Two Types of Pain in One Patient

25 yo CM with quadriplegia after a MVA is at a long-term rehabilitation facility on a vent. During his 4-month hospital stay, he developed a stage III sacral decubitus.

Pain management team is consulted.

Patient complains of two types of pain:
-"in my butt" - nociceptive pain from the sacral decubitus
-"shooting, burning pain in my right leg" - neuropathic pain

What are his current pain medications?
Dilaudid 2 mg IV q 4 hr PRN pain
Tylenol 650 mg PO q 6 hr PRN pain

What can be done better?
He needs around the clock pain medications. PRN only is not adequate.

The treatment for these two types of pain is different.

Nociceptive pain:
Tylenol 650 mg PO q 6 hr (i.e. not PRN)
Duragesic patch 25 mcg/hr q 72 hr
Dilaudid 4 mg IV q 4 hr PRN pain

Neuropathic pain:
Neurontin 400 mg PO qhs x 3 d
then
400 mg po BID x 3 d
then
400 mg PO TID

What happened?
Patient reported that his sacral pain decreased from 10/10 to 4/10 the next day, after adjusting therapy.

It took a week for the Neurontin to start working for the neuropathic pain.

What did we learn from this case?
Always evaluate all the places where the patient is feeling pain.
Pain may be of different origin in different places, e.g. nociceptive vs. neuropathic and may require different treatments.

Created: 3/2005
Updated: 8/2005