Comprehensive Pain Care of Long Island

Myofascial Pain Syndrome constitute a group of disorders characterized by very sensitive small regions called triggerpoints which are located in a muscle or connective tissue. Further complications include muscle spasm, tenderness on pressure, stiffness, limitation of motion and weakness.

What are Triggerpoints (TP)?

TP are small circumscribed hypersensitive regions in muscles or in connective tissue (ligaments, joint capsules, tendons, etc.) which have a specific and typical area of referred pain. The TP is so called because its stimulation, like pulling of the trigger of a gun "shoots" the pain into a distant zone called the reference (or target) area.

TP usually originate pain in conditions diagnosed as myalgia (muscle pain) muscular or non articular rheumatism, myositis (myofascitis, muscle inflammation), fibrositis (inflammation of fibrous tissue) fibromuyositis. Similarly in bursitis, capsulitis, tendinitis and particularly in sprains the pain is concentrated in TP. Injection of TP in above conditions usually results in prompt and permanent relief proving that the pain originated in the TP.

What Induces Triggerpoints?

Any kind of local injury to myofascial structures (muscles, ligaments, and related tissues) can induce TP. Even slight injuries, blows, or sprains will induce TP if not treated properly immediately and become chronic. This traumatic triggerpoints are usually the cause of pain in ankle, back, or neck sprains. Beside acute injury chronic repetitive minor stresses are frequent causes of TP. Postural abnormalities, stresses of daily activities using the same muscles constantly, abnormal stress distribution in lower limbs (flat feet, knock knees, etc.) belong to these chronic irritants.

Another cause of TP is inflammation like arthritis, myositis, rheumatism and other connective tissue, chronic infection, etc. Nerve injuries and disorders including nerve compression like in slipped interveterbral disc induce TP which may persist long after the compression ceased. Endocrine particularly (thyroid) dysfunction and metabolic disorders, psychogenic stress exhaustion are predisposing factors.

Muscle spasm (longlasting contraction of muscle) is also caused by pain of any origin and in turn induces pain which maintains the spasm. A vicious cycle of pain-spasm-pain develops which can be broken up promptly by infiltration with local anesthetics. However, if the vicious cycle is allowed to continue for a longer time the blood supply to the muscle is strangled and causes spotty ischemic muscle damage. Metabolites which induce pain are trapped in the tender spots and become long after the original cause of pain subsided can induce permanent damage to muscle tissue and TP.

Psychological tension (inability to relax the muscles) may induce the pain-spasm-pain cycle which results in triggerpoints.

What is the Best Treatment for Triggerpoints?

Once a chronic TP develops with fibrotic scar formaton in the muscle, the most effective and best treatment is a TP injection. This consists of needleing of the entire triggerpoint combined with infiltration by local anesthetic (xylocain, similar to novocaine). Properly performed, a TP injection relieves the pain instantly and completely and opens the scar tissue so that the blood circulation removes the entrapped irritating metabolites. A complete cure of the pathological tissue changes as source of pain distinguished TP injections from acupuncture, which in some cases may induce temporary relief of pain, but does not remove the pathological source of it.

In suitable cases TP should be cured by injection, because in no other way can a pathologic process be reversed so completely, so quickly and so permanently. Other treatments of TP include ultra-sound (a deep heating device) and/or deep needling massage. Both methods are much more painful and less effective than the injections.

After TP injections the muscle still tends to develop spasm and therefore spasm relieving physical therapy (usually three sessions/week after each injection) are important. Heating, electric stimulation to relax the muscle, manual massage by therapist, relaxation and stretching exercises are irreplaceable in after treatment of TP injections. Gradually as the TP pain improves the intensity of exercises is upgraded to develop muscle strength, endurance, and flexibility.

What Can You Do for Best Recovery After Injection?

The usual course of recovery after TP injection consists of 4 stages. Immediately after the injection the local anesthesia is complete and there is no pain. Frequently pain from other TP also ceases, temporarily, and patient feels relieved. About 1 hour later the anesthetic wears out and a local soreness from mechanical effect of needling occurs. The soreness is felt like a bruise in contrast with the original TP pain which is similar to a deep tooth ache. The soreness can be controlled by the mild pain killers. After 2-3 days the injected TP is usually not sore anymore.

If after a triggerpoint injection you still have pain - what is the explanation? You should be aware of the fact, that even properly executed shots affects only the injected TP permanently. However - in the same area or in the same muscle many TP may still be active and only the physician's thorough examination can establish where the pain originates. Another TP in the area sometimes close to the injected one, but not identical with the first, may be the source of persistent pain.

Frequently patients become concerned with pain occurring after injection in an area which had not been painful prior to the shot. What happens is that while a very painful TP exist in one area (for example over the shoulder blade) this overshadows the less intensive pain (i.e. in neck) and patient feels only the intensive pain. When the intensive pain is eliminated by injection the less severe pain in the neck becomes the worse one dominating the mind. The patient is under the impression that the pain is migrating. It is important to realize that the newly felt TP which popped up are less painful and are evidence of improvement.

Measurement of Triggerpoints - A device called "Pressure Threshold Meter" which was introduced by me helps in doubtful cases to diagnose triggerpoints and evaluate quantitatively the effect of treatment.

What Happens to Triggerpoints?

If the TP is untreated - or conventional nonspecific therapy is used like heat, diathermy, massage, exercises, supports, etc. the pain can be relieved but the TP persists. The sensitivity of a TP may be decreased gradually but usually remains a constant source of irritation, the patient favors the area, and pain occurs on minor stresses, exertion, etc. Favoring the back or sprained ankle with persisting TP induces increased stress to the other side or to the compensating structures.

You will be admitted through the Ambulatory Surgery Unit, an IV will be started, you will be pre-hydrated which means that fluid will be put in through your IV. You are then be brought up to the operating room, not because it is surgery, but because it is the most sterile area in the hospital. You are then placed on the fluoroscopic table, which is the X-ray table, and with the use of X-ray we can locate the exact area of which is causing the problem. The IV conscious sedation is then given. We use a little bit of sedatives to cause relaxation. The needles are then performed and a local anesthetic and steroids are injected. These are not steroids that muscle builders use - these are steroids that remove immflammation. Once the procedure is completed, you will be placed back on your stretcher and return to the ambulatory surgery unit where you will be monitored and watched for a while. Once we are secure that you are back to your normal state, meaning that there is no more numbness or excessive sedation, you will be discharged home to be followed up in the office within one week.

Introduction:

We the staff of CPC of LI want you to understand what w are doing and why, as only by working closely together can we hope to achieve the best results. Although we can offer different nerve blocks and medicines to try to relieve the pain, that is only part of a person's suffering; answering your questions to relieve anxiety is the other part. The more you understand, the more comfortable you feel, the better our chances are of success.

Anatomy and Theory

The epidural space or sac is an area of fatty tissue which surrounds the membrane which encompasses the spinal cord and the cerebrospinal fluid. This membrane is called dura, thus the name: epidural - "outside the dura." This space also contains lymph vessels and veins. It is through this space that the spinal nerves pass as they travel from the spinal cord to the rest of the body or return to the cord from the tissues and organs.

By injecting various volumes and concentrations of different medications, we can bathe these nerves at chosen sites along the spinal column as they enter and exit this space. Various degrees of anesthesia are achieved in the body, dependent on the extent to which the nerves are numbed. Higher concentrations are used for patients undergoing surgery to numb the sensory nerves and to relax the muscles. Lower concentrations may be used to selectively numb those nerves which relay pain sensation, without compromising those nerves to the muscles. Thus, patients with chronic pain can get relief and remain active. (Indeed, such pain relief allows the person to become more active.) Local anesthetics are generally used in these blocks, although dilute solutions of narcotics can also be used to provide pain relief.

At the time of the initial needle stick, a thin plastic, spaghetti-like catheter is threaded through the needle into the epidural space. The needle is then removed with the catheter remaining in place, and the patient can resume their usual daily activities. Through this catheter, additional medication can be injected (without the use of additional needles) either continuously (with the aid of a battery driven pump), or intermittently. Both options provide lasting relief for weeks or months, as long as the catheter remains in place.

As in any invasive procedure the possibility of complications exist. These can occur at the time the catheter is placed; (placement of the catheter and injection of the medicine into one of the veins in the area, or into the space beneath the dural membrane, infection, lowering of the blood pressure, headache, etc.), or they can occur if the catheter moves weeks or months after it has been placed and functioning. We will discuss all of these possibilities in the clinic. Epidural nerve blocks have an excellent safety record. Indeed, most people have heard of them as a result of a friend or family member having an epidural at the time of labor, to relieve the discomfort of the uterine contractions.

Two or three days prior to your scheduled block, drink lots of fluids. An extra 2-3 glasses of water per day is fine. You should not do this if you have any heart problems or high blood pressure.

Please have a friend or family member accompany you to the office the day of your block. Come to the Nerve Block Clinic. We will ask that you either lie on your side, or remain seated leaning over. In either position, the more you can curve your back (like an angry cat) the easier the procedure will be. We will examine your back in order to locate the right spot for the needle insertion. Once this area is determined, we will cleanse the skin with a cold, brown soap solution. The skin at the needle insertion will be numbed with local anesthetic. (This is the area about the size of a dime.) You will feel what is often described as a "bee bite" followed by a transient localized burning sensation. Through this numbed area, the epidural needle will be slowly advanced until the epidural space is reached. At this point it is extremely important that you remain stilland do not move your back. When we are confident that the needle is in the correct position, we will inject a small test dose of local anesthetic. You will be asked to move your feet, and to tell us if you feel dizzy or faint, if you hear ringing in your ears, or if you have a metallic taste in your mouth. If we are still satisfied with the needle position, the plastic catheter will then be threaded through the needle. Occasionally patients describe a momentary "shooting sensation" traveling down either leg. This is nothing to be alarmed about, but tell us as it aids our positioning of the catheter. Once the catheter is in place and the needle is removed, you can relax. The catheter will then be securely taped to your back. The entire procedure takes 1O - 15 minutes, and is generally not painful.

Avoid strenuous activity for the rest of the day following your block. Walk with assistance, and do not drive. Your chronic pain may feel worse in the hours after the catheter is placed. This is normal and transient. After the block, resume taking your pain medications; we will plan to gradually taper them. While the catheter is in place, it must remain dry. Baths, shower, and swimming are forbidden. Sponge baths are fine.

We will instruct your family or friends and yourself on how to carecare for the catheter, and the correct way of safely administering the medications in a sterile manner. Some patients will be given solutions of local anesthetics to inject into the epidural catheter. After each injection, it is common to experience flushed, warm legs, and lightheadedness. A friend or family member should always stay with you for 3O minutes after each injection. If you feel faint, hear ringing in your ears, have a metallic taste in your mouth, find that you cannot move your legs after an injection or feel uncomfortable in any way, please call us. (516-661-O4OO 9am - 5pm Monday through Friday or call ______ and ask to speak to the anesthetist on call.

At times patients will be given dilute narcotic solutions to inject into the catheter. Side effects, although infrequent, include nausea, itchy skin, urinary hesitancy, and respiratory depression. We will discuss all of the above mentioned symptoms in greater detail in the clinic, but never hesitate to call us if you have any questions.

By working together we will balance the catheter medications with those you take by mouth in order to relieve as much of your pain as possible. Under no circumstances should you alter or adjust the dosage of the catheter medications without consulting us. When performed correctly, with close supervision, epidural analgesia is an excellent option for certain patients with chronic pain.

In Conclusion:

We hope this introduction has answered your questions. It is only a brief summary, not a patient consent form. We will talk about this block, in greater detail, in the clinic. If any questions remain, write them down so we can discuss them further.

The staff of the Nerve Block Clinic realizes that most of our patients are greatly distressed by their pain. They are often frustrated by the inability of other types of therapies to help them. We face the most difficult and challenging problems.... By working together, we can try to provide relief.

Patient Information Form

We the staff of CPC of LI want you to understand what we are doing and why, as only by working closely together can we hope to achieve the best results. We can offer different nerve blocks and medicines to try to relieve your pain. In addition, we feel that answering your questions is just as important. The more you understand, the more comfortable you feel, the better are our chances of success.

Anatomy and Theory:

Pain of the pelvic and peroneal areas can be treated by the blocking of the nerves innervating the affected areas as they exit the spinal column in the back. The injection of different solutions to numb the nerves or to lessen the inflammation provides the pain relief. Such injections can be made at various points along the path of the nerve. Transsacral nerve block injections are placed at a point in the nerve's path when it has already passed out of the spinal column.

Chronic pain is transmitted through an abnormal pathway where the same nerve impulses are repeatedly recycled. The instillation of local anesthetics breaks this abnormal cycle, and may provide relief for weeks t months from a series of several blocks over a 3-4 week period.

Chronic pain is transmitted through an abnormal pathway where the same nerve impulses are repeatedly recycled. The instillation of local anesthetics breaks this abnormal cycle, and may provide relief for weeks to months from a series of several blocks over a 3-4 week period.

As in any invasive procedure, the possibility of a complication exists. Risks include infection, rectal injection, compromise of the control of bowel and bladder function and possible lower leg weakness. We will discuss all of the risks in greater detail in the clinic.

Block Preparation and Procedures:

We ask for your cooperation before and immediately after the placement of the block. Do not take any of your pain medications for the 6 hours proper to the time of scheduled block. This will aid in assessing the effectiveness of ____ blood. Other prescribed medications should be taken normally (e.g. blood pressure and heart pills etc.)

A friend or family member should accompany you to the hospital the day of your scheduled block. At the time of the block we will examine your back to locate the precise sites for the placement sites for the placement of the needle(s). These sites are near the middle of your back and can be quite a distance from the area which is painful. The area will then be cleansed with a cold brown soap solution, and the skin at the sites of the needles (areas the size of a dime), will be numbed with the injection of a local anesthetic. Patients often describe this as a small bee bite followed by a momentary burning sensation as the skin is numbed. Through these areas the block needles will be placed. When we are satisfied with their positions, a solution of local anesthetic will be injected. This is usually not painful, however patients sometimes describe a discomfort during the injection. It is very important that you do not move while the injections are being placed.

After a brief period of observation, you will be able to return home. Strenuous activity, (which includes driving) should be avoided for the rest of the day. You should resume taking your pain medicines in the usual manner; we will gradually taper these drugs. If you feel short of breath, dizzy, faint, nauseated, or uncomfortable in any way, please call us....we want to know (516-661-O4OO).

It is impossible to predict how effective the block will be. Two patients with the same problem and background can have very different results. Usually a series of 8-1O blocks are needed to provide effective relief. If these are successful, we can consider injecting a different solution which produces a more permanent block (lasting from several months to years).

In Conclusion:

We hope this introduction has answered your questions. It is only a brief summary, not a patient consent form. We will talk about this block in greater detail in the clinic. If any questions remain, write them down so we can address them further.

The staff of CPC of LI realizes that most of our patients are greatly distressed by their pain. They are frustrated by the inability of other types of therapies to help them. We face the most difficult and challenging problem.... By working together, we can try to provide relief.

Introduction:

We the staff of the Nerve Block Clinic, want you to understand what we are doing and why, as only by working closely together can we hope to achieve the best results. We can offer different nerve blocks and medicine, to try to relieve your pain. In addition, we feel that answering your questions is just as important. The more you understand, the more comfortable you feel, the better our chances are of success.

Anatomy and Theory:

Pain syndromes of the upper abdomen and thorax such as post herpetic neuralgia (pain from shingles) and post thoracotomy syndrome can be treated by the blocking of the nerves innervating the affected areas as they exit the spinal column in the back. The injection of different solutions to numb the nerves provides the pain relief. Such injections can be made at various points along the -path of the nerve. Paravertebral nerve block injections are placed at a point in the nervels pathway when it has already passed out of the spinal column.

Chronic pain is transmitted through an abnormal pathway where the same impulses are repeatedly recycled. The instillation of local anesthetics breaks this abnormal cycle and may provide pain relief for weeks to months. Often prolonged and effective relief may often be obtained from a series of several blocks given over a 3-4 week period.

As in any inovative procedure, the possibility of a complication exists. Risks include infection, intravasoular or intrathecal injections (into a blood vessel or spinal space) pneumothorax and intrapleural injection. Because of these possibilities, we use a fluroscopy machine to take x-rays at the time of your initial blocks, to best assure that the needle placement is accurate. We will discuss all of the procedure risks in greater detail in the clinic.

Preparation and Procedure:

We ask for your cooperation before and immediately after the placement of the block.

1. Do not take any of your pain medications for the 6 hours prior to the time of your scheduled block. Other prescribed medicines should be taken normally (eg. blood pressure or heart pills, etc.).

2. Please refrain from eating any solid foods beginning 8 hours prior to the scheduled block. You may have clear liquids for breakfast the morning of the block.(This includes tea, broth, jello, etc.).

A friend or family member should accompany you to the special procedure area of the Radiology Department in the hospital the day of your scheduled block.

At the time of the block we will examine your back to locate the precise site(s) for the placement of the needle(s). These sites are often in the middle of your back, quite some distance from the area which is painful. The area will then be cleansed with a cold brown soap solution. And the skin at the sites of the needles (an area the size of a dime) will be numbed with the injection of a local anesthetic. Patients often describe this as a small bee bite followed by a momentary burning sensation. Through these areas the - block needles will be placed. When we are satisfied with their accuracy, a solution of local anesthetic will be injected. This is usually not painful, however, patients sometimes describe a discomfort during the injection. It is vea important that you do not move while the injections are being placed. We will ask if you have feelings of dizziness, ringing in your ears, or if you have a metallic taste in your mouth.

After a brief period of observation, you will be able to return home. Strenuous activity, which includes driving, should be avoided for the rest of the day. You should resume taking your pain medicines in the usual manner; we will gradually taper these drugs. If you feel short of breath, dizzy, faint, nauseated, or uncomfortable in any way, please call us .... we want to know. (212/794-6840, 9am-5pm, M-F, or call 794-7900 and ask to speak with the anesthetist on call).

It is impossible to predict how effective the block will be. Two patients with the same problem and background can have very different results. Usually a series of 8-10 blocks are needed to provide effective relief. If these are successful, we can consider injecting a different solution which produces a more permanent block (lasting from several months to years).

In Conclusion:

We hope this introduction has answered your questions. it is only a brief summary, not a patient consent form. We will talk about this block in greater detail in the clinic. If any questions remain, write them down so we can discuss them further.

The staff of the Nerve Block Clinic realizes that most of our patients are greatly distressed by their pain. They are frustrated by the inability of other types of therapies to help them. We face the Most difficult and challenging problem .... By working together, we can try to provide relief.

Introduction:

We, the staff of CPC of Long Island, want you to understand what we are doing and why, as only by working closely together can we hope to achieve the best results. We can offer different nerve blocks and medicines to try to relieve your pain. In addition, we feel answering your questions is just as important. The more you understand, the more comfortable you feel, the better our chances are of success.

Anatomy and Theory:

The sympathetic nervous system is a specialized set of nerve fibers which innervate blood vessels and various nerves throughout the body. (These are not the same nerves which connect the spinal cord with the skin and muscles providing sensation and muscle control.) The sympathetic nerves leave the spinal cord from segments in the thoracic and lumbar regions. They immediately form into two thick long bundles which travel on either side of the spinal column and are called the sympthetic chains. From these structures, the sympathetic nerves leave towards their destinations throughout the body.

By numbing these nerves at the site of the sympathetic chain, we can treat several pain syndromes and peripheral vascular problems of the pelvic region and lower extremities. Lumbar sympathetic nerve blocks are used to relieve the pain of reflex sympathetic cystrophy and causalgia of the lower extremity. Other disorders such as Buerger's disease, arterial crush injuries and phantom limb pain can also be treated by such a nerve block.

Accurate needle placement for a lumbar sympathetic block is essential, since there are several important structures in the area of the sympathetic chain. A misplaced needle could result in the injection of solution into a blood vessel (the aorta on the left, and the vena cava on the right) or into the lung space. The ureters of the kidney and the spinal canal are in this area as well. Thus as in any procedure, complications are a possibility. We will discuss these risks in greater detail in the clinic. In experienced hands, a lumbar sympathetic block remains an excellent option for the patient with chronic pain in the pelvic area or lower extremities.