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More About Interventional Pain Management - Page 3
How well does diagnostic imaging or physical examination delineate a pain source?
Patients often arrive to the pain management clinic under the impression that the cause of their pain is known. Many are able to recite x-ray findings, physical findings and their diagnosis. It seems logical that if there is an x-ray abnormality and pain, that the pain must be related to the x-ray abnormality: This is where the opportunity for intervention is often lost: A recent study has shown that only approximately 1 in 7 patients without distinctive diagnostic imaging abnormalities and neurologic deficit (not pain) was diagnosed appropriately as to the cause of the pain and in a second study, 40-67% of patients referred to pain management centers had inaccurate diagnoses.
So how does one make the diagnosis?
A diagnostic injection entails the administration of small amounts of local anesthesia precisely at the site of the suspected pain generator; if the pain resolves then the source of the pain has been confirmed allowing for specific treatments directed at the source; if the pain does not resolve then the source of the pain remains unknown requiring more diagnostic injections to isolate the source. The concept of diagnostic injections is straight forward however the fact that we are human complicates everything: It is estimated that approximately 30% or more of patients will report pain relief following a diagnostic injection for reasons other than the effect of the local anesthesia (placebo response); to improve the reliability of diagnostic injections, evidence shows that a second diagnostic injection will greatly reduce the placebo response however two diagnostic injections prior to the actual interventional procedure is not well received by patients or insurance companies.
So what does this mean to a patient?
In a discipline as inexact as pain medicine, clear-cut answers are hard to find. When patients find themselves in the situation where they are receiving repetitive treatments of questionable benefit, it is of paramount importance that all avenues have been explored. Understanding that such a large percentage of pain may come from the facets, discs and/or sacro-iliac joints and that diagnostic imaging and physical findings are not diagnostic in a large percentage of circumstances simply means that the facets, discs and/or sacro-iliac joints must be carefully evaluated. These areas may yield specific, interventional opportunity for the relief of pain that is far superior to nonspecific treatment. The risks of trying to locate the source of the pain verses the risks of living with the pain are small. Patients owe it to themselves to take charge and make sure that opportunity for pain relief is not overlooked. Back to page 2.