New Mexico Pain Management

While our above described tissue regeneration procedures are our greatest emphasis, in the right situation the other interventional procedures listed below can be very meaningful. They may have significant temporary effect in controlling pain, they may have permanent effects in and of themselves, or they may be part of a process that also involves tissue regeneration procedures.

It is a common strategy in interventional pain management to destroy some nerves that are causing pain. The nerves do grow back over part of a year and hopefully behave better. We believe such strategies have a place, yet we approach this process of neurolysis or neuroablation with some caution. We use milder, safer versions of these techniques in a few clinical situations. For example, a Morton's neuroma is a painful enlargement of nerve tissue in the foot near the toes. We find neurolysis to be a reasonable strategy for this disfigured nerve. While destruction of the neuroma is sometimes attempted all at once using stronger methods with risk of surrounding tissue damage and side-effects, we use a mild 4% alcohol injection, repeated comfortably over several occasions, to accomplish the same goal more safely.

There are two nervous systems

somatic nervous system - normal motor and sensory nerves that most people are familiar with. It is organized like a centralized federal government, with the brain and spinal cord in charge.

autonomic nervous system - another very extensive system that controls blood flow, sweating and many other secretions, digestion, heart beat and other organ functions. It also has significant influence on pain. It is then divided into two parts.

• The parasympathetic nervous system is the autonomic nerves that help us relax, secrete and digest.
• The sympathetic nervous system is the autonomic nerves that stop secretion and peripheral blood flow in response to fight or flight situations, or perhaps just greater situational stresses.

The autonomic nervous system is organized in a less centralized manner. The brain and spinal cord participate, but there are also powerful regional offices, like local or state governments. These regional offices are larger masses of nerve tissue called ganglia, situated in front of the spine, from the neck to the tail bone. A few of these can be safely be injected in-office, particularly with technique modified for safety, targeting not full block but incremental therapeutic regulation of the ganglion in question.

On some occasions we may use local anesthetic blocks for anesthetizing the region where a tissue regenerating procedure will occur. This is not always necessary, but if we decide to seek such pre-anesthetization, it may be locally (called a tissue bed block) or upstream on the nerve that innervates the region to have a procedure (somatic nerve block). Because we seek to keep local anesthetic volumes modest, and because we preferably try to avoid motor block (the ability to subsequently use the limb in question), the amount of block that we chose to effect may be partial.

The nerves that people usually think of are somatic nerves. Injection of these nerves with local anesthetic can block nerve impulses to some degree. Blocking pain impulses in a nerve may have some value in management of pain. After the somatic nerve block wears off, the pain will most likely return unless the cause of the nerve pain is addressed. Thus we emphasize tissue regeneration procedures as longer-term solutions. However, the good news is that after nerve blocks some of the time the pain upon return of nerve function may be less, at least for some period of time. And it is reasonable to repeat such somatic nerve blocks at some time after the pain escalates once again.

Each situation is unique. The nerve in question, the patient's overall medical condition, and other factors may determine how aggressively we chose to block the nerve in question. Our preference is for lesser, milder blocks for a number of reasons, but each unique situation has to be considered as it presents itself.

We soften and reduce scar tissue from cuts, scrapes, burns and surgery. Such scars may not be a problem for some people, but in some cases the scars may be painful or they may subtly or frankly limit full and easy motion of the involved body part.

Furthermore, autonomic nerves spread through the body like rivers or networks of thinner and thinner wires. If they bump up against a scar they have been known to continue building up a hundred fold near the dead scar tissue. In the case of such small autonomic nerves, they may not hurt locally but may send strong signals back to their regional office (autonomic ganglion). Acting on this strong feedback, the ganglion may alter blood flow or other functions on erroneous information coming from the scar. In other words, some scars can be responsible for pain or other symptoms in distant areas of the body. While it is difficult to verify if such feedback is occurring or altering regional function, this possibility increases our reasons for considering your scars when we build a plan to ameliorate your pain.

Many substances can be injected into the scars: water, local anesthetic, or a scar tissue dissolving agent such as a natural enzyme. Patients often don't feel a needle going into scar tissue.

Trigger points are muscle knots that most adults have experienced in places such as the upper back. The knots are contracted muscle tissue where the muscle's pulling action is more focused. And, such knots are always part of a taut band that extends from one end of the muscle to the other. Such trigger points are a problem for at least the following reasons:

• local pain at the trigger point
• referred pain from the trigger point, even far from the trigger point
• muscle shortening
• muscle weakening and atrophy because the muscle can't be used and strengthened through its full range of motion
• simple or complicated dysfunction of other muscles and joints in the region effected by the dysfunctional, shortened muscle

For a variety of reasons, we feel that injections are often the most effective means of releasing these taut bands and trigger points.

Like any medical method, such injections have some limitations. Stretching may also be needed right after, and perhaps long after, most such injections. We avoid trigger point injection in some areas because of greater technical difficulty or risk. In some simple situations release of trigger points with injection may lead to long or seemingly permanent relief, but more commonly the causes of the stress on the muscle also need to be studied and treated.