Dr Child's Casebook: Perceiving Pain

There is no pain without brain, they say. But for the brain to detect and interpret pain signals correctly, it is necessary for the brain to understand the pain pathway. This can be tricky when signals are mixed. How then to diagnose the source of the pain?

Q: A patient who has been diagnosed with a type B aortic dissection (starting in the chest at the level of the left armpit and travelling down to the pelvic area), emailed Dr Child from her hospital bed requesting advice about pain relief.The slow-release morphine, which is meant to last for 12 hours, appeared to not do so in her case, and she experienced pain specifically in her lower back (over her kidneys) around nine hours after each dose, and which became unbearable and did not seem to respond to top-ups of oramorph. This led to the patient wondering if the pain had anything to do with Dural Ectasia - as she was aware that those with Marfan can experience this problem.

A: I am so sorry that you are in pain. Over the years your back pain was probably due to stretchy ligaments, or discs between the vertebrae thinning. That should respond to Naproxen or Brufen.

However, a dissected aorta type B is painful, with pain referred to the back, and your pain between the shoulder blades is more typical of dissection pain. If morphine does not work, try codeine. A low dose may help temporarily.

When it comes time for surgery the anaesthetist should know that certain anaesthetics may not work for you, similar to the resistance found in Joint Hypermobility Syndrome (Ehlers Danlos Syndrome), so do discuss this before your surgery.

65 per cent of Marfan syndrome people have Dural Ectasia, which is an outpouching of the sheath which surrounds the spinal cord. In most cases there are no symptoms at all. So it is very unlikely it is causing you the pain that you describe. Nor should the dissection affect any Dural Ectasia you may have. This is dissection pain most probably.

I hope you feel better soon. Stay in touch. I do not think your pain is due to Dural Ectasia. That gives rise to headaches and tingling and numbness in the legs. Not the back.

Dr Child's Casebook: Perceiving Pain
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