PERINEURAL THERAPY and NERVE HYDRODISSECTION

Perineural Therapy is a safe and very effective technique that involves injecting a small amount of a mild sugar solution (5% dextrose) around constricted nerves that lie just under the skin to eliminate pain and restore motion.

These skin nerves are very easy to damage and can become pain sources by the process of Neuropathic Inflammation. This is a type of inflammation that has only been recognized relatively recently. Neuropathic inflammation occurs when damaged nerves produce small proteins, called peptides, that affect the tissues around them. They do this in response to trauma, pressure, or injury.

For those of you who like to nerd out on detail, there are receptors on the surface of your nerve cells called the TRPV-1 Receptors (transient receptor potential vanillin – type 1). These TRPV1 nerves (pronounced like trip-v-1) are very claustrophobic. They do not like being enclosed or surrounded by even light touch. Pressure or touch on a nerve that surrounds it (like a ring on a finger) will cause it to swell and start producing proteins that affect all the structures that are in communication with it. Two of these proteins are called substance P (p stands for pain) and CGRP-1 (calcitonin-gene-related peptide) that cause other soft tissue structures to break down. This process of degeneration of the soft tissues from the irritated TRPV-1 nerves is what leads to pain along the nerve tract and can even change the appearance and sensitivity of the skin and underlying tissue making it feel ropy or lumpy to the touch. In my opinion, this is what most doctors diagnose as Fibromyalgia.

Once these nerves are irritated, they are kept irritated very easily by routine muscle contraction, holding positions (like bad posture), being hit, or even with bra straps and tight clothing. Normal pain medications like advil do not affect this inflammation pathway and so they tend to have limited benefit for this type pain. Since these TRPV-1 nerves connect to every other structures in the body, they need to be addressed whenever there is an established and longstanding pain or injury.

Fortunately, it has been observed clinically and in studies that injection of dextrose (usually 5% dextrose) under the skin will relieve neuropathic pain usually completely and within seconds. Of note, this is without any local anesthetic such as lidocaine. This typically needs to be repeated but after several treatments (between 3 to 6 treatments) leads to progressive benefit and according to ultrasound follow up shows evidence of stimulating healing of deeper structures. Patients will know after the first or second treatment whether this will be of benefit for them, meaning if it doesn’t help after 2 treatments, we need to look at other causes of your pain.

Perineural Deep injection, is the same process as above only the nerves that need to be treated are deeper in the body. This can happen where they pass through muscle and fascia layers, or where they pass over bone. This stretch is accomplished by flooding the area with fluid and is called hydrodissection – using fluid to do the dissecting. This is done with the same 5% dextrose as above and is sometimes guided with ultrasound to confirm correct placement.

FAQs

1. What does a typical treatment look like with Dr. Bentham?

An injection therapy visit is interactive and will last anywhere from 30 minutes to 1 hour. While Perineural therapy treats the nerves, we may find though that your pain may be coming from another structure like a ligament, muscle, or scar – so we treat those using different techniques. One advantage of this approach is that you get instant feedback that directs the treatment. We treat, re-evaluate, then move to the next tissue type and injured site in the same session, with the intention of 100% symptom relief before you leave the office. This tells us if we are treating the right spot. Granted we don’t always hit 100%, it is at least the aim depending on the size of the area being treated.

2. Is ultrasound necessary to get the injection in the right place?

We have and use diagnostic ultrasound at our clinic when it is necessary to visualize deeper structures or for injections in higher risk areas. It is not always required, but it is important for some treatments.

3. Do Perineural injections hurt?

While people do feel the needle (though we use a tiny one), the solution we’re injecting is painless since it is the same pH and concentration as your body fluids. You may feel a bit of a twinge of a nerve when we hit the right spot, however it is not particularly painful.

4. How many treatments are needed?

The response to perineural is quite individual and is dictated by one’s healing response and severity of injury. Most patients require 3-6 treatments. I closely follow your progress to determine whether we are on the right course of action.

5. What conditions are best helped by Perineural Therapy?

Neuropathic pain and Fibromyalgia are particularly responsive. Carpal tunnel syndrome, shoulder pain, arm pain, leg pain, knee pain, hip pain, ankle pain, back pain. Anywhere there are nerves and there is pain. It can take up to 6 treatments for resolution of pain.

6. What is the cost of treatment?

An injection visit ranges in cost from $150-300 depending on the number of areas, structures, and type of injections needed. At the initial consultation the doctor will give you an estimate of the expected cost of treatment.

7. Is the visit covered by my extended health benefits (Blue Cross, Great West or Sunlife etc)?

If your plan has coverage for Naturopathic Medicine (and they pretty much all do), we can bill them directly for part or all of your visit depending on your coverage. .