Read the Case-Based Curriculum for Neurology Residents.

such as topical capsaicin and narcotics of various strengths may also be used. Many physicians
adopt an "analgesic ladder" approach to pain management, often using salicylares and NSAIDs,
occasionally selecting from a shon list of favored adjuvants such as amitriptyline for chronic use,
reserving "weak" opioid mixtures (e.g., acetaminophen with codeine) for brief courses of strictly
limited quantity for acute severe pain, and rarely ifever using "strong" opioids (e.g.,
hydromorphone) (2). Published guidelines for an "adequate" dnrg trial for each analgesic
empirically tried include candid discussion of the need for trial and error, drug titration one at a
trme, initiadng with smallest-size available oral tablet, increasing every 3 to 7 days as tolerated
and required, close communication between patient and staff weekly or biweekly, and increasrng
until satisfaction or intolerable side effects are reported. Hisrorica.l analgesic trials must be
deemed inadequate and inconclusive if dose incrcase was curtailed shon ofintended analgesic
level for reasons other than intolerance, or if intolerance followed too-fast titration or too many
drugs being used simulraneously (3). The goal of analgesic trials, individually and in
combination, is ro provide partial, incremental analgesia when a cure is not possible (4).
GRPS is a new rerm for a subclass of neuropathic pain
"causalgia"
syndromes traditionally termed
and
"reflex symparheric dystrophy" (RSD), which often but not invariablv follo* ^
subacute sequela of trauma and other conditions (5). Neurologist Weir Mitchell usei "causalgia"
to describe a syndrome including severe buming pain in the hand after major partial injury to the
brachial plexus during the Civil War. The diagnostic weight of different fnysical and iialnostic
signs observed in various combinations in rhe "syndrome" varies grcatly amtng authoritie;, bur
by definition, causaigia or CRPS-II requires an identifrable nerve lesion usually in a ',named"
peripheral nerve, plexus or root structure. The pain is severc, persistent, and usually burning in
qua.lity' including hyperargesia (minimar stimulus evokes disproportionate pain), irodynia
(innocuous stimulus like touch changes to noxious dysesthesia such as buming), and hyperpathia
(temporal su[rmadon of repear srimuli into crcscendo pain); and is associated-with .,".ying'
amounts of edema: cutaneous changes of color, temperature, sweat, and nail growttr l"Lofmc
changes"); stiffness; local osteoporosis; and eventual fixed contracrurcs. ftielain sustai;ng
mechanism is controversial, some implicating sympathetic effercnts at certain stages, thus
advocating symparhetic blocks for diagaosis and treatment. others vigorously argue for a
significant psychological sustaining mechanism. A similar constellation of sympioms and signs,
not associated with an identifiable nerve lesion, constitutes RSD or cRpSl. Meaningful use of
CRPS (or RSD/causalgia) terminology entails making a distincrion between causalgia and RSD,
and therefore demands a neurologically sophisticated examination, imaging, neurodiagnostic and
other studies.
cNP is chronic pain nor associated with a marignancy. It encompasses many types of
moderate to severe chronic pain syndromes, including neurogenic (painful polyneuropithies,
zoster, trigeminal neuralgia and other facial pains, CRpS), inractable headache, spinal pain
(including "failed back syndrome"), arthritis, bums, sickle cell, AIDS rclated, and pelviCpain.
Designating these syndromes as chronic nonmalignant pain distinguishes them from cancir
associated pain, where recent experience with opioids in cancer centers has established for them
a more accepted role in the medical community and morc secure standing in law and regulations.