Richard H. Rho

Complex Regional Pain Syndrome

Complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy, is a regional, posttraumatic, neuropathic pain problem that most often affects 1 or more limbs. Like most medical conditions, early diagnosis and treatment increase the likelihood of a successful outcome. Accordingly, patients with clinical signs and symptoms of CRPS after an injury should be referred immediately to a physician with expertise in evaluating and treating this condition. Physical therapy is the cornerstone and first-line treatment for CRPS. Mild cases respond to physical therapy and physical modalities. Mild to moderate cases may require adjuvant analgesics, such as anticonvulsants and/or antidepressants. An opioid should be added to the treatment regimen if these medications do not provide sufficient analgesia to allow the patient to participate in physical therapy. Patients with moderate to severe pain and/or sympathetic dysfunction require regional anesthetic blockade to participate in physical therapy. A small percentage of patients develop refractory, chronic pain and require long-term multidisciplinary treatment, including physical therapy, psychological support, and pain-relieving measures. Pain-relieving measures include medications, sympathetic/somatic blockade, spinal cord stimulation, and spinal analgesia.

Contemporary Management of Neuropathic Pain for the Primary Care Physician

Neuropathic pain (NP), caused by a primary lesion or dysfunction in the nervous system, affects approximately 4 million people in the United States each year. It is associated with many diseases, including diabetic peripheral neuropathy, postherpetic neuralgia, human immunodeficiency virus-related disorders, and chronic radiculopathy. Major pathophysiological mechanisms include peripheral sensitization, sympathetic activation, disinhibition, and central sensitization. Unlike most acute pain conditions, NP is extremely difficult to treat successfully with conventional analgesics. This article introduces a contemporary management approach, that is, one that incorporates nonpharmacological, pharmacological, and interventional strategies. Some nonpharmacological management strategies include patient education, physical rehabilitation, psychological techniques, and complementary medicine. Pharmacological strategies include the use of first-line agents that have been supported by randomized controlled trials. Finally, referral to a pain specialist may be indicated for additional assessment, interventional techniques, and rehabilitation. Integrating a comprehensive approach to NP gives the primary care physician and patient the greatest chance for success.

Preoperative Gabapentin for Acute Post-thoracotomy Analgesia: A Randomized, Double-Blinded, Active Placebo-Controlled Study

Background:  The role of preoperative gabapentin in postoperative pain management is not clear, particularly in patients receiving regional blockade. Patients undergoing thoracotomy benefit from epidural analgesia but still may experience significant postoperative pain. We examined the effect of preoperative gabapentin in thoracotomy patients.

Management of Cerebral Spinal Fluid Leak Complicating Spinal Cord Stimulator Implantation

Abstract:  Accidental puncture of the dura mater with resultant leakage of cerebral spinal fluid (CSF) and development of postdural puncture headache (PDPH) is a known potential complication of percutaneous placement of spinal cord stimulator (SCS) leads. However, the implications and management strategies for this complication have not been thoroughly reported. We report two cases of SCS lead placement complicated by CSF leak and PDPH.

Incidence of Clinically Significant Percutaneous Spinal Cord Stimulator Lead Migration

To examine the incidence of percutaneous spinal cord stimulator lead migration, given current hardware and surgical technique.

Topical amitriptyline combined with topical ketamine for the management of recalcitrant localized pruritus: A retrospective pilot study

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Ultrasound-guided transversus abdominis plane injection with computed tomography correlation: a cadaveric study

Background Ultrasound-guided transversus abdominis plane (TAP) injections are increasingly being used as an alternative to traditional perioperative analgesia in the abdominal region. With the use of a “blind” TAP block technique, these procedures have had variable success in cadaver and in vivo studies. For more accurate injection with the intended medication, ultrasound guidance allows visualization of the correct layer of the abdominal wall planes in which the thoracolumbar nerves reside. Objective To assess the spread of various volumes of contrast placed under live ultrasound guidance into the TAP using computed tomography (CT). Methods Four TAP blocks were performed on 2 fresh frozen cadaver torsos with predetermined contrast volumes of 5, 10, 15, or 20 mL. A CT scan of the cadaver was then performed and interpreted by a musculoskeletal radiologist. This cadaver study was carried out at a tertiary care academic medical center. Results Cranial–caudal spread of injected contrast correlated with increasing injectate volume and was roughly 1 vertebral level (end plate to end plate) for the 5 mL injection and 2 vertebral levels for the 10, 15, and 20 mL injections. However, the degree of injectate spread may be different for live patients than for cadavers. Conclusion This study helps further the understanding of injectate spread following ultrasound-guided TAP injections. Specifically, it suggests that 15 mL provides additional cranial–caudal spread and may be an optimal volume of anesthesia.

Topical Amitriptyline-Ketamine for the Treatment of Brachioradial Pruritus

Timothy J. Poterucha, BS; Sinead L. Murphy; Mark D. P. Davis, MD; Paola Sandroni, MD, PhD; Richard H. Rho, MD; Roger A. Warndahl, RPh; William T. Weiss, RPh; Departments of Dermatology (Dr Davis), Neurology (Dr Sandroni), Anesthesiology (Dr Rho), and Pharmacy Services (Messrs Warndahl and Weiss), Mayo Clinic, Rochester, Minnesota. Mr Poterucha is a medical student at Mayo Medical School, Rochester. Ms Murphy is a college student at Amherst College, Amherst, Massachusetts

Incidence of neuropathic pain after radiofrequency denervation of the third occipital nerve

The purpose of this study was to identify the incidence of neuropathic pain occurring after radiofrequency neurotomy of the third occipital nerve (TON). This study was conducted at a teaching hospital from January 1, 2008, to March 31, 2010. With institutional review board approval, Current Procedural Terminology codes were used to identify patients who received radiofrequency ablation (RFA) of the nerves supplying the C2-3 facet joint and the TON. The C3 dorsal ramus provides innervation to the C2-3 facet joint and the suboccipital cutaneous region, and procedures that included ablation to this region were reviewed for complications. Postprocedural data were collected by reviewing follow-up appointment notes and telephone calls. Included were patients who had new neuropathic pain in the distribution of the TON after RFA. They described what they were feeling as burning, tingling, or numbness. All patients who presented with complaints had normal neurologic findings and no secondary cause for their symptoms. The included patient medical records were then reviewed for severity and duration of symptoms and the need for treatment with pain medication. Sixty-four patients underwent C2-3 RFA or TON RFA, and 12 patients were identified as experiencing ablation-induced third occipital neuralgia, an incidence rate of 19%. This finding suggests that patients undergoing RFA of the nerves supplying the C2-3 joint or TON are at risk for postprocedural third occipital neuralgia. This possibility may affect providing informed consent as well as anticipating and managing postprocedural pain.

Treatment of Genitofemoral Neuralgia After Laparoscopic Inguinal Herniorrhaphy With Fluoroscopically Guided Tack Injection

OBJECTIVE This report illustrates that genitofemoral neuralgia can result from laparoscopic inguinal herniorrhaphy and offers a management strategy for this pain syndrome. DESIGN A patient experienced pain in the distribution of the genitofemoral nerve after laparoscopic herniorrhaphy. Under fluoroscopy, the point of maximal tenderness was elicited and was found to be at the site of a surgical tack placed during the hernia repair. A genitofemoral nerve block was performed at the site of the surgical tack. This resulted in complete resolution of pain symptoms. RESULTS The patients treatment and recovery are described. CONCLUSIONS Recognition and proper diagnosis of genitofemoral neuralgia after laparoscopic herniorrhaphy may result in appropriate therapy and hasten recovery.