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Chronic Pain Syndrome: Differential Diagnoses & Workup

Author: Manish K Singh, MD, Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience
Coauthor(s): Jashvant Patel, MD, Medical Director, Department of Pain Medicine and Comprehensive Rehabilitation, Medical College of Pennsylvania Hahnemann University; Rollin M Gallagher, MD, MPH, Clinical Professor, Departments of Psychiatry and Anesthesiology, Director for Health Policy and Primary Care, Penn Pain Medicine, University of Pennsylvania; Director, Pain Management Service, Philadelphia Veterans Affairs Medical Center
Contributor Information and Disclosures

Updated: Jun 29, 2009

Differential Diagnoses

[Lumbar Degenerative Disc Disease]
Mononeuritis Multiplex
Achilles Tendon Injuries and Tendonitis
Morton Neuroma
Adhesive Capsulitis
Myofascial Pain
Brachial Neuritis
Neoplastic Brachial Plexopathy
Carpal Tunnel Syndrome
Neoplastic Lumbosacral Plexopathy
Cervical Disc Disease
Osteoarthritis
Cervical Myofascial Pain
Osteoporosis and Spinal Cord Injury
Cervical Spondylosis
Piriformis Syndrome
Cervical Sprain and Strain
Plantar Fasciitis
Complex Regional Pain Syndromes
Radiation-Induced Brachial Plexopathy
Fibromyalgia
Radiation-Induced Lumbosacral Plexopathy
Lateral Epicondylitis
Rotator Cuff Disease
Lumbar Facet Arthropathy
Spasticity
Lumbar Spondylolysis and Spondylolisthesis
Thoracic Outlet Syndrome
Mechanical Low Back Pain
Traumatic Brachial Plexopathy
Medial Epicondylitis
Trochanteric Bursitis
Meralgia Paresthetica

Other Problems to Be Considered

Other musculoskeletal and neuropsychological diseases

Hernias (eg, obturator, sciatic, inguinal, femoral, perineal, spigelian, umbilical)
Neoplasia of the spinal cord or sacral nerves
Mononeuropathy and nerve entrapment
Abdominal epilepsy
Abdominal migraines
Pelvic floor pain syndrome
Rectus abdominis pain
Faulty posture and chronic pelvic pain
Bipolar disorders and depression
Chronic visceral pain syndrome
Chronic fatigue syndrome
Substance abuse

Reproductive system

Adenomyosis
Adhesions
Adnexal cysts
Cervical stenosis
Dyspareunia
Endocervical and endometrial polyps
Endometriosis and endosalpingiosis
Uterine leiomyomas
Ovarian retention syndrome
Ovarian remnant syndrome
Pelvic varicosities and pelvic congestion syndrome
Vulvodynia
Pelvic floor relaxation disorders
Accessory and supernumerary ovaries

Urinary system

Chronic and recurrent urinary tract infections
Urolithiasis
Pelvic floor dysfunction
Urethral diverticulum
Chronic urethral syndrome

Gastrointestinal system

Chronic intermittent bowel obstruction
Colitis
Chronic constipation
Diverticular disease
Inflammatory bowel disease
Irritable bowel syndrome
Peritoneal cysts

Workup

Laboratory Studies

  • The decision to perform any laboratory or imaging evaluations is based on the need to confirm the diagnosis and to rule out other potentially life-threatening illnesses. Sometimes certain investigations are needed to provide appropriate and safe medical or surgical treatment. The recommended treatment should be based on clinical findings or changes in examination findings.
  • Extreme care should be undertaken during diagnostic testing for chronic pain syndrome. Carefully review prior testing to eliminate unnecessary repetition.
  • Routine CBC count, urinalysis, and selected tests for suspected disease are important. Urine or blood toxicology is important for drug detoxification, as well as opioid therapy.

Imaging Studies

  • Several imaging studies (eg, radiographic studies, magnetic resonance imaging [MRI], computed tomography [CT] scanning) are important tools for the workup of a patient with chronic pain syndrome. (See images below and Images 1-3, 6, 7.)
Sagittal magnetic resonance imaging (MRI) scan of...

Sagittal magnetic resonance imaging (MRI) scan of the cervical spine in a patient with cervical radiculopathy. This image reveals a C6-C7 herniated nucleus pulposus.

Sagittal magnetic resonance imaging (MRI) scan of...

Sagittal magnetic resonance imaging (MRI) scan of the cervical spine in a patient with cervical radiculopathy. This image reveals a C6-C7 herniated nucleus pulposus.


Axial magnetic resonance imaging (MRI) scan of th...

Axial magnetic resonance imaging (MRI) scan of the cervical spine in a patient with cervical radiculopathy. This image reveals a C6-C7 herniated nucleus pulposus.

Axial magnetic resonance imaging (MRI) scan of th...

Axial magnetic resonance imaging (MRI) scan of the cervical spine in a patient with cervical radiculopathy. This image reveals a C6-C7 herniated nucleus pulposus.


Osteoarthritis of the knee, Kellgren stage III.

Osteoarthritis of the knee, Kellgren stage III.

Osteoarthritis of the knee, Kellgren stage III.

Osteoarthritis of the knee, Kellgren stage III.


Oblique view of the cervical spine demonstrates 2...

Oblique view of the cervical spine demonstrates 2 levels of foraminal stenosis (white arrows) resulting from facet hypertrophy (yellow arrow) and uncovertebral joint hypertrophy.

Oblique view of the cervical spine demonstrates 2...

Oblique view of the cervical spine demonstrates 2 levels of foraminal stenosis (white arrows) resulting from facet hypertrophy (yellow arrow) and uncovertebral joint hypertrophy.


T1-weighted sagittal magnetic resonance imaging (...

T1-weighted sagittal magnetic resonance imaging (MRI) scan of the cervical spine in a patient with rheumatoid arthritis shows basilar invagination with cranial migration of an eroded odontoid peg. There is minimal pannus. The tip of the peg indents the medulla, and there is narrowing of the foramen magnum, due to the presence of the peg. Inflammatory fusion of several cervical vertebral bodies is shown.

T1-weighted sagittal magnetic resonance imaging (...

T1-weighted sagittal magnetic resonance imaging (MRI) scan of the cervical spine in a patient with rheumatoid arthritis shows basilar invagination with cranial migration of an eroded odontoid peg. There is minimal pannus. The tip of the peg indents the medulla, and there is narrowing of the foramen magnum, due to the presence of the peg. Inflammatory fusion of several cervical vertebral bodies is shown.


More on Chronic Pain Syndrome

Overview: Chronic Pain Syndrome
Differential Diagnoses & Workup: Chronic Pain Syndrome
Treatment & Medication: Chronic Pain Syndrome
Follow-up: Chronic Pain Syndrome
Multimedia: Chronic Pain Syndrome
References
Further Reading

References

  1. Tang NK, Salkovskis PM, Hodges A, et al. Chronic pain syndrome associated with health anxiety: a qualitative thematic comparison between pain patients with high and low health anxiety. Br J Clin Psychol. Mar 2009;48:1-20. [Medline].

  2. Rowbotham M, Harden N, Stacey B, et al. Gabapentin for the treatment of postherpetic neuralgia: a randomized controlled trial. JAMA. Dec 2 1998;280(21):1837-42. [Medline].

  3. [Best Evidence] Irving G, Jensen M, Cramer M, et al. Efficacy and tolerability of gastric-retentive gabapentin for the treatment of postherpetic neuralgia: results of a double-blind, randomized, placebo-controlled clinical trial. Clin J Pain. Mar-Apr 2009;25(3):185-92. [Medline].

  4. Nijs J, Van Oosterwijck J, De Hertogh W. Rehabilitation of chronic whiplash: treatment of cervical dysfunctions or chronic pain syndrome?. Clin Rheumatol. Mar 2009;28(3):243-51. [Medline].

  5. Durosaro O, Davis MD, Hooten WM, et al. Intervention for erythromelalgia, a chronic pain syndrome: comprehensive pain rehabilitation center, Mayo Clinic. Arch Dermatol. Dec 2008;144(12):1578-83. [Medline].

  6. [Best Evidence] Ranoux D, Attal N, Morain F, et al. Botulinum toxin type A induces direct analgesic effects in chronic neuropathic pain. Ann Neurol. Sep 2008;64(3):274-83. [Medline].

  7. [Best Evidence] Kroenke K, Bair MJ, Damush TM, et al. Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: a randomized controlled trial. JAMA. May 27 2009;301(20):2099-110. [Medline].

  8. Crook J, Rideout E, Browne G. The prevalence of pain complaints in a general population. Pain. Mar 1984;18(3):299-314. [Medline].

  9. Deyo RA, Walsh NE, Martin DC, et al. A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain. N Engl J Med. Jun 7 1990;322(23):1627-34. [Medline].

  10. Forss N, Kirveskari E, Gockel M. Mirror-like spread of chronic pain. Neurology. Sep 13 2005;65(5):748-50.

  11. Gitlin MC. Chronic non-cancer pain: an overview of assessment and contemporary management. J La State Med Soc. Feb 1999;151(2):93-8. [Medline].

  12. Grabois M. Comprehensive evaluation and management of patients with chronic pain. Cardiovasc Res Cent Bull. Apr-Jun 1981;19(4):113-7. [Medline].

  13. Turk DC, Melzack R, eds. Handbook of Pain Assessment. New York, NY: Guilford Press; 1992.

  14. Harden RN. A clinical approach to complex regional pain syndrome. Clin J Pain. Jun 2000;16(2 Suppl):S26-32. [Medline].

  15. Jaaskelainen SK, Rinne JO, Forssell H, et al. Role of the dopaminergic system in chronic pain -- a fluorodopa-PET study. Pain. Feb 15 2001;90(3):257-60. [Medline].

  16. Jain KK. An evaluation of intrathecal ziconotide for the treatment of chronic pain. Expert Opin Investig Drugs. Oct 2000;9(10):2403-10. [Medline].

  17. Justins DM. Management strategies for chronic pain. Ann Rheum Dis. Sep 1996;55(9):588-96. [Medline].

  18. King JC, Goddard MJ. Pain rehabilitation. 2. Chronic pain syndrome and myofascial pain. Arch Phys Med Rehabil. May 1994;75(5 Spec No):S9-14. [Medline].

  19. Landau B, Levy RM. Neuromodulation techniques for medically refractory chronic pain. Annu Rev Med. 1993;44:279-87. [Medline].

  20. Luzzi G, O''Leary M. Chronic pelvic pain syndrome. BMJ. May 8 1999;318(7193):1227-8. [Medline].

  21. Maleki J, LeBel AA, Bennett GJ, Schwartzman RJ. Patterns of spread in complex regional pain syndrome, type I (reflex sympathetic dystrophy). Pain. Dec 1 2000;88(3):259-66. [Medline].

  22. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. Nov 19 1965;150(699):971-9. [Medline].

  23. Moore J, Kennedy S. Causes of chronic pelvic pain. Baillieres Best Pract Res Clin Obstet Gynaecol. Jun 2000;14(3):389-402. [Medline].

  24. Merskey H, Holzman AD, Turk DC, eds. Pain Management: A Handbook of Psychological Treatment Approaches. New York, NY: Pergamon Press; 1986.

  25. Portenoy RK, Foley KM. Chronic use of opioid analgesics in non-malignant pain: report of 38 cases. Pain. May 1986;25(2):171-86. [Medline].

  26. Rickert VI, Kozlowski KJ. Pelvic pain. A SAFE approach. Obstet Gynecol Clin North Am. Mar 2000;27(1):181-93. [Medline].

  27. Rook JC, Pesch RN, Keeler EC. Chronic pain and the questionable use of the Minnesota Multiphasic Personality Inventory. Arch Phys Med Rehabil. Aug 1981;62(8):373-6. [Medline].

  28. Schwartzman RJ, Maleki J. Postinjury neuropathic pain syndromes. Med Clin North Am. May 1999;83(3):597-626. [Medline].

  29. Severens JL, Oerlemans HM, Weegels AJ, et al. Cost-effectiveness analysis of adjuvant physical or occupational therapy for patients with reflex sympathetic dystrophy. Arch Phys Med Rehabil. Sep 1999;80(9):1038-43. [Medline].

  30. Steege JF. Office assessment of chronic pelvic pain. Clin Obstet Gynecol. Sep 1997;40(3):554-63. [Medline].

Further Reading

Related eMedicine topics:
Arthritis, Rheumatoid
Chronic Pelvic Pain
Chronic Pelvic Pain Syndrome and Prostatodynia
Corticosteroid Injections of Joints and Soft Tissues
Epidural Steroid Injections
Fibromyalgia [Pediatrics: General Medicine]
Fibromyalgia [Physical Medicine and Rehabilitation]
Fibromyalgia [Rheumatology]
Image-guided Stellate Ganglion Blocks
Osteoarthritis [Orthopedic Surgery]
Osteoarthritis [Physical Medicine and Rehabilitation]
Osteoarthritis [Rheumatology]
Osteoarthritis, Primary
Paraspinal Injections - Facet Joint and Nerve Root Blocks
Pathophysiology of Chronic Back Pain
Rheumatoid Arthritis [Physical Medicine and Rehabilitation]
Rheumatoid Arthritis [Rheumatology]
Therapeutic Injections for Pain Management
Virtual Reality Biofeedback in Chronic Pain and Psychiatry

Clinical guidelines:
Chronic pelvic pain. In: Guidelines on chronic pelvic pain. European Association of Urology - Medical Specialty Society.  2008 Mar.  55 pages.  NGC:006454

Fibromyalgia treatment guideline. University of Texas at Austin School of Nursing, Family Nurse Practitioner Program - Academic Institution.  2005 May.  13 pages.  NGC:004350

General treatment of chronic pelvic pain. In: Guidelines on chronic pelvic pain. European Association of Urology - Medical Specialty Society.  2008 Mar.  13 pages.  NGC:006520

Management of fibromyalgia syndrome. American Pain Society Fibromyalgia Panel - Independent Expert Panel.  2004 Nov 17.  8 pages.  NGC:004057

Prostatitis and chronic pelvic pain syndrome. In: Guidelines on the management of urinary and male genital tract infections. European Association of Urology - Medical Specialty Society.  2008 Mar.  10 pages.  NGC:006494

Psychological factors in chronic pelvic pain. In: Guidelines on chronic pelvic pain. European Association of Urology - Medical Specialty Society.  2008 Mar.  8 pages.  NGC:006519

Clinical trials:
Botulinum Toxin Type A for the Treatment of Male Chronic Pelvic Pain Syndrome (BTX-URO-01)

Efficacy of TMS in Chronic Idiopathic Pain Disorders

Neurotropin to Treat Chronic Neuropathic Pain

Supporting Effect of Dronabinol on Behavioral Therapy in Fibromyalgia and Chronic Back Pain

Transcranial Magnetic Stimulation for Treating Women With Chronic Widespread Pain

Keywords

chronic pain syndrome, pain management, pain relieffibromyalgia, chronic pain, muscle pain, arthritis pain, pain medicine, TENS, TENS unit, pain meds, pain treatment, pain therapy, nerve block, pain medications, treatment for painchronic pain treatment, chronic pain relief, pain relievers, neuropathic pain, chronic pain management, spinal cord stimulation, nerve stimulation, nerve blocks, chronic regional pain syndrome, transcutaneous electrical nerve stimulation, chronic benign pain syndrome, chronic intractable benign pain syndrome

Contributor Information and Disclosures

Author

Manish K Singh, MD, Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience
Manish K Singh, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American Association of Physicians of Indian Origin, American Headache Society, American Medical Association, and American Society of Regional Anesthesia and Pain Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Jashvant Patel, MD, Medical Director, Department of Pain Medicine and Comprehensive Rehabilitation, Medical College of Pennsylvania Hahnemann University
Jashvant Patel, MD is a member of the following medical societies: Alberta Medical Association, American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Society of Regional Anesthesia and Pain Medicine, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Rollin M Gallagher, MD, MPH, Clinical Professor, Departments of Psychiatry and Anesthesiology, Director for Health Policy and Primary Care, Penn Pain Medicine, University of Pennsylvania; Director, Pain Management Service, Philadelphia Veterans Affairs Medical Center
Rollin M Gallagher, MD, MPH is a member of the following medical societies: Academy of Psychosomatic Medicine and American Academy of Pain Medicine
Disclosure: Nothing to disclose.

Medical Editor

Martin K Childers, DO, PhD, Associate Professor, Department of Neurology, Wake Forest University Health Services
Martin K Childers, DO, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Congress of Rehabilitation Medicine, American Osteopathic Association, Christian Medical & Dental Society, and Federation of American Societies for Experimental Biology
Disclosure: Allergan pharma Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Richard Salcido, MD, Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine
Richard Salcido, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Medical Association, and American Paraplegia Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Denise I Campagnolo, MD, MS, Director of Multiple Sclerosis Clinical Research and Staff Physiatrist, Barrow Neurology Clinics, St Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consortium of MS Centers
Denise I Campagnolo, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, and Consortium of Multiple Sclerosis Centers
Disclosure: Teva Neuroscience Honoraria Speaking and teaching; Serono-Pfizer Honoraria Speaking and teaching; Genzyme Corporation Grant/research funds investigator; Biogen Idec Grant/research funds investigator; Genentech, Inc Grant/research funds investigator; Eli Lilly & Company Grant/research funds Novaritis; Novaritis  Novaritis; MSDx LLC Grant/research funds investigator; BioMS Technology Corp Grant/research funds investigator; Avanir Pharmaceuticals Grant/research funds investigator

 
 
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