ICL 7.2: Acute & Chronic Pain

Question 1

what are the risk factors for pain?

Answer 1

1. older > younger
2. female > male
3. socioeconomic = low education level, income, housing status, and unemployment
4. comorbidities = obesity and depression

Question 2

what are the most common types of pain?

Answer 2

1. headache
2. back pain
3. neck pain
4. hip/knee
5. abdominal

Question 3

what is the psychosocial impact of pain?

Answer 3

Negative effects on health perception, relationships, social interactions

Increased depressive symptoms

Question 4

what is the economic impact of pain?

Answer 4

1. cost of direct medical care (physical therapy, inpatient services, pharmacy)
2. additional ancillary services
3. lost work productivity

Question 5

what are the differences of pain in men and women?

Answer 5

WOMEN
1. more likely to experience pain

2. higher levels of pain
3. more likely to use analgesics
4. persistent pain

MEN
1. consume more opioids

2. more die from OD
3. more likely to dropout and terminate outpatient treatment
4. higher pain threshold

Question 6

how do you assess pain

Answer 6

1. HPI
2. PE
3. ordering tests

Question 7

what’s the most important of an HPI in relation to pain?

Answer 7

1. time

acute = less than 3 months
chronic = more than 3 months

2. onset

what were they doing when it started?

Question 8

what is somatic pain?

Answer 8

poorly defined boundaries, fluctuates in size

dull, achy

Question 9

what is radicular pain?

Answer 9

narrow band-like boundary, longitudinally in the lower limb

shooting, electric

Question 10

what sign is concerning about someones pain?

Answer 10

pain that is not relieved by rest should be really concerning

Question 11

what do you do during a PE for pain?

Answer 11

1. Palpation for tenderness
2. Assessing active and passive range of motion
3. Neurologic
   - Sensory deficits
   - Motor deficits
   - Reflexes

Question 12

what diagnostic tests an you do for pain?

Answer 12

not recommended if pain is less than 4-6 weeks

they’re used to corroborate clinical findings but they’re often unlikely to show significant pathologies; HPI and PE are much more useful

Question 13

what test is best for lower back pain?

Answer 13

MRI

it’s the gold standard for determining etiology of LBP and radicular pain

it gives you the best resolution of spinal canal, cord, neural foramina, NRs, disc spaces

Question 14

what is a pro of x-rays over CT and MRI?

Answer 14

they show you dynamic change!

you can ask someone to flex and extend and see the limb in both positions

Question 15

what are some of the electrodiagnostic tests you can do?

Answer 15

1. Electromyography (EMG)
2. Nerve Conduction Velocity (NCV)
3. Somatosensory Evoked Potentials (SSEPs)

these are useful when features are inconclusive or indistinguishable from peripheral neuropathy

Question 16

what are red flags of pain?

Answer 16

conditions which may pose significant threat to life or neurologic function

they 100% require further diagnostic testing

Question 17

what are the various red flags of pain?

Answer 17

1. younger than 20 or over 50

< 20: Congenital/developmental anomalies

> 50: Prone to neoplasms, fractures, infections

2. duration of symptoms (chronic or acute)
3. constitutional symptoms

fever, chills, malaise, night sweats, weight loss

4. systemic illness (cancer, IVDA, transplant)
5. incontinence, saddle anesthesia, bilateral neurologic symptoms
6. history of trauma
7. unrelenting pain

Question 18

which symptoms are a sign of cauda equine syndrome?

Answer 18

incontinence, saddle anesthesia, bilateral neurologic symptoms

Question 19

A 30 year old man reports new onset back pain that started 2 weeks ago when helping a friend move furniture off of a truck. He reports the pain worsens with activity, but significantly improves with rest. Reports pain is located in the lower back, and does not radiate down the legs. Which of the following would be the best next step in managing this patient?

Answer 19

reassurance

pain hasn’t been going on for long, improves with rest, and isn’t very severe

there’s no red flags!

Question 20

what is radiculopathy?

Answer 20

nerve root damage

Question 21

what is radiculitis?

Answer 21

inflammation of nerve roots

Question 22

what is radicular syndrome?

Answer 22

it’s a broad category that suggests clinical signs and symptoms secondary to pathology/dysfunction of sensory spinal nerve roots or dorsal root ganglion

Question 23

what’s the etiology of radicular syndrome?

Answer 23

1. lesions of intervertebral disc
2. degenerative spinal disorders
3. lesions involving the spinal nerve, DRG or plexuses

entrapment neuropathies (piriformis and ischial tunnel syndrome), generate pain in multiple dermatomes of peripheral nerve

Question 24

what are the clinical features of radicular syndrome?

Answer 24

1. Pain

Sharp, shooting, lancinating

2. Paresthesias
3. Numbness; loss of sensation
4. Weakness

Gait disturbances, reduced muscle strength, diminished reflexes

5. Travels along narrow band

Question 25

what is spinal stenos?

Answer 25

clinical syndrome with neurogenic claudication or radicular pain due to narrowing of spinal or nerve root canal and compression of its elements it can be congential vs. acquired or central vs. lateral

Question 26

what is acquired spinal stenosis?

Answer 26

due to things like: 1. disc degeneration 2. disc bulging 3. facet joint hypertrophy 4. thickening of ligamentum flavum 5. osteophyte formation

Question 27

what is central stenosis?

Answer 27

causes compression of NR of cauda equina

Question 28

what is lateral stenosis?

Answer 28

causes compression of exiting spinal NRs

Question 29

what are the clinical features of spinal stenosis?

Answer 29

1. neurogenic claudication 2. radicular pain 3. axial pain patients tend to walk with a stooped posture, decrease range of lumbar extension but the pain is relieved by sitting down or pushing a walker/shopping cart note: unilateral symptoms usually indicate lateral stenosis

Question 30

what is neurogenic claudication?

Answer 30

a sign of spinal stenosis radiating pain, posterolateral aspect of thighs and legs sorse with walking and lumbar extension relieved by sitting down, pushing a walker/shopping cart

Question 31

how do you diagnose spinal stenosis?

Answer 31

MRI or CT MRI will show you pathologic lesions CT will show bony abnormalities or lateral recess

Question 32

what is facet syndrome?

Answer 32

facet = synovial joint composed of the superior and inferior articular processes of vertebrae the facet joint is innervated by the medial branch of the posterior ramus at the same level and from one level above can cause patients to have shopping cart sign

Question 33

what causes facet syndrome?

Answer 33

some causes may include systemic inflammatory arthritis, synovitis, synovial cysts, infections

Question 34

what are the clinical symptoms of facet syndrome?

Answer 34

1. unilateral or bilateral pain 2. worsens with spinal extension, twisting, prolonged standing/upright posture 3. relieved with forward flexion, walking, and rest 4. NO neurologic findings

Question 35

what is post-laminectomy syndrome?

Answer 35

a syndrome of pain following surgery --> patients with persistent or worsened pain/symptoms after surgery

Question 36

what are the causes of post-laminectomy syndrome?

Answer 36

1. prolonged trauma to the nerve/region prior to surgery, inability to heal 2. surgical trauma to the nerve/region during surgery 3. scar tissue formation after surgery 4. structural changes of the spine after surgery

Question 37

what conditions can post-laminectomy syndrome lead to?

Answer 37

1. radiculopathies 2. facet joint arthropathy and pain 3. spinal stenosis 4. neuralgia 5. chronic low back pain

Question 38

A 52 year old woman reports pain that is worst in the “small of the back”. The pain worsens with standing and improves with leaning forward. She notes that during grocery shopping, she finds herself leaning forward onto the cart to prevent persistent pain. Which of the following is the most likely diagnosis?

Answer 38

more information is needed it could be lumbar spinal stenosis, lumbar facet pain or lumbar post-laminectomy syndrome because they all have the shopping cart sign for spinal stenosis you'd expect shooting radicular pain

Question 39

how does acute pain effect the body?

Answer 39

acute pain leads to changes in neural function persistent noxious signaling in the periphery leads to enduring maladaptive neuroplastic changes at the dorsal horn and higher CNS structures, releasing neurotropic factors maladpative brain remodeling which leads to alterations in the corticolimbic circuitry so we need to stopacute pain to reduce development into chronic pain

Question 40

what are the conservative medication treatment options for pain?

Answer 40

1. NSAIDs 2. acetaminophen 3. corticosteroids 4. muscle Relaxants 5. neuropathic Medications like antidepressants and anticonvulsants

Question 41

what are the conservative therapy treatment options for pain?

Answer 41

1. Exercise/Weight Loss 2. Physical Therapy Traction Manual therapies 3. Chiropractic Care Manipulation (questionable safety) 4. Psychological Therapy Behavioral Therapy Biofeedback

Question 42

what are the conservative alternate therapy treatment options for pain?

Answer 42

1. heat 2. cryoptherapy 3. electricity 4. orthotics 5. work rehab 6. chinese medicine; acupuncture and herbal medicine

Question 43

what are the interventional treatment options for pain?

Answer 43

1. intra-articular joint injections 2. epidural steroid injections (interlaminar or transforaminal approach) 3. peripheral nerve blocks 4. radio frequency ablation of nerves

Question 44

what are the advancds interventional options for pain?

Answer 44

1. spinal Cord Stimulation 2. peripheral Nerve Stimulation 3. intrathecal Drug Delivery Devices 4. minimally Invasive Lumbar Decompression (MILD) 5. interspinous Spacer 6. kyphoplasty/Vertebroplasty

Question 45

what are the surgical treatment options for pain?

Answer 45

1. surgical discectomy | 2. surgical decompression

Question 46

what is surgical discectomy?

Answer 46

necessary in cases of cauda equina syndrome, progressive motor deficits microdiscectomy has been reported to be better than traditional discectomy

Question 47

what is surgical decompression?

Answer 47

remove posterior aspect of the spine and put it screws and rods --> wide laminectomy, removing spinal laminae and ligamentum flavum from pedicle to pedicle laminotomy, removes smaller area --> preserves spinal stability and high rate of restenosis

Question 48

what are good prognostic factors of a patient returning to work following spine injury?

Answer 48

1. younger, native, highly educated with high income 2. married, stable social networks, self-confident, low levels of disease severity 3. long working history with job 4. employer that care and wishes for patient to return to job 5. returning to work within 2-3 months