ASIPP Practice Guidelines - Pain Physician

Manchikanti et al • ASIPP Practice Guidelines
31
are being used as a diagnosis that usually implies a persistent
pattern of pain that may have arisen from organic causes
but which is now compounded by psychological and social
problems resulting in behavioral changes. Even though
the Task Force was asked to adopt such a label, particularly
for use in billing in the United States, there was general
agreement in the Task Force that this would not be
desirable. The Task Force also noted that the term “chronic
pain syndrome” is often, unfortunately, used pejoratively
(140). However, the literature shows that chronic pain
syndrome is not a common phenomenon in general, and it
is particularly very infrequent in the elderly (143). In addition,
Hendler et al (144), to whom a number of suspected
“psychosomatic” cases have been referred, found organic
origin of the pain in 98% of cases. Subsequently, Hendler
and Kolodny (145) estimated that the incidence of psychogenic
pain is only 1 in 3000 patients.
Chronic pain has been estimated to cost the American society
approximately $120 billion a year in treatment, lost
revenues, and wages. Some frightening estimates show
that annual total costs for back pain itself, including disability
and litigation, are more than $100 billion (146).
Annual direct medical costs for back pain are estimated at
around $33 billion, with chronic pain around $45 billion.
Approximately 28% to 30% of the US population suffer
with some kind of chronic painful condition(s).
PATHOPHYSIOLOGIC BASIS
Spinal pain is inclusive of all painful conditions originating
from spinal structures ranging from the discs to muscles
and ligamentous attachments. In contrast, nonspinal pain
encompasses a multitude of other painful conditions, ranging
from peripheral neuralgias to reflex sympathetic dystrophy
and arthritis. Any structure with a nerve supply
capable of causing pain similar to that seen in clinically
normal volunteers, which is susceptible to diseases or injuries
that are known to be painful, can cause pain (32, 33,
41, 42, 56, 147-185). For a structure to be implicated, it
should have been shown to be a source of pain in patients,
using diagnostic techniques of known reliability and validity
(32, 33, 41, 42, 151-169). The structures responsible
for pain in the spine include the vertebrae, intervertebral
discs, spinal cord, nerve roots, facet joints, ligaments,
and muscles (32, 33, 41, 42, 147-165, 168, 170-185). Similarly,
muscles, ligaments, various joints including (atlantooccipital
joints, atlantoaxial joints, and sacroiliac joints),
sensory nerves, the sympathetic nervous system, and visceral
organs have been implicated in pain of nonspinal origin
(166, 167, 169, 186-215).
Facet joints have been implicated as responsible for spinal
pain in 15% to 45% of patients with low back pain (178-
183) and 54% to 60% of patients with neck pain utilizing
controlled diagnostic blocks (184, 185). The degeneration
of the disc resulting in primary discogenic pain is seen
commonly with or without internal disc disruption alleged
to be the number one cause of spinal pain (162, 163, 174,
180, 216-260). Disc degeneration is a well accepted sequela
of the normal aging process, particularly of the lower
lumbar levels. Kirkaldy-Willis et al (216) described the
pathogenesis of degenerative changes in the aging spine
entailing three phases, whereas Handel et al (217) described
a structural degenerative cascade for the cervical spine with
four phases. In this model, degenerative cascade is viewed
in a context of a three-joint complex, with involvement of
changes in the disc structure and composition paralleling
changes in the articular cartilage and ligaments of joints.
Internal disc disruption has been considered as a commonly
overlooked source of chronic low back pain (163, 226).
In fact, a controlled study reported the prevalence of pain
due to internal disc disruption as 39% in patients suffering
with chronic low back pain (174). The prevalence of cervical
discogenic pain in patients with chronic neck pain of
traumatic origin was shown to be 61% (162). However,
the prevalence of cervical discogenic pain has not been
formally studied. In contrast, disc herniation is seen in a
small number of patients ranging from 4% to 6% (163,
173, 222-230, 255-260).
Postlaminectomy syndrome or pain following operative
procedures of the spine is also becoming a common entity
in modern medicine (261-292). Although the exact incidence
and prevalence of postlaminectomy syndrome is not
known, it is estimated that 20% to 30% of spinal surgeries
(occasionally as high as 40%), may not be successful as a
result of either the surgery being inadequate, incorrect, or
unnecessary. Unfortunately, poor outcomes may result
following a well indicated and well performed surgical
procedure. It has also been shown that 20% to 30% of
patients over 65 who underwent lumbar spine operations
had one or more subsequent operations within four years
(289). Waddell et al (290) noted that in all studies of back
pain, 10% to 15% of patients account for 80% to 90% of
the total health care compensation and cost for spinal disorders,
and the 1% to 2% of patients who undergo surgery
are the most expensive group. Keskimaki et al (292), in a
study of population-based regional and interspeciality
variations of lumbar disc surgery and reoperations described
that back surgery in the United States has been
shown to be five times more common than in the United
Pain Physician Vol. 4, No. 1, 2001