Subject: Re: chronic pain and insomnia following multiple surgeries on ankle
Forum: The Neurology and Neurosurgery Forum
Topic Area: Pain
Posted by CCF Neurlogy MD:NT on October 09, 1998 at 23:54:55:
In Reply to: chronic pain and insomnia following multiple surgeries on ankle posted by JY on October 09, 1998 at 11:29:50:

He is 44 and an associate professor of anatomy and physiology at a community
college in Texas. He originally ruptured the proneaus longus tendon in his
right ankle 10 years ago. Since that time he has had 7 surgeries that have
attempted to help fix his ankle problem. His 6th surgery was in Nov 1997, 7th
surgery in July 98, and he is scheduled for a C-C joint fusion next week.

He has unrelenting pain in his foot, to the point he begs for amputation.
He describes the pain as burning, tingling, and so annoying he cannot think
of anything else.

He is unable to sleep, even though he takes quite strong pain medicine and
sleeping aids. He develops severe hives quite regularly. Large white, then
red, bumps appear that are raised and very hard and quite itchy. It has
been almost impossible to figure out if this is caused from a particular
medication because it happens very frequently with different combinations
of meds. He can sleep for only very short periods of time. He is very weary,
depressed, and feels quite hopeless. Because of his background, he understands
anatomy and physiology very well and constantly tries to figure out what
is going on. We feel quite sure that a big part of his problem has to do
with nerve malfunction either from multiple surgeries or some mechanical
problem with impingement. He enjoys nothing about life at the moment and
can't concentrate on anything. He is working with a foot specialist who
is trying to determine if he can fix any mechanical problems with his foot.

Any information or suggestions on how to treat or diagnose the nerve pain
would be very appreciated. He has seen a pain management doctor, had lumbar
blocks, MRIs, etc. We keep hoping that there will be something that can give
him relief.

Dear JY:

Your husband's symptoms may represent causalgia. Even relatively minor nerve injury (as may occur after trauma or surgery) can lead to a mis-wiring and loss of insulation in the small nerve fibers which can persistently fire even in the absence of stimulation. This can cause severe burning pain, commonly along with some swelling, redness, and excessive sweating. Some pain experts suspect that the sympathetic nervous system has a role to play in causing this pain, although this is quite controversial. Treatments such as pain medications, sympathetic blocks and nerve block, and even surgery have had variable success in uncontrolled studies.

Seeing a neurologist in a major academic center specializing in peripheral nerve problems to diagnose the possible nerve lesion, and subsequently following up with a pain specialist with expertise in regional pain syndromes would help.

In case a visit to Cleveland is feasible, I can strongly recommend Dr. Michael Stanton-Hicks, a pain specialist at the Cleveland Clinic who is a world-renowned expert on causalgia and other regional pain syndromes, and also one of the authors of a recent textbook on the subject. Appointments can be made by calling (800)223-2273.

Good luck!

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