Pain management can be categorized as simple or complex – depending on the cause of the pain. A good example of less complex pain would be nerve root irritation from a herniated disc (with some pain radiating down the outside of one’s leg). This pain can be alleviated with a steroid injection, physical therapy, or both. If the pain does not go away, there are alternatives (skilled professionals) to treat the pain, including:

• Medication management
• Physical therapy or chiropractic therapy
• Psychological counseling and support
• Acupuncture and alternative therapies; and
• Referral to other medical specialists

These skills and services are necessary because pain can involve many aspects of a person’s daily life.

How is pain treatment guided?

The concept behind most interventional procedures for treating pain is that there is a specific structure in the body with nerves of sensation generating the pain. For a structure to cause pain, it must have a nerve supply, be susceptible to injury, and stimulation of the structure should cause pain. Pain management has a role in identifying the precise source of the problem and isolating the optimal treatment.

What are the basic types of pain?

How pain is treated depends largely upon what type of pain it is. There are many sources of pain. One way of dividing these sources of pain is to divide them into two groups, nociceptive pain, and neuropathic pain.

Nociceptive pain

Examples of nociceptive pain are a cut or a broken bone. Tissue damage or injury initiates signals that are transferred through peripheral nerves to the brain via the spinal cord. Pain signals are modulated throughout the pathways. This is how one becomes aware that something is hurting.

Most back, leg, and arm pain is nociceptive pain. Nociceptive pain can be divided into two parts, radicular or somatic.

Radicular pain: Radicular pain stems from irritation of the nerve roots, for example, from a disc herniation. It goes down the leg or arm in the distribution of the nerve that exits from the nerve root at the spinal cord. Associated with radicular pain is radiculopathy, which is weakness, numbness, tingling or loss of reflexes in the distribution of the nerve.

Somatic pain: Somatic pain is pain limited to the back or thighs. The problem that doctors and patients face with back pain, is that after a patient goes to the doctor and has an appropriate history taken, a physical exam performed, and appropriate imaging studies (for example, X-rays, MRIs or CT scans), the doctor can only make an exact diagnosis a minority of the time. The cause of most back pain is not identified and is classifies as idiopathic. Three structures in the back which frequently cause back pain are the facet joints, the discs, and the sacroiliac joint.

Neuropathic pain

Neuropathic pain is pain caused by damage or disease that affects the nervous system. Sometimes there is no obvious source of pain, and this pain can occur spontaneously. Classic examples of this pain are shingles and diabetic peripheral neuropathy.

Neuropathic pain includes

• Complex regional pain syndrome (CRPS), also called reflex sympathetic dystrophy;
• Sympathetically maintained pain;
• Fibromyalgia;
• Interstitial cystitis; and
• Irritable bowel syndrome

Treatment of neuropathic pain

The various neuropathic pains can be challenging to treat. However, with careful diagnosis and often a combination of treatments, there is an excellent chance of improving the pain and return of function.

Medications are a mainstay of the treatment of neuropathic pain. In general, they work by influencing how the body handles pain information. Most pain information is filtered out by the central nervous system, usually at the spinal cord level.

Many medications to treat neuropathic pain operate on this filtering process. The medications used for neuropathic pain include antidepressants, which influence the amount of serotonin or norepinephrine, and antiseizure medications, which act on various neurotransmitters, such as GABA and glycine.

One of the most powerful tools for treating neuropathic pain is the spinal cord stimulator, which directly delivers tiny amounts of electrical energy onto the spine. Stimulation works by interrupting inappropriate pain information being transferred to the brain. It also creates a tingling in the pain extremity, which masks pain.

What are other causes of pain?

• Headaches
• Facial pain
• Peripheral nerve pain
• Coccydynia
• Compression fracture
• Myofasciitis
• Torticollis
• Piriformis syndrome
• Plantar fasciitis

Headaches and facial pain, including atypical facial pain and trigeminal neuralgia

Headaches are a major source of discomfort and lost productivity in the workplace. Many effective treatments exist for persisting headaches, including medication, biofeedback, injections, and implants, depending upon the precise type of headache.

Atypical facial pain can be debilitating. Often it can be treated by injections into local nerve tissue (such as the sphenopalatine ganglion).

Trigeminal neuralgia, is a condition that most commonly causes very intense intermittent shooting pain in the face.

Peripheral nerve pain

Peripheral nerve pain, or neuropathy, can be debilitating. It can respond well to simple treatments such a trigger point injections with anesthetic medicines and cryoablation.

Coccydynia

Coccydynia is simply pain in the region on the tailbone, or coccyx. It can result from trauma or arise without apparent cause. The initial treatment is conservative, with oral pain relief medicines (analgesics).

Compression fractures

Compression fractures of the bony building blocks (vertebral bodies) are common in the elderly due to osteoporosis, or loss of calcium in the bone. With less calcium, the bone becomes weak and can break. Like any fracture, compression fractures hurt. Like any fracture, they are treated by stabilization, in this case, by injecting cement into the bone in a procedure known as a vertebroplasty or kyphoplasty. Vertebroplasty is an effective way to treat the pain of compression fractures. Kyphoplasty uses a balloon to restore height to the compressed vertebral body.

Myofasciitis and Torticollis

Myofasciitis (pain in the muscles, whether in the neck or back) often responds to conservative physical therapy treatments (for example, massage and exercise). If the pain persists, trigger point injections can be used. If the trigger point injections provide temporary relief, sometimes Botox injections can help. Botox can relax the muscles for six or more months, with long-term relief of pain.

Torticollis is spasm of the muscles in the neck, forcing the sufferer to hold his or her neck tilted or rotated to the side.

Piriformis Syndrome

The piriformis muscle goes from the hip to sacrum (tailbone). It is important in that the sciatic nerve passes through it. Piriformis syndrome is a spasm of the piriformis muscle. When the muscle goes into spasm, it can squeeze the sciatic nerve, causing pain going down the leg. Piriformis syndrome will usually respond to physical therapy.

Plantar fasciitis and lateral epicondylitis

Plantar fasciitis (heel pain) and lateral epicondylitis (tennis elbow) are two common pain problems. Treatment starts with conservative options, such as rest, non-steroidal anti-inflammatory medications, steroid injections, over-the-counter pain medications, physical therapy, and, for heel pain, shoe inserts.

About Dr. Bagwe

Dr. Bagwe is a leading orthopedic surgeon specializing in ankle and foot reconstruction. If you are looking for an orthopedic surgeon near you then look no further. Dr. Bagwe is an industry leader when it comes to foot and ankle surgery doctors in St. Louis. Dr. Bagwe and his friendly and professional team is ready to welcome you and tell you everything you need to know.

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