Chronic Foot Pain

[Papa Lou]

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This is a 45 year old patient with Charcot foot who has severe constant neuropathic pain. She uses high dose opioids to remain functional. I am tapering after inheriting this patient. Pain is flaring up. I am considering sympathetic nerve blocks. But would anyone do anything like phenol on the cutaneous nerves or RFA or something weird and experimental like that? Any other ideas?

 

[lobelsteve]

This is a 45 year old patient with Charcot foot who has severe constant neuropathic pain. She uses high dose opioids to remain functional. I am tapering after inheriting this patient. Pain is flaring up. I am considering sympathetic nerve blocks. But would anyone do anything like phenol on the cutaneous nerves or RFA or something weird and experimental like that? Any other ideas?

How high a dose and how functional? Maybe keep her functional by swapping out the ksi.

 

[Papa Lou]

She came on fentanyl 100mcg/72h and oxycodone 15 TID. First visit I reduced to 50mcg patch and refilled the oxycodone. Plan is to come off patches in 2-3 month's time and stay on the oxycodone. That's around 300MED to currently 185MED. What is KSI? Her foot is like a bag of bones. She initially smashed it and has broken it several times since. It's not exactly Charcot although she is diabetic. Meds are doing very little otherwise (gaba/lyrica/snris)

 

[painfree23]

She came on fentanyl 100mcg/72h and oxycodone 15 TID. First visit I reduced to 50mcg patch and refilled the oxycodone. Plan is to come off patches in 2-3 month's time and stay on the oxycodone. That's around 300MED to currently 185MED. What is KSI? Her foot is like a bag of bones. She initially smashed it and has broken it several times since. It's not exactly Charcot although she is diabetic. Meds are doing very little otherwise (gaba/lyrica/snris)

I had a guy who had pain from unfused hardware in his foot. He had a second surgery, bone stimulator placed, did not help with fusion. Surgeon is out of ideas. Luckily not on opiates, but don't really know what to offer? Similar to this case op is presenting, not sure what else to offer.

 

[cbest]

PL - DRG stim?

 

[lobelsteve]

She came on fentanyl 100mcg/72h and oxycodone 15 TID. First visit I reduced to 50mcg patch and refilled the oxycodone. Plan is to come off patches in 2-3 month's time and stay on the oxycodone. That's around 300MED to currently 185MED. What is KSI? Her foot is like a bag of bones. She initially smashed it and has broken it several times since. It's not exactly Charcot although she is diabetic. Meds are doing very little otherwise (gaba/lyrica/snris)

Crap. 100mcg fentanyl. Got 2 guys on that. Both heading to bospice, tbough one might already have passed.

KSI = keyboard seat interface.

 

[Orin]

I'd agree with a LSB or a trial of DRG vs peripheral stim trial. Depending on the protoplasm, a tibial or peroneal stim is a simple enough thing without the neuraxial risk, especially if they respond well to a single shot nerve block.

There's always the percutaneous vagal stim stuff if you're not excited about needling and need a distraction for them while you're cutting the candy. I'm not sure if they're FDA approved yet?

 

[BobBarker]

Nucynta ER. You have done very good if she ends up on Nucynta ER 100mg BID and 40 mg oxycodone a day

 

[DOctorJay]

DRG trial for sure. easy in office single lead (S1) case without sedation. very low risk.

 

[101N]

If you are going to do the stim tell her that a successful trial is 50% pain relief and therefore a mandatory 50% taper prior to the perm.

Then when reality strikes rotate her to buprenorphine and call it a day.

 

[painfree23]

DRG trial for sure. easy in office single lead (S1) case without sedation. very low risk.

What about scs? How do u get this stuff approved? I have so much trouble with some insurance companies giving me the run around saying it's only indicated for failed back, PAD or CRPS

 

[DOctorJay]

this may be CRPS II with some type of nerve injury because of the foot deformity and prior fractures. would want to examine closer but that would be my play. DRG much better relief of focal foot pain in my experience than traditional SCS.

 

[Papa Lou]

Excellent thanks for advice.
I will continue to taper opiods.
I will offer LSB.
I probably won't but may offer ankle blocks in the office for acute flareups.
I will do DRG if insurance permits. However I think she's medicaid which will be an issue for that.

 

[painfree23]

Excellent thanks for advice.
I will continue to taper opiods.
I will offer LSB.
I probably won't but may offer ankle blocks in the office for acute flareups.
I will do DRG if insurance permits. However I think she's medicaid which will be an issue for that.

Ankle block -- do you mean like in anesthesia regional block for foot procedures (field block of all 5 nerves)?

 

[SeniorWrangler]

I see lots of postsurgical foot pain in my clinic, so this is an interesting topic.
I have tried doing regional blocks a few times for well-defined pain distribution without a lot of success. I have had more benefit with topicals and desensitization.
I haven't seen these things work nearly as well in people on chronic opioids, though, and discourage anything stronger than tramadol.

 

[NJPAIN]

Along the lines of SCS for foot pain; for those who do NOT have DRG available, what is your preference Nevro HF10 or St. Jude? I have a 50 year old with left foot CRPS who needs a trial. He has a component of LBP and LLE pain probably related to gait disturbance from the foot.

 

[kstarm]

CRPS is a dissociative disorder. Opioids allow people to dissociate and not get better. If the dissociation and the opioids can be addressed then patients can move forward. Often times with chronic foot pain there is considerable myofascial dysfunction on top of the neuropathic pain from the various guarding and bracing the patient is doing. Teaching them how to break the guarding and stretch out the foot and lower ext is very helpful as well.