• Trigeminal neuralgia is an illness where pain arises because of the trigeminal nerve
• Depending on which branch is affected, we may felt trigeminal neuralgia pain over the eye, cheek or jaw area
• It only affects one side of the face at a time
• Pain can be stabbing, electrical and severe, such that the person can’t do anything or even eat or drink
• The pain lasts for seconds initially but may last for minutes or longer. In the intervening period between attacks, there will be no pain.

What are the causes of trigeminal neuralgia?

• It usually happens spontaneously i.e. bad luck, but occasionally, it can happen after a surgery or dental procedure due to damage to a branch of the trigeminal nerve
• Sometimes it is from a blood vessel pressing on the nerve deep in the brain. The pulsation of the artery wears the outer covering of the nerve, leading to increased sensitivity
• Rarely, the condition is due a tumour or multiple sclerosis 

How can you treat trigeminal neuralgia?

• Medications
  • Carbamazepine is usually tried first after a blood test to exclude a serious idiosyncratic reaction
  • Gabapentin and pregabalin can also be tried 
• Pain procedures
  • Trigeminal or sphenopalatine blocks or radiofrequency
• Surgery to decompress the nerve when there is evidence of vascular compression on the MRI
• Gamma knife surgery: can be effective but requires more radiation; may need to be repeated

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What are the symptoms of pudendal neuralgia?

• Burning sensation and sharp pain 
• Felt over buttock, groin or thigh
• Worse when sitting
• Better when lying down or standing
• Can be over one or both sides
• There may be some numbness or change in sensation as well
• Usually associated with overactivity of the pelvic floor, with effects on urination, defecation and sexual intercourse

What are the causes?

• Entrapment of the pudendal nerve as it travels between muscle planes
• Happens over the piriformis, between the gluteus maximus and sacrospinous ligament, or between the sacrospinous ligament and the superior gemellus , or in the pudendal canal
• Affects people who sit too long like taxi drivers, cyclists and women who have given bith normally
• Can also be due to trauma on a bicycle or motorbike

How to treat pudendal neuralgia?

• Not easy to determine cause or to find exact point of entrapment
• Aim is for pain management and improvement of quality of life
• Changes in lifestyle
  • Soft cushions
  • Stop sitting so long, stop cycling
  • Walk around every 20-30 min at the office
• Pelvic floor exercises and physiotherapy
• Medications
  • Acetaminophen, NSAIDs and etoricoxib, celecoxib
  • Pregabaline and gabapentin
  • Amitriptyline
  • Weak opioids like tramadol
• Pain procedures:
  • Injections to relax the muscles
  • Nerve blocks
  • Pulse radiofrequency
    • may improve symptoms
    • can be effective but may need to be repeated
    • aim is for a 50% reduction in pain
• Surgery to free the pudendal nerve

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What is postherpetic neuralgia?

• Postherpetic neuralgia is a complication of shingles
• The rash over a bandlike distribution commonly occurs over the trunk but can also be anywhere, including the head and neck or over the limbs
• If there is a rash over the face, this is a medical emergency and you will need to seek early treatment to prevent complications such as blindness
• When the rash goes away but the pain continues, this is postherpetic neuralgia and happens in 20% of people

What are the symptoms?

• Pain over the previous area of rash and blisters
• Pain may be described as burning and itching, aching or sharp
• Pain is worse when there is a change in temperature
• May have some associated numbness
• Your may feel tired, unable to sleep and have poor appetite, and feel depressed

What is the outcome of postherpetic neuralgia?

• It can last from weeks to months. Most resolve after 3 months.
•  In about 20%, the pain does not go away even after a year
• The pain can be annoying for some people, but it can be severe and excruciating for others

What are the risk factors for getting postherpetic neuralgia?

• Old age
• Having a severe rash
• A weak immune system due to disease or chemotherapy
• Pain and burning and tingling sensation right before the rash appears
• Not receiving medications within 3 days of the rash appearing

How to treat postherpetic neuralgia?

• Best way is to prevent shingles by taking a vaccine
• Antivirals can be given within the first 3 days of the rash
• Mild pain killers like acetaminophen, NSAIDs or etoricoxib can be tried first
• Lignocaine patches and capsaicin creams can also be tried
• Other medications include
  • Gabapentin and pregabalin
  • Amitriptyline and nortriptyline
  • Opioids
  • Injections to the affected area
• Pain procedures include:
  • Sympathetic blocks
  • Epidural steroid injections
  • Pulse radiofrequency of the affected dorsal root ganglion
  • Spinal cord stimulation
  • neurolysis (destruction) of the affected nerve

The post Post-herpetic neuralgia (Pain after zoster) appeared first on Pain Treatment Specialist Singapore | Pain Doc.

• Trigger points are lumpy spots in your muscle that are tender and irritable
• Pressing on a trigger point can cause pain over an area or somewhere else
• Symptoms tend to be consistent i.e. pressing on the same trigger point should lead to the same site and type of pain

What is myofascial pain syndrome?

• This happens when someone has 2 or more trigger points in the muscle and the covering over the muscle, known as the ‘fascia’

What is the cause of trigger points?

• Nerve impingement
  • A herniated disc or bony spur presses on the nerve, leading to trigger points in the area controlled by that nerve
• Prolonged pain
  • Pain in a certain area that is not treated causes changes in the nerves that carry the signal to the brain, leading to extreme sensitivity over the area
• Muscle overuse
  • The frequency of the muscle usage and small tears results in insufficient time for the muscle to heal up
  • There is inflammation and less oxygen and nutrients; the muscle fibres shorten and need even more nutrients, leading to a vicious cycle
  • There are ‘polymodal’ nerve receptors inside the muscle that can turn them into trigger points
• Poor physical fitness
• Ageing
  • Middle aged people between 30-60 are more likely to get it
• Poor posture
• Stress and mental illness like anxiety, depression, PTSD
• Lack of vitamins and iron
• Poor sleep
• Trauma and accidents

How do we treat trigger points?

• Medications
  • Paracetmaol and NSAIDs and COX 2 inhibitors
  • Muscle relaxants
  • Weak opioids like tramadol for a short time
  • Strong opioids are not recommended
• Physiotherapy
  • Cold packs to reduce inflammation
  • Hot packs to increase blood flow and circulation
  • Stretching and strengthening
  • Posture training and changes in office ergonomics
  • Massage
• Laser light therapy
• TENS machine
• Acupuncture
• Pain procedures

What pain procedures are available for treatment of trigger points?

• Trigger point injections with:
  • Dry needling
  • Steroid
  • Concentrated Glucose
  • Local anaesthetic
  • Biologics like PRP (under research)
• Ultrasound guided nerve blocks to target the underlying nerve responsible
• Radiofrequency procedure to target the joint that is in pain that is causing the trigger point
• Nucleoplasty to treat the disc herniation and relieve pressure on the irritated nerve

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Abdominal pain can be hard to diagnose because it contains so many organs like:

• stomach
• small bowel
• large bowel
• kidneys
• spleen
• gallbladder
• liver
• pancreas

What are the causes of abdominal pain?

Infections, autoimmune diseases, vascular diseases, cancer can also cause abdominal pain. The risk of all these are lowered by having a healthy diet. We are what we eat.

It can be even more confusing because structures that are not in the abdomen, but are around it like the skin, muscle, spine, disc and nerves can all give rise to pain as well. The nerves that give sensation to organs in the abdomen come from the same spinal segment as the bladder and reproductive organs. An issue with the bladder can cause abdominal pain even though there may be nothing wrong in the abdomen, and vice versa.

Common causes of a new abdominal pain include:

• Diarrhea
• Constipation
• Gastroenteritis
• Stress / Abdominal migraines

Causes of chronic abdominal pain that does not seem to go away include:

• Irritable bowel syndrome
• Lactose intolerance
• Gluten intolerance
• Food allergies

Causes of severe abdominal pain include:

• Kidney stones
• Gallbladder stones
• Strangulated bowel
• Perforated bowel, stomach
• Ruptured appendix
• Ruptured aortic aneurysm

What does the location of the abdominal pain mean?

Abdominal pain that is everywhere and not really at one spot may be due to :

• Gastroenteritis / stomach flu
• irritable bowel syndrome
• ruptured appendix and bowel
• constipation
• diarrhea

Pain that is lower down in the abdomen may be due to:

• Appendicitis
• Bowel obstruction
• Torsion of the ovary
• Ectopic pregnancy
• Fibroids
• Endometriosis
• Pelvic inflammatory disease
• Ovarian cysts
• Urinary infection

Pain in the upper part of the abdomen may be due to:

• Gastric reflux
• Gastric ulcer
• Heart attack
• Gallstones
• Lung infection

Pain in the center may be due to:

• appendicitis
• stomach flu
• poisons
• vascular diseases
• autoimmune diseases

When should I see a doctor?

You should seek medical attention if you:

• Cough, vomit or pass blood in your stools
• Have a fever
• Turn yellow
• Have difficulty passing breathing
• Feel nauseas and sick (and are sure you are not pregnant)
• Been losing weight for no reason
• Have a loss of appetite
• Have a change in your bowel habits for over a week
• Have persistent abdominal pain

What tests are there to investigate my abdominal pain?

After taking a medical history and doing a physical examination, the doctor may ask for one of the following tests:

• Abdominal X ray: to look for things gall stones and to see if there is free gas which signals a perforated bowel
• X ray of the kidney, ureter, bladder: to look for kidney stones
• Ultrasound scan
• CT scan
• MRI scan

Perhaps the most useful investigations to look for issues and exclude cancer will be the oesophagoscopy and a colonoscopy. People over the age of 50 should undergo screening every few years.

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What is a migraine headache?

• It is one sided in most people, both sided in 30%
• It builds up slowly, is throbbing, and is worse when there is exertion and activity
• Patients find relief by lying down in a dark room
• Lasts anything from 3 hours to 3 days
• There is sensitivity to light and sound, and there be an aura which refers to changes to your vision or hearing right before the attack happens
• It can be treated with medications or pain procedures like a sphenopalatine injection or occipital nerve block

What is a tension headache?

• It is always on both sides of the head. If it is not symmetrical, it is unlikely to be tension headache
• There is a pressure sort of sensation along with tightness
• Comes on slowly
• Can last for many days
• Usually manageable with simple pain killers

What is a cluster headache?

• It is a headache that is felt behind the eye or around one temple
• Always on one side
• Severe in intensity, coming on quickly within minutes
• Continuous and excruciating
• Lasts 30 mins to 3 hours
• There may be a red-eye, a blocked nose, and droopy eyelids
• Strong opioids may be required
• Can try sphenopalatine blocks or stellate ganglion blocks

What is a cervicogenic headache?

• This is a headache due to wear and tear or injury of the small joints of the neck
• Problem lies in the neck but is felt in the back of the head, neck as well as the trapezius
• It can be treated with physiotherapy, medications and pain procedures that target the small nerves that cause the pain sensation i.e. radiofrequency ablation

What is occipital neuralgia?

• Pain at the back of the head near the bony prominences
• May have an electric sensation or a dull ache
• It can spread upwards over the scalp
• There may be nausea vomiting, difficulty balancing, and slurred speech
• Treatment includes medications, injections, pulse radiofrequency to the nerve 
• Occasionally surgery may be required to free up the nerve that is caught in between the muscles

What is sinus headache?

• This occurs as a result of sinusitis, an infection of the sinuses
• It mimics migraines and tension headaches
• There may be fever and tenderness over the sinuses
• Treatment will require antibiotics and surgery to open up the sinuses for drainage

What is post-trauma headache?

• Can be due to injury, trauma, or surgery to the skull
• There is headache, giddiness, and changes to mood, as well as personality changes
• It may be difficult to concentrate, and oversensitivity to light or sound
• Medications may be tried first
• Occipital or sphenopalatine blocks may be tried to hasten recovery

What is medication over-use headache?

• Medications like opioids and paracetamol that are used to treat headache can become the source of headache if taken over a long time
• Treatment is to stop the medications
• A preventer like amitriptyline may be used for long term control
• It can be difficult to ascertain which medicine is causing the headache

The post Headache appeared first on Pain Treatment Specialist Singapore | Pain Doc.

• Complex regional pain syndrome (CRPS) is an illness that is described as having pain for longer and in excessive amounts compared to what is normal
• Typically after an injury to an arm or leg.
• Although it sometimes improves on its own, there are instances where the condition is chronic and very disabling.

How does complex pain syndrome occur?

• CRPS occurs after an injury to the arm or leg, although the condition has been noted to occur at other parts of the body, albeit more rarely. 
• Type I is not related to any nerve injury. 
• Type II is correlates to the same area of nerve damage.

Who is prone to CRPS?

• Women are afflicted more than men
• Peak affected age is 40
• Rare in children or the elderly

What is the outcome of Complex regional Pain Syndrome?

• Variable outcomes
• Most recover over time, occasionally taking years
• Some correlation with recovery of the injured nerve
• CRPS can lead to long-term disability if not treated early
• Young children and teenagers as well as the elderly tend to recovery
• Young adults and middle aged adults tend not to do as well
• Smoking, diabetes and a history of chemotherapy as well as some autoimmune conditions can affect healing and recovery

What are the complications of CRPS?

• The bones and muscles weaken and the joint will become painful or stiff, making it hard to move or walk
• The skin, hair and nails become discoloured, the area becomes swollen
• As the muscles become tightened for a prolonged period, the hands or feet cane become permanently deformed

How do we prevent CRPS?

• Early physiotherapy and mobilisation and treatment
• High dose Vitamin C

How can we treat CRPS?

• Physiotherapy and exercise to prevent stiffness and contractures, and to prevent detrimental changes in the nervous system 
• Occupational therapy to aid the patient in coping with the condition and living as normally as possible
• Psychotherapy to manage the anger, anxiety and depression, as well as the negative thoughts that perpetuate CRPS
• Medications:
  • Amitriptyline and Nortriptyline
  • Duloxetine and Venlafaxine
  • Gabapentin and Pregabalin
  • Lignocaine patch and Capsaiccin
  • Opioids
  • NSAIDs and Etoricoxib, Celecoxib
  • Targeted injections
• Pain procedures:
  • Sympathetic nerve blocks
    • can be very effective in some patients
  • Pulsed radiofrequency of the dorsal root ganglia
    • Seeks to ‘reset’ the abnormal sensitivity of the nerve
    • Can be done as a day procedure
  • Spinal cord stimulation
    • A more permanent solution where an electrode and battery pack is placed in your body
  • Intrathecal pumps
    • For those who require high doses of opioids but are unable to tolerate their side effects
• Others:
  • Acupuncture
  • Mirror-box therapy and graded motor imagery
  • Intravenous immunoglobulin

The post Complex Regional Pain Syndrome appeared first on Pain Treatment Specialist Singapore | Pain Doc.

Who is at risk for having pain over the tailbone? 

• Females are 5 times as likely to have tailbone pain, probably because of stress in the pelvis from pregnancy and delivery
• Patients who are overweight 
• Patients who have rapid weight loss, due to the loss of cushioning around the tailbone. Their tailbone is also more likely to move forward, which increases pressure and pain.

Causes of tailbone pain include

• Fall with direct impact on tailbone
• Prolonged sitting on hard surfaces like cycling
• Difficult labour
• Assisted delivery
• Abnormal disc in the spine
• Anatomical variant (type 2/3/4 coccyx)
• Tailbone that moves too much or too little
• Abnormal muscle tone of the pelvic floor muscles

Symptoms of cocccygodynia / tailbone pain

• Sensation of ‘cutting’ or ‘pulling’
• Need to sit on one buttock and lift the other off to take weight off the tailbone
• Worse on prolonged sitting or when standing up from sitting position
• Better when sitting on legs in a kneeling positing
• Pain worse when defecating, coughing or when having a period
• Pain during sexual intercourse

How do you treat coccygodynia?

• Physiotherapy, massage and medications
• Pain procedures:
  • caudal epidural
  • Steroid injections
  • ganglion impar injection/radiofrequency
  • spinal cord stimulation
• Open surgery

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