Board-Certified Physician Specializing in Interventional Pain Management at Greater Atlanta Pain & Spine
Answered 10 days ago
In an outpatient pain practice, one subtle but important early cue I pay attention to is a change in a patient's baseline pain pattern, particularly when the pain becomes more constant, localized, and is accompanied by unusual tenderness or warmth at a recent injection or procedure site. Unlike typical post-procedure soreness, which tends to gradually improve, this type of change often feels different to the patient and may be paired with mild fatigue or a general sense of "not feeling right," even before classic signs of infection like fever appear. I recall a patient who returned shortly after a spinal injection describing persistent, localized discomfort that wasn't improving as expected. On exam, there was slight warmth and increased sensitivity in the area, but no obvious systemic symptoms. Based on that subtle shift, we proceeded with early evaluation and initiated treatment promptly. It turned out to be an early localized infection, and addressing it quickly prevented progression and the need for more aggressive intervention. What I've learned is that trusting these small deviations from a patient's normal recovery pattern, and taking them seriously, can make a significant difference. Early recognition allows for timely treatment and helps avoid more serious complications.
As a vertigo expert, one of the most important subtle clinical cues I look for is a mismatch between what I see in room light and what is revealed during advanced oculomotor testing. If a patient presents with a normal oculomotor exam in room light, but then demonstrates spontaneous nystagmus or gaze-evoked nystagmus when tested in complete darkness using infrared video oculography goggles, this strongly suggests a peripheral vestibular issue, often a subacute viral infection of the inner ear (vestibular neuritis). This finding is easy to miss because visual fixation in normal lighting can suppress nystagmus. Without removing fixation using infrared goggles, many providers may incorrectly conclude the exam is normal. I've seen numerous patients with persistent, unexplained vertigo who had otherwise normal workups, including normal brain MRIs, where this subtle finding revealed the true diagnosis of subacute vestibular neuritis. Clinically, this matters because viral vertigo is one of the most common causes of vertigo after BPPV, and it can be triggered by viruses such as herpes, Epstein-Barr, or more recently, long COVID. In many cases, patients may not yet show obvious systemic signs of infection, making these subtle eye movement findings the earliest and most actionable clue. There was a particularly memorable case where a patient had been experiencing ongoing dizziness with inconclusive testing elsewhere. Their exam appeared normal until I repeated oculomotor testing in darkness with infrared goggles, at which point clear spontaneous nystagmus emerged. That single finding shifted the diagnosis toward subacute vestibular neuritis and allowed us to guide care toward addressing the underlying viral process rather than continuing to treat symptoms alone. Especially since 2020, I have observed a significant increase in waxing and waning viral-related vertigo, likely related to immune system changes seen with long COVID. Recognizing these subtle early signs allows for earlier, more targeted intervention, often preventing prolonged symptoms and unnecessary treatments.