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Dx Pain Blocks; Practiced Neural and Structural :

Therapeutic Injections for Pain Management

"Commonly Practiced Neural and Structural Blocks
Several somatic and peripheral neural blockade procedures are useful for therapeutic and diagnostic purposes. Although the opportunity to block specific nerves can be considered limitless in the hands of an experienced interventionist with appropriate radiographic guidance, only some of the available procedures are mentioned below to highlight their usefulness as potential tools for a neurologist involved in the diagnosis and treatment of pain.

Therapeutic injections for extra-axial soft tissue structures Therapeutic injections frequently are used as a mode of treatment in general or subspecialty practices, especially orthopedics, psychiatry, and rheumatology. Many musculoskeletal disorders respond amenably to injections, including intra-articular and extra-articular tissues of many synovial joints, bursae, muscles, and tendons. Pain from extra-axial articular structures often is managed best by the aforementioned subspecialists.

Understanding a few key principles can help the neurologist determine the structural anatomy of an articular pain syndrome and respond efficiently by specialty referral, especially when certain symptoms indicate a potentially serious etiology. In most cases, patients with generalized arthralgia and arthropathy should be referred to a rheumatologist; therefore, this article concentrates primarily on localized pain disorders. In fact, the neurologist often is requested to differentiate whether pain is localized to a joint or periarticular structures or is referred from diseased neural structures.

Pain referral from joints or other soft tissue structures typically does not assume a myotomal or dermatomal pattern. Pain arising from superficial soft tissue structures that can be identified by palpation often permits more precise localization of the causative tissue or structure. However, pain that is referred from extra-axial joint capsules and other periarticular structures, such as ligaments, tendons, bursae, and muscles, may be more difficult to differentiate. Pain from bone and periosteum is usually well localized and rarely radiates; however, this discrepancy between "soft" and "hard" structures remains unexplained.

The manner in which the pain from symptomatic joints responds to biomechanical stressors is often the key to localization and causation. Pain that is worse when the joint is used suggests a mechanical etiology, especially if improved with rest. Pain in bed at night should bring about concern for a serious underlying etiology and almost always requires investigation. Persistent pain that does not fluctuate despite activity or rest is also worthy of diagnostic inquiry. Psychogenic or operant pain frequently is described as continuous and often more intense and disabling with certain activities, eg, worse at work and better with recreation. Pain and stiffness that are present in the early morning or after inactivity may be a harbinger of inflammatory arthropathy in extra-axial and axial joints. Patients with monoarticular deformity, swelling, stiffness, and warmth should be referred to the appropriate musculoskeletal specialist for evaluation.

Many common afflictions of extra-axial soft tissue structures are amenable to management by a neurologist who is skilled in the evaluation and treatment of musculoskeletal disorders. Bursae are fluid-filled sacs that facilitate smooth movement between articulating structures. Subcutaneous bursae, such as the olecranon and prepatellar bursae, form in response to normal external friction. Deep bursae, such as the subacromial bursa, form in response to movement between muscles and bones and may or may not communicate with adjacent joint cavities. "Adventitious" bursae form in response to abnormal shearing stresses (eg, over first metatarsal head) and are not uniformly present.

Acute or subacute bursitis (most often affecting subacromial, subscapular, prepatellar, and trochanteric bursae) frequently presents with severe disabling pain that can be relieved promptly by injection of LA. Depending on the size of the targeted bursa, a dilute solution of bupivacaine (0.25-05%) with epinephrine 5 mg/mL, with 40 mg of methylprednisolone (Depo Medrol) or an equivalent corticosteroid (ie, Celestone), is often dramatic in its effect. If the bursa is swollen and contains fluid, aspiration should be performed prior to injection for laboratory studies including cultures for a possible infectious agent.

Tendons act as functional anatomical bridges between muscle and bone. Tendinitis is also a common cause of outpatient evaluation for moderately severe to severe, often disabling, pain. Among the most frequent syndromes are bicipital tendinitis, lateral epicondylitis (tennis elbow), medial epicondylitis (golfer's elbow), and supraspinatus (rotator cuff) tendinitis. Long-acting LAs, such as bupivacaine, coupled with a long-acting corticosteroid are often effective. Repeated use of corticosteroids may risk toxicity to the soft tissues, and long-term use can result in adverse systemic effects that are associated with Cushing syndrome. Occasionally, patients experience a "steroid flare" and develop increased pain in the injection site over 24-48 hours; however, local beneficial effects usually follow after the flare resolves. Exercise and physical modalities, including ice and heat, are fitting adjuncts. LA infiltration alone without corticosteroids can be repeated until permanent benefit is achieved.

Muscle spasm and myofascial pain (ie, trigger points) and treatment of syndromes considered controversial by some, such as that caused by the piriformis and scalene muscles (thoracic outlet syndrome), are other commonly considered indications for injection treatment. The tenets of managing these syndromes must be emphasized, however; therapeutic injections are considered adjunctive to an overall treatment plan that includes postural correction, ergonomic modification of contributory occupational factors, appropriate strengthening and flexibility exercises, and concomitant use of physical modalities.

Painful scars following injury or surgery also may be associated with pain and hyperesthesia. Infiltration of LA, sometimes accompanied by corticosteroids, has been reported to be beneficial in many cases. Concomitant topical or oral agents may be useful, as well as application of transcutaneous electrical stimulation (TENS).

Neuromata can develop in nerves that are entrapped subsequent to traumatic neurosection or following surgery for amputation. Infiltration with LA is useful not only from a therapeutic standpoint but also diagnostically. LA without epinephrine mixed with a depot corticosteroid can suppress spontaneous ectopic discharges suspected of producing pain and paresthesia. Supplemental treatment with anticonvulsants may improve outcome if relief is incomplete.

Intra-articular injections of a dilute solution of LA, usually in combination with corticosteroids or articular lubricating agents, frequently are advocated for severe pain associated with chronic degenerative arthritis, especially in weight-bearing joints. Intra-articular injection of LAs into spinal facet joints is discussed in a later section of this article; however, injection of extra-axial joints is considered beyond the scope of the primary theme and the audience addressed in this article. Suprascapular nerve block:
The suprascapular nerve branches from the brachial plexus and serves as the primary sensory supply for the shoulder joint. Suprascapular nerve block can be helpful for the management of severe pain caused by bursitis, periarthritis, or arthritis when intra-articular and periarticular injection of LA and steroids are contraindicated, ineffective, or to be avoided.

Suprascapular nerve block provides anesthesia to the shoulder joint, which allows physical therapy to implement improved range of motion caused by adhesive capsulitis or excessive periarticular muscle guarding. Technically the procedure is easy to perform; however, satisfactory blockade is not achieved uniformly in all cases. When blockade is inadequate, concomitant use of radiography or a peripheral nerve stimulator can provide more accurate placement of the needle and improve anesthetic administration.

To perform a suprascapular nerve block, the practitioner locates the suprascapular notch by first forming 2 bisecting lines—one extending along the spine of the scapula and another that bisects this line and extends to the inferior angle of the scapula.

Using the technique advocated by Bonica, an 8-cm, 22-gauge needle is introduced through a skin wheal of LA placed in the outer triangle about 1.5 cm from the bisection point. The shaft of the needle is directed anteriorly, caudally, and medially into the supraspinatus fossa just lateral to the suprascapular notch. The needle is withdrawn until its point lies within the subcutaneous tissue and then re-introduced to a point that is approximately 5 mm medial to the first contact. The needle should enter the notch; contact with the nerve is verified if paresthesia is evoked. If no paresthesia is elicited, sequential insertions may be necessary, or location of the nerve can be facilitated by electrical nerve stimulation.

Bupivacaine (3-5 mL) or other long-acting LA, in addition to a short-acting LA, should provide an adequate block for diagnostic purposes, and thereafter, allow appropriate physical therapy intervention.

Femoral nerve block:
Femoral nerve block just below the inguinal ligament can be used as a diagnostic tool in patients who present with anterior thigh pain or can be combined with a sciatic nerve block to produce sympathetic neural blockade of the lower extremity. Femoral nerve block can alleviate severe pain related to posttraumatic or postoperative causes (eg, fracture of the neck of the femur).

Using the technique described by Bonica, this procedure is performed with the patient in a supine position. The midpoint of a line joining the anterosuperior iliac spine and pubic tubercle usually overlies the femoral artery. A short-acting LA is used to raise a skin wheal approximately 1 cm lateral to the junction of the femoral artery in the inguinal ligament. See the images below.

While palpating the artery under the second finger of the left hand, a 5-cm, 22-gauge or 25-gauge, short-beveled needle is introduced with the right hand through the skin wheal and is perpendicularly advanced through the skin until paresthesia is elicited in the distribution of the femoral nerve, preferably by using an electrical nerve stimulator or ultrasound for guidance. Usually 8-10 mL of 1% lidocaine with epinephrine produces analgesia for 3-4 hours, whereas the same volume of 0.25% bupivacaine with epinephrine produces analgesia for 6-8 hours. If longer analgesia is required, the concentration of bupivacaine can be increased to 0.5% with epinephrine or a continuous block can be applied by placing an infusion catheter at the site.

Lateral femoral cutaneous nerve block:
A lateral femoral cutaneous nerve block confirms the presumptive diagnosis of lateral femoral cutaneous neuralgia or meralgia paresthetica and may provide symptomatic relief. Using the technique described by Bonica, a 5-cm, 22- or 25-gauge, short-bevel needle is introduced through a skin wheal of 1% lidocaine that is 1.5 cm caudal to the anterosuperior iliac spine just below the inguinal ligament at an angle of approximately 60° to the skin.

Usually a volume of 5-8 mL of LA is required; addition of corticosteroids may produce therapeutic relief for meralgia paresthetica. Oral medications (tricyclic antidepressants or anticonvulsants) can be added for improved pain relief.

Sciatic nerve block:
The sciatic nerve is derived from the L4, L5, and the S1-S3 nerve roots; these nerve roots become enjoined on the anterior surface of the piriformis muscle. The nerve then travels inferiorly and leaves the pelvis just below the piriformis muscle via the sciatic notch. The sciatic nerve lies anterior to the gluteus maximus muscle and is halfway between the greater trochanter and the ischial tuberosity. The sciatic nerve courses downward past the lesser trochanter to lie posterior and medial to the femur. In the mid thigh, the nerve gives off branches to the hamstring muscles and the adductor magnus muscle. In most patients, the nerve divides to form the tibial and common peroneal nerves in the rostral popliteal fossa.

A posterior sciatic nerve block is useful for evaluation and management of distal lower extremity pain that is thought to be caused by the sciatic nerve. Sciatic nerve block with local anesthetic can be used during differential neural blockade to determine the anatomy of distal lower extremity pain. If destruction of the sciatic nerve is considered, this technique is sometimes useful as a prognostic indicator of the degree of motor and sensory impairment that the patient may hope to experience.

In some cases of acute pain, sciatic nerve block with local anesthesia may be used to provide urgent relief. Examples of this clinical scenario include distal lower distal extremity fractures or trauma. Sciatic nerve block can alleviate pain while waiting for other pharmacologic methods to become effective. Sciatic nerve block combining local anesthetic and corticosteroids is occasionally used to treat persistent distal lower extremity pain that is thought to be secondary to inflammation or when entrapment of sciatic nerve by the piriformis muscle is suspected. Destruction of the sciatic nerve is occasionally indicated for palliation of persistent distal lower extremity pain secondary to malignancies.

A posterior sciatic nerve block into the subgluteal region is usually performed with the patient in a lateral decubitus position with the top leg flexed. Ultrasonography-guided needle placement enhances safety and provides more accurate needle position. In these cases, the ultrasound transducer is placed in the subgluteal region midway between the greater trochanter and ischial tuberosity. After the sciatic nerve is located, the skin is infiltrated with local anesthetic, a 22-gauge needle that is 10-12 mm long or a 25-gauge, 3.5-inch needle is directed in a perpendicular plane.

Needle movement can be ultrasound guided or may be gently and slowly advanced until it elicits paresthesia. If bone is encountered prior to paresthesia, the needle is redirected along a line joining the sacral hiatus and the greater trochanter. During redirection, the needle is steered deeper, not to exceed 2 cm.

Once paresthesia is elicited in the distribution of the sciatic nerve, the needle is withdrawn 1 mm, and the patient is observed to rule out any persistent paresthesiae. Further guidance and confirmation of tip placement can be obtained using electrical nerve stimulation. If a nerve stimulator is used, dorsiflexion and plantar flexion of the foot are noted. If paresthesiae resolve and careful aspiration is unrevealing, then 20-25 mL of 1% preservative-free lidocaine can be slowly injected.

If the pain has an inflammatory component, then the local anesthetic can be combined with 80 mg of methylprednisolone that is incrementally injected. Subsequent daily nerve blocks can be carried out in a similar manner substituting 40 mg of methylprednisolone before the initial 80 mg dose. Pressure should be applied to the injection site to decrease the incidence of postblock ecchymoses and hematoma formation.

The primary side effects from sciatic nerve block have been mentioned and include ecchymoses and hematoma. Maintaining pressure at the injection site can usually avoid this complication.

The sciatic nerve can also be blocked anteriorly in patients who cannot assume the Sims or lithotomy position because of lower extremity trauma. This is also a useful technique when the clinician desires performance of a combination of nerve blocks for the lower extremity, perhaps also including the lateral femoral cutaneous, femoral, and obturator nerves, and in some cases, the lumbar plexus.

The anterior approach requires that the patient is positioned in supine with the leg in a neutral position. The greater trochanter and the crease of the groin on the involved side are identified by palpation. An imaginary line is then drawn parallel to the crease of the groin that runs from the greater trochanter to the center of the thigh. This center point is then identified and prepared with antiseptic solution. A 25-gauge, 3.5-inch needle is then slowly advanced perpendicular to skin until it impinges on the femur. Again, nerve stimulation techniques can be used as described for guidance.

When the needle reaches the bony surface of the femur, it is then walked slightly superiorly and medially off the top of the lesser trochanter. When the sciatic nerve is reached, paresthesia is elicited; if a nerve stimulator is used, dorsiflexion and plantar flexion of the foot is elicited. The patient should be warned prior to stimulation or paresthesia so that they respond immediately. Paresthesia is usually elicited at a depth 1 inch beyond initial body contact. Once the needle elicits paresthesia, it is withdrawn about 1 mm. If paresthesia is not persistent and aspiration is negative, then as much as 20 mL of 1 % preservative-free lidocaine can be slowly infused. Methylprednisolone can be added to treat an inflammatory component, similar to that described with the posterior approach.

In some cases, physicians choose to block the tibial and peroneal branches of the sciatic nerve at the popliteal fossa. By definition, the popliteal fossa is defined cephalically by the semi-membranosis and semi-tendinosis muscles medially and the biceps femoris muscle laterally. Its caudal extent defined by the gastrocnemius muscle both medially and laterally. If this quadrilateral is bisected, as shown in the image below, the clinically pertinent area would be the cephalolateral quadrant.

Here, both tibial and common peroneal nerve blockade is possible. The tibial nerve is the larger of the 2 and separates from the common peroneal nerve at the upper limit of the popliteal fossa. The tibial nerve continues the straight course of the sciatic nerve, running lengthwise through the popliteal fossa directly under the popliteal fascia between the heads of the gastrocnemius muscles. With the patient prone, the patient is insructed to flex the leg at the knee, which allows more accurate identification of the popliteal fossa.

When identified, it is divided into equal medial and lateral triangles.

A mark, such as “X,” is placed 5 cm superior to the skin crease of the popliteal fossa and 1 cm lateral to the midline of the triangles. A 22-gauge, 4-cm to 6- cm needle is directed at a 45-60 degree angle to the skin, and then the needle is advanced in an anterior and superior direction. Paresthesia is sought and if obtained 38-48 mL of local anesthetic is injected. Potential problems include vascular obstructions that also occupy the popliteal fossa. Intravascular injections should occur infrequently when proper precautions and technique are used. In these cases ultrasound guidance and nerve stimulation may be helpful.

Occipital nerve blocks:
Occipital nerve block can be applied for diagnostic, prognostic, and therapeutic purposes in patients with headache, neuralgia, and other painful conditions of the posterior aspect of the head. Using the technique described by Bonica, the greater occipital nerve is blocked by needle placement just above the superior nuchal line and approximately 2.5-3 cm lateral to the external occipital protuberance. If reaching the nerve and eliciting paresthesia are difficult, then 5 mL of LA can be injected on the medial side of the artery, 2 mm superficial to the skull. Frequently, care must be taken during this block not to allow anesthetic fluid to spread laterally, as it may affect the glossopharyngeal nerve, causing hoarseness and difficulty in swallowing. See the image below. Anatomy of the fifth cranial nerve ganglion (trigeAnatomy of the fifth cranial nerve ganglion (trigeminal) along with innervation and peripterygoid relationship.

Trigeminal nerve blocks<:
Trigeminal ganglion block commonly is used for diagnostic and prognostic purposes when considering trigeminal neurolysis for patients with trigeminal neuralgia. The trigeminal ganglion is located intracranially, situated lateral to the internal carotid artery and cavernous sinus and posterosuperior to the foramen ovale.

The foramen ovale is approximately 1 cm in diameter and serves as the cranial opening through which the mandibular nerve exits; it lies approximately in the same horizontal plane as the zygoma at the level of the mandibular notch, immediately dorsolateral to the pterygoid process.

Anatomy of the fifth cranial nerve (trigeminal) gaAnatomy of the fifth cranial nerve (trigeminal) ganglion and foramen ovale (cross-sectional view). Lateral view of mandibular notch and plane of zygoLateral view of mandibular notch and plane of zygoma. Correlate with cross-sectional view of the fifth cranial nerve (trigeminal) ganglion and foramen ovale.

Trigeminal ganglion blockade should be performed only by skilled and experienced interventionists. Using the technique described by Brown, the patient is placed in a supine position.

A 22-gauge, 10-cm needle is inserted through a skin wheal approximately 3 cm lateral to the corner of the mouth and medial to the masseter muscle in a direction that bisects the plane formed by the midpoint of the pupil with the patient staring at the ceiling. This allows the needle tip to contact the infratemporal surface of the greater wing of the sphenoid bone, immediately anterior to the foramen ovale at a depth of 4.5-6 cm.

Once the needle is positioned firmly against this bony target, it is withdrawn and redirected in a stepwise manner until it enters the foramen ovale at a depth of about 6-7 cm, approximately 1.5 cm beyond the initial needle length required to contact the bone. As the foramen is entered, paresthesia in the mandibular distribution usually is evoked. Further slight and careful movement of the needle may elicit paresthesia in the distributions of the ophthalmic and maxillary nerves. These additional paresthesiae verify a periganglionic placement of the needle tip.

Aspiration should be performed first to check for CSF because the posterior two thirds of the trigeminal ganglion is enveloped in the reflection of the dura. One milliliter of a short-acting LA then can be injected. If neural blockade is incomplete after 5-10 minutes, an additional 1-2 mL of LA can be injected or the needle can be repositioned to obtain a more complete block. The most concerning complication with this procedure is subarachnoid injection. Moreover, because the needle passes through a highly vascular region, hematoma formation is a possibility.

Maxillary nerve blockade also can be useful for diagnosis and treatment of facial neuralgia. The maxillary nerve is entirely sensory and exits through the foramen rotundum. Using the technique described by Brown, the patient is placed in supine position with the head and neck rotated away from the side to be blocked.

Pertinent anatomy with regard to the maxillary bloPertinent anatomy with regard to the maxillary block. Anatomy of maxillary block.

A 22-gauge, 8-cm needle is inserted through the mandibular notch and advanced in a medial and cephalad direction until it meets the lateral pterygoid plate at a depth of approximately 5 cm.

The needle is then withdrawn and redirected in a stepwise manner by walking the bevel off the pterygoid plate, to a depth 1 cm beyond initial contact, until it lies within the pterygopalatine fossa. Once the needle rests in a satisfactory position, 5 mL of LA is injected. Because of the maxillary nerve's proximity to the infraorbital fissure, LA may spill into the orbit and affect eye movement or vision. Because the vascularity of this region is rich, hematoma formation is a possible complication; some subjects may develop a black eye following this block, again because of the close proximity of the orbit.

Mandibular nerve block is similarly useful for diagnosis and treatment of facial neuralgia. The mandibular nerve is primarily a sensory nerve and exits the cranium through the foramen ovale, traveling parallel to the posterior margin of the lateral pterygoid plate, then descending inferiorly and laterally toward the mandible.

The anterior division of the mandibular nerve is principally motor and supplies the muscles of mastication, whereas the posterior division is principally sensory and supplies the skin and mucous membranes overlying the jaw and skin anteriorly and superior to the ear.

The Brown technique for performing this block begins with the patient in supine position with the head and neck turned away from the side to be blocked.

The patient is instructed to open and close the mouth gently so that the operator can identify and palpate the mandibular notch. A 22-gauge, 8-cm needle is inserted in the midpoint of the mandibular notch and directed at a slightly cephalad and medial angle through the notch to the lateral pterygoid plate at a depth of approximately 5 cm. The needle is then withdrawn to a subcutaneous position and carefully walked off the posterior border of the pterygoid plate in a horizontal plane. The needle should not be advanced more than 0.5 cm past the depth of the pterygoid plate because the superior constrictor muscle of the pharynx can be pierced easily. When the needle is in appropriate position, 5 mL of LA can be administered. Complications include hematoma formation and subarachnoid injection.

Distal trigeminal blocks can be performed to target specific distal branches of the 3 divisions of the trigeminal nerve, specifically the supraorbital branch of the ophthalmic nerve, infraorbital branch of the maxillary nerve, and mental branch of the mandibular nerve. These blocks are performed with a 25-gauge needle directed at the superficial foraminal site, where approximately 2-3 mL of LA can then be injected.

Distal trigeminal block technique. See text for deDistal trigeminal block technique.

Glossopharyngeal nerve blocks:
Glossopharyngeal nerve block is also performed for diagnosis and management of neuralgia. The glossopharyngeal nerve exits the jugular foramen at the base of the skull in close association with structures of the cheek, including the parotid gland and vagus nerve. It then descends into the neck between the internal and external carotid arteries.

A glossopharyngeal block can be carried out intra-orally or using a peristyloid technique. If the block is performed intra-orally, the patient must be capable of opening the mouth, and adequate topical anesthesia of the tongue is necessary to allow needle placement at the base of the tonsillar pillar. While using this approach, care must be taken because of the proximity of the glossopharyngeal nerve to the internal carotid artery, which lies immediately lateral to the tip of the correctly positioned needle.

Intraoral anatomy and glossopharyngeal block technIntraoral anatomy and glossopharyngeal block technique. The peristyloid approach, also described by Brown, begins with the patient in a supine position with the head neutral.

A 22-gauge needle is inserted at the midpoint of a line between the mastoid process and angle of the mandible and advanced until it reaches the styloid process. Palpation of the styloid process should be maintained while the needle is inserted until it reaches this structure. The needle is then pulled back and redirected to slip off the posterior border of the styloid process. Careful aspiration for blood is necessary because of the intimate relationship of both the internal jugular vein and carotid artery to the glossopharyngeal nerve.

Other blocks, including cervical plexus, superior laryngeal, translaryngeal, and retrobulbar blocks, are usually best performed by anesthesiologists or surgical subspecialists. These blocks are usually performed to achieve regional anesthesia, although a retrobulbar block can be useful diagnostically for determining the etiology of eye pain.

Sympathetic Blocks: [From Medscape]

*Sympathetic block (upper extremity, stellate; lower extremity, lumbar). Ensure that this is performed by a trained individual.
Inject a local anesthetic into the stellate and upper dorsal sympathetic ganglia to block the efferent sympathetic impulses from the involved extremity. Lidocaine or bupivacaine, with or without epinephrine, is usually used.
This procedure warms the skin, inhibits sweating, and causes flushing.
A successful blockade is indicated by the development of ipsilateral Horner syndrome, ie, ptosis, miosis, and enophthalmos.
Symptoms usually abate within 30 minutes, confirming the diagnosis. Once the patient is adequately blocked, ensure their participation in hand therapy. Although the interruption lasts only a few hours, the benefits may persist for several days.
Use 1-2 blocks per week. An average of 4-5 blocks is required to permanently relieve symptoms. For symptoms that are not adequately relieved after 4-5 blocks, institute a continuous stellate blockade via a subcutaneously placed catheter or conduct an operative sympathectomy.

Sympatholytic drugs:
*Sympatholytic drugs may be efficacious when used alone in early disease.
*Sympatholytic drugs may be beneficial in combination with sympathetic block or sympathectomy in later stages of the disorder.
*Regional intravenous sympathetic blockade with sympatholytic drugs, such as phenoxybenzamine, using a Bier block–like procedure may be helpful, but results have varied. This is most useful in early disease.
*A randomized study performed in 2000 suggested that intrathecal baclofen, a GABA-receptor agonist, relieved the dystonia and, in some cases, the hand pain in patients with RSD. This suggests that GABA-ergic inhibitory pathways may also be important in the pathogenesis of RSD.

Medications Used in Treatment:
1. Post-herpetic neuralgia: additional treatment with an injectable local anesthetic with water soluble corticosteroid.
2. Non-opioid analgesics: Ultram® Ultracet®/tamadol
3. NSAIDs: ibuprofen, Anaprox®DS Naprosyn®/naproxen,mefenamic acid Ketoralac®/ketorolac, Clebrex®/celecoxib, etodolac, Cataflam® Voltaren, Compounded DMSO/ Flexeril/ Ketoprofen, Sprix®/ketorolac
4. Opioid Agonist/Antagonists: Buprenex® Butrans®/buprenorphine, pentazocine-naloxone, butorphanol
5. Anticholingeric/opioid: Belladonna/opium
6. Muscle relaxers: Flexeril, carisoprodol with NSAIDs, aspirin, and codeine.

*[Editor] Whenever the physician can pinpoint the origin of the pain and inject using local anesthesia with a water soluble corticosteroid, the benefits are not only pain relief. The patient realizes that the pain is real and that treatments may offer permanent relief to some. Some after a series of trigger point injections benefit from using topical agents with NSAIDs, DSMO, and a muscle relaxer.

*[Editor] The use of these 'trigger points' by Janet Travell, M.D. catapulted John f. Kennedy from a wheelchair in the Senate to the White House. In my office, they are a mainstay of management for headaches, migraines, painful menstrual periods (only local anesthesia), lumbosacral, sciatic, elbow and shoulder pain. Thereby limiting both referrals and MRI/CT Scanning.

[Editor] The use of nandrolone to relieve the pain of Stage IV endometriosis was reported by this author. Antedotal reports of nandrolone relieving joint pain in osteoporosis patients persist as well.

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