Common pain syndromes

Myofascial pain
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caused by repetitive and/or causative injury (ie: gardening, whiplash)

known injury
characterized by regional pain syndrome
found in contiguous muscle groups, not dermatomal
trigger points:
o contracted bundle of sarcomeres that have become ischemic
o pressing or palpating the trigger point (in the belly of the muscle) causes
pain in a usual painful distribution
treatment: stretching, physical therapy, and injection of trigger points with
local anesthetic and steroid. Can treat acute symptoms with opiates

Fibromyalgia
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o
o

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NOT a diagnosis of exclusion (as was once believed)

generalized pain syndrome
tender points (not trigger):
o there are 18 defined tender points, a patient needs to have 11 of 18 to
have a diagnosis of fibromyalgia
o tender points are tender to palpation and there is no radiation.
characterized by pain in 4 body quadrants (general pain)
associated with depression, fatigue, non-restorative sleep (less REM type sleep,
not restful, pts are exhausted and complain of vivid dreams during sleep)
treatment: aerobic exercise, antidepressants (TCAs)

Trigeminal neuralgia (tic douloureux)

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defined by sharp, shooting, lancinating pain in the distribution of the trigeminal

nerve (ophthalmic, maxillary, mandibular).
Most commonly affects V2 (maxillary) nerve> V3>V4.
only last for 2-3 seconds with NO pain between episodes
normal physical exam
usually unilateral
usually in females
triggered by any sensation or activity in the distribution of the trigeminal nerve (ie:
scratching head, brushing teeth.
most common anatomic cause for trigeminal nerve irritation is compression of the
nerve by the superior cerebellar artery.
Genetta procedure: neurosurgeon places a teflon sponge between the artery and
nerve.
trigeminal neuralgia is a associated with multiple sclerosis (due to
demyelination). So patients presenting with trigeminal neuralgia should be
evaluated for MS
know the anatomic origin of the trigeminal nerves:
o Gasserion ganglion (lies in Meckels cave):
o V1 exits Meckels cave through the superior orbital fissure
o V2 exits through the foramen rotundum

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V3 exits through the foramen ovale

Treatment:
o Carbamazepine! - side effect is agranulocytosis (routine CBCs
necessary)
o Second line baclofen
o ablation of nerve (rhizotomy) ablate Gasserion ganglion
o chemical ablation with phenol in glycerol
o radiofrequency
o gamma knife
o Genetta procedure

IV Phenytoin
Only IV anticonvulsant used to abort neuropathic pain crises
Rapid administration can lead to hypotension and bradycardia
Side Effects: Fibrocyte stimulation causes gingival hypertrophy
Hepatotoxicity

Atypical facial pain

o
o
o

facial pain : doesnt fit the trigimnal neuralgia criteria and may have associated
with allodynia (NOT seen in trigeminal neuralgia)
episodes may last as long as a few minutes to hours (in trigeminal neuralgia, the
pain is only seconds)
treatment: Baclofen, EMLA cream, lidoderm patch, NSAIDS, opioids, other
adjuvant agents

CRPS (Complex Regional Pain Syndrome)

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used to be called RSD (reflex sympathetic dystrophy which is synonymous with

type 1) or causalgia which is synonymous with type 2
the key symptom of CRPS is continuous, intense pain out of proportion to the
severity of the injury, which gets worse rather than better over time
most often affects one of the arms, legs, hands, or feet. Often the pain spreads
to include the entire arm or leg in a non dermatomal pattern
vasomotor and sudomotor) changes
typical features include dramatic changes in the color and temperature of the skin
over the affected limb or body part, accompanied by intense burning pain, skin
sensitivity, sweating, and swelling
early edema and erythema
later dystrophy, atrophy, vasoconstriction
pain lasts longer than should
two types, but the symptoms are the same for both:
o type 1: no obvious nerve injury
o type 2: obvious injury to nerve
treatment:
o physical and occupational therapy (needs sympathetic sensory input)
o CRPS is no longer believed to be only sympathetically mediated, so
regional sympathetic blocks are not the treatment of choice, but it can be
a therapeutic tool for PT/OT.

Sympathetic blocks: Stellate gangion block (for upper ext), lumbar

sympathetic block (for lower ext), and hypogastric plexus block (for pelvic
pain).
- Stellate ganglion: C7-T1 star-shaped ganglion along the anterior vertebral bodies
- the sign of a successful stellate ganglion block is a 1 degree Celsius increase
in skin temp (via skin probe) on the ipsilateral arm NOT Horners
- Horners is seen in >90% of successful stellate ganglion blocks. What you find in
Horners (know these 5 signs) miosis, ptosis, anhidrosis, lacrimation, nasal congestion
and enophthalmos
o

Phantom pain

more proximal the amputation the more likely the patient is to have it
there is no difference in incidence if there is a traumatic amputation versus a
surgical amputation.-pain mimics the pain the patient used to have before the
limb was amputated
3 Types:
Stump Pain
o Somatic pain or may be neuropathic if there is a neuroma in the scar
line
o May be secondary to ill fitting prosthesis or bone spur
o Usually gets better
o Treatment with NSAIDS and opioids
Phantom Sensation
o Sensation of existing limb.. usually resolves over time. Almost 100%
patients experience this after amputation but 60% have resolution
over 6 months.
Phantom Pain
o Thought to be usually Sympathetically mediated pain, can use
sympathetic blocks to treat or nerve blocks or neuroma injections with
local anesthetic and steroids.
o Some literature suggests that the Best way to treat is by prevention,
epidural infusion placed 3-5 days before amputation patient less likely
to have pain
o Nerve blocks are useful
100% of patients will have phantom sensation after amputation, but 50% will
have phantom pain (the more proximal the amputation, the greater the risk for
phantom pain)

Post Herpetic Neuralgia

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o
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Reactivation of latent Varicella zoster in dorsal root ganglion

Incidence 1:10,000 in general population, but incidence is greatly increased in
immunocompromised people (25% incidence in pts with Hodgkins)
risk factor for PHN: age >50 yrs (75% of acute zoster in people over 70 yrs)
Dermatomal distribution, usually unilateral (may be seen bilaterally in
immunocompromised patients)
Keep in mind that the pain of acute herpes zoster may precede a rash by 2-30
days, but usually the pain starts with the onset of the rash
paroxysms of pain: burning, aching, stabbing

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also associated with hypoesthesia, anesthesia, allodynia, and hyperalgesia

poor sleep and mood
Pain lancinating or dysesthetic, dermatomal distribution
Can have pain without the rash zoster sin herpeticae
Rash is pustular (4-7 days), then crusts (10-12 days)
>50% occurs in the thoracic dermatome (most commonly T3-8)
25% occurs in the V1 distribution of the trigeminal nerve
myelitis or encephalitis is possible if the motor nerves are involved.
Ramsay-Hunt Syndrome: acute facial paralysis that occurs in association with
herpetic blisters of the skin of the ear canal, auricle, or both. Varicella zoster in
the geniculate ganglion of CN VII.
Treatment:
o antivirals (start early in the disease course, earlier the better, as soon as
you identify the rash)
acyclovir
famiciclovir
valcyclovir has independent analgesic effects, studies to show
that there is a greater decrease in incidence of post-herpetic
neuralgia with valcyclovir than with the other antivirals
o systemic steroids
studies show decrease pain (when used with acyclovir)
decrease inflammation of nerve root, therefore decrease residual
damage
o mild analgesics (acetaminophen, NSAIDs)
o opoids
o TCAs (early treatment can decrease incidence of post herpetic neuralgia)
o topical: calomine, capsaicin
o nerve blocks: intercostal, neuraxial, sympathetic blocks
o membrane stabilizers
do a lidocaine IV infusion trial (2-5 mg/kg drip for 1 hour in
monitored setting)
if pt has improvement in pain, then start mexilitene PO
Topical lidoderm avoid if the rash is still wet.