ASIPP Practice Guidelines - Pain Physician

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Manchikanti et al • ASIPP Practice Guidelines 33 and/or social history consists of a review of the past history of the patient including past experiences, illnesses, operations, injuries, and treatment; family history, including a review of medical events in the patient’s family, hereditary diseases, and other factors; and social history appropriate for age reflecting past and current activities. Past history in interventional pain medicine includes history of past pain problems, motor vehicle, occupational, or nonoccupational injuries; history of headache, neck pain, upper-extremity pain, pain in the upper, or mid back or chest wall, pain in the lower back or lower extremities, and pain in joints; and disorders such as arthritis, fibromyalgia, or systemic lupus erythematosus. Family history includes history of pain problems in the family, degenerative disorders, familial disorders, drug dependency, alcoholism, or drug abuse; and psychological disorders such as depression, anxiety, schizophrenia, and suicidal tendencies, etc. Family history of medical problems is also important. Social history includes environmental information, educa- Table 4. Features of somatic and radicular pain Somatic or referred pain Radicular pain i. Causes ♦ Facet joint-mediated pain ♦ Disc herniation ♦ Sacroiliac joint-mediated pain ♦ Annular tear ♦ Myofascial syndrome ♦ Spinal stenosis ♦ Internal disc disruption ii. Symptoms Quality ♦ Deep, aching ♦ Sharp, shooting ♦ Poorly localized ♦ Well localized ♦ Back worse than leg ♦ Leg worse than back ♦ No paresthesia ♦ Paresthesia present ♦ Covers a wide area ♦ Well defined area ♦ No radicular or shooting pain ♦ Radicular distribution Modification ♦ Worse with extension ♦ Worse with flexion ♦ Better with flexion ♦ Better with extension ♦ No radicular pattern ♦ Radicular pattern Radiation ♦ Low back to hip, thigh, groin ♦ Follows nerve root distribution ♦ Radiation below knee unusual ♦ Radiation below knee common ♦ No radicular pattern ♦ Radicular and shooting pain iii. Signs Sensory alterations ♦ Uncommon ♦ Probable Motor changes ♦ Only subjective weakness ♦ Objective weakness ♦ Atrophy is rare ♦ Atrophy may be present Reflex changes ♦ None ♦ Commonly described but seen occasionally Straight leg raises ♦ Only low back pain ♦ Reproduction of leg pain ♦ No root-tension signs ♦ Positive root-tension signs Adapted and modified from Manchikanti (41) Pain Physician Vol. 4, No. 1, 2001
Manchikanti et al • ASIPP Practice Guidelines 34 tion, marital status, children, habits, hobbies, and occupational history, whenever available. Physical Examination Physical examination in interventional pain medicine involves general, musculoskeletal, and neurological examination. Examination of other systems, specifically cardiovascular, lymphatic, skin, eyes, and cranial nerves is recommended based on the presenting symptomatology. Medical Decision Making Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by three components, including; 1. Diagnosis/management options with a number of possible diagnoses and/or the number of management options; 2. Review of records/investigations, with number and/or complexity of medical records, diagnostic tests, and other information that must be obtained, reviewed, and analyzed; and , 3. Risk(s) of significant complications, morbidity and mortality, as well as comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options. Psychological evaluation, laboratory evaluation, imaging techniques, electromyography and nerve conduction and somatosensory evoked potentials are also an extension of evaluation process. It is beyond the scope of these guidelines to discuss these techniques of assessment. Appropriate history and physical examination with the assistance of other evaluations should direct a physician to formulate a provisional diagnosis. Features of somatic and radicular pain are outlined in Table 4. However, various pitfalls with conventional evaluation of low back pain are also illustrated in Table 5. A suggested algorithm for comprehensive evaluation and management of chronic pain is illustrated in Fig. 2. In summary, the following criteria should be considered carefully in performing interventional techniques: 1. Complete initial evaluation, including history and physical examination. 2. Physiological and functional assessment, as necessary and feasible. 3. Definition of indications and medical necessity: • Suspected organic problem. • Nonresponsiveness to less invasive modalities of treatments except in acute situations such as acute disc herniation, herpes zoster and postherpetic neural- Table 5. Pitfalls with conventional evaluation of low back pain “Specific anatomic etiology is clearly and objectively identified in only 10% to 20%.” 1. Radiographic “abnormalities” are frequently clinically irrelevant. 2. True sciatica occurs in only 1% to 2% of the patients. 3. No universal criteria are established for scoring the presence, absence, or importance of particular signs. 4. Quantification of the degree of disability and the association to treatment outcomes is difficult. 5. Interpretation of biomedical findings relies on “clinical judgments,” “physician’s experience,” and “quasi-standardized criteria.” 6. Routine clinical assessment is frequently subjective and unreliable. 7. Physical examination and diagnostic findings are subjective. 8. The discriminative power of common objective signs has been questioned. 9. Reliance on general “clinical impression” to detect gross psychological disturbances is “hopelessly inaccurate.” 10. It is usually not possible to make a precise diagnosis or identify anatomic origin of the pain by routine clinical assessment. Adapted and modified from Manchikanti (41). Pain Physician Vol. 4, No. 1, 2001
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