Feature Article 01/15/99

Procedure Practice 01/15/99 - Coding Recommendations

Chronic Pain Disorders

Terminology - Common Chronic Pain Disorders - Common Pain Management Modalities

Pain in its many forms is one of the major reasons we seek medical attention. Over 65 million Americans suffer from painful illnesses every year, and over 90% of all illnesses are first noticed because of pain. Chronic pain can lead to depression, interpersonal problems, decreased productivity, and unemployment.

Pain may arise from a discrete cause, such as postoperative pain or pain associated with a malignancy, or it may be a syndrome in which pain is the primary problem, such as neuropathic pains or headaches. The diagnosis of painful syndromes relies on the interpretation of patient history; review of laboratory, imaging and electrodiagnostic studies; occupational and avocational assessments; and physical examination.

Acute pain is an alert that something is wrong within the body. It protects the body from further damage and thus can be beneficial. When pain does not resolve after medical treatment and is prolonged, it no longer serves a protective function. Chronic pain is a complex medical condition that refers to pain that has lasted beyond the expected time for a particular disease, syndrome, or injury. Such pain can be caused by a variety of conditions including crush injury, nerve or spinal cord injury, spinal cord lesions, or lesion and/or injury to the brain. It is frequently severe enough to limit a person's activity and make it difficult to function at work or at home. To further complicate matters, a variety of psychological and behavioral changes occur in patients with long-standing pain.

Chronic pain can occur long after nerve and tissue damage has apparently healed. In this situation pain seems to come from an injury that is not really there. It is a problem caused by pain nerves incorrectly telling the brain that a severe injury is present. The result is severe pain without an injury to cause it. Nonetheless, the pain signals sent to the brain make the pain very real to the person experiencing it. Chronic pain can result in severe mental stress and sometimes major behavioral changes or depression. These problems sometimes result in patients becoming so depressed that they are not able to work or carry on activities of daily living.

Terminology
   

A basic understanding of pain descriptors is helpful in deciphering the diagnostic statements encountered by coders in their medical record reviews. Following are some frequently used terms and their definitions.

• Allodynia: Pain due to a stimulus which does not normally provoke pain

• Analgesia: Absence of pain in response to stimulation that would normally be painful

• Anesthesia: Absence of all sensory modalities

• Dermatome: The sensory segmental supply to the skin and subcutaneous tissue

• Dysesthesia: An unpleasant abnormal sensation, whether spontaneous or evoked

• Hyperesthesia: Increased sensitivity to stimulation

• Hypoesthesia: Diminished sensitivity to stimulation

• Neuralgia: Pain in distribution of one or more nerves

• Neuritis: Inflammation of one or more nerves

• Neurogenic/neuropathic pain: Pain initiated or caused by a primary lesion, dysfunction, or transitory perturbation in the peripheral or central nervous system

• Neuropathy: Dysfunction or pathologic change in one or more nerves; mononeuropathy if in one nerve; mononeuropathy multiplex if in several nerves; polyneuropathy if symmetrical and bilateral

• Pain threshold: The least experience of pain that an individual can recognize

• Pain tolerance level: The greatest level of pain that a subject is prepared to tolerate

• Paresthesia: An abnormal sensation, either spontaneous or evoked

• Peripheral neuropathy: Pain initiated or caused by a primary lesion or dysfunction in the peripheral nervous system

• Radiculopathy: A disturbance of function or pathologic change in one or more nerve roots

• Radiculitis: Inflammation of one or more nerve roots

• Sympathetic nervous system: A network of nerves extending the length of the spine that controls involuntary functions such as opening and narrowing blood vessels.

• Trigger point: A hypersensitive area or site in muscle or connective tissue, usually associated with myofascial pain syndromes

Common Chronic Pain Disorders
  

Reflex sympathetic dystrophy (RSD) is a condition that follows injury to an arm or leg. RSD is also known as causalgia and sympathetic dystrophy. The extremity is painful, diffusely swollen, tender to the touch, and weak. Often trophic skin changes (for example, hyperhidrosis) accompany the pain and swelling, and the extremity may be excessively hot or cold. The syndrome is caused by abnormal nerve impulses after injury arising in the network of nerves known as the sympathetic nerve system. The sympathetic nerve system regulates blood flow and temperature sensation. In addition, special sympathetic nerves carry pain signals. After some injuries, the sympathetic nerve system may be activated inappropriately and cause decreased blood flow with increased pain. This pain is typically burning and severe.
  

Myofascial pain syndrome (MPS) describes a chronic nondegenerative, noninflammatory musculoskeletal pain condition. Distinct areas within muscles or their delicate connective tissue coverings (fascia) become abnormally thickened and tight. When the myofascial tissues tighten and lose their elasticity, neurotransmitter ability to send and receive messages between the brain and body is damaged. These areas of thick, ropelike bands of fascia are called trigger points, and they can cause pain long after a muscle injury should have healed. Trigger points refer pain both locally and distantly. Each trigger point can develop satellite and secondary trigger points. Tender trigger points cause symptoms that vary from mild discomfort to incapacitating pain. Symptoms include muscle stiffness and aching and sharp shooting pains or tingling and numbness in areas distant from the trigger point. The discomfort may cause sleep disturbance, fatigue, and depression. Most commonly trigger points are in the neck, back or buttocks.
  

Fibromyalgia syndrome (FMS) is a chronic central nervous system, neuroendocrine, non-degenerative, non-inflammatory, pain amplification disorder. It is systemic and biochemical in nature. It is responsible for diffuse body-wide pain, tender points that hurt but don't refer pain, and sleep disturbances. Lab tests for FMS are valid only to rule out other conditions. No blood test can accurately identify FMS. Fibromyalgia syndrome was first described by William Balfour, a surgeon at the University of Edinburgh, in 1816. Since then, the medical profession has called it many different names, including chronic rheumatism, myalgia, pressure point syndrome, and fibrositis.

The official definition requires that tender points must be present in all four quadrants of the body accompanied by widespread, continuous pain for at least three months. Tender points occur in pairs on various parts of the body. Because they occur in pairs, the pain is usually distributed equally on both sides of the body.

In traumatic FMS, tender points are often clustered around an injury. These clusters can also occur around a repetitive strain or a degenerative and/or inflammatory problem, such as arthritis.
  

Costochondritis (Tietze's syndrome) is painful inflammation of the cartilage that attaches the ribs to the sternum. It most commonly affects the 3rd or 4th ribs and may mimic cardiac pain. Symptoms include chest tightness, sharp chest wall pain with radiation into the arm, and increased pain with movement. Onset of the syndrome is generally before age 40 and both men and women are equally affected. Usually the cause of the inflammation is unknown, however it can arise from a chest injury, respiratory infection, or unusual strenuous physical activity.

For most people, costochondritis lasts from six months to a year; however, for some people it remains a chronic condition.
  

Chronic low back pain accounts for billions of healthcare dollars each year. Eight out of ten people will have a problem with back pain at some time during their lives. Back pain is more likely to occur during the ages of 30 to 50, the most productive period of most people's lives. While most episodes of low back pain are self-limited, for some people these episodes of back pain become chronic. Many etiologies for chronic back pain exist. Some of the most common include obesity and physical deconditioning, spinal injury, nerve root compression, and intervertebral disk degeneration.
  

Occipital neuralgia is characterized by pain in the cervical and posterior regions of the head which may or may not radiate into the sides of the head and into the facial and frontal regions. The occipital nerves enter the scalp over the back of the skull and transmit sensation from a large portion of the scalp. Patients complain of severe headache over the back, top, and sides of the scalp. The headache may be described as "burning, stabbing, tingling, or electric" in nature. There may also be loss of sensation or numbness over the painful area.
  

Trigeminal neuralgia is a disorder of the trigeminal, or fifth cranial nerve. Another common name for trigeminal neuralgia is tic douloureux . The chief characteristic is sharp electrical pain which lasts for seconds. This pain is triggered by touching a specific area of the skin.
  

Cervicogenic headaches are headaches due to nerve pathology in the back of the neck in the cervical spine area. The upper nerves of the neck and the trigeminal nerve in the face are on the same pathway to the brain. The trigeminal nerve is responsible for the perception of pain in the head. This connection explains why a cervical nerve disorder can exhibit headache as a primary symptom. Many patients who are diagnosed with cervicogenic headache have the traditional symptoms of tension headache. In addition, many patients who have positive tests for cervicogenic headache may also have the symptoms of migraine and cluster headache.

Common Pain Management Modalities
   

Transcutaneous electrical nerve stimulation (TENS) has been used with varying degrees of success in the management of chronic pain. Electrodes are applied to either side of a pain site. The TENS machine then administers an electrical stimulus across the nerves in the area. The electrical stimulation reduces the capacity of nerves to transmit pain signals. Treatment can be repeated as required depending upon how long the relief lasts.
  

Cryotherapy is destruction of nerves with an ice ball produced by intense cold at the end of a probe. The pain relief is temporary and may last up to two weeks.
  

Epidural steroid injection is injection of long lasting steroid medication into the epidural space surrounding the spinal cord and the nerve roots. The steroid reduces nerve inflammation, which in turn reduces pain, numbness, and other symptoms caused by nerve irritation or swelling. The injection consists of a mixture of local anesthetic (like lidocaine or bupivacaine) and a steroid medication (triamcinolone or methylprednisolone). The immediate effect is usually from the local anesthetic injected. This wears off in a few hours. The cortisone starts working in about 3 to 5 days and its effect can last for several days to a few months. A series of three injections at three to four week intervals is a common treatment course.
  

Facet joint injection is an injection of long lasting steroid into the facet joints of the vertebrae. The steroid reduces the inflammation of tissue in the joint space, which in turn reduces pain and other symptoms caused by irritation of the joint and surrounding structures. Like epidural steroid injections, the solution injected is composed of a mixture of local anesthetic and steroid medication. The procedure is performed with the patient either lying on the stomach or sitting (for cervical injections) under x-ray control.
   

Sacroiliac joint injection is an injection of long lasting steroid into the sacroiliac joints located on either side of the low back area. The steroid reduces the inflammation of the joint space tissue, which reduces pain due to inflammation of the joint and surrounding structures. The injection consists of a mixture of local anesthetic and steroid medication. It is done with the patient lying on the stomach under x-ray control.
  

Epidurolysis (RACZ) procedure is done to dissolve scar tissue from entrapped nerves in the epidural space of the spine so that medications can reach inflamed, painful areas. Scarring is most commonly caused from bleeding into the epidural space following back surgery and the subsequent healing process. Sometimes scarring can occur when a disk ruptures and its contents leak out.

The procedure requires a series of three injections. First, under fluoroscopic guidance, a catheter is inserted in the epidural space up to the area of scarring. The first injection of medications is made via this catheter. The second injection is done the following day. On the third day, the catheter is injected and then removed. The injection consists of a mixture of local anesthetic and steroid as well as x-ray contrast dye to visualize the scarred space, and hyaluronidase – and concentrated sterile salt solution to soften scar tissue.
  

Radio frequency lesioning is a procedure using a specialized machine to interrupt nerve conduction and reduce pain on a semi-permanent to permanent basis. A needle is placed under x-ray guidance and a local anesthetic is injected. After confirmation of the needle tip position, a second needle is inserted. The tissues surrounding the needle tip are heated when electric current is passed using the radio frequency machine for a few seconds. This procedure effectively "burns" the nerves and destroys the pain pathways.
  

Dorsal column spinal cord stimulator therapy employs a specialized device to stimulate nerves with tiny electrical impulses via small electrical wires placed on the spinal cord. It is a treatment modality for patients with chronic severe pain due to nerve tissue damage who have not responded to conservative treatments. The procedure is done in two stages. First, temporary wires are placed and an external generator is used by the patient to generate electrical current. If this trial is successful in relieving pain, then the permanent generator is placed under the skin. Wires are placed along the spinal cord under x-ray guidance. For the pain involving lower back and lower extremities, the wires are inserted in the midline at the lower back. The generator is then placed on the side of the abdomen. For the pain involving upper extremities, the wires are inserted in the midline at the upper back. The generator is then placed on the side of the chest.
   

Spinal myeloscopy is a relatively new procedure performed to release scar tissue around spinal nerve roots. A miniature fiberoptic scope is placed into the epidural space of the spine after local anesthesia has been applied to the skin. The space in the lower back is then examined, scar tissue released, and a combination of local anesthetic and steroid is injected directly onto inflamed nerves. Spinal myeloscopy is usually performed after routine epidural steroid injections have failed to relieve pain.
   

Occipital nerve stimulation is a new treatment for patients who suffer from occipital neuralgia. Using tiny electrodes placed just beneath the skin, the occipital nerve is stimulated and pain is replaced with a minor tingling sensation to which the patient becomes accustomed. The electrodes and battery-operated generator, which are smaller than a cardiac pacemaker, are then completely implanted under the skin. The procedure is reversible and initial results have been positive.
   

Nerve blocks are injections of anesthesia sometimes in conjunction with steroid medication to reduce nerve inflammation and block pain. Nerve blocks are administered in various sites depending upon the nature and location of the pain under treatment. Some of the most common nerve blocks are:

• Occipital nerve blocks are injections of anesthesia into the back of the neck in order to treat pain going up the back of the head. By injecting the peripheral nerves in the neck which relate to damaged structures, impulses to the trigeminal nerve are blocked and cervicogenic headache is relieved

• Stellate ganglion blocks are used to relieve upper extremity pain syndromes. The stellate ganglion is a collection of sympathetic nerves in the upper neck on either side of the larynx. It is the nerve center for the hands, arms and shoulders. A local anesthetic is injected into the ganglion. Epinephrine may be added to prolong the beneficial effects of the injection. The injection permits increased blood flow to the area and can often decrease or stop the pain. A series of three to six injections is usually performed over a period of two to three weeks. The number of injections depends upon the severity and duration of the extremity pain.

• Intercostal nerve blocks are used to relieve severe pain caused by rib fractures, or chest pain associated with pleurisy, acute herpes zoster, and post herpetic neuralgia. Intercostal nerve blocks are injections of long-acting local anesthetic and sometimes a steroid around the nerves of the ribcage. The injection interrupts the signals sent along the intercostal nerves, reduces pain and inflammation, and promotes healing and function. It may be necessary to perform intercostal nerve blocks on a weekly basis until significant improvement occurs.

• Lumbar sympathetic blocks are injections of local anesthetic into the sympathetic nerve tissue located on the either side of spine. The injection blocks the sympathetic nerves to reduce pain, swelling, redness and sweating changes in the lower extremity. The injection consists of a local anesthetic (like lidocaine or bupivacaine). Epinephrine or Clonidine may be added to prolong the effects of the injection. It is done either with the patient lying on stomach under fluoroscopic x-ray guidance.
     

Neurolysis is the destruction of a nerve by injection of ethanol, phenol, or other neurolytic agents at sites of chronic intractable pain.

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