This chapter will discuss the different types of pain noted with different neurologic sequelae. Chronic pain treatments and diagnosis of pain syndromes that occur with spinal cord injury, back pain, complex regional pain syndrome, post herpetic pain, and phantom limb pain will be described as will the possible therapies utilized to treat the pain. The differing types of pain associated with each neurologic condition will be described. The treatment of somatic pain from tissue injury and visceral pain from organ systems is described. These types of pain will be contrasted with the neuropathic pain that is the most difficult to treat and is due to damage to the nerve itself. Strategies for treatment of each of these pain types are described as well as the use of multimodal treatment to help minimize the central nervous system side effects while increasing the effectiveness of the various medications.
The goal of this chapter is to give a practical approach to managing some of the more common types of pain in neurologic patients.
There are several issues that should be mentioned that apply to most, if not all, of the neurological patients with chronic pain. While this list of considerations is by no means exhaustive, it can be used to help guide the decision-making process when working with this group of patients.
Pain that is persistent and lasts longer than it is expected to last, or pain that is severe should be treated as soon as possible, and if possible, the underlying cause should be remedied.
The longer the pain persists, the more likely it is to become chronic. It is much easier to produce resolution of pain in an acute setting than it is to achieve resolution in long-standing or chronic pain.
In general, chronic pain is treated first with conservative measures and then with progressively more aggressive or invasive measures.
The biggest exception to this is if a patient begins to progressively lose strength or function; in this case rapid intervention may be required.
The mental health of the chronic pain patient should be often considered. Bringing in mental health professionals to assist with patient care is often helpful. In cases of overt suicidal or homicidal ideation, emergent psychiatric consultation is indicated.
GOALS FOR ACUTE AND CHRONIC PAIN
A fundamental difference exists in the treatment goals for acute and chronic pain. In acute pain, the acronym RICE is often seen, meaning rest, ice, compression, and elevation, in the setting of acute soft tissue injury. While this works well for acute injury, this is not the case for chronic pain. The focus of chronic pain treatment is to make the patient as functional and active as possible.
While bringing the patient’s pain under control is an important component of treatment, it can be difficult to measure ...