Handbook of Pain Medicine - 2nd Edition Chapter-by-Chapter Download
Uploaded by
g.hynhpuynh.coongtachHandbook of Pain Medicine - 2nd Edition Chapter-by-Chapter Download
Uploaded by
g.hynhpuynh.coongtachHandbook of Pain Medicine - 2nd Edition
Visit the link below to download the full version of this book:
https://medipdf.com/product/handbook-of-pain-medicine-2nd-edition/
Click Download Now
This page intentionally left blank
HANDBOOK OF
PAIN MEDICINE
SECOND EDITION
Dr (Prof.) GP Dureja
Former Professor, All India Institute of Medical Sciences, New Delhi
Director, Delhi Pain Management Centre, New Delhi
ELSEVIER
A division of
Reed Elsevier India Private Limited
Handbook of Pain Medicine, 2/e
GP Dureja
ELSEVIER
A division of
Reed Elsevier India Private Limited
Mosby, Saunders, Churchill Livingstone, Butterworth-Heinemann and Hanley &
Belfus are the Health Science imprints of Elsevier.
© 2014 Elsevier.
First edition 2004
Second edition 2014
All rights reserved. No part of this publication may be reproduced, stored in a
retrieval system, or transmitted in any form or by any means, electronic, mechani-
cal, photocopying, recording or otherwise, without the prior permission of the
publisher.
ISBN: 978-81-312-3466-2
Medical knowledge is constantly changing. As new information becomes avail-
able, changes in treatment, procedures, equipment and the use of drugs become
necessary. The authors, editors, contributors and the publisher have, as far as it is
possible, taken care to ensure that the information given in this text is accurate and
up-to-date. However, readers are strongly advised to confirm that the information,
especially with regard to drug dose/usage, complies with current legislation and
standards of practice. Please consult full prescribing information before issuing prescrip-
tions for any product mentioned in this publication.
Published by Elsevier, a division of Reed Elsevier India Private Limited.
Registered Office: 305, Rohit House, 3 Tolstoy Marg, New Delhi 110 001.
Corporate Office: 14th Floor, Building No. 10B, DLF Cyber City, Phase II,
Gurgaon 122 002, Haryana, India.
Publishing Manager: Ritu Sharma
Project Manager – Medicine & eExamZone: Shabina Nasim
Development Editor: Shravan Kumar
Copy Editor: TNQ
Publishing Operations Manager: K Sunil Kumar
Project Manager: Nayagi Athmanathan
Production Manager: NC Pant
Cover Designer: Raman Kumar
Typeset by TNQ, Chennai
To My
Parents, Wife and Children
v
This page intentionally left blank
Preface
Relief of pain and suffering is one of the most important tasks a physician
can undertake. Pain Medicine, a superspeciality devoted to managing
acute and chronic pain conditions, is now a very well-established and rec-
ognized branch. Pain physicians are now exclusively managing difficult
and complex pain syndromes where conventional treatment modalities
have been unsuccessful. Adequate pain management requires an in-depth
understanding and knowledge of evaluating a pain patient, appropriate
assessment and quantification of his pain state, precision diagnosis of
cause of pain and a judicious selection of treatment modalities. In the past
two decades, it has been our constant endeavour to formulate guidelines
and standardize protocols for our population for an effective management
of acute and intractable chronic pain states.
This book has been designed to fill in the void for comprehensive
guidelines on pain practice and to provide information on clinical practice
protocols rather than experimental study data. The highlight of the second
edition of the book is an in-depth description of the management protocols
of common benign and malignant pain states. Nine new chapters have
been included in this book, and all previous chapters have been revised.
Notable inclusion is a chapter on how to set up a pain clinic, particularly
useful for the young pain physicians. The book also includes a separate
section on pain management in rheumatological disorders. Advanced
interventional pain management techniques such as radiofrequency abla-
tion, spinal neuromodulation and spinal augmentation techniques (e.g.
vertebroplasty and kyphoplasty) have been dealt in greater details.
A special feature of the book is its appendices, which provide use-
ful information on commonly used drugs, common pain terminologies,
equipment used in pain management, pain websites and expanded forms
of abbreviations used in pain medicine.
This handbook will be extremely useful for all specialists involved in
chronic pain management, viz. pain physicians, anaesthesiologists, sur-
geons, neurologists, orthopaedic surgeons, neurosurgeons, internists,
rehabilitation experts, psychologists and family practitioners.
GP Dureja
vii
This page intentionally left blank
Contributors
Dhamodaran Palaniappan MD Anaesthesiologist, East Hartford, CT, USA
Rani Sunder MD Paediatric Anaesthesiologist, Washington University at
St. Louis, 1 Barnes Jewish Hospital Plz, Saint Louis, MO, USA
Prashanth SM MD Anaesthesiologist/Pain Physician, Boston, USA
Rengarajan J MD Pain Physician, Miami, FL, USA
Dhruv Bibra DA DNB FPM Consultant Pain Physician, Delhi Pain Management
Centre, New Delhi, India
Gunjeet Dua MD Anaesthesiologist, Guys and St Thomas NHS Trust, Bromley, UK
Wg Cdr Sunil Chaturvedi MD Senior Consultant Anaesthesiologist,
Indraprastha Apollo Hospitals, New Delhi, India
Sudesh Prakash MD Senior Consultant Anaesthesiologist, Yashoda Hospital,
Ghaziabad, India
Sushma Limaye DA Anaesthesiologist, Mumbai, India
ix
This page intentionally left blank
Contents
Preface vii
Contributors ix
I
GENERAL PRINCIPLES OF PAIN MANAGEMENT
1. Evaluation of the Pain Patient 3
2. Pain Measurement and Assessment 19
3. Radiography and Imaging in Pain Medicine 43
4. Ultrasonography in Pain Medicine 61
5. Pharmacotherapeutics (Drugs) in Pain Management 69
6. Neurolytic Agents 97
7. How to Set Up a Pain Clinic? 105
8. Acute Pain Management: Practical Guidelines 113
II
CHRONIC PAIN SYNDROMES
9. Myofascial Pain Syndromes 129
10. Headache 143
11. Neck and Shoulder Pain 157
12. Back Pain 165
13. Facetogenic Pain 181
14. Knee Pain 193
15. Neuropathic Pain: Mechanisms and Management 203
16. Herpetic Neuralgia 217
17. Orofacial Pain 223
18. Scar Neuralgia/Painful Scars 235
19. Complex Regional Pain Syndrome 239
20. Pelvic Pain 253
21. Perineal Pain 267
22. Peripheral Vascular Diseases 273
xi
xii CONTENTS
III
PAIN MANAGEMENT: NEW PERSPECTIVES
23. Pain Management in Rheumatological Diseases 285
24. Pain Management in the Elderly 305
25. Osteoporosis 319
26. Pain Management by Rehabilitative Approaches 329
IV
CANCER PAIN
27. Cancer Pain 341
28. Cancer Pain Management 345
V
ADVANCED INTERVENTIONAL PAIN
MANAGEMENT
29. Advanced Interventional Pain Management Modalities 363
30. Spinal Cord Stimulation for Management of Chronic Intractable Pain 367
31. Continuous Intrathecal Drug Delivery Systems for Management of Cancer and
Nonmalignant Pain 375
32. Radio Frequency Ablation in Pain Management 383
33. Vertebroplasty and Kyphoplasty 391
34. Management of Spasticity 397
APPENDICES
Appendix 1: Definition of Commonly Used Pain Terms 415
Appendix 2: Common Abbreviations in Pain Medicine 423
Appendix 3: Equipment for Pain Management: Interventional and Noninterventional
Techniques 427
Appendix 4: Professional Journals, Magazines and Newsletters on Pain 433
Bibliography and Suggested Further Readings 473
S E C T I O N I
GENERAL PRINCIPLES
OF PAIN
MANAGEMENT
1 Evaluation of the Pain Patient 3
2 Pain Measurement and Assessment 19
3 Radiography and Imaging in Pain Medicine 43
4 Ultrasonography in Pain Medicine 61
5 Pharmacotherapeutics (Drugs) in Pain Management 69
6 Neurolytic Agents 97
7 How to Set Up a Pain Clinic? 105
8 Acute Pain Management: Practical Guidelines 113
This page intentionally left blank
C H A P T E R
1
Evaluation of the Pain
Patient
A perceptual phenomenon, like pain, is not accessible to objective vali-
dation. The subjective experience of pain is universal and one of the most
common reasons that a patient seeks a clinician's help. Patients are referred
to pain clinics by other hospital departments wishing to have help in man-
aging their patients in pain. The referring physicians, however, may have
widely varying opinions about what they expect the patients in the pain
clinic to achieve, which they in turn convey to them.
As the saying goes, ‘Healing begins with the history.’ Clinicians should
be able to put the patient at ease and should then ask open-ended ques-
tions that will give the patient an opportunity to describe the pain in their
own terms. A good way to start may be ‘Tell me all about your pain.’
This generally will allow the patient to describe what he or she believes is
important. This is indeed therapeutic in itself.
TAKING HISTORY OF A PAIN PATIENT
Obtaining history is a skill. The cornerstone of accurate pain diag-
nosis is the medical history. In this age of superfast technology, a large
amount of time and energy is often given to investigations at the expense
of time spent with the patient in collecting a coherent and relevant
history.
Enquiries about the nature of the pain have three main purposes.
1. T he patient's description of symptoms may be helpful in diagnosing
the cause of the pain.
2. A description of the type of pain may be important in choosing the
most appropriate treatment for that symptom.
3. It may give the pain clinician an idea of the patient's reaction to the
pain, and the effects that it has on his or her life.
3
4 1. EVALUATION OF THE PAIN PATIENT
Common Questions in the Pain Targeted History
1. T he pain clinician finds out if the pain was followed by any physical
or psychological events or trauma in the patient's life.
2. Is there a history of trauma, surgery or other medical illnesses?
3. Has the pain been continuously present, or are there pain-free
periods? Are there any obvious factors that might account for these
fluctuations?
4. Is the pain constant, getting worse or better with time or are there
diurnal variations?
5. How does the patient describe his pain? Visceral pains are usually
described as dull aching, sickening pain, which is difficult to localize.
Neuralgic pain is generally described as stabbing, shooting, lancinating
or lightning-like in some areas. Associated with pain may be other
sensory disturbances such as tenderness, paraesthesias, hyperalgesia,
hyperpathia or anaesthesia. Myofascial pain may be described as
dull, diffuse aching pain with some tender areas. There may also be
associated paraesthesias, and pain on combing the hair or putting a hat.
6. Has the pain been investigated previously; if so, how and what were
the findings? What was the patient told previously about the pain?
What operations, drugs, physical treatments, and so on have been
applied, and what were the results of such treatments?
7. It is also important to enquire about any other major areas of the
patient's medical, psychiatric, social and employment histories.
Summing up all the above points, the targeted history in a pain patient
includes the following:
1. ode of onset
M
2. Chronicity and duration
3. Site of pain
4. Tempo (duration and frequency)
5. Character and severity
6. Associated factors
a. Premonitory symptoms and aura
b. Precipitating factors
c. Environmental factors
d. Family history
e. Age at onset
f. Pregnancy and menstruation
g. Gender
h. Past medical and surgical histories
i. Socioeconomic considerations
j. Psychiatric history
k. Medications, drug and alcohol use
I. GENERAL PRINCIPLES OF PAIN MANAGEMENT
Taking History of a Pain Patient 5
Psychosocial History
The algologist or the pain clinician will find it useful to know about
patient's previous pain experiences and the reaction to them. The anxiet-
ies associated with pain can lead to phobic and avoidance behaviours,
such as kinesiophobia (fear of movement), which must be identified to be
treated and which often persists long after the original conditioning stim-
ulus has become a history. Psychosocial problems, which could be sup-
pressed or managed prior to the onset of pain syndrome, become terrible
barriers to progress and success unless specifically identified as problems.
Such problems are often ignored by insurance adjusters in the mistaken
belief that the physical domain is their only responsibility and the psycho-
logical aspect somehow is the patient's own responsibility. Therefore, it is
important to
• C onsider the role of formal or informal psychometric testing
• Know about contributions of family, friends, employers, culture and
others to the pain syndrome
• Estimate the degree of pain augmentation
• Quantify the degree of pain suffering
• Obtain an adequate sexual history
• Ask for any professional or financial problems
• Look for internal versus external locus of pain control
General Aspects
Some valuable aids to enhance the interview output
• T he patient should be appropriately gowned and be sitting upright
and at eye level with the interviewer, if possible.
• Old records, investigations and scans are obtained before the
consultation.
• The pain physician pays full attention, listens patiently and does not
interrupt the patient or allow outside interruptions.
• Physician remains nonjudgemental; her/his own moral, religious and
political beliefs are irrelevant to this process.
• The physician is honest and open with the patient.
• Both the patient and the physician can trust the confidentiality of both
the consultations and the medical records.
Physical Examination
Physical examination is an extension of the history providing objec-
tive support if performed efficiently and methodically. The very physical
aspect of examining the patient imparts a reassuring sense of personal
caring to the entire consultation. Patients want to be examined, expect to
