Chapter 40 Chronic Pain Management
Multidisciplinary chronic pain management
1. Why is multidisciplinary teamwork necessary for managing chronic pain? What are the components of such a multidisciplinary team? How are patients usually referred to a pain clinic?
2. How should the initial evaluation of a patient be carried out in the pain clinic? How is a treatment plan established for a patient evaluated in a chronic pain clinic?
3. Name some treatment modalities for the management of chronic pain.
4. List some of the psychological components of the chronic pain disease process. What is the potential value of the Minnesota Multiphasic Personality Inventory when evaluating patients with chronic pain?
Common pain syndromes
5. What is meant by the term low back pain? What is the usual pattern of recovery for patients presenting with low back pain?
6. How does the typical patient with low back pain present to a pain physician?
7. What are the pathophysiologic mechanisms which commonly contribute to low back pain?
8. How can chronic low back pain arising from the lumbar facet joints be distinguished from lumbar radiculopathy?
9. What are some warning signs on the initial history and physical when evaluating a patient with low back pain that may indicate significant physical comorbidity that should be promptly investigated?
10. How should a physician approach medical therapy for the most common presentations of low back pain?
11. What are the socioeconomic considerations of low back pain and its treatment? What are some risk factors for developing chronic low back pain?
12. What is neuropathic pain? What are some of the typical signs and symptoms of neuropathic pain?
13. What is postherpetic neuralgia?
14. What treatment modalities have been used for the treatment of postherpetic neuralgia?
15. What are some of the side effects of tricyclic antidepressants that may limit their usefulness in elderly patients with postherpetic neuralgia?
16. What is diabetic peripheral neuropathy? How does it present?
17. What is complex regional pain syndrome? What differentiates type I and type II complex regional pain syndromes?
18. What are the clinical manifestations of complex regional pain syndrome?
19. How is the diagnosis of complex regional pain syndrome of the upper or lower extremity made?
20. What is the treatment for complex regional pain syndrome? How does the time delay to diagnosis and treatment affect treatment outcome?
21. What pharmacologic agents are commonly used for intravenous regional sympathetic nerve blockade? How is this technique believed to work?
Cancer-related pain
22. What are the various ways in which cancer can cause pain? What is the primary treatment for cancer pain?
23. What are some oral analgesics used to treat persistent cancer pain? What is the World Health Organization stepwise approach to managing cancer-related pain?
24. When oral intake by patients is limited, what are some alternative routes of analgesic drug delivery used to manage persistent cancer pain?
25. What are some neurosurgical procedures for the treatment of chronic pain that may be useful in cancer patients in whom less invasive procedures have been unsuccessful in providing pain control?
26. Which is the most common uniformly efficacious neurolytic block for visceral malignancy? What are the limitations of such a block?
Pharmacologic management of chronic pain
27. What are some of the pharmacologic agents used for pain management?
28. What are simple analgesics and how can they be useful in chronic pain management? How are cyclooxygenase-2 selective drugs useful for chronic pain management and how do they differ from nonselective drugs?
29. How do antidepressants exert their actions? List some antidepressants commonly used for pain management and their side effects.
30. Which anticonvulsants are commonly used for pain management? What are the most common side effects associated with each agent? What are the first-line treatments for neuropathic pain?
31. What potential problems are encountered by physicians when prescribing opioids?
32. What basic principles guide the use of opioids in terminally ill patients as compared with those with nonmalignant chronic pain?
33. What are the current guidelines for the stepwise pharmacologic management of neuropathic pain?
Interventional pain therapies
34. What is meant by the term interventional pain therapy? Name some of the commonly performed interventional procedures used to treat pain.
35. How is an epidural steroid injection useful as an interventional therapeutic procedure? What side effects should patients be informed about?
36. What are the different techniques used to inject steroids into the epidural space? What is the rationale for using one technique over another?
37. When should a physician suspect the facet joint as a cause of low back pain? How can a facet joint block be useful as a diagnostic tool?
38. What is the role of radiofrequency ablation in the long-term management of persistent facet-related pain?
39. What is the current role of lumbar diskography in the management of lumbosacral pain?
40. What is minimally invasive disk decompression? How does it work and what is a limitation of this procedure?
41. How are sympathetic nerve blocks useful as a diagnostic tool in chronic pain management? What is the current evidence of their role in managing chronic pain syndromes?
42. What is the anatomical location of stellate ganglion? How is a stellate ganglion block useful in the management of chronic pain?
43. How is a stellate ganglion block performed? Describe a safer alternative to the conventionally performed stellate ganglion block.
44. List the common conditions for which stellate ganglion block is used in treatment.
45. What are the signs of a successful stellate ganglion block?
46. What are the complications of stellate ganglion block?
47. What is the anatomic location of the celiac plexus and what are the structures that lie immediately adjacent to the celiac plexus?
48. What are the most common techniques by which a celiac plexus block can be performed?
49. What is the clinical indication for a celiac plexus block?
50. How does a celiac plexus block differ from a splanchnic nerve block?
51. What are the complications associated with celiac plexus block?
52. Describe the applied anatomy of the lumbar sympathetic chain.
53. What are some of the clinical uses of a lumbar sympathetic block? List the complications that may be encountered while performing a lumbar sympathetic block.
54. What fundamental physiologic principle forms the basis of spinal cord stimulation?
55. What is the current role of spinal cord stimulation in managing chronic pain syndromes?
Answers*
Multidisciplinary chronic pain management
1. Chronic pain is a complex disorder and patients suffering from chronic pain usually have biologic disease that coexists with cognitive, affective, behavioral, and social factors. Hence, management of such a disease process requires the expertise of health care providers from a range of medical specialties. The team at most centers consists of a physician, often an anesthesiologist, a psychologist, and a physical therapist working together. Patients are usually referred to a chronic pain clinic by their primary care physicians for a problem with chronic pain that has not responded to conventional medical therapy.
2. On his or her arrival to a chronic pain clinic, the patient should be evaluated by a physician with expertise in pain medicine. During the initial evaluation, the potential psychological, medical, and social contributions to the patient’s pain should be evaluated. While it would be ideal for a psychologist and a physical therapist to also evaluate each new patient and then this multidisciplinary team meet to discuss the various aspects of the patient’s history, as well as a probable diagnosis, this is seldom possible in today’s constrained health care environment. Nonetheless, the physician who conducts the initial evaluation must devise a treatment plan for each patient that takes into consideration all aspects of the patient’s care and arranges for appropriate referral to other members of the team when needed. (699)
3. Treatment modalities available in most chronic pain clinics include oral pharmacotherapy, diagnostic and therapeutic nerve blocks, the neuraxial administration of opioids, neurostimulation techniques, biofeedback, and physical therapy. (699)
4. Chronic pain as a disease process may include psychiatric and psychological manifestations, some of which include depression, insomnia, and avoidance of social and vocational obligations. Dependence on analgesics and visits to multiple physicians are common among patients with chronic pain. The Minnesota Multiphasic Personality Inventory is a useful test for the detection of many of these common comorbidities that often coexist in those suffering with chronic pain. (699)
Common pain syndromes
5. Low back pain (LBP) is the most common reason why people seek medical attention and is also known as lumbosacral pain. This refers to pain in either the lumbar or the sacral spinal region. Anatomically, the region is defined as the area of the back between the tip of the twelfth thoracic spinal process up till the sacrococcygeal joint. Most people presenting with low back pain recover with no treatment. A majority recover by 6 weeks (60% to 70%) or mostly by 12 weeks (90%). The recovery after 12 weeks, however, is slow and uncertain. (699, Figure 43-1)
6. Patients presenting with low back pain usually have pain either localized to the back region (acute or chronic lumbosacral pain) or distributed in the area of nerve (acute or chronic radicular pain). Acute radicular pain is typically caused by a herniated nucleus pulposus in younger patients. Signs of radiculopathy include numbness, weakness, or loss of deep tendon reflexes in the area of the affected nerve. In the elderly, foraminal narrowing may affect the spinal nerve leading to acute radicular pain. Patients presenting with chronic radicular pain require a detailed search for a reversible cause of nerve root impingement. MRI or electrodiagnostic testing could give some clues to the cause of pain in patients who have had prior surgery. Acute lumbosacral pain with no radicular symptoms in most cases may be myofascial in origin and require no further radiologic investigation. Chronic lumbosacral pain may arise from many parts of the vertebral unit; most commonly implicated are the sacroiliac joint, lumbar facets, and the intervertebral disks. Diagnostic nerve blocks involving injection of local anesthetic at these anatomic sites leading to temporary pain relief can aid in localizing the origin of pain. Diagnosis and treatment of the patient with low back pain rely on the location of pain (primarily radicular or lumbosacral) and the duration of symptoms (acute or chronic). (700-701)
7. The following pathophysiologic mechanisms result from degenerative changes in the spinal functional unit due to aging and injury, and can give rise to lumbosacral and/or lumbar radicular pain:
Synovitis in the facet joints leading to capsular laxity and subluxation; facet-related pain is predominantly localized over the lumbosacral junction.
8. Pain arising from the lumbar facet joint is predominantly localized near the lumbosacral junction, while lumbar radicular pain is localized within the leg. The pain arising from facet joints is usually diagnosed by the injection of a small volume of local anesthetic into the joint under fluoroscopic guidance. Substantial pain relief suggests that pain originates from inflammation of that particular joint. However, a substantial number of patients will report pain reduction even when a nonactive agent such as normal saline is injected. This placebo response can complicate certain diagnosis using diagnostic injections. (700)
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