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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 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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stepG

Figure G. CL-HA injection, 0.15 cc, L5.

Step 3c: For the S3-S4, due to the normal convexity of the lower sacrum, slowly insert a 2-inch, 21G hypodermic needle at a 30º angle laterally from the perpendicular, through the skin wheal until it first encounters tissue resistance (take caution not to perforate the sacral foramen and enter the sacral portion of the spinal canal) (see Figure H). Fix the hub of the needle with the opposite hand to lock its position in place, and then slowly introduce 0.2 cc of the injectate at each site.

stepH

Figure H. CL-HA injection, 30-degree approach angle, S4

Step 3d: For the regional and sclerotomal innervation of the greater trochanter (sciatic nerve and L5 nerve root), slowly insert a 1½ inch, 25G hypodermic needle perpendicularly through the skin wheal until its first encounters tissue resistance. Fix the hub of the needle with the opposite hand to lock its position, and then slowly introduce 0.15 cc of the injectate at each site (see Figure I).

stepI

Figure I. Cl-HA injection, 0.15 cc, greater trochanter (sciatic nerve and L5 sclerotome).

stepJ

Figure J. Compression and extension of the viscous CL-HA infero-laterally.

Compression and Extension of CL-HA

Step 4. The CL-HA is notably viscous. To increase its extension and coverage along the long axis of the target nerve, firmly compress the injectate infero-laterally using an applicator and/or the operator’s digit (see Figure J). Dress the wounds with sterile adhesive bandages (see Figure K).

stepK

Figure K. Sterile dressings.

Post-Procedure Assessment & Follow-Up

Step 5. Assess the degree of pain relief/score at 20 min. There may be no change to a drop of 2 to 3 points. At 72 hours, maximal relief usually develops. Note that some patients may struggle in using the concept of pain scores; in this case, the patient was asked for a simple overall percent improvement in relief of pain.

Step 6. The need for additional treatment may be determined by contacting the patient at 72 hours and 1 week. A visual analog scale pain score of 0 to 4 out of 10 is to be expected, with a duration from 8 weeks to 6 months. These results may continue to improve after repeated CL-HA injections. In some cases, depending on the underlying pathology, there may be permanent relief of neuropathic pain.

Last updated on: August 1, 2018
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Cross-Linked Hyaluronic Acid for the Management of Neuropathic Pelvic Pain
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