>> DR. HIBNER:: We basically send patients home with the printed instructions of the things
they can and cannot do after surgery and with exercises they're supposed to do. And also,
Loretta, my physical therapist, she keeps in touch with the patient's own physical
therapists at home and kinda monitors their progress and tells their physical therapist what to do.
>> DR. VIGNA:: What are the medications people are using chronically for this or inacutely?
>> DR. HIBNER:: So, patients use medications specifically for the nerves would be their
gabapentin, the Neurontin ā€"
>> DR. VIGNA:: Neurontin.
>> DR. HIBNER:: ā€" or Lyrica, the pregabalin. I do believe that patients need appropriate
pain management to prevent that central sensitization or to reverse it. So they need pain
management. They need narcotics. They ā€"
>> DR. VIGNA:: How high a dose narcotics are ā€" I know spinal-cord injury pain. You need
high-dose narcotics to really help the neuropathic pain from spinal-cord injury. What
kind of doses are these patients requiring to maintain their function?
>> DR. HIBNER:: I've seen patients on really large doses, either methadone or oxycodone.
>> DR. VIGNA:: Long-acting strong ā€"
>> DR. HIBNER:: Long-acting _____. I leave that up to whoever's doing patient's pain
management. The other medications that patients often use is Cymbalta, which is an
antidepressant, but it works pretty well for chronic pain.
>> DR. VIGNA:: Effexor.
>> DR. HIBNER:: Effexor. As far as muscle relaxants, the one that I really, really believe it
works ā€" it's a compounded suppository of five milligrams of valium and four milligrams
of baclofen, and it's a vaginal suppository. And as far as pelvic-floor muscle spasm, I
think it works better than anything else. The other suppository that seems to help is
belladonna and opium, the B&O suppository. Those are not compounded. They actually are
available at the pharmacy. They tend to be more expensive, though.
There is a device called InterStim, which is actually made by Medtronic, and it is made
for urinary urgency and frequency. It is not really approved for pain; however, there is
some physicians right now around the country that start placing the InterStim not how it
is intended to be placed into the S2, S3 foramen in the sacrum, but they are placing it
into the Alcock's canal next to the pudendal nerve with fairly good results, and this is
actually a procedure where we'll start doing in our practice just to add to all the other
things that we're already doing.
>> DR. VIGNA:: So that's a nonnarcotic modality that could potentially help pain long-term in
a patient who has persistent pain after decompression?
>> DR. HIBNER:: Correct. I think there is a small percentage of patients that are completely
pain-free. I believe that about 70, 80 percent of patients with all the procedures we do
are better as far as pain goes. Even after all these procedures, very rarely we eliminate the pain completely.
>> DR. VIGNA:: Tell us about your experience with the depression, the ā€" how these problems
are affecting the family unit.
>> DR. HIBNER:: So, whenever I come in the room with ā€" to see a patient with pudendal
neuralgia, and let's say it's a husband and a wife, and the wife is the one with pudendal
neuralgia pain. I almost always do that. I kinda jokingly say, entering into the room,
"So who's the patient?" And almost every time, both of them say, "I am." What it tells me
is that the husband is ā€" or the other family counterpart, the spouse, is equally
affected by this, even though that's not the person with pain, but that person is equally
affected, complete lack of sexuality. And it's not only that intercourse, intravaginal
penetration that hurts, but a lot of these women have pain with sexual arousal, and even
the thought of intercourse or thought of ā€" any thought that gets them aroused will
cause pain. Patients are absolutely debilitated by pain caused by mesh, and a lot of them are even suicidal.