What are people doing for post-procedure headache? (not PDPH)

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drrosenrosen

drrosenrosen

Pain Sturgeon
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Generally I just tell people that it will get better, don't offer any treatments if it's not a true PDPH. Side effect of steroid, whatever. Does anybody else do something different?
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drrosenrosen said:
Generally I just tell people that it will get better, don't offer any treatments if it's not a true PDPH. Side effect of steroid, whatever. Does anybody else do something different?
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are you doing a ACGME Pain Fellowship.....

I take it you didnt do an anesthesia residency?
 
There are many patients who report headaches after procedures, and many of them are not post-dural puncture headaches.

Obviously, you want to rule out typical PDPH first, and treat for PDPH if appropriate.

The other headaches can be addressed with a good history. Does the patient have headaches? Is this similar? caffeine? Hypertension? What is their blood pressure? Visual changes? Medication changes? ETC. Then, I usually review Fluoro images and op notes for type of procedure. If probability of dural puncture is low, and headache does not sound life theatening, I usually reassure them the first night after the procedure. I have found that steroids will often raise BP in the HTN patients, and the headache typically will get better if they take their meds over 24-48 hours. Of course, you will want them to check BP, temp, etc. Make sure they are not having fever/chills/meningismus, of course. Other times, someone will get a non-positional headache the night following the procedure with no apparent etiology other than the steroid. I reassure them as well, and usually goes away. Sometimes the headache is due to lack of sleep, as steroids will often cause insomnia for 24-48 hours. Other times, I think the patient hears the risk/benefit discussion prior to the procedure, and focuses in on the risk of headache and it becomes a psychological thing. Your best friend in these situations is a good nurse with experience who can ferret out the ones you need to be worried about and obtain a good history.
 
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Actually, out of my fellowship now. ACGME approved fellowship, anesthesiology residency. In private practice. Was there a specific reason for your question?
 
I did a post-injection survey of 300 consecutive patients about 4 years ago. The incidence of headache was the same in the ESI pts (about 200 pts) as the non ESI (about 100). All were patients who had procedures under fluoro. Both groups had headaches for 1-2 days after injection at a rate of 2%. None were postural.

Interestingly, I recently had a patient complain of 48 - 72 hours of HA after LESI, but it only bothered her when she laid down. Sitting or standing there was no HA. It resolved on it's own.

Bedrock - lol. 😉
 
bedrock said:
Sleep thinks that anesthesiologists are the only physicians who can practice good pain medicine.
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or that you shouldnt just hope wait on a PDPH if it's soo debilitating. Especially if it's >1 week old. By tht time the chances of it getting better is less. You have to do something (IVF, caffeine, blood patch, etc). It doesnt just get 'better' on its own...

If one has done an anesthesiology residency and did labor epidurals, some insight could be transferred.

Why are you so defensive? Feel inadequate? Chill out.
 
I've only done 3-4 blood patches but they all worked like miracles and I was the big hero. My partner always wants to try IV caffeine but it has never worked from what I've seen. For a true, postural PDPH, I love doing an epidural blood patch.
 
most PDPH resolve within a week without any intervention/medication what so ever...

in fact, i haven't done a blood patch in 4 years now... the neuros who do spinal taps and get PDPH tell their patients to lay in bed for a week, drink coffee/coke, take some tylenol - and because those patients do fine they aren't even referring for blood patches... i have taken the same approach.

the reason why it is a bigger deal in the post-partum population, is that it is very important for the mom to feel well, sit upright and breast feed their child - hence a bit more aggressiveness in that population...

sleep.... sometimes it is better to ask questions about the issue rather than question the physician - you will learn more, and will suffer less attacks on this board.
 
Besides, he specifically said post-procedure headache, not PDPH.

It can be one of most common side-effects of ESI. again not PDPH.

I give tylenol in recovery. It goes away gradually. If it didn't, I'd want to see patient back in the office, make sure no neurologic deficits, r/o hypertensive crisis, meningitis, etc. Then a few tabs of vicodin.
 
SSdoc33 said:
yeah, PDPH do get better on their own.

sleep, don't be a dick.
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My intention was two fold.

1)if he's a troll, non-acgme accreditted guy trying to 'learn' pain mgt over the internet, that's an issue. Most of us who go to a ACGME accred fellowship SHOULD know how to treat PDPH....

2) Yes PDPH does get better on it's own. However, there are MANY that do not. I've had to f/u and do blood patches on patients who had a neurologist do a spinal with larger gauge needle (note they dont always use the 25G whitacre's we use in the pain clinic and anesthesiology). I've seen these patients try conservative treatment for weeks and then even months and then finally need to get a blood patch. So if you mean after say 6-8 months pts all get better from PDPH, I dont think I've followed a pt with PDPH for that long, I'd venture to say most people on here havent either.

They come to the pain clinic or are referred since the pain is debilitating or significantly causing them to limit their ADLs. Usually,the whole 'wait and see' approach and caffeine have been exhausted...
 
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i do a blood patch a week...i dont much like them, but hey, whatever... only in the post-labor do we do them quickly.

most of the referrals we get likely dont have PDPH, but have the same headache that necessitated the LP in the first place. Its so annoying to tell the patient that they will likely still have a headache after a blood patch, if this is the same headache as before the LP. The patients always say the same thing "my doctor said you would fix my headache with the blood patch"
"did you have a headache before the LP"
"yes, i have had this headache for weeks/months now, its the same headache"
"does it get better lying down?"
"No"
"then you dont need a blood patch"


funny, i have never blood patched my own patient...


Tenesma said:
most PDPH resolve within a week without any intervention/medication what so ever...

in fact, i haven't done a blood patch in 4 years now... the neuros who do spinal taps and get PDPH tell their patients to lay in bed for a week, drink coffee/coke, take some tylenol - and because those patients do fine they aren't even referring for blood patches... i have taken the same approach.

the reason why it is a bigger deal in the post-partum population, is that it is very important for the mom to feel well, sit upright and breast feed their child - hence a bit more aggressiveness in that population...

sleep.... sometimes it is better to ask questions about the issue rather than question the physician - you will learn more, and will suffer less attacks on this board.
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Ditto on the Sleep is Dick comment
 
sleep:

drrosenrosen ain't a troll

his thread headline specifically said postprocedure headache NOT PDPH...

your exposure in residency/fellowship is a bit twisted... in the real world you will learn that things are a bit different...
 
Thanks for having my back, tenesma. Yes, I clearly stated in the OP that I was talking about non-dural puncture ha. But I can appreciate sleep being defensive - we are all feeling a lot more defensive of our field right now and making sure that undertrained individuals don't ruin what's left of it for us and our patients.
 
drrosenrosen said:
Thanks for having my back, tenesma. Yes, I clearly stated in the OP that I was talking about non-dural puncture ha. But I can appreciate sleep being defensive - we are all feeling a lot more defensive of our field right now and making sure that undertrained individuals don't ruin what's left of it for us and our patients.
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👍

I guess you check out.

Bedrock et al....I love comments from people like you and SS. The 'non anesthesiologists' folks on here will whine about anesthesiologists thinking they are better etc. However, the interesting part is those same NONanesthesiologists are the ones that are the first to try to 'make up' diagnoses like 'chronic fatigue syndome'. They are also the same ones that try to use ultrasound for various "MSK" injections or therapy, not necessarily to help patients but to increase billing..
 
Double ditto on my previous comment.

Sleep -
anesthesiologists **** does stink just the same
as us other "lowly PMR trained pain Docs"
 
SleepIsGood said:
👍

I guess you check out.

Bedrock et al....I love comments from people like you and SS. The 'non anesthesiologists' folks on here will whine about anesthesiologists thinking they are better etc. However, the interesting part is those same NONanesthesiologists are the ones that are the first to try to 'make up' diagnoses like 'chronic fatigue syndome'. They are also the same ones that try to use ultrasound for various "MSK" injections or therapy, not necessarily to help patients but to increase billing..
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Holy F'in sheet! Are you serious? Are you real?

I've seen plenty of anesthesiologists doing more US than I do, plenty diagnosing BS things, and even worse, giving out opioids like candy. Myself and my PM&R partner are the only pain guys in town who do not put everyone on Norco and Oxycontin.

You really do feel superior don't you?
 
PMR 4 MSK said:
Holy F'in sheet! Are you serious? Are you real?

I've seen plenty of anesthesiologists doing more US than I do, plenty diagnosing BS things, and even worse, giving out opioids like candy. Myself and my PM&R partner are the only pain guys in town who do not put everyone on Norco and Oxycontin.

You really do feel superior don't you?
Click to expand...

Again, I love how you and some of your friends on here all of a sudden 'label' someone saying they are 'superior' etc. Did I say that?

Again, I know plenty of anesthesiologists. We do use Ultrasound for nerve blocks, which I think is a reasonable thing. But there are many, many more PMR folks using it to dx various "MSK" pathologies like an inflammation of a tendon or a muscle. Are you kidding me? When people do accidental intraneural injections, it's difficult to discern that using an ultrasound. Seeing edema or 'inflammation' around a tendon is just as hard with the current ultrasound technology. I've even heard PMR folks saying it's a SHAM and they have no idea what they are looking for. When anesthesiologists use ultrasound to perfomr nerve blocks , there' an actual end point we are looking for. One can actually see the medicine going around the nerves, or see stimulation if using a nerve stimulator, etc.

Obviously, on this board there are way more PMR folks so it's only natural you guys will be defensive.

As far as opoids being wrongly used. You will say you are the only one using it correctly, I'm sure that's waht the guy that operates right next to you says as well.
 
SleepIsGood said:
👍

I guess you check out.

Bedrock et al....I love comments from people like you and SS. The 'non anesthesiologists' folks on here will whine about anesthesiologists thinking they are better etc. However, the interesting part is those same NONanesthesiologists are the ones that are the first to try to 'make up' diagnoses like 'chronic fatigue syndome'. They are also the same ones that try to use ultrasound for various "MSK" injections or therapy, not necessarily to help patients but to increase billing..
Click to expand...

I'm PMR trained so take this for what it's worth. I've seen a few PMR guys that I thought were gaming the system to a certain extent. But I've also seen anesthesia folks doing things like repetetive nerve blocks to control chronic pain. I'm talking about not using any ablative therapy, just doing blocks over and over, something specifically discouraged in the new ASA guidelines. Anesthesia guys seem to be more focused on the here and now, "what can I do right now to help with the pain", sort of neglecting the long-term chronic nature of pain management (IMHO). My anesthesia partner thinks I am way too conservative with everything; opiates, interventions, etc. In his primitive mind, he believes I am timid. Anyway, there are distinct advantages to either path and the path does not make the man. If you can't see that, you are a really dense individual. Maybe you are the one with an inferiority complex from being pissed all over by so many surgeons for 3 years? That would screw me up 😀
 
hyperalgesia said:
I'm PMR trained so take this for what it's worth. I've seen a few PMR guys that I thought were gaming the system to a certain extent. But I've also seen anesthesia folks doing things like repetetive nerve blocks to control chronic pain. I'm talking about not using any ablative therapy, just doing blocks over and over, something specifically discouraged in the new ASA guidelines. Anesthesia guys seem to be more focused on the here and now, "what can I do right now to help with the pain", sort of neglecting the long-term chronic nature of pain management (IMHO). My anesthesia partner thinks I am way too conservative with everything; opiates, interventions, etc. In his primitive mind, he believes I am timid. Anyway, there are distinct advantages to either path and the path does not make the man. If you can't see that, you are a really dense individual. Maybe you are the one with an inferiority complex from being pissed all over by so many surgeons for 3 years? That would screw me up 😀
Click to expand...

Outliers exist everywhere. however, in the above post you called your partner 'primitive'. Ever say that to his face w/o saying it over the internet?

See that's the sort of thing I'm referring to. PMR folks and others try to learn certain interventional things from anesthesiologists (or even join them). Then eitehr because they were not properly trained, timid, or just uncomfortable (which is ok by the way) will say what the anethesiology trained person is doing is incorrect. I've talked to group leaders at TWO places so far that stated they would never hire a PMR doc again. Why, because they were too slow, wanted all these useless tests for simple lumbar radic for a herniated disc (EEG, NCV/EMG..which they can bill for and was simply gaming the system). Is that the norm? I dont know. but I can tell you for two groups I've talked to so far, it has been.

BTW..the great thing about having worked with surgeons in the OR is this-->efficiency. We've been conditioned to be accurate and efficient.

News to you. IF you dont like interventions, dont go into interventional pain management. Just dont go around talking down about it. Any physician can Rx opioids, you dont have to do a fellowship. But if you are going to slap the hands of those that FED you, then there's going to be discordance.

again, not trying to degrade any particular field. But I do think, if you (not just you) are going to call yourslf a "interventionalist" you have got to hack it as one.
 
I don't mean to diminish the contribution that anesthesiologists have made to pain mgmt. And yes, I have seen some PM&R people overuse diagnostics.

I think it's mostly a matter of perspective. In anesthesiology, being bold seems like kind of a virtue. In training, being circumspect and contemplative is probably not as valued as being assertive and confident. But in all medical specialties, the axiom, "Do no harm" is the default value when approaching a patient. That means the default is always no intervention. We don't walk into a patient's room with a touhy in one hand and a RF cannula in the other.
 
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Please guys, we are under attack by Obama, the insurance companies, the medical boards, the lawyers, and our fat smoking patients who want us to "fix them, for free yet" lets not cannibalize each other. Divided we all fall.😍
 
facets said:
Please guys, we are under attack by Obama, the insurance companies, the medical boards, the lawyers, and our fat smoking patients who want us to "fix them, for free yet" lets not cannibalize each other. Divided we all fall.😍
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👍
 
agree...no in-fight.

as far as i can see, there are variations among interventionists in their interventional skills, no doubt about it. anesthesiology-trained interventionists are the ones i will use for myself, not only because their background is more procedural but more importantly they are tuned to deal with emergency in procedure room since it's part of anesthesiology requirement.

does it mean PM&R docs don't make good pain doc? no, they definitely have their advantage in diagnosis and rehab-related treatment modality.

with the requirement of ACGME-accredited fellowship training, it's just a matter of time when the variation of interventional/diagnostic skills will be even out.
 
We should put this pissing contest to bed.

Does anyone remember the ISIS course where Windsor went up against 2 other guys in a cadaver discogram needle placement contest?

We may need to bring it back...

Windsor won with 3 needles placed in 17 seconds. Yes, not 17 seconds of fluoro time, but 17 seconds on the stopwatch.

I am not the fastest guy out there, but I will guarantee my meds reach their target in the safest and most direct method possible. I want a pain procedure throwdown! Bring it on.
 
lobelsteve said:
We should put this pissing contest to bed.

Does anyone remember the ISIS course where Windsor went up against 2 other guys in a cadaver discogram needle placement contest?

We may need to bring it back...

Windsor won with 3 needles placed in 17 seconds. Yes, not 17 seconds of fluoro time, but 17 seconds on the stopwatch.

I am not the fastest guy out there, but I will guarantee my meds reach their target in the safest and most direct method possible. I want a pain procedure throwdown! Bring it on.
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LOL. you guys have needle placing contests at these ISIS events? was that a real event planned at the meeting, or was it something a few of you guys were just doing for fun?
 
Having done and Anesthesiology pain fellowship and PMR residency, I can say there are pros and cons to both background specialties. Russo and nvsmr did the same and would agree with me.

I've seen an anesthesiologist pith the cervical cord during an ILESI, the patient scream in pain, and the anesthesiologist simply give more propofol to shut the patient up. I've seen plenty of PM&R pain docs who wont give their patients any sedation at all We both have rotten apples or simply green apples.

I personally think it is a good thing that we can learn from each others disparate primary specialties.

I used U/S during fellowship do regional blocks. Regional anesthesia has virtually no use in outpatient chronic pain. However, I'm glad I got the experience; maybe I'll need to place a brachial plexus catheter in a CRPS patient some day for PT. U/S is useful for sure for image guided injections at many joints, tendons, and small peripheral nerves in the chronic pain setting.
 
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i can't believe you guys are responding to the resident/fellow....

sleep: you have a very narrow view of the world --- and i suspect within a few years you are going to re-read your posts and realize it.
 
i think the bottom line is that PMR trained physicians are just bad humans. at least thats how i see it.😀
 
lobelsteve said:
Not bad humans, sub-humans.
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According to some people on here, apparently only the residents/fellows are the 'subhumans'. I guess certain attndings were just born as almighty attendings w/o having done a residency/fellowship😎
 
SleepIsGood said:
According to some people on here, apparently only the residents/fellows are the 'subhumans'. I guess certain attndings were just born as almighty attendings w/o having done a residency/fellowship😎
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no we just waited till we were attendings to act like one:meanie:
 
SleepIsGood said:
When people do accidental intraneural injections, it's difficult to discern that using an ultrasound.
Click to expand...

funny - I just did an EMG on a patient who's peroneal nerve was PIERCED and injected by an anesthesia pain doc who injected the knee using a posterolateral approach through the biceps femoris tendon into the peroneal nerve. This was for lateral thigh/calf pain that didn't quite respond to the series of 3 epidurals he did for the lumbar radiculopathy. When the patient got shooting pain into the lateral calf and almost kicked the doc, he then proceeded to inject into the nerve. 3 months later, the patient came to see my partner knee surgeon who sent the patient to me for a EMG to confirm the diagnosis.

There are bad apples in every field. You can talk to any physician in any field and they will be able to give at least one example of how their field has corrupt and unethical docs. The Brown hand clinic is the hand surgery equivalent of the "laser spine center". There are docs who charge $2000 for a course of prolotherapy. What about the anti-aging docs? Or the fertility doc who created the octomom? I could go on and on.

Also, I don't know how working in an OR as an anesthesiologist "conditions you to be accurate and efficient". Does that mean you can accurately and efficiently record vitals at regular intervals?? :laugh:

And the whole "Any physician can Rx opioids, you dont have to do a fellowship." comment I wholeheartedly disagree with. More patients die of opioid related deaths than those who die from interventional procedures. the whole point of doing a pain fellowship is to gain the knowledge base in order to practice pain medicine - not just gain procedural skills. Most procedures that we as pain docs do are not that hard. It usually involves needles of different sizes, good knowledge of anatomy, and target practice using image guidance. Even SCS/pump implants are "minor" surgeries compared to what our surgical colleagues do every week. None of us would be able to manage a big dural tear or an expanding epidural hematoma unless your background is spine surgery.

I have colleagues and mentors who trained in anesthesia, neurology, and PM&R - and I have learned from all of them. I have learned a lot from this forum. There are a lot of defensive insecure people out there and unfortunately the opportunity to professionally and usefully share information is lost on them.


I would like to know though, how would you rank in order of superiority??

chiropractors
non-anesthesia residency ACGME fellowship trained pain docs
anesthesia pain docs with no fellowship training
CRNAs performing pain procedures
spine surgeons performing pain procedures
anesthesia pain fellow currently in a fellowship
interventional radiologists performing pain procedures
:meanie:
 
Not only are there bad apples in all fields, there are plenty who feel their chosen is field is the best, because it was the best for them. Plenty of docs disparage other fields, particularly those they see as competitors. Physiatry overlaps many fields, so we take it from a lot of docs. For those fields we don't overlap with, they have no idea what we do, and for many, they just comment on what they've heard about it.

Most any doc could do anything a Physiatrist does, if they were so motivated to learn. But many of the patient populations we work with are the undesirables of medicine - the non-glorious patients.

If you spend cerebral energy on why your field is better, or another is worse, you are losing time you can spend doing what you set out to do - make this world a little better, making a few people happier.

Nobody has ever won a pissing contest on the internet.

edit - this post not aimed at anyone specifically. Please don't take it personally.
 
lobelsteve said:
Sleep, if they make you sit at the kids table again, you can show up at my place. Fried turkey and a low country boil. Yum.
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Is that the combo of the duck/chicken/turkey they do in the south. Dont know how those guys do it....
 
SleepIsGood said:
Is that the combo of the duck/chicken/turkey they do in the south. Dont know how those guys do it....
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Thats why you are the fellow(grasshopper) and I'm the attending (dragon). That is a Turducken. Famous by Madden on NFL broadcasts. Frying a turkey is best done by reviewing Alton Brown's show on the food network. Google it . I'm from nj, so a Yankee transplant to georgia. But we'll leave an extra seat at the table.
 
lobelsteve said:
Thats why you are the fellow(grasshopper) and I'm the attending (dragon). That is a Turducken. Famous by Madden on NFL broadcasts. Frying a turkey is best done by reviewing Alton Brown's show on the food network. Google it . I'm from nj, so a Yankee transplant to georgia. But we'll leave an extra seat at the table.
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as long as you dont burn down your porch, fried turkey is one of the greatest things on this planet
 
My suggestion for Sleep's Thanksgiving dinner would be... Crow
 
SleepIsGood said:
Family ritual of yours?

It's alright, I'd rather try the SOuth East offer..
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To spell it out for you... I was referring to the idiom "eating crow"(hint: Google it)--which in your case would be very appropriate
 
lonelobo said:
To spell it out for you... I was referring to the idiom "eating crow"(hint: Google it)--which in your case would be very appropriate
Click to expand...

Hey buddy, thanks for your great thoughts. :idea:
 
lonelobo said:
To spell it out for you... I was referring to the idiom "eating crow"(hint: Google it)--which in your case would be very appropriate
Click to expand...

I don't think he understands the figurative aspect of that phrase. I don't think he ever heard of that before.
 
SleepIsGood said:
Outliers exist everywhere. however, in the above post you called your partner 'primitive'. Ever say that to his face w/o saying it over the internet?

See that's the sort of thing I'm referring to. PMR folks and others try to learn certain interventional things from anesthesiologists (or even join them). Then eitehr because they were not properly trained, timid, or just uncomfortable (which is ok by the way) will say what the anethesiology trained person is doing is incorrect. I've talked to group leaders at TWO places so far that stated they would never hire a PMR doc again. Why, because they were too slow, wanted all these useless tests for simple lumbar radic for a herniated disc (EEG, NCV/EMG..which they can bill for and was simply gaming the system). Is that the norm? I dont know. but I can tell you for two groups I've talked to so far, it has been.

BTW..the great thing about having worked with surgeons in the OR is this-->efficiency. We've been conditioned to be accurate and efficient.

News to you. IF you dont like interventions, dont go into interventional pain management. Just dont go around talking down about it. Any physician can Rx opioids, you dont have to do a fellowship. But if you are going to slap the hands of those that FED you, then there's going to be discordance.

again, not trying to degrade any particular field. But I do think, if you (not just you) are going to call yourslf a "interventionalist" you have got to hack it as one.
Click to expand...


I may very well be wrong--but I have yet to see a clear example of someone who does something really fast w/o sacrificing thoroughness (in the medical world). I remember I had a co-resident on the rehab unit who admitted pts twice as fast as me and whenever I was on call all the calls were on her pts. Her notes were terrible but she went home by 3pm. At my current gig, I do the injections more slowly than the prior pain docs and I do not really care. the pts comment how much less pain I cause them and the staff said to me "what is that stuff you inject before the steroid that shows up on the screen-the last guys never did that"

They are, btw, considered the premier pain group in my state based on marketing I suppose.
 
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