Case Studies and Testimonials

The following are details of case studies and accompanying testimonials. Please select:

 Miscellaneous Letters and Notes of Thanks
 Case Study 1 - Intractable Shoulder pain following a road traffic accident
 Case Study 2 - Low Back Pain
 Case Study 3 - Intractable Post Surgical Knee Pain
 Case Study 4 - Complex Regional Pain Syndrome
 Case Study 5 - Sacro Iliac Joint Pain following Trauma




Miscellaneous Letters and Notes of Thanks

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Case Study 1 - Intractable Shoulder pain following a road traffic accident

History

Mr J B was involved in a serious road traffic accident.

He was in a traffic queue and his car was hit from behind at speed by a truck.

MR J B suffered several injuries but the most debilitating was an injury to the nerves supplying his shoulder.

When he first came to see me he had been living in constant pain for several years and going through a stressful medico legal assessment.

I initially tried a Cervical Epidural with Local Anaesthetic and Steroid which had some limited benefit. A repeat procedure had no effect at all.

I moved onto Pulsed Radiofrequency to the Cervical Nerve Roots C5 and C6 which supply the shoulder area. Mr Bolton found some very useful benefit with this treatment. He has now had two treatments.

Testimony

Testimonial"Dear Dr Gaspar,
I feel I have to write this letter to you just to let you know how pleased I am with your kind and considered treatment and utter concern for my well being.
As you know on Dec 11th 2006 I had a serious road traffic accident with severe whip lash injuries and suffered over the years until 2010 when I was referred to you for assistance.
You carried out a very professional examination and took the time to actually read through my notes and medical history and the consequence of this was that you carried out several treatments, some with moderate success and others not so successful. However you did not give up and carried on determined to find some sort of relief from the pain and discomfort I was in. You put yourself out even phoning me at night in your free time when you should have been spending time with your family or relations etc.

You persisted and eventually carried out your latest treatment which gave me great relief from pain and made my life a whole lot better and easier to bare.

I can honestly say that throughout my treatments with you, you have been most professional and concerned about my welfare and can only thank you for your concern and professional treatment when it is the norm to knock the doctors and the health service.

It is wonderful to get such treatment and care from a very busy and professional doctor who puts his patients before himself and I thank you once again.

Yours sincerely,

J B
"

Comments

Mr J B has suffered what is known as a brachial plexus injury involving the nerve roots C5 and C6. It has lead to what is known as neuropathic pain in the area involved.

Pulsed RF has proved useful in managing his pain. It could be repeated about 3 to 4 times a year. It may however become ineffective.

There are a number of other treatments that could help Mr J B such Peripheral Stimulation and Spinal cord stimulation, see animations on SCS for more information.

Mr J B is likely to require lifelong pain management.



Case Study 2 - Low Back Pain History

Mrs J S is and elderly lady. Her life was being increasingly restricted by left sided low back and buttock pain. My clinical findings showed up left sided facet joint and sacroiliac joint pain. (See animations for further information on these conditions)

I initially carried out some diagnostic/ therapeutic blocks to these joints using Local Anaesthetic and Steroid. Mrs J S had significant pain relief from these injections for several months.

The next time I did these injections I also carried out some Pulsed Radiofrequency to the nerves supplying the facet joints as well as LA and steroid injections. Mrs S has had now over 6 months benefit.

TestimonialTestimony

"Dear Dr Gaspar
I want to thank you for the wonderful treatment you gave me. I am an elderly lady who prided myself on being quite fit and enjoying long beach walks with my dog until I developed arthritis and the pain made me much less active- thankfully after your treatment I am able to enjoy beach and country walks again.
Yours sincerely
J S
"

Comments

Lumbar facet joint and sacroiliac joint pain is very common problem. It happens as a result of wear and tear of the spine and develops as people get older. It can be extremely restricting in terms of walking and standing and can come to restrict a person's life very considerably.

There are three recognised treatments for facet joint pain:
1) Injection of LA and steroid
2) Pulsed Radiofrequency to nerves supplying the joint.
3) Thermal Radiofrequency ablation or burns to the nerves supplying the joint.

It is my practice to carry out a diagnostic/ therapeutic block with LA and Steroid to the facet joints which should help for approximately 3 months. If this is successful then I will proceed to using PRF with LA and steroid and this usually extends the benefit to 6 months and possibly longer.

Thermal RF ablation can result in good pain relief for several years but the difficulty is that in a small number of patients the burnt nerves can send off unpleasant burning sensations. The original back pain may have been helped by the procedure but patients maybe left with a new very disabling pain. This is called Deafferentation Pain.

Most Pain Specialists use Thermal RF ablation for facet joint pain. However, I am treating several patients who have been left with Deafferentation Pain having had this treatment- this has occurred in one patient after a treatment I administered and 5 patients from Thermal RF treatments given by other Pain Specialists. It is therefore my practice not to burn nerve unless it absolutely necessary.



Case Study 3 - Intractable Post Surgical Knee Pain

History

Mrs D M is woman in her 30s who underwent a Knee Endoscopy for ongoing knee pain. Following the operation, she discovered that she had different sort of pain and also stiffness. Her Orthopaedic Surgeon undertook another knee endoscopy to see if there was anything that had been missed or a new problem. This only made the pain worse.

A second opinion was sought from a separate surgeon who undertook a further operation- again no benefit was derived and pain continued to deteriorate and intensify.

I saw Mrs D M some months later. She was very distressed and devastated by the fact that a relatively simple operation had left her in a terrible situation. Her knee was tense, swollen and her pain had come to dominate her entire life.

It was clear from the outset that this was no longer a mechanical or problem with the structures within the knee. This was clearly a nerve pain pathway disruption problem, i.e. this was a Neuropathic Pain problem.

I initially managed Mrs D M pain with pain medication such as opiates and anti neuropathic tablets called Pregabalin and Gabapentin (See Drug Information website page). These tablets helped for a while but Mrs D M started experiencing some unpleasant side effects. Concurrently, I first tried doing some nerve blocks to the sensory nerves which carry pain information the knee. I targeted these nerves at the area called the nerve root. This is where they form connections to the spinal cord within the spinal canal in an area called the Epidural Space. These Transforaminal Epidural Nerve Root Injections did not help very much. I then blocked the Sympathetic Nerves. Her pain was also controlled to some extent by Lumbar Sympathetic Nerve Blocks and these were repeated on several occasions. Unfortunately these injections became less effective in time.

Finally, she was referred for Spinal Cord Stimulation. Following a successful trial the patient went onto have a full system implanted.

Testimony

Testimonial"Dear Dr Gaspar,
I am writing to let you know that I have had my spinal cord stimulator fitted and everything is going very well with my pain control.

I had a two week residential course at St Thomas' Hospital in London in the October 2010 in preparation for the procedure. We did exercises, had information sessions, input from physios, review of medication info re coping strategies, pacing etc. The hospital have found that the implant is more successful if you are fully informed and prepared.

I had a weeks' trial with a temporary stimulator in Jan 2011 to make sure it would work for me.

I had the full implant on the 15th March and have just had a check up to see if everything is working as it should. The consultant asked me let you know that everything is going well and they are very pleased.

The hospital has been very supportive and has looked after me very well. The actual operation was at Guys and but all the other appointments are at St Thomas'.

I have also moved house to a bungalow and this is so much more easier to manage too. So all in all everything is going very well and I feel happy.

I would like to thank you for your help in getting my pain under control.

Yours sincerely

D M
"

Comments

This case highlights some important issues that I see in my Pain Clinic.

Firstly, whenever anyone has any surgery of any type, there is ALWAYS a risk that they may end up with a chronic nerve damage pain that may come to dominate their life. Once any tissue has been cut, there is a risk that the nerves supplying that area and taking the pain sensation to the spinal cord and the brain can become permanently damaged leading to Chronic Nerve Damage or Chronic Neuropathic Pain.

Unfortunately this is a fact that is often not recognised by many Surgeons and I hardly ever see Chronic Pain as risk factor mentioned on the consent form.

Furthermore when it does occur, it is often not recognised and as such the initial response of trying to deal with this problem by carrying out further surgery can often make things worse or "fire things" up in the already disrupted Pain Pathway.

Also, because there is a general lack of knowledge about the causes, manifestations and the impact of Chronic Pain, many Surgeons and Medical Practitioners are not sure how to deal with the situation and the patient. The whole thing can deteriorate.

The fact that Mrs D M could not find a satisfactory answer to her ongoing problems compounded her of sense frustration and desperation. In all types of post surgical pain, there are number pain procedures that can be applied to help reduce the intensity of pain.

Firstly, a full explanation is essential.

A combination of tablets and nerve blocks can usually help.

I usually try blocking the sensory pain pathways to see if it makes any difference and then I try blocking the sympathetic nerves. The Sympathetic Nerves control things like blood flow to the arms, legs and internal organs; they control sweating; they movement of the hairs on the skin surface in hot and cold weather.

When the pain pathway becomes disrupted the Sympathetic System can bizarrely become involved in abnormal pain generation. This is called Sympathetic Mediated Pain.

In this case I initially tried to block the normal sensory nerves carrying pain with what is known as Transforaminal Epidural Nerve Root Blocks but it did not make any difference. I then tried blocking the Sympathetic Nerves to the knee with a procedure called a Lumbar Sympathectomy, which did help for a while. When these injections failed Mrs D M was helped by Spinal Cord Stimulation.

Spinal Cord Stimulation is progressing very rapidly and it can be applied to a great number of chronic pain problems. This case illustrates its' successful use in post surgical knee pain.

Spinal Cord Stimulation should always be done using a Multi Disciplinary Team approach. I am very proud to say that my clinic works with some of the leading experts to provide this service both in my NHS and Private Practice.



Case Study 4 - Complex Regional Pain Syndrome

History

Mrs J C is a lady in her mid 50s. She fractured her right wrist after a fall. She went to the fracture clinic and it was put in a plaster of paris cast. This was removed after 6 weeks. Everything looked OK but she was still experiencing a great deal of pain and discomfort. She mentioned it to her Surgeon but reassured that all would be well and she was discharged from the clinic.

The pain and discomfort continued and also the hand and arm started to swell. Mrs J C tried to put it out of her mind but the pain and discomfort continued. After about a year following the initial fracture, she presented to my clinic. It was immediately obvious that she had a condition called a Complex Regional Pain Syndrome.

Mrs J C again did not do well on tablets. I tried a number of Sympathetic Nerve Blocks. Firstly a Stellate Ganglion Block which only had limited benefit, (see animations). This was followed by T2/T3 Sympathetic Block which helped to a greater extent.

However Mrs JC felt repeated blocks were not the way forward for her as she feared the return of the pain.

I tried a new technique called External Peripheral Neurostimulation. This involves the placement of a nerve probe over the skin close to the affected nerves and a current of a particular frequency is applied through a special power generator. This stimulates the nerve(s). In this case, I applied the probe to the brachial plexus (i.e. the collection of nerves that supply the arm) at the point where these nerves pass under the clavicle, (collar bone).

This gave immediate relief of pain and improved blood flow and arm felt much lighter for approximately 24 hours. I gave Mrs J C three treatments and each one lasted a similar length of time. Mrs J C decided to buy the machine herself and is successfully using the device at home to manage her pain.

Testimony

Testimonial"Dear Dr Gaspar,
We felt we must write in appreciation of the care that has been delivered by all concerned at the Pain Clinic. Each appointment or telephone consultation has always left my wife and I feeling totally confident in every aspect of your service.

We are both more informed about CRPS and the pain relief options.

Thank you Dr Gaspar

Kindest regards

JC
"

Comments

Complex regional pain syndrome (CRPS) is a chronic pain condition that can affect any area of the body, but often affects an arm or leg leading to intense pain and stiffness of the limb. We are not sure what causes CRPS. There are several theories but it seems to be an over exaggerated immune, inflammatory response to an injury or trauma leading to abnormal increased activity in the pain pathways and also the sympathetic system.

It is usually managed by a combination of antineuropathic medication and Sympathetic Blocks. If these treatments fail then the Spinal Cord or Peripheral (electrodes implanted around the nerve(s) or nerve complex) may be a therapeutic option.

In Mrs J C's case, I have tried a new technique being pioneered by colleague Dr Teo Goroszeniuk at St Thomas's Hospital in London, External Peripheral Neurostimulation. The results were dramatic.

I have several patients now who have responded to this treatment and have gone on to buy their own device and are successfully managing their pain at home.

It is proving to be a very useful, simple, drug free way of patient's taking control of their own Pain Management.



Case Study 5 - Sacro Iliac Joint Pain following Trauma

History

Mrs H H is lady in her late 30s who was involved in a horrific road traffic motorway accident. Several members of her family were killed. She survived but suffered a number of serious injuries and also suffered psychological trauma.

When the "dust settled" she was left with a constant debilitating gnawing sensation in her right lower back and buttock area.

Initially it was dismissed as psychological by her treating medical practitioners. When I saw Mrs H H about 2 years or so after the injury, I immediately felt that she had either damage to the L5/S1 facet joint or to the Sacro Iliac Joint. The MRI scan pointed in the direction of the L5/S1 as being the source of her problems.

I undertook a L5/S1 facet joint injection which was negative for any improvement to her pain. I subsequently undertook a SIJ block which gave immediate relief for about 2 months. I then went onto carry out a Sacro Iliac joint denervation using a technique called Cooled Radiofrequency Ablation/ Denervation.

Mrs H H received a 75% reduction in her pain and so far, this has lasted about 10 months.

Testimony

Testimonial" I was airlifted from the scene of a fatal RTA with severe injuries in 2007. My GP could only offer analgesic support to combat my debilitating, constant lower back pain. I found Dr Gaspar's Pain Clinic through word of mouth and self-referral for private treatment. Following initial surgery my pain has reduced to about 25% of the previous level, and has become much more manageable. I may need further operations but I have utmost confidence that I am in very safe hands. Most GPs are unaware of the potential of Dr Gaspar's clinic to change peoples lives. I would urge anyone to invest a small amount of time needed to see how he can change your life.

H H
"

Comments

SIJ pain is a very disabling condition. The transfer of pressure through the spine and into the pelvis and then onto the legs occurs through the correct function of this joint.

Mrs HH was not able to stand and carry out her daily activities.

The treatment of SIJ pain is not widely known outside of Pain Medicine circles. Physiotherapists really struggle to manage this condition. The nerve supply of the SIJ is very complex and comes from at least 10 separate nerves. The correct management involves a diagnostic/ therapeutic nerve block which if successful should be treated with Radiofrequency Denervation of all the nerves.

I have said in Case History 2, that it is not my practice to burn nerves unless necessary. This is the only condition at the moment where I carry out RF ablation treatment. The nerve supply to the SIJ is so complex that Pulsed RF is not applicable. Moreover there is separate technique I use called Cooled RF which helps create a larger burn as even conventional RF burns are not large enough to treat to cover all the nerves supplying the SIJ.

There is a risk of deafferentation pain with Cooled RF. The benefits need to be weighed against the potential risks. There are no easy answers.

At some point I expect Mrs H H's pain to return. The Cooled RF treatment could be repeated or there is an alternative involving Peripheral Neurostimulation which could be used in the treatment of this condition. Again this is being pioneered by Dr T Goroszeniuk with whom I work very closely.

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