CHAPTER 156 Approach to the Patient with Chronic Pain
Evaluating a patient with chronic pain involves multiple considerations on the part of the physician. This chapter provides a brief overview of the initial evaluation of a patient with chronic pain in the neurosurgical clinic. This process may be time-consuming given the numerous previous medical and surgical interventions that these patients have often endured. Moreover, these previous treatment failures place a higher burden on the physician treating a patient with chronic pain. The patient has been frustrated by previous treatment failures and does not want this pattern to continue. Moreover, the expectation remains that treatment should be able to completely cure the patient’s pain. These factors should be taken into account, not just in terms of setting realistic expectations with the patient but also in determining a treatment plan.
Before Arrival
Chronic pain patients are often referred by their primary physician, another pain physician, or another neurosurgeon. To assist in establishing a focus for the referral, it is often helpful to ask the patient to obtain a referral letter from the physician. This provides a baseline from which to begin discussion of the patient’s problem. Furthermore, it also establishes a line of communication with the other physician, which is crucial for several reasons. First, the referring physician is often the primary physician and therefore needs to be informed of the results of the consultation for overall coordination of care. Moreover, because a referral for evaluation does not guarantee that the evaluating physician will accept any part of the patient’s care, the referring physician needs to understand the reasoning behind the evaluation and any steps that can be taken for further treatment of the patient. Finally, this also serves as a conduit for obtaining the patient’s medical records.
Physicians should obtain as complete a record of previous treatments and outcomes as possible, especially operative reports, psychological reports, diagnostic testing (electromyography, diskography, and so on) reports, imaging studies and reports (before and after each surgical procedure), specialist consultations, physical therapy summaries, and relevant office notes. It is also helpful to know whether there have been applications for long-term worker’s compensation disability or social security disability.
The Initial Visit
At the initial visit it is of paramount importance to establish the parameters and goals for the encounter. Included in this visit is achieving an understanding of the patient’s goals not just for the initial encounter but for the physician-patient relationship as well. Patients need to understand the capabilities and limits of the relationship (which parts of care that the evaluating physician may or may not be willing to assume) to avoid later misunderstandings that can erode the patient’s trust in the physician. In addition, some patients have expectations that are unrealistic as part of any therapeutic relationship, and it is very useful to understand this at the outset. For example, relieving a substantial portion of the patient’s pain may be deemed an adequate result by the surgeon but be viewed by the patient as a failure. Additionally, even the definition in the mind of the patient and physician of what constitutes chronic pain may be substantially different.
The evaluating physician should approach these patients with an open mind, both to their specific initial pain complaints and to their underlying diagnosis in general. Chronic pain is different from acute pain because the name implies the failure of previous medical and surgical care. The patient should be informed that the chronic pain evaluation will include examining events in the patient’s care from the beginning of the problem. Most patients with chronic pain have undergone numerous evaluations, have explained their story ad nauseam, and may become disenchanted or angry at the thought of having to go through it again. They should be reassured that this is a key part of determining both why their previous treatments have not succeeded and whether there are any further surgical treatments that may provide them with their desired outcome. In addition, patients should understand that more than a single visit may be needed to fully evaluate the situation and determine a therapeutic course of action and that further diagnostic testing or other consultative evaluations, such as psychological testing, may also be required.
It is essential to try to determine the causes of previous treatment failures so that they will not be repeated with poor clinical and psychological outcomes for the patient. The failure of previous medical or surgical attempts to relieve pain may be due to failure of the treatment itself, but it might also be related to a variety of underlying psychosocial issues. Pain relief that is judged adequate by a previous physician may not have been helpful enough for the patient. Possible reasons for previous treatment failures are listed in Table 156-1.
TABLE 156-1 Possible Reasons for Previous Treatment Failure
During this visit the evaluating physician would also be wise to pay close attention to the patient’s mannerisms during history taking and physical examination. Determining the patient’s motivations for the visit and attitudes toward past and future treatments is crucial in formulating an impression of the patient’s past care and devising an appropriate plan that moves forward. Some patients are undergoing further evaluation only because they would like a new clinician to take over opioid prescribing for them after a falling out with their previous physician. Alternatively, some may be in the clinic only because they see this as the sole way to obtain disability benefits.
Careful note should be taken of the patient’s vocal mannerisms and the amount of eye contact made with the physician. These and other similar factors provide crucial clues to the patient’s psychological state, such as motivation, depression, and anxiety.
Still other patients are in the clinic only at the urging of their spouse or child. Consequently, it is also important to observe the family members who accompany the patient. Do they constantly interrupt and speak for the patient? Do they speak about their own difficulties that are the result of the patient’s pain syndrome more than about the pain syndrome itself? Some significant others can be enabling to the patient’s pain syndrome. Others may not grasp or simply be in denial regarding the true extent of the problem. It may be necessary to redirect the interview toward the patient during the interview while acknowledging the life stressors that all those around the patient experience because of the pain syndrome.
History
General Aspects
Although a thorough history is a de facto part of any initial patient encounter, the history obtained from a chronic pain patient must be even more probing because of the many twists and turns involved in the story. In evaluating patients with chronic pain, a detailed history may be substantially more helpful than imaging or other testing in making a diagnosis and formulating a treatment plan. The history provides important information not only about the possible mechanisms and pathophysiology of the patient’s pain but also about the emotional and psychological status of the patient. The physician and patient must both be tolerant during this process because the physician may ask numerous questions (both open ended and leading) to draw out the patient’s detailed history and the patient may go on for an extended period recounting past travails. It takes a skilled physician to guide these patients and help withdrawn, depressed, or fearful patients open up while guiding and focusing overly talkative or angry patients. Keeping these sometimes complex patient histories chronologically organized is a good way to stay on track.
Many chronic pain patients are taking significant amounts of multiple medications from different classes of drugs, each of which can cause cognitive slowing and clouding of memory. If these side effects are suspected of preventing accurate history taking, gradual reduction of some of this medication may be considered before an interview in the hope of somewhat clearing the patient’s sensorium.
What are the patient’s expectations, both for the initial visit and for care in general (both with the interviewing physician and overall)? This is an important factor to glean at the initial visit. If the patient simply wants to be certified as disabled or to have narcotic prescriptions refilled, this may not be an appropriate patient to accept into the practice. If the patient has already retained legal services, what is the purpose? Again, this is important for determining the patient’s motivations for care.
In obtaining the history it is especially useful for the physician to avoid leading or closed-ended questions. Although some direction to the history is important to prevent the history from spiraling off in unproductive paths, physicians should not box the patient in by injecting their preconceptions into the patient’s story. This is not an easy task for the neurosurgeon, especially in the middle of a packed clinic schedule. However, a history thus obtained will be a more complete and revealing one.
Pain History and Onset
It is helpful to first establish the characteristics of the current pain, including standard factors such as location, quality, radiation, duration, and exacerbating and alleviating factors. This provides much information about whether the pain may be classified as neuropathic or nociceptive. Once the current baseline is established, the pain may be analyzed in relation to the past history.
The relationship of the current pain to the original pain is a key factor. Does this pain represent a continuation or progression of an original pain complaint? If so, it may indicate that previous treatments were not applied properly or to their fullest extent, that the treatments were inappropriate, or that the previously applied diagnosis was incorrect. In this case, it is extremely useful to explore which past treatments were used and to what extent they were used, along with a detailed account of their effects on the pain. This enables the physician to determine whether some of these treatments should be repeated in some form.
If the current pain is substantially different from the original pain, it may imply that a different process may be responsible for the current pain or that the current pain is the result of a treatment side effect. Patients often undergo misguided treatments of pain syndromes, and such treatments can themselves cause further pain. As stated previously, procedural complications can also result in pain that is unlike the initial pain. The physician should be cautious of patients whose pain changes significantly in location and character after each treatment. A detailed listing of previous treatments can then possibly be used to exclude them as subsequent therapeutic options.
The circumstances surrounding the initial onset of the pain are important as well. It is important to note whether there was an obvious inciting incident associated with the pain and whether this mechanism is consistent with the patient’s original complaints. The location and distribution, quality, intensity or severity, and duration of the first pain should be ascertained. Detailed information should be elicited about the exact activities that the patient was performing at the time of pain onset. Did the pain immediately become disabling or was there a gradual buildup? Did the patient report the pain to anyone at the onset? Were there any other associated neurological symptoms (weakness, numbness, paresthesias, bladder/bowel changes) at the time and did any of them develop in subacute fashion? Did the patient notice any change in color, swelling, or other anatomic alteration of the injured region, either immediately or subsequently? Was any treatment applied immediately?
Pain that is the result of an activity on the job presents a special situation because of the issues surrounding worker’s compensation claims. This history needs to be even more fastidiously documented, including the exact time and date of the injury. Other information should be also obtained, such as whether the patient continued to work after the injury, when and to whom the injury was reported, and the response of the patient’s employer to the injury regarding the patient’s work status. The history in such cases should also probe the general demands of the patient’s job and the patient’s satisfaction with the job and whether any interpersonal tension exists at work.
Neuropathic pain syndromes, such as complex regional pain syndrome types 1 and 2, most often have an antecedent injury that sets the syndrome in motion. Trigeminal neuralgia is an exception to this generalization because it frequently has a spontaneous onset. Nociceptive pain, such as degenerative spondylitic pain, may not have a single defined inciting incident but instead may be slowly progressive over time. The physician should be wary of patients whose pain syndrome does not seem compatible with the mechanism of onset. This should prompt further questions regarding other work and life events that may have contributed to the pain syndrome.
The physician should also ascertain the impact of the pain on the patient’s daily life. This is accomplished by asking the patient to provide a timeline of an average day. This portion of the history should include the times of awakening, bedtime, and any naps. General activities during the waking hours of day should be described, including how much time the patient spends at each and the effect of each (if any) on the patient’s pain level. This is intended to give the physician an impression of the tolerance of the patient for standing, sitting, and other activities. Moreover, it serves as an important window for the physician into the psychological effects of the pain on the patient’s life and the level of disability that the patient is experiencing.
Pain Characteristics
In giving a history about the current pain complaint, the patient should be asked to describe in detail the current quality, site, radiation, severity, and alleviating/exacerbating characteristics of the pain at the time of evaluation and to indicate whether any of these factors has changed since the onset or during the interval. Factors that have no effect on the pain are important as well. Such factors include stress and other emotional disturbances, movement, pressure, heat or cold, coughing, sneezing, straining, and deep breathing. Although the visual analog scale (VAS) is far from a perfect method of measuring a patient’s pain level, it is one of the most commonly accepted scales. This VAS commonly ranges from “no pain” (0) to “the worst pain imaginable” (10). Rather than asking the patient for integer ratings, it is better to provide a sheet of paper with four 10-cm lines and the ends of these lines labeled with the 0 and 10 descriptions just mentioned. The four lines are for the patient to record not just a momentary VAS rating but also an average rating over the past 30 days and the best and worst pain ratings. Physicians should be wary of patients whose pain either never varies from 10 or is rated as “11” on a scale of 0 to 10. These patients may have a nonanatomic cause of their pain.
In eliciting a description of the pain, the physician should be able to classify the pain as localized, radiating, or referred. Localized pain continues at the same location as its origination. This pain may be associated with other anatomic and sensory changes at the site of the pain, such as hyperalgesia, wind-up hyperpathia, and color and trophic changes of the skin. Pain may also be described as radiating along the distribution of a nerve root’s dermatome or the innervation of a peripheral nerve. This pain is distinct from that referred from a deep visceral structure to a separate distinct anatomic location. Classic examples are back pain or superficial abdominal pain from chronic pancreatitis and scapular pain from cholecystitis.
The quality of the pain is tied to this in that pain attributable to a superficial cause is often sharp and well localized whereas referred pain from deep somatic or visceral disease is dull, diffuse, and poorly localizable. The quality of the pain may also be assessed in terms of the length of the painful episodes, as well as factors that exacerbate and alleviate the pain. For instance, the pain of type 1 trigeminal neuralgia will often be described as brief episodes of sharp, lancinating, or electrical pain with defined triggers (i.e., talking, eating, brushing teeth), whereas trigeminal neuropathic pain may consist of constant aching, burning pain with different exacerbating factors. Some of these factors may include activity level, positioning, the time of day, weather conditions (either current or forthcoming), life stressors, and environmental factors.
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