EVALUATION OF THE PATIENT

Providing the patient with neuropathic pain the same workup sequence and treatments utilized for inflammatory pain will not provide sufficient results in either realm to establish patient satisfaction. Acute pain is fundamentally different from chronic pain. Inflammatory pain is a biologically necessary, physiologic response with the purpose of signaling impending or ongoing tissue damage. It provokes an escape response to safety.^{[8] [15]} The signal function in neuropathic pain is diminished, if not absent, yet the pain complaints become entangled with the patient's physical and psychosocial world. Equally true, a patient's neuropathic pain is not equivalent to his or her suffering—which is related more to the individual's ability to cope (or not cope) with the painful condition. This entity brings in strongly the perceptual, affective, cognitive, and behavioral aspects of pain.^{[16] [27] [28]} Challenging the authenticity of the patient's pain, because the cause is not obvious or the therapeutic response less than stellar, will only provoke more dramatic pain behaviors which cannot help but impede the diagnostic evaluation and the subsequent therapeutic environment. In reality, the duration of neuropathic pain dictates that many spheres of the patient's existence may be adversely affected by pain.^{[8] [16] [27] [28]}

That said, it is intuitive that the evaluation protocol must be both systematic and thorough. The commanding purpose of this evaluation is to identify accurately what is and what is not wrong with the patient. One must establish a differential diagnosis and a working diagnosis at which the initial treatment will be aimed, because treating the cause of the pain, rather than merely the symptoms, will more likely lead to success in management. ^[29] This is an inexact science, given each patient's individual mix of physiologic and psychological components and the extent of his or her neurophysiologic reorganization. Implied in this reality is the need for an integration of multidisciplinary input in the evaluation scheme. It would be a most unique and remarkable physician who had expertise in all of the specialties which neuropathic pain in its broadest presentation manifests.

The evaluation process starts with an understanding of the reason for referral of the patient. His/her agenda must be clarified (at each visit) to make the evaluation time efficient. If a 47-year-old man with radicular low back pain for 9 weeks is referred specifically for consideration of an epidural steroid injection after the failure of conservative therapy, there is little reason to initiate the entire multispecialty evaluation sequence. The most appropriate questions to ask in this circumstance are whether there is a physical or psychosocial contraindication to providing the requested service. This would not be true for the same patient referred after six years of back pain, unemployment, and four lumbosacral spine operations. In this circumstance it is appropriate to clarify whether one is being asked to simply evaluate the patient and provide a second opinion, broaden the treatment options, or assume management of the patient. The modern-day multidisciplinary thrust not only helps to establish the diagnosis but assures consideration of reputable, contemporary therapy.^{[8] [29] [30]}

History

Patient evaluation starts with the review of related medical records. This provides an organizational outline of the patient's problem and permits the doctor to impress the patient with his or her interest, knowledge, and concern. For the patient who has wound his/her way through the uncaring health care system and encountered none of the above, this first impression is an oasis of hope. This also helps to forge a resilient doctor-patient relationship that will be crucial in the explanation and planning phase of treatment management. The doctor may note evidence of the patient's diminishing satisfaction and self-esteem because endless workups didn't

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The history regarding any pain problem should include information about: the pain's date and circumstances of onset; its location, quality, and temporal characteristics; whether there is radiation; the association with other symptoms (e.g., nausea and vomiting, numbness, weakness); what makes the pain better or worse; and what the pain interferes with or prevents. Routine medical information such as allergy history, current medications, past surgical history, past medical history, and review of systems is required, as are assessment of the patient's occupational, social, psychological/emotional, cultural, and economic circumstances.^{[27] [28] [29] [30] [31] [32] [33] [34]}

Customarily this abundance of vital information is obtained by having the patient fill out a questionnaire. When this tool is correctly developed by the practice, the information is provided in a systematic, convenient, and usable format. The primary document can also include conventional pain diaries, assessment scales for pain and distress, and pain drawing (the graphic presentation of pain may be more informative than the patient's verbal descriptors).

The chronology of the pain problem thus established fosters more productive talk-time for the patient and doctor, thus adding admirable effectiveness to the patient evaluation. The questionnaire also provides a framework for follow-up evaluation, data collection, and quality improvement projects.