Pain Medicine (eBook)

Robert Jason Yong, MD, MBABrigham and Women’s Hospital/Harvard Medical SchoolDepartment of Anesthesiology, Perioperative and Pain MedicineMichael Nguyen, MDBrigham and Women's Hospital/Harvard Medical SchoolDepartment of Anesthesiology, Perioperative and Pain MedicineEhren Nelson, MDBrigham and Women's Hospital/Harvard Medical SchoolDepartment of Anesthesiology, Perioperative and Pain MedicineRichard D. Urman, MD, MBABrigham and Women's Hospital/Harvard Medical SchoolDepartment of Anesthesiology, Perioperative and Pain Medicine

Foreword 5
Preface 6
Contents 7
Contributors 17
Part I: General 25
1: Anatomy and Physiology: Mechanisms of Nociceptive Transmission 26
Fibers Types of Nociceptors 26
Molecular Properties of Nociceptors 27
Heat 27
Cold 27
Mechanosensation 27
Voltage-Gated Channels 27
Central Projections 28
Suggested Reading 28
2: Pharmacology of Pain Transmission and Modulation 29
Nociceptive Nerve Fibers 29
From Pain Transduction … 29
… to Pain Transmission 29
Selected Key Players in Pain Processing 30
Descending Pain Modulation 31
References 31
3: Development of Pain Systems 32
Physiologic and Behavioral Pain Assessment Measures in the Fetus and Newborn 32
General: Development of Pain Systems, by Gestational Age (GA) 33
Development of Pain Behavior in the Fetus and Newborn 33
Development of Peripheral and Dorsal Horn Mechanisms of Nociception and Nociceptive Connections in Higher Centers 33
Long-Term Consequences of Neonatal Pain 34
References 34
Suggested Reading 34
4: Peripheral and Central Sensitization 35
Functional Changes 35
Molecular Mechanisms of Sensitization 36
Peripheral Sensitization 36
Posttranslational Changes 36
Altered Gene Expression 36
Central Sensitization 36
Wind-Up (Homosynaptic Potentiation) 36
Heterosynaptic Potentiation 36
Other Mechanisms 37
Suggested Reading 37
5: Designing, Reporting, and Interpreting Clinical Research Studies 38
Formulating Hypotheses 38
Determining Goals/Aims of Study 38
Minimizing Bias 38
Research Design 39
Presenting Data 39
Evaluating Statistical Significance 39
Interpreting the Literature and Understanding Limitations 39
Suggested Reading 40
6: Animal Models of Nociception and Pain 41
Why Animal Research? 41
Ethics of Animal Experimentation 41
Study Design 41
Current Models Evaluate 42
Commonly Used Tests for Pain/Nociception 42
Limitations 42
Future Research 42
Suggested Reading 42
7: Ethical Standards in Pain Management and Research 43
Fundamentals 43
Autonomy 43
Beneficence 43
Nonmaleficence 44
Justice 44
Double Effect 44
Professionalism and Quality Assurance 44
Ethical Standards of Research Design, Review and Implementation, Informed Consent, Use of Animals 44
Informed Consent 44
Use of Animals 44
Suggested Reading 44
8: Epidemiology 45
Definitions 45
Measurements of Burden of Disease in a Population 45
Methods of Evaluating Risk Factors for Pain 45
Risk Factors for Development of Chronic Pain 46
Risk Stratification to Guide Treatment 46
Impact of Pain 46
Interpreting Diagnostic and Predictive Tests 47
Suggested Reading 47
Part II: Assessment and Psychology of Pain 48
9: Pain Assessment 49
Introduction 49
Goals of Pain Assessment 49
Measuring Pain 49
Outcome Measures in Pain Studies 50
Basic Requirements 50
Current Issues 50
Future Development 50
Methods of Pain Assessment 50
Clinical Interview 51
Pain Scales and Questionnaires 51
Diaries 52
Experimental Pain Assessment 52
Behavioral Observation 52
Psychophysiologic Evaluation 52
Assessment of Family Members and Significant Others 52
Specific Patient Populations 53
Elderly Patients 53
Nonverbal/Cognitively Impaired 53
Pediatric Patients 53
Suggested Reading 53
10: Physical Exam of the Cranial Nerves 54
The Cranial Nerves Can Be Divided in Five Functional Major Systems: Smell (I), Vision and Eye Movements (II, III, IV, VI, VIII), Face Function (V, VII), Oropharyngeal Function (IX, X, XII), and Head/Neck Movement (XI) 54
Olfactory Nerve (I) [Smell] 54
Optic Nerve (II) [Eye Vision] 54
Pupils 55
Occulomotor (III), Trochlear (IV), Abducens (VI) and Vestibulocochlear (VIII) Nerve [Eye Movements/Hearing] 55
Trigeminal (V) and Facial (VII) Nerve [Facial Sensation and Movements] 56
Glossopharyngeal (IX), Vagal (X), and Hypoglossal (XII) Nerve [Speech and Swallowing] 57
Accessory Nerve (XI) [Head/Neck Movement] 57
11: Neck 58
Introduction 58
Physical Examination 58
Question 59
References 60
Suggested Reading 60
12: Shoulder 61
Introduction 61
Physical Examination 61
Questions 62
Reference 62
Suggested Reading 63
13: Elbow 64
Introduction 64
Physical Examination 64
Question 66
References 66
Suggested Reading 66
14: Abdomen 67
Introduction 67
Physical Examination 67
Potential Sources of Abdominal Pain Due to Nerve Entrapments 67
Questions 68
References 68
Suggested Reading 68
15: Low Back 69
Introduction 69
Physical Examination 69
Reference 71
Suggested Reading 71
16: Hip 72
Introduction 72
Physical Examination 72
Questions 73
Reference 74
Suggested Reading 74
17: Knee 75
Introduction 75
Physical Examination 75
Questions 77
Reference 77
Suggested Reading 77
18: Ankle 78
Introduction 78
Physical Examination 78
Questions 80
Suggested Reading 80
19: Vascular 81
Introduction 81
Physical Examination 81
Questions 82
Suggested Reading 82
20: Dystonia 83
Introduction 83
Physical Examination 83
Questions 84
References 84
Suggested Reading 84
21: Pain Assessment Tools 85
Methods of Pain Assessment 85
Self-Report Pain Measurement 85
Pain Scales 85
Pain Intensity 85
Pain Questionnaires 86
Pain Quality 86
Psychological Functioning 87
Global Rating of Quality and Improvement 87
Pain-Related Physical and Emotional Functioning 88
Behavioral Pain Measurement 88
Behavioral Observation 88
Dementia in Elderly 88
Pediatric Postoperative Pain Assessment 88
Pediatric Critical Care Pain Assessment 89
Biological Pain Measurement 89
Experimental Pain Assessment 89
Psychophysiologic Evaluation 89
Suggested Reading 89
22: Functional Assessment Tools 90
Introduction 90
Functional Assessment Questionnaires 90
Global Pain Related Physical Functioning 90
Multidimensional Pain Inventory (MPI) 90
Brief Pain Inventory (BPI) 91
Short-Form Brief Pain Inventory (SF-BPI) and PEG 91
Pain Disability Index (PDI) 91
Back Pain Related Physical Functioning 91
Oswestry Disability Index (ODI) 91
Roland-Morris Disability Questionnaire (RDQ) 91
Global Pain Related Emotional Functioning 92
Beck Depression Inventory II (BDI-II) 92
Profile of Mood States (POMS) 92
Hospital Anxiety and Depression Scale (HADS) 92
Patient Health Questionnaire 8 (PHQ-8) 92
Functional Capacity Evaluation (FCE) 93
Introduction 93
Physician Role 93
General Functions of FCEs 93
Limitations of FCEs 93
Suggested Reading 93
23: Placebo and Pain 95
Introduction and History 95
Definitions 95
Mechanism of Placebo 95
Placebo in the Literature 95
Incidence of the Placebo Effect 96
References 96
24: Cervical Spine Imaging: Normal Anatomy and Degenerative Disease 97
Anatomy 97
Imaging 97
Degenerative Disease of the Cervical Spine 99
Imaging Indications 99
Imaging Evaluation 100
Disc and Osseous Degenerative Changes 100
Spinal Stenosis 102
Instability 102
Suggested Reading 103
25: Electrical Nerve Stimulation 104
Electromyography (EMG) 104
Indications 104
Contraindications 104
General Technique 104
Spontaneous Activity 104
Spontaneous Activity Grade 105
Analysis of EMG 105
Clinical Pearls 105
Nerve Conduction Velocities (NCS) 105
Indications 105
Contraindications 105
General Technique 105
Study Types 105
Limitations 105
Clinical Pearls 106
Somatosensory Evoked Potentials (SSEPs) 106
Indications 106
Limitations 106
Suggested Reading 106
26: Quantitative Sensory Testing: QST 107
Definition of QST 107
Indications for QST for Clinical Practice 107
How to Perform QST 107
Diagnostic Value of QST 108
Limitations of QST 108
References 110
27: Lumbar Spine Imaging: MRI 111
MR Imaging 111
Indications 111
Technique 111
Evaluation 111
Suggested Reading 114
28: Trigeminal Nerve Imaging 115
References 122
29: Lumbar Spine Imaging: X-Ray and CT 123
X-Ray Imaging 123
Indications 123
Technique 123
Evaluation 123
CT Imaging 125
Suggested Reading 126
30: Lumbar Spine Imaging: Myelography 127
Myelography 127
Indications 127
Technique and Evaluation 127
Suggested Reading 129
Part III: Psychology 130
31: Psychosocial and Cultural Aspects of Pain 131
Pain Is a Biopsychosocial Experience 131
Individual Differences in Affective, Cognitive, and Behavioral Responses to Pain 132
Coping Styles: Definition and Effect on Pain Experience and Response to Treatment 132
Effects of Active vs. Passive Toward Biopsychosocial Treatment Model 132
Passive-Cognitive: (“I Need a Cure”) 132
Passive-Cognitive: (“There Is No Cure Possible”) 132
Unexplained Pain 132
Active-Cognitive/Behavioral: (“Pain Will Remain, Suffering Is Optional”) 133
Cultural and Environmental Factors: Effect on Expectations, Disability, Treatment Outcomes, and Maintenance of Treatment Effects 133
Cultural, Environmental, Racial Variations, and Family Influence in Experience and Expression of Pain 133
Common Emotional Problems and Psychiatric Disorders Associated with Pain 134
Suggested Reading 134
32: Sex and Gender in Pain 135
Epidemiology of Pain 135
Gender and Opioids 135
Gender Differences in Pain Perception 135
Substance Abuse and Treatment 136
Summary 136
References 136
Part IV: Addiction 137
33: Addiction 138
Defining Addiction 138
Opioids 138
Intoxication 138
Withdrawal 139
Implications in Pain Treatment 139
Alcohol 139
Intoxication 139
Withdrawal 139
Implications in Pain Management 140
Cannabis 140
Intoxication 140
Withdrawal 140
Implications in Pain Treatment 140
Stimulants 140
Intoxication 140
Withdrawal 141
Implications in Pain Management 141
Sedatives/Tranquilizers 141
Intoxication 141
Withdrawal 141
Implications in Pain Management 141
Assessing Risk of Addiction 141
Managing Risk 142
Assessing for Nonmedical Use and Addiction 142
Suggested Reading 142
34: Addiction: Substance Abuse 143
References 144
Suggested Reading 144
Part V: Treatment of Pain 145
35: Pharmacology of Pain Transmission and Modulation 146
Transduction 146
Transmission 146
Modulation 146
Perception 147
Suggested Reading 147
36: Short-Acting Opioids 148
Opioids 148
Mechanism of Action 148
Receptor Classification 148
Short-Acting Opioids 148
Exogenous Short-Acting Opioids 148
Short-Acting Opioid Antagonist 149
Relative Properties 149
Hepatic Extraction Ratio 149
Potency 149
Lipid Solubility 149
pKA 149
Drug Interactions 149
Clinical 150
Clinical Indications 150
Special Considerations 150
Clinical Pearls 150
Literature Review 150
Suggested Reading 150
37: Long-Acting Opioids 151
Long-Acting Opioids 151
Relative Properties 151
Hepatic Extraction Ratio 151
Potency 151
Lipid Solubility 151
pKA 152
Drug Interactions 152
Clinical 152
Clinical Indications 152
Special Considerations 152
Clinical Pearls 152
Literature Review 153
Suggested Reading 153
38: Methadone 154
Mechanism of Action 154
Drug Interactions 154
Clinical 154
Clinical Indications 154
Initiation 154
Weaning 155
Special Considerations 155
Clinical Pearls 155
Suggested Reading 155
39: Buprenorphine 156
Mechanism of Action 156
Drug Interactions 156
Clinical 156
Clinical Indications 156
Initiation 156
Weaning 157
Special Considerations 157
Clinical Pearls 157
Suggested Reading 157
40: Nonsteroidal Anti-Inflammatory Medications 158
Nonsteroidal Anti-Inflammatory Medications 158
Mechanism of Action 158
Drug Interactions 158
Clinical 159
Clinical Indications 159
Initiation (Using Ibuprofen as an Example) 159
Weaning 159
Special Considerations 159
Clinical Pearls 159
Literature Review 159
Suggested Reading 159
41: Acetaminophen 160
Acetaminophen 160
Mechanism of Action 160
Drug Interactions 160
Clinical 160
Clinical Indications 160
Initiation 161
Weaning 161
Special Considerations 161
Clinical Pearls 161
Literature Review 161
Suggested Readings 161
42: Tricyclic Antidepressants 162
Tricyclic Antidepressants 162
Mechanism of Action 162
Drug Interactions 162
Clinical 162
Clinical Indications 162
Initiation (Using Amitriptyline as an Example) 163
Weaning 163
Special Considerations 163
Clinical Pearls 163
Literature Review 163
Suggested Reading 163
43: Selective Serotonin Reuptake Inhibitors 164
Mechanism of Action 164
Drug Interactions 164
Clinical 164
Clinical Indications 164
Initiation (Using Paroxetine as an Example) 165
Weaning 165
Special Considerations 165
Clinical Pearls 165
Suggested Reading 165
44: Serotonin-Norepinephrine Reuptake Inhibitors 166
Mechanism of Action 166
Drug Interactions 166
Clinical 166
Clinical Indications 166
Initiation (Using Duloxetine as an Example) 167
Weaning 167
Special Considerations 167
Clinical Pearls 167
Literature Review 167
Suggested Reading 167
45: Atypical Antipsychotics 168
Atypical Antipsychotics 168
Mechanism of Action 168
Side Effects 168
Clinical 169
Special Considerations 169
Literature Review 169
Suggested Reading 169
46: Benzodiazepines 170
Benzodiazepines 170
Mechanism of Action 170
Drug Interactions 170
Clinical 170
Clinical Indications 170
Treatment of Anxiety (by psychiatrists) 170
Weaning 171
Special Considerations 171
Clinical Pearls 171
Literature Review 171
Suggested Reading 171
47: Anticonvulsants 172
Anticonvulsants 172
Mechanism of Action 172
Drug Interactions 172
Clinical 173
Clinical Indications 173
Initiation: Using Gabapentin as an Example 173
Weaning 173
Special Considerations 173
Clinical Pearls 173
Suggested Reading 173
48: Muscle Relaxants 174
Muscle Relaxants 174
Mechanism of Action 174
Drug Interactions 174
Clinical 175
Clinical Indications 175
Initiation: Using Cyclobenzaprine 175
Weaning 175
Special Considerations 175
Clinical Pearls 175
Suggested Reading 175
49: Local Anesthetics 176
Local Anesthetics 176
Mechanism of Action 176
Drug Interactions 176
Clinical 176
Clinical Indications 176
Weaning 177
Special Considerations 177
Clinical Pearls 177
Suggested Readings 177
50: Corticosteroids 178
Mechanism of Action 178
Immune Modulating 178
Anti-inflammatory 178
Other 178
Individual Agents 178
Indications 179
Adverse Reactions 179
Clinical Pearls 179
Literature Review 179
Reference 179
Suggested Readings 180
51: Immunoglobulin G 181
Immunoglobulin G 181
Mechanism of Action 181
Drug Interactions 181
Clinical 182
Clinical Indications 182
Duration 182
Special Considerations 182
Clinical Pearls 182
Literature Review 182
Suggested Reading 182
52: NMDA Antagonists 183
Background 183
Mechanism 183
When Activated 183
Hyperalgesia and the Role of the NMDA Receptor 184
NMDA Antagonists 184
Ketamine 184
Methadone 184
Suggested Readings 185
53: Antihistamines 186
Antihistamines 186
Mechanism of Action 186
Drug Interactions 186
Clinical 186
Clinical Indications 186
Initiation: (Using Promethazine as an Example) 187
Special Considerations 187
Clinical Pearls 187
Suggested Reading 187
54: Sympatholytic Agents 188
Overview of Sympatholytic Agents 188
Adrenergic Receptor Antagonists 188
Description and Mechanism of Action 188
Examples 188
Clinical Indications 188
Side Effects 189
Interactions 189
Weaning 189
Alpha-2 Adrenergic Receptor Agonists 189
Description and Mechanism of Action 189
Examples 189
Clinical Indications 189
Side Effects 189
Interactions 189
Weaning 190
Other Sympatholytics 190
Description and Mechanism of Action 190
Suggested Readings 190
55: Miscellaneous Adjuvant Analgesics 191
Acetaminophen 191
Nonsteroidal Anti-inflammatory Drugs (NSAIDs) 191
Side Effects 191
Antidepressants 192
Side Effects 192
Anticonvulsants 192
Side Effects 192
Suggested Reading 193
56: Serotonin Syndrome 194
Pharmacology 194
Clinical 194
Clinical Manifestations 194
Diagnostic Criteria 194
Special Considerations 194
Treatment 194
Clinical Pearls 195
Suggested Readings 195
Part VI: Psychological Treatments 196
57: Cognitive-Behavioral Therapy 197
Reconceptualization 197
Skills Acquisition 197
Maintenance and Post-treatment Follow-up 197
Suggested Readings 198
58: Behavioral Interventions 199
Operant Behavior Therapy (OBT) 199
Respondent Therapy 200
Suggested Readings 200
59: Psychiatric Comorbidities and Treatments 201
Somatization Disorder 201
Depression 201
Anxiety 202
Sleep Disorders 202
Substance-Related Disorders 202
Personality Disorders 203
Schizophrenia 203
Transcranial Magnetic Stimulation (TMS) Treatment Modality 203
Suggested Readings 204
60: Stimulation-Produced Analgesia 205
Introduction 205
Acupuncture 205
Mechanism of Action 205
Efficacy 205
Contraindications 206
Side Effects 206
TENS 206
Spinal Cord Stimulation 206
Background 206
Mechanism of Action 207
Efficacy 207
Complications 207
Contraindications 207
Suggested Readings 207
Part VII: Interventional Pain Management 208
61: Interlaminar Epidural Steroid Injection: Cervical and Lumbar 209
Indications 209
Equipment/Materials 209
Procedure 209
Complications 210
Clinical Pearls 211
Evidence 211
Lidocaine Only vs with Steroid 211
Interlaminar vs Transforaminal 211
Suggested Readings 212
62: Lumbar Transforaminal Epidural Steroid Injection 213
CPT Codes 213
Indications 213
Procedure 213
Steps 213
Fluoroscopy Image (Fig. 62.1) 214
Clinical Pearls 214
Evidence 214
References 215
63: Cervical Facet Injection/Medial Branch Block 216
CPT Codes 216
Background 216
Indications 216
Procedure 216
Steps 217
Clinical Pearls 217
Evidence 217
References 218
64: Thoracic Facet Pain/Medial Branch Blocks 219
CPT Codes 219
Background 219
Indications 219
Procedure 219
Steps 219
Clinical Pearls 220
Evidence 220
References 220
65: Lumbar Facet Block 221
Indications 221
Contraindications 221
Anatomy 221
Equipment/Materials 221
Procedure 221
Steps 221
Complications 222
Clinical Pearls 222
Evidence 223
Lumbar Facet Joint Injection vs. Lumbar Medial Branch Block 223
Suggested Readings 223
66: Lumbar Medial Branch Radiofrequency Lesioning 224
CPT Code 224
Indications 224
Steps 224
Clinical Pearls 225
Evidence 225
References 226
67: Sacroiliac Joint Injection 227
CPT Codes 227
Background 227
Pain Distribution 227
Procedure 228
Steps 228
Evidence 228
References 229
68: Sacroiliac Joint Pain/ L5 Dorsal Ramus and S1–S3 Lateral Branch Radiofrequency Ablation 230
CPT Code 230
Background 230
Procedure 230
Steps for L5 dorsal ramus and S1–S3 lateral branch radiofrequency ablation 230
Evidence 231
References 232
69: Lumbar, Thoracic, and Cervical Discography 233
CPT 233
Indication 233
Contraindications 233
Complications 233
Equipment/Materials 234
General 234
Lumbar Discography 234
Thoracic Discography 234
Cervical Discography 234
Procedure 234
Steps for Lumbar Discography 234
Steps for Thoracic Discography 236
Steps for Cervical Discography 237
Positive Discogenic Pain Criteria 237
Lumbar Discography 237
Thoracic Discography 238
Cervical Discography 238
Clinical Pearls 238
General 238
Lumbar Discography 239
Thoracic Discography 239
Cervical Discography 239
Evidence 240
Dual- vs Single-Needle Techniques 240
Antibiotics 240
Analgesic Discography 240
References 240
Suggested Readings 240
70: Epidural Blood Patch 241
CPT 241
Indications 241
Contraindications 241
Equipment/Materials 241
Procedure: Fluoroscopic-Guided Epidural Blood Patch 241
Steps (See Epidural Steroid Injection Procedure Chapter for Sample Images) 241
Complications 243
Clinical Pearls 243
Evidence 243
15, 20, or 30 cc of Blood? 243
Suggested Readings 243
71: OnabotulinumtoxinA Injections for Chronic Migraine 244
Procedure 244
Clinical Pearls 244
Evidence 245
Suggested Readings 245
72: Spasmodic Torticollis/Cervical Dystonia (CD) 246
CPT 246
Indications 246
Equipment/Materials 246
Procedure 246
Steps 246
Complications 247
Specific Complications 247
Clinical Pearls 247
Evidence 247
Suggested Readings 247
73: Occipital Nerve Block 248
CPT 248
Indications 248
Equipment/Materials 248
Procedure 248
Steps 248
Complications 249
Clinical Pearls 249
Evidence 249
Suggested Readings 250
74: Supraorbital Nerve Block 251
Indications 251
Equipment/Materials 251
Procedure 251
Steps 251
Complications 251
Clinical Pearls 251
Evidence 252
Suggested Readings 252
75: Auriculotemporal Nerve Block 253
CPT 253
Indications 253
Equipment/Materials 253
Procedure 253
Steps: The Procedure Can Be Performed with or Without Ultrasound 253
Complications 254
Clinical Pearls 254
Evidence 255
Suggested Readings 255
76: Trigeminal Nerve Block 256
CPT 256
Indications 256
Equipment/Materials 256
Procedure 256
Steps 256
Complications 257
Clinical Pearls 258
Evidence 258
Suggested Readings 258
77: Gasserian Ganglion Block 259
CPT 259
Indications 259
Equipment/Materials 259
Procedure 259
Steps 259
Complications 262
Clinical Pearls 262
Evidence 262
Suggested Readings 263
78: Stellate Ganglion Block 264
Stellate Ganglion Block 264
Anatomy 264
Surrounding Anatomy 264
Indications 264
Painful Conditions 265
Vascular Conditions 265
Other Conditions 265
Contraindications 265
Techniques 265
Side Effects 266
Complications 266
Suggested Readings 266
79: Celiac Plexus Block 267
CPT 267
Indications 267
Equipment/Materials 267
Procedure 267
Steps 267
Retrocrural Approach 267
Complications 269
Clinical Pearls 269
Evidence 269
Additional Reading 269
80: Lumbar Sympathetic Block 270
CPT 270
Indications 270
Equipment/Materials 270
Procedure 270
Steps 271
Complications 272
Clinical Pearls 272
Evidence 272
References 273
81: Superior Hypogastric Plexus Block 274
CPT 274
Indications 274
Equipment/Materials 274
Procedure 274
Steps 274
Complications 275
Clinical Pearls 275
Evidence 276
Neurolytic Blocks and Opiate Consumption 276
Local Anesthetic +/? Steroid for Nonmalignant Pain 276
References 277
82: Ganglion of Impar Injection/Neurolysis 278
Indications 278
Equipment/Materials 278
Procedure 278
Steps 278
Complications 279
Clinical Pearls 279
Evidence 279
Additional Readings 279
83: Brachial Plexus Blocks 280
Equipment/Materials 280
Single-Shot Block 280
Continuous Catheter Placement 280
Procedures: Four Locations for Blockade 280
Interscalene Block 280
Complications 282
Clinical Pearls 282
Supraclavicular Block 282
Complications 284
Clinical Pearls 284
Infraclavicular Block (Fig. 83.3) 284
Complications 286
Clinical Pearls 286
Axillary Block (Fig. 83.4) 286
Complications 288
Clinical Pearls 288
Evidence 288
Interscalene Nerve Block and GA Versus GA Alone in Shoulder Surgery 288
Perineural Injections Versus Perivascular Injection in Axillary Block 289
Additional Reading 289
84: Thoracic Paravertebral Block 290
Equipment/Materials 290
Single-Shot Block 290
Continuous Catheter Placement 290
Procedure: Traditional Technique 290
Laminar Technique 291
Ultrasound-Guided Technique 291
Complications 293
Clinical Pearls 293
Evidence 293
Paravertebral Block Efficacy and Safety for Breast Surgery 293
Laminar Technique Efficacy 294
Additional Reading 294
85: Intercostal Nerve Block 295
Ultrasound-Guided Procedure 295
Landmark Technique 296
Complications 296
Additional Reading 296
86: Transversus Abdominis Plane (TAP) Block 297
Procedure 297
Complications 298
Clinical Pearls 298
Evidence 298
Spread with Single Injection 298
Efficacy of TAP Block as Postoperative Pain Control Adjuvant 298
Additional Readings 299
87: Anterior (Abdominal) Cutaneous Nerve Block 300
Indications 300
Equipment/Materials 300
Procedure 300
Complications 301
Clinical Pearls 302
Evidence 302
Management of ACNES in a Large Cohort [5] 302
References 303
88: Ilioinguinal Nerve Block 304
Indications 304
Equipment/Materials 304
Procedure 304
Complications 305
Clinical Pearls 306
Evidence 306
References 306
Additional Reading 306
89: Genitofemoral Nerve Block 307
Procedure 307
Landmark/Fluoroscopic Guidance Approach 307
Step Ultrasound Approach 308
CT-Guided Approach 308
Complications 308
Clinical Pearls 308
Evidence 308
Additional Reading 308
90: Lateral Femoral Cutaneous Nerve Block 310
Procedure 310
Complications 310
Clinical Pearls 311
Evidence 312
Anatomic Landmarks Versus Ultrasound Guidance 312
Efficacy 312
Additional Reading 312
91: Piriformis Muscle Injection (Fluoroscopically Guided) 313
Procedure 313
Complications 314
Clinical Pearls 314
Evidence 314
Additional Reading 315
92: Sonographically Guided Iliopsoas Injection 316
Indications 316
Equipment/Materials 316
Procedure 316
Complications 316
Clinical Pearls 317
Evidence 318
Consult the Following Articles 318
Additional Readings 318
93: Saphenous Nerve Block 319
Indications 319
Equipment/Materials 319
Procedure 319
Complications 321
Clinical Pearls 321
Evidence 321
Above-the-Knee Versus Below-the-­Knee Versus At-the-Knee? 321
Saphenous Nerve Block During TKA? 321
References 321
94: Pudendal Nerve Block 322
Transvaginal/Transrectal Approach 322
Fluoroscopic-Guided Transgluteal Approach 322
Ultrasound-Guided Transgluteal Approach 323
Fluoroscopic-Guided Transsacral S2–S4 Block 323
Additional Reading 325
95: Trochanteric Bursa Injection 326
Procedure 326
Complications 326
Clinical Pearls 327
Evidence 327
Intra-Bursal Steroid Use 327
“Blind” Injection 327
Additional Reading 327
96: Ischial Bursa Injection 328
Procedure 328
Steps: 328
Blind 328
Ultrasound Guided 328
Fluoroscopy Guided 329
Complications 330
Clinical Pearls 330
Evidence 330
Blind Versus Ultrasound Versus Fluoroscopy 330
Additional Reading 331
97: Intra-articular Shoulder Joint Injection (Fluoroscopically Guided) 332
Procedure 332
Complications 333
Clinical Pearls 333
Evidence 333
Intra-articular Steroid Use 333
Additional Reading 334
98: Intra-articular Hip Joint Injection (Fluoroscopically Guided) 335
Procedure 335
Complications 336
Clinical Pearls 336
Evidence 337
Intra-articular Steroid Use 337
Additional Reading 337
99: Intra-articular Knee Joint Injection (Fluoroscopically Guided) 338
Procedure 338
Complications 339
Clinical Pearls 339
Evidence 340
Intra-articular Steroid Use 340
Additional Reading 340
100: Ultrasound-Guided Ankle Joint Injection 341
Indications 341
Equipment/Materials 341
Tibiotalar Joint Injection 341
Subtalar Joint Injection 342
Complications 343
Clinical Pearls 343
Evidence 343
Procedure 344
Superficial Peroneal Nerve (SPN) Block 344
Deep Peroneal Nerve (DPN) Block 344
Saphenous Nerve Block 344
Posterior Tibial Nerve (PTN) Block 345
Sural Nerve Block 346
Complications 346
Clinical Pearls 346
Evidence 347
References 347
Additional Reading 347
101: Small Joint Injections 348
Procedure 348
Foot/Ankle 348
Sternoclavicular Joint 348
Additional Reading 350
Part VIII: Surgical Pain Management 351
102: Intrathecal Drug Delivery 352
Procedure 352
Complications 353
Additional Reading 353
103: Spinal Cord Stimulation 354
Procedure 354
Steps for Percutaneous Technique Following a Temporary Trial 354
Clinical Pearls 355
Evidence 356
Additional Reading 356
104: Peripheral Nerve Stimulation 357
Equipment/Materials 357
Procedure 357
Complications 358
Clinical Pearls 358
Evidence 359
Additional Reading 359
105: Peripheral Nerve Field Electrostimulation 360
Introduction 360
Additional Reading 360
106: Minimally Invasive Ligamentum Decompression (MILD) Procedure 362
Procedure 362
Additional Reading 363
107: Vertebroplasty and Kyphoplasty 364
CPT 364
Preparation 364
Procedure 365
Complications 367
Clinical Pearls 367
Evidence 367
Efficacy 367
Vertebroplasty Versus Kyphoplasty 367
References 367
Additional Reading 367
108: Radio-Frequency Venous Ablation 368
Associated Procedures 368
Indications 368
Complications 368
Pearls 368
Anatomy 369
Equipment 369
Procedure Description 369
Additional Reading 369
109: Physical Medicine and Rehabilitation: Physical Modalities, Orthoses, Assistive Devices, and Manipulation 371
Physical Modalities 371
Heat 371
Cryotherapy 372
Electricity 372
Orthoses 372
Spinal Orthotics 372
Ankle Foot Orthoses (AFO) 373
Knee Orthoses 373
Assistive Devices 373
Canes 373
Walkers 373
Crutches 373
Splinting and Casting 374
Manipulation 374
References 374
110: Work Rehabilitation 375
Overview 375
Scope of the Chapter 375
Definition 375
Paradigm Shift 375
Evidence-Based Approach 376
Evaluation 376
Fundamental Components ICF Evaluation* 376
Risk Factors 376
Assessment Tools 376
Management 376
Multidisciplinary Approach 377
Treatment/Target Intervention 377
Interventions 377
Treatment Outcomes [3] 377
Key Findings in Literature 377
Summary 378
Key Concepts 378
References 378
111: Complementary, Alternative, and Integrative Therapies (CAIT) 379
Overview 379
Alternative Medical Systems 380
Traditional Chinese Medicine 380
Homeopathy 380
Ayurvedic Medicine 381
Mind-Body Interventions 381
Mindfulness-Based Interventions 381
Qigong 381
Tai Chi 382
Yoga 382
Energy-Based Therapies 382
Biologically Based Therapies 382
Herbal Supplements 382
Food as Medicine 385
References 385
Additional Reading 387
Part IX: Clinical States 388
112: Taxonomy of Pain Systems 389
Pain 389
Analgesia 389
Anesthesia Dolorosa 389
Dysesthesia 389
Paresthesia 389
Allodynia 389
Hyperalgesia 389
Hyperesthesia 390
Hyperpathia 390
Hypoalgesia 390
Hypoesthesia 390
Neuralgia 390
Neuritis 390
Neuropathic Pain 390
Central Neuropathic Pain 390
Peripheral Neuropathic Pain 390
Neuropathy 390
Nociception 390
Nociceptive Neuron 391
Nociceptive Pain 391
Nociceptive Stimulus 391
Nociceptor 391
Noxious Stimulus 391
Pain Threshold 391
Pain Tolerance Level 391
Sensitization 391
Central Sensitization 391
Peripheral Sensitization 391
Additional Reading 391
113: Acute Pain 393
Epidemiology of Postoperative Acute Pain 393
Physiologic and Psychological Effects of Inadequate Acute Pain Control 393
Major Classes of Drugs 393
Perioperative Pain Management 394
Preemptive Analgesia 394
Postoperative Analgesia 394
IV Patient-Controlled Analgesia (PCA) (Table 113.3) 395
Non-pharmacological Methods 395
Clinical Outcomes to Be Evaluated 395
Additional Reading 395
114: Cancer Pain: Assessment 396
Assessing Type of Pain 396
Nociceptive Pain 396
Neuropathic Pain 396
Acute Pain Syndromes 396
Chronic Pain Syndromes 397
Assessing Pain Severity 397
Psychological Considerations 397
Additional Reading 397
115: Cancer Pain: Pharmacological Treatment 398
Principles of Treatment 398
Analgesic Ladder Approach 398
Pharmacologic Management 399
Side Effect Management 400
References 400
Additional Reading 400
116: Cancer Pain: Interventional Therapies 401
Anesthetic Approaches Include Peripheral Nerve Blocks 401
Celiac Plexus Block 401
Risks 401
Superior Hypogastric Plexus Block 401
Risks 402
Ganglion Impar Block 402
Technique 402
Interventional Radiologic Approaches 402
Medications 402
Additional Reading 402
117: Cancer Pain: Palliative Care 403
End-of-Life Pain Syndromes 403
End-of-Life Symptoms Besides Pain 404
Additional Reading 404
118: Cervical Radicular Pain 405
Anatomy 405
Differentiation of Radicular from Somatic Pain (Table 118.1) 405
History Taking and Neurologic Examination: Role and Limitations 405
Medical Imaging: Reliability and Validity 406
Electrodiagnostic Studies 406
Commonly Used Interventions 406
Surgical Treatment: Indications and Use 407
119: Neck Pain 408
Introduction 408
Anatomy 408
Use of Conventional Imaging 409
Invasive Tests 410
Nonsurgical Intervention 410
120: Lumbar Radicular Pain 411
Anatomy 411
Causes and Differentiation Between Low Back Pain and Somatic Referred Pain 411
History and Neurologic Examination: Reliability, Validity, and Limitations 412
Medical Imaging and Electro-­diagnostic Testing: Indications and Validity 412
Natural History and Relevance to Management 413
Commonly Used Interventions: Evidence-Based 413
Surgical Treatment: Indications and Efficacy 413
Additional Reading 413
121: Low Back Pain 414
Anatomy 414
History and Physical Examination 414
History 414
Physical Examination 414
Imaging and Tests 415
Prognostic Risk Factors and Psychosocial Factors 415
Interventions: Medical and Surgical 415
Medical Therapies 415
Surgical Therapies 415
Multidisciplinary Therapy 415
References 416
122: Degenerative Lumbar Spinal Stenosis 417
Brief Overview, Definition, and Epidemiology of Degenerative Lumbar Spinal Stenosis (dLSS) 417
Common Clinical Presentation 417
Imaging and Diagnostic Pearls 418
Conservative Management of dLSS 418
Non-operable vs. Operable Intervention 418
Special Considerations in Contemporary Management of dLSS 419
Additional Reading 419
123: Musculoskeletal Pain 420
Epidemiology 420
Anatomy and Physiology 420
Mediators of Inflammation, Tissue Destruction, and Repair 420
Molecular and Cellular Basis of Immunity and Autoimmunity 421
Neurophysiology 421
Psychosocial Aspects 421
Classification and Clinical Characteristics of Musculoskeletal Diseases 421
Assessment of Activity and Severity of Rheumatic Disease 421
Treatment and Rehabilitation of Musculoskeletal Pain/Disability 422
Additional Reading 422
124: Muscle Pain and Myofascial Pain 423
Myofascial Pain 423
Pathophysiology 423
Symptoms 423
Risk Factors 423
Clinical Management 424
Clinical Pearls 424
Additional Reading 424
125: Fibromyalgia 426
Overview 426
Evaluation 426
Treatment 427
Additional Readings 427
126: Piriformis Syndrome 428
Definition 428
Anatomy 428
Mechanism of Injury 429
Incidence 429
Differential Diagnosis 429
Signs and Symptoms 429
Imaging 429
Treatment Options 429
Additional Readings 430
127: Carpal Tunnel Syndrome 431
Carpal Tunnel Syndrome 431
Clinical Management 432
Additional Readings 432
128: Compression Fracture Pain 433
Introduction 433
Pathophysiology 433
Clinical Manifestations 434
Management 434
Additional Readings 435
129: Post-thoracotomy Pain Syndrome: PTPS 436
What is PTPS? 436
Definition of Chronic Postsurgical Syndrome 436
Epidemiology and Risk Factors for PTPS 436
Clinical Presentation of PTPS 437
Differential Diagnosis 437
Prevention Strategies for the Development of PTPS 437
References 437
130: Post-Mastectomy Pain Syndrome 438
Introduction 438
Risk Factors 438
Pathophysiology 438
Clinical Manifestations 439
Treatment 439
Additional Readings 440
131: Peripheral Vascular Disease 441
References 442
132: Chronic Venous Insufficiency 443
Introduction 443
Etiology 443
Pathophysiology 443
Risk Factors 443
History and Physical Exam 443
CEAP Classification 444
Diagnosis 444
Treatment 444
Conservative Therapy 444
Vein Ablation Therapies 445
References 445
133: Sphenopalatine Ganglion: Function and Block 446
Innervation of Sphenopalatine Ganglion 446
Sphenopalatine Block 446
Procedure Steps 446
Complications 447
Evidence 447
References 447
134: Phantom Limb Pain 448
Definition 448
Differential Diagnoses 448
Characteristics 448
Pathophysiology 448
Treatment 449
References 450
135: Visceral Pain Syndromes 451
Introduction 451
Pathophysiology 451
Clinical Manifestations 452
Management 452
Additional Readings 453
136: Chronic Urogenital Pain 454
Anatomy 454
Nerves-Plexus Blocks 454
Epidemiology 454
Clinical 454
Treatment 455
Interventional Treatments 455
Additional Reading 456
137: Labor Pain 457
Mechanisms of Pain During Labor 457
Benefits of Labor Analgesia 457
Consequences of Labor Analgesia 457
Management of Labor Pain: Inhalation Agents 458
Management of Labor Pain: Parenteral 458
Management of Labor Pain: Regional 458
Management of Labor Pain: Nonpharmacologic 459
References 459
Additional Reading 460
Part X: Headache and Facial Pain 461
138: Migraine Headaches 462
Epidemiology 462
Clinical Picture 462
Migraine Phases: Prodrome—Aura—Headache—Postdrome 462
Migraine Without Aura 463
Migraine with Aura 463
Chronic Migraine 463
Migraine Equivalent 464
Pathophysiology 464
Diagnostic Testing 464
Treatment 464
Additional Reading 465
139: Tension-Type Headache 466
ICD-10 466
Summary 466
Definition and Epidemiology 466
Pathophysiology 466
Clinical Features 467
Treatment 467
Additional Reading 467
140: Cluster Headaches 468
ICD-10 468
ICHD III Beta-Cluster Headache 468
Definition and Diagnosis 468
Cluster Headache—ICHD Diagnostic Criteria 468
Epidemiology 469
Pathophysiology 469
Clinical Features 469
Diagnosis 469
Treatment 469
Additional Reading 470
141: Medication Overuse Headache 471
ICD-10 471
Definition 471
Clinical Picture 471
Pathophysiology 471
Clinical Pearl 472
Additional Reading 472
142: Occipital Neuralgia 473
Definition 473
Anatomy 473
Pathophysiology 473
Diagnosis 473
Physical Examination 474
Differential Diagnosis 474
Testing 474
Management 474
Clinical Pearl 474
Additional Reading 474
143: Trigeminal Neuralgia 475
G50.0 Trigeminal neuralgia 475
Definition 475
Pathophysiology 475
Clinical Features 475
Diagnosis 476
Treatment 476
144: Trigeminal Autonomic Cephalalgias (TACs): Cluster Headache, Paroxysmal Hemicranias, SUNCT, SUNA 477
Cluster Headache 477
Diagnosis and Management 477
Paroxysmal Hemicrania 478
SUNCT and SUNA 478
Part XI: Nerve Damage 479
145: Neuropathic Pain 480
Neuropathic Pain: Definition 480
Prevalence 480
Evaluation and Diagnosis 480
Etiologic Classification 481
Examples of Common Painful Neuropathies 481
Treatment Modalities 481
Additional Reading 482
146: Diabetic Neuropathy 483
Introduction 483
Diabetic Neuropathy 483
Pathophysiology of Diabetic Neuropathy 483
Management 483
Evidence 485
Additional Reading 485
147: Complex Regional Pain Syndrome 486
Description 486
Types 486
Epidemiology 486
Pathophysiology 486
Signs/Symptoms 487
Diagnosis 487
Treatment 487
Summary 488
Additional Reading 489
148: Post-Herpetic Neuralgia 490
Introduction 490
Risk Factors 490
Pathophysiology 490
Clinical Manifestations 491
Management 492
Additional Reading 492
Part XII: Special Cases 493
149: Pain in Older Adults 494
Background and Demographics 494
Physiologic Changes with Aging 494
Pain Assessment in Older Adults 495
Barriers to Effective Management 495
Pharmacologic Management 495
Non-pharmacologic Management 496
References 497
Additional Reading 497
150: Words That Hurt, Words That Help! 498
Introduction 498
Suggestions and Their Consequences 498
Communication and the Placebo Effect 499
Nocebo Effect of Communication 499
Ethical Communication 499
Summary 500
References 500
151: How to Communicate with Patients in Pain 501
Levels of Communication 501
Conscious Communication 501
Subconscious Communication 501
The LAURS of Communication 501
Listening 501
Acceptance 502
Utilization 502
Reframing 502
Suggestion 502
Other Useful Language Structures 503
Double Binds 503
Failure Words 503
Avoid Jargon 503
The GREAT Template (Greeting, Rapport, Evaluation, Addressing Concerns, Termination) 503
Greeting, Goal 503
Rapport 503
Evaluation, Examination, Explanation, Expectation 503
Addressing Concerns 503
Termination of Interaction 504
Special Considerations 504
Summary 504
References 504
152: Hypnosis for Pain Relief 505
Introduction 505
Evidence Base 505
Neuroimaging 505
Cognitive Neuroscience 506
Neuroplasticity, Hypnosis, and Different Ways of Processing Information 506
Applications to Pain Medicine 506
Conclusion 507
References 507
153: Regenerative Medicine for Pain Management 509
Terminology and Definitions 509
Types of Regenerative Medicine Therapies 510
PRP and Clinical Applications 511
Clinical Applications 512
Typical Use Case Scenarios and Sample Therapy Protocol 512
Bone Marrow and Clinical Applications 512
Clinical Applications 512
Typical Use Case Scenarios and Sample Therapy Protocol 512
Adipose and Clinical Applications 513
Clinical Applications 513
Typical Use Case Scenarios and Sample Therapy Protocol 513
Compliance with the FDA 514
Additional Reading 514
Index 515