Caring for the emergency department patient with chest pain represents an important challenge to the emergency physician. Chest pain is the second most common presentation among all emergency department patients, accounting for approximately 6 million visits per year in the United States. Chest pain may represent a benign condition or a time-critical life threat; symptom overlap between benign and serious conditions can make an accurate chest pain diagnosis challenging. This review covers the pathophysiology, assessment, stabilization, diagnosis and treatment, and disposition and outcomes of chest pain. The figure shows an algorithm outlining the approach to the patient with chest pain. Tables list critical and noncritical diagnoses in patients presenting with chest pain: history, physical examination, and bedside testing; risk factors or associations for acute coronary syndrome, pulmonary embolism, and aortic dissection; characteristics of the chest pain story to diagnose acute coronary syndrome; ABCDEs of resuscitation for patients with unstable vital signs; critical and noncritical diagnoses in patients presenting with chest pain: history, diagnosis, and treatment; prevalence of pulmonary embolism in patients classified as low or high probability for this diagnosis by Wells score, modified Geneva score, and gestalt; commonly recognized pitfalls in the workup and diagnosis of chest pain in the emergency department; critical diagnoses in patients presenting with chest pain: history, disposition, and outcome; and summary of current recommendations.

This review contains 1 highly rendered figure, 11 tables, and 54 references.

Key words: acute coronary syndrome, acute myocardial infarction, anginal pain, aortic dissection, cardiac-related pain, chest pain, coronary artery disease, non–ST segment elevation myocardial infarction, pulmonary embolism, ST segment elevation myocardial infarction

Neck pain is one of the most common symptoms that we see in patients presenting to a pain center for treatment. The complex nature of pain generated by various elements in the neck as well as their radiation patterns sometimes makes it difficult to diagnose and treat a patient’s pain. A proper diagnosis is important for providing optimal management of neck pain. Axial neck pain mainly refers to the pain generated by the osseous elements and the intervertebral disks in the vertebral column. Neurologic pain presents differently from axial pain, exhibiting different characteristics and radiation patterns. The following review discusses the causes of axial neck pain, diagnoses, and available treatments. 

This review contains 7 figures, 4 tables, and 26 references.

Keywords: Neck pain, range of motion, whiplash, subluxation, cervical spine, facet joints

Lumbar or lower back pain is a very debilitating condition that affects  almost one fifth of the adult population during a given year. Almost everyone walking on two feet is bound to suffer from some back pain during their lifetime. The health care burden for treating low back pain is enormous, especially if the lost work hours are combined with the amount used in diagnosing and treating low back pain. Lumbar facet (zygapophysial) joints are one of the major components involved in causing lower back pain. Diagnosing the pain generator is more of an art than a science. Combining various parameters in the patient’s history, physical examination, and diagnostic studies is not much different from solving a murder mystery. Although facet joint pain may be accompanied by other pain generators, that is, lumbar intervertebral disks, nerve roots, and vertebral bodies, once treated, the relief in pain is more helpful in performing proper rehabilitation and improving further deterioration in low back pain. Muscles are almost always painful due to myofascial pain syndrome that accompanies the facet joint–related pain. Treating one without addressing the other leads to failure in management and optimization of patient’s pain and function. Several treatments are available for treatment of facet joint–mediated pain, including steroid injections using a miniscule amount and radiofrequency ablation of the nerves supplying the facet joints (medial branches of the dorsal primary ramus of the lumbar nerve root). With proper diagnosis and treatment, a patient’s pain and function can be optimized to a level where it may not impact the day-to-day activities or even resumption of the patient’s routine job function. The following review describes the anatomy, pathophysiology, diagnosis, and treatment of lumbar facet joint–mediated pain.

Key words: facet joint pain, facet joint syndrome, low back pain, medial branch radiofrequency, spondylolisthesis

Diskogenic low back pain (LBP), defined as pain that originates from a damaged vertebral disk, is a common cause of LBP. It is characterized by a three-phase cascade of degeneration marked by dysfunction, instability, and stabilization. A distinct pathologic characteristic of the disks from patients with diskogenic LBP has been found to be the formation of the zones of vascularized granulation tissue, with extensive innervation extending from the outer layer of the annulus fibrosus into the nucleus pulposus along a torn fissure. In addition, there appears to be an association between microbial infection and symptomatic disk degeneration. Low-virulence microorganisms, in particular Propionibacterium acnes, might be causing a chronic low-grade infection in the lower intervertebral disks in some patients. The diagnosis of diskogenic pain is primarily based on clinical manifestations, physical examinations, imaging studies, and provocative diskography. Diskogenic pain should be differentiated from other axial back pain conditions, such as facet arthropathy, sacroiliac joint pain, myofascial strain and pain, vertebral compression fracture, and other, less common conditions. Treatment options should be tailored to individual needs. Early and gradual physical and behavioral therapies are encouraged. Pharmacologic therapy, composed primarily of analgesics, nonsteroidal antiinflammatory drugs, muscle relaxants, and antidepressants, may have modest positive effects. A subset of patients with Modic type I changes in magnetic resonance imaging may benefit antibiotic therapy directed at the infected disks by P. acnes and other low-virulence microorganisms. There is evidence that supports the use of epidural steroid injections and intradiskal injections (methylene blue, ozone, steroids) for diskogenic pain. Additional options include intradiskal biacuplasty, gray ramus communicans nerve blocks/radiofrequency ablation, and intradiskal stem cell injections for disk repair/regeneration, all of which have gained support in clinical trials. These treatment modalities have shown promise to provide equal or even better outcomes compared with surgical spinal fusion or total disk replacement with an artificial disk.   

This review contains 2 figures, 12 tables and 153 references

Keywords: Lumbar spondylosis, low back pain, diskogenic pain, herniated disk, annulus fibrosus, nucleus pulposus, osteoarthritis

Bertolotti syndrome is caused by a lumbosacral transitional vertebra,  a congenital variation of the most caudal lumbar vertebra, characterized by an enlarged transverse process that articulates or fuses with the sacrum, ilium, or both. This syndrome accounts for 4.6 to 7% of cases of low back pain in adults and for more than 11% of patients with low back pain who are under 30 years old. The primary effect of lumbosacral transitional vertebra is reduced and asymmetrical motion between the transitional vertebra and the sacrum, resulting in early arthritic changes at pseudoarticulation; the secondary effect is the progressively compensatory modifications in the biomechanics of the mobile vertebral segments superior to the transitional vertebra related to restriction in rotation and bending motion at the lumbosacral articulation. Bertolotti syndrome should be considered in the differential diagnosis of low back pain. Clinical findings include low back pain in the midline or paramedian area that is reproduced with palpation along the base of the lumbosacral spine and near the posterosuperior iliac spine and aggravated by forward flexion, excessive extension, or lateralization of the back to the same side of the mega-apophysis. A plain x-ray is diagnostic; the extension-flexion lumbosacral radiographs in anteroposterior, lateral, and oblique views demonstrate lumbosacral transitional vertebra, with an enlarged unilateral or bilateral transverse process of the most distal lumbar vertebra, abnormally articulating with the ala of the sacrum and degenerative changes of the pseudarthrosis. Other imaging studies, such as computed tomography and magnetic resonance imaging of the lumbosacral spine and selective radiculography of the spinal nerve, could provide additional detailed anatomic information. Major differential diagnoses of Bertolotti syndrome include sacroiliac joint pain, myofascial pain, lumbar facet pain, lumbar disk herniation, compression fracture, and Baastrup disease/interspinous bursitis. These conditions are not mutually exclusive and, in fact, often coexist. A course of conservative management, including activity modification, medication management with nonsteroidal antiinflammatory drugs, muscle relaxants, and rehabilitative physical therapy, should be offered initially. Due to the multifactorial etiology of low back pain in patients with Bertolotti syndrome, procedures such as diagnostic intrapseudoarticular block for arthritis, medial branch block for facet arthropathy, diskography for diskogenic pain, and selective nerve roots block for radiculopathy can potentially help identify the primary and secondary origins of the pain. Surgical treatment of Bertolotti syndrome was only slightly better than conservative treatment and should only be used in very selective patients with disk pathology. To achieve long-term improvement by any of these therapeutic options, a continuing physical rehabilitation program is often needed.

Key words: Bertolotti syndrome, intrapseudoarticular block, transitional lumbosacral vertebra, transverse process  

Baastrup disease (BD), an uncommon back pain syndrome, is characterized by pathologic approximation of adjacent spinous processes on a sagittal plane image. BD occurs most commonly at the lumbar L4-L5 level and tends to be more common in the elderly. The etiology is not precisely known, but BD may develop secondary to chronic active inflammatory facet arthropathy, leading to interspinous osteophytes and approximation of the adjacent spinous processes. Clinically, BD should be considered in the differential diagnosis of back pain if there is (1) midline back pain reproduced with palpation of the spinous process and exacerbated by extension of the lumbar spine and (2) direct contact of adjacent spinous processes on the lateral view of a plain x-ray image. Magnetic resonance imaging is more sensitive in detecting interspinous inflammation and the formation of bursa and new bone. Major differential diagnoses of BD include proliferative hyperostosis of the lumbar spinous processes, degenerative disease of the spine, sclerotic bone metastases to the spine, and ankylosing spondylosis. BD can be managed initially with nonsteroidal antiinflammatory drugs, a short-term steroid dose pack, and physical therapy. Injection of a local anesthetic to the inflamed spinous process and associated interspinous ligaments may be diagnostic, and injection of a local anesthetic/corticosteroid combination may be therapeutic. Surgery is reserved for patients with refractory BD. Surgical options include interspinous process decompression devices and excision of the affected spinous processes.

Chronic pain originating from the sacroiliac joint (SIJ) is common. Pathophysiology is often related to biomechanical derangement affecting the SIJ or traumatic, degenerative, arthritic, and idiopathic changes of the SIJ. Diagnosis of SIJ pain is suggested by typical patterns of distribution, pain characteristics, and a combination of provocative tests, confirmed by diagnostic block of the SIJ, and differentiated from several other causes of low back pain. Multimodal therapy includes educational, physical, pharmacologic, interventional, and surgical approaches and should be individualized. The efficacy and safety of radiofrequency denervation of the sacroiliac joint have been demonstrated in randomized controlled trials. Multiple modalities of radiofrequency treatment exist, and comparative effectiveness studies are required to determine the most efficacious and cost-effective treatment modality. 

Early diagnosis of chronic pancreatitis is possible by combining clinical information with pancreatic function testing, endoscopic ultrasonography, histology, and traditional imaging techniques such as magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP). Such an approach helps improve the sensitivity and specificity of these complementary modalities. Pain management of chronic pancreatitis involves multidisciplinary and multimodal approaches. Behavioral modifications such as alcohol cessation, nutritional optimization, and cognitive-behavioral therapy play a significant role for better long-term outcomes. Pharmacologic management is directed at relieving both psychological and physical symptoms, and combination pharmacotherapies are often needed to address pancreatic deficiency, abdominal pain, and psychological disorders. Interventional approaches to celiac plexus and splanchnic nerve blocks and denervation (radiofrequency ablation, endoscopic or surgical denervation) may provide significant and prolonged pain relief. Neuromodulation in the form of spinal cord stimulation is a viable option for long-term pain relief. Managing complications of chronic pancreatitis, such as gastrointestinal complications (peptic ulcer, bile duct stenosis), pseudocysts, malnutrition, depression, diabetes, and painful diabetic neuropathy, is an integral part of comprehensive treatment and requires close collaboration between members of a multidisciplinary team.  

This review contains 1 figures, 2 tables and 64 references

Key words: behavioral modifications, celiac plexus, chronic abdominal pain, chronic pancreatitis, interventional therapy, pharmacologic modulation, splanchnic nerves, surgical intervention

Endometriosis, a chronic and progressive condition characterized by the presence of endometrial tissue outside the uterus, accounts for about one third of the cases of chronic pelvic pain in women. Pain in endometriosis may be due to nociceptive, inflammatory, and/or neu­ropathic mechanisms. The clinical presentation is often variable between patients, and diagnostic laparoscopy for visualization and biopsy of lesions is the gold standard for diagnosis. The treatment may consist of two elements: chronic pelvic pain itself as a diagnosis and endometriosis as a disease. Hormonal therapy is used to reduce the amount of estrogen and hence reduce symptoms such as pelvic pain and dysmenorrhea. In patients with severe endometriosis, surgical removal of lesions, adhesions, and cysts and restoration of pelvic anatomy may be preferred. Both hormonal and surgical treatments have been shown to be effective in decreasing pain symptoms associated with endometriosis. A variety of analgesics, including nonsteroidal antiinflammatory drugs, opioids, tricyclic antidepressants, dual reuptake inhibitors of serotonin and norepinephrine, and antiepileptic drugs, have been used to ameliorate pain in endometriosis, with varying degrees of success. In patients with persistent symptoms, interventional pain management procedures may be performed to target the visceral and somatic organs and their innervations. Infertility is the most common complication of endometriosis. Between 10 and 20% of women with endometriosis have recurrence of the disease regardless of the treatment they receive. The recurrence of pain may be due to remodeling of the central nervous system, the role of the reproductive tract in reactivating pain, and incomplete removal or recurrence of lesions.

This review contains 2 tables and 52 references 

Key words:chronic abdominal pain, chronic pelvic pain, dyschezia, dysmenorrhea, dyspareunia, endometrioma, endometriosis, hormonal therapy, infertility, retrograde menstruation, visceral pain 

Both assessment and management of pain in children present challenges for perioperative physicians, including surgeons, anesthesiologists, intensivists, and pediatricians, among others. Several reports have indicated that pediatric pain is undertreated postoperatively compared with pain in adults, resulting in both severe physical consequences, such as the development of chronic pain and complex regional pain syndromes, and significant psychological distress, such as nightmares and reversal of learned behavior. Moreover, chronic pain in childhood has been shown to heighten the risk for mental health problems in adulthood. Children with chronic pain (n = 14,790) reported higher rates of lifetime anxiety disorders (21.1% versus 12.4%) and depressive disorders (24.5% vs 14.1%) as adults. Although many evidence-based practice guidelines for pain management in younger people have been developed, adherence is often less than complete.

The perioperative physician should be aware of barriers in pediatric pain management and be able to address them, thus improving pain management and patient outcome. Some of the problems in dealing with pediatric pain management include a realization of the controversies as to the age at which children feel pain, how pain can be assessed from the newborn to the adolescent, how the level of education and involvement of parents impact the situation, and a general knowledge of available pain treatments for the pediatric population. 

Key words: complications, opioids, pediatrics, postoperative pain, regional techniques

Phantom limb is a complex pain phenomenon that is perceived by patients after a limb has been amputated. Many patients have the persistent perception that the particular limb that was lost is still present. This phenomenon, which may be painful and nonpainful, may develop immediately after amputation or in years following the incident. This phenomenon should not be confused with residual limb pain, formerly described as “stump pain,” which is pain that resides in the residual limb attached to the body. Phantom limb pain (PLP) is described similarly to other neuropathic pain conditions as burning, gnawing, stabbing, pressure, aching, squeezing, and knifelike. PLP is associated with a myriad of symptoms and considered one of the most challenging chronic pain conditions. The underlying mechanism of this phenomenon can be supraspinal, spinal, and peripheral. PLP remains a very challenging condition to treat. The therapies are similar to those of any other neuropathic pain states. A multimodal approach that includes interventional therapy, pharmacotherapy, rehabilitation, surgery, and preemptive analgesia working together improves success. 

Key words: Amputation, amputee, central sensitization, mirror therapy, neuropathic pain, phantom limb pain, residual limb pain

Clinicians often encounter individuals who present with pain that they cannot adequately explain based on the degree of damage or inflammation noted in peripheral tissues. This typically prompts an evaluation looking for a cause of the pain. If no cause is found, these individuals are often given a diagnostic label that merely connotes that the patient has chronic pain in a region of the body, without an underlying mechanistic cause. Fibromyalgia (FM) is merely the current term for widespread musculoskeletal pain for which no alternative cause can be identified. This review covers the epidemiology, etiology/genetics, pathophysiology and pathogenesis, diagnosis, differential diagnosis, treatment, and complications and prognosis of FM. Figures show underlying mechanisms that can cause chronic pain; an individual’s “set point” or “volume control setting” for pain as set by a variety of factors, including the levels of neurotransmitters that either facilitate pain or reduce pain transmission; the 2011 Fibromyalgia Survey Criteria; symptoms and syndromes frequently seen in individuals with FM; the distribution of the 2011 Fibromyalgia Survey scores in a large cohort of individuals undergoing joint replacement surgery; and an algorithm showing the importance of dually focused treatment for FM and other chronic pain conditions. Tables list clinical characteristics of centralized pain, pharmacologic therapies for FM, and nonpharmacologic therapies for FM.

This review contains 6 figures, 9 tables, and 78 references.

Keywords: Fibromyalgia, chronic low back pain, headache, temporomandibular joint disorder, gastrointestinal disorder, irritable bowel syndrome (IBS), nonulcer dyspepsia, or esophageal dysmotility,  interstitial cystitis, chronic prostatitis, vulvodynia, vulvar vestibulitis, and endometriosis

Complex regional pain syndrome (CRPS) is a multisymptom syndrome involving aberrant pathophysiology of the peripheral, autonomic, and/or central nervous systems. The central feature is severe, often debilitating pain. This is accompanied by a collection of sensory, motor, autonomic, skin, and/or bone abnormalities. A key feature is allodynia, where otherwise innocuous stimulation will cause pain and hyperalgesia. The patient will present with varying degrees of pain, allodynia, hyperalgesia, swelling, and color and temperature changes. There are often changes in motor function, such as muscle stiffness or even involuntary movements. Regional osteopenia, changes to hair and nail growth, and dystrophic cutaneous changes may occur. The Budapest criteria have been twice validated and are used to diagnose CRPS. A patient-centric clinical approach is important in the treatment of CRPS. Key domains to be addressed in the management of CRPS include rehabilitation and pain management with adjunct psychological therapy. It is important that these interventions happen concurrently within the continuum of care. With the guidance of a physician, physical therapist, occupational therapist, and neuropsychologist, rehabilitative training programs are designed to address motor, sensory, and cognitive deficits.

Key Words: Budapest criteria, complex regional pain syndrome, reflex sympathetic dystrophy, sympathetically mediated pain

Although long an integral part of the health systems of societies all around the globe, the role of complementary and alternative medicine (CAM) in Western medicine has become better defined over the past few years, especially in multidisciplinary pain management. Many patients have expressed dissatisfaction at conventional treatments of therapy, medications, and procedures. Often they have sought adjunctive treatments to make up for deficits in efficacy and to minimize unwanted side effects. CAM has been a source to fill the void. Additionally, physical modalities that promote the mind-body connection in pain states have emerged in common practice. Of the physical modalities helpful in the concurrent management of pain, yoga has emerged as one of the most effective options. The medical literature has identified acupuncture as efficacious and safe and determined that it may have benefit as a sole therapy or in conjunction with traditional interventions. Although nutraceuticals and marijuana have received lay press exposure and interest, as pain therapeutics, the mechanism of action of these agents needs to be more precisely elucidated and regulatory bodies need to ensure quality control and dosage safety in society.  

This review contains 4 figures, 1 table and 118 references

Key Words: acupuncture, lower back pain (LBP), medical marijuana, nutraceuticals, transcutaneous electrical nerve stimulation (TENS)

Management of pain in the spinal cord–injured patient can be a stressful and difficult challenge for both the patient and the physician. In spinal cord injury (SCI), pain can occur immediately or months later, with the potential for persistent pain throughout a lifetime. Unfortunately, pain in this population is often overshadowed or minimized. This is often due to bigger concerns of physical immobility, medical comorbidities, and functional capacity. Achieving pain control leads to a higher likelihood of patients regaining independence in their activities of daily living (ADL), along with providing biopsychosocial benefits to them and their contacts. Using a classification system based on injury acuity, location, and characterized pain state to identify pain generators can help practitioners implement targeted treatment plans. A combination of interventional, physical, pharmacologic, and psychological treatment will help attack the interminable issues that develop along the life span of a patient after injury. Promptly starting treatment will improve our successful management of SCI pain with care that is preventive rather than reactionary.  

Deaf patients face unique obstacles in health care and pain management. Not every facility that deaf patients encounter is going to have the proper resources to effectively communicate with them even if regulations are mandated. The Americans with Disabilities Act (ADA) requires that health care institutions provide means of communication for patients, their family members, and hospital visitors who are deaf or hard of hearing. Very little research has been done regarding how the hearing-impaired population effectively communicates pain experiences. Hearing loss can be accompanied by an additional disability, which can further complicate communication between health care providers and deaf patients. Although resources are available to aid communication between health care practitioners and deaf individuals, resources related to hearing loss plus additional disabilities and health care are lacking. Health care providers should educate themselves and their staff so that they are prepared to treat a deaf patient and accommodate the patient’s communication needs.

Most women experience some degree of pain during pregnancy. Back painoccurs in about half of all pregnant women, with pain typically in the low back due to the physiologic changes in the body that occur with pregnancy, such as weight gain, changed center of gravity, increased ligament and joint laxity, and altered posture. Pelvic pain, leg cramps, and abdominal pain are all common among pregnant women.Many women who have pain during pregnancy are reluctant to use analgesics due to concerns about what the medications may do to their unborn child. Because of this, it is hypothesized that many women are either undertreated for pain or do not receive any treatment. Chronic, severe pain that is ineffectively treated is associated with hypertension, anxiety, and depression, all of which do not lead to a healthy pregnancy.A variety of interventional procedures are commonly performed during pregnancy that can safely alleviate pain. This review goes into detail about the types of pain treatments that are available to pregnant women and are safe and effective in alleviating pregnancy-related pain.

Keywords: Pelvic pain, leg cramps, abdominal pain, hypertension, anxiety, depression, joint laxity, ligament laxity, back pain, analgesics, pregnancy

Pain after childbirth is common. The incidence of chronic postpartum pain is rising and has been shown to have a negative impact on the mother, the baby, and the rest of the family. Estrogen heightens pain sensitivity in women, and high levels of estrogen are normally seen during pregnancy. In patients who have had a cesarean section, postpartum pain can be caused by several different factors, including pain at the point of incision, infection at the incision site, suture breakdown, tape burn, or collection of fluid under the skin. In addition to complications during a cesarean section, other complications can arise during childbirth that require the use of pain medications, and this can cause concern for mothers who are breast-feeding. This review outlines the types of complications that can occur in mothers after the delivery of a baby and the types of medications they are prescribed. Additionally, this review outlines which drugs are safe for the breast-feeding mother and baby as well as medications that should be used with caution.

The past few decades have seen a shift in breast cancer surgery to a more conservative approach from radical mastectomy to breast-conserving therapy and from axillary node dissection to minimally invasive sentinel node biopsy. The adoption of more conservative surgical approaches was taken with the aim of reducing morbidity after surgery and improving long-term functional capacity. This review outlines complications that can arise in treating breast cancer and the therapies that can be used to treat patients with these conditions.

This review contains 3 tables and 47 references.

Key words:  breast cancer, biopsy, chemotherapy, endocrine therapy, lymphedema, lymphatic drainage, mastectomy, radiotherapy 

Cancer pain is complex and challenging to treat. Pancreatic cancer pain occurs in 75% of patients and over 90% of patients in advanced stages. Pain management should be individual to the patient and involve a multidisciplinary approach. No one treatment modality has been found to be effective in alleviating pancreatic cancer pain; therefore, all treatment options should be considered. Opioids are a cornerstone of cancer pain management; however, the neurolytic celiac plexus block can be a useful treatment modality in pancreatic cancer patients. This review discusses the types of pain that are seen in pancreatic cancer patients and how to treat that pain through a multimodal, multidisciplinary approach.

This review contains 3 figures and 28 references.

Ankle sprains are a very common injury, suffered by approximately 25,000 patients per year, and affect all age groups, including children, athletes, and the elderly. The recognition of the type of ankle sprain (medial, lateral, syndesmotic) affects early and late management of ankle sprains. Also discussed are the acute diagnosis and treatment of ankle sprains, as well as the consequences of chronic ankle instability, which may include serious conditions such as complex regional pain syndrome and chronic ankle instability. Surgical and nonsurgical treatment, evaluation, prognosis, and prevention are also discussed.

Key words:ankle pain, ankle sprain, chronic ankle instability, complex regional pain syndrome, cryoneuroablation, high ankle sprain, lateral ankle sprain, medial ankle sprain, 

Over the past two decades, the incidence of legal and illegal drug abuse and dependency has increased at alarming levels, resulting in a rise in the number of associated deaths. Multiple resources are available to manage addiction, including the use of buprenorphine with or without naloxone. Consequently, more and more patients are requiring this treatment and are presenting for elective and emergent surgery where treatment of acute postoperative pain in the setting of buprenorphine use becomes challenging due to its unique properties. Buprenorphine has unique properties in which it binds to the opioid (mu) receptor with a higher affinity than other opioids. Buprenorphine is bound for a long period of time (32 hours), but its opioid effects have a ceiling. Since the receptors are occupied, when illegal or prescribed opioids are abused, they cannot activate the occupied receptors, and, in parallel, the effects that lead to addiction, tolerance, and craving are limited. However, in the surgical setting, increased opioid use may be appropriately needed to manage pain, which is hindered and limited by buprenorphine. Using current studies and strategies, we propose an algorithm to effectively manage buprenorphine in the perioperative setting.

Hematologic cancers represent about 10% of new cancer diagnoses annually in the United States and account for a comparable number of US cancer deaths each year. These patients experience an array of acute and chronic pain syndromes that appreciably impair their quality of life. The pathogenesis, management, and complications of multiple myeloma, lymphoma, and leukemia are reviewed to provide a better understanding of the underlying pain processes. Skeletal-related events due to bony involvement, including pain, pathologic fractures, hypercalcemia, and spinal cord compression, along with renal insufficiency, represent a significant portion of complications faced by multiple myeloma patients. Opioids continue to be the foundation of cancer analgesia in accordance with the World Health Organization three-step analgesic ladder. Many of the long-term complications in lymphoma patients are due to treatment with toxic chemotherapy regimens along with radiation. Many of the complications seen in leukemia are nonspecific and common to cancer and its treatment in general. Bone pain is common for a number of reasons in leukemia, typically manifesting as a throbbing deep and dull ache. An array of pain syndromes develop from diagnosis through cancer survival that command a multifaceted management approach.

This review contains 7 tables, 3 figures and 40 references.

Complex regional pain syndrome (CRPS) is the worst pain known to humankind. It has been classified as pain worse than cancer pain, amputation of a digit, or labor pain. The difference is that CRPS is a chronic condition that lasts for many years. As in all medical conditions, the essential piece to diagnosis of CRPS is based on the clinical history and physical examination. The diagnosis of CRPS depends on the following: pain, color and temperature asymmetry, swelling, and nail and hair growth changes. The intensity of the pain is far more than expected from the inciting injury and in some cases from immobilization. The pain spreads to a wider area than the original site. It may spread to the opposite side and even to the whole body, including the viscera. The pain is unrelated to any physical activity but does increase significantly with using the body part. A color differential between the affected and the unaffected side is often very obvious but may not be present continuously. A temperature differential of 1.1ºC between the affected and the unaffected side is considered significant. The color and temperature differential is not as obvious in the torso or the axial skeleton as in CRPS of the abdomen, perineum, or chest wall. The swelling is much more evident in the initial stages of the condition and can vary from a small area of pitting edema to large diffuse swelling to the point of skin becoming thin and glossy and even breaking down. Hair changes may consist of darker, coarser hair or light and sparse hair. Nails may be brittle, discolored, and ridged. There is no gold standard test to diagnose CRPS. Testing may be done to rule out another possible diagnosis.

Almost every physician is bound to come across patients with connective tissue disorders, especially Ehlers-Danlos syndrome (EDS). These patients present with a cluster of conditions, including chronic joint, muscle, and neuropathic pain; easy fractures; gastrointestinal symptoms; orthostatic intolerance; headaches; spinal pain; urinary symptoms; recurrent joint subluxations and dislocations; and aneurysm. The incidence of EDS is 10 in 100,000. These patients have a genetic defect in their collagen. A weak connective tissue makes the joints hypermobile, causes muscle fatigue,  easy bruising, fragile skin, spinal pain, and headaches. The diagnosis is made clinically based on a medical history and clinical examination. It does not depend on genetic testing. The Beighton score has been the most widely accepted for diagnosing EDS. It has proven to be a very consistent screening tool. The most common symptom patients present with is pain. They have increased pain at different stages of their life; as adolescents, they have growing pains. These pains are usually worse during periods of growth spurt. The pain is intense and usually in the lower extremity around the knees, and they have leg cramps, especially at night. Concerned parents are told to ignore it, and no specific treatment is offered to these children. As adults, patients present with a more specific pain to either a region or the spine. Musculoskeletal pain is most commonly around the neck, upper back, hips, legs, and forearms. In most cases, the pain is around the weight-bearing muscles, such as the legs and spine. Patients with EDS present with both nociceptive (structural) and neuropathic pain; in some cases, the neuropathic pain component may be more prominent than the nociceptive component and vice versa. One of the major issues in EDS is a loss of proprioception, also known as joint position sense. Proprioception is the ability of a joint to determine its position, detect movement, and sense resistance to force. EDS is associated with other coexisting conditions, such as postural orthostatic tachycardia syndrome (POTS), mast cell activation syndrome (MCAS), Chiari malformation, and tethered cord syndrome. Significant fatigue is a common feature in EDS. The reason for fatigue may be an abnormality of the muscle structure, POTS, MCAS, and excessive dependence on muscles to maintain posture in light of ligamentous laxity. 

Osteoarthritis (OA) of the knee is the most common form of degenerative joint disease, affecting 13.9% of adults age 25 years and older and 33.6% of those 65 years and older. Some predisposing risk factors include age, obesity, infection, repetitive use, occupation, and previous trauma. Mild OA usually presents as pain in the knee with difficulty bending or straightening the knee, swelling, weakness, instability, locking, and clicking or snapping of the knee. A diagnosis can be made clinically and confirmed by x-ray showing narrowing of the joint space in mild cases; however, bone changes, subchondral cysts, and formation of bony spurs can be seen in more advanced stages. Treatment of mild to moderate OA involves a multimodal approach that includes lifestyle modifications, physical therapy, and electrical stimulation with or without pharmacologic management. Interventional therapies such as intra-articular corticosteroid injections and viscosupplementation are usually reserved for severe symptoms. Pharmacologic modalities such as acetaminophen, nonsteroidal antiinflammatory drugs, weak opioids, and duloxetine can be used as a single agent or combination therapy. Novel approaches to the treatment of OA include nerve growth factor inhibitors, botulinum toxin type B injections, and intra-articular platelet-rich plasma but are not well supported due to a lack of sufficient evidence.

Key words: arthritis, degenerative joint disease of the knee, diagnosis, etiology, guidelines, noninflammatory arthritis, osteoarthritis of the knee, treatment

Although less common than cervical or lumbar pain, thoracic pain is not an uncommon presentation in pain clinics. Thoracic pain may be nociceptive, neuropathic, mixed, or idiopathic. It can originate from bony structures, facet joints, intervertebral disks, or muscles and fascia. In addition, pain from the diaphragm, cervical spine, chest, and abdominal viscera may be referred to the thoracic region. Some of the conditions that should be kept in the differential include ankylosing spondylitis, Tietze syndrome, costochondritis, diffuse idiopathic skeletal hyperostosis, Scheuermann kyphosis, thoracolumbar junction syndrome, osteoarthritis, rheumatoid arthritis, vertebral compression fractures, facet arthropathy, and primary cancer and metastatic disease of the spine. This review focuses on thoracic pain of spinal and musculoskeletal origin. However, it is imperative not to overlook visceral pain because it may be associated with a life-threatening condition.

Key words: ankylosing spondylitis, costochondritis, diffuse idiopathic skeletal hyperostosis, Maigne syndrome, sacroiliitis, Scheuermann kyphosis, slipping rib syndrome, thoracolumbar junction syndrome, Tietze syndrome 

Cervical radiculopathy refers to injury or compression to the cervical nerve root(s) that results in pain and/or numbness distribution of the nerve. Clinically, patients present with neck and/or arm pain and numbness in the concordant dermatomes or myotomes. In the absence of “red flag” symptoms, treatment consists of conservative, medical, and interventional therapies. This review covers the epidemiology and etiology, pathophysiology and pathogenesis, diagnosis, treatment, and prognosis of cervical radiculopathy. The figure shows the cervical vertebrae and associated neural elements. Tables list the “red flag” symptoms suggesting prompt evaluation, clinical correlates among patients with cervical radiculopathy, and the differential diagnosis of cervical radiculopathy.

This review contains 1 figure, 3 tables, and 36 references

Key words: C7 nerve root, cervical nerve compression, cervical nerve injury, cervical nerve root, cervical radiculopathy, cervical spondylosis, neck pain 

Lumbar spinal stenosis is a degenerative condition that develops and progresses slowly over time. Lumbar spinal stenosis may be local, segmental, or generalized. The majority of lumbar spinal stenosis cases are acquired, degenerative stenosis, resulting from aging of the spine or following surgery or infection. Management of lumbar spinal stenosis is challenging and requires the integration of the history, clinical findings, and results of diagnostic imaging. Magnetic resonance imaging is the most commonly used imaging modality in diagnosing lumbar spinal stenosis. Typical features of spinal stenosis with neurogenic claudication include an increase in symptoms with extension and a decrease with flexion. With lateral recess stenosis or foraminal stenosis, isolated radiculopathy can occur. Spinal stenosis is classified as mild, moderate, and severe, ranging from one third to two thirds of the canal, and grade I to grade III classification of neurogenic intermittent claudication. Management of lumbar spinal stenosis is largely conservative except in cases of severe spinal stenosis and neurogenic claudication with or without paresis and other symptoms. Nonsurgical management of lumbar spinal stenosis includes drugs, physiotherapy, epidural injections, multidisciplinary rehabilitation, and spinal cord stimulation. Minimally invasive techniques include minimally invasive lumbar spinal decompression, interspinous spacers, and endoscopic surgical decompression. The final treatments include open surgery with decompression with or without fusion and spinal cord stimulation.

Key words: acquired stenosis, central spinal stenosis, congenital stenosis, decompression with fusion, decompression without fusion, endoscopic spinal decompression, epidural injections, foraminal spinal stenosis, interspinous spacers, lateral spinal stenosis, lumbar spinal stenosis, minimally invasive lumbar decompression, neurogenic claudication, percutaneous adhesiolysis, shopping cart syndrome, spondylolisthesis, vascular claudication

Pain due to thoracotomy is among the most severe pain experienced after surgery. It has both neuropathic and myofascial components. About 50% of patients suffer from chronic postthoracotomy pain 1 year after surgery. Thoracic paravertebral block or thoracic epidural analgesia is recommended as the first-choice therapy for thoracotomy analgesia.  Preoperatively initiated thoracic epidural analgesia is associated with better pain control and decreased incidence (and intensity) of chronic postthoracotomy pain compared with postoperative (epidural or intravenous) analgesia. Compared with inhalation anesthesia, total intravenous anesthesia significantly reduced the incidence of chronic postthoracotomy pain syndrome, which is notoriously challenging to treat. Gabapentinoids and antidepressants may be beneficial for the neuropathic component of chronic postthoracotomy pain syndrome. A pregabalin and methylcobalamin combination has been shown to be safe and effective in the treatment of chronic postthoracotomy pain, with minimal side effects. Interventional therapies such as intercostal nerve block or ablation, spinal cord stimulation, and targeted subcutaneous neuromodulation may be indicated in more refractory and debilitating cases.

This review contains 1 table, and 57 references.

Key words: chronic postthoracotomy pain, cryoneurolysis, intercostal nerve block, open thoracotomy surgery, paravertebral block, postthoracotomy pain, postthoracotomy pain syndrome, spinal cord stimulation, thoracic epidural analgesia, thoracotomy, total intravenous analgesia, video-assisted thoracoscopic surgery