| THINGS THAT GO OUCH
IN THE NIGHT |
Page
3 of 3 |
| by Howard Liss, MD
and Donald Liss, MD |
Pain unrelieved by rest
Sometimes, the lack of relief of symptoms
at night should raise antennae. Statistically, although patients
between age 20 and 50 need rarely undergo lumbosacral x-rays
for low-back pain, one of the symptoms which should trigger
suspicion is unremitting pain. If the patient describes pain
which is positional, this generally points to a mechanical
cause. Pain worsened by sitting, arising, or associated with
flexion and rotation is often discogenic. Pain worsened by
extension is often related to the facet joint. Pain exacerbated
by walking is often associated with lumbar spinal stenosis.
But ... pain which is unrelieved at night in any position
may signify an underlying malignancy. This is especially true
if there has been an associated loss of appetite, weight,
or other constitutional symptoms such as change in bowel habits.
At any rate, although most patients with this symptom do not
have malignancy, this symptom should nevertheless trigger
a more thorough diagnostic evaluation. One needs to have a
high index of suspicion in these patients.
The other broad category of patients with
unremitting pain are those patients with non-malignant but
non-mechanical pain. Patients with visceral pain may present
with complaints that seem musculoskeletal. A patient with
perforated duodenal ulcer, for example, may present with acute
mid-back pain which is severe and may be mistaken for muscular
or spine pain. Only a high index of suspicion after thorough
examination will lead to appropriate diagnostic testing.
Summary
In summary, most patients do not arrive
with an easy answer to their diagnostic dilemmas. Patients
have not read the textbook before arriving in the practitioner’s
office. It is therefore imperative that every component of
the medical history and physical examination be viewed discriminately
and thought about judiciously. The effect of nighttime and
bed rest on pain is an important example of this. The pattern
of clinical presentation should affect our clinical impression
and, therefore, our diagnostic workup; this in turn affects
our treatment plan.
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