Postherpetic Neuralgia Treatment In Delhi

Postherpetic Neuralgia 

Herpes Zoster is caused by the reactivation of the same virus which causes chickenpox. If you have had chickenpox before, the virus lies inactive in the nervous system till the time it gets an opportunity (such as in old age or when the body’s immunity is reduced) to spread along the nerve. This produces the typical rash of Herpes Zoster accompanied by pain, numbness, itching, skin pigmentation and sometimes scarring. One out of five patients goes on to develop PHN where the pain persists for more than 120 days after the onset of rash. PHN is rare in the age group below 50 years and incidence increases after the age of 60 years. Risk factors for PHN or persisting pain include older age and widespread rash with severe pain at the onset.

Presentation

Pain character in PHN is generally burning, shooting, throbbing or electric shock-like and this may occur spontaneously or in response to stimuli. It is most commonly observed in the chest wall region (thoracic dermatomes) and in the distribution of the ophthalmic branch of the trigeminal nerve (around the eye). You may find the pain is more severe at night time and during periods of stress. It is often accompanied by hypersensitivity of the involved area. In some cases, muscle weakness may be present. About half of the patients recover within a year and in the remaining the course is variable. In one study it was observed that the proportion of patients with spontaneous resolution of pain decreased with increasing time since the onset of herpes zoster.

Management

Prevention of PHN is important and includes vaccination, early use of antiviral agents. Acute pain control at the time of onset is important. In selective cases, oral steroids are considered. Those with persisting pain can be challenging to treat and Multi-disciplinary approach is preferred. Drug combination therapy is often used with a combination of systemic medications and topical agents (gels/patches /creams). Unfortunately, some of the topical options such as 8% capsaicin patch, 5% lidocaine patch are not available in India currently.

Apart from medications Interventions/ injections such as nerve blocks, drug infusions, neuromodulation is a reasonable option to consider. Sympathetic nerve blocks including stellate ganglion block are often used. Most evidence suggesting short-term benefits and hence they may need to be repeated. It is important to address any concomitant psychological factors and maladaptive coping mechanisms.

Chronic Headache Pain Treatment In Delhi

Headache is a common problem. Fortunately, a significant proportion of headaches can be managed by commonly used painkillers. In certain types of headaches, prophylactic agents are used to reducing the frequency of attacks. However, there still remains a subgroup of patients with difficult to manage headaches despite all measures. For this subgroup, the pain clinic offers interventions and multi-disciplinary input, over and above the traditional approach of using painkillers. The multi-disciplinary approach helps in addressing concomitant magnifiers/ triggers such as anxiety, depression, altered sleep cycle, medication overuse, lifestyle, and poor posture.

Cervicogenic Headaches Download PDF »

In clinical practice, an overwhelming majority of headaches are either a tension-type headache, migraine, cluster headache or medication overused headache. Extracranial sources of headaches such as nerves, joints, and muscles can be easily missed. The term Cervicogenic Headaches is used for headaches originating from cervical spine pathology or surrounding soft tissues. Examples include neck facet or Atlantoaxial joint pathology, headaches secondary to the third occipital nerve, supraorbital neuralgia, and occipital neuralgia, sternocleidomastoid, and trapezius muscle spasms. These types of headaches may be accompanied by neck pain, stiffness and are commonly undertreated.

Some of the interventions available via the pain clinic include

Facet Joint Injections & Radiofrequency ablation

Headaches originating from facet joints are more commonly observed in the elderly and after whiplash injury (flexion/extension injuries). Clinical diagnosis is often difficult as the features overlap with other types of headaches. Diagnostic injections can help identify the pain generators in such cases. Pain originating from these joints can be felt in the base of the skull, neck, upper back, mid-back and shoulders. Please follow the link to Facet joint injections to find out more about this treatment.

Third Occipital Nerve Block and Radiofrequency

The third occipital nerve originates from the cervical spine and supplies sensation to a joint in the neck (C2-3 zygapophyseal joint) and a small area at the back of the head. This nerve or the joint it supplies can be a source of headaches localized to the back of the head on one side. Sometimes the headache can spread towards the top of the head. This occurs more commonly after a whiplash injury.

A diagnostic block involving the injection of a local anesthetic close to the nerve can help determine if this nerve is the source of your headache. This is performed under x-ray guidance. If the diagnostic test is positive then radiofrequency ablation of the nerve can provide long-lasting relief.

Occipital Nerve Block and Radiofrequency

Greater Occipital Nerve (GON) block is frequently utilized in the management of different types of headaches and for establishing the diagnosis of occipital neuralgia. This nerve is located at the back of the head and pain originating from this presents as shooting, stabbing pain with altered sensation in the area supplied by the nerve. Sometimes the area can be unusually sensitive.

A nerve block can be performed distally using landmarks or proximally using ultrasound. This nerve travels through various fascial planes and has the potential of getting entrapped anywhere along the path. I prefer to use the proximal approach as this targets the nerve soon after it originates from the spinal nerves before it gets entrapped anywhere along its course. Local anesthetic block can help in confirming the diagnosis and radiofrequency treatment can help provide long-lasting pain relief.

Sphenopalatine Ganglion Block

Sphenopalatine ganglion is a collection of nerve cells located behind the nose which serves as a relay center for messages being transmitted to the brain. This is closely linked to one of the main nerves involved in headaches, facial pain (trigeminal nerve) and many other nerves such as those involved in the regulation of tear glands.

Sphenopalatine ganglion block is used for conditions such as cluster headaches, migraine, atypical facial pain and cancer of head and neck. A block with local anesthetics temporarily interrupts the transmission of nerve impulses producing pain relief. It can be performed by inserting local anesthetic soaked cotton swabs through the nose with the head tilted backward. Alternatively, it can be performed using x-ray guidance from the side of the face. The duration of pain relief is variable.

Botox for Migraine

Botox is well known for its cosmetic usage. When injected into muscles it partially blocks the nerve impulses and reduces the muscle contractions. In chronic migraine this can help by reducing the frequency of headaches and the effects can last for 8 - 12 weeks.

Botox is not the first line treatment for migraine and is used in adult patients with chronic migraine who have unsuccessfully tried at least three other medications to prevent migraine. Diagnosis of chronic migraine is made when patients have 15 or more headache days in a month of which at least eight are migraine headaches.

Other Nerve Blocks & Pulsed Radiofrequency

Blocks and radiofrequency treatment of nerves e.g. supraorbital, supratrochlear nerve are used when the pain is localised to the distribution of a specific nerve.

Trigger Point Injection

Muscles ability to contract and relax plays an important role in body functioning. When muscles fail to relax, they form knots or tight bands known as trigger points. In simple words trigger points are irritable areas/ bands of tightness in a muscle. Pressure over a trigger point produces local soreness and may refer pain to other body parts. Common causes include inflammation, injury of the muscle or the neighbouring structures. Poor posture and repetitive strain are other predisposing factors. Trigger points can limit the range of movement; affect posture predisposing other areas to unaccustomed strain.

Trigger points are commonly found in head, neck, and shoulder muscles. They can be the source of localised pain, headaches and may also play a role in magnifying headaches due to other causes e.g. migraine, tension headache.

Trigger point injections are performed in an outpatient/ day-care setting and involve injection of local anaesthetic with or without a small dose of steroid into the painful muscle. The local anaesthetic blocks the pain sensations and the steroids help in reducing the inflammation, swelling. I prefer to perform these injections under ultrasound guidance as it improves the accuracy and reduces the chances of complications. Post injection physiotherapy is essential to prevent recurrence and maximise the benefits.

These interventions are used in combination with physiotherapy, psychology, medication optimisation and complimentary therapies (such as acupuncture, TENS, meditation, ayurveda and wellness).

Know more about Headache - Click here

 

Abdominal and Pelvic Pain Treatment In Delhi

Tag: Pelvic Pain Treatment In Delhi

Pudendal nerve is one of the main nerves of the pelvis, with one nerve on each side. It runs from the lower back, along the pelvic floor to supply the genitals, lower part of rectum, and perineum (area between the sit bones). This nerve is closely involved with urinary and bowel functions.

Pudendal neuralgia is a condition related to irritation or damage of pudendal nerve, which presents as pain or altered sensation in the genital, rectal region or deep inside the pelvis. It is more common in women and is also addressed as cyclist syndrome, Alcock’s canal syndrome and pudendal nerve entrapment. Despite the significant advances in the evaluation and management of chronic pelvic pain, it often goes unrecognised. It can be associated with other conditions such as Chronic Pelvic Pain Syndrome, dysfunctional voiding, painful bladder syndrome, chronic prostatitis etc.

Signs and symptoms of Pudendal Neuralgia

• Burning, shooting, electric shock like, crushing, aching, prickling or itching sensation in the areas of pelvis supplied by the pudendal nerve.
• Pain worse on sitting or exercising and resolves when lying flat (as during the night) or standing
• Better when sitting on the toilet seat
• Intermittent initially but can change to a constant pain with time It can radiate (travel) to buttocks (around ischial spines) and legs (inner thigh), feet

Other symptom which may be present include

• Urge to go to the toilet often (urinary frequency) or a feeling of a bladder infection,
• Pain on passing urine
• Increased sensitivity in pelvic area
• Numbness, pins and needles sensation in pelvis
• Pain during sex or sexual arousal or orgasm/ ejaculation. It sometimes presents as persistent sexual arousal
• Foreign body/fullness sensation in rectum, vagina or perineum (like a tennis ball)
• Rectal pain with an urgent need to open the bowels

Causes of Pudendal Neuralgia (PN)

• Compression or entrapment of pudendal nerve (cycling, prolonged sitting, pelvic floor muscle spasm, any growth pressing on the nerve)
• Stretching of the nerve as during childbirth or surgery
• Direct Injury to pudendal nerve as during pelvic trauma, falls on the buttock or even with severe constipation
• Compression at the level of spinal cord or nerve roots
• Biochemical injury from infections and diseases (diabetes, multiple sclerosis, viral infection- herpes zoster, HIV)

PN Management

Management of this condition requires active patient participation and use of a combination of lifestyle changes, medical interventions. Treatment includes

• Lifestyle changes are aimed at reducing the irritation of the nerve. These include avoiding activities which increase pain such as cycling, prolonged sitting, constipation etc, using a special cushion while sitting.
• Neuropathic pain killers- these can help in reducing the pain
• Injections such as pudendal nerve block, pelvic flood muscle or tender point injections Often a series of injections are performed for maximal benefit.



Pudendal Nerve Block:

The injection is performed for treatment of pelvic and genital pain. Resolution of pain a diagnostic nerve block, even if temporary, supports the diagnosis of pudendal neuralgia. These blocks also serve an important therapeutic role. As discussed previously the compression of nerve can occur anywhere along the path and hence sometimes a series of injections may be required. These blocks are performed as a day care procedure under local anaesthesia. Using image guidance (ultrasound, fluoroscopy or CT guidance) helps to improve safety and chances of success. If required your doctor may recommend pulsed radio frequency treatment of pudendal nerve for a more sustained response in future.
• Pulsed radio-frequency treatment of the pudendal nerve, sacral nerve roots
• Supervised Physiotherapy aimed at the pelvic floor muscles. This can help with muscle spasms, imbalances and in correcting other dysfunctions
• Psychological support including cognitive behavior therapy, meditation, mindfulness, self management and relaxation exercises

 

Joint Pain Treatment In Delhi and Other Musculoskeletal Conditions

Globally, musculoskeletal pain is a common reason of disability and seeking medical advice. It may be localised to one area or present as a widespread/ multisite pain. Musculoskeletal symptoms may be a consequence of orthopaedic, neurologic or rheumatologic processes and hence a comprehensive history and examination is required. Based on the findings further tests and imaging are requested to confirm the diagnosis or rule out other serious conditions.

This section focuses on minimally invasive non surgical interventions available via pain clinic for joint pain and some other common musculoskeletal conditions. The interventions listed below are most often used as a part of multi-disciplinary management in combination with medications, physiotherapy, complementary therapy and psychology input  as required.

Shoulder Pain

Shoulder pain may be an isolated problem localised to the shoulder or be a part of widespread pain as in rheumatoid arthritis. A combination of history, examination and diagnostic investigations is utilised to identify the pathology and guide further management. Diagnostic ultrasound scan is an effective bedside tool as it can reliably identify common shoulder pathologies and reduce the requirement of additional investigations. I routinely perform ultrasound scans at the time of initial assessment. Read More »

Hip Pain

Hip pain is a common condition and can be quite disabling because of the impact on walking. Pain may be localised to the front, side or back of the hip joint. Common cause for anterior hip pain is joint problems such as arthritis, that on the outer side of hip is greater trochanteric pain syndrome whereas posterior hip pain may arise from multiple sources such as sacroiliac joint, lumbar spine, piriformis muscle etc. It is important to evaluate lumbar spine as spine pathology commonly coexists and can be responsible for producing/ exacerbating hip pain. Read More »

Knee Pain

Knee pain can be a source of significant disability in all age groups as it limits mobility. It can be classified into traumatic or non traumatic and based on the site of pain into anterior, medial, lateral and posterior. The common reasons for knee pain vary with age group and pain site .Pain from other sites such as hip and lumbar spine can also present knee pain. Read More »

Other Common Musculoskeletal Conditions

These are common problems involving staining/overuse of forearm tendons which attach to the bony prominences on the upper arm bone close to the elbow joint. Tennis elbow involves the tendons attaching to the outer side of elbow and repetitive activities involving gripping or twisting of forearm makes this pain worse. It may affect one or more tendons and it’s not uncommon for the pain to radiate down further into the forearm. Read More »

Thoracic spine and Chest wall Pain Treatment In Delhi

Tag: Thoracic spine treatment in Delhi,  Chest wall pain treatment in Delhi 

• This section covers pain anywhere between shoulders to the bottom of ribs. It can arise from
• Inside the thoracic cavity (inside chest)
• From the chest wall including the thoracic spine
• Be referred from the neighboring areas and structures such as the abdomen, cervical spine.
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Chest wall pain can originate from any of the chest wall structures including bones, joints, muscles, cartilage, ligaments, tendons, nerves, skin and soft tissue. It generally increases with arm movement and is accompanied by localized tenderness.

Some common conditions/situations leading to chest wall pain are

• Prolonged unaccustomed physical activity. This may cause muscle soreness which can persist
• The spine can be a source of posterior chest pain. Pain may arise from joints including those between the vertebrae (facet joints), between the ribs and vertebrae (costovertebral joints, costotransverse joints), discs, spinal ligaments, muscles (paravertebral muscles) and the nerves. The pain can radiate towards the side of the chest and as far as the front of the chest and abdomen
• Other joints such as the one between the collar bone and sternum or the ones between the ribs and sternum can also be a source of chest wall pain. Inflammation of the cartilage connecting the ribs to the sternum is known as costochondritis
• Infections such as Shingles commonly affect the thoracic area (Post Herpetic Neuralgia)
• Rheumatological disorders such as rheumatoid arthritis, ankylosing spondylitis
• Post-surgical pain arising after surgeries such as heart, lung, breast surgery
• Nerve injury or damage as a result of surgery, trauma or otherwise.
• Cancer which has spread to chest wall or bones

Management

The treatment will depend on the cause of pain. A multi disciplinary approach using a combination of medications, physiotherapy, psychology and injections is the preferred approach. Please follow the links to read more about these.