痛症八大誤区（摘译）

估计有116万美国人患有慢性疼痛，正确的疼痛诊治，可以减轻疼痛，但普遍存在的误区可以阻碍痛症的准确诊治，疼痛的控制，从而防碍功能的恢复和保持正确的生活质量。有人相信这些错误传说, 有的流行于病人中，也有的则是由医师延续下去。

斯科特格拉泽（Scott Glaser），医学博士，DABIPP，美国介入疼痛医师协会会长，大芝加哥疼痛专家和董事会成员，和疼痛管理部门在约翰霍普金斯大学医学教育主任和疼痛主任史蒂芬P.科恩（Steven Cohen )，MD， ，在沃尔特里德国家军事医疗中心的研究，讨论了痛症八大误区。

误区1。止痛药是天生不好。

这个误区源于各种错误新闻报道，例如在2008年近15000美国人死于处方止痛药物过量而致，新闻报道中误用上隐，成隐等造成民众误解。

科恩博士说：“止痛药是没有好坏之分，他们是一个需要被医师完全掌握，病人理解，医患有效沟通，并合理应用与严格观察副作用及风险的痛症治疗有效方法，”。

科恩博士说，最重要的是根据病人病痛处方止痛药，因人而异。例如，癌症疼痛的老年患者可能反应良好阿片类药物，但与年轻患者背部疼痛是一个风险较高的发展容忍甚至痛觉过敏，使人体对疼痛更敏感。

“这就像一切，这些事情都必须逐案的基础上确定的，”他说。

误区2。咨询委员会和准则委员会的建议是黄金标准。

根据患者的保护和支付得起的医疗法，以降低医疗费用，不影响覆盖或质量的情况下创建的独立支付咨询委员会及以医疗性介为中心的成果研究所制定了所谓黄金标准以指导保险公司限制医疗服务。许多痛症医生，包括格拉泽博士和ASIPP的董事会和首席执行官，科恩博士说及介入痛症协会 Laxmaiah Manchikanti主席都认为应该废除这些以协助保险公司为主，限制病人治疗的黄金标准。

误区3。所有背部疼痛是一样的。

初级保健医生和神经科医师不具备足够的知识或方法来治疗腰背痛，导致他们对腰背痛的认识停留在较低的传统认识上。
格拉泽博士说，有许多不同的结构，可导致椎间关节，骶髂关节和这些关节与神经的影响，如背部疼痛。其他原因包括手术失败综合征，包括相邻的水平椎间盘突出症，不稳定和神经损伤的后遗症。每个处方治疗腰痛的原因是不同的。

误区4。核磁共振总是腰痛的诊断结果。

虽然核磁共振成像可以提供客观图像，如椎间盘退化性疾病和椎间盘膨胀，但图像可能与疼痛不相关，研究结果发现在正常人群，随着年龄的增加椎间盘退化和椎间盘膨胀均会发生。
“核磁共振诊断疼痛的敏感性，实际上具有非常低的的，”格拉泽博士说。 “椎间盘退化性疾病是人类老年退变，如果你对无症状的50岁人进行检查，90％的核磁共振都会有椎间盘退行性疾病。”

科恩博士，大型随机试验说明：核磁共振成像不改善的治疗结果，不影响决策。核磁共振图像有非常低的特殊性和缺乏相关疼痛和治疗结果。

误区5。疼痛治疗只是硬膜外注射。

格拉泽博士说，介入性疼痛医师专家已经开发出了不同的治疗方法 - 包括注射，神经阻滞和neurolytic程序 -来治疗不同来源的疼痛。

误区6。手术是背部疼痛容易修复
。
这个误区来自一个＂希望＂：手术可以治愈背部疼痛的希望。但往往现实中手术是无法治愈腰背痛的。格拉泽博士说。“手术后可以短期无症状，但你不能阻止椎间盘退化性疾病，”他说。 “手术只能尽量减少症状。”

科恩博士说，大多数的研究表明，延伸到腿部或颈部疼痛延伸到手臂与背部疼痛的患者，手术效果是暂时的。术后前6个月，患者会比没有手术者更好，但有两年后手术效果消失。
腰背部手术，同所有手术一样，有其风险，格拉泽博士说。通常情况下，风险是不值得轻易选择手术方法。
“腰背部手术是一个易失败的风险很高的手术” 他说。 “腰痛手术应是最后的选择，除非有压迫脊髓或神经根，这实际上是极其罕见的。”

误区7。可以每年只有三个类固醇注射。

这个说法没有科学依据，格拉泽和科恩俩位博士说。一些保守的疼痛医生仍然相信和根据这个误传进行治疗。注射类固醇不同于口服类固醇，格拉泽博士说。口服类固醇，会产生一大堆的健康问题，如形成白内障，青光眼和骨质疏松症的风险增加。他说，由于类固醇注射属沉淀剂型，基本作用为注射局部，不存在口服类固醇全身副作用。

科恩博士说，做多次注射的决定应取决于患者治疗反映。如果病人在一次注射治疗后疼痛100％缓解，那就不必再注射。

误区8。任何人都可以做痛症诊治

去年，路易斯安那州最高法院裁定，疼痛诊治需要由医生进行。 ASIPP还试图在伊利诺伊州通过类似法案。

格拉泽博士说。 “痛症注射治疗是微创，其实是有风险的，因为注射部位非常接近脊椎及中枢神经系统。没有适当培训的护士或医生助理或医师，不应该允许执行这些治疗。”

科恩博士说：“事实是，你可以教别人做硬膜外类固醇注射，你可以教他们将骨钉打入骨折部位，但这并不说明他们能行医，”他说。 “最重要的是知道什么是治疗指征，任何人都可以取出阑尾，但你需要很多经验，知道什么状况需要治疗，以及如何识别和治疗并发症。”

8 Myths About Pain Management
November 18, 2011

For the estimated 116 million Americans suffering from chronic pain, proper pain management can improve functionality and quality of life as well as reduce pain, but pervasive myths can hinder treatment. Some of these myths are believed by patients while others are perpetuated by physicians.

Scott Glaser, MD, DABIPP, president of Pain Specialists of Greater Chicago and a board member of American Society of Interventional Pain Physicians, and Steven P. Cohen, MD, director of medical education for the pain management division at Johns Hopkins and director of pain research at Walter Reed National Military Medical Center, discuss eight myths surrounding pain management.

1. Narcotics are inherently bad. This myth has been supported by recent headlines after the release of the Center for Disease Control report that found almost 15,000 Americans died from prescription opioid overdose in 2008. The issue is not that cut-and-dried, Dr. Glaser says.

"Narcotics aren't good or bad; they're a treatment option with risks that need to be appreciated, communicated, and dealt with," he says. "They're not inherently evil, and doctors who prescribe them aren't evil. For some folks, they're life savers. It enhances their quality of life without adverse side effects. It's easy to lose sight of that fact in the pandemonium surrounding the epidemic of prescription drug abuse."

Dr. Cohen says the important thing is to prescribe drugs based on individual patients. For example, an older patient with cancer pain might respond well to opioids, but a young patient with back pain is at a higher risk for developing tolerance or even hyperalgesia, a condition that makes the body more sensitive to pain.

"It's like everything else; these things have to be determined on a case-by-case basis," he says.

2. Advisory board and guideline committee recommendations are the gold standard. Both the Independent Payment Advisory Board and the Patient-Centered Outcomes Research Institute were created under the Patient Protection and Affordable Care Act to reduce the cost of healthcare without affecting coverage or quality. Many interventional pain management physicians, including Dr. Glaser and ASIPP's chairman of the board and CEO, Laxmaiah Manchikanti, MD, think they should be repealed.

"I think it is a myth perpetuated by well-meaning folks at the highest levels of government that a group of epidemiologists and non-practicing physicians and statisticians can come up with appropriate recommendations for billions of people when the issue of best treatment isn't even settled in medical literature," Dr. Glaser says.

Dr. Cohen, who oversees numerous clinical trials, says advisory boards and guidelines committees are the "lowest level of acceptable evidence."

"Many reach different conclusions based on the same articles evaluated with different criteria," he says. "It depends a lot on the perspective [of the members]. The best guidelines consist of recommendations from a multidisciplinary group, including multiple specialties, private practice, military and government."

3. All back pain is the same. This myth is found among patients, some primary care physicians, and multiple specialists, Dr. Glaser says. Primary care physicians and specialists such as neurologists don't have the knowledge of the causes or the tools to treat back pain which leads them to lump lower back pain in to one broad category rather than attempt to understand the unique causes. Dr. Cohen calls this a naïve statement and says distinguishing different types of back pain is essential to determining treatment.

"Perhaps the broadest and most critical categorization is to differentiate between mechanical pain and nerve pain," he says. "This is a really important categorization because it affects treatment at all levels."

Dr. Glaser says there are many different structures that can cause back pain such as the intervertebral joints, the sacroiliac joints and effects on the nerves traversing these joints.  Other causes include failed back surgery syndrome and the sequelae including adjacent level disc disease, destabilization and nerve damage. The prescribed treatment for each cause of back pain is different.

4. MRI always results in a back pain diagnosis. While MRIs can provide objective information about back disorders, such as degenerative disc disease and bulging discs, they rarely point to the cause of the pain because of the incidence of these findings in the normal population increases with age. Dr. Glaser says many issues that show up in an MRI might have been present before the patient experienced any pain.

"MRIs actually have very low sensitivity for diagnosing pain," he says. "Degenerative disc disease is so common in human beings that if you do MRIs on asymptomatic 50-year-olds, 90 percent will have some findings consistent with a degenerative disc disorder."

Dr. Cohen, who will be releasing a large, randomized trial on MRI use next month, says MRIs don't improve outcomes and don't affect decisions. They have very low specificity and are poorly correlated with pain and treatment outcomes.

5. Pain management is only epidurals. Dr. Glaser says interventional pain management specialists have developed different treatments — including injections, nerve blocks and neurolytic procedures — for different sources of pain.

"Pain management has evolved as a subspecialty because of the advancement and knowledge of the causes of pain through advances in our knowledge in anatomy and the sensory innervation of the joints in the lumbar spine," Dr. Glaser says.

6. Surgery is an easy fix for back pain. This myth comes from a hope that surgery can cure back pain, but often there is no cure for back pain, Dr. Glaser says.

"It can be made asymptomatic, but you can't stop degenerative disc disease," he says. "You can only minimize the symptoms."

Dr. Cohen says most studies show that in patients with back pain extending to legs or neck pain extending into the arms, surgery works temporarily. For the first six months, patients are better off than they would have been without surgery, but that benefit wears off after two years.

"First of all, it doesn't work in everyone," he says. "Even if it works, it may not improve long-term outcomes."

Like all surgery, back surgery has its share of risks, Dr. Glaser says. Oftentimes, the risk is not worth the benefit for this elective procedure, he says.

"Back surgery is associated with a high risk of failure," he says. "Even a microdiscectomy can be associated with rapid onset of epidural fibrosis or scarring. Surgery for back pain is always an elective procedure unless there's compression of the spinal cord or nerve roots, which is actually extremely rare."

7. Only three steroid injections can be given per year. This myth has no foundation in science, say both Drs. Glaser and Cohen. Some conservative pain management physicians still believe and treat based on this myth. A steroid injection is not like taking an oral steroid, Dr. Glaser says. With an oral steroid, consistent dosing means increased risk for a whole host of health problems such as cataract formation, glaucoma and osteoporosis. Because the steroid is injected, the medicine more or less stays put, he says. The same risk isn't there.

Dr. Cohen says the decision to do multiple injections should depend on how the patient responds. If the patient gets 100 percent relief from one injection, there's no point in doing more, he says. If a patient fails to obtain relief from the first injection, it might make sense to do a second injection in a different manner, such as using a different approach or a higher volume of medication, he says.

8. Anybody can do pain management. There has been a movement to allow nurses and physician's assistants to perform some pain management procedures. Last year, the Supreme Court of Louisiana ruled that pain management is a medical practice and needs to be performed by physicians. ASIPP also tried to get a similar bill passed in Illinois.

"The fact is that there are risks," Dr. Glaser says. "These procedures are minimally invasive but maximally dangerous. We're working very close to the spine. A nurse or physician's assistant or a physician without appropriate training should not be allowed to perform these procedures."

Just because someone can be taught to perform pain management procedures, such as epidural steroid injections, doesn't mean they should, Dr. Cohen says.

"The truth is you can teach somebody to do an epidural steroid injection, you can teach them to put a screw into a bone, but that doesn't constitute the practice of medicine," he says. "The important thing is to know when something is indicated. Anyone can take an appendix out, but you need a lot of experience to know when the treatment is indicated, and how to identify and treat complications."