IT therapy was increased by using a lower concentration (2 mg/mL) and lower daily doses (<3 mg/d) of morphine. Furthermore, microdose therapy was feasible, safe, and cost-effective in the outpatient setting.

Suprascapular Nerve Blocks and Neurolysis

Suprascapular nerve blocks are used to treat both acute and chronic shoulder pain. The nerve contributes motor supply to the muscles of the rotator cuff and provides sensation to the posterior part of the shoulder. Acute postoperative pain resulting from thoracotomies and arthroscopic shoulder surgeries is amenable to suprascapular nerve block. In addition, the pain practitioner can use this block to treat inoperable chronic, debilitating shoulder pain arising from a wide range of pathologies. Repeated nerve blocks, however, may be challenging and carry the risk of complications; hence, pulsed radiofrequency, cryoablation, catheters, chemical neurolysis, and neuromodulation may be attempted to facilitate long-term relief and aggressive physical therapy. The nerve can be localized by various approaches with the use of fluoroscopy and ultrasound to ensure a localized and effective spread of local anesthetic.

Hypogastric Plexus Blocks

Hypogastric plexus block is the primary sympathetic block for pelvic pain secondary to benign and malignant conditions. Innervation of the pelvis is complex, and pain emanating from pelvic organs has a visceral, somatic, and neuropathic component to it. The plexus, though traditionally called the superior hypogastric plexus, also includes the inferior hypogastric plexus which has been a target of interest in peripheral malignancies of the pelvis. Along with medical management, hypogastric plexus blocks and neurolysis has been an important part of a pain practitioner’s armamentarium. Although evidence to support the use of hypogastric plexus is lacking in the form of robust randomized clinical trials, this block is frequently used in terminal cancer pain to provide an improved quality of life in terminal cancer patients. The approaches to this block vary according to the expertise of the practitioner with all techniques being comparable in their relief.

Chest Wall Blocks and Neurolysis

Chest wall blocks are used in pain medicine to diagnose and treat acute and chronic pain conditions of the chest wall and abdomen. Patients presenting with unilateral or bilateral pain associated with a variety of neuropathic conditions are good candidates for these blocks. The blocks relieve pain involving the parietal pleura, skin, and intercostal muscles and usually do not affect or help the more deep-seated visceral painful states. While radiofrequency ablation is used more commonly for benign, chronic, continuous pain, chemical neurolysis is reserved for the terminally ill cancer pain of the chest wall primarily due to complications related to placement and spread of the neurolytic agents. Complications related to intercostal nerve blocks including the dreaded pneumothorax and vascular absorption should mandate that the technique be done either with fluoroscopic guidance or ultrasound; however, there are no good studies indicating that localization techniques prevent these complications completely.

Peripheral Nerve Stimulator

Peripheral nerve stimulation is an essential intra- and postoperative monitor of neuromuscular function and serves as a guide during critical periods including intubation and recovery from a general anesthetic. This is monitored by evaluating the muscular response to supramaximal electric stimulation of a peripheral motor nerve. Common sites include facial nerve (facial twitch) and ulnar nerve (thumb abduction). There are five patterns of stimulation commonly elicited. These are single-twitch stimulation, train-of-four (TOF) stimulation, double-burst stimulation, tetanic stimulation, and posttetanic count stimulation. There is good emerging evidence that objective monitoring performed perioperatively ensuring a TOF ratio greater than 0.9 will cause a subsequent decrease in the incidence of postoperative residual paralysis.

Pregnancy and Substance Abuse

Substance abuse is increasing in incidence worldwide, including pregnant women who are highly vulnerable to its effects. Pregnant women should be screened routinely for substance abuse. Because self-report may be unreliable, toxicology screens can be useful, especially if multiple drugs are being abused. Each individual drug has unique maternal and fetal effects. Licit substances such as alcohol, nicotine, and caffeine are more frequently abused. Complete cessation of alcohol should be encouraged to avoid the development of Fetal Alcohol Syndrome (FAS) and long-term neurobehavioral effects. Marijuana is the most commonly abused illicit drug. Opioid maintenance programs can be utilized in opioid addicted patients (including heroin and cocaine) to avoid relapses. Neonatal abstinence syndrome should be expected in these infants and managed appropriately.