THE BIOCHEMICAL ORIGIN OF PAINby Sota Omoigui

CHAPTER 10

L.A. Pain Clinic CASE REPORTS

Mr. M. H.
A 27- year old male presented with an 11-year history of low back pain following a motor vehicle accident. Injuries sustained during the accident included burst fracture of the lumber spine at the L2 and L3 levels, and a fractured pelvic bone. The patient had a history of repeated surgeries in the spine with multiple fusions, the placement of a Harrington Rod which was later removed and the use of pedicle screws. On presentation, low back pain was a severe constant aching, graded nine on a pain scale of one to ten. Pain was radiating to both lower extremities experienced as a burning, with numbness and tingling on both thighs and legs.

Physical examination revealed a scar over the lumber spine in the midline. There was marked tenderness from the thoracic spine T9 to the sacrum S1. In addition, there was moderate spasm of the lumber paraspinal muscles. Range of motion was reduced to thirty degrees of flexion at the lumber spine; extension was limited to five degrees. Sensory perception of a pinprick was significantly reduced in both right and left L2 to L4 dermatomes. However, the motor strength was normal globally.

Initial treatment consisted of a refill of Oxycodone SR 40mg, 2-3 tabs P.O. q 12hrs. Other medications prescribed were Roxicodone 15mg, 1 tab P.O. q 4-6 hrs, Tizanidine 2mg P.O. bid, 4mg P.O. q hs, Oxcarbazepine 300mg P.O bid and Tolmetin DS 400mg P.O tid with meals. The patient was subsequently scheduled for a chemodenervation procedure with Botulinum toxin. Two months later chemodenervation of the lumber paraspinal muscles with Botulinum toxin was carried out. This resulted in a drop in pain score from nine to five within five days of the procedure. More relief was noted in the aching pain and spasms in the lower back following the procedure compared to the burning pain felt in the lower extremities. Two additional chemodenervation procedures were done over a period of six months. Each time after the procedures, the pain score in the lower back would drop further than before. The most dramatic pain relief was observed after Anakinra injection 100mg was given subcutaneous; the pain score dropped from a score of ten to two in twenty minutes. The Anakinra injection was repeated three weeks later with similar result.

Ms. R.B
39- year old female presented with a twenty-month history of aching and burning pain on the entire left side of the body. Onset of pain was preceded by a cerebro-vascular accident resulting in paralysis and paresthesia of the left side of the body.. The pain felt by the patient was constant and severe; graded ten on a scale of one to ten. There was also muscle spasms associated with her pain.

The patient was diagnosed to have hypertension at the age of eighteen years, had coronary angioplasty for recurrent angina at the age of thirty-five years. Blood work done before surgery revealed a deficiency in Protein S. A family history of hypertension, Protein S deficiency and Lupus was also noted. She was on Warfarin, Atenolol, Amlodipine, Acetaminophen 300mg/ codeine 30mg, Carisoprodol and Amitriptyline. Physical examination showed hyperesthesia and hyperpathia on the left side of the body. Also noted were increased motor tone, spasticity and hyperreflexia on the left upper and lower limbs. A working diagnosis of neuropathic pain and spastic hemi paresis, post CVA was made.

The patient was commenced on Tizanidine 2mg P.O bid, 4mg P.O qhs, acetaminophen 2.5mg / Oxycodone 325mg 1 tab P.O q 6hr, prn pain, and Oxcarbazepine 300mg P.O two times daily. She was told to discontinue Carisoprodol and amitriptyline that she had been taking. A two- week appointment was made for review and to receive Etanercept injection.

On re-evaluation two weeks later, her pain score had dropped to six on the pain scale. Subsequently, she was given Etanercept 25 mg injection subcutaneous in her left arm. She was re-evaluated one week later and she gave the information that her pain score dropped from six to two within six hours of receiving the Enbrel injection.

Mr. C.N.
45-year-old male presented with sixteen-year-old history of low back pain and four year old history of neck pain. Pain started gradually without an immediate preceding trauma. However he had several falls on his previous construction jobs. His pain was constant, severe, radiates to both upper and lower extremities with associated numbness and tingling. The radicular symptoms were felt in the left leg and toes, right and left third to fifth fingers. He also complained of muscle spasms in the lower back and thighs, and in the shoulders.

Previous MRIs done had showed multiple- level disc bulges and degenerative changes in both the cervical and lumbar spine. He has had several surgical procedures done prior to presentation. These procedures included lumbar laminectomy (L3 – L5), diskectomies and nerve root blocks in the cervical and lumbar spine. All these only afforded him temporary pain relief.

Moderate tenderness was noted in the cervical spine and cervical paraspinal muscles on examination, with moderate reduction in range of motion. He also had mild tenderness in the muscles around the right and left shoulders. Moderate tenderness was also noted in the lumbosacral spine with spasms and stiffness in the lumbar paraspinal muscles. The range of motion, however, was full. Neurological examination revealed decreased sensory perception of the pinprick on both right and left C8 dermatome. A diagnosis of post laminectomy lumbar syndrome, lumbar and cervical facet arthropathy with radiculopathy was made.

Subsequently, chemodenervation of the peripheral nerves and paraspinal muscles was done using Botulinum toxin. In addition, the patient was injected with Anakinra 100mg subcutaneously. On re-evaluation one week later, the patient gave the information that his pain dropped significantly. His back and neck pain score dropped from a value of nine to three within one hour of receiving the injections. His radicular symptoms improved one day after the procedures.

Mr. S .P
43-year-old male was being treated for chronic low back pain when he complained of severe, and constant burning pain and hypersensitivity in his skin and joints throughout the entire body, worse in the extremities. No information was given at this initial presentation about any precipitating factor. There was no history of fever or malaise. Prior to presentation, he was being treated with Clarithromycin after a diagnosis of phlebitis and toxic neuropathy. He did not comply with the antibiotic treatment despite obtaining some relief. Physical examination showed the patient was in moderate distress, but alert and oriented. Body temperature and blood pressure were within normal range. Chest examination was normal. The skin was erythematous, especially overlying the veins, with generalized hyperesthesia and allodynia. He also had mild to moderate tenderness in the bilateral shoulder, elbow, wrist and knee joints without joint swelling or heat.

A diagnosis of neurogenic inflammation to rule out Rheumatoid arthritis and phlebitis was made. The patient was told to complete the course of antibiotics. And he was to continue pain medications and therapy while awaiting blood test results from work up performed. On re evaluation one week later, he was still having severe burning pain, which was made worse after bathing in a warm Jacuzzi. Blood work results were still pending. The patient then gave the information that he had injected himself with adulterated cocaine prior to the onset of his burning pain. He had gone to see a Toxicologist who analyzed the remaining sample of the drug that was injected. The injected cocaine was found to be adulterated with chlormezanone (Trancopal). Subsequently, he was placed on Leflunomide 100mg P.O once daily for three days, then 20mg P.O once daily and Methadone 10mg P.O q 6hrs. On re-evaluation one week later, his burning pain had improved tremendously with the pain score dropping to 2/10 from an initial score of 6/10.

Mr. C.N.
45-year-old male presented with complaints of severe pain in his right shoulder after falling on the shoulder from a height of about three feet. His pain was constant and severe, with associated difficulty abducting the joint. Patient had been seen by an orthopedic surgeon who had ordered an MRI of the right shoulder. The MRI revealed a complete rotator cuff tear involving the anterior aspect of the supraspinatus tendon adjacent to the intertuberous sulcus. The patient was advised to get immediate surgical repair of his rotator cuff. When the patient presented in our clinic he was in a lot of pain. Examination revealed severe tenderness to palpation of the right rotator cuff. His range of motion examination showed a severe limitation of abduction at 20 / 180 degrees. Mr. C.N. was placed on Tolmetin sodium 400mg P.O. three times daily with meal and Oxycodone 5mg 1-2 tabs P.O. q 4hr. He had only a slight improvement on the medications. He was subsequently given Anakinra 100mg subcutaneously. Within two minutes of administration of the Anakinra, patient was able to fully raise his right shoulder to 180 / 180 degrees and was quite surprised. On re-evaluation one week later, he gave the information that his pain dropped from a score of 9/10 to 3/10 within five minutes of receiving the Anakinra injection. The duration of pain relief lasted for one month. He was given a second injection of Anakinra 100 mg SC that has given sustained pain relief for five months till the time of publication.

Mrs. M. H..
53-year-old female with a five-year history of generalized body pain involving the joints and soft tissue. She has been receiving specialist pain management following a diagnosis of fibromyalgia, myofascial pain and osteoarthritis. She also had a four-year history of intermittent abdominal pain, worse in the lower abdominal regions, passage of loose stool with occasional bloodstains. After undergoing endoscopy with biopsy, her abdominal condition was diagnosed to be ulcerative colitis by a Gastroenterologist. As part of her chronic pain management, she was given Anakinra 100mg subcutaneously. This resulted in relief of her joint and soft tissue pain and remission of her ulcerative colitis as evidenced by resolution of abdominal pain within two days of the injection. This remission lasted for six months up till the time of publication. The remission was accompanied by an increase in appetite and a slight gain in weight.

Mrs. V.C.
40-year-old female presented with a fourteen-year history of generalized body pain. Pain was described as severe, constant aching, aggravated by activity, relieved slightly and transiently by pain medications. She also had insomnia, extreme fatigue, and a history of Irritable Bowel Disease. Her primary care physician had diagnosed her to have Fibromyalgia. She has also had several tender point injections with local anesthetic before her referral for pain management. On examination, the patient could only walk with the aid of a walker due to severe pain and weakness. She had eighteen out of eighteen Fibromyalgia tender points detected by mild digital pressure, muscle spasms in the cervical and lumbar paraspinal muscles and spasms in both shoulders. Subsequently she was placed on Oxycodone 20 mg P.O. q8-12hrs, acetaminophen 750/ Hydrocodone 7.5mg, 1-2 Tabs P.O. q 4hr, prn pain, and Baclofen 10mg, ½ tab P.O., tid. In the following months she had trigger point injections using local anesthetics and steroid, and also denervation of peripheral nerves and muscles in spasms using Botulinum toxin. After each of these procedures the patient’s pain score would drop from a score of 10/10 to 4-5/10 within three days. The relief would persist for several weeks before pain will gradually increase to a score of 10/10. During an exacerbation of the patient’s condition, she was treated with intra-venous infusion of methylprednisolone succinate 125mg. This resulted in a dramatic pain relief with associated resolution of fatigue. The pain dropped to a score of 2/10 as never before, and muscle spasms were mild and infrequent.

Mrs. J.B.
64-year-old female presented with a fifteen-year history of low back pain and severe pain in the tailbone, which started after a slip and fall on the buttocks. Examination of the spine revealed marked tenderness in the lumbar spinous processes and paraspinal muscles as well as the coccyx. MRIs of the lumbar spine, sacrum and coccyx were ordered. These revealed multiple-level diffuse disc bulge in the lumbar spine measuring 3-4mm with displacement of the posterior longitudinal ligament, neural foramina narrowing and disk desiccations. However, there were no signs of fracture in the lumbar spine, sacrum and coccyx. She has had two lumbar spine epidurals, several trigger point injections using local anesthetic and steroid, in addition to hydromorphone 4mg, 1-2 tabs P.O. q4hr, prn pain, morphine SR 60 mg P.O q12hr, and Rofecoxib 50mg P.O. qd. These treatments only resulted in moderate and transient pain relief in the lumbar region. The pain over the coccyx persisted until the patient was given Etanercept injection 25mg subcutaneously. Within two days, the patient had significant relief of pain in the tailbone and lower back. Her requirement for oral hydromorphone 4mg decreased from six tablets daily with three tablets of morphine SR 60 mg to just one tablet of hydromorphone 4mg. The pain relief was significant and lasted one month before gradually increasing to the pre-Etanercept injection levels.