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Ultimate Pain Management

Consultants

Let us together rewrite a part of Rheumatology.

I am working in Pain Management since last twenty years. Not only that I have vast and valuable experience in the treatment of Pain syndromes but I have devised new modalities and established new algorithm for the treatment of Osteo-Arthritis Knee Joint, Chronic low back Pain and other major myalgic problems. My work has given new concepts that are supplemented by clinical results. Our findings are:

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Institute

Patients

Low back pain chronic or acute

Chronic as well acute low back pain, are both suitable cases to be treated in pain management. In Chronic low back pain the level of Success that has been achieved to treat the condition, by this new treatment algorithm of finding and treating the Trigger Spots is magnificent (14 ) . Back is the site of very strong Paravertebral Muscles that remain performing actions all the day around. These muscles contract on their line of action and this is their safety for health. However any time if due to bad posture, undue contraction or working out of line of action may cause a twitch that may be sufficient enough to initiate a series of developments that would lead to acute low back pain. This would then apparently recover and may at later stages reveal dull diffuse pain that may turn into Chronic Low Back pain (31). This dull diffuse pain is most probably because of the fibrosis that has occurred at the site of lesion where muscles fibers are damaged and are replaced by fibrous tissue.

This fibrous tissue being non flexible behaves as a foreign tissue / body inside the muscle mass. This non flexible tissue may pull upon, cause compression or irritation to the surrounding tissue causing diffuse pain. The feeling of pain will then initiate spinal reflex that will put the group of muscles into contraction. Thus a vicious cycle is initiated that will cause pain leading to muscle spasm and more pain. A problem that will become chronic and may linger on for years. (31)

However the basic principle to treat this problem is to break this vicious circle by any available palliative measure like analgesics, muscle relaxants and Physiotherapy. To some extent this condition may be prevented from being aggravated. However we shall remember one principle that as long as the organic cause persists, the problem will recur.

Thus like all other conditions that demand treating the organic cause, this fibrosis also demand healing, which most probably is dissolution of the fibrosis in this case, before patient can be termed as cured. The knowledge of these lesions are utmost important (14) . These were revealed in serial unmasking of the chronic lumbago cases (Table.1).

When the spine exhibits osteoarthritic changes, especially the lumbar spine, the associated changes are very commonly seen from L3 through L5. Symptoms include pain, stiffness, and occasional radicular pain from spinal stenosis. Spinal stenosis is caused by facet arthritic changes that result in compression of the nerve roots. The occurrence of an acquired spondylolisthesis is a common denominator of arthritis of the lumbar spine. However as is explained elsewhere despite these radiological findings patient may still benefit from this new treatment regimen indicating that the radiological findings may not be the true representative of clinical presentation of pain and there may be other causative factors that need to be made note of (14,32).

These points are tabulated as under:

Trigger points of sacro-ileitis:

This is the condition most commonly seen as a case of chronic lumbago localized at the sacroiliac region. This condition is also identified as most agonizing by the patients. Normally termed as Sacro-Ilietis this seems to be a misnomer as the pain does not always localize in the joint. In 90 % of cases the pain localizes in the soft tissue on the back of the sacrum a little laterally placed. Only in some 10 % of cases the trigger spot turns out to be in close proximity to the sacroiliac joint. This condition cause acute pain to the patient and severe disability when he gets up in the morning. It is very disabling. The patients say that they improve gradually as the sun rises. However the result to treatment is very rewarding.

Pain of Facet joints:

Localizes accurately between the spinous processes. It presents as pain in the lumbar region often between L3 to Sacrum. It characteristically localizes close to the central line as compared to the pain of Fibrositis that localizes a little laterally in the strong paravertebral Muscles. This is in fact the best possible way to identify fasciitis accurately without getting involved into expensive and tedious investigative procedures. The only indication of fasciitis is pain. Once the pain is localized and pinpointed to an approximation error of a couple of mm. Then academic interest of identifying the type of lesion underneath becomes secondary. Pinpoint identification makes it possible to inject at the exact site and this ensures the curing of the lesion.

Fibrotic points:

Inside the strong paravertebral muscles fibrotic lesions extend and are often identified from L1 to the level of Sacrum. These are a little laterally placed compared to the Points of Fasciitis pain and are out of the range of corresponding spinous processes. These fibrotic points are the result of previous cured acute low back pain that had left behind healing of these injured muscle fibers by fibrosis. These fibrotic lesion explained elsewhere results as irritating spots that causes a vicious circle of pain and spinal reflex finally leading to spasm of the local group of Muscles. This phenomenon finally takes the shape of Chronic Low Back Pain. These points are more deeply placed in the paravertebral muscles Mass.

Points of Lumbo Dorsal fascia:

There are certain points that are identified to be more laterally placed and are superficial. These points are more probably in the Lumbo Dorsal fascia. They may respond to injection therapy or may not and thus give controversial results. In the former case the pain is due to fibrosis while in latter case these are most probably neuralgic points. These may persist causing pain.

Points in and around hip joint:

This is the pain of the muscles around hip joint. Rarely these muscles harbor trigger spots that cause excruciating pain leading to lumbago-sciatica. These are rarely localized to the joint. However when they localize it becomes easy for the patient to point to the joint. Otherwise in these cases clinical presentation is so confusing that it makes it essential to treat the back and make it pain free before it become evident that the pain finally localizes in the trochanteric muscles. The incidence of these cases is very less. These trigger points are deep seated and difficult to access because of large muscles mass here.

Syed Zahid Hussain Bokhari, Latest on Osteoarthritis and Myalgia: The Technique of "Unmasking and treating the underlying problem. ISBN: 978-3-8454-3712-5 " LAP LAMBERT Academic Publishing, 2011

  • Lumbago- sciatica:
  • may be classified as:

    • Benign Lumbago- sciatica
    • Malignant Lumbago- sciatica

    1. Benign Lumbago- sciatica

    Chronic low back pain in certain conditions radiate the pain down to the buttocks or the lower limb on the affected side. There may be various radiological findings in CT Scan or MRI.

    However it is matter of chance that those radiological findings are there and they may not be causing the pain. There may be a big difference between a radiologist's findings and clinical response of the pain problem to the conservative treatment of pain management. In fact in these cases there may be various findings such as disc prolapse, cord stenosis, lipping, spondylolisthesis etc. But are these causing pain to the patient, is debatable. It is only possible by having executed conservative pain management therapy through this new treatment algorithm to the patient that the clinical response will reveal that the clinical symptoms were because of certain trigger spots that were amenable to treatment through injection technique. The radiological findings would persist but the patients would have markedly improved. Thus this Lumbago- sciatica would be benign. Majority of the cases are of the same order.

    It is important here to discuss that without this concept of trigger spots in mind, most of the patients are diagnosed as cases of disc prolapse and cord stenosis on radiological examination and are finally subjected to surgical treatment that may not always help the patient in relieving their symptoms. These surgeries then become injudicious and shall be avoided as they are not addressing the problem, but in fact are permanently disturbing the normal anatomy of the patient of the area subjected to surgery and reducing the chances of the patient to benefit from simple conservative procedures anymore.

    Thus patients of Chronic low back pain with radiological findings, that indicate towards surgical intervention, shall ideally only be subjected to surgery once they have been exposed to trigger spots therapy through the technique of "Unmasking and treating the underlying problem" and their problems still persist. However another criterion for surgical intervention could be neurological deficit demanding an early intervention to relieve compression. Thus we conclude that radiological findings are not always the true indicators of the cause of clinical symptoms of pain.

    2. Malignant Lumbago- sciatica

    These would be those cases of lumbago-sciatica that would have disc prolapse or cord stenosis as an organic cause leading to the symptoms of sciatica.

    Acute Pain in disc prolapsed cases seems to be an exaggerated response of the group of local Muscles (Para vertebral). These cause acute spasm and exhibit pain. Anxiety of the patient may add to it making it an absolute agonizing condition that requires immediate relief. They may respond well to the Pain Management. However as there is an organic cause and there is a prolapse that may be pressing upon various tissues including vessels and nerves in near vicinity thus the Symptoms of neurological deficit and referred pain along the course of the pressed nerve will persist. It will require correction as and when indicated. Simple conservative treatment of the injection technique only remains partially effective in helping these patients to get out of acute pain.

    It is particularly noted that problems pertaining to the low back pain are always of multiple nature. There would be a chance that along with this definite organic cause as indicated by radiological examination some trigger spots like fibrositis , fasciitis or sacro-ileitis may also be adding up to the clinical symptoms. Thus it is always paying to start the treatment in conservative and to treat the patients with the above technique. It results in the relief of the symptoms of the underlying conditions. Any pain due to disc prolapse or cord stenosis will persists at the end of the treatment. As an end result the surgeon can evaluate the patient far better, assessing the pros and cons of surgical treatment and can suggest the patient to live with, if the remnant problem is manageable.

    To conclude, in Malignant Lumbago- sciatica certain symptoms of sciatic pain may persist and the patient may require surgical intervention and would definitely benefit from it. However clinical results with the new treatment regimen show that patients with Malignant Lumbago- sciatica are just a fraction of the cases of low back pain.

    Residual Symptoms Complex "RSC".

    Syed Zahid Hussain Bokhari, Latest on Osteoarthritis and Myalgia: The Technique of "Unmasking and treating the underlying problem. ISBN: 978-3-8454-3712-5 " LAP LAMBERT Academic Publishing, 2011