Injection of Cross-Linked Hyaluronic Acid For Neuropathic Pain – Practical Pain Management – June 15, 2017
Postsurgical neuropathic pain is a frequent problem
I have developed a treatment method that uses commercially available cross-linked hyaluronic acid (Restylane and Juvéderm) that provides prolonged, significant relief without side effects.
The first use of cross-linked hyaluronic acid to treat neuropathic pain was presented at the 2015 Annual Meeting of the American Academy of Pain Medicine in National Harbor, Maryland.
In the 34-month retrospective chart review, 15 neuropathic pain patients (7 women, 8 men) with 22 pain syndromes were studied. The average age of the patients was 51 years, with a mean pain duration of 66 months. The pretreatment average visual analog scale (VAS) pain score was 7.5 out of 10. After treatment, the VAS was reduced to 1.5 out of 10, and the average duration of relief was 7.7 months
Since I presented my original work, I have treated an additional 75 patients with similar pain syndromes (ie, postherpetic neuralgia, carpal tunnel and tarsal tunnel syndrome, Bell’s Palsy tinnitus and head pain, etc)
Due to the likely mechanisms of action at work, I have designated this method of treatment as Cross-Linked Neural Matrix Antinociception (XL-NMA)
I present a case report of a patient with persistent neck and hand pain after undergoing cervical spine surgery.
Hyaluronic acid (HA), a proteoglycan, is a linear anionic polysaccharide3 composed of glucuronic acid and N-acetylglucosamine repeating units. It naturally occurs throughout the extracellular matrix (ECM) of the skin (56%),4 connective, epithelial, and neural tissues.
Cross-linked HA is an FDA-approved, commercially available cosmetic agent, which is marketed under the brand names Juvéderm
While the native, non-cross-linked form of HA is a liquid and metabolized in a day, the molecular cross-linking of the HA binds its individual polymeric chains and forms a viscoelastic hydrogel, accounting for its longevity (6 to 12 months) and its hygroscopic ability to absorb 1,000 times its weight in water.
A 60-year-old male came to our office in April 2016 with persistent neck and bilateral hand pain after undergoing posterior cervical spine decompression at C3-C4, C4-C5, with posterior fusion, local autograft, and posterior segmental instrumentation, with lateral mass screws at C3, C4, C5. His neck injury occurred in April 2015 after a backward fall at work, when he struck his head and felt a pop in his neck.
Postoperatively, he developed increasing pain and numbness, with severe constant burning pain to the dorsa of both hands and neck (Figure 1). During anteroflexion of his neck, severe electric-like shocks radiated down his neck and spine to both upper and lower extremities. The numbness in his hands was most severe when lying on his right side.
In late April 2016, the patient’s right hand was treated with Restylane (0.15 mL). The injectate was administered by placing a port with a 20-gauge needle, and then inserting a 27-gauge microcannula (DermaSculpt) with a blunt tip. To compare, the left hand was treated with a mixture of 2% plain lidocaine (2 mL) and 0.25% plain bupivacaine (4 mL). The dose per site was 1.0 to 1.5 mL
Twenty-four hours after the procedure, the patient noted that digits 4 and 5 on his right hand had persistent palmar numbness but no pain, while in digits 1, 2, and 3, most of the numbness was gone but his fingertips still hurt (pain score, 4 to 5). The burning numbness in the dorsal hand had completely resolved. Overall, he felt 75% improved.
At 4 months, the patient noted his right-hand pain remained 75% to 85% improved, with a tolerable level of numbness in the lateral aspects of digits 1 and 2. There were no untoward reactions or effects.
Note: Any relief from the local anesthetic administered to the left hand had resolved 1 week after the procedure, with his pain returning to baseline in that hand. Interestingly, the patient noted that although the burning numbness pain on the top of his left hand had resolved after local anesthetic injection, it was replaced by a very unpleasant, annoying sensation of numbness.
The article continues with many more details.