Leaders:
The following are four case reports of commonly seen pain management problems. They are basic information about patients including an individual*s history and physical findings. The lab work, other signs and symptoms and treatments will be discussed and demonstrated (as appropriate). The goal of this workshop is to recognize these problems and understand the treatments, which are mostly, extensions of routine anaesthesia procedures.
Case 1:
A previously healthy 28-year-old man was involved in a motor vehicle accident 3 years ago. He was the driver of a car that was hit from behind at a stop sign. Despite wearing a seatbelt, his forehead did contact the steering wheel. There was no loss of consciousness. Immediately, he recalls an ache in his neck that rapidly became quite painful over a few hours. In hospital, X-rays were inconclusive. He was given prescriptions for analgesics and follow up physiotherapy. Over the next few weeks, the pain became more widespread. now involving the shoulders and midthoracic region. He had frequent occipital headaches. Physiotherapy seemed to make the pain worse. Traction, Ultrasound and exercises were used. Hot and cold packs, as well as a T.E.N.S. helped temporarily. The pain was not improving. The patient is unable to lift grocery bags, the garbage, perform any household chores. He rates his pain at 9/10 on a visual analog scale. It is burning, continuous, exacerbated by damp weather, sudden neck movements, any lifting or reaching and prolonged sitting. Nothing seems to make it better.
His family physician arranged a CT scan that was interpreted as normal. He was referred to a chiropractor who only helped temporarily. The headaches did improve. Massage therapy was helpful only for a few hours.
Over time, he has had considerable difficulty sleeping. The pain will prevent him from falling asleep and will waken him 3 - 4 times per night. He has become fatigued, irritable and cannot concentrate for long on any task. He has become discouraged as he recognizes his behavioral changes. They have led to increasing difficulties with his wife and children. He has lost his job and many friends. The insurance company is denying his claim.
On examination, he has become tearful recounting the latter part of the history. He does not use his arms in any broad gestures. The range of motion of his neck is limited in flexion, lateral flexion and rotation. Extension is painful but normal. Motor and sensory exams of the upper limbs are normal. However. abduction of the arms is painful. He has multiple trigger points of the trapezius. erector spinae, omohyoid. rhomboid and infraspinatus muscles. The skin over these points has allodynia.
Case 2:
A 33-year-old nurse was assisting a patient (90 kg) in transfer to bed from his wheelchair. However, the patient collapsed once he was standing. She caught him while flexed at the waist. then rotated, moving him onto the bed. Immediately, she experienced a sharp, severe pain in the left low back, radiating into her left leg. Once she had settled him into bed, she reported the injury and was sent to Health Services. Muscle strain was diagnosed and she was prescribed exercises, physiotherapy and a muscle relaxant. There she rested for a time and felt better. So, she returned to the ward to finish the shift. However, the pain increased as the shift progressed. On returning home, she was limping markedly. The next day she was unable to get out of bed. When she tried, the pain was severe. A few days later, she went to physiotherapy where she was taught back strengthening exercises. Traction, hot and cold packs were applied with some help. With the aid of analgesics, she returned to work. On the first day, she bent over to pick up a patient*s book and her back locked. She was unable to stand up.
The pain continues in the left low back radiating to the left buttock and posteriorly down the leg to the knee. She feels the left leg is a bit weaker than the right. She cannot stand, walk or sit for any length of time. Standing at a sink or getting out of the car is particularly difficult. She is unable to make a bed or lift anything. When her back locks up, she will be in bed for 2 - 3 days. Warm baths, massage and analgesics can improve the pain. WCB thinks she is faking.
On examination, she walks with a limp. She cannot sit still while you question her, frequently standing, stretching and pacing around the room. The lumbar lordosis is lost. There are two exquisite areas of allodynia, with trigger points over the left L4-5 and L5-Sl facet joints. The range of motion of the back is altered. Flexion is normal but she has difficulty returning to standing. with a cogwheel motion. Extension is very limited due to pain. Rotation is reduced on the right due to some pain and pressure. Lateral flexion to the right is limited. Motor and sensory examinations are within normal limits. Patrick*s test and Gaenslen*s manouevre are negative. Pelvic compression and rocking are negative. There is only mild tenderness over the left posterior superior iliac spine. Straight leg raise is limited by back pain only to 60 degrees on the right 45 degrees on the left.
Case 3:
A 45-year-old mover was routinely lifting a washing machine from a dolly onto the floor when it slipped. While trying to regain control, he felt a sudden pain, like lightening, in his back radiating down the side of his leg to his foot. He had trouble with his back 10 years ago. but no pain in the leg. This was a careful worker, who understood the risks and how to avoid them. lie had always worked hard. Initially, he was off work for 3 days. As the pain in the leg worsened, he went to his physician. Plain x-rays revealed disc space narrowing at L5-S 1. He was sent for a CT myelogram. This revealed a prolapsed disc impinging on the left L5 nerve root significantly. There was considerable facet hypertrophy at the left L5-S 1 facet joint. He was referred to an orthopedic surgeon who proceeded with a laminectomy and discectomy This relieved his pain for 3 months. Then, the pain returned. The surgeon repeated the CT scan that did not show any disc remnants or other pathology to explain the pain.
At the time he visits you his pain is in the low back (milder) with severe paroxysms of pain (with associated muscle spasms) radiating into the leg in an L5 distribution. He must limp to ambulate. He cannot sit stand or walk for any length of time. He cannot lie down comfortably. He sleeps almost upright in a chair. The sleep is frequently interrupted. He is very depressed, as he is unable to work. The pain will be relieved only by Tylenol #3 10 - 12 tablets per day. Even so, this only gives partial relief
On examination, he is an obese man, who limps into the room, with a painful expression on his face. It seems like quite an effort just to walk from the change room into the examination room. He cannot sit evenly on the chair. His body shifts continuously. The range of motion of the back is limited by pain in flexion to 45 degrees but the other movements are normal. He has a well-healed scar in the lower lumbar region. There are trigger points bilaterally on the erector spinae groups. The skin is quite sensitive. Tests of the sacroiliac joints are negative. Straight leg raising is normal on the right but limited by back and leg pain on the left to 30 degrees. Motor examination reveals decreased strength in left hip extension, knee flexion and ankle dorsiflexion. Sensory exam reveals decreased pinprick and cold in L5 on the left, to a lesser extent on the right. S1 has slightly reduced sensation on the left.
Case 4:
A 23-year-old female was sitting in a restaurant when the chalkboard with the day*s specials fell onto her right wrist. There was immediate pain with excoriation of the skin. The wrist became swollen with a large ecchymosis. She was seen in the Emergency Room where the wrist was splinted. An x-ray was unremarkable. There were no fractures noted. She was advised to put ice on the wrist and perform some simple range of motion exercises. Eventually. the swelling diminished but the pain persisted. After three months. she was re-evaluated but new x-rays were unremarkable. She was sent to physiotherapy and given Tylenol #3*s. The pain increased over the next 3 months and she was able to perform fewer tasks with the hand. Her sleep was affected, as was her concentration at university. The hand felt cold all the time. The pain was located in the wrist with radiation proximally to the elbow and distally to the dorsum of the hand. She complains that if the wind or rain touch the wrist, that it feels like fire. She must protect the hand in the shower. Someone must cut up her food, if two utensils are required.
On examination, the right wrist is mottled. shiny and cold with little hair compared to the left side. There is mild, diffuse swelling. The veins have collapsed. Capillary refill is mildly reduced. The wrist and dorsum of the hand have allodynia. Pinprick and cold produce hyperalgesia and allodynia respectively. Strength is markedly diminished due to pain. She has difficulty with digit flexion, extension, adduction and abduction. Flexion and extension of the wrist are very painful and limited.