Taking a Comprehensive Approach in Tackling Regional Pain Syndromes

LAS VEGAS — Being able to appropriately diagnose, manage, and treat neck and back pain can go a long way when your patient is experiencing painful conditions. Jumping to the solution before correctly assessing the situation at hand could result in adverse effects for your patient. 

As more than 100 million people suffer from chronic pain, clinicians are tasked with identifying new ways to treat a population that is aging, gaining more weight, and living longer. While physicians may not necessarily be able to prevent pain from occurring, they can do their best to comfort patients enduring painful conditions.   

“Many regional pain syndromes mimic each other,” said Srinivas Nalamachu, MD, a clinical associate professor at Temple University and president and clinical director of the International Clinical Research Institute in Overland Park, Kansas. “Sometimes patients may have more than one condition. It is important to know what we are dealing with to be able to come up with the right intervention.”

A patient’s acute low back pain will typically go away in 2 to 3 weeks, and less than 10% will have chronic issues.¹ Guidelines call for the use of acetaminophen, nonsteroidal anti-inflammatory agents (NSAIDs), muscle relaxants, and physical therapy as first-line treatment.² If pain is uncontrollable, referral to a specialist may be required.

Improving clinician diagnostic skills can assist physicians with formulating a differential diagnosis. Dr. Nalamachu noted that new pharmacologic and interventional treatment options have been proven to be essential in providing patients with pain relief. 

“There is limited education and training in medical schools and primary care residencies on these conditions,” he said. 

Other back pain conditions warranting attention include lumbosacral radiculopathy, facet joint arthritis, sacroiliac dysfunction, piriformis syndrome, and ankylosing spondylitis. In addition, although rare, pelvic pathology and ischial bursitis should also be considered as contributing to regional pain syndromes. 

Several items are of significance when evaluating back pain: patient history, previous diagnostic testing, functional history, previous interventions, and a thorough evaluation for diagnosis and management. 

Following on the heels of back pain is neck pain. Dr. Nalamachu noted that contributing to the increase in complaints of neck pain are sedentary lifestyles and poor posturing associated with increased use of computers. 

Common neck conditions include regional myofascial pain syndrome and cervical degenerative disk disease. Whiplash occurring as a result of a motor vehicle accident is another common etiology of neck pain. 

As with back injuries, physicians assessing patients for neck pain complaints should obtain a patient history, conduct a physical examination, and review diagnostic testing. 

Numerous nonpharmacologic approaches are available to address neck and back pain: physical therapy, therapeutic massage, chiropractic manipulation, acupuncture, and bracing. 

Pharmacologic interventions include over-the-counter medications (acetaminophen, NSAIDs), prescription NSAIDs, skeletal muscle relaxants, adjuvant therapies (eg, anticonvulsants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors), and opiates.

Interventional procedures may also be considered to relieve neck and back pain: steroid injections, radiofrequency ablation, spinal cord stimulators, and botulinum toxin injections.

Surgery should be carefully considered, according to Dr. Nalamachu, as it is typically associated with a high failure rate. Operative procedures may often address the structural problem, but they do not always address the pain. 

“As the population is aging, it is important that healthcare providers know how to diagnose and manage these conditions in an efficient way,” he said. “By doing so, we can improve their function and sometimes prevent them from becoming a victim of chronic pain.”

References

1. Dillingham T. Evaluation and management of low back pain: An overview. State Art Rev. 1995;9:559-574.
2. American College of Physicians. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Available at: https://www.acponline.org/mobile/clinicalguidelines/guidelines/low_back_pain_1007.html. Accessed August 13, 2015.