CASE-2—chronic back pain
COMMENTARY
Eleven years before evaluation by the author, a 39-year-old man de- Pain and inflammation can remain in the periphery as well as develop
veloped severe lumbar spine pain following multiple sports injuries. He a centralized component. Amputations are the classic example. In
had a lumbar laminectomy, which did not relieve his pain. His attempts these situations both sites have to be treated.
at treatment after surgery included epidural corticoids, chiropractic manipulation, transcutaneous electrical
CASE-4—genetic autoimmune
nerve stimulation (TENS), and opioids
disease with adulthood pain
Figure Good Reasons to Make a Clinical Diagnosis
at standard dosages. Magnetic resof Centralized Pain
onance imaging of his spine showed
A 29-year-old woman with an Asian
degenerative changes including disc
Pacific heritage was referred for seprotrusions and spinal stenosis. His
vere, constant “pain all over.” Before
pain remained constant, and an applireferral she didn’t have a specific
cation or injection of lidocaine into or
diagnosis other than nondescriptive
over his pain site did not relieve pain.
“myofascial pain.” On evaluation she
Determine if patient needs testing for
He has multiple cytochrome P450 deproved to have hyperextension of
fects and requires a high daily opioid
joints. She gave a history of a ruptured
inflammatory markers and serum hormone levels
dosage for symptomatic pain control.
uterus during pregnancy, periodic feHe requires testosterone replacement.
vers, gastrointestinal pain, and arthralHe was prescribed pregnenolone and
gias. Joint pain and fevers had begun
Eliminate useless peripheral treatment measures
human chorionic gonadotropin, which
during childhood. She has cytochrome
has lessened his pain and allowed him
P450 defects of 2D6 and 2C9. A diagto reduce opioid dosages while mainnosis of Ehlers-Danlos syndrome has
Avoid mislabeling patients as drug seekers,
taining gainful employment.
been assigned to her. Her pain treatpseudo-addicts, or mentally ill
ment has consisted of opioids, human
chorionic gonadotropin, and oxytocin.
COMMENTARY
She has responded well in that she has
some pain-free hours and can carry on
The chronic low back pain patient is
Justify aggressive pharmacologic treatments
a marital relationship, attend school,
the most common patient with cenand work part-time.
tralized pain seen in clinical practice. A diagnosis of centralized pain
Provide a definitive diagnosis to help settle
should be assigned when the pain is
COMMENTARY
disability and worker’s compensation claims
constant and when peripheral treatments such as paraspinal or epidural
Patients with genetic autoimmune
corticoids, topical lidocaine, or physdiseases are beginning to attend
Establish a solid reason to prescribe opioids
ical manipulation do not relieve pain.
pain practices. Symptoms such as
This patient appears to benefit from
recurrent infections, arthralgias, feand help satisfy regulators
adjunctive hormone treatments.
ver, headache, and gastrointestinal
complaints begin in childhood. Many
children with these diseases are deCASE-3—amputation
Educate about centralized pain to all
scribed as sickly but are never given
concerned parties including family, pharmacists,
a specific diagnosis. The patient may
While serving in the Middle East, a
subsequently develop severe, cen45-year-old male veteran had an
regulators, legal community, and
tralized pain in adulthood. These
above-knee amputation owing to injuthird-party payers
conditions include a group of entities
ries from an incendiary device explothat are given various names such as
sion. His stump pain has been constant
Ehlers-Danlos syndrome, Marfan synand excruciating over a 7-year period
drome, Behçets disease, Still’s disease,
despite multiple surgeries to remove
ganglions. He didn’t respond to standard opioid dosages so he was Schmidt’s syndrome, ankylosing spondylitis, and systemic lupus eryreferred to the author. At the time of evaluation his leg was too sensi- thematosus. Although each may have a specific gene X