Case 2 Gareth Suneil Ramessur Mbbs Bsc Hons FRCA DipHEP

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Gareth, 40-year-old man, is referred to you with persistent pain and tingling around his neck and upper limbs. The pain started following a road traffic accident during which he sustained whiplash injury several months ago. He has tried various pain killers and physiotherapy without much benefit. The attending neurologist has requested you to see Gareth. A recent MRI of cervical spine is showing arthritic changes in the cervical facet joints.

Explain your approach to Gareths problem?

Though the presentation and investigations indicate pain secondary to the whiplash injury and cervical facet joint arthropathy, it essential that a detailed first-hand history and clinical assessment are performed.

During your session with Gareth he reveals that he is a former intravenous drug abuser. Your examination reveals tenderness over the lower paracervical regions and trigger points of trapezius and sternocleidomastoid muscles on the right side. Gareth explains that his pain is a constant and dull ache and his sleep is disturbed due to the pain. He also mentions that there is an ongoing claim for compensation from the insurance company. You offer to inject the trigger points and perform a cervical facet joint injection. Gareth accepts this and undergoes the treatment.

A few weeks later Gareth is back to see you and states that the injections did not work. He wants to know why the pain is persisting. During your interview, Gareth admits that the court case is not going in his favor because of the past history of drug abuse.

What is your explanation?

In whiplash injury, pain course can be difficult to predict. Pain can persist for many years. There could be periods of remission and exacerbation. Regular medications and interventions such as physiotherapy, trigger point injections, and acupuncture have all been tried with variable success. Another interesting aspect of pain in such situations is that the ongoing litigation can have a profound psychological effect and can affect patient's perception of pain. Pain is highly subjective and as a pain specialist you have to trust your patient in order to perform proper assessment and recommend appropriate treatment.

Gareth says he would like to try acupuncture as one of his friends has had some success with it.

What would you say to Gareth?

Pain experience is purely subjective. In situations like whiplash injury, there is no single measure that is 100% successful. In fact, a multimodal approach is often the favored path. You should always try to give a thoughtful consideration to the patient's beliefs and preferences. You agree that Gareth should try acupuncture, while continuing his medications, physiotherapy, and rehabilitation program.

Three weeks later Gareth is back to see you. He is looking very unwell. He tells you that his pain is now throbbing in nature and is constant. It is radiating to his neck and arm. He mentions that he is coughing up blood. You notice that his voice has become hoarse and there is a diffuse swelling over the right supraclavicular area.

What should you do now?

Since his symptoms are rapidly progressing, it would be prudent to arrange for an immediate investigation of his neck. An ultrasound or CT/MR scan would be an appropriate choice. It is possible that the pain may be due to a vascular abnormality. You should check his hemoglobin level and arrange for a vascular surgical consult. You are soon informed that the CT scan demonstrates an aneurysm of the subclavian artery. He consequently has surgery to correct it. You see Gareth four weeks after his surgery and he is pleased to inform you that his pain has now resolved. He also informs you that he has won the lawsuit.

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