Bone pain?

[SommeRiver]

I have a late 30's female patient with a history of leukemia (bone marrow transplant, chemo, nephrectomy), who has lateral hip and thigh pain. Unilateral pain. No obvious exacerbating or alleviating factors. Moderate to severe intensity, constant.

She's got femoral diaphysis infarctions, several of them, and they match up exactly where she hurts. The lateral hip distribution isn't the main focus, it is the proximal and lateral thigh.

She's got buttock pain as well, which was positive on provocative maneuvers for SIJ pain, so I tried/failed an SIJ injxn like a year ago. I told her before the shot it probably wouldn't work. Tons of things hurt at the SIJ and cause positive provocative maneuvers. Needless to say, we aren't pursuing any further injections.

I have resigned myself to Norco, which keeps her employed and working. It helps her, so I haven't stopped it. With her nephrectomy, I am limited on meds, and I do all the normal monitoring of the Norco. She has an ORT of like 0.

My question is whether or not any of you have dealt with something like this, and if so what did you do? Do these infarctions hurt? I know sickling hurts like hell, but this isn't sickle cell and we're not causing ischemia.

Anyone have any ideas? I saw tons of esoteric BS in fellowship, but I haven't ever seen one of these and I've been following her for over a year now, and we're just treading water...I have explained that treading water alone is perhaps our only option, and she gets it...No problems there...

Edit - May I wantonly inject PRP all up and down the femur while charging her COLD HARD CASH and make her perfect, or is there someone here in the pocket of the stim industry who can ENSURE me 100% relief because one of their favorite reps told them about this type of patient that some anonymous doctor implanted with herculean results?

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[willabeast]

I have a late 30's female patient with a history of leukemia (bone marrow transplant, chemo, nephrectomy), who has lateral hip and thigh pain. Unilateral pain. No obvious exacerbating or alleviating factors. Moderate to severe intensity, constant.

She's got femoral diaphysis infarctions, several of them, and they match up exactly where she hurts. The lateral hip distribution isn't the main focus, it is the proximal and lateral thigh.

She's got buttock pain as well, which was positive on provocative maneuvers for SIJ pain, so I tried/failed an SIJ injxn like a year ago. I told her before the shot it probably wouldn't work. Tons of things hurt at the SIJ and cause positive provocative maneuvers. Needless to say, we aren't pursuing any further injections.

I have resigned myself to Norco, which keeps her employed and working. It helps her, so I haven't stopped it. With her nephrectomy, I am limited on meds, and I do all the normal monitoring of the Norco. She has an ORT of like 0.

My question is whether or not any of you have dealt with something like this, and if so what did you do? Do these infarctions hurt? I know sickling hurts like hell, but this isn't sickle cell and we're not causing ischemia.

Anyone have any ideas? I saw tons of esoteric BS in fellowship, but I haven't ever seen one of these and I've been following her for over a year now, and we're just treading water...I have explained that treading water alone is perhaps our only option, and she gets it...No problems there...

Edit - May I wantonly inject PRP all up and down the femur while charging her COLD HARD CASH and make her perfect, or is there someone here in the pocket of the stim industry who can ENSURE me 100% relief because one of their favorite reps told them about this type of patient that some anonymous doctor implanted with herculean results?

I would try her on Turmeric (ground up root). Costco has it. Try it for 2 weeks if no improvement then stop it. According to a nephrologist i spoke to a few years ago Turmeric does not hurt kidneys. Get an OK from her PCP anyway. If Turmeric fails then try some neuropathic pain meds (TCAs gabapentin etc.) Finally i would consider other Dx. Uncommon presentations of common diseases are more common than common presentations of uncommon diseases. Would look for the usual suspects. Disclaimer - i am retired and doing my best to forget the last 40 years.

 

[lobelsteve]

Norco. Add butrans if needed. See every 3 months. Glad she beat cancer.

 

[SommeRiver]

I forgot to add we've done turmeric, alpha lipoic acid, nortriptyline, gabapentin, and Lyrica.

 

[SommeRiver]

Norco. Add butrans if needed. See every 3 months. Glad she beat cancer.

Okay. Thanks man.

 

[Orin]

Has she seen an orthopedic onc surgeon who specializes in core decompression and bone grafts for AVN/osteonecrosis? I would get that done sooner rather than later, with the understanding that this would be heroic as it's better described for hip AVN.

I agree that there's a neuropathic component so trial LSBs and consider electoral neuromod if you want to avoid IT therapy.

Duloxetine vs Venlafaxine if not done?
Consider referral to an academic cancer pain doc if available?

 

[lobelsteve]

QUOTED FROM OP: I have resigned myself to Norco, which keeps her employed and working. It helps her, so I haven't stopped it. With her nephrectomy, I am limited on meds, and I do all the normal monitoring of the Norco. She has an ORT of like 0.

Why do anything else? What risks are we taking on procedures, referrals, etc when she is functional and working on low dose opiates?
Why does bone infarct have a neuropathic component? I find that unfounded and believe someone saying this is only looking to take their hammer and hit this nail with SCS or other money making procedures. If this was my sister: it is what it is, do nothing different.

 

[Ronin1]

Sometimes opiates are ok....

 

[SommeRiver]

Has she seen an orthopedic onc surgeon who specializes in core decompression and bone grafts for AVN/osteonecrosis? I would get that done sooner rather than later, with the understanding that this would be heroic as it's better described for hip AVN.

I agree that there's a neuropathic component so trial LSBs and consider electoral neuromod if you want to avoid IT therapy.

Duloxetine vs Venlafaxine if not done?
Consider referral to an academic cancer pain doc if available?

Thanks for the input.

I have a sneaking suspicion the things you listed are going to fail, and we're gonna be right back to where we started, probably spend a lot of money.

I think I may image her again (previous was like 2 years ago) at some point to track this.

 

[Orin]

...No obvious exacerbating or alleviating factors. Moderate to severe intensity, constant.
...Needless to say, we aren't pursuing any further injections.
...I have resigned myself to Norco
...Anyone have any ideas?
...I've been following her for over a year now, and we're just treading water...I have explained that treading water alone is perhaps our only option, and she gets it...No problems there...

Why do anything else? What risks are we taking on procedures, referrals, etc when she is functional and working on low dose opiates?
Why does bone infarct have a neuropathic component?

I think I always read these differently and assume the patient/provider are asking for help. I agree the risks are real and they aren't zero. Still, it is a discussion with the patient. I didn't think the OP was asking for a pat on the back for their plan, but maybe they just wanted some validation, and I shouldn't have tried to offer solutions instead of listening.

The component of the presentation that supports neuropathic component is the constant nature, and you know there are nerves in that infarcted area that can suffer ischemic or compressive damage due to flow/swelling/etc. You could run them through the surveys to be sure, and they will likely end up in the mid-range. Basic science people tell me there's preclinical data for neuropathic meds helping in all types of odd bone diseases, but I agree it's not as clear cut as a nerve entrapment or radic.

It's not that anything needs to be done if they're happy enough, but when people ask for options I offer them with the appropriate cautions. I agree Butrans and an SSRI/SNRI would be better if they help enough. A cancer diagnosis/recovery shouldn't mean they need to have a poor QOL moving forward, but if they're okay, then let it ride.

I wouldn't send them to an overly aggressive surgeon or pain doc, but most patients seem to like understanding that there are crazy options out there to try if they insist on being guinea pigs. I would rather send them to someone I trust to not be a complete hack job than let them find the best snake oil salesman that'll fuse their SI joint with magic beans or PRP their St 30 point to fix things.

Still, an LSB is simple to do and lower cost/risk than proceeding directly to an SCS/DRG/PNS trial.

 

[Orin]

I think I may image her again (previous was like 2 years ago) at some point to track this.

What imaging are you thinking?

 

[soccrwz]

if we are think hip joint pain could consider ABFON, I had some success with for a patient with AVN awaiting hip surgery.

 

[painfree23]

if we are think hip joint pain could consider ABFON, I had some success with for a patient with AVN awaiting hip surgery.

ABFON? any resources on techniques for this?

 

[soccrwz]

ABFON? any resources on techniques for this?

 

[SommeRiver]

I think I always read these differently and assume the patient/provider are asking for help. I agree the risks are real and they aren't zero. Still, it is a discussion with the patient. I didn't think the OP was asking for a pat on the back for their plan, but maybe they just wanted some validation, and I shouldn't have tried to offer solutions instead of listening.

The component of the presentation that supports neuropathic component is the constant nature, and you know there are nerves in that infarcted area that can suffer ischemic or compressive damage due to flow/swelling/etc. You could run them through the surveys to be sure, and they will likely end up in the mid-range. Basic science people tell me there's preclinical data for neuropathic meds helping in all types of odd bone diseases, but I agree it's not as clear cut as a nerve entrapment or radic.

It's not that anything needs to be done if they're happy enough, but when people ask for options I offer them with the appropriate cautions. I agree Butrans and an SSRI/SNRI would be better if they help enough. A cancer diagnosis/recovery shouldn't mean they need to have a poor QOL moving forward, but if they're okay, then let it ride.

I wouldn't send them to an overly aggressive surgeon or pain doc, but most patients seem to like understanding that there are crazy options out there to try if they insist on being guinea pigs. I would rather send them to someone I trust to not be a complete hack job than let them find the best snake oil salesman that'll fuse their SI joint with magic beans or PRP their St 30 point to fix things.

Still, an LSB is simple to do and lower cost/risk than proceeding directly to an SCS/DRG/PNS trial.

I hear you.

My point of the thread is to see if there is something I'm leaving off the table that would be reasonable.

I do not consider her QoL to be poor, in fact it is pretty good. Certainly not perfect. She's young and outgoing and works, which is something.

The reimaging thing is an MRI of the thigh just to see if these infarctions are...still there I guess? Progressed or worsened? Resolved?

If progression occurred I would send to Heme I guess...

 

[Ducttape]

its not in the LFCN distribution, is it?



lobelsteve says to "own the bone". what say you to bisphosphonates?

 

[lobelsteve]

its not in the LFCN distribution, is it?



lobelsteve says to "own the bone". what say you to bisphosphonates?

yes please, worth trying and Miacalcin.

 

[SommeRiver]

its not in the LFCN distribution, is it?



lobelsteve says to "own the bone". what say you to bisphosphonates?

Good thought on the LFCN, but no. It is deep. Hx of APL leukemia and apparently this isn't that uncommon.

I'm thinking Butrans at some point, but Norco is stable and she is living her life productively.

 

[deleted993114]

I have a late 30's female patient with a history of leukemia (bone marrow transplant, chemo, nephrectomy), who has lateral hip and thigh pain. Unilateral pain. No obvious exacerbating or alleviating factors. Moderate to severe intensity, constant.

She's got femoral diaphysis infarctions, several of them, and they match up exactly where she hurts. The lateral hip distribution isn't the main focus, it is the proximal and lateral thigh.

She's got buttock pain as well, which was positive on provocative maneuvers for SIJ pain, so I tried/failed an SIJ injxn like a year ago. I told her before the shot it probably wouldn't work. Tons of things hurt at the SIJ and cause positive provocative maneuvers. Needless to say, we aren't pursuing any further injections.

I have resigned myself to Norco, which keeps her employed and working. It helps her, so I haven't stopped it. With her nephrectomy, I am limited on meds, and I do all the normal monitoring of the Norco. She has an ORT of like 0.

My question is whether or not any of you have dealt with something like this, and if so what did you do? Do these infarctions hurt? I know sickling hurts like hell, but this isn't sickle cell and we're not causing ischemia.

Anyone have any ideas? I saw tons of esoteric BS in fellowship, but I haven't ever seen one of these and I've been following her for over a year now, and we're just treading water...I have explained that treading water alone is perhaps our only option, and she gets it...No problems there...

Edit - May I wantonly inject PRP all up and down the femur while charging her COLD HARD CASH and make her perfect, or is there someone here in the pocket of the stim industry who can ENSURE me 100% relief because one of their favorite reps told them about this type of patient that some anonymous doctor implanted with herculean results?

Stim won't help nociceptive pain.

1. try Nucynta if she can afford
2. topical diclofenac- only 8% systemically absorbed
3. make sure she does not have a sclerotomal referred pattern from L4/L5
4. consider shorter term periods of oral steroids, recognizing the increased risk of fracture

Ironically, I have experienced that very same pain due to one of my cancers. What worked for me? Nucynta, NSAIDs, and steroids. I am chronically on low dose steroid. Of course, you have to weigh that benefit with the risk of osteoporosis and fractures. For me, the trade off is definitely worth it.

 

[JelloIsJigglin]

Stim won't help nociceptive pain.

1. try Nucynta if she can afford
2. topical diclofenac- only 8% systemically absorbed
3. make sure she does not have a sclerotomal referred pattern from L4/L5
4. consider shorter term periods of oral steroids, recognizing the increased risk of fracture

Ironically, I have experienced that very same pain due to one of my cancers. What worked for me? Nucynta, NSAIDs, and steroids. I am chronically on low dose steroid. Of course, you have to weigh that benefit with the risk of osteoporosis and fractures. For me, the trade off is definitely worth it.

NSAIDs and oral steroids a little counter productive, no?

 

[SommeRiver]

Stim won't help nociceptive pain.

1. try Nucynta if she can afford
2. topical diclofenac- only 8% systemically absorbed
3. make sure she does not have a sclerotomal referred pattern from L4/L5
4. consider shorter term periods of oral steroids, recognizing the increased risk of fracture

Ironically, I have experienced that very same pain due to one of my cancers. What worked for me? Nucynta, NSAIDs, and steroids. I am chronically on low dose steroid. Of course, you have to weigh that benefit with the risk of osteoporosis and fractures. For me, the trade off is definitely worth it.

I'm debating Nucynta and Butrans.

I'm sort of hesitant to make the switch bc the Norco is still working very well.

The minute it looks like it isn't I'll pull the trigger. She has options is the good thing I guess.

 

[lobelsteve]

Just for shts and giggles:

Change her to Butrans and gets anaphylaxis/dies.

Plaintiff estate atty asks why you changed a regimen that was working well and keeping her at work?

 

[SommeRiver]

Just for shts and giggles:

Change her to Butrans and gets anaphylaxis/dies.

Plaintiff estate atty asks why you changed a regimen that was working well and keeping her at work?

...because some dudes on an internet forum told me to...

 

[painfree23]

My dream is to have a practice with no med management for these reasons. I agree she needs something but just too much of a hassle.

 

[Ferrismonk]

If Norco BID is working and she's productive, just stick with it. It's not Oxycontin 80 for God's sake. Like you said risk is low.

Medically speaking a couple norco isn't a problem and as long as risks/benefits make sense, do it. For me, it's all the medico-legal stuff that's involved. Opiate contract, risk scoring, UDS, PDMP monitoring, phone calls/messages, insurance authorizations, pharmacy calls, etc, etc, etc. If you're willing to do all that for Butrans, just stick with Norco.

 

[SommeRiver]

My dream is to have a practice with no med management for these reasons. I agree she needs something but just too much of a hassle.

This is no hassle

 

[Ducttape]

...because some dudes on an internet forum told me to...

But... no one is telling you to...

 

[painfree23]

If Norco BID is working and she's productive, just stick with it. It's not Oxycontin 80 for God's sake. Like you said risk is low.

Medically speaking a couple norco isn't a problem and as long as risks/benefits make sense, do it. For me, it's all the medico-legal stuff that's involved. Opiate contract, risk scoring, UDS, PDMP monitoring, phone calls/messages, insurance authorizations, pharmacy calls, etc, etc, etc. If you're willing to do all that for Butrans, just stick with Norco.

How often would you see a patient like this in the office? Monthly?

 

[SommeRiver]

How often would you see a patient like this in the office? Monthly?

I see her Q3M. I haven't checked her urine in 9 months.

 

[painfree23]

I see her Q3M. I haven't checked her urine in 9 months.

Do u just post mark on her scripts or give her 3 months worth at a time?

 

[SommeRiver]

I date Rx...May fill on Aug 14 for example.

You can give 90 days of opiates, and I have maybe 3 ppl I will give 6 months of tramadol.

 

[deleted993114]

I'm debating Nucynta and Butrans.

I'm sort of hesitant to make the switch bc the Norco is still working very well.

The minute it looks like it isn't I'll pull the trigger. She has options is the good thing I guess.

If Norco is working and they are low risk, stick with it. Despite the risks of prescribing narcotics, I think the gloves are off in situations of oncology. Having been, and currently in their shoes, I am very sympathetic to cancer patients and try my all to help them. A little thing can make a world of difference for their lives, and after all, that is why we are here.

Butrans and Nucynta would be lower risk, but it is hard to argue with something that is working and not being abused.

I know that meds are very unpopular. However, there are those who benefit and are able to carry on their lives with doses of meds below 90 mg eqiv morphine.

Meds are high risk from a legal standpoint and I can certainly understand docs not wanting to prescribe any meds anymore- that is perfectly understandable in this environment and probably the most prudent thing to do.

 

[SommeRiver]

I have zero qualms about Rx'ing opiates to functional individuals with...I don’t know if I should use this term...REAL problems who for any number of reasons can't seek out a cure and are "condemned" to pain.

I have a solid number of 75 year old men and women lit up with aged backs who either can't have surgery, shouldn't have ANOTHER surgery, or have failed routine injxns like RFA or epidurals.

Norco BID helps some of them, and I find no reasons to deny them that.

Many of my pts are rural and lived "hard," and they don't want opiates, but they sometimes use them.

Give them to my mom if she's ever in their shoes...

 

[drusso]

I have a late 30's female patient with a history of leukemia (bone marrow transplant, chemo, nephrectomy), who has lateral hip and thigh pain. Unilateral pain. No obvious exacerbating or alleviating factors. Moderate to severe intensity, constant.

She's got femoral diaphysis infarctions, several of them, and they match up exactly where she hurts. The lateral hip distribution isn't the main focus, it is the proximal and lateral thigh.

She's got buttock pain as well, which was positive on provocative maneuvers for SIJ pain, so I tried/failed an SIJ injxn like a year ago. I told her before the shot it probably wouldn't work. Tons of things hurt at the SIJ and cause positive provocative maneuvers. Needless to say, we aren't pursuing any further injections.

I have resigned myself to Norco, which keeps her employed and working. It helps her, so I haven't stopped it. With her nephrectomy, I am limited on meds, and I do all the normal monitoring of the Norco. She has an ORT of like 0.

My question is whether or not any of you have dealt with something like this, and if so what did you do? Do these infarctions hurt? I know sickling hurts like hell, but this isn't sickle cell and we're not causing ischemia.

Anyone have any ideas? I saw tons of esoteric BS in fellowship, but I haven't ever seen one of these and I've been following her for over a year now, and we're just treading water...I have explained that treading water alone is perhaps our only option, and she gets it...No problems there...

Edit - May I wantonly inject PRP all up and down the femur while charging her COLD HARD CASH and make her perfect, or is there someone here in the pocket of the stim industry who can ENSURE me 100% relief because one of their favorite reps told them about this type of patient that some anonymous doctor implanted with herculean results?

Suboxone, guided imagery, check PCS, PHQ-9, PROMIS, SOAPP-R, ORT, MMPI, refer to addiction med or palliative care for longitudinal care.

 

[SommeRiver]

Suboxone, guided imagery, check PCS, PHQ-9, PROMIS, SOAPP-R, ORT, MMPI, refer to addiction med or palliative care for longitudinal care.

You're forgetting VIP, FBI, and CIA.

 

[Orin]

You're forgetting VIP, FBI, and CIA.

Needs more lasers