Intervention/surgery for widespread pain

[interjectionreflection]

Hi everyone, I was hoping to get some input from the group on patients with generalized pain.


I'm getting a lot of referrals for patients with fibromyalgia. Majority of these patients have been tried on standard medications and have tried conservative measures. When I get these referral (the centre I work at does not screen consults and accepts all referrals) it's typically something along the lines of "cervical myelopathy" or "cervical, thoracic and lumbar radiculopathy":

In my opinion, these patients are best served by a multidisciplinary setting. In my area, this is only available at the academic center. Unfortunately most of these patients are either rejected from that clinic or have previously been seen and nothing has been offered/worked for them (oftentimes including multiple interventional treatments).

I find it difficult to reconcile when these patients do have some abnormalities on the MRI such as Central or foraminal stenosis. But when I try to get the history they have pain starting from the ears all the way down. It is hard for them to distinguish from a radicular pattern because there's overlapping diffuse pain. They also Express multiple symptoms like balance concerns etc. On the BPI they shade in the entire body for their location of pain. The dilemma that I have is discussing interventions with these patients --it's hard to know whether it is asymptomatic imaging finding at this point or there's an overlap and they are unable to distinguish the symptoms. I educate them on what I think is going on. In fellowship, these patients would typically be filtered out and sent to the cbt, psychology, aquafit class and pain programming pathways so we would not see as much of them.

I did try interventions on some of these patients and they always ended up having new symptoms afterwards. When I did try a nerve block or an epidural and it did not alleviate any symptoms I tried to explain to the patients that this is likely not the cause of their pain but the majority of them are extremely disappointed and push for surgical opinion. I've had a few patients make the claim that injections don't treat these conditions so they still have "nerve issues". I did send some to our surgical group and they were never a surgical candidate. I don't want to overwhelm the burden of referrals to my surgeons but the same time I find a lot of these patients don't accept my opinion on the matter.

We've all had these patients that are unable to provide a clear history. How do you guys counsel these patients and which one of them do you actually take for interventions? My second question would be if we are liable if we refuse an intervention on these patients based on our clinical judgment or referral to a surgeon and something becomes of their issues?

I appreciate any thoughts on the matter.

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[Taus]

What was done in your fellowship was correct. No interventions indicated. Great way to piss off your surgeons as well. Adjuvant meds. Pain psych/Biofeedback/CBT, CAM referrals. Otherwise NTO.

 

[callmeanesthesia]

I’ll try MBB. I can confidently tell them it didn’t cause their pain to get worse because the numbing only lasts about 6 hours. No ESI unless nerve root compression with concordat symptom complaints. I’ve had a surprising number of patients do well with it for the focal area treated (or at least they tell me it works, and I’m not prescribing them opiates so I don’t see them having a big incentive to keep coming back otherwise).

I still preach the importance of low-impact physical activity, and if applicable smoking cessation and weight loss. I tell them the injections are not a cure, just a temporary treatment to reduce the pain and facilitate activity. Whether they listen is another matter, but I try.

 

[MD87]

I work in an ortho group. I tell patients I don’t feel their symptoms/imaging are surgical. If they insist, I send a message to one of my colleagues who reviews the imaging and my description of symptoms and then they say “no surgery.” That way it only wastes 2 minutes of their time as opposed to being stuck in a room for 30 minutes with the patient. If you don’t work with any surgeons within your practice it may be more difficult if they don’t have access to your imaging.

 

[RoloTomassi]

I say something along the lines of "I can see you're in a lot of pain, but I specialize in spine, and don't think the source of you pain is spinal. I'm happy to give you names of other spine docs if you'd like a second opinion on if it's spinal. [Insert academic or docs you don't like]. It could be something more systemic. It might be worthwhile to see a rheumatologist [they see a lot of fibro in my area, don't mind workup for inflammatory disease], but again, in my opinion it's not spinal. If I did any procedures, it'd waste your time and money and likely not help, and there's the potential for nerve injury, paralysis, infection, and death with the procedures I do."

 

[Agast]

Do not do a pain procedure if you cannot identify a pain generator. Refer those patients on to a wellness center. For that kind of pain they would probably feel better with the focus on supplements/hormonal balance etc. Many of them are also starting to prescribe low dose naltrexone.

 

[Orin]

In my opinion, these patients are best served by a multidisciplinary setting. In my area, this is only available at the academic center. Unfortunately most of these patients are either rejected from that clinic or have previously been seen and nothing has been offered/worked for them (oftentimes including multiple interventional treatments).

Are we not naming and shaming? In general, there are one or two people at an academic center that will at least try, but most of them are not interested in these cases.

The conversation is simple but painful. You have multifocal pain. We can't fix it all. We can try medications. We can try interventions but surgery will cause more harm than help. Despite that all, we won't be able to fix things. You to learn to live life despite the pain, so you have to do the psych and PT visits. You can do that with anyone, but I focus on injections for X, Y, Z. As I can't help, think about these people in the state, or these programs in the region.

 

[JBM16BYU]

Recommendations for fibromyalgia, central sensitization, widespread body pain, and chronic pain syndromes in the absence of rheumatologic, inflammatory, cancer, or immune-mediated disease really comes down to maximizing healthy living and potentially trying adjuvant medications. Physical therapy, exercise programs, aquatic therapies. Cognitive-behavioral therapy. Potentially trying pregabalin, duloxetine, or low-dose naltrexone (seen benefits with some individuals but not all). Smoking cessation. Sleep hygiene. Anxiety and depression management. Opioid cessation. Mayo Clinic in Rochester and Florida (not sure about Arizona) have outpatient Pain Rehabilitation programs which are a few weeks of intensive physical therapy, occupational therapy, CBT, biofeedback, medication (including opioid and benzo) tapering and cessation, and pain psychology, along with lectures and coursework. These appear to have worked well for individuals that buy into the program and keep living that way afterwards. I personally would not inject them as the pain is more of a centralized phenomenon making them have whole-body pain rather than a focal point of injury.

 

[Asclepius186]

Unless it’s a slam dunk obvious localized pathology don’t inject. You’ll regret it when they come back complaining of how their pain is worse now and describe all sorts of nonsensical side effects that they claim were due to the injection.

 

[GlowInTheDark]

They get requested to do two months of low-impact aerobic exercise multiple days a week for 30-60 minutes and then follow up with me. Most are already on Cymbalta or Gabapentin or have “allegedies”/failed/didn’t help. You’re rarely their first stop.

No point in doing any procedure as they will never hit the stupid benchmark insurances have laid out for them to get a second anyway.

 

[BobBarker]

The morbidly obese patients you could start on a GLP1 (mounjaro, Saxenda, Ozempic) , discuss diet/exercise, bring them in for monthly weight checks/exercise updates. That would be the most helpful.

 

[lobelsteve]

The morbidly obese patients you could start on a GLP1 (mounjaro, Saxenda, Ozempic) , discuss diet/exercise, bring them in for monthly weight checks/exercise updates. That would be the most helpful.

Sounds good. Who is equipped for this? This is an FP dream weight loss cash clinic setup. Or their PA/NP.

 

[Ducttape]

i think this is a role for Series of 3

DRG

Vertiflex

Basovertebral RFA

Cluneal block

peripheral stim

PRP

but darned, she will be pissed when she is told that there isnt an injection to save her.

 

[BobBarker]

I do it. Just wrote a Saxenda rx 1 minute ago.

 

[lobelsteve]

i think this is a role for Series of 3

DRG

Vertiflex

Basovertebral RFA

Cluneal block

peripheral stim

PRP

but darned, she will be pissed when she is told that there isnt an injection to save her.

Group across town does all of those and then says, send to Ducttape.

 

[Analgesia108]

Aquatherapy has worked well for such patients - they definitely need concurrent psychological counseling

 

[drrosenrosen]

Every once in a while you'll have a reasonable patient who has a fibromyalgia diagnosis, but is able to distinguish a discrete pain with correlating imaging. Those are amenable to procedures. I have several "fibro" patients who do well with lumbar RF for example. But these patients you're describing, with truly generalized pain, can't give a good history, etc, are not going to do well with interventions. I wonder how well they do with multidisciplinary programs, too, to be honest. There's been discussion back here before about CBT working best with patients who have a certain level of education. But in general, even though it's a difficult conversation to have, the best thing you can do is not doing anything interventional, and steer them away from surgery

 

[interjectionreflection]

Unless it’s a slam dunk obvious localized pathology don’t inject. You’ll regret it when they come back complaining of how their pain is worse now and describe all sorts of nonsensical side effects that they claim were due to the injection.

I agree and this has been my approach as well, I do not inject if I cannot see any correlatable imaging findings to their presentation. The ones I struggle with the most are the ones with severe cervical central canal stenosis (no cord signal change) and they present with so many symptoms in addition to their diffuse body pain (i.e hurts from neck to arms and down back to legs etc) with balance disturbances hand numbness but usually have no long tract findings on examination. My clinical intuition tells me that this is not related to the stenosis however I always wonder how liable we would be if I did not sent to a surgeon.

 

[willabeast]

My gut feeling is you are being dumped on. Spent 20 + years as a pain doc in an HMO and almost never was sent patients with generalized pain from the ears down. But if you get a patient with generalized pain who cannot sleep and the reason for not sleeping is a specific non generalized pain (for example CRPS) then you can certainly help with the CRPS and then the lack of sleep is fixed then the generalized pain dissipates.

 

[Ferrismonk]

Hand this out. No interventions unless you think it'll actually help.

 

[DubVille]

Hand this out. No interventions unless you think it'll actually help.

Ahh the irony. From college of rheumatology.

Every rheum in town refuses to do anything but diagnose fibro and send to "pain management."

 

[DrMDAware]

Ahh the irony. From college of rheumatology.

Every rheum in town refuses to do anything but diagnose fibro and send to "pain management."

Ah yes.

And only after they tell me the SI joints appear normal and therefore a SIJ injection is not indicated.

 

[Ferrismonk]

Ahh the irony. From college of rheumatology.

Every rheum in town refuses to do anything but diagnose fibro and send to "pain management."

I remind patients that Rheumatologists invented the term Fibromyalgia. They are the Fibro specialists.

Here's a good short review:

Learn About the Long History of Fibromyalgia

Learn about this history of fibromyalgia, which goes back hundreds of years, the important milestones of the disease, and where we are now.

www.verywellhealth.com

 

[KateFan]

Evaluation of clinical relationship of serum niacin and dopamine levels in patients with fibromyalgia syndrome

The aim of this study was to investigate the role of serum niacin and dopamine (DA) levels and their clinical importance in fibromyalgia syndrome (FMS) patients. Between April 2018 and October 2018, a total of 53 female patients (mean age: 38.3±5.5 ...

www.ncbi.nlm.nih.gov

FMS appears to have a nutritional, or lack thereof, basis...

 

[Ducttape]

problems with this study
not blinded.

they used median values for analysis but the ranges were very similar. FMS patients 6.87 to 503, for non FMS patients 5 to 503.

and there is no definitive causal relationship.

do FMS patients have a nutritional deficiency that leads to widespread pain?
or do they have widespread pain and then have changes in diet that lead to niacin deficiency?

finally, if it is a "nutritional" deficiency, does replacement of niacin relieve fibromyalgia pain?

hint - it hasnt with vitamin D, vitamin B-12, ALA, vitamin C, Vitamin E, all of which have been touted as the "cause" of fibromyalgia, and all of which were found to be low in some study of fibromyalgia patients......


and i should note, i could not find descriptions of chronic widespread pain syndromes in patients suffering from pellagra

 

[lobelsteve]

 

[Ligament]

Why are you scheduling fibro patients? Instruct your new patietnt coordinator to block such patients.