Radio Freq Nuerotomy/Abalation and Pain Control Question

Hey everyone,

This Thursday I get the first side of my procedure done (which was previously done about 15 months ago) where they use a minimally invasive procedure/surgery to guide a heating element into the L5 region and create lesions on the medial branch nerve endings (after a few days, the pain signal gets atleast partially interupted until the nerve "heals".). The procedure is short lived, but its pretty painful and you are awake during it (the worst part being the electrical "jolts" use to test and ensure they have the right location.

Last time I had this procedure done, I received permission to take a breakthrough dosing of my Nucynta aka tapentadol (150mgs as opposed to 75) which DID really help with the pain. The downfall was that the side effects for Nucynta increase in a curve-like fashion rather than linear. The side effects are more like 4x as prominent on 150 as they are on 75, not 2x but it seems its pain relieving ability is a bit curved too. At a pain intensity of 8, 1 Nucynta can bring it down to about 6-7 while 2 could literally bring it down to 0 (about 90 minutes post medication). The side effects I believe are mostly from the NRI properties and can be quite intense to include auditory hallucinations, panic attack, mild but anxiety producing visual perceptive changes (corner of eye "ghosts", a stone looks like a bug for 2 or 3 seconds, ect) VERY vivid closed eye visuals (intense 3d dreams in which voices and imagines seem very real), and hyperventilation. I believe the opioid effects add to this somewhat, such as the naseua and sweating.

Its important to note the side effects from 75mgs for me are pretty well tolerated, only occasionally causing issues. At this dose, its cognitive effects are mild and "feels" more like an anti depressant than opioid.

Recently, when I saw my PM, I was in a pain spike, so I requested some presnidone and my doctor said no because it could interfere with the procedure (perhaps lower immunity and residule effects could make it seem like the pain reduction from the procedure was greater than it actually is??)

I know I'm going to be in higher pain than normal with this procedure. I also know my medication works better than for example hydrocodone (by far, and 80 percent of the time it provides adequate relief, overall im impressed with Nucynta), but not as well as hydromorphone for example. I have a pretty decent relationship with my doctor and I certainly don't want to jeopardize that.

I want to request a limited fill (3 day supply) of either morphine or hydromorphone, but after being turned down for presnidone, I'm kind of fearing this could be an issue. Should I not request it and then provided the pain comes (im about 75 percent sure it will go to an 8 or 9 on the scale) THEN request it?

I think part of my fear comes with previous dealings with the VA, who claimed I was faking my injury. My current pain management center ordered an MRI which confirmed the injury and thus got me started on proper pain meds. It took a while to get over the "its all in your head" approach from the VA, who seemed to think I had an "issue".  Any advice would be greatly appriciated.

I know how my body responds to hydromorphone in pain because when I was in the ER room about 2 years ago, that is what they gave me and I went from passing out pain to being able to walk out of the hospital the same day. It is strongly sedating and it did produce some mild but tolerable "delium" like effects, but they were far far more tolerable than the Nucynta and 4mgs of hydromorphone would provide equal relief to about 150mgs of Nucynta with less side effects. Hmmmm.

 

I really hope the procedure will provide some much needed relief...

If you have a good relationship with your Dr. I would just contact them again and tell them exactly what you are saying here. That you are really worried about the spike in pain you are going to have right after the procedure and what else can he recommend for you to do. And just say, "I know you do not want to do a round of Prednisone...is there something else perhaps that I can get for breakthrough pain for a few days afterwards until it calms down"? Especially mention the intolerable side effects if you were to just up your Nucynta..

And then see what he says. It certainly can't hurt to try...

Keep us posted!!

@momtokids...I was only given shots of hydromorphone, not the tablet. Upon leaving, they got permission from my PM to allow me to have a small script for percocet, which I was surprised of since I didn't request it. They gave me presnidone then too which REALLY helped. So in short, I'm unfamiliar with hydromorphone in tablet form but I do know its not as potent taken orally as it is via intermuscular injection. Oxycodone at low doses I can tolerate fine, but higher doses seem to have an unpleasant "stimulatory" effect, although not to the degree of a high nucynta dose. Thus the reason I was specifically considering a request for hydromorphone as its effects aren't stimulating.

A medication that can serve as breakthrough (lower dosing perhaps?) or a replacement for 2 or 3 days altogether (perhaps the same med at the next dose up?) seems like the two best options. I really don't want to be over medicated, but I'd rather be overly sedated then over stimulated with anxiety and wierd "mental" effects.


@Snowbunny, I think I am going to ask my doctor, I just need to get over this idea that I'm not going to the VA, I'm going to a professional pain management doctor that's affiliated with a major hospital. Thanks for the well wishes ;)

@straydog, they would not give me light sedation for the procedure, which kind of surprised me since it seems to be an option with some doctors. My doctor does ask to let him know if while heating it gets too painful so maybe that's the reason? Lidocaine itself also has a slightly "lethargic" feeling too. The worst part is trying to focus on the pain from the jolts while ensuring its not traveling down the leg.....by the time you say "I'm good" you are feeling quite a bit of pain as they turn up the amps each second or so.


Thanks for the comments everyone. :)

I do think I'm going to ask in the way snowbunny presented because honestly if they gave me presnidone, I'd take that over a break through med. However, I have to go back again in 3 weeks so I don't think presnidone will be an option till the other side is done, so it presents a good case for breakthrough medication as an alternative for what normally could be handled with presnidone.

Nucynta is a great medication overall..........but like most synthetic or new age pain medications, it has both its limitations and side effects.