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15 Articles in Volume 18, Issue #5
Chronic Pelvic Pain: The Need for Earlier Diagnosis and Diverse Treatment
Cross-Linked Hyaluronic Acid for the Management of Neuropathic Pelvic Pain
Fentanyl: Separating Fact from Fiction
Gender Bias and the Ongoing Need to Acknowledge Women’s Pain
Letters to the Editor: 90 MME/day Ceiling; Ehlers-Danlos; Redefining Pain
Post-Menopausal MSK Pain and Quality of Life
PPM Welcomes Dr. Fudin and Dr. Gudin as New Co-Editors
Practitioner as Patient: Understanding Disparities in CRPS
States Take Action to Manage Opioid Addiction
Step-by-Step Injection Technique to Target Endometriosis-Related Neuropathic Pelvic Pain
The Many Gender Gaps in Pain Medicine
The Need for Better Responses to Vulvar Pain
Topical Analgesics for Common, Chronic Pain Conditions
Topical Medications for Common Orofacial Pain Conditions
What’s the safest, effective way to taper a patient off of opioid therapy?

Step-by-Step Injection Technique to Target Endometriosis-Related Neuropathic Pelvic Pain

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This article describes a technique described in the full paper:  Cross-Linked Hyaluronic Acid for the Management of Neuropathic Pelvic Pain.

 

Supplies and Materials

stepA

Figure A. CL-HA procedure tray.
 

The injectates used in the presented case came prepackaged in a 1 mL syringe (Restylane11 and Juvéderm12). The hyaluronic acid (HA) content was 20 mg/mL and 24 mg/mL, respectively. The procedure tray is shown in Figure A. The volumes used ranged from 0.15 to 0.25 mL per site. However, the amount used was a function of the virtual injection compartment’s volume surrounding the neural target. For the S3 and S4 site, 0.25 ml was necessary. However, as the dose increases per site (0.5 to 1mL), extra-arterial tamponade must be considered and immediately treated if it supervenes (ie, hyaluronidase [Hylenex] or recombinant hyaluronidase administered to quickly dissolve the injectate, along with any other measures to maintain and support arterial blood flow). In this case, no significant arterial blood flow was at risk.

The following steps were applied in the case presented and may be considered in similar cases.

XL-NMA Technique

Step 1. Subserving Sensory Nerve Identification:20-21 Clinically determine the principal sensory nerve or neural complex subserving the affected painful area (ie, rt. dorsal cutaneous nerve branches of T11-L5, S1-S4, sciatic nerve, and L5 nerve root (see Figures B-D).

stepB

Figure B. Sensory nerve sites subserving painful region.

stepC

Figure C. Patient Lt. lateral decubitus - localization of sensory neural points and nerves subserving painful region of greater trochanter (sclerotomal sciatic nerve and L5 nerve root).22

stepD

Figure D. Localization of sensory neural points and nerves subserving painful region, T11-L5.

Note that sensory afferent pathways may be variable (eg, the respective innervated dermatome, sclero-tome, myotome, or all three). This variation is typical in a chronic pain state.

Step 1a. When several nerves are involved, perform differential nerve blocks separately (test injections of possible nerves with local anesthetic, 1 to 2 mL, 2% plain lidocaine). After 10 min, assess the relief after each neural point injected. The neural point that provided the most relief will be the first target for the cross-linked neural matrix antinociception (XL-NMA). Keep anesthetic volumes low to avoid local anesthetic spread across various nerves. After the most responsive nerves have been identified, wait 3 to 7 days for complete anesthetic washout and then schedule XL-NMA.

Step 1b. Identify and mark the target sensory nerve points for the rt. dorsal cutaneous nerve branches of T11-L5, S1-S4, sciatic nerve, and L5 nerve root as shown in Figures B-D. The various target points for the dorsal cutaneous nerve branches of T11-L5, are for the most part, just lateral to the transverse process at the level of the myofascial plane (see Figure E). For the S1-S4 targets, these are located at the level of the posterior sacral foramina’s myofascial plane S1-S4 and the affected anatomical region of the sciatic nerve and L5 nerve root sclerotomal innervation are also found at the level of the myofascial plane, lateral aspect of the greater trochanter, where usually three distinct sites can be identified.

stepE

Figure E. CL-HA injection, tissue resistance plane, L4.

For all nerves, with the exception of S3 and S4 (S4 sacral nerve is variable, and not present in all patients, hence, for completeness, it is treated routinely), aim perpendicularly and inject just above the myofascial plane. For the S3 and S4 nerves, enter and aim the needle at a 30º angle laterally from the perpendicular. The S5 sacral nerve was not treated in this case. However, it may be a valid target in other cases as it is a component of the coccygeal plexus, which also includes a branch from S4, and the coccygeal nerve, forming the anococcygeal nerve and thereby providing sensory innervation to the skin in the coccygeal region.

Step 2. Skin Wheal Preparation

Cleanse the target treatment area with alcohol, and raise a skin wheal with a mixture of 0.5 mL 2% plain lidocaine and
1 mL plain bupivacaine using a 30-gauge, ½-inch needle (see Figure F).

stepF

Figure F. Skin wheal preparation.

Injection of Cross-Linked Hyaluronic Acid

Step 3a. For the dorsal cutaneous nerve branches of T11-L5, slowly insert a 1½-inch, 25G hypodermic needle perpendicularly through the skin wheal until it encounters tissue resistance. At that point, with the opposite hand, fix the hub of the needle to lock its position in place (see Figure G), and then slowly introduce 0.15 cc of the injectate at each site.

Step 3b: For the S1-S2, slowly insert a 1½-inch, 25G hypodermic needle perpendicularly through the skin wheal until its first encounters tissue resistance (take caution not to perforate the sacral foramen and enter the sacral hiatus portion of the spinal canal). As above, fix the hub of the needle with the opposite hand to lock its position in place (see Figure G), and then slowly introduce 0.15 cc of the injectate at each site.

Last updated on: August 2, 2018
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Cross-Linked Hyaluronic Acid for the Management of Neuropathic Pelvic Pain
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