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Chapter 47. Chronic Pain Management

Richard W. Rosenquist, MD; Bruce M. Vrooman, MD

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    AMA Citation
    Rosenquist RW, Vrooman BM. Rosenquist R.W., Vrooman B.M. Rosenquist, Richard W., and Bruce M. Vrooman.Chapter 47. Chronic Pain Management. In: Butterworth JF, IV, Mackey DC, Wasnick JD. Butterworth J.F., IV, Mackey D.C., Wasnick J.D. Eds. John F. Butterworth, IV, et al.eds. Morgan & Mikhail's Clinical Anesthesiology, 5e New York, NY: McGraw-Hill; 2013. http://accessmedicine.mhmedical.com/content.aspx?bookid=564&sectionid=42800580. Accessed June 07, 2020.
    MLA Citation
    Rosenquist RW, Vrooman BM. Rosenquist R.W., Vrooman B.M. Rosenquist, Richard W., and Bruce M. Vrooman.. "Chapter 47. Chronic Pain Management." Morgan & Mikhail's Clinical Anesthesiology, 5e Butterworth JF, IV, Mackey DC, Wasnick JD. Butterworth J.F., IV, Mackey D.C., Wasnick J.D. Eds. John F. Butterworth, IV, et al. New York, NY: McGraw-Hill, 2013, http://accessmedicine.mhmedical.com/content.aspx?bookid=564&sectionid=42800580.

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  • image Pain may be classified according to pathophysiology (eg, nociceptive or neuropathic pain), etiology (eg, postoperative or cancer pain), or the affected area (eg, headache or low back pain).
  • image Nociceptive pain is caused by activation or sensitization of peripheral nociceptors, specialized receptors that transduce noxious stimuli. Neuropathic pain is the result of injury or acquired abnormalities of peripheral or central neural structures.
  • image Acute pain is caused by noxious stimulation due to injury, a disease process, or the abnormal function of muscle or viscera. It is nearly always nociceptive.
  • image Chronic pain is pain that persists beyond the usual course of an acute disease or after a reasonable time for healing to occur; this healing period can vary from 1 to 6 months. Chronic pain may be nociceptive, neuropathic, or mixed.
  • image Modulation of pain occurs peripherally at the nociceptor, in the spinal cord, or in supraspinal structures. This modulation can either inhibit (suppress) or facilitate (intensify) pain.
  • image At least three mechanisms are responsible for central sensitization in the spinal cord: (1) wind-up and sensitization of second-order wide dynamic range neurons; (2) dorsal horn neuron receptor field expansion; and (3) hyperexitability of flexion reflexes.
  • image Chronic pain may be caused by a combination of peripheral, central, and psychological mechanisms.
  • image Moderate to severe acute pain, regardless of site, can affect the function of nearly every organ and may adversely influence perioperative morbidity and mortality.
  • image The evaluation of any patient with pain should include several key components. Information about location, onset, and quality of pain, as well as alleviating and exacerbating factors, should be obtained along with a pain history that includes previous therapies and changes in symptoms over time.
  • image Psychological evaluation is useful whenever medical evaluation fails to reveal an apparent cause for pain, pain intensity is disproportionate to disease or injury, or when depression or other psychological issues are apparent.
  • image Myofascial pain syndromes are common disorders characterized by aching muscle pain, muscle spasm, stiffness, weakness, and, occasionally, autonomic dysfunction.
  • image Ninety percent of disc herniations occur at L5-S1 or L4-L5. Symptoms usually develop following flexion injuries or heavy lifting and may be associated with bulging, protrusion, or extrusion of the disc.
  • image Back pain caused by spinal stenosis usually radiates into the buttocks, thighs, and legs. Termed pseudoclaudication or neurogenic claudication, the pain is characteristically worse with exercise and relieved by rest, particularly sitting with the spine flexed.
  • image Diabetic neuropathy is the most common type of neuropathic pain.
  • image Complex regional pain syndrome (CRPS) is a neuropathic pain disorder with significant autonomic features that is usually subdivided into two variants: CRPS 1, formerly known as reflex sympathetic dystrophy (RSD), and CRPS 2, formerly known as causalgia. The major difference between the two is the absence or presence, respectively, of documented nerve injury.
  • image Trigeminal neuralgia (tic douloureux) is classically unilateral and usually located in the V2 or V3 distribution of the trigeminal nerve. It has an electric shock quality lasting from seconds to minutes at a time and is often provoked by contact with ...

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