Pain
Management
Pain Management is:
The evaluation and treatment of pain!
It starts with a detailed evaluation of the cause and factors
increasing pain.
Evaluation
Before one looks for treatment, it is extremely important
to know why one gets back pain. Back pain is as common as
the common cold. Many back pain problems are benign, self-limited.
But some back pain may be a serious condition that needs treatment
by skilled experts. In either event, today we are able to
treat all back pain successfully. Please take your time, and
before you decide on your treatment, be sure to read my lecture
on this matter presented below. Send me an e-mail
if you need more information or help.
Here at CMOC, Dr. Rezaian has presented a new clinical classification
for diagnosing the etiology (cause of) of low back pain based
on patient history. Using this practical classification has
enabled us to diagnose successfully, and therefore treat,
over 98% of 600 patients with low back pain.
Since adopting this classification method, we have seen 600
new patients with back pain. All have been correctly diagnosed.
There has not been one patient with so called psychiatric
back pain. We, of course, believe that there are psychiatric
patients with psychological pain. However, we firmly believe
that when the back pain has a physical etiology, the psychological
disturbances can be secondary manifestations and not necessarily
the primary cause of pain. One example is in our testimonials
section, a patient was diagnosed with psychiatric back pain,
but under our classification the patient was properly diagnosed
and successfully treated.
A common pain - Sciatica
Sciatica, a condition named after the sciatic nerve that extends
down each of your legs from your hip to your heel. It sometimes
affects people who spend a lot of time sitting. One of the
causes of Sciatica is the herniated or slipped or bulging
disc. These herniated or bulging discs occur most commonly
in the lumbar (lower back) part of the spine. The pain is
generally felt running down the back of one or both legs.
Tingling, numbness or muscle weakness may also indicate this
condition.
Herniated discs aren't the only cause of sciatica. Sciatica
may also result from trauma, diabetes, or compression or inflammation
of nerves in your lower back sometimes referred to as pinched
nerves, among other causes.
Swimming and walking are good exercises to strengthen your
back. Strong abdominal muscles also protect your back. Sciatica
pain and sciatica discomfort are often cured by removing the
cause of the pinched nerve, such cause is often a herniated
disc that could be treated by performing a minimally invasive
discectomy on the area of the lower back where the inflammation
or compression of the nerve is present.
We have reviewed the medical literature and have found no
similar classification. We trust that this new classification
can now be useful as a standard for other practicing physicians.
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A NEW CLINICAL CLASSIFICATION OF LOW PACK
PAIN: A PRACTICAL
GUIDE FOR DIAGNOSING ETIOLOGY BY PATIENT
HISTORY
S.M. Rezaian, M.D., I.M. Spector, D.O., A.
Collins, M.D.
California Orthopaedic Medical Clinic, Inc., Beverly Hills,
CA 90211-2927, USA
Abstract. Based on a review of 600 patients with back
problems, we have designed a new classification for practical
clinical diagnosis of back pain. The purpose of this article
is to present this classification.
Introduction
Low back pain is surpassed only by the common cold as a cause
of lost workdays in the general population. About 80% of the
population develops back pain at some time in life. Since
low back pain is the most common chief complaint, surpassing
headaches in many clinics, almost all physicians can expect
to advise the patient with disability. Yet diagnosing the
cause of low back pain can be an unclear and often unresolved
task for the physician. Most textbooks give a long list of
causes for backache, but matching individual patients against
such lists is an illogical and inefficient method of diagnosis.
Searching medical journals over the past ten years for etiological
classification of low back pain, one finds that the majority
of back pain remains undiagnosed etiologically, so called
idiopathic or nonspecific back pain. It seems imperative that
if we are to treat low back pain properly, we must first be
clear on what it is we are treating.
In this paper, we will present a new practical clinical etiological
classification of low back pain based on the simple history
given by the patient. This will enable the practicing physician
to make a quick etiological diagnosis and, therefore, to treat
the low back pain patient properly. We have used this classification
and come to correct pathological diagnosis in over 98% of
600 consecutive patients with low back pain treated from December
1984 to January 1991.
A New Clinical Classification of Low Back Pain
Based on a review of these 600 patients with back problems,
we have created a new practical classification for the diagnosis
of back pain. According to this classification, there are
only two types of back pain in medicine: the constant or malignant
pain, and the intermittent or benign pain.
Constant Back Pain
Constant low back pain occurs day and night, at work and
at rest, when the patient is happy, and when angry or depressed.
We call this type of pain malignant pain.
Fortunately malignant low back pain is rare and comprises
only 3-5% of all low back pain. The etiologies of this type
of pain, irrespective of the injury that may be reported by
the patient, may confuse the picture and include: infection,
benign or malignant tumor, or more rarely a vascular lesion
such as aortic aneurysm. If the patient has back pain, runs
a low fever, or feels some chills toward the evening, look
for disc or other obscure infection. Ask for relevant investigation.
On the other hand, if the patient has constant pain, has lost
his/her appetite, and has lost some weight, look for malignant
tumor (primary or secondary). If the patient does not run
a fever and has not lost weight, suspect a benign tumor or
vascular abnormality.
Intermittent Back Pain
Intermittent low back pain is relieved for some period of
time within a 24-hour period. We call this type benign pain,
and it comprises nearly 95% of all low back pain.
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Subclassification of Intermittent Low Back Pain. There are
five subclassifications of intermittent low back pain:
- Low back pain that is relieved by rest and aggravated
by activities (over 80%). This pain is caused by macro or
micro instability of the spine. It is commonly produced
by physical injury. If this pain is limited to the back
and does not increase with abdominal tension such as coughing,
laughing, sneezing, or straining, it is due commonly to
ligament(s), and more rarely to muscle damage on the back.
On the other hand, if the pain radiates to the legs or arms
and is aggravated by abdominal tension such as sneezing,
coughing, laughing, or straining, look for discopathy and
radiculopathy lesions. This type of back pain is commonly
seen in active people 20-50 years of age.
- Low back pain that is aggravated suddenly and is accompanied
by weakness of the muscles, urinary problems, or both, caused
by cauda equina syndrome. Look for acute or subacute midline
rupture of disc L3-4 and more rarely L4-5. This may be seen
in all ages and comprises 1-2% of all back pain.
- Low back pain that gets worse at rest and gets better
with exercise and activities, accompanied by joint stiffness,
should lead one to consider inflammatory disease, particularly
ankylosing spondylitis. This type is commonly seen in middle-aged
persons.
- Low back pain that gets worse with straightening the back
is reported by patients who state they cannot lie flat with
the lower limbs straight. They normally feel more pain with
walking and are relieved if they stoop or bend forward.
One should ask for the presence of claudication and then
differentiate claudication from endarteritis. This type
is seen in the age group over 60 years with history of degenerative
discopathy of the lumbar spine. This is mostly due to spinal
stenosis.
- Low back pain that is accompanied by a skin lesion (systemic
lupus erythematosus or café-au-lait), or multiple
joint involvement that changes with cold and hot weather
speaks for the correct diagnosis of systemic lupus erythematosus
and rheumatoid arthritis.
Using the above classification system, we have been able
to diagnose every patient with low back pain in this sample
of 600 patients. We have confirmed our diagnosis with objective
tests and have rendered correct treatment on over 99% of the
patients to the degree that they have returned to work even
after being on disability for up to 8 years.
It was surprising that we did not find a single case of so
called psychiatric back pain. Conversely, we have diagnosed
correctly a large number of patients who had been referred
for psychiatric therapy which of course did not relieve their
back pain. Their pain fit well in our classification, and
they were successfully treated.
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Laboratory Studies Indicated for Investigation and Evaluation
of Back Pain.
- X-rays including flexion and extension views are required
to have a general evaluation of bone structure and to have
a baseline for further development. Many authors do not
recommend X-rays for back pain of less than 6 weeks’
duration. We disagree since the first X-ray immediately
after injury may be normal, but 6-8 weeks later may show
degenerative change, and one may then relate these changes
to the injury.
- Complete blood cell count (CBC), urine analysis, erythrocyte
sedimentation rate (ESR), and blood chemistries including
alkaline phosphatase and acid phosphatase are indicated
in the management of malignant back pain.
- Magnetic resonance imagine (MRI) is indicated for any
patient who demonstrates neurological deficit, e.g., numbness
on nerve distribution, deep tendon reflex changes, or weakness
of special groups of muscles.
- A computerized axial tomography (CAT) scan is helpful
to demonstrate bony changes, e.g., osteophytes, old fractures,
bony destruction, spinal stenosis.
- Myelography and CAT scan are helpful in evaluation of
complicated cases, e.g., patient with failed back surgery.
- Bone scan is necessary to rule out bony lesions due to
infection or malignancy.
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