Patients with pain disorders pose many clinical challenges for the attending physician. Even experienced clinicians occasionally arrive at the point where diagnostic, work-up, treatment, or prognostic thinking becomes blocked. Pain teaches the reader to recognize and appropriately treat a variety of pain disorders using a case study format. Divided into three section, chronic pain conditions, chronic pain and related disorders, and treatment overview, and derived from consultation requests from providers in medical practice, the cases are written in a format that encourages the reader to formulate a differential diagnosis and treatment plan for a variety of pain problems. Succinct in its presentation and logical in its layout, Pain is the perfect resource for the busy practitioner on the go.
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Tabitha A. Washington, MD, MS Associate Pain Fellowship Program Director, Pain Medicine Department of Anesthesiology Dartmouth Hitchcock Medical Center Assistant Professor of Anesthesiology Dartmouth Medical School Lebanon, NH Khalilah M. Brown, MD, MPH Fellow Pain Medicine Department of Anesthesiology Dartmouth Hitchcock Medical Center Lebanon, NH Gilbert J. Fanciullo, MD, MS Director, Section of Pain Medicine Department of Anesthesiology Dartmouth Hitchcock Medical Center Professor of Anesthesiology Dartmouth Medical School Lebanon, NH
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SECTION I CHRONIC PAIN CONDITIONS 1. Complex Regional Pain Syndrome Commonly over diagnosed, CRPS has little especial association with the Autonomic Nervous System, does not involve Dystrophy, and has no known Reflex associated with it. Type 1 is the classical Reflex Sympathetic Dystrophy differing from Type 2- Causalgia, only in that Type 2 involves injury to a major nerve. 2. Peripheral Neuropathy The debilitating pain of peripheral neuropathy can be difficult to treat and relies on pain management and treatment of the underlying pathology. This chapter reviews the causes, sign and symptoms, diagnostic criteria and treatment options available for these patients. 3. Post-Herpetic Neuralgia Post-herpetic neuralgia is a devastating and painful consequence of shingles (herpes zoster) and is most common in the elderly and the immunocompromised. Medications are the mainstay of treatment, however caution should be used in the elderly secondary to side effects. 4. Post-Stroke Central Pain Often thought only in association with thalamic pain syndrome following infarct to the thalamus, pain following stroke may occur with any setting of stroke affecting nociceptive fibers at any level. Neuropathic or central pain can occur in up to 8% of patients after a stroke. Medical treatment usually begins with a trial of Lamotrigine and a second-line drug may be added. For severe, refractory cases, repetitive transcranial magnetic stimulation (rTMS) may be offered. 5. Multiple Sclerosis Related Pain Multiple sclerosis (MS) is usually associated with a loss of sensation; however, since the late 1800s, physicians have recognized that pain is often associated with multiple sclerosis and can at times be the heralding symptom. Pain can occur in 29-86% of MS patients an can include neuropathic pain, dysesthetic pain and trigeminal neuralgia, as well as somatic pain mostly originating from back pain and painful spasms. Medication, physical therapy, behavioral therapy, occupational therapy, interventional procedures, baclofen pump placements, and surgical interventions have been employed. 6. Radiculopathy Probably the most common cause of neuropathic pain, lumbar and cervical radiculopathy are frequently encountered clinical entities while thoracic is more rare. These syndromes may involve an anatomical abnormality and can be gratifying to both diagnose and treat, but a nonanatomical abnormality syndrome is equally as common and presents more of a diagnostic and therapeutic dilemma or even conundrum. 7. Brachial Plexus Avulsion Injury Brachial plexus injuries are most commonly due to trauma, of which, motor cycle accidents are the most common. Men are most frequently affected. Other causes can include; penetrating or sports related injuries, falls, work related accidents, radiation therapy and iatrogenic causes (ie, first rib resection, shoulder surgery, interventional radiology). The most common mechanism of injury is a traction injury due to forceful separation of the neck from the shoulder. Persistent brachial plexus pain is often treated in a fashion similar to neuropathic pain. 8. Superficial Radial Nerve Injury This small sensory nerve can be a cause of excruciating pain when injured iatrogenically. Diagnosis can be confusing and treatment a challenge. 9. Post-Thoracotomy Pain Syndrome (Acute and Chronic Pain) Persistent post-thoracotomy pain syndrome (PTPS) is one of the most prevalent sources of chronic post-operative pain. Up to 20-70% of patients may complain of symptoms consistent with post-thoracotomy pain. Targeting the points before, during, and after surgery that could decrease the risk of PTPS has been understudied and there is no clear evidence for any specific recommendations. That being said, recommendations and standard of care include a multimodal analgesic approach during surgery and perioperatively with nonopioid and local anesthesia. Treatment of chronic PTPS can include medical therapy, interventional therapy and in those with refractory disease, spinal cord stimulation. 10. Dental Pain Branches of the Trigeminal Nerve are not infrequently injured during routine dental procedures and can produce symptoms similar to Tic Douloureux. Proper anatomical localization and an understanding of the mechanism of injury can be important considerations in selecting treatment approaches or determining prognosis. 11. Trigeminal Neuralgia and Atypical Facial Pain Trigeminal neuralgia is a debilitating disease that affects a subset of patients. This chapter focuses on the epidemiology, diagnostic criteria and management of patients. Special considerations to the elderly population who are at higher risk of developing side effects from treatment. 12. Phantom Limb Pain Phantom pain is described as pain or dysesthesia that is caused by interruption or discontinuation of sensory nerve impulses by destroying or injuring the sensory nerve fibers after amputation or deafferentation. The usual cause of pain is due to trauma or surgical manipulation. The incidence of phantom limb pain varies across studies and is on the order of 2-80%; however, the average appears to be between 40-70%. Medical therapy should be tried initially and should not be considered a failure until narcotic therapy has been trialed. Surgical therapy including spinal cord stimulator placement and DREZ lesions should be reserved for refractory cases. 13. Spinal Cord Injury Pain Injury to the spinal cord can occur via trauma, infection, ischemia, toxicity, tumor, radiation, disease or other causes. The pattern of pain may still be changing years or even decades after injury. The level of pain and disability may be very high and effective treatment options may be illusory. 14. Ramsey Hunt Syndrome (Geniculate Neuralgia) Ramsay- Hunt Syndrome is a rare entity that was first described in the early 1907 by James Ramsay Hunt. There are three Ramsay-Hunt Syndromes that vary dramatically from one another with the only similarity being that they were described by the same person. In this article, we will discuss Ramsay Hunt Syndrome Type II, commonly known as herpes zoster oticus and is accompanied by a peripheral facial palsy. It is the second most common cause of atraumatic peripheral facial nerve palsy. 15. Supraorbital Neuralgia Supraorbital neuralgia is pain in the distribution of the supraorbital nerve that is often caused by a provoking stimulus, such as goggles or helmets. However, other causes should be excluded with history, physical exam and neuroimaging studies. 16. Glossopharngeal Neuralgia Glossopharyngeal neuralgia (n…