Coccyx or tailbone is the last bone at the end of the spine. Pain in the region of tailbone is called coccydynia. Common causes include trauma, childbirth and repeated strain on the coccyx. Patients may have increased mobility which triggers the inflammation. Other causes include fracture, infection and tumour.
Most patients present with pain on sitting or getting up from sitting position and localised tenderness around the coccyx. Pain during bowel movement of sex may be present. Diagnosis is made based on history and examination findings. Sometimes tests such as x-rays, CT scans and MRI’s are requested. Treatment involves avoiding further strain on the coccyx-using appropriate cushions, weight management, simple painkillers combined with physiotherapy, manipulation and injections such as
Coccyx/ Sacrococcygeal Joint Injection – these are performed under x-ray or ultrasound guidance and involve injecting local anaesthetics and a small dose of steroids in or around the sacrococcygeal joint. It is not uncommon for the ligaments around the coccyx to be the pain generator and these are often injected at the same time. The procedure is performed as a day case under local anaesthesia.
Ganglion Impar block and Radiofrequency - ganglion impar is a collection of nerves located in front of the sacrum and coccyx. This procedure involves injecting a local anaesthetic and steroids mixture under x-ray guidance close to ganglion impar. The needle position is verified by giving a dye (contrast) before injection. Radiofrequency treatment is performed if the benefits of injection are short lasting
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Chronic abdominal pain is a common reason for seeking medical attention. Pain generators in abdominal pain are not always easy to identify and may be located inside the abdomen, in the abdominal wall or in the nearby organs with pain being referred to the abdomen. ACNES is a common cause of abdominal wall pain and it involves entrapment of small nerves which supply the skin of abdominal wall as they pass through the abdominal muscle (lateral part of rectus muscle). A study from a Dutch teaching hospital found approximately 2% of patients presenting to emergency department with acute abdominal pain suffered from ACNES.
ACNES presents as localized unilateral abdominal pain and patients can usually pinpoint painful areas close to the middle of abdomen. Pain may be provoked by position change or tensing of abdominal muscles and is generally independent of food intake, bowel habits. Trauma or previous surgery can also contribute to the entrapment of these small nerves. Abdominal wall pain is frequently unrecognized and this often leads to a magnitude of investigations, specialist consultations, prolonged suffering, overtreatment and inefficient utilization of resources.
Ultrasound guided injections are used to confirm the diagnosis of ACNES and provide pain relief. Ultrasound guidance can not only help in identifying local but also helps in improving the accuracy and safety of injections. Sometimes repeat injections are required to provide sustained pain relief. I have successfully identified and treated ACNES on numerous occasions- most often after local trauma or surgeries such as caesarean section, open/ laparoscopic abdominal surgeries etc.
Headache is a common problem. Fortunately a significant proportion of headaches can be managed by commonly used painkillers. In certain types of headaches prophylactic agents are used to reduce the frequency of attacks. However, there still remains a subgroup of patients with difficult to manage headaches despite all measures. For this subgroup pain clinic offers interventions and multi-disciplinary input, over and above the traditional approach of using painkillers. Multi-disciplinary approach helps in addressing concomitant magnifiers/ triggers such as anxiety, depression, altered sleep cycle, medication overuse, life style and poor posture.
Cervicogenic Headaches Download PDF »
In clinical practice, an overwhelming majority of headaches are either a tension-type headache, migraine, cluster headache or medication overused headache. Extra cranial sources of headaches such as nerves, joints and muscles can be easily missed. The term Cervicogenic Headaches is used for headaches originating from cervical spine pathology or surrounding soft tissues. Examples include neck facet or Atlantoaxial joint pathology, headaches secondary to third occipital nerve, supraorbital neuralgia, and occipital neuralgia, sternocleidomastoid and trapezius muscle spasms. These types of headaches may be accompanied by neck pain, stiffness and are commonly undertreated.
Some of the interventions available via the pain clinic include
Headaches originating from facet joints are more commonly observed in the elderly and after whiplash injury (flexion/extension injuries). Clinical diagnosis is often difficult as the features overlap with other types of headaches. Diagnostic injections can help identify the pain generators in such cases. Pain originating from these joints can be felt in the base of the skull, neck, upper back, mid-back and shoulders. Please follow the link to Facet joint injections to find out more on this treatment.
The third occipital nerve originates from the cervical spine and supplies sensation to a joint in the neck (C2-3 zygapophyseal joint) and a small area at the back of head. This nerve or the joint it supplies can be a source of headaches localised to the back of head on one side. Sometimes the headache can spread towards the top of the head. This occurs more commonly after whiplash injury.
A diagnostic block involving injection of local anaesthetic close to the nerve can help determine if this nerve is the source of your headache. This is performed under x ray guidance. If the diagnostic test is positive then radiofrequency ablation of the nerve can provide long lasting relief.
Greater Occipital Nerve (GON) block is frequently utilized in management of different types of headache and for establishing the diagnosis of occipital neuralgia. This nerve is located at the back of head and pain originating from this presents as shooting, stabbing pain with altered sensation in the area supplied by the nerve. Sometimes the area can be unusually sensitive.
Nerve block can be performed distally using landmarks or proximally using ultrasound. This nerve travels through various fascial planes and has the potential of getting entrapped anywhere along the path. I prefer to use the proximal approach as this targets the nerve soon after it originates from the spinal nerves before it gets entrapped anywhere along its course. Local anaesthetic block can help in confirming the diagnosis and radiofrequency treatment can help provide long pasting pain relief.
Sphenopalatine ganglion is a collection of nerve cells located behind the nose which serves as a relay centre for messages being transmitted to the brain. This is closely linked to one of the main nerves involved in headaches, facial pain (trigeminal nerve) and with many other nerves such as those involved in regulation of tear glands.
Sphenopalatine ganglion block is used for conditions such as cluster headaches, migraine, atypical facial pain and cancer of head and neck. A block with local anaesthetics temporarily interrupts the transmission of nerve impulses producing pain relief. It can be performed by inserting local anaesthetic soaked cotton swabs through the nose with the head tilted backward. Alternatively, it can be performed using x-ray guidance from the side of the face. The duration of pain relief is variable.
Botox is well known for its cosmetic usage. When injected into muscles it partially blocks the nerve impulses and reduces the muscle contractions. In chronic migraine this can help by reducing the frequency of headaches and the effects can last for 8 - 12 weeks.
Botox is not the first line treatment for migraine and is used in adult patients with chronic migraine who have unsuccessfully tried at least three other medications to prevent migraine. Diagnosis of chronic migraine is made when patients have 15 or more headache days in a month of which at least eight are migraine headaches.
Blocks and radiofrequency treatment of nerves e.g. supraorbital, supratrochlear nerve are used when the pain is localised to the distribution of a specific nerve.
Muscles ability to contract and relax plays an important role in body functioning. When muscles fail to relax, they form knots or tight bands known as trigger points. In simple words trigger points are irritable areas/ bands of tightness in a muscle. Pressure over a trigger point produces local soreness and may refer pain to other body parts. Common causes include inflammation, injury of the muscle or the neighbouring structures. Poor posture and repetitive strain are other predisposing factors. Trigger points can limit the range of movement; affect posture predisposing other areas to unaccustomed strain.
Trigger points are commonly found in head, neck, and shoulder muscles. They can be the source of localised pain, headaches and may also play a role in magnifying headaches due to other causes e.g. migraine, tension headache.
Trigger point injections are performed in an outpatient/ day-care setting and involve injection of local anaesthetic with or without a small dose of steroid into the painful muscle. The local anaesthetic blocks the pain sensations and the steroids help in reducing the inflammation, swelling. I prefer to perform these injections under ultrasound guidance as it improves the accuracy and reduces the chances of complications. Post injection physiotherapy is essential to prevent recurrence and maximise the benefits.
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Pain in cancer may arise due to many reasons and is often the presenting complaint leading to the diagnosis of cancer. It may be
Pain can be of differentiated into background pain (which is always present in the background and is managed with regular medications) and breakthrough pain (pain which breaks through your regular pain relief). Breakthrough pain may occur unprovoked or may be triggered by external or internal factors. In cancer patients different types of pain may coexist. It is not just limited to pain arising from inflammation and tissue damage for example cancer of pancreas spreading to neighbouring organs and nerves leading to visceral and neuropathic pain respectively and a distant spread to bones producing bone pain. Different types of pain present differently for example
Pain relief needs to be tailored to the cause, severity and duration of pain. In most cases a reasonable control can be achieved by using a combination of methods. Multimodal, Multi disciplinary approach provides the opportunity to maximise pain relief and provide support not only for the physical needs but also for the emotional, spiritual and social needs.
Some of the management options available via a pain clinic are
This involves using different classes of medications to optimise the pain control. Using a combination of drugs helps to minimise side effects and maximise the benefits. Whilst considering the drug therapy many factors need to be considered like type of pain, cause and severity of pain, other medical problems and medications being used, medications tried previously, pre existing nausea/vomiting, constipation, ability to take and absorb medications, liver and kidney function etc. Apart from the standard medications mentioned in other sections some other medications are used more often in cancer pain such as steroids, biphosphonates (for bone pain).
Nerves are commonly targeted in pain relieving interventions for example pudendal nerve for perineal or rectal pain, suprascapular nerve for shoulder pain, intercostal nerves for chest wall pain etc. The pain impulses being transmitted via the nerves can be temporarily blocked using local anaesthetics. The transmission of impulses can be reduced for longer duration using Neurolytic procedures, which involve injection of alcohol or phenol instead of local anaesthetic. Examples of neurolytic procedures include
suprascapular nerve pulsed radiofrequency for shoulder pain involves exposure to high frequency electrical current in the RF range (≈ 500 kHz). This exposure can be continuous generating high temperatures or pulsed where the temperature is kept below 42 °C. Pulsed RF can be used to target most nerves including those with motor components. The resulting neural modification affect’s the transmission of pain impulses producing pain relief.
Certain procedures such as pumps to deliver medicines directly in the spine (intra thecal pumps) are performed more often for cancer pain.
Cancer is often accompanied by anxiety, depression and fear of the worst. A psychologist can help in analysing these thoughts rationally and developing a positive approach. They can help by teaching relaxation techniques, coping strategies and by reducing the effect of mood on pain.
Fibromyalgia is one of the common causes of long-term widespread body pain. Pain may be accompanied by other symptoms including
Pain clinic is the ideal place to manage fibromyalgia as it brings together the skills of a wide range of specialists working together as a team. This multi-disciplinary approach is essential to minimise the impact on the quality of life. A combination of drug and non-drug treatments can help manage the symptoms. I offer personalised pain management plans on lines of Pain Management Programme (PMP). I can help you
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