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Thoracic Paravert. DRG PRF

Dr. Gil Faclier on March 28, 2018 at 10:29 am

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    • Gil FaclierDr. Gil Faclier
      Joined: Feb 14, 2016
      Posts: 1

      I have a 20 year old male with unexplained right abdominal pain. The Patient had a appendectomy. Pathology “appearance shiny & glistening”. Microscopic appearance, chronic inflammation. Pain unresolved. Multiple imaging, US, etc. Pain corresponds to levels T8-10 ie right flank to umbilicus. abdominal soft with mild tenderness RLQ. Abdominal wall entrapment negative.
      The parents have heard of PV DRG PRF
      Very sane family. No evident psych issues.
      Does anyone have any experience, advice as this man is young. I have explained to all that this does not give him a diagnosis and if successful, is temporary.

      • Gabor B RaczGabor B Racz
        Joined: Mar 28, 2016
        Posts: 30

        This is a very rare problem with two possible etiologies. I was called by Mohammed Tariq, M.D. recently to look at a patient from Pakistan with many years duration of severe loin, flank, umbilical pain and Allodynia. The patient could not stand any contact and he already had three DRG electrodes and two more to the T9 nerve root. The patient following this had almost no allodynia, still some pain and was able to sit up and touch his toes. I recognized the condition to be similar to a couple of others I had seen in London were Adnan Alkaisy, M.D. had placed two 8 contact electrodes. One of them was posterior to the nerve roots covering T9 10 and 11 and a T8 and down to T9, 10, 11 just towards the painful side dorsal column stimulation with excellent results. There is a name for this condition……”Nutcracker Syndrome” and Loin Pain with Micro-Hematuria and Macro-Hematuria. The supposed mechanism is the innervation of the kidney, where the artery and the vein or a split in the artery compresses the nerves. The name of surgery is “Switch Operation”, sometimes utilized with apparently a loss of the Kidney. I called Dr. Alkaisy last night and he is reporting a large series of this condition. He recommends that there should be epidural nerve root mapping published by Larkin, Carragee and Cohen a prospective randomized double blind trial. The second diagnostic option is described in the Second Edition of Techniques of Neurolysis, a 13 year old girl had abdominal wall pain T 10 pain and was unable to sit up and bend forward to touch her toes. She had her gall bladder taken out and the appendix as well in a prolonged hospitalization. The pain remained unchanged; I did a mapping in the area of T9, 10, 11 and found her epidural space densely scarred down from what appeared to be a leaky disk. Not significantly deformed, but thinner, Did Thoracic Neuroplasty and a 5 day infusion of Local Anesthetic and Fentanyl that resulted in several months pain relief and repeated the infusion procedure two more times. The last visit was a rather long drive to report that she had no more pain and was happy. The etiology is either a renal artery innervation issue with compression of the nerve or discogenic scarred nerve root.
        Can the patient touch his toes?
        Have you done a Dural Tug?
        Has there been a Thoracic MRI report?

        • Gil FaclierDr. Gil Faclier
          Joined: Feb 14, 2016
          Posts: 1

          Thank you for the comments
          Patient has full back & thoracic ROM.
          Thor MRI normal.
          Dural tug &epidural mapping. Please explain the technique
          Can you explain epidural mapping
          Please include the reference Larkin, Carragee and Cohen
          – Gil Faclier

            • Gabor B RaczGabor B Racz
              Joined: Mar 28, 2016
              Posts: 30

              Thank you for your continued interest.

              The dural tug is explained below:

              To appreciate the dural movement, I suggest you review the Cervical Neuroplasty video on Paincast in a patient that had three electrode placed at the C2 Level for Nucleus Caudalis stimulation. Electrodes adhere to the dura and indicate dural mobility. The dura is inserted to the foramen magnum and during the flexion rotation of the patients head and neck, the dura moves from 1 – 1.5 vertebral body lengths. The most richly innovated structure is the posterior longitudinal ligament. Therefore the Dural Tug is performed with the patient sitting up and then bending forward as much as possible and you flex and push the head down. This movement of the dura causes the patient to identify the exact location where the pain is coming from which is were the dura is adhered to the posterior longitudinal ligament. The picture of the lady pointing was taken the day before her procedure and the skin is marked with a pen. The next day the right picture has the patient were the Dural Tug is initiated and she points to the left side at the L2 Neural Foramen which is where the pain spiked during the TUG. This was confirmed by flouroscopy with a pointer to the left L2 Neural Foramen. Inter-laminar catheter mapping and Neuroplasty was performed on this patient and she had 3 years of complete pain relief I hope this helps and I will attach a video where I have one of my patient’s doing a Dural Tug” soon.

              With regards to mapping:

              Mapping is identifying painful nerve roots in the epidural space by sensory rate (50hz) stimulation with usual epidural catheter placement preferably with the RX2 coude needle for safety and ability to direct the catheter towards the target site. 

              CATHETER – Needs to have an exposed stainless steel spring tip (Brevi-Kath or Tun-L-XL™/24 Epimed Int.) which is used as the active negative electrode by alligator clipping onto the metal stylet. The positive electrode is either an alligator clip to a ground pad or onto a needle that has been placed under the patient’s skin to complete the circuit. Once you are close to or touching the nerve root, just contact can elicit pain. The mapping is the process of slowly increasing voltage in the 0.345 volt range. The patient is instructed to report any sensation of stimulation (i.e, paresthesia) and then the patient is asked “DO YOU FEEL IT” or tell as soon as you feel it. Followed by “IS THIS YOUR PAIN”. 

              The stimulating catheter now moved to the next level and the same process is repeated, followed by the next level. Once the painful nerve root is identified, you verify by repeat stimulation by patient recognition. 

              The patient will be able to identify the painful nerve roots without causing pain by just reaching the sensory threshold and recognizing the pain pathways.

              • Gil FaclierDr. Gil Faclier
                Joined: Feb 14, 2016
                Posts: 1

                Thanks very much for your explanation and help

              • Nitin Goyalnitin goyal
                Joined: Mar 13, 2018
                Posts: 0

                Hello sir, any diagnostic block like sympathetic plexus block given?? Sharing a wonderful article on mapping. thank you


                The Evolving Treatment Of Pain


                • Abdelfatah AmrAbdelfatah Amr
                  Joined: Mar 1, 2016
                  Posts: 3

                  Any suggestions regards interventional management for malignant thoracic pain ( mesothelioma and breast cancer). DRG RF is not always effective is there another effective approach?


                    • Harold CordnerHarold Cordner
                      Joined: Apr 16, 2016
                      Posts: 0

                      Try SCS with the lead lateral toward the gutter. I have had great success with this approach

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