PLAN:
1. Refer to OT (if not already being treated by one) for continuing hand exercises and mobilization. This resulted in a marked improvement over the ensuing weeks.
2. The methadone was increased gradually and, at 10 mg in morning and afternoon and 15 mg in the evening, helped his pain and decreased his need for "rescue" medications to periods when he knew his pain would be worsened, for example, just before physical therapy.
3. Continue on the nortriptyline and gabapentin.
4. Encourage him to investigate prospects of returning to work, in some administrative position.
5. See at regular intervals.
If the above regimen had not been successful referral to a Pain Specialist would have been appropriate. In this patient a radial nerve block may have been indicated. If it successfully reduced his pain by more than 50%, he may have been a candidate for a surgical opinion regarding possible lysis of adhesions around the nerve or even a peripheral nerve stimulator if other conservative therapy was ineffective. A lidocaine infusion to see the potential efficacy of sodium channel blockers would be another consideration.
Sympathetic maintained pain is unlikely as cold did not make his pain worse, however, a stellate ganglion block may assist in determining the role of sympathetic stimulation in maintaining his pain. Other opioids might be trialed if methadone was proving ineffective or if there were significant side effects.
After a period (2-3 months) of stable pain control a slow taper of gabapentin and later opioids should be trialed to assess if they are both still indicated. Unfortunately long term use of these medications is very common in this type of pain syndrome.
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