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Hey, was curious to see what you guys might suggest for a case i have.
Young 25 y.o female , seen may 2011 for severe neuropathic pain Left C4-C5 topography following surgery in 2008 for arnold chiari malformation. No post op complications, no signs of superior motoneuron , no neuro deficits. MRI 2010 showed hydromyelia from c2-c7 . No syrinx.EMG negative. Treated with high does of lyrica, ad 300 bid , which seems to help but patient too droggy to be functional . reduced to 150 bid with intro of nortyptilline 20 mg...no change. intro of topical ketamine, lidocaine cream, no change. Patient becoming more and more depressed, with sever functional incapacity due to pain. Added Cymbalta up to 60 mg. If it doesnt work, would anyone try Keppra? (had some successes with it in central pain). If so, do you wean the lyrica? and at what speed?
anyone would try narcotics ( they have been proven helpful in neuropathic pain) ?
Interventionally, although the pain topography does correspond to C5, I have no evidence to say that C5 nerve root is affected and that a CESI would work.
Unfortunately, in as much as I would love to trial neuromodulation if all else fails, being in Canada, this would be wishful thinking .
Seeing the gradual functional and emotional deterioration, ill attempt some CBT and psychotherapy as well .
Any suggestions would be greatly appreciated.
Young 25 y.o female , seen may 2011 for severe neuropathic pain Left C4-C5 topography following surgery in 2008 for arnold chiari malformation. No post op complications, no signs of superior motoneuron , no neuro deficits. MRI 2010 showed hydromyelia from c2-c7 . No syrinx.EMG negative. Treated with high does of lyrica, ad 300 bid , which seems to help but patient too droggy to be functional . reduced to 150 bid with intro of nortyptilline 20 mg...no change. intro of topical ketamine, lidocaine cream, no change. Patient becoming more and more depressed, with sever functional incapacity due to pain. Added Cymbalta up to 60 mg. If it doesnt work, would anyone try Keppra? (had some successes with it in central pain). If so, do you wean the lyrica? and at what speed?
anyone would try narcotics ( they have been proven helpful in neuropathic pain) ?
Interventionally, although the pain topography does correspond to C5, I have no evidence to say that C5 nerve root is affected and that a CESI would work.
Unfortunately, in as much as I would love to trial neuromodulation if all else fails, being in Canada, this would be wishful thinking .
Seeing the gradual functional and emotional deterioration, ill attempt some CBT and psychotherapy as well .
Any suggestions would be greatly appreciated.
