Injections for Chronic Pain

Total Page:16

File Type:pdf, Size:1020Kb

Injections for Chronic Pain Injections for Chronic Pain a, b c Virtaj Singh, MD *, Andrea Trescot, MD , Isuta Nishio, MD KEYWORDS Chronic pain Regenerative injections Trigger point injections Botulinum toxins KEY POINTS Even in the setting of chronic pain, various injections can still have a useful role in facilitating a rehabilitation program. Spinal injections, such as epidural steroid injections and facet joint injections, are among the most commonly used procedures in most pain practices; but a growing number of practices are considering less common injections, such as trigger point injections, regen- erative injections/prolotherapy, and injections using botulinum toxins. INTRODUCTION Although interventional procedures should be used cautiously in the setting of chronic pain, there is a role for a variety of injections to facilitate patients’ overall rehabilitation program. There are many resources available, including a prior edition of Physical Med- icine and Rehabilitation Clinics of North America, which discuss the more conventional spinal injections. The focus of this article is on lesser-known injection options for treating chronic pain. The authors separately discuss trigger point injections (TPIs), regenerative injections (prolotherapy), and injections using botulinum toxins (BTx). TRIGGER POINT INJECTIONS Myofascial pain syndrome (MPS) is a common musculoskeletal pain syndrome char- acterized by a myofascial trigger point (MTrP) at muscle, fascia, or tendinous inser- tions. A MTrP is a hyperirritable tender spot, frequently associated with taut band that, on palpation, is firmer in consistency than adjacent muscle fibers. When com- pressed, an MTrP may cause patient vocalization or a visible withdrawal (which is known as the jump sign). a Department of Rehabilitation Medicine, Seattle Spine & Sports Medicine, University of Washington, 3213 Eastlake Avenue East, Suite A, Seattle, WA 98102, USA; b Pain and Headache Center, 5431 Mayflower Lane, Suite 4, Wasilla, AK 99654, USA; c Department of Anesthesiology and Pain Medicine, VA Puget Sound Health Care System, University of Washington, 1660 South Columbian Way, S-112-Anes, Seattle, WA 98108, USA * Corresponding author. E-mail address: [email protected] Phys Med Rehabil Clin N Am 26 (2015) 249–261 http://dx.doi.org/10.1016/j.pmr.2015.01.004 pmr.theclinics.com 1047-9651/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved. 250 Singh et al Stretching and exercise are the foundation of treatment and management of MPS; however, for refractory cases, needle therapy may be offered. This therapy may include TPIs (using local anesthetics, corticosteroids, and/or BTx), dry needling (DN) (intramuscular stimulation [IMS]), and acupuncture. Local Anesthetics Despite the popularity of TPIs, there is no conclusive evidence that demonstrates superior effectiveness of TPIs over DN in the treatment of MPS.1,2 One systematic re- view of randomized controlled trials found that direct injection to MTrPs was indeed effective but that the nature of the injected substance did not influence the outcome; hence, the investigators concluded that the beneficial effects of TPIs were likely the result of needle insertion or placebo.1 However, another review showed short-term benefits of TPIs with lidocaine that were superior to DN or placebo.3 It is conceivable that local pain and soreness associated with needling can be ameliorated with local anesthetic injection.2 Corticosteroids Although inflammation may play a role in MPS, there is no evidence that the injection of corticosteroid provides any enhanced benefits.4 In addition, corticosteroids carry the risk of local muscle necrosis and adrenal suppression. Thus, the use of corticosteroids for TPIs is not recommended. Botulinum Toxin Botulinum toxin (BTx) is a potent neurotoxin produced by the bacterium Clostridium botulinum that blocks acetylcholine release into the neuromuscular junction, leading to prolonged muscle relaxation (typically lasting 3 to 4 months). BTx is used for a va- riety of pain procedures as discussed separately in this article later. Briefly, the authors discuss the use of BTx in TPIs. In TPIs, BTx is thought to reduce muscular ischemia and free entrapped nerve end- ings. Central and peripheral antinociceptive properties of BTx have also been postu- lated. Despite these mechanisms that could theoretically offer a benefit for patients with MPS, the use of BTx injections for myofascial trigger points is controversial. Meta-analyses of randomized trials in patients with neck pain have found no benefit of BTx intramuscular injections in the short-term (4 weeks) or long-term (6 months) when compared with placebo.5,6 Although a recent review7 showed inconclusive ev- idence regarding the effectiveness of BTx in the treatment of MPS, an older Cochrane review found moderate evidence that BTx injections are not effective.3 In sum, given the high cost of the medication and questionable evidence for its efficacy, cost and clinical value should be carefully assessed before considering BTx injections for MPS. Dry Needling Dry needling (DN) (also known as intramuscular stimulation [IMS]) involves the practice of using a small-gauge needle (sometimes acupuncture needles) to irritate the MTrP without injecting any substance (as opposed to those discussed earlier). Systemic re- views and meta-analyses of randomized controlled trials suggest that DN is an effec- tive therapy for MPS.1,8,9 If DN is used to specifically target MTrPs, it is most effective when a local twitch response (LTR) (brisk contraction of the taut band) is elicited.10 A fast-in-fast-out technique has been advocated to elicit a maximal number of LTRs. The needle penetrates the taut band of the muscle, is withdrawn to superficial subcu- taneous tissue, then redirected to another area in proximity (Fig. 1). Deep DN to the Injections for Chronic Pain 251 Taut band Trigger point locus Trigger point region Fig. 1. TPIs and DN to myofascial trigger point. (Courtesy of Isuta Nishio, MD.) muscle (eg, 15 mm) has been shown to be more effective than superficial DN (eg, 2 mm).11 Acupuncture Acupuncture is an increasingly popular treatment of a broad spectrum of chronic conditions, including chronic pain. However, the number of needles used, the fre- quency of sessions, stimulation frequency, and current amplitude to obtain optimal ef- ficacy remains a matter of debate. A Cochrane review found that, in the short-term, acupuncture is more effective for chronic low back pain and neck pain compared to no treatment or sham acupuncture.12 Other meta-analyses have also demonstrated the effectiveness of acupuncture for chronic pain when compared with no acupunc- ture or sham (needles placed in non-acupucture sites).13,14 The data suggest that the benefits of acupuncture are clinically relevant and greater than placebo; however, the observed differences in effectiveness between acupunc- ture and sham acupuncture are smaller than those between acupuncture and no acupuncture. This pattern of findings indicates that the nonspecific physiologic and psychological effects of needling may be more important than the actual acupuncture technique itself.14,15 Needing Therapy: Mechanism of Action The exact mechanism by which DN relieves MTrP and MPS has yet to be fully eluci- dated. DN has been shown to diminish spontaneous electrical activity when LTR is eli- cited.16 Hong and Simons17 suggested that LTR or referred pain seems to be mediated through a spinal reflex in response to stimulation of a sensitive locus (noci- ceptor) that is in the vicinity of an active locus (motor end plate). Because DN is most effective when LTR is elicited,4 it is theorized that DN may relieve MTrP via inhibition of dysfunctional activity in the motor end plate of the skeletal muscle motor neuron. Acupuncture has been used for various pain conditions in addition to MPS. There is increasing evidence of correlations and similarities between MTrPs and acupuncture points in terms of their distribution and referred pain patterns.18,19 An electrophysio- logic study showed that some acupuncture points are indeed MTrPs.20 Acupuncture analgesia seems to be a manifestation of integrative processes at different levels of the central nervous system (CNS).21 The gate control theory (Melzack and Wall22) may in part explain these processes; namely, the theory postulates that non- noxious sensory input (eg, touch, pressure, vibration) into the CNS can modulate 252 Singh et al pain perception by activating inhibitory interneurons.22 Furthermore, the possible role of endogenous opioids has been implicated in both TPIs and acupuncture as their analgesic effects can be in part reversed by naloxone.23,24 Key Points There is no firm evidence that TPIs are superior to DN or acupuncture for MPS; however, TPIs with local anesthetic may offer additional benefits via relieving pain associated with soreness from the needling procedure itself. There is no strong evidence to support the use of corticosteroid or BTx in TPIs. DN seems to be effective for MPS, especially when LTR is elicited. Acupuncture seems to be effective for chronic pain, but nonspecific physiologic and psychological effects may play a significant role in its benefits. The mechanism of action in needling therapy seems to be multifactorial, including integrative CNS processes and endogenous opioid peptides. REGENERATIVE INJECTIONS Regenerative injection therapy (RIT) encompasses a spectrum of injection treatments designed to stimulate repair of damaged tissue. These injections
Recommended publications
  • Radiculopathy Vs. Spinal Stenosis: Evocative Electrodiagnosis Identifies the Main Pain Generator
    Functional Electromyography Loren M. Fishman · Allen N. Wilkins Functional Electromyography Provocative Maneuvers in Electrodiagnosis 123 Loren M. Fishman, MD Allen N. Wilkins, MD College of Physicians & Surgeons Manhattan Physical Medicine Columbia University and Rehabilitation New York, NY 10028, USA New York, NY 10013, USA [email protected] ISBN 978-1-60761-019-9 e-ISBN 978-1-60761-020-5 DOI 10.1007/978-1-60761-020-5 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2010935087 © Springer Science+Business Media, LLC 2011 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.
    [Show full text]
  • Piriformis Syndrome: the Literal “Pain in My Butt” Chelsea Smith, PTA
    Piriformis Syndrome: the literal “pain in my butt” Chelsea Smith, PTA Aside from the monotony of day-to-day pains and annoyances, piriformis syndrome is the literal “pain in my butt” that may not go away with sending the kids to grandmas and often takes the form of sciatica. Many individuals with pain in the buttock that radiates down the leg are experiencing a form of sciatica caused by irritation of the spinal nerves in or near the lumbar spine (1). Other times though, the nerve irritation is not in the spine but further down the leg due to a pesky muscle called the piriformis, hence “piriformis syndrome”. The piriformis muscle is a flat, pyramidal-shaped muscle that originates from the front surface of the sacrum and the joint capsule of the sacroiliac joint (SI joint) and is located deep in the gluteal tissue (2). The piriformis travels through the greater sciatic foramen and attaches to the upper surface of the greater trochanter (or top of the hip bone) while the sciatic nerve runs under (and sometimes through) the piriformis muscle as it exits the pelvis. Due to this close proximity between the piriformis muscle and the sciatic nerve, if there is excessive tension (tightness), spasm, or inflammation of the piriformis muscle this can cause irritation to the sciatic nerve leading to symptoms of sciatica (pain down the leg) (1). Activities like sitting on hard surfaces, crouching down, walking or running for long distances, and climbing stairs can all increase symptoms (2) with the most common symptom being tenderness along the piriformis muscle (deep in the gluteal region) upon palpation.
    [Show full text]
  • Piriformis Syndrome Is Overdiagnosed 11 Robert A
    American Association of Neuromuscular & Electrodiagnostic Medicine AANEM CROSSFIRE: CONTROVERSIES IN NEUROMUSCULAR AND ELECTRODIAGNOSTIC MEDICINE Loren M. Fishman, MD, B.Phil Robert A.Werner, MD, MS Scott J. Primack, DO Willam S. Pease, MD Ernest W. Johnson, MD Lawrence R. Robinson, MD 2005 AANEM COURSE F AANEM 52ND Annual Scientific Meeting Monterey, California CROSSFIRE: Controversies in Neuromuscular and Electrodiagnostic Medicine Loren M. Fishman, MD, B.Phil Robert A.Werner, MD, MS Scott J. Primack, DO Willam S. Pease, MD Ernest W. Johnson, MD Lawrence R. Robinson, MD 2005 COURSE F AANEM 52nd Annual Scientific Meeting Monterey, California AANEM Copyright © September 2005 American Association of Neuromuscular & Electrodiagnostic Medicine 421 First Avenue SW, Suite 300 East Rochester, MN 55902 PRINTED BY JOHNSON PRINTING COMPANY, INC. ii CROSSFIRE: Controversies in Neuromuscular and Electrodiagnostic Medicine Faculty Loren M. Fishman, MD, B.Phil Scott J. Primack, DO Assistant Clinical Professor Co-director Department of Physical Medicine and Rehabilitation Colorado Rehabilitation and Occupational Medicine Columbia College of Physicians and Surgeons Denver, Colorado New York City, New York Dr. Primack completed his residency at the Rehabilitation Institute of Dr. Fishman is a specialist in low back pain and sciatica, electrodiagnosis, Chicago in 1992. He then spent 6 months with Dr. Larry Mack at the functional assessment, and cognitive rehabilitation. Over the last 20 years, University of Washington. Dr. Mack, in conjunction with the Shoulder he has lectured frequently and contributed over 55 publications. His most and Elbow Service at the University of Washington, performed some of the recent work, Relief is in the Stretch: End Back Pain Through Yoga, and the original research utilizing musculoskeletal ultrasound in order to diagnose earlier book, Back Talk, both written with Carol Ardman, were published shoulder pathology.
    [Show full text]
  • New York Chapter American College of Physicians Annual
    New York Chapter American College of Physicians Annual Scientific Meeting Poster Presentations Saturday, October 12, 2019 Westchester Hilton Hotel 699 Westchester Avenue Rye Brook, NY New York Chapter American College of Physicians Annual Scientific Meeting Medical Student Clinical Vignette 1 Medical Student Clinical Vignette Adina Amin Medical Student Jessy Epstein, Miguel Lacayo, Emmanuel Morakinyo Touro College of Osteopathic Medicine A Series of Unfortunate Events - A Rare Presentation of Thoracic Outlet Syndrome Venous thoracic outlet syndrome, formerly known as Paget-Schroetter Syndrome, is a condition characterized by spontaneous deep vein thrombosis of the upper extremity. It is a very rare syndrome resulting from anatomical abnormalities of the thoracic outlet, causing thrombosis of the deep veins draining the upper extremity. This disease is also called “effort thrombosis― because of increased association with vigorous and repetitive upper extremity activities. Symptoms include severe upper extremity pain and swelling after strenuous activity. A 31-year-old female with a history of vascular thoracic outlet syndrome, two prior thrombectomies, and right first rib resection presented with symptoms of loss of blood sensation, dull pain in the area, and sharp pain when coughing/sneezing. When the patient had her first blood clot, physical exam was notable for swelling, venous distension, and skin discoloration. The patient had her first thrombectomy in her right upper extremity a couple weeks after the first clot was discovered. Thrombolysis with TPA was initiated, and percutaneous mechanical thrombectomy with angioplasty of the axillary and subclavian veins was performed. Almost immediately after the thrombectomy, the patient had a rethrombosis which was confirmed by ultrasound.
    [Show full text]
  • Lumbosacral Plexus Entrapment Syndrome. Part One: a Common Yet Little-Known Cause of Chronic Pelvic and Lower Extremity Pain
    3-A Running head: ANAESTHESIA, PAIN & INTENSIVE CARE www.apicareonline.com ORIGINAL ARTICLE Lumbosacral plexus entrapment syndrome. Part one: A common yet little-known cause of chronic pelvic and lower extremity pain Kjetil Larsen, CES, George C. Chang Chien, D O2 ABSTRACT Corrective exercise specialist, Training & Rehabilitation, Oslo Lumbosacral plexus entrapment syndrome (LPES) is a little-known but common cause Norway of chronic lumbopelvic and lower extremity pain. The lumbar plexus, including the 2 Director of pain management, lumbosacral tunks emerge through the fibers of the psoas major, and the proximal Ventura County Medical Center, sciatic nerve beneath the piriformis muscles. Severe weakness of these muscles may Ventura, CA 93003, USA. lead to entrapment plexopathy, resulting in diffuse and non-specific pain patterns Correspondence: Kjetil Larsen, CES, Corrective throughout the lumbopelvic complex and lower extremities (LPLE), easily mimicking Exercise Specialist, Training & other diagnoses and is therefore likely to mislead the interpreting clinician. It is a Rehabilitation, Oslo Norway; pathology very similar to that of thoracic outlet syndrome, but for the lower body. This Kjetil@trainingandrehabilitation. two part manuscript series was written in an attempt to demonstrate the existence, com; pathophysiology, diagnostic protocol as well as interventional strategy for LPES, and Tel.: +47 975 45 192 its efficacy. Received: 23 November 2018, Reviewed & Accepted: 28 Key words: Pelvic girdle; Pain, Pelvic girdle; Lumbosacral plexus entrapment syndrome; February 2019 Piriformis syndrome; Nerve entrapment; Double-crush; Pain, Chronic; Fibromyalgia Citation: Larsen K, Chien GCC. Lumbosacral plexus entrapment syndrome. Part one: A common yet little-known cause of chronic pelvic and lower extremity pain.
    [Show full text]
  • Prolotherapy: a Nontraditional Approach to Knee Osteoarthritis
    ® Priority updates from the research literature PURLs from the family Physicians inquiries network Andrew H. Slattengren, DO; Trent Christensen, MD; Shailendra Prasad, Prolotherapy: A nontraditional MBBS, MPH; Kohar Jones, MD North Memorial Family approach to knee osteoarthritis Medicine Residency, University of Minnesota, Minneapolis (Drs. Dextrose injections into the knee can reduce pain and Slattengren, Christensen, and Prasad); Department improve a patient’s quality of life. of Family Medicine, The University of Chicago (Dr. Jones) PURL s E D i tor Kate Rowland, MD, MS Department of Family PRACTICE CHANGER acid, and corticosteroid injections. Cost, ef- Medicine, The University Recommend prolotherapy for patients with ficacy, and safety limit these therapies.3 of Chicago knee osteoarthritis (OA) that does not re- Prolotherapy is another option used spond to conventional therapies.1 to treat musculoskeletal pain. It involves repeatedly injecting a sclerosing solution STRENGTH OF RECOMMENDATiON (usually dextrose) into the sites of chronic B: Based on a 3-arm, blinded, randomized musculoskeletal pain.4 The mechanism of controlled trial (RCT). action is thought to be the result of local tis- Rabago D, Patterson JJ, Mundt M, et al. Dextrose prolotherapy for sue irritation stimulating inflammatory path- knee osteoarthritis: a randomized controlled trial. Ann Fam Med. 2013;11:229-237. ways, which leads to the release of growth factors and subsequent healing.4,5 Previous studies evaluating the usefulness of prolo- ILLUSTRATIVE CASE therapy have lacked methodological rigor, a 59-year-old woman with OA comes to your have not been randomized adequately, or office with chronic knee pain. She has tried ac- have lacked a placebo comparison.6-9 etaminophen, ibuprofen, intra-articular cortico- steroid injections, and physical therapy without significant improvement in pain or functioning.
    [Show full text]
  • Thoracic Outlet Syndrome: Evaluation and Management
    nalytic A al & B y i tr o s c i h e Kocyigi and Kuyucu, Biochem Anal Biochem 2016, m m Biochemistry & e i h s c t 5:2 r o i y B DOI: 10.4172/2161-1009.1000274 ISSN: 2161-1009 Analytical Biochemistry Review Article Open Access Thoracic Outlet Syndrome: Evaluation and Management Figen Kocyigi T1* and Ersin Kuyucu2 1School of Physical Therapy and Rehabilitation, Pamukkale University, Turkey 2Department of Orthopaedics and Traumatology, Istanbul Medipol University, Faculty of Medicine, Istanbul, Turkey *Corresponding author: Figen Kocyigi T, School of Physical Therapy and Rehabilitation, Pamukkale University, 20070, Denizli, Turkey, Tel: +90-258-4444295; Fax: +90-258-2964494; E-mail: [email protected] Rec date: March 04, 2016; Acc date: May 21, 2016; Pub date: May 24, 2016 Copyright: © 2016 Kocyıgı T et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract Thoracic outlet syndrome is an umbrella term that describes the potential compression of the brachial plexus, subclavian vein or subclavian artery by different clinical disorders. This review covers the classification, clinical findings, physical examination findings and management of this challenging syndrome under the light of recent scientific research. Various medical specialties can encounter TOS within their field of expertise. TOS should not be viewed as a single clinical entity that simply manifests variations from one patient to another. TOS is composed of three very discrete subgroups, and treatment should be individualized after diagnosis is definite.
    [Show full text]
  • ICD9 & ICD10 Neuromuscular Codes
    ICD-9-CM and ICD-10-CM NEUROMUSCULAR DIAGNOSIS CODES ICD-9-CM ICD-10-CM Focal Neuropathy Mononeuropathy G56.00 Carpal tunnel syndrome, unspecified Carpal tunnel syndrome 354.00 G56.00 upper limb Other lesions of median nerve, Other median nerve lesion 354.10 G56.10 unspecified upper limb Lesion of ulnar nerve, unspecified Lesion of ulnar nerve 354.20 G56.20 upper limb Lesion of radial nerve, unspecified Lesion of radial nerve 354.30 G56.30 upper limb Lesion of sciatic nerve, unspecified Sciatic nerve lesion (Piriformis syndrome) 355.00 G57.00 lower limb Meralgia paresthetica, unspecified Meralgia paresthetica 355.10 G57.10 lower limb Lesion of lateral popiteal nerve, Peroneal nerve (lesion of lateral popiteal nerve) 355.30 G57.30 unspecified lower limb Tarsal tunnel syndrome, unspecified Tarsal tunnel syndrome 355.50 G57.50 lower limb Plexus Brachial plexus lesion 353.00 Brachial plexus disorders G54.0 Brachial neuralgia (or radiculitis NOS) 723.40 Radiculopathy, cervical region M54.12 Radiculopathy, cervicothoracic region M54.13 Thoracic outlet syndrome (Thoracic root Thoracic root disorders, not elsewhere 353.00 G54.3 lesions, not elsewhere classified) classified Lumbosacral plexus lesion 353.10 Lumbosacral plexus disorders G54.1 Neuralgic amyotrophy 353.50 Neuralgic amyotrophy G54.5 Root Cervical radiculopathy (Intervertebral disc Cervical disc disorder with myelopathy, 722.71 M50.00 disorder with myelopathy, cervical region) unspecified cervical region Lumbosacral root lesions (Degeneration of Other intervertebral disc degeneration,
    [Show full text]
  • Neurogenic Thoracic Outlet Syndrome: Current Diagnostic Criteria and Advances in MRI Diagnostics
    NEUROSURGICAL FOCUS Neurosurg Focus 39 (3):E7, 2015 Neurogenic thoracic outlet syndrome: current diagnostic criteria and advances in MRI diagnostics Stephen T. Magill, MD, PhD,1 Marcel Brus-Ramer, MD, PhD,2 Philip R. Weinstein, MD,1 Cynthia T. Chin, MD,2 and Line Jacques, MD1 Departments of 1Neurological Surgery and 2Radiology and Biomedical Imaging, University of California, San Francisco, California Neurogenic thoracic outlet syndrome (nTOS) is caused by compression of the brachial plexus as it traverses from the thoracic outlet to the axilla. Diagnosing nTOS can be difficult because of overlap with other complex pain and entrapment syndromes. An nTOS diagnosis is made based on patient history, physical exam, electrodiagnostic studies, and, more recently, interpretation of MR neurograms with tractography. Advances in high-resolution MRI and tractography can confirm an nTOS diagnosis and identify the location of nerve compression, allowing tailored surgical decompression. In this report, the authors review the current diagnostic criteria, present an update on advances in MRI, and provide case examples demonstrating how MR neurography (MRN) can aid in diagnosing nTOS. The authors conclude that improved high-resolution MRN and tractography are valuable tools for identifying the source of nerve compression in patients with nTOS and can augment current diagnostic modalities for this syndrome. http://thejns.org/doi/abs/10.3171/2015.6.FOCUS15219 KEY WORDS neurogenic thoracic outlet syndrome; MRI; MR neurogram; DTI; MR tractography; diffusion tensor imaging EUROGENIC thoracic outlet syndrome (nTOS) is a Both syndromes have similar symptoms, but diagnosing rare condition that consists of a constellation of nTOS requires identification of a direct source of compres- symptoms resulting from compression of the bra- sion, while patients without a clear source of compression Nchial plexus as it travels from the thoracic outlet to the fall into the disputed TOS category and may not respond axilla.
    [Show full text]
  • The Piriformis Syndrome. a Sciatic Nerve Entrapment Misdiagnosed As Lumbar Radiculopathy
    VOLUME 72 | ISSUE 2 | APRIL - JUNE 2021 Actcase reportA The Piriformis Syndrome. A sciatic nerve entrapment misdiagnosed as lumbar radiculopathy. A case report and literature review E.K.Frangakis M.D. abstract The term Piriformis Syndrome describes an extrapelvic pressure of the whole or part of the Sciatic Nerve, at the level of the Piriformis muscle caused by various conditions and characterized Clinically by symptoms of sciatica. As early as 1928 Yeoman described extra pelvic entrapment of the sciatic nerve by the piriformis muscle as a cause of sciatica. After Mixter and Barr in 1934 described nerve root compression by disc pro- lapse as a cause of sciatica, this diagnosis dominated the Clinical thinking for nearly three decades and what had been previously described was nearly forgotten. The development of imaging techniques revealed other intraspinal compressing elements. On the other hand, cases of negative root exploration for Sciatica focused attention to extrapelvic sciatic nerve pathology. This report concerns the case of a patient, who after a nega- tive root exploration for severe sciatica proved to have an extrapelvic cause for this problem at the level of the piriformis muscle due mainly to anatomic variation of the sciatic nerve in relation to the piriformis muscle. KEY WORDS: Sciatica, Sciatic nerve, Piriformis Muscle Case report referred her to a specialist who treated her with A sixty-four-year lady suffered from a severe sci- epidural steroid injection and physiotherapy with- atica in the S1 distribution of the left leg i.e. pain out any improvement. The patient was referred to in the left buttock radiating to the posterior aspect us with the diagnosis of Lumbar radiculopathy.
    [Show full text]
  • Chapter 30 When It Is Not Cervical Radiculopathy: Thoracic Outlet Syndrome—A Prospective Study on Diagnosis and Treatment
    Chapter 30 When it is Not Cervical Radiculopathy: Thoracic Outlet Syndrome—A Prospective Study on Diagnosis and Treatment J. Paul Muizelaar, M.D., Ph.D., and Marike Zwienenberg-Lee, M.D. Many neurosurgeons see a large number of patients with some type of discomfort in the head, neck, shoulder, arm, or hand, most of which are (presumably) cervical disc problems. When there is good agreement between the history, physical findings, and imaging (MRI in particular), the diagnosis of cervical disc disease is easily made. When this agreement is less than ideal, we usually get an electromyography (EMG), which in many cases is sufficient to confirm cervical radiculopathy or establish another diagnosis. However, when an EMG does not provide too many clues as to the cause of the discomfort, serious consideration must be given to other painful syndromes such as thoracic outlet syndrome (TOS) and some of its variants, occipital or C2 neuralgia, tumors of or affecting the brachial plexus, and orthopedic problems of the shoulder (Table 30.1). Of these, TOS is the most controversial and difficult to diagnose. Although the neurosurgeons Adson (1–3) and Naffziger (10,11) are well represented as pioneers in the literature on TOS, this condition has received only limited attention in neurosurgical circles. In fact, no original publication in NEUROSURGERY or the Journal of Neurosurgery has addressed the issue of TOS, except for an overview article in NEUROSURGERY (12). At the time of writing of this paper, two additional articles have appeared in Neurosurgery: one general review article and another strictly surgical series comprising 33 patients with a Gilliatt-Sumner hand (7).
    [Show full text]
  • Patients 2011
    BEULAH LAND PRESS JOURNAL ISSN 1944-0421 (print) ISSN 1944-043X (online) o f Doctors PROLOTHERAPY SHARE YOUR EXPERIENCE V OLUME THREE | ISSUE FOUR | DECEMBER 2011 w ww.journalof prolotherapy.com Calling all Prolotherapists! Do you have a Prolotherapy article you would like published in the Journal of Prolotherapy? We would love to review it and help you share it with the world! For information, including submission guidelines, please log on to the authors’ section of www.journalofprolotherapy.com. V OLUME THREE [ JOURNAL of PROLOTHERAPY.COM] [ 708-84 8-5011] | ISSUE FOUR | DECEMBER Patients 2011 TELL US YOUR STORIES | PAGES The Journal of Prolotherapy is unique in that it has a target audience of 737 both physicians and patients. Help spread the word to other people like -848 yourself who may benefit from learning about your struggle with chronic pain, and first-hand experience with Prolotherapy. For information on how to tell your story in the Journal of Prolotherapy, please log on to the contact section of www.journalofprolotherapy.com. B EULAH LAND PRESS [ for Doctors & Patients] CURING SPORTS INJURIES and Enhancing Athletic Performance WITH PROLOTHERAPY Just as the original book Prolo Your Pain Away! aected the pain management eld, Prolo Your Sports Injuries Away! has rattled the sports world. Learn the twenty myths of sports medicine including the myths of: • anti-inflammatory medications • why cortisone shots actually weaken tissue • how ice, rest, & immobilization may actually hurt the athlete • why the common practice of taping and bracing does not stabilize injured areas • & why the arthroscope is one of athletes’ worst nightmares! AVAILABLE AT www.amazon.com www.beulahlandpress.com & IN THIS ISSUE OF THE JOURNAL OF PROLOTHERAPY Table of Contents The Ligament Injury-Osteoarthritis 790 Connection: The Role of Prolotherapy in Ligament The Case for Prolotherapy – Repair and the Prevention of 741 The Opening Argument Osteoarthritis Julie R.
    [Show full text]