November 19, 2018

Diverse Treatments Without Narcotics

An adolescent dancer with radiating lower back and hip pain, a teen soccer player suffering severe concussion related headaches, a 9-year-old Little League pitcher with nerve impingement in his right shoulder, neck and back—what do they all have in common? Where orthopedic treatments fell short, they found complete relief from their chronic pain through steroid injection therapy with pediatric pain specialist Irfan Suleman.

The dancer, 14-year-old Grace Megargel of Forest Hill, Maryland, was born with a lowest lumbar vertebra abnormally joined to both the right sacrum and ilium, which resulted in chronic pain exacerbated by standing, sitting or leaning forward, and especially by dancing. Her congenital abnormality was missed until Johns Hopkins pediatric orthopedic surgeon Paul Sponseller detected it on a scan. While fusing the left side would ease the girl’s pain, Sponseller noted, it would also limit her mobility. As a first step, he suggested steroid injection therapy with Suleman.

“I reviewed the MRI with the radiologist and developed a plan to see if a right sacroiliac (SI) joint injection would help,” says Suleman. “Her injection was a bit more challenging because of a small lumbar cyst, but we delivered the injection and the pain is completely gone.”

The injection is also diagnostic regarding how the patient responds, notes Suleman. “If the pain goes away, it was coming from the SI and not somewhere else,” Suleman says.

He adds, however, that because of the nature of her competitive dancing activity, the pain may return and require another injection. “But we know where the pain if coming from, the source of the pain, and we know how to manage it.”

The soccer player suffered a concussion after an opposing player’s elbow hit her head. After evaluation at a concussion clinic for intermittent pain on the back and right side of her head, the patient was referred to Suleman. He injected a right occipital ultrasound guided nerve block, resulting in complete resolution of her pain.

Similarly, Suleman found an answer for the young pitcher whose pain was so intense, and the top of his right shoulder was so sensitive, that he would jump at the slightest touch. Another provider prescribed a topical lidocaine patch, which failed to relieve the pain. Suleman, who identified the culprit as a suprascapular nerve impingement, took a different tack.

“After targeting the nerve with an injection, there is no more hypersensitivity,” says Suleman. “He’s back on the mound, pitching again and everything is back to normal.”

Suleman administers the injection treatments to young patients under deep IV sedation to reduce their risk of moving, which can cause complications. Steroid injections do not come without risks, he notes, including suppression of the immune system with too many injections. To reduce risks, Suleman minimizes injections and, with the aid of ultrasound and fluoroscopy imaging, targets treatments precisely to the problem area. He also adamantly promotes collaborative holistic pain management without the use of narcotics.

“In our multidisciplinary clinic we go into great detail in a three-hour evaluation to identify any mechanical problems and behavioral issues in the patient’s life, and diagnose exactly what is going on,” says Suleman. “On that basis we determine whether the patient is in need of a stressor treatment, physical therapy, or an intervention. With the correct evaluation, we can focus on the right treatment.”

The pediatric interventional chronic pain management service at Johns Hopkins is among only a few such programs in the country. For more information, visit the Pain Rehabilitation Program website.