Dear Snow/Ms. Whyte -

Fear not, you don't have to fly across the country to find a pain specialist who can hook you up to a series of blocks right away and coordinate them with PT. And besides, you don't have the luxury of waiting two months for an appointment. Giving a LSB under fluoroscopy is as "bread and butter" a procedure as they come for pain management specialists, and while I've heard of some anesthesiologists without pain management training screwing things up, I am personally unaware of that being done by an ABPM certified specialist.

There are a few things you can do with names that the ABPM search engine generates. You could run them through PubMed to see if they have written anything, you can ask what hospitals they are affiliated with and whether that is the sole place the doctor works, has offices, etc. Unless they are part of a large and well respected group practice (say, something affiliated with a premier dept. of a medical school) I would be wary of guys who spend a day here and a day there through the week: it typically implies that they are serving in a contract capacity and are regarded by the hospitals they serve as more or less fungible. Then too, you can post names of candidates here in order to receive unfiltered comments on the physicians for whatever they are worth: be careful of strong reviews from someone who may have joined the forum just to make the pitch. Finally, it's important that they take insurance, both for the obvious reason, and also because (at least in my experience) those who don't are typically more interested in making money than making you better.

Quite honestly, I'm pretty sure there are guys out there who are secretly relieved when blocks no longer work on a patient and they can get on to what they regard as serious business: implanting pumps and spinal cord stimulators. Effective Jan 1 of this year [I think], doctors were required to disclose certain "emoluments" they received from Big Pharma and the medical device manufacturers, but what was paid prior to the new law taking effect is all water over the dam.

And just in case someone wants to suggest you are being alarmist (when actually it’s managed care pushing patients through the most conservative treatments first, and not given the go-ahead for something more invasive until it’s too late to be of any real use) check out the following to see how the other half lives, not that they haven’t earned the right: A Unique Presentation of Complex Regional Pain Syndrome Type I Treated with a Continuous Sciatic Peripheral Nerve Block and Parenteral Ketamine Infusion: A Case Report, Adam Everett, Brian Mclean, Anthony Plunkett, and Chester Buckenmaier, Pain Medicine, 2009 Sep;10(6):1136-9. Epub 2009 Sep 9, FULL ONLINE TEXT @ http://www.rsds.org/2/library/articl...n_Plunkett.pdf:

Walter Reed Army Medical Center-Army Regional Anesthesia & Pain Medicine, Washington, DC 20307, USA.

Abstract
OBJECTIVE: To successfully treat a patient with complex regional pain syndrome, refractory to standard therapy, to enable a rapid and full return to professional duties.

SETTING: This case report describes the rapid resolution of an unusual presentation of complex regional pain syndrome type I after four days of treatment with a continuous sciatic peripheral nerve block and a concomitant parenteral ketamine infusion. The patient was initially diagnosed with complex regional pain syndrome (CRPS) I of the right lower extremity following an ankle inversion injury. Oral medication with naproxen and gabapentin, as well as desensitization therapy, failed to provide any relief of her symptoms. She was referred to the interventional pain management clinic. A lumbar sympathetic block failed to provide any relief. The patient was diagnosed with CRPS I and was admitted for treatment with a continuous peripheral nerve block and parenteral ketamine.

CONCLUSION: This case suggests therapeutic benefit from aggressive treatment of both the peripheral and central components of CRPS.

PMID: 19744217 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/19744217

And for articles discussing how a couple of other therapies – “mirror box treatments” and continuous 5-day sub-anesthetic ketamine infusions - also work only relatively early in the disease, see, Body Perception Disturbance (BPD) in CRPS, Lewis J, McCabe CS, Practical Pain Management 2010 Apr:60-66, at 63 and n. 38, ONLINE TEXT @ http://www.rsds.org/2/library/articl..._April2010.pdf, citing, A controlled pilot study of the utility of mirror visual feedback in the treatment of complex regional pain syndrome (type 1), McCabe CS, Haigh RC, Ring EFJ, Halligan PW, Wall PD, Blake DR, Rheumatology 2003;42:97-101, ONLINE TEXT @ http://www.rsds.org/2/library/articl..._Ring_etal.pdf, and, A Pilot Open-Label Study of the Efficacy of Subanesthetic Isomeric S(+)-Ketamine in Refractory CRPS Patients, Ralph-Thomas Kiefer, Peter Rohr, Annette Ploppa, Boris Nohé, Hans-Jürgen Dieterich, John Grothusen, Karl-Heinz Altemeyer, Klaus Unertl, and Robert J. Schwartzman, Pain Med. 2008;9(1):44-54, at 51, ONLINE TEXT @ http://www.rsds.org/2/library/articl...ohr_Ploppa.pdf

Finally, I encourage you to spare no effort in pursuing all potentially available cures within the next few months (including, if need be, 10 day out-patient ketamine infusions if the blocks alone do not put you into full remission. Indeed, there is strong evidence that neurocognitive impairments may otherwise kick in for people who have CRPS at the one year mark: such as the ability if this former federal court litigator to keep his medical appointment strait, notwithstanding the fact that anyone else looking at his faithfully maintained calendar could see that there were irreconcilable conflicts on a given day: of course, keeping track of the day if the week would have been helpful. Neuropsychological deficits associated with Complex Regional Pain Syndrome, Libon DJ, Schwartzman RJ, Eppig J, et al, J Int Neuropsychol Soc., 2010 May;16(3):566-73. Epub 2010 Mar 19, ONLINE TEXT @ http://www.rsds.org/2/library/articl...ychol_2010.pdf . And in this regard, you might also wish to check out the 2010 CRPS Blockbuster, Abnormal thalamocortical activity in patients with Complex Regional Pain Syndrome (CRPS) Type I, Walton KD, Dubois M, Llinás RR, Pain 2010 Jul;150(1):41-51. Epub 2010 Mar 24, ONLINE TEXT @ http://www.rsds.org/2/library/articl..._Pain_2010.pdf , as well as its accompanying Commentary Article, Thalamocortical dysrhythmia and chronic pain, Jones EG, Pain 2010 Jul;150(1):4-5. Epub 2010 Apr 14, ONLINE TEXT @ http://www.rsds.org/2/library/articl..._Pain_2010.pdf

Time to seriously get underway. Feel free to bounce any and all further questions off this forum or use the PM feature for anything requiring discretion, and generally keep us posted.

Mike