Tophaceous Gout Treated with Krystexxa (uricase) and Anakinra (Il-1 inhibitor)

This 37yr old man had severe gout and first presented for treatment aged 26. Conventional management with Allopurinol failed over the years and when he re-presented to me at KHMC this young working father was severely affected, in great pain  and significantly disabled by widespread, tophaceous gout.  Gout is caused by an accumulation in joints and tissue of uric acid. In severe cases, the urate forms visible deposits called tophi. This is called tophaceous gout and is exceptionally difficult to treat conventionally. Continue reading

Resistent lateral Epicondylitis (Tennis Elbow) treated by autologous Platelet rich Plasma injection

The patient was in her late forties and works in an office occupation involving a good deal of keyboard work.  She developed pain on the outside of the elbow causing problems with  grip, lifting everyday objects and work functions. The problem worsened and she was treated with a steroid injection along with physical therapy and splinting, the repeated both  times with only transient benefit. I therefore treated her with aPRP injection under ultrasound control to the areas of inflammation on he lateral epicondyle.  She told me it was pretty painful and it took about 2 months but she is ow completely pain free.

aPRP is a recently described treatment for tendon and soft-tissue injuries.  A volume of the patient’s own blood is removed and centrifuged (spun) under sterile conditions to separate the platelet cells which are then resuspended in the patients own plasma (blood fluid) and used by injection.  Platelets cells are biologically active and secrete growth factors and other agents which have anti-inflammatory and tissue repair effects.  They can succeed where the conventional steroid injections  fail, as here.  Reported outcomes are more long-lasting than simple steroid injection.

Importantly the regenerative effects and the fact they are very safe in use may make them a better choice for certain conditions where repeated use of steroid is to be avoided because of potentially weakening effects of steroid in tendons and cartilage.  aPRP is also being used in knee regenerative procedures and works as an effective injection for inflamed knee joints (Prof Annan Shetty, personal communication).

 

Knee Pain Treated by Geniculate Nerve Pulse RF

This  patient is a busy 50 year old with advanced OA of the knees. He is still working, coaches football and likes to b out and about. Once again he is much took young to consider knee replacement and has had previous arthroscopic treatments.  He has good function but is beginning to struggle with the persisting pain, especially after hard session of coaching.  I treated with Hyaluroanan injections (synvisc) and combined these with PRF (Pulsed Radio Frequency) modulation of the 3 main sensory nerves to the knee (The Geniculate branches as shown below).  He is currently almost pain free and very pleased with the response.

This image shows electrodes in position to treat the right knee with pulse RF pain modulation to the 3 main "Geniculate" nerves to the knee.

This image shows electrodes in position to treat the right knee with pulse RF pain modulation to the 3 main “Geniculate” nerves to the knee.

The reported technique related too this is to use RF Heat lessening to remove the nerve supply permanently.  Pulse RF energy, on the other hand, modulates nerve pain transmission but does not remove the nerve altogether and one must expect the pain to return. However PRF treatments are usually durable and responses of 12 -24 months are not uncommon. This is a new treatment and for the moment I am more comfortable with modulating rather than removing Geniculate nerves, particularly in younger patients until there is more experience with the technique.

Severe OA Hip Pain Treated by Femoral and Obturator nerve Pulse RF and Injection

Patent was a lady in her early 60’s with advanced OA of the hip considered too young for surgery and advised to seek conservative treatment.  I employed a combination of injections of a small volume of steroid and hyaluronan joint injections along with Pulse RFR modulation of the sensory nerves to the hip (i.e. all 3 available treatments).  The results were a dramatic and in my experience exceptional relief of pain.  A very notable feature was the restoration of hip function. Prior to treatment the patient felt her hip was weak and she had great difficulty flexing it – for example she had to lift her leg up to get it out of the car. It had been like this for many years. After treatment she could move it normally and apparently with normal power.  I think this reflects a combination of a bit of joint lubrication but importantly loss of inhibition of muscle function by pain.  she is currently almost completely pain free and delighted to be so.

This is entirely new treatment, neither I nor the patient knows how long it will last but responses to Pulse RF treatments are usually quite long-lived, up to 24 months in dic treatments. I will update as and when the patient returns.

The image (from Kimberley Clarke) shows electrodes in position to treat the obturator and femoral nerve branches which supply pain sensation to the hip.

The image (from Kimberley Clarke) shows electrodes in position to treat the obturator and femoral nerve branches which supply pain sensation to the hip.

MODIC antibiotic therapy (MAST). Antibiotics for Back pain

There have been sporadic reports in the literature over many years that certain cases of back pain characterised by a particular MRI appearance of the vertebrae called Modic change (after the clinician who described them) are associated with the presence of low grade infection in the adjacent intervertebral disc.  In May of this year, Dr Hanne Albert of the University of Southern Denmark published a landmark trial of the use of high dose antibiotic (Augmentin/Co-Amoxiclav: a standard Penicillin based antibiotic) in a group of patients with back pain, with really excellent results (Eur Spine J. Online 13 Feb 2013, paper available on request).  Continue reading

Complex disc-related (discogenic) back pain and sciatica treated by Disc Fx . Black disc on MRI

Intervertebral discs can tear through and through causing slipped disc sciatica as in case 3 or they can partially tear and cause complex patterns of back pain and sciatica, often bilateral. The history is of episodes of back pain and spasm (“my back goes out”) becoming more frequent and severe and finally pain is continuous with further episodes of worsening, often with trivial provocation or even spontaneously. Continue reading

Day Case Endoscopic Discectomy for a young mother with severe sciatica

This young mother developed back problems in pregnancy which worsened with the demands of motherhood culminating in the onset of intense, severe disabling sciatica due to a slipped disc. She presented within 2 weeks disabled by severe pain. MRI scan confirmed a large slipped disc a t L5/S1 (figure 1).  Initial treatment with a targeted nerve root steroid (epidural) injection made little impact. She was disabled from looking after her child and the pain could not be controlled.  At this point she would be candidate for conventional open microdiscectomy surgery but, in view of her family demands, she did not want to have to go into hospital, nor to have the time off required to recover from surgery. Continue reading