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Principles of Pain Management for Anaesthetists
This page intentionally left blank
Principles of Pain Management for
Anaesthetists

Stephen Coniam MA MB BChir FRCA

Consultant in Anaesthesia and Pain Medicine, Frenchay Hospital, Bristol, UK

Janine Mendham MBChB MRCP FRCA

Consultant in Anaesthesia and Pain Medicine, Frenchay Hospital, Bristol, UK

Hodder Arnold
A MEMBER OF THE HODDER HEADLINE GROUP
First published in Great Britain in 2006 by
Hodder Arnold, an imprint of Hodder Education and a member of the
Hodder Headline Group,
338 Euston Road, London NW1 3BH

http://www.hoddereducation.com

Distributed in the United States of America by

Oxford University Press Inc.,
198 Madison Avenue, New York, NY10016
Oxford is a registered trademark of Oxford University Press

© 2006 Stephen Coniam and Janine Mendham

All rights reserved. Apart from any use permitted under UK copyright law,
this publication may only be reproduced, stored or transmitted, in any form,
or by any means with prior permission in writing of the publishers or in the
case of reprographic production in accordance with the terms of licences
issued by the Copyright Licensing Agency. In the United Kingdom such
licences are issued by the Copyright licensing Agency: 90 Tottenham
Court Road, London W1T 4LP.

Whilst the advice and information in this book are believed to be true and
accurate at the date of going to press, neither the author[s] nor the publisher
can accept any legal responsibility or liability for any errors or omissions that
may be made. In particular, (but without limiting the generality of the
preceding disclaimer) every effort has been made to check drug dosages;
however it is still possible that errors have been missed. Furthermore, dosage
schedules are constantly being revised and new side-effects recognized. For
these reasons the reader is strongly urged to consult the drug companies’
printed instructions before administering any of the drugs recommended in
this book.

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging-in-Publication Data

A catalog record for this book is available from the Library of Congress

ISBN-10 0 340 81648 1

ISBN-13 978 0 340 81648 6

1 2 3 4 5 6 7 8 9 10

Commissioning Editor: Serena Bureau/Clare Christian

Project Editor: Clare Patterson
Production Controller: Jane Lawrence
Cover Design: Nichola Smith

Typeset in 9/12 Minion by Charon Tec Pvt. Ltd, Chennai, India

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Printed and bound in Great Britain by CPI Bath.

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Contents

List of Figures vii

List of Tables ix
Preface xi
Acknowledgements xiii
Introduction: Pain, Anaesthetists and Pain Teams xv
Abbreviations Used in this Book xvii

Section One 1
1 Pain as a Physiological Process 3
2 Assessment of the Patient with Pain 24
3 Pharmacology of Pain Relief 37

Section Two 63
4 Management of Acute Pain: Principles and Practice 65
5 Acute Pain: Special Situations 96
6 Acute Back Pain and Sciatica 132

Section Three 137

7 Treating Chronic Pain: Use of Drugs 139
8 Treating Chronic Pain: Nerve Blocks 147
9 Treating Chronic Pain: Injection of Joints and Soft Tissues 162
10 Treating Chronic Pain: Stimulation and Physical Techniques 166
11 Treating Chronic Pain: Implantation of Devices to Modify Pain 170
12 Psychological Aspects of Pain Management 183
13 Chronic Pain: The Common Problems 193
14 Chronic Pain: Back and Neck Pain 225

Section Four 233

15 Pain in Malignant Disease 235

Index 253
This page intentionally left blank
List of Figures

1.1 Kneeling figure of Descartes (1664 from Traite de l’homme) 4

1.2 Schematic diagram of the gate control theory of pain 4
1.3 Schematic diagram of a nociceptor 6
1.4 Tissue injury: inflammation and nociceptor sensitization 6
1.5 The arachidonate pathway 6
1.6 Release of various endogenous inflammatory factors following tissue injury 7
1.7 Neurotrophins and their preferred receptors 9
1.8 Primary afferent axons 12
1.9 Primary afferent axons: relation between firing thresholds and stimulation intensity 12
1.10 Pain pathways 13
1.11 Rexed’s laminae 14
1.12 Serotonergic and noradrenergic pathways of pain 16
1.13 Transmission and NMDA receptors 21
2.1 Example of a pain map 26
2.2 Types of verbal rating scales 28
2.3 (a) Visual analogue scale; (b) Pain relief scale 29
2.4 Measuring pain relief 30
3.1 Metabolism of codeine 43
4.1 WHO analgesic ladder 72
4.2 Algorithm for use of epidural infusion 80
4.3 Algorithm for use of patient controlled analgesia (PCA) 90
5.1 The faces scale 100
5.2 Vertical scale 100
5.3 Cross-section of the penis 105
5.4 Pain management for patients on long-term opioid treatment 110
5.5 Management of opioid drug users/methadone programme patients 111
5.6 Scalp innervation: (a) facial view and (b) coronal view 117
5.7 Algorithm for the use of intravenous morphine in the recovery ward 130
5.8 Summary flowchart of the basic steps in management of pain 131
8.1 Anatomy of the sacrum showing the common position of the sacral hiatus 149
8.2 Caudal block. The position of the needle within the caudal canal 149
8.3 Transverse view showing anatomical positioning of needle for lumbar sympathetic block 151
8.4 Diagrammatic representation of the radiographic appearance of the injected contrast medium
during a sympathetic block 151
8.5 Stellate ganglion block. Schematic diagram showing anatomical relations in transverse section of the neck 152
8.6 Transverse section showing anatomical relations of coeliac plexus block 153
8.7 Coeliac plexus block – direction of needle insertion 154
8.8 Line drawing showing areas of contrast spread during coeliac plexus block 154
8.9 The base of the brain 155
8.10 The trigeminal nerve in the middle cranial fossa 156
8.11 Lumbar paravertebral injection 158
viii List of Figures

8.12 (a,b) Dorsal nerve root ganglion block 159

8.13 Schematic diagram showing the anatomical location of the spinothalamic tract 161
9.1 Injection of the lumbar facet joints 163
9.2 Nerve supply to facet joints at L4/5 and L5/S1 163
9.3 Targets for facet joint denervation 164
11.1 Areas stimulated in spinal cord stimulation and the electrode settings that may produce such stimulation 172
11.2 Internal components of an intrathecal pump 180
13.1 Tender points in fibromyalgia 208
13.2 Algorithm for management of rheumatoid arthritis 221
List of Tables

1.1 Types of opioid receptor 10

1.2 Types of primary afferent axon 12
1.3 Stimuli associated with Rexed’s laminae 14
1.4 Types of neuropathic pain 18
1.5 Differences between inflammatory and neuropathic pain 23
2.1 Pain terminology 25
2.2 Points to consider when taking the history of a patient in pain 27
2.3 Assessment of improvement in pain 28
3.1 The Oxford league table of analgesic efficacy 37
3.2 Ratio of COX-2 to COX-1 selectivity 40
3.3 Non-steroidal anti-inflammatory drugs: associated risk factors 41
3.4 Opioid equivalent doses 48
3.5 Intranasal diamorphine for children: calculation of the volume of saline added to the opioid 48
3.6 Number needed to treat (NNT) for antidepressants in various conditions 53
3.7 Number needed to treat (NNT) for carbamazepine in various conditions 54
3.8 Number needed to treat (NNT) for other drugs in various conditions 54
3.9 Side effects of lidocaine at various plasma concentrations 56
3.10 Dose chart for botulinum toxin 62
4.1 Some myths and truths about analgesia 66
4.2 Metabolic and endocrine responses to surgery 67
4.3 Levels of evidence 69
4.4 Relief of pain: current levels of achievement 69
4.5 Epidural level and site of surgery 74
4.6 Epidural analgesia: management of complications 78
4.7 Epidural analgesia: risk of complications 78
4.8 Summary of specific nerve blocks 83
4.9 Management of constipation 87
4.10 Management of problems with patient controlled analgesia 91
5.1 FLACC (Face, Legs, Activity, Crying and Consolability) pain assessment tool 100
5.2 Comparison of morphine metabolism at birth and in adulthood 101
5.3 Fentanyl dosing chart 103
5.4 Diamorphine dilution chart 103
5.5 Various caudal epidural blocks for children 104
5.6 Methadone conversion table 112
5.7 Withdrawal symptoms 1: vital signs and corresponding scores 114
5.8 Withdrawal symptoms 2 115
5.9 Differential diagnosis of pain of neurosurgical procedures 116
5.10 Scalp blocks for pain of neurosurgical procedures 117
5.11 Management of pain in the emergency room in children and adults 126
8.1 Branches of the trigeminal nerve 156
11.1 Hormonal changes with intrathecal infusions 181
x List of Tables

13.1 Complications of microvascular decompression 198

13.2 Pain related to spinal cord injuries 202
13.3 Nerve entrapment syndromes 216
13.4 Postoperative neuropathies 217
13.5 Disease modifying antirheumatic drugs used in the treatment of rheumatoid arthritis 222
15.1 Treatments for neuropathic pain 243
15.2 Other symptoms of malignant disease 250
Preface

This book was written in response to a request by trainee based. Sufficient basic information on drug-based therapy
anaesthetists about what they could read about pain that and some of the commonly performed injection techniques
would give them the core knowledge required for their train- with which an anaesthetist may wish to become familiar is
ing. All anaesthetists need a working knowledge of pain relief provided, but more complex techniques and the details of
in postoperative care, with information about developments physical and psychologically based pain management will
in analgesic drugs and the means by which they are adminis- require further training to gain practical expertise.
tered in particular situations. In addition, many anaesthetists We hope that anaesthetists of all grades will find this a
become involved in the management of chronic pain and pal- useful source of information on the management of pain
liative care; if not always personally involved with the continu- and that other professional groups will find it a helpful guide
ing management of these problems, then at least through their to the field of pain and its treatment.
anaesthetic management of patients who are receiving treat-
ment for chronic pain. It is important that these anaesthetists, Stephen Coniam
as well as other physicians and paramedical professionals who Janine Mendham
deal with such patients, have a basic understanding of the med- Bristol
ical, physical and psychological approaches to management of March 2005
these patients.
This book aims to provide an overall view of pain, both
acute and chronic, and the ideas upon which treatment is
This page intentionally left blank
Acknowledgements

Line illustrations contributed by Rose Marriott RGN, Pain Clinic Sister to the Frenchay Hospital Pain Clinic.
We would also like to thank Dr Nicholas Ambler for his help with ‘Psychological Aspects of Pain
Management’ and Nicola Mackey RGN, Acute Pain Sister, for her help with the ‘Management of Acute Pain’.
This page intentionally left blank
Introduction: Pain, Anaesthetists and
Pain Teams

Pain is an almost universal human experience. There is the commonest manifestations of disease and trauma, the relief
surely almost no being in the history of humankind who of pain became a major aim of medical and allied practitioners,
could claim to have never experienced some pain, and yet its with drugs such as opium, cannabis and alcohol being used for
nature and its meaning often defy description and under- many centuries. However, in the late nineteenth century, med-
standing. Pain is a personal experience and we have no icine was developing as a science and theory of disease related
absolute means of comparing one person’s pain experience to specific pathology became important. Pain as a symptom of
with that of another. To be in pain is generally understood to disease appeared to be a less important target for medicine and
be an unpleasant state, and yet this is not always agreed. Pain the palliation of pain became subsidiary to medical manage-
may be one aspect of suffering, but may be accompanied by ment of the disease. At the same time, anaesthesia became a
other factors: emotions such as distress, despair and anger, as developing area of medicine, and the prime aim of anaesthesia
well as dysfunction and disability, which make up the fuller was to relieve the pain of surgery.
picture of human suffering. Anaesthetists increasingly had a role to play in pain relief as
Acute pain is so often temporally connected with injury or this expanded into the postoperative and post-trauma peri-
the onset of disease that most people regard pain as part of ods. In the mid twentieth century, pain relief was still mainly
that injury or disease process. They may not understand the concerned with acute pain, and the treatment of cancer was
physiological mechanisms behind that sensation of pain, but mainly disease rather than symptom orientated. In the latter
they feel that they understand the reason for the pain. there was a movement for the symptomatic palliation of pain
Cutting, crushing, burning or puncturing of the body’s in cancer patients, and the hospice movement and the devel-
structure produces pain. We like to think that all biological opment of palliative care as a specialty were able to develop
processes have evolved for a specific function and we can the long-term management of pain in disease. Following the
rationalize the production of this sensation which we call second world war a few pioneering surgical practitioners real-
pain as a highly developed protective mechanism. Injury pro- ized that there was an enormous number of injured people
duces pain so that we try to avoid injury or repeating injuri- who continued to suffer from pain despite the fact that their
ous activity. Pain prevents mobility and so could be seen as wounds had healed, and tried to develop techniques of deal-
an evolved behaviour to allow injured limbs to be rested and ing with this chronic pain.
heal. It has always been more difficult to explain why some- Attempts to deal with cancer pain or post-trauma pain
times pain persists long after the injury has healed, or even often relied on nerve blocking techniques, following the
arises when there is no clear injury. belief that if a body structure was painful, then it was neces-
Human beings have always been concerned with trying to sary to destroy its nerve supply to relieve the pain. Many of
relieve pain, or in some situations inflict pain on others. In one these attempts to treat pain were therefore delegated to
form or another it has been one of the forces which have anaesthetists who were seen to be good at performing nerve
shaped our development. Primitive societies may have associ- blocks. Some anaesthetists managed to reserve a little time
ated pain with evil forces and tried to harness magical powers between their duties in the operating theatre to see patients
to control pain. Gradually societies have discovered physical with chronic pain problems and if possible to offer some
interventions or medicines which have some effect on the form of intervention. The need for this service was gradually
sensation of pain. The use of stimulation techniques such as accepted by the health service, and eventually separate pro-
acupuncture, or numerous animal, vegetable and mineral vision was made for pain relief services through outpatient
derivatives as medicines have at times achieved moderate clinics, inpatient treatment and consultation services. The
success in the search for effective pain control. As pain is one of increasing understanding of the physiology, pathology and
xvi Introduction

psychology of pain resulted in an expansion of chronic pain pain control and recommended improvements. These included
management from a nerve block service to a more multidis- the identification of individuals or teams with a special respon-
ciplinary service exploring the broader use of medication, sibility for monitoring postoperative pain control, applying
psychological techniques and physical rehabilitation in the effective means of pain control, and educating nursing and
long-term management of pain. This has developed a wider surgical colleagues directly involved with the postoperative
communication between different specialties in an attempt care of patients. At about the same time reports appeared
to move from an anaesthetist-orientated service to multidi- from America and later from the UK and Australia, describ-
mensional management of the chronic pain sufferer. It is ing the use of an ‘acute pain team’ in hospitals who fulfilled
common for the practitioner trained in anaesthesia to act as these roles. The concept has been developed to include most
a coordinator, bringing together the different aspects of acute hospitals in the UK with improvements in the pain
management of chronic pain, as well as providing some of management of postoperative patients. The pain team may
the medical interventions that may be appropriate. consist of one anaesthetist or nurse – alone, together or in
The management of acute pain has perhaps surprisingly combination with other healthcare staff to provide a daily
been slow to evolve over the past decade and a half. Anaes- supervision of pain relief techniques in the hospital, monitor
thetists have usually tried to have some input into the post- efficacy and provide support and advice for other staff on
operative control of pain, but this has often been poorly wards. The closer attention to and monitoring of pain relief
organized and unable to provide any continuity of care or has improved the quality of patient care even when using
feedback of response. A report commissioned jointly by the pain relief techniques that have long been available but have
Royal College of Anaesthetists and the Royal College of not been used for maximum benefit.
Surgeons in 1989 considered the poor state of postoperative
Abbreviations Used in this Book

9 THC delta-9-tetrahydrocannabinol NGF nerve growth factor

5-HT 5-hydroxytryptamine NK neurokinin
ACE angiotensin-converting enzyme NMDA N-methyl-D-aspartate
AMP adenosine monophosphate NNH number needed to harm
AMPA -amino-3-hydroxy-5-methyl-4-isoxazolepro- NNT number needed to treat
pionic acid NOS nitric oxide synthetase
ASIC acid-sensing ion channel NRS numerical rating scale
ATP adenosine triphosphate NSAID non-steroidal anti-inflammatory drug
BDNF brain-derived neurotrophic factor PaCO2 partial pressure (arterial) of carbon dioxide
BPI Brief Pain Inventory PAG periaqueductal grey
CB cannabinoid PaO2 partial pressure (arterial) of oxygen
CCK cholecystokinin PCA patient controlled analgesia
CGRP calcitonin gene-related peptide PCEA patient controlled epidural analgesia
CNS central nervous system PET positron emission tomography
COX-2 cyclo-oxygenase-2 PHN post-herpetic neuralgia
CPSP central post-stroke pain PID pain intensity difference
CRPS complex regional pain syndrome PNS peripheral nerve stimulation
CSF cerebrospinal fluid PO per oral
DBS deep brain stimulation PR per rectum
DMARD disease modifying antirheumatic drug PRN as required
DREZ dorsal root entry zone SaO2 arterial oxygen saturation
GABA -aminobutyric acid SCI spinal cord injury
GDNF glial cell line-derived neurotrophic factor SCS spinal cord stimulation
HIV human immunodeficiency virus SF-36 Short Form 36
IL interleukin SNS sympathetic nervous system
ICU intensive care unit SpO2 oxygen saturation as measured by pulse oximetry
LANR low-affinity neurotrophin receptor SSRI serotonin selective reuptake inhibitor
LMWH low molecular weight heparin TENS transcutaneous electrical nerve stimulation
M-3-G morphine-3-glucuronide TNF tumour necrosis factor
M-6-G morphine-6-glucuronide trkA tyrosine kinase receptor A
MAS multisynaptic ascending system TRPV transient receptor potential (vanilloid)
MCS motor cortex stimulation TTX tetrodotoxin
mGluR glutamate receptor VAS visual analogue scale
MPQ McGill pain questionnaire VPL ventral posterolateral (nucleus)
MRI magnetic resonance imaging VPM ventral posteromedial (nucleus)
MS multiple sclerosis VR vanilloid receptor
MST slow release morphine WDR wide dynamic range (neurones)
MVD microvascular decompression WHO World Health Organization
This page intentionally left blank
Section One
This page intentionally left blank
1 Pain as a Physiological Process

Pain is an unpleasant sensory and emotional experience activated by nociceptors. These generate the withdrawal
associated with actual or potential tissue damage, or reflex so both the sensation of physiological pain and the
described in terms of such damage. flexion withdrawal reflex occur together to protect the body
International Association for the Study of Pain (1979) from a potentially hostile environment. The frequent sensa-
tion of pain and the withdrawal reflex produce learning
behaviour.
INTRODUCTION Acute pain results from tissue injury or inflammation.
Thus, although tissue injury has already occurred, pain aids
The word pain is derived from the Latin poena meaning healing because it tells us to rest. The injured area and sur-
‘punishment’ from the ancient belief that pain results from rounding tissue are hypersensitive to all stimuli so contact
some kind of retribution. What is pain? It is difficult to define, with external stimuli is avoided.
ranging from a mild intermittent irritation to severe contin- Some people are born without a sense of pain (congenital
uous pain. It is accompanied by emotional and autonomic insensitivity to pain). Some people are unable to feel pain
events and produces a wide range of responses among individ- whereas others may feel pain but lack the affective response
uals. The definition of pain applies to acute pain, cancer pain that accompanies pain. When the normal response to pain is
and chronic non-cancer pain. impaired, many injuries, such as broken bones, are incurred
and treatment is often delayed or inadequate. These people
Acute pain may develop pressure sores, damaged joints or missing and
damaged fingers, and they usually die young.
The International Association for the Study of Pain defines
acute pain as ‘pain of recent onset and probable limited dur-
ation’. It usually has an identifiable temporal and causal rela-
tionship to injury or disease.
THE HISTORY OF PAIN

Direct ascent to the brain

Chronic pain
The kneeling figure of Descartes (1596–1650) in Fig. 1.1
Chronic pain is defined as pain lasting for long periods of
depicts a burning sensation irritating the filaments of a nerve
time and persisting beyond the time of healing of an injury.
in the foot, ascending directly to the brain through that nerve,
Often there is no clearly identifiable cause.
with the brain being the centre of sensation. It was thought
Pain can be further classified into nociceptive pain (where
at that time that specific neural pathways mediated pain.
the normal pain signalling pathways are intact) and neuro-
pathic pain (where an abnormality or malfunction at the
peripheral or central nervous system level results in pain per- Neural specificity theory
ception in the absence of tissue damage, i.e. a malfunction of
the normal signalling systems). Neuropathic pain and noci- This theory (Von Frey, 1894) became enshrined in the
ceptive pain have different physiological and clinical charac- medical texts of the early twentieth century. Von Frey pro-
teristics, requiring different management strategies. posed that there were four main senses – warmth, cold,
touch and pain – and that each sensation was transmitted
Why do we need pain? by one nerve ending. It is now known that this theory is
both anatomically and physiologically incorrect and that
Nociceptive pain acts as a warning system that protects our nearly any type of stimulus will produce pain if it is intense
bodies from further injury. Flexor motor neurones are also enough.
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