COMMON PAIN SYNDROME

Departemen Anestesi, Perawatan Intensif &

Manajemen Nyeri
Fakultas Kedokteran – Universitas Hasanuddin
Makassar
 LOW BACK PAIN
 PAIN IN EMERGENCY
 MYOFASCIAL PAIN SYNDROME
(MPS)

2
Low Back Pain
 Epidemiology
Extremely common:
 lifetime prevalence: 70-80%
 1 year prevalence: 15-20%
 Physician Task
 History: symptoms
 Physical examination: signs
 Investigation: laboratory, imaging

 Diagnosis: accurately

 Treatment: appropriately
Goal: pain free, return to activity
Anatomy: Lumbar Spine
Lumbar vertebra

Disk

Nerve root

Facet joint

SI joint
Anatomy: Lumbar spine
Pain Sensitive Structures
 Intervertebral joint
 Annulus
 Facet capsule, synovium
 Vertebra
 Periosteum
 Muscles, ligaments
 Nerve
 Blood vessels
 Function of Spine
 Protection
 spinal cord, nerve roots
 Motion
 flexibility
 Stability
 structural support and balance
 Hematopoisis
Mobile, Stable, Painless, Harmless
 Dysfunction
Etiology
Pathology
 Congenital
Deformity
 Trauma
Instability
 Tumor
Stiffness
 Infection
Neural tissue
 Inflammation
compression
 Degeneration
 Miscellaneous
 Pathophysiology: Degeneration
Nucleus pulposus Annulus fibrosus
Herniation Tear
Dehydration Bulging

Intervertebral disc narrowing

Facet arthrosis Ligamentum flavum

Osteophyte Hypertrophy
Capsule hypertrophy Buckling
 Clinical Presentation
 Pain
 Low back pain
 Low back pain + leg pain (Radikuler Pain)
 Neurological disturbance
 Radiculopathy: pain, numbness, weakness
 Clinical Syndromes
 Mechanical back pain and/or leg pain
 Nonmechanical back pain and/or leg pain
 Sciatica
 Neurogenic claudication
Mechanical back pain and/or leg pain
 Exacerbate by activity, changes in position
or prolonged sitting
 Relieved with rest esp. in supine position

e.g. degenerative disc pathology,

spondylolisthesis
Nonmechanical back pain and/or leg pain
 Constant pain
 Minimally affected by activity
 Unrelieved with rest
 Usually worse at night or early morning

e.g. spinal tumor, infection

 Diagnostic Tool
 History taking
 Physical examination
 Investigation
 Radiography
 Laboratory
 History
 Onset
 Duration and frequency
 Location and radiation
 Aggravating and alleviating factors
 Time of day
 Intensity
 Neurological abnormality
 Disability
 Basic Elements of
Physical Examination
 Inspection
 Palpation
 Range of motion
 Neurologic examination
 Special test (provocative test)
 Evaluation of related areas (hip, SI joint)
 Discogenic Pain Syndrome
 Predominant back pain: daily and persist
 Occasionally report subjective radicular
irritability
  weight bearing for prolonged period
(standing, sitting)
  rest
 Normal neurologic examination
 Diagnosis by exclusion
 Sciatica
 Predominant leg pain rather than low back
pain
 Neurologic symptoms and signs in specific
nerve root distribution
 Nerve root tension signs: positive
 Neurogenic claudication
 Low back and buttock pain
 Radiating leg or calf pain
 Worse with ambulation
 Worse with spinal extension
 Relieved with flexion maneuver
 Absent nerve root tension signs

e.g. spinal stenosis

 Facet Syndrome
 Unilateral or bilateral deep dull pain: low
back, buttock and hip
 Can radiate into the thigh and down to the
knee in a nondermatomal distribution
  by twisting or rotational motion,
extension, moving from sitting to standing
  by standing, walking, rest, repeated
activity
 Facet Syndrome
 Morning stiffness
 Normal neurologic examination
 No radicular pain
 Tenderness over the affected facet joint
 Sacroiliac Joint Syndrome
 Pain over the SI joint
 Referred pain to groin, trochanter and
buttock
 Sitting intolerance
 SI joint tenderness
 Pain aggravated by provocative tests
 No associated radiculopathy
 Radicular Syndrome
 Nerve root irritation or compression
 Predominant leg pain, dermatomal
distribution
 Radicular pain (neuropathic pain)
  activity, coughing, sneezing, valsava
maneuver, bending
  rest lying
 Nerve root tension sign: positive
 Neurologic examination may be equivocal
 Red Flags Signs
Serious
 Rest pain,
underlying
night pain
condition
 Constitutional symptoms:
 Fever, weight loss
 Infection

 Neurological
Tumor deficit
 Cauda equina syndrome
 Trauma
 Acute severefracture
 Pathologic pain

Early and aggressive evaluation

 Treatment of Low Back Pain

Conservative Surgical
 Conservative Treatment
 Complementary
Bed rest and alternative therapies
 Education
Medications
 Ergonomic
Exercises modification
 Orthoses
 Physical modalities
 Injections
 Injection
Diagnostic and therapeutic
 Discography
 Epidural corticosteroid injection
 Selective nerve root block
 Facet joint injection, medial branch block
 Sacroiliac joint injection
 Invasive and have potential complications
 Indication: failed initial conservative
treatments
 Surgical Treatment: Indications
 Cauda equina syndrome
 bowel bladder dysfunction
 Progressive neurologic deficit
 Failure of conservative treatment
 Surgical Treatment: Procedures
 Decompression
 Discectomy
 Laminectomy
 Stabilization
 (fusion + instrumentation)
 Miofascial Pain
Syndrome (MPS)
 Nyeri Miofasial
Cause : Micro or macro injury
Clinical Pictures Myofascial Pain Syndrome
Pain (Bizarre referred pain but specific to each TrP)
Autonomic Symptom(s)
Associated neurologic symptom(s)
Frequently associated Autonomic
& neurologic symptoms

 Abnormal sweating,
lacrimation, dermal
flushing, and vasomotor and
temperature change
 Cervical MPS may be
associated with neuro-
otologic symptoms,
including imbalance,
dizziness, and tinnitus
 Other neurologic
symptoms, include
paresthesias, numbness,
blurred vision, twitches, and
trembling
 18 tender point
Common Point of
Chronic Widespread Pain :
Miofascial Pain Syndrome
Fibromyalgia
 Etiology of Myofascial
Trigger Points
(Overload Principle)

Acute Overuse
Traumatic and/or sport-
related
Chronic Overuse poor
posture with chronic
repetitive motions

Physiologic load is ideal

Field Work  Office Syndrome
WWW
Pathophysiology
Trigger Point
(The interplay)

Motor end-plate Concept

Muscle Fiber Concept
ANS Concept
Central Mechanism
 1. Motor end-plate Concept
2. Muscle fiber concept Mechanical
Chemical
3. ANS concept Psychological Stress

Neurovasoactive
Substances
such as bradykinin,
Substance P,
Serotonin, and
histamine

Central MTrP
 4. Central Mechanism
Higher Center
Facilitatory and
Inhibitory Pathways

Spinal Cord Plasticity

- NMDA receptor : Wind-up
- Glial cell
- A-beta fiber sprouting
Peripheral Sensitization
- Wake up “silent” nociceptor
- A-beta syntisize receptor

NB : Spinal and supraspinal : nerve injury in animal model

Diagnostic Criteria (R/O AndR/I)
Hx : Regional Pain Syndrome
PE : Palpable Trigger Point

Common characteristic of the TrP :

1. Hyperirritable Spot
2. Reproducible referred symptom
3. Palpable of Taut band or nodule
 First Principles
Myofascial Trigger Points are identified

by physical examination, specifically

by palpation

“rope-like” nodularity to
the taut band should appreciate
High touch is important as High
technology
From Theory : Cut off 4 kg/sq.cm.
To Practice
Reliability varies and depends on
 The palpation skills
 Training of the examiner and
 The depth and the size of the muscle

(80% agreement)
MPS Management

Correct
Perpetuating
Factors
Eradication
Trigger Point
 MPS Management
In practice
MPS is The largest cross-road of
conventional and alternative medicine

Trigger Point Eradication : Short-term goal

Correct Perpetuating Factor : Long-term goal
 Trigger Point Eradication

There are more than

one strategies to
eradicate the Trigger
Point

Evidence Based?
Which one is the best?
 Fundamental Strategy

 Subsidize
loading at the
Collagen
TrP & Elastin

STRETCHING
Focus Review : Myofascial Pain. Arch Phys Med Rehabil Vol 83, supple 1, March 2002.
Massage

Local
Stretch
 Local
Stretch

Reactive
Vasodilatation

Wash out
Waste products
 Acupuncture or Dry Needling

71% anatomical correlate between MTrPs and Acupuncture Point

 Trigger Point Injection

Dry Needling or
Mechanical Effect

Pharmacological Effect Volume Effect

 Medications

For Trigger Point releasing?

For symptomatic pain treatment?
For relieving post treatment soreness?
For Perpetuating Factor(s) correction?
 Mechanical factor
Overload Principle
Good Poor Articular
Posture Posture Dysfunction

Structural
Inadequacy Biomechanic Correct Manipulation
Posture
Wrong
Biomechanic TrP Overload
Office Syndrome
Posture & Body Mechanic

Ergonomics
Human-Machine System
Pain in Trauma patients
 TRAUMA

Tissue / Organ damage

Symphato – adrenal Pain

Response

Vital Function Disturb. Neuroendocrin-metabolic Psychologic

(A-B-C-D) Response Response
 TRAUMA
TRAUMA

ACUTE ELECTIVE (SURGERY)

TISSUE / ORGAN DAMAGE

PAIN

STRESS HORMONE  PHYSIOLOGIC DISTURBANCE

Cortisol Limited thorax expansion
Ephinefrin Pulse  , blood pressure 
Renin Oxygen consumption 
Aldosteron Immobilization
Glucagon Metabolism disturbance
Immunologic disturbance

PAIN < MORBIDITAS / MORTALITAS <

S
 Pain Assessment

 Subjectively : pain is easy to assess

 Objectively : pain is difficult to assess
 Few physical signs of pain , not spesific
 Complain, cry, grimace,
 Confusion, agitation, restlessness, hypertension,
tachycardia  Hypoxemia? , hypovolemia?
Emergence ?
 Agonizing pain : bradycardia, hypotension,
nausea, vomiting, sweating, dilated pupil and
pallor  other causes ?
 Pain Management on trauma
patient
No “preemptive analgesia”
Remember resuscitation and stabilization
Concern about “masking effect”
Causal factors correction
Close monitoring time by time
60
 Resuscitation Phase
Analgesia should not be withheld, during the
resuscitation,unless :
• Hemodynamic instability
• Respiratory depression
• Profound sedation or coma
Titrated intravenous opioids / ketamin / NSAID
Tailored to individual
Close monitoring of vital functions 62
 Pain management
Pharmacological approach
Analgesic drug
Regional analgesia

Non-pharmacological approach
communication – information and education
Correct some trauma cause
Reposition – immobilize fracture
Splinting
Drainage hemopneumothorax
urgical
WFSA
WFSA ANALGESIC
ANALGESIC LADDER
LADDER FOR
FOR ACUTE
ACUTE PAIN
PAIN

PSYCHOLOGICAL &
SOCIAL SUPPORT

strong
Opioids by weak
Injection, Opioid
local anestesia By mouth
and NSAIDs and NSAIDs Aspirin
(as pain &
decreases) NSAIDs
 Balanced Analgesia
Opioid – non opioid – adjuvant
Centrally – peripherally effect
Side effect decrease
Emergency Phase
i.v  intermittent, continue, PCA

Acute Phase
i.v/i.m?/sc?  intermittent, continue, PCA
Regional Block  single, kontinyu
p.o/sup

Rehabilitation Phase
p.o/sup
 Environmental and other
adjuncts

1. Comfortable surroundings ( AC ,lights, quiet area,

music?)
2. A calm, clear manner of communication, information
and education.
3. Splinting and minimal or gentle handling of injured
parts
4. Family or friend presence ( if possible, safe, and
desired)
5. Etc.
THANK YOU VERY MUCH