Category: Painful Conditions

ILIOINGUINAL ENTRAPMENT NEUROPATHY

Overview

Small collections of nerve fibers called cutaneous nerves supply sensation to every section of our skin. These nerves allow us to sense temperature changes, light touch, pressure and pain. Occasionally, these nerves can get trapped in other tissues such as scars. When this happens, the patient may experience pain along the nerve. The most common entrapment neuropathy is carpal tunnel syndrome where the median nerve gets trapped in the soft tissues of the wrist. Another common site for nerve entrapment is the groin. Many sufferers have had previous low abdominal surgery such as C-sections or hernia repairs. These scars can lead to entrapment of two nerves called the ilioinguinal and hypogastric nerves causing low abdominal pain. Other risk factors for abdominal entrapment neuropathies include obesity and tight fitting clothing.

Diagnosis

In establishing a diagnosis, the doctor will rule out problems with the internal organs through a careful history and physical, and may order diagnostic studies such as blood work, urinalysis, X-rays, ultrasound, CAT scans or MRIs. Once all internal problems have been eliminated, the most likely diagnosis is an entrapped nerve. The next step is to have the nerve injected by an expert, usually a pain doctor. If the pain goes away temporarily with the injection of local anesthetic, the diagnosis is confirmed. Unfortunately there is no X-ray study that reveals the presence of an entrapment neuropathy. The X-rays are only useful to rule out problems with the internal organs.

Treatment

Obesity and tight fitting clothing are two conditions that contribute to entrapment neuropathies of the low abdomen. Therefore, obese patients should try to lose weight to relieve the nerve compression. Tight fitting jeans should be avoided. If the patient has severe pain, injections of the nerve with anti-inflammatory drugs can sometimes give long-term relief. In those cases where nerve blocks and weight reduction fail to relieve the discomfort, surgery can be performed to remove the nerve from the scar. This procedure is not always successful because the surgery can again result in more scar formation. Nonetheless, many patients report good long-term relief after surgery.

Prevention

• Maintain ideal body weight
• Appropriate fitting clothing
• Avoid smoking
• Proper diet

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SHINGLES

Overview

Shingles is an infection of an individual nerve root by the same virus that causes chicken pox, also known as the herpes zoster virus. The disease can be painful and can develop almost anywhere in the body, but is most commonly displayed on the face, chest and abdomen.

A day or two after the pain begins; a characteristic rash erupts, which is composed of small fluid-filled blisters on top of reddened skin. The blisters are limited to a band on the right or left side of the body. If the rash crosses over the middle of the body it is not shingles because the virus affects one nerve corresponding to an area of the skin. Each cutaneous or skin nerve in the human body stays on the right or left side and does not cross over. Initial infection of the shingles virus occurs when chicken pox is contracted as children or young adults. The body’s immune system forces the virus to settle in an inactive form inside the nerve cells. When the chicken pox virus reactivates, it moves down the nerve fibers to the skin and the rash erupts. In addition to the skin, the nervous system is involved. In fact, if the virus attacks the optic nerve of the eye, it may leave the patient with temporary blindness.

In most patients, after the eruption of shingles, the rash will heal and the pain will subside after a period of three to five weeks. However, there are exceptions. In older patients there is a greater risk the virus can actually leave permanent nerve damage, causing pain long after the rash is healed. In some patients, the pain may persist for the rest of their lives.

Treatment

Medical science is now developing antiviral drugs. These are similar to antibiotics that were developed in the 1950’s to treat bacterial infections. One of the first antiviral drugs developed was acyclovir. This drug can help resolve herpes infections. As soon as the rash breaks out, acyclovir is prescribed in large doses for a period of approximately 10 days. This can help alleviate the attack and prevent permanent nerve damage in some patients.

Additionally, early intervention with nerve blocks done by pain physicians can also prevent the development of post-herpetic neuralgia. Post-herpetic neuralgia is the name given to the painful condition that exists long after the viral infection is over. Combination therapy of the acyclovir and nerve blocks is the most effective treatment strategy for preventing this painful development.

There is treatment for patients suffering from post-herpetic neuralgia. Drugs used to treat seizures, such as Tegretol and Dilantin, can be of some help. Antidepressants are used to treat post-herpetic neuralgia as well. The antidepressants raise levels of chemicals in our brain that are the body’s natural mood elevators. These mood elevators also raise levels of endorphins in the brain, which are the body’s natural narcotics. Consequently, by taking antidepressants, we can elevate the body’s internal narcotics without having to rely on narcotics prescribed by the doctor.  Therefore, antidepressants are superior to narcotics because dependence can develop in narcotics.

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BACK PAIN

Overview

If you suffer from low back pain you are not alone. It is estimated, at any given time approximately 15% of all Americans have recurrent low back pain. By definition acute low back pain is severe, sudden in onset and short term. Chronic low back pain lasts longer than six months. Low back pain can be disabling, by not allowing sufferers to sleep, enjoy recreational activities, to take care of the household or go to work.

Diagnosis

About 90% of all low back pain is because of poor body mechanics. This may contribute to or be a result of arthritis, muscle tears or ligament strains. However, 10% of the time low back pain may indicate a serious underlying medical problem such as an infection or severe inflammatory arthritis. The most important factor in determining the diagnosis is the history and physical. Low back pain coming from a problem with the lumbar spine tends to be sudden in onset, worse during the day when we are weight bearing and relieved when we lay down. The serious medical causes of low back pain tend to be more gradual in onset, develop slowly and are usually worse during the night.

Ninety percent of the time back pain will go away on its own with education, mild pain relievers and a little bit of rest. When back pain is severe and chronic, the diagnostic tests are not always revealing. We are not always sure why the back is hurting despite the use of today’s best technology.

There are four structures in the back that cause pain: nerves, muscles, ligaments and joints. The Pain Management Center uses diagnostic injections to determine the cause of pain. When the physician does an injection, the following may occur: 1.) The patient may get good long-term relief, in which case the problem is identified and solved. 2.) The patient may get short-term relief, in which case a diagnosis is made. 3.) The patient may receive no relief, in which case the next structure is injected. Up to four injections are made into the different structures until a diagnosis can be determined.

Treatment

Is determined by the duration of the back pain and the diagnosis.

• Acute: In the event of acute onset of low back pain, the best therapy is rest for 48 hours
• Onset: along with anti-inflammatory medicine such as Motrin. It is important to note
  lying or sleeping position and to take pressure off the stained back muscles. Lumbar pillows are beneficial and help keep the back in neutral alignment, thereby relieving pressure. After the 48-hour period, gradually resume normal activities. Some  residual discomfort may persist, but should  subside. Oral medications should only be used for short periods as they can lead to high blood pressure, kidney or liver problems and ulcers in the stomach or small intestine. Usually within four weeks 90% of patients with low back pain will improve to the point where they have minimal or no discomfort. Proper posture and strength training can help reduce further incidence.
• Persistent Discomfort: If you have persistent discomfort, see your doctor. He/She may initiate an examination or diagnostic tests to rule out a medical cause for low back pain.
• Chronic: The pain doctor may inject one of the four structures to determine a diagnosis.
  Physical therapy may be used concurrently or as a follow-up to help reduce or prevent further pain. Physical therapy focuses on body alignment, mechanics and awareness, as well as flexibility and exercise.

Oral medications should only be used for short periods as they can lead to high blood pressure, kidney or liver problems and ulcers in the stomach or small intestine.

It is important to note lying or sleeping position in order to take pressure off the strained back muscles. Lumbar pillows are beneficial and help keep the back in neutral alignment, thereby relieving pressure.

Prevention

• Note sleep posture
• Consider a lumbar support pillow
• Maintain an ideal body weight
• Maintain proper posture for all daily activities (e.g.) walking, sitting or driving
• Do proper strength training
• Do proper flexibility training
• Avoid smoking
• Reduce stress

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MERALGIA PARASTHETICA

Overview

This disorder is also known as lateral femoral cutaneous neuralgia. It is defined as the itching, tingling, burning or other unusual sensations moving across the skin at the top or outer side of the upper portion of the thigh. The patient will experience more or less sensitivity to light touch. The disorder is caused by a disruption in the normal function of the nerve that originates near the pelvis and moves across the top of the thigh, quite close to the surface. Research shows the condition is caused by a sudden traumatic injury or by constant pressure on the lateral femoral cutaneous nerve, which passes along the front of the hip and thigh. Patients with large, protuberant abdomens may develop this problem from compression of the nerve while sitting. Alternatively, patients can develop this problem while standing with their hips pressed against a hard object, like a barber or hair stylist who leans on the armrest of a client’s chair. Extending the hip can aggravate the pain, and some patients will describe numbness at the top or side of the affected thigh. Though the symptoms are troubling, they are usually due to superficial irritation and do not affect the deeper muscles.

Diagnosis

A physical examination will help confirm the patient has decreased sensitivity to light touch over the affected thigh. Many doctors will use electronic nerve conduction tests also. Doctors who specialize in pain management can use injections or nerve block treatments that are placed around the affected nerve to confirm the diagnosis.

Treatment

Some patients can find temporary relief with the use of nonsteroidal anti-inflammatory medications. If applicable, patients will be asked to not wear tight garments, like corsets or belts, which can compress the nerve as it emerges from the hip on its course to the top of the thigh. Obese patients will be asked to lose weight. If the disorder is linked to a specific activity, a physical therapist or occupational therapist will assist with developing alternative methods of performing the activities that are less likely to cause repeated irritation of the affected nerve. Long-term relief of meralgia paresthetica can be found through the use of nerve block treatments containing an anesthetic medication along with anti-inflammatory medications that are injected around the nerve. The injections are usually given in a series of three to five treatments over several weeks for maximum effect. Occasionally nerve stimulation measures, such as a TENS unit, are utilized. Surgery is only considered as a last resort in the most difficult cases.

Prevention

• Maintain ideal body weight
• Avoid compressing the hip area
• Proper diet

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TEMPORAL NEURALGIA

Overview

Temporal neuralgia involves irritation of the temporal nerve, which originates at the sides of the head and rises to the top of the head. The irritation is most commonly related to muscle tension around the temporal nerve itself. This can be caused from various muscular disorders in the head, including irritation of the temporomandibular joint (TMJ) in the jaw. It is often characterized as sharp or spasm-like. It tends to occur in episodes and may be severe enough to cause a person to alter their day-to-day lifestyle. A more serious but relatively rare disorder, temporal arteritis, can occur with inflammation of the temporal nerve itself.

Diagnosis

Doctors will concentrate the physical examination on muscular disorders in the head, neck and jaw. A behavioral evaluation is sometimes needed as well. Doctors may use X- ray and/or laboratory studies in the evaluation of temporal neuralgia. Injections of anesthetics, sometimes in combination with anti-inflammatory medications, around the temporal nerve can help diagnose the disorder. If the block works and completely resolves the symptoms, the diagnosis of temporal neuralgia is confirmed. If the nerve block of the temporal nerve is only partially effective, there may other disorders causing or involved with the symptoms.

Treatment

Nerve block treatments around the temporal nerve may give relief that lasts for several weeks at a time. These may be used on an ongoing basis to manage the pain from temporal neuralgia. If excess tension in the muscles around the temporal nerve are involved in the symptoms, biofeedback or muscle relaxation techniques may be used as an additional treatment.

If the disorder arises from irritation in the temporal mandibular joint, dental treatment through the use bite splints in conjunction with physical therapy exercises may be used to relieve symptoms. Traditional headache medications, both preventative and abortive, can be used to provide some relief in temporal neuralgia.

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