Trigger points / Nerve blocks

I have to admit that I like doing procedures.  That is what I liked about surgery and the ER. Today was great because we were running the neurology pain clinic. We had lots of patients who suffer from chronic pain. Many of the patients we saw were in a lot of pain and others symptoms / pain was questionable. You always have to be alert for drug seeking behavior. The cool part about today is that I was able to do several nerve blocks. I also got to do a few botox injections in the neck and other muscles to ease pain due to spasms. 

The coolest case was a 65 year old man who had open heart surgery 18 months ago. Following the surgery he notices that he had intense pain in his chest wall. He had sen multiple doctors regarding the pain. AT first everyone told him that it was pain from having his chest cracked open. However after 6 months the pain persisted and was very intense. He was not able to lie down for more than 10 - 15 minutes before the pain became unbearable and he had to stand up and walk around. He could not remember the last time he had more than 2 hours of sleep in a given night. It seemed like living torture. After multiple visits to multiple  doctors someone final thought that the pain must be neurological in nature and they referred him to a neurologist. 

He came to us in desperation. You could tell that the pain was real, hew was not malingering. he could barely tolerate any pressure on it even when we distracted him while palpating the chest wall. He winced and actually had what is called the chandelier sign which is when the doctor touches the painful area evoking so much pain the patient reaches for the chandelier. He was dripping in sweat just from us trying to localize the pain. We were able to determine that he most likely had a nerve caught in or under the wiring used to close his sternum following the heart surgery. After open heart surgery actual wires are used to reconnect the sternum. Usually these wires are left in fore life. We had lots of cadavers in anatomy lab that had these wires in their sternum as remnants of their surgery. 

Once we had our diagnosis we used lidocaine derivative with a longer half life to numb the nerves in the area. The idea is, if the numbing medication gets rid of the pain then you can localize the pain to the nerves in that area. If you inject and get no pain relief then the pain could be from a different source. My attending physician allowed me to do the injections under his guidance and supervision. The last thing you want to do is go between 2 ribs and inject the heart. It was such a great feeling to see this great big guy who had been suffering from pain so long he was nearly suicidal, get such relief from these injections that he started to cry tears of joy and say "thank you doctor" over and over again. "I haven't felt this way in 18 months, I forgot what it is like to be pain free!" he blurted out.

Unfortunately the pain relief would only last 6 - 8 hours but we now had a concrete diagnosis and we could try a couple different treatments and ultimately have the wires removed if needed. This case was very rewarding and kept us going most of the day. 

I included an x-ray that shows some of the wiring used to close the sternum following surgery. If you look in the middle of the chest in the upper 1/2 and slightly to the left side you will see the wiring holding the sternum together.