In Search of the Best Pain Clinic in LA: Rare Disorders

By | September 8, 2011

I was always taught in medical school, "When you hear hoof beats, think of horses, not of zebras." But what happens if you find yourself standing in the middle of the Masai Mara?

 

In the search for the best pain clinic in Los Angeles, very few people use the ability to diagnose and treat rare disorders as a selection criterion for a number of reasons. Firstly most of the time the diagnosis turns out to be wrong. There is an old saying that I remember from medical school, “When you hear hoof beats, think of horses, not zebras.” Secondly treatment for these disorders is often only partially effective at best so proof of benefit is difficult to obtain. Finally there are the complicating issues of comorbidities. As in previous blogs, I think that a clinical example will do more to explain the problem than pages of discussion.

Tami, not her real name is a woman, who was sent to me by a young internist and hospitalist in the Encino Tarzana area, Alan Fozailoff (this is his real name) with the primary complaint of L arm and hand pain as well as R ankle pain. Because he is young and does a lot of work at the Providence Tarzana Medical Center emergency room and inpatient wards, the patients that Alan send me tend to be very interesting people. Tami had been working as a veterinary assistant about 15 years ago when in the course of her work a partially anesthetized Labrador Retriever got loose. As a result of the accident Tami suffered a severe laceration to her L upper arm and a fracture of the R ankle.

Ever since the accident she had suffered from a burning pain starting just above her left elbow and running down the ulnar border of her arm into the last two fingers of her left hand. She also suffered from a burning pain in the area of the right instep, despite that fact that surgical correction of her ankle fracture appeared excellent. Although only in her mid thirties, Tami was completely disabled by her injuries.

When I examined Tami I found that she was exquisitely tender in the area of the original laceration and repair in her left upper arm in the area of the spiral groove of the humerus. She was also exquisitely tender in the space between the tibia and fibula just above her right ankle.

Early on she was diagnosed as having reflex sympathetic dystrophy of her left upper extremity and had been treated with intermittent stellate ganglion blocks, which were effective but short lived. She claims to have had a sympathectomy of that extremity, but I could not find a scar in any of the usual places. I did find a scar on the medial aspect of the left elbow and asked her if she had undergone an ulnar nerve transposition. Tami said that it was done at the same time as the supposed sympathectomy.

I then asked her what diagnosis had been made with respect to her right foot. She told me that that pain in her foot was not as severe as the pain in her arm and that the doctors had alternately told her that it was arthritis or psychosomatic. In my examination of her I could find no evidence of either condition.

I told Tami that I thought that she had RSD not only of the left upper extremity but of the right lower extremity as well. Both injuries were classic. The laceration of the left upper arm was in the area of the ulnar nerve as was the distribution of her pain. The pain in the right instep corresponded to a branch of the fibular nerve, which had probably been injured either in the original ankle fracture or in the subsequent repair. The textbook presentation of this injury is the Maisonneuve Fracture, which presents as an isolated fracture of the head of the fibula, but which always involves a tear in the syndesmosis between the tibia and fibula. The fibular nerve in the lower leg runs in this syndesmosis and is often injured in ankle fractures. Although the Maisonneuve Fracture is the textbook presentation, in my experience injury to the fibular nerve is actually occurs more frequently with bimalleolar fractures or trimalleolar fractures of the ankles, simply because these fractures are much more common than the Maisonneuve Fracture. When Tami asked why her previous physicians had missed the significance of this injury, I told her that I really couldn’t say. Perhaps because they were only looking for horses?


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