The patient is a 18-year-old male who was involved in a severe dirt bike accident in 2005. As a consequence to the accident, he underwent multiple facial reconstructive surgeries and eventually a cervical surgery to repair a CSF leak at the level of the C5-C6. According to his mother he did have a CSF cyst that was compressing the structures in that area, the patient had surgery on the cyst. According to his mother they connected the cyst through the intrathecal space in order to have the cyst drain its fluid into the intrathecal space. This procedure did not help to relieve the patient’s pain. He continues to experience neck pain that radiates into the thoracic area and low back, which is severe enough to interfere with his enjoyment of life. He has been taking opioids and muscle relaxant which marginally helped control the pain. The patient’s description of the pain: Burning, aching, throbbing, stabbing, and pressure like sensation.Duration: Constant. Intensity: 7/10. Radiation and distribution: Posterior neck and radiates down into the thoracic and low back area. Aggravating factor: The patient states that any kind of physical activity that causes exertion would aggravate his pain. Alleviating factors: Nothing.
2. Status post trauma with multiple facial reconstructions.
3. Arachnoid cyst that extends from the cervical spine into the lumbar spine.
4. Neuropathic pain.
1. I strongly recommend the patient to stop smoking since this only aggravates the problems.
2. Lyrica 75 mg once a day. He does complain of burning pins and needles pain. He tried Neurontin in the past, but was discontinued for reasons that are not clear to me. I discussed with him the risk, benefit, and alternative to the Lyrica and will try the medication for at least one month at a 75 mg once a day. If he experiences relief with this, we would titrate the medication up.
3. Recommend trigger point injections versus neural prolotherapy. I discussed with the patient and the family the performance of neural prolotherapy versus trigger point injection. We will try some trigger point injections today.
4. Followup in one week for evaluation and determination of continuation of the trigger point injection and neural prolotherapy treatment. Also, the patient will bring a letter from his primary physician stating whether they are going to continue with opiate regimen. At this time, no class 2 opioid will be prescribed to the patient. I discussed with the patient and the mother the risk, benefit, alternatives to use an opioid therapy. This is an 18-year-old male that will have pain for most of his life due to the multiple traumas and surgery that he underwent. It is in his best interest to find an alternative treatment that does not involve the use of opioid and will decrease or eliminate his pain. That is why, it is my recommendation to stay away or minimize the use of opioid as much as possible. We will also try some compounding gels that will be prescribed to the patient for future basis. The patient will follow up in one week.