Hi Dr. Aeby,
Have you ever had a pt present with pinpoint pain on their abdomen that is described as constant burning? I saw a 41 y/o healthy active duty G4P4 who was referred for pelvic pain, but actually has a constant burning sensation on her abdomen, mid right quadrant. It started in 2005 suddenly and after a w/u, someone decided to scope her and took out her right ovary for unclear reasons in 2006. The pain is still there and she hasn't tried anything for it, but it's supposedly getting worse. She now has a 4x5 cm fibroid which was why she was referred to me. I don't think that the fibroid is related to her pain at all. It really appears like it's some sort of neuropathy. We don't have neurology here. Would you start her on neurontin for off-label use for neuropathic pain?
Thanks,
Dearest XXX,
She has a trigger point. Take your time and using light finger touch exactly identify the point (or points, sometimes they have a couple more along the dermatome). I usually use a sharpy pen or the like to map the spots. If I'm right about this patient, she will have exquisite pain, right on the spot but be pain free just next to it. Now take a 10cc syringe with .25% plain bupivicaine and a 24 guage needle. wipe with an alcohol swab and stick the needle just through the skin, right over the spot. Slowly work the needle straight down and ask her to tell you when you hit the spot. If you reach facia, you've gone to far, back the needle up (without making a new hole in the skin), move it over a little and try again. When you hit the spot, you'll know it, it's very sore. With the tip in the spot, inject 3-5cc of local (basically, you don't want to put more than 5cc in one spot and you don't want to use more than 20cc total, so divide it up accordingly). This will reproduce her pain and actually be quite sore for a few seconds. After injecting, wiggle the tip around a bit to break up the trigger point and move on to the next spot. Always start with the medial points and move lateral so you don't wipe out the nerve and eliminate your ability to hit the trigger point.
Let her rest for about 10-20 minutes after the injection. When you examine her, she will be pain free. The bupivicaine will last 4-6 hours but the effect will last lots longer, and with luck will be permanent. Some patients need 2 or more treatments.
Here's an old reference (I used to work with this guy as a medical student):
Slocumb J. Neurologic factors in chronic pelvic pain: trigger points and the abdominal pelvic pain syndrome. Am J Ob/Gyn, 249:536, 1984
Let me know if your have questions about that.
Dr. Aeby
So, now folks can comment on this, post their own questions or pearls, what ever. I might even be moved to make the occasional editorial comment.
Hope to see you all out there. Spread the word!
DocAeby
I was able to finally sign up to be your blog follower today. I am actually scheduled to see this patient again sometime in the next few weeks and will try this injection technique. She has told me over the phone that she has had a little improvement in her pain with the Neurontin as well, but her pain is still there. I'll keep you posted.
ReplyDeleteHere's an update on the above-mentioned patient. She stopped the neurontin, stating that it didn't help at all actually. She came in this past week and had the same pain. I tried the injection technique as described above by Dr. Aeby and found her trigger point. She had almost immediate pain relief which lasted for a few hours. I received an email later from her that day stating that the pain came back. I plan to have her return to my clinic for another injection in the next few weeks.
ReplyDeleteHere's a question. Has anyone heard of the new Prima Bella device used for nausea and vomiting of pregnancy? Has anyone tried it?
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