Measuring the Quality of Pudendal Nerve
Perineural Injections

Background: Pudendal neuropathy is a tunnel syndrome characterized by pelvic pain and may include bowel, bladder, or sexual dysfunction or a combination of these. One treatment method, pudendal nerve perineural injections (PNPIs), uses infiltration of bupivacaine and corticosteroid around the nerve to provide symptom relief. Bupivacaine also anesthetizes the skin in the receptive field of the nerve that is injected. Bupivacaine offers rapid pain relief for several hours while corticosteroid provides delayed pain control often lasting 3 to 5 weeks. Not all pudendal nerve blocks may provide complete pain relief but long-term pain control from the steroid appears to be associated with immediate response to bupivacaine. We offer a method of evaluating the quality of a pudendal block on the day it is performed using pinprick sensation evaluation. Objective: To demonstrate that pinprick sensory changes provide a simple and rapid method of measuring response to local anesthetic and pain reduction provided by a PNPI on the day it is performed. This response defines the quality of each PNPI. Study Design: This is a case series based on retrospective review of a private practice database that is maintained by HealthEast hospitals in Minnesota. Database information includes standard physical examination, recording techniques, and treatment processes that had been in place for several years. Setting: Private practice in United States. Methods: Patients with a diagnosis of pudendal neuropathy are treated with PNPIs. Two hours after each block, 2 endpoints are measured: response to a sensory pinprick examination of the pudendal territory and difference in patient-reported pain level before and after nerve block. Fifty-three men from a private practice treating only pelvic pain received the treatment in 2005. Reported pain level was not recorded for 2 patients. Results: Bupivacaine in perineural injections produces varying degrees of analgesia or hypalgesia to pinprick. Normal pinprick response suggests pudendal nerves were not penetrated by bupivacaine. Patient responses varied from complete, i.e. all 6 branches anesthetized to none. Most men had 2 – 5 nerve branches anesthetized. One man had a single nerve branch that responded to bupivacaine. Three men failed to respond to local anesthetic. Changes in pre-PNPI to post-PNPI pain scores were significantly decreased (n = 51, P-value < 0.0001), indicating that bupivacaine in the PNPI reduced pain. Forty-one patients (80.4%) indicated less pain after the procedure and only 2 patients (4.0%) indicated more pain. The number of nerve branches successfully anesthetized was also significantly correlated with change in score. On average, an additional successful nerve branch anesthetized corresponded to a drop of about 0.66 in the change score (n = 51, P - value = 0.0005). Conclusion: PNPIs relieve pain. Anesthesia affected all 6 pudendal nerve branches in only 13.2% of patients. Complete pain relief occurred in 39.2%. This argues against use of perineural pudendal blockade as a diagnostic test. Pain relief after PNPI is associated with number of nerve branches that are anesthetized. At 2 hours after a PNPI its quality (the number of the 6 nerve branches with reduced response to pinprick from the perineural local anesthetic) is associated with subjective reduction of pain. Key words: Pudendal neuralgia, chronic perineal pain, pudendal nerve block, sensory examination, neurologic examination, pain management, chronic pelvic pain syndrome

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Pulsed Radiofrequency Ablation of Pudendal Nerve for Treatment of a Case of Refractory Pelvic Pain

January 2018 - Pain Physician ◽

10.36076/ppj.2017.e454 ◽

2017 ◽

Vol 3 (20;3) ◽

pp. E451-E454 ◽

Cited By ~ 1

Author(s):

Stephanie Jones

Keyword(s):

Radiofrequency Ablation ◽

Pain Relief ◽

Pelvic Pain ◽

Pudendal Nerve ◽

Pudendal Neuropathy ◽

Ischial Spine ◽

Pulsed Radiofrequency ◽

Pudendal Neuralgia ◽

Mr Neurography ◽

The Right

Pudendal neuralgia (PN) is a result of pudendal nerve entrapment or injury, also called “Alcock syndrome.” Pain that develops is often chronic, and at times debilitating. If conservative measures fail, invasive treatment modalities can be considered. The goal of this case report is to add to a small body of literature that a pulsed radiofrequency (PRF) ablation can be effectively used to treat PN and to show that high resolution MR neurography imaging can be used to detect pudendal neuropathy. Case Presentation: We present a case of a 51-year-old woman with 5 years of worsening right groin and vulva pain. Various medication trials only lead to limited improvement in pain. The first diagnostic right pudendal nerve block was done using 3 mL of 0.25% bupivacaine with 6mg of betamethasone using a transgluteal technique and a target of the right ischial spine; this procedure resulted in ~8 hours of > 50% pain relief. The patient was then referred for MR neurography of the lumbosacral plexus. This study revealed increased signal of the right pudendal nerve at the ischial spine and in the pudendal canal, findings consistent with the clinical picture of PN. Six weeks after the initial block, the patient underwent a second right transgluteal pudendal nerve block, utilizing 3 mL of 0.25% bupivacaine with 40 mg of triamcinolone acetonide; this procedure resulted in ~8 hours of 100% pain relief. Satisfied with these results the patient decided to undergo pudendal nerve PRF ablation for possible long-term relief. For this therapeutic procedure, a right transgluteal approach was again utilized. PRF ablation was performed for 240 seconds at 42° Celsius. Following this ablation the patient reported at least 6 weeks of significant (> 50%) pain relief. Discussion and Conclusion: In this paper we presented a case of successful treatment of PN with PRF ablation and detection of pudendal neuropathy on MR neurography. We believe that transgluteal PRF ablation for PN might be an effective, minimally invasive option for those patients that have failed conservative management. MR neurography employed in this case is not only helpful in confirming the diagnosis of PN but could also be useful in ruling out other causes of pelvic pain, such as genitofemoral neuropathy, endometriosis, adenomyosis, or pelvic mass lesion. To conclude, transgluteal PRF ablation can serve as a viable treatment option for mitigating symptoms of pudendal neuropathy and MR neurography is useful in confirming a clinically suspected diagnosis of PN. Key words: Pelvic pain, pudendal neuralgia, MR neurography, pulsed radiofrequency ablation, transgluteal technique, Alcock canal syndrome

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A Prospective Multicentre Study to Evaluate the Efficacy and Tolerability of Osmotic Release Oral System (Oros®) Hydromorphone in Opioid-Naive Cancer Patients: Results of the Korean South West Oncology Group Study

Pain Research and Management ◽

10.1155/2015/458389 ◽

2015 ◽

Vol 20 (6) ◽

pp. 293-299 ◽

Cited By ~ 3

Author(s):

Eun-Kee Song ◽

Hyunjeong Shim ◽

Hye-Suk Han ◽

DerSheng Sun ◽

Soon-Il Lee ◽

...

Keyword(s):

Quality Of Life ◽

Pain Relief ◽

Cancer Pain ◽

Pain Intensity ◽

Cancer Patients ◽

Pain Control ◽

Intensity Difference ◽

Front Line ◽

Long Acting

BACKGROUND: Osmotic release oral system (OROS®) hydromorphone is a potent, long-acting opioid analgesic, effective and safe for controlling cancer pain in patients who have received other strong opioids. To date, few studies have examined the efficacy of hydromorphone for pain relief in opioid-naive cancer patients.OBJECTIVES: A prospective, open-label, multicentre trial was conducted to determine the efficacy and tolerability of OROS hydromorphone as a single and front-line opioid therapy for patients experiencing moderate to severe cancer pain.METHODS: OROS hydromorphone was administered to patients who had not previously received strong, long-acting opioids. The baseline evaluation (visit 1) was followed by two evaluations (visits 2 and 3) performed two and 14 weeks later, respectively. The starting dose of OROS hydromorphone was 4 mg/day and was increased every two days when pain control was insufficient. Immediate-release hydromorphone was the only accepted alternative strong opioid for relief of breakthrough pain. The efficacy, safety and tolerability of OROS hydromorphone, including the effects on quality of life, and patients’ and investigators’ global impressions on pain relief were evaluated. The primary end point was pain intensity difference (PID) at visit 2 relative to visit 1 (expressed as %PID).RESULTS: A total of 107 patients were enrolled in the present study. An improvement in pain intensity of >50% (≥50% PID) was observed in 51.0% of the full analysis set and 58.6% of the per-protocol set. The mean pain score, measured using a numerical rating scale, was significantly reduced after two weeks of treatment, and most adverse events were manageable. Quality of life also improved, and >70% of patients and investigators were satisfied with the treatment.CONCLUSIONS: OROS hydromorphone provided effective pain relief and improved quality of life in opioid-naive cancer patients. As a single and front-line treatment, OROS hydromorphone delivered rapid pain control.

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Pain Relief as an Integral Part of the Palliative Care

Open Access Macedonian Journal of Medical Sciences ◽

10.3889/oamjms.2018.163 ◽

2018 ◽

Vol 6 (4) ◽

pp. 739-741 ◽

Cited By ~ 3

Author(s):

Marija Sholjakova ◽

Vesna Durnev ◽

Andrijan Kartalov ◽

Biljana Kuzmanovska

Keyword(s):

Quality Of Life ◽

Palliative Care ◽

Pain Relief ◽

Pain Control ◽

Palliative Therapy ◽

The Other ◽

Spiritual Problems ◽

Active Care ◽

Different Origin

BACKGROUND: Palliative therapy represents active care for patients whose illness has such nature that is not responding to the curative treatment. The palliative care aims to provide comfort and prevention from the suffering of the patients at the end of their life. Treatment of the pain presents an important integral part of palliative care.AIM: This article aims to discuss and answer to some of the analgesic regimes and therapeutic dilemmas.RESULTS: Pain control, in addition to the other treatments such as alleviation of psychological, sociological and spiritual problems, has a priority. The proper pain management can achieve a better quality of life for the patients and their families.CONCLUSION: It can be concluded that because of the different origin of the pain, the use of analgesic therapy should be individualised and adapted to the real need of every person. Finally, only a good organisation and institutionalisation of the palliative care in one society could permit better prevention of suffering at the end of the life.

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Assessment of pain control, quality of life, and predictors of success after gamma knife surgery for the treatment of trigeminal neuralgia

Neurosurgical FOCUS ◽

10.3171/foc.2005.18.5.9 ◽

2005 ◽

Vol 18 (5) ◽

pp. 1-7 ◽

Cited By ~ 29

Author(s):

Ajay Jawahar ◽

Rishi Wadhwa ◽

Caglar Berk ◽

Gloria Caldito ◽

Allyson Delaune ◽

...

Keyword(s):

Quality Of Life ◽

Patient Satisfaction ◽

Pain Relief ◽

Trigeminal Neuralgia ◽

Gamma Knife ◽

Pain Control ◽

Gamma Knife Surgery ◽

Patient Satisfaction Score

Object There are various surgical treatment alternatives for trigeminal neuralgia (TN), but there is no single scale that can be used uniformly to assess and compare one type of intervention with the others. In this study the objectives were to determine factors associated with pain control, pain-free survival, residual pain, and recurrence after gamma knife surgery (GKS) treatment for TN, and to correlate the patients' self-reported quality of life (QOL) and satisfaction with the aforementioned factors. Methods Between the years 2000 and 2004, the authors treated 81 patients with medically refractory TN by using GKS. Fifty-two patients responded to a questionnaire regarding pain control, activities of daily living, QOL, and patient satisfaction. The median follow-up duration was 16.5 months. Twenty-two patients (42.3%) had complete pain relief, 14 (26.9%) had partial but satisfactory pain relief, and in 16 patients (30.8%) the treatment failed. Seven patients (13.5%) reported a recurrence during the follow-up period, and 25 (48.1%) reported a significant (> 50%) decrease in their pain within the 1st month posttreatment. The mean decrease in the total dose of pain medication was 75%. Patients' self-reported QOL scores improved 90% and the overall patient satisfaction score was 80%. Conclusions The authors found that GKS is a minimally invasive and effective procedure that yields a favorable outcome for patients with recurrent or refractory TN. It may also be offered as a first-line surgical modality for any patients with TN who are unsuited or unwilling to undergo microvascular decompression.

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Quality Assurance for Interventional Pain Management Procedures in Private Practice

January 2018 - Pain Physician ◽

10.36076/ppj.2008/11/43 ◽

2008 ◽

Vol 1;11 (1;1) ◽

pp. 43-55

Author(s):

YiLi Zhou

Keyword(s):

Quality Assurance ◽

Patient Satisfaction ◽

Pain Management ◽

Pain Relief ◽

Private Practice ◽

Complication Rates ◽

Large Joint ◽

Management Procedures ◽

Interventional Pain Management

Background: A recent study has indicated that quality assurance for interventional pain management procedures (IPMPs) can be achieved in university pain clinics. However, the issue of quality assurance for IPMPs in private practice has not yet been addressed. Objective: This study was designed to monitor the quality of IPMPs in a private pain practice in north Florida. Methods: From November 2005 to July 2006, we monitored the quality of IPMPs in a private pain practice in north Florida. Questionnaires regarding degree of pain relief, patient satisfaction, and complications were handed to patients immediately after the completion of each IPMP. Follow-up phone calls were also made to patients 1 day after the IPMPs. Results: A total of 771 (male: 249, female: 522) patients with a mean age of 58.1 years participated in the study. Office-based IPMPs included lumbar and cervical epidural steroid injections, lumbar and cervical facet joint blocks, selective nerve root blocks, lumbar and cervical sympathetic nerve blocks, sacroiliac joint injection, and large joint injections. Seven-hundred patients (90.8%) reported various degrees of pain relief immediately following IPMPs. Average pain score decreased by 4.3 on a 0 to 10 scale (p=<0.001). Number needed to be treated (NNT) to reach 50% or more pain relief immediately after IPMPs was 1.4. Six-hundred ninety-two (89.7%) patients were satisfied or very satisfied with the results of IPMPs. sixty-two patients (8%) developed headaches after IPMPs, which lasted from 30 minutes to 4 days. None of these patients required a blood patch. Five patients developed moderate vasovagal responses during IPMPs, in which their heart rates decreased to <45/min, BP <90/60mmHg. The IPMPs were aborted immediately. All of these patients recovered uneventfully within a few minutes. No other serious adverse events were reported. Conclusions: The results of the current study suggest that high quality private interventional pain programs with high efficacy, high patient satisfaction, and low complication rates can be achieved through appropriate staff training, proper monitoring of patients during IPMPs, and adequate handling of patients after the IPMPs. Key words: Interventional pain management procedures, quality assurance, efficacy, patient satisfaction

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Role of 3 Tesla MR Neurography and CT-guided Injections for Pudendal Neuralgia: Analysis of Pain Response

January 2018 - Pain Physician ◽

10.36076/ppj/2019.22.e333 ◽

2019 ◽

Vol 4 (22;4) ◽

pp. E333-E344

Author(s):

Avneesh Chhabra

Keyword(s):

Study Design ◽

Pelvic Pain ◽

Chronic Pelvic Pain ◽

Pudendal Nerve ◽

Pain Response ◽

Pudendal Neuropathy ◽

Pudendal Neuralgia ◽

Ct Guided ◽

Perineural Injection

Background: Magnetic resonance neurography (MRN) has an increasing role in the diagnosis and management of pudendal neuralgia, a neurogenic cause of chronic pelvic pain. Objective: The objective of this research was to determine the role of MRN in predicting improved pain outcomes following computed tomography (CT)-guided perineural injections in patients with pudendal neuralgia. Study Design: This study used a retrospective cross-sectional study design. Setting: The research was conducted at a large academic hospital. Methods: Patients: Ninety-one patients (139 injections) who received MRN and CT-guided pudendal blocks were analyzed. Intervention: A 3Tesla (T) scanner was used to evaluate the lumbosacral plexus for pudendal neuropathy. Prior to receiving a CT-guided pudendal perineural injection, patients were given pain logs and asked to record pain on a visual analog scale. Measurement: MRN findings for pudendal neuropathy were compared to the results of the CTguided pudendal nerve blocks. Injection pain responses were categorized into 3 groups – positive block, possible positive block, and negative block. Statistical Tests: A chi-square test was used to test any association, and a Cochran-Armitage trend test was used to test any trend. Significance level was set at .05. All analyses were done in SAS Version 9.4 (SAS Institute, Inc., Cary, NC). Results: Ninety-one patients (139 injections) who received MRN were analyzed. Of these 139 injections, 41 were considered positive (29.5%), 52 of 139 were possible positives (37.4%), and 46 of 139 were negative blocks (33.1%). Of the patients who had a positive pudendal block, no significant difference was found between the MRN result and the pudendal perineural injection response (P = .57). Women had better overall response to pudendal blocks, but this response was not associated with MRN findings (P = .34). However, positive MRN results were associated with better pain response in men (P = .005). Patients who reported bowel dysfunction also had a better response to pudendal perineural injection (P = .02). Limitations: Some limitations include subjectivity of pain reporting, reporting consistency, absence of a control group, and the retrospective nature of the chart review. Conclusion: Pudendal perineural injections improve pain in patients with pudendal neuralgia and positive MRN results are associated with better response in men. Key words: MRI, MRN, CT injection, pudendal neuralgia, pudendal nerve, pelvic pain, chronic pelvic pain, pudendal neuropathy

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Percutaneous Radiofrequency Hip Joint Denervation

10.5772/intechopen.96708 ◽

2021 ◽

Author(s):

Nieves Saiz-Sapena ◽

Vicente Vanaclocha-Vanaclocha ◽

José María Ortiz-Criado ◽

Leyre Vanaclocha

Keyword(s):

Quality Of Life ◽

Pain Relief ◽

Hip Joint ◽

Pain Control ◽

Joint Pain ◽

Pulsed Radiofrequency ◽

Total Hip ◽

Sensory Denervation ◽

Hip Arthroplasties

With an aging population, chronic osteoarthritic hip joint pain is becoming a major issue. Most patients with hip pain can control their pain with conservative measures but with a gradual reduction in their quality of life. When gradually reduced ambulation and pain become recalcitrant, total hip arthroplasty is the next step. For most patients, this is a good way to improve pain control and to recover some quality of life, but for a few this aggressive surgical procedure is not possible. Sometimes co-morbidities make total hip arthroplasties undesirable. At other times, the age of the patients recommends to wait for a while. In these cases, other options have to be explored. Percutaneous partial hip joint sensory denervation has become a notable option as it can provide acceptable rates of pain relief with minimal surgical aggressiveness. There are three modalities to perform it: thermal, cooled and pulsed radiofrequency.

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Improved Pain Control with Combination Spinal Cord Stimulator Therapy Utilizing Sub-perception and Traditional Paresthesia Based Waveforms: A Pilot Study

Anesthesiology and Pain Medicine ◽

10.5812/aapm.113089 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Amnon A. Berger ◽

Ivan Urits ◽

Jamal Hasoon ◽

Jatinder Gill ◽

Musa Aner ◽

...

Keyword(s):

Spinal Cord ◽

Pain Relief ◽

Pain Control ◽

Rating Scale ◽

Pulse Generator ◽

Numerical Rating Scale ◽

Failed Back Surgery

Background: Chronic back and neck pain affects 20% of Americans. Spinal cord stimulation (SCS) is an effective therapy for otherwise refractory chronic pain. Traditional SCS relies on low-frequency stimulus in the 40 - 60 Hz range causing robust paresthesia in regions overlapping with painful dermatomes. Objectives: This study aims to determine the effect of superimposing sub-perception stimulation in patients who previously had good long-term relief with paresthesia. Methods: This is a prospective observational trial examining patients who had previously been implanted with paresthesia based SCS for failed back surgery syndrome (FBSS) or complex regional pain syndrome (CRPS). These patients presented for implantable pulse generator (IPG) replacement based on battery depletion with an IPG capable of combined sub-perception and paresthesia based SCS therapy. Patients were assessed immediately following the exchange and four weeks later using a telephone survey. Their pain was assessed on each follow up using a Numerical Rating scale (NRS); the primary outcome was the change in NRS after four weeks from the exchange day. Secondary outcomes included paresthesia changes, which included the subjective quality of sensation generated, the overall subjective coverage of the painful region, subjective variation of coverage with positional changes, and global perception of the percentage improvement in pain. Results: Based on our clinic registry, 30 patients were eligible for IPG exchange, 16 were consented for follow up and underwent an exchange, and 15 were available for follow up four weeks following. The average NRS decreased from 7.47 with traditional SCS to 4.5 with combination therapy. 80% of patients reported an improvement in the quality of paresthesia over traditional SCS therapy, and in most patients, this translated to significantly improved pain control. Conclusions: Our findings suggest improved pain relief in patients who had previously had good results with paresthesia based therapy and subsequently underwent IPG exchange to a device capable of delivering combined sub-perception stimulation. The mechanism of action is unclear though there may be an additive and/or synergistic effect of the two waveforms delivered. Larger studies with long-term follow-up are needed to elucidate the durability of pain relief and the precise mechanism by which combined subperception and paresthesia based SCS may improve overall patient outcomes.

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Postoperative Pain Relief Using Local Anesthetic Instillation

Foot & Ankle ◽

10.1177/107110078800800612 ◽

1988 ◽

Vol 8 (6) ◽

pp. 350-351 ◽

Cited By ~ 12

Author(s):

Michael H. Bourne ◽

Kenneth A. Johnson

Keyword(s):

Side Effects ◽

Postoperative Pain ◽

Pain Relief ◽

Local Anesthetic ◽

Pain Control ◽

Effective Means ◽

Technical Skill ◽

Foot Pain ◽

Additional Time ◽

Outpatient Procedures

Effective pain control following surgery is a concern. Oral narcotic agents may be effective yet have many side effects. Parenteral agents are impractical in outpatient procedures. Local blocks may distort tissue planes and require additional time and technical skill to administer. We have found that instillation of local anesthetic (0.5% bupivacaine [Marcaine, Sensorcaine]) into the wound prior to closure is a safe and effective means of providing significant reduction in postoperative foot pain.

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CT-Guided Percutaneous Infiltration for the Treatment of Alcock’s Neuralgia

January 2018 - Pain Physician ◽

10.36076/ppj.2011/14/211 ◽

2011 ◽

Vol 3;14 (2;3) ◽

pp. 211-215

Author(s):

Dimitrios K. Filippiadis

Keyword(s):

Computed Tomography ◽

Pain Relief ◽

Local Anesthetic ◽

Efficient Method ◽

Pudendal Nerve ◽

Mobility Impairment ◽

Painful Condition ◽

Ct Guided ◽

Alcock’S Canal ◽

Long Acting

The pudendal nerve may be strained either between the sacrospinous and sacrotuberous ligaments at the ischial spine level or within Alcock’s canal. Alcock’s neuralgia is a rare, painful condition caused by compression of the pudendal nerve within Alcock’s canal (pudendal canal) which is an aponeurotic tunnel that cannot be stretched. Patients usually present with intense, unilateral pain involving anatomic areas along the pudendal nerve’s root, genital, anal, and pelvic regions causing mobility impairment. A computed tomography (CT) - guided percutaneous infiltration of the pudendal nerve with a mixture of a local anesthetic and a long-acting corticosteroid is a safe and efficient method that reduces the pain caused by the neuralgia. Corticosteroids and local anesthetics interfere with the neurons, the encoding, and the processing of noxious stimuli; interrupt the pain-spasm cycle; and reduce inflammation. The injected glucocorticosteroid may take 3-5 days to reach its anti-inflammatory effect; therefore, the initial pain relief from the local anesthetic is followed by a baseline pain return and then secondary pain relief at 3-5 days. The procedure is performed under minimal or no anesthesia. In general, at discharge, a responsible person must accompany the patient and ensure a safe return home. Clinical evaluation is performed after 7-10 days. There are 2 types of potential complications that are associated with percutaneous steroid infiltrations: intra-operative (associated with needle placement) and post-operative (infection, bleeding and those associated with the injectate administration). In all cases that steroids were administered within therapeutic doses, no complications were noted. In conclusion, CT-guided percutaneous infiltration with a mixture of long-acting corticosteroid and local anesthetic seems to be a safe and efficient method for the treatment of Alcock’s neuralgia. Key words: Alcock’s canal, neuralgia, corticosteroid, pudendal; nerve, local anesthetic, computed tomography, infiltration, percutaneous, image guided.

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