Purposes of the Guidelines
The purposes of these Guidelines are to (1) optimize pain control, recognizing that a pain-free state may not be attainable; (2) enhance functional abilities and physical and psychologic well-being; (3) enhance the quality of life of patients; and (4) minimize adverse outcomes.
These Guidelines focus on the knowledge base, skills, and range of interventions that are the essential elements of effective management of chronic pain and pain-related problems. The Guidelines recognize that the management of chronic pain occurs within the broader context of health care, including psychosocial function and quality of life. These Guidelines apply to patients with chronic noncancer neuropathic, somatic (e.g., myofascial), or visceral pain syndromes. The Guidelines do not apply to patients with acute pain from an injury or postoperative recovery, cancer pain, degenerative major joint disease pain, headache syndromes (e.g., migraine and cluster), temporomandibular joint syndrome, or trigeminal or other neuralgias of the head or face. In addition, the Guidelines do not apply to pediatric patients and do not address the administration of intravenous drugs or surgical interventions other than implanted intrathecal drug delivery systems and nerve stimulators.
These Guidelines are intended for use by anesthesiologists and other physicians serving as pain medicine specialists. The Guidelines recognize that all anesthesiologists or other physicians may not have access to the same knowledge base, skills, or range of modalities. However, aspects of the Guidelines may be helpful to anesthesiologists or other physicians who manage patients with chronic pain in a variety of practice settings. They may also serve as a resource for other physicians, nurses, and healthcare providers (e.g., rehabilitation therapists, psychologists, and counselors) engaged in the care of patients with chronic pain. They are not intended to provide treatment algorithms for specific pain syndromes.
Summary of Recommendations
I. Patient Evaluation
* All patients presenting with chronic pain should have a documented history and physical examination and an assessment that ultimately supports a chosen treatment strategy.
▪ A pain history should include a general medical history with emphasis on the chronology and symptomatology of the presenting complaints.
▪ A history of current illness should include information about the onset, quality, intensity, distribution, duration, course, and sensory and affective components of the pain and details about exacerbating and relieving factors.
▪ Additional symptoms (e.g., motor, sensory, and autonomic changes) should be noted.
▪ Information regarding previous diagnostic tests, results of previous therapies, and current therapies should be reviewed by the physician.
▪ In addition to a history of current illness, the history should include (1) a review of available records, (2) medical history, (3) surgical history, (4) social history including substance use or misuse, (5) family history, (6) history of allergies, (7) current medications including use or misuse, and (8) review of systems.
▪ The causes as well as the effects of pain (e.g., physical deconditioning, change in occupational status, and psychosocial dysfunction) and the impacts of previous treatment(s) should be evaluated and documented.
○ Physical examination: The physical examination should include an appropriately directed neurologic and musculoskeletal evaluation, with attention to other systems as indicated.
○ Psychosocial evaluation: The psychosocial evaluation should include information about the presence of psychologic symptoms (e.g., anxiety, depression, or anger), psychiatric disorders, personality traits or states, and coping mechanisms.
▪ An assessment should be made of the impact of chronic pain on a patient's ability to perform activities of daily living.
▪ An evaluation of the influence of pain and treatment on mood, ability to sleep, addictive or aberrant behavior, and interpersonal relationships should be performed.
▪ Evidence of family, vocational, or legal issues and involvement of rehabilitation agencies should be noted.
▪ The expectations of the patient, significant others, employer, attorney, and other agencies may also be considered.
○ Interventional diagnostic procedures: Appropriate diagnostic procedures may be conducted as part of a patient's evaluation, based on a patient's clinical presentation.
▪ The choice of an interventional diagnostic procedure (e.g., selective nerve root blocks, medial branch blocks, facet joint injections, sacroiliac joint injections, and provocative discography) should be based on the patient's specific history and physical examination and anticipated course of treatment.
▪ Interventional diagnostic procedures should be performed with appropriate image guidance.
▪ Diagnostic medial branch blocks or facet joint injections may be considered for patients with suspected facet-mediated pain to screen for subsequent therapeutic procedures.
▪ Diagnostic sacroiliac joint injections or lateral branch blocks may be considered for the evaluation of patients with suspected sacroiliac joint pain.
▪ Diagnostic selective nerve root blocks may be considered to further evaluate the anatomic level of radicular pain.
▪ The use of sympathetic blocks may be considered to support the diagnosis of sympathetically maintained pain.
▪ They should not be used to predict the outcome of surgical, chemical, or radiofrequency sympathectomy.
▪ Peripheral blocks may be considered to assist in the diagnosis of pain in a specific peripheral nerve distribution.
▪ Provocative discography may be considered for the evaluation of selected patients with suspected discogenic pain.
▪ Provocative discography should not be used for the routine evaluation of the patient with chronic nonspecific back pain.
* Findings from the patient history, physical examination, and diagnostic evaluation should be combined to provide the foundation for an individualized treatment plan focused on the optimization of the risk–benefit ratio with an appropriate progression of treatment from a lesser to greater degree of invasiveness.
* Whenever possible, direct and ongoing contact should be made and maintained with the other physicians caring for the patient to ensure optimal care management.
Multimodal or Multidisciplinary Interventions
* Multimodal interventions should be part of a treatment strategy for patients with chronic pain.
* A long-term approach that includes periodic follow-up evaluations should be developed and implemented as part of the overall treatment strategy.
* When available, multidisciplinary programs may be used.
Single Modality Interventions
* Ablative techniques (other treatment modalities should be attempted before consideration of the use of ablative techniques):
○ Chemical denervation (e.g., alcohol, phenol, or high concentration local anesthetics) should not be used in the routine care of patients with chronic noncancer pain.
○ Cryoablation may be used in the care of selected patients (e.g., postthoracotomy pain syndrome, low back pain [medial branch], and peripheral nerve pain).
○ Thermal intradiscal procedures: IDET may be considered for young, active patients with early single-level degenerative disc disease with well-maintained disc height.
○ Radiofrequency ablation:
▪ Conventional (e.g., 80°C) or thermal (e.g., 67°C) radiofrequency ablation of the medial branch nerves to the facet joint should be performed for low back (medial branch) pain when previous diagnostic or therapeutic injections of the joint or medial branch nerve have provided temporary relief.
▪ Conventional radiofrequency ablation may be performed for neck pain.
▪ Water-cooled radiofrequency ablation may be used for chronic sacroiliac joint pain.
▪ Conventional or other thermal radiofrequency ablation of the dorsal root ganglion should not be routinely used for the treatment of lumbar radicular pain.
* Acupuncture: Acupuncture may be considered as an adjuvant to conventional therapy (e.g., drugs, physical therapy, and exercise) in the treatment of nonspecific, noninflammatory low back pain.
○ Joint blocks:
▪ Intraarticular facet joint injections may be used for the symptomatic relief of facet-mediated pain.
▪ Sacroiliac joint injections may be considered for the symptomatic relief of sacroiliac joint pain.
○ Nerve and nerve root blocks:
▪ Celiac plexus blocks using local anesthetics with or without steroids may be used for the treatment of pain secondary to chronic pancreatitis.
▪ Lumbar sympathetic blocks or stellate ganglion blocks may be used as components of the multimodal treatment of CRPS if used in the presence of consistent improvement and increasing duration of pain relief.
▪ Sympathetic nerve blocks should not be used for the long-term treatment of non-CRPS neuropathic pain.
▪ Medial branch blocks may be used for the treatment of facet-mediated spine pain.
▪ Peripheral somatic nerve blocks should not be used for long-term treatment of chronic pain.
* Botulinum toxin:
○ Botulinum toxin should not be used in the routine care of patients with myofascial pain.
○ Botulinum toxin may be used as an adjunct for the treatment of piriformis syndrome.
* Electrical nerve stimulation:
○ Neuromodulation with electrical stimulus:
▪ Subcutaneous peripheral nerve stimulation: Subcutaneous peripheral nerve stimulation may be used in the multimodal treatment of patients with painful peripheral nerve injuries who have not responded to other therapies.
▪ Spinal cord stimulation: Spinal cord stimulation may be used in the multimodal treatment of persistent radicular pain in patients who have not responded to other therapies.
* Spinal cord stimulation may also be considered for other selected patients (e.g., CRPS, peripheral neuropathic pain, peripheral vascular disease, and postherpetic neuralgia).
* Shared decision making regarding spinal cord stimulation should include a specific discussion of potential complications associated with spinal cord stimulator placement.
* A spinal cord stimulation trial should be performed before considering permanent implantation of a stimulation device.
▪ TENS should be used as part of a multimodal approach to pain management for patients with chronic back pain and may be used for other pain conditions (e.g., neck and phantom limb pain).
* Epidural steroids with or without local anesthetics:
○ Epidural steroid injections with or without local anesthetics may be used as part of a multimodal treatment regimen to provide pain relief in selected patients with radicular pain or radiculopathy.
▪ Shared decision making regarding epidural steroid injections should include a specific discussion of potential complications, particularly with regard to the transforaminal approach.
▪ Transforaminal epidural injections should be performed with appropriate image guidance to confirm correct needle position and spread of contrast before injecting a therapeutic substance
▪ Image guidance may be considered for interlaminar epidural injections to confirm correct needle position and spread of contrast before injecting a therapeutic substance
* Intrathecal drug therapies:
○ Neurolytic blocks: Intrathecal neurolytic blocks should not be performed in the routine management of patients with noncancer pain.
○ Intrathecal nonopioid injections:
▪ Intrathecal preservative-free steroid injections may be used for the relief of intractable postherpetic neuralgia nonresponsive to previous therapies.
▪ Ziconotide infusion may be used in the treatment of a select subset of patients with refractory chronic pain.
○ Intrathecal opioid injections: Intrathecal opioid injection or infusion may be used for neuropathic pain patients.
▪ Shared decision-making regarding intrathecal opioid injection or infusion should include a specific discussion of potential complications.
▪ Neuraxial opioid trials should be performed before considering permanent implantation of intrathecal drug delivery systems.
* Minimally invasive spinal procedures: Minimally invasive spinal procedures (e.g., vertebroplasty) may be used for the treatment of pain related to vertebral compression fractures.
* Pharmacologic management:
○ Anticonvulsants: Anticonvulsants (e.g.,α-2-delta calcium-channel antagonists, sodium-channel antagonists, and membrane-stabilizing drugs) should be used as part of a multimodal strategy for patients with neuropathic pain.
▪ Tricyclic antidepressants should be used as part of a multimodal strategy for patients with chronic pain.
▪ Serotonin–norepinephrine reuptake inhibitors should be used as part of a multimodal strategy for a variety of chronic pain patients.
▪ Selective serotonin reuptake inhibitors may be considered specifically for patients with diabetic neuropathy.
○ Other drugs:
▪ As part of a multimodal pain management strategy, extended-release oral opioids should be used for neuropathic or back pain patients, and transdermal, sublingual, and immediate-release oral opioids may be used.
▪ For selected patients, ionotropic NMDA receptor antagonists (e.g., neuropathic pain), NSAIDs (e.g., back pain), and topical agents (e.g., peripheral neuropathic pain) may be used, benzodiazepines and skeletal muscle relaxants may be considered.
○ A strategy for monitoring and managing side effects, adverse effects, and compliance should be considered for all patients undergoing any long-term pharmacologic therapy.
* Physical or restorative therapy:
○ Physical or restorative therapy may be used as part of a multimodal strategy for patients with low back pain.
○ Physical or restorative therapy may be considered for other chronic pain conditions.
* Psychological treatment:
○ Cognitive behavioral therapy, biofeedback, or relaxation training: These interventions may be used as part of a multimodal strategy for patients with low back pain, as well as for other chronic pain conditions.
○ Supportive psychotherapy, group therapy, or counseling: These interventions may be considered as part of a multimodal strategy for chronic pain management.
* Trigger point injections: These injections may be considered for treatment of myofascial pain as part of a multimodal approach to pain management.
For these Guidelines, a literature review was used in combination with opinions obtained from expert consultants and other sources (e.g., ASA members, ASRA members, open forums, and Internet postings). Both the literature review and opinion data were based on evidence linkages or statements regarding potential relationships between clinical interventions and outcomes. The interventions listed below were examined to assess their impact on a variety of outcomes related to chronic noncancer pain.Cited Here...
I. Patient evaluation:
1. Medical records review or patient condition
2. Physical examination
3. Psychological and behavioral evaluation
4. Interventional diagnostic procedures
Diagnostic facet joint block
Diagnostic sacroiliac joint block
Diagnostic nerve block (e.g., peripheral or sympathetic, medial branch, celiac plexus, and hypogastric).
II. Multimodal or multidisciplinary pain management programs (e.g., pain centers vs. single discipline care)
III. Single Modality Interventions
1. Ablative techniques:
Cryoneurolysis or cryoablation
Thermal intradiscal procedures (intervertebral disc annuloplasty [IDET], transdiscal biaculoplasty)
Conventional or thermal radiofrequency ablation (facet joint, sacroiliac joint, dorsal root ganglion)
Facet joint injections
Sacroiliac joint injections
Nerve or nerve root blocks
Celiac plexus blocks
Lumbar sympathetic blocks or lumbar paravertebral sympathectomy
Medial branch blocks
Peripheral nerve blocks
Stellate ganglion blocks or cervical paravertebral sympathectomy
5. Electrical nerve stimulation:
Peripheral nerve stimulation
Spinal cord or dorsal column stimulation
6. Epidural steroids:
Interlaminar steroids versus placebo
Interlaminar steroids with local anesthetics versus without local anesthetics
Transforaminal steroids versus placebo
Transforaminal steroids with local anesthetics versus without local anesthetics
7. Intrathecal drug therapies
Intrathecal neurolytic blocks
Intrathecal nonopioid injection (e.g., ziconotide, clonidine, or local anesthetics)
Intrathecal opioid injection
8. Minimally invasive spinal procedures
Kyphoplasty (percutaneous, glue, and balloon)
Percutaneous disc decompression
9. Pharmacologic interventions
Alpha-2-delta calcium channel antagonists
Sodium channel blockers
Selective serotonin–norepinephrine reuptake inhibitors
Selective serotonin reuptake inhibitors
NMDA receptor antagonists
Sustained or controlled-release opioids
Skeletal muscle relaxants
10. Physical or restorative therapy
11. Psychologic treatment or counseling
Cognitive behavioral therapy, biofeedback, or relaxation training
Supportive psychotherapy or group therapy