Читать книгу Why It Hurts - Dr. Aneesh Singla - Страница 22

One patient, David, saw me for pain control after spine surgery. He was managing his pain with high doses of opiates but he was still clearly uncomfortable.

“Is this how I am going to be for the rest of my life?” he asked. “I was expecting to be fixed by now.”

I simply couldn’t find an effective way to control his pain, so David went back to see his surgeon, who subsequently diagnosed an infection in David’s spine. Another surgery removed the new infection and after that the pain completely resolved. If I’d simply turned off his pain at his request, that infection would have spread.

Another similar case comes to mind. A friend, Nancy, was training for a marathon when she developed severe hip pain. At first, she thought it was a strain. She kept running under the assumption that the pain was muscular and that the best thing to do was just push through it. Unfortunately, it didn’t get better.

Nancy’s X-rays came back normal so an MRI was ordered, and that revealed a stress fracture. Nancy had to pull out of training and spend four weeks on crutches. Without that diagnosis, she might have run the marathon with painkillers, causing a more severe injury, perhaps even a displaced hip fracture.

A spine surgeon colleague once referred a patient with a disc herniation to me, requesting a nerve root block. This is a procedure where a local anesthetic and a steroid are delivered directly to the patient’s spine to temporarily decrease the perception of pain and decrease the inflammation along the nerve.

We use nerve root blocks when we suspect inflammation or compression of the spinal nerve by a herniated disc. The nerve block serves diagnostic and therapeutic purposes: If the patient sees a significant benefit, the surgeon can perform highly localized surgery to free the compressed nerve and alleviate the pain with the smallest possible intervention. In other cases there may be multiple compressed nerves, in which case the nerve root block will not provide the same complete relief.

In this case, we performed the nerve block and the patient did well, finding complete relief while the local anesthetic was working. This established the diagnosis and I planned to send her back to the spine surgeon for a procedure to permanently solve the problem. Given the severe compression, we were both certain she would require surgery.

The funny thing was, her pain never returned. This experience taught me that, on occasion, simply abolishing the pain temporarily can have a lasting effect. Perhaps the injection interrupts pain just long enough to stop the wind-up phenomenon from spiraling out of control. Perhaps the nerve pathway simply stops sending off the alarm that something is wrong. Perhaps the finely tuned inflammatory response receives a signal to turn off for a while because the communication with the sensory nerves is turned off. This is sometimes the case when there is no serious problem present, but simply nerve irritation, which once treated results in extended pain relief. The reprieve from pain can help turn off the alarm, as long as there is no serious problem lingering. It also helps us as physicians differentiate what is a mechanical compression problem of the nerve versus simple inflammation. The spine surgeon who referred me the patient was somewhat perplexed as well. He wondered whether I’d used steroids in the injection, but I hadn’t.