Pain Management -- Upper Extremity Case

[etherRN]

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This pt was referred to a Pain Management anesthesiologist for chronic upper extremity pain...

25 yo M with hx of guitar playing x 15 years. Starting having Lt FA pain/paresthesia in 2001. Seen by excellent hand surgeon practice (this group did Neil Armstrong's surgery). Dx with Carpal Tunnel/Pronator Terres syndrome. Tx was surgical release of Carpal Tunnel (endoscopic) and release of Pronator in 2002. Pain was alleiviated until late 2004 when he started to experience Lt FA pain similar to that prior to surgery. This time around, dx changed to Thoracic Outlet Syndrome and Olecranon Bursitis. Tx was corticosteroid injection to elbow, and PT. Pain did not subside and internist has been supplementing PT with 10/660 Hydrocodone since June 2005.

Anywhoo, he has developed a drug tolerance BIG time. Today he saw the hand surgery practice and dx was Thoracic Outlet, Olecranon Bursitis, Carpal Tunnel, and Pronator Teres. They still didn't have a prognosis for him; he was referred to a Pain Management anesthesiologist. He was instructed to show up to the first appointment NPO and to make sure he had a ride home.

Do any of you know much about tx of chronic upper extremity nerve pain --any Rx recipes or recommendations? Why would he be told to show up to the first appt NPO, and to have a ride home (is this standard for a pain management office visit)?

 

[Noyac]

NPO and ride home is pretty standard. This is because of sedation and blocks that are done. In this case I would look for some sort or CRPS signs. Those are hyperasthesia, allodynia, dystrophic changes to the skin, decreased range of motion, and on and on. Without any of these, I would be reluctant to do any type of sympathetic block like a stellate ganglion. The other problem is his narcotic dependence. This guy needs a dx. so that he can get the correct treatment and get off the narcs. If he truely has these syndromes you mentioned then narcotics are a poor treatment. A good start would be Neurontin and some sleep enhancers like Elavil. I could go on and on but this should get you started.
PS: I am not a pain management doc. I just slept at a holiday inn last night.

 

[zippy2u]

Gawd, these little wussy guitar players with blisters on their fingers; they don't make um like Keith Richards anymore! ---Zippy

 

[Noyac]

Gawd, these little wussy guitar players with blisters on their fingers; they don't make um like Keith Richards anymore! ---Zippy

I don't think Kieth could ever feel his fingers.

 

[bigdan]

Mr. Richards has a LONG history of his own personal "pain management protocol".

dc

 

[etherRN]

Thanks Noyac. I checked out the other drugs that you mentioned and they do seem like good alternatives. Sleep has been a problem, so has depression (considering the circimstances). A tricyclic such as Elavil was a good recommendation. Also, thanks for listing the symptoms that would require a block -- I don't think his condition would necessitate a block. You are right; he needs a dx and a prognosis! He really wants to be able to again.
Anyway, I'm glad your slept at the Holiday Inn last night - big help. Now I have an

 

[PainPhysicians]

Forearm parasthesias, you should do an MRI of the neck to rule out canal or foraminal stenosis to complete the work up. If the pain is any worse with extension of the neck, lateral flexion, or lateral rotation then I would get an MRI. Also, could suggest an EMG to localize which nerve (if it is a nerve) that is being impinged.

If the MRI is positive for foraminal stenosis, could try an epidural injection. In the absence of allodynia or hyperalgesia, I doubt the dx of CRPS.

Good luck!

 

[jetproppilot]

PS: I am not a pain management doc. I just slept at a holiday inn last night.

HAHAHAHAHHAHAHAHHAHAHAHAHHAHAHAHAHA. Great, Dude. Great.

 

[etherRN]

The pt was prescribed Neurontin and Elavil! He says he is sleeping better and stated, "Once the Neurontin kicks in (my pain) is pretty non-existant." It's helped him to quit the narcs cold turkey. Good call Noyac. 👍

 

[Noyac]

The pt was prescribed Neurontin and Elavil! He says he is sleeping better and stated, "Once the Neurontin kicks in (my pain) is pretty non-existant." It's helped him to quit the narcs cold turkey. Good call Noyac. 👍

I guess that Holiday Inn thing really works. Go figure.