Intractable Pain, Pain Centralization, and the “Big Five” Main Causes of Intractable Pain:
The first cause of all Intractable Pain is the phenomenon of Pain Centralization, more commonly referred to as Centralized Pain Syndrome, or CPS. Centralization of Pain is the first factor in all Intractable Pain.
Any nerve injury in the spine, brain, joints, extremities or muscles may cause inflammation in the brain unless the pain is cured within about 6 weeks after the injury. When the brain tries to heal itself due to excess inflammation, it may trap or implant the memory of the pain. Pain that implants itself in the brain is referred to as central because the nervous system is divided into two parts: the brain and spinal cord being the central component and the nerves outside the brain that go to arms, legs, and the organs in the interior of the body as the peripheral component.
Figure 1: Flow-chart illustrating how centralized pain develops in the nervous system.
When the pain lodges in the brain, it is not curable and causes constant 24/7 pain and insomnia. Immune, inflammatory cells called the “microglia” cause inflammation inside the brain and spinal cord when they are activated by a painful injury, disease, or trauma. This inflammation is called “neuroinflammation” as it is confined to the central nervous system (CNS) which is the brain, spinal cord, and cauda equina (nerve roots). Neuroinflammation traps the bioenergy of pain in a process called centralization thereby producing constant, severe, suffering pain.
Major characteristics of central pain are that it causes the automatic, non-voluntary “autonomic” nervous system, the hormone “endocrine” system and immune system to become over-aroused and stimulated. This over-stimulation of the nervous and immune systems often leads to auto-immune syndromes. Neuroinflammation is a similar process as peripheral inflammation that occurs in muscle or joints, the difference is that it takes place in the glial cells of the brain and spinal cord.
Regardless of the initial cause of pain, centralized pain produces a typical profile which includes constant unremitting pain, rapid heartrate, high blood pressure, over-heating, loss of appetite, sweating, cold hands and feet, insomnia, anxiety, and fatigue.
The pain centralization process that causes pain to become Intractable can be brought on by various painful medical, genetic and traumatic events, and by spinal degeneration. The most commonly encountered causes of Intractable Pain include, but are not limited to the following “Big Five”:
- Arachnoiditis: Lumbar and cervical
- Reflex sympathetic dystrophy (RSD) sometimes called complex regional pain syndrome (CRPS)
- Genetic connective tissue and metabolic disorders (Ehlers-Danlos, Marfans, Porphyria, sickle cell disease, others)
- Post-viral encephalopathy/neuropathy
- Traumatic brain injury
Arachnoiditis: Lumbar and cervical inflammation of the arachnoid layer of the spinal column which can be caused by trauma, infection, toxins, or friction between the arachnoid layer and spinal cord or nerve roots.
Adhesive Arachnoiditis: This condition is present when there are adhesions, or clumping together of the arachnoid layer and the spinal cord or nerve roots in the cauda equina. This clumping together of the nerve roots is visible on contrast magnetic resonance images- (MRI). Surgery, radiographic dyes, infections, and medical procedures such as epidural corticosteroid injections may accelerate the development of adhesive arachnoiditis if a chronic spinal condition, and cauda equina neuroinflammation are present. Patients with genetic, connective tissue disorders such as Ehlers-Danlos and Marfans commonly develop AA.
Reflex sympathetic dystrophy (RSD) sometimes called Complex Regional Pain Syndrome (CRPS): RSD/CRPS is caused by damage to, or malfunction of, the peripheral and central nervous systems. It is usually limited to one limb or region, but can spread throughout the body. The affected area can become very red, swollen and very painful to the touch. Many have pain throughout their entire body.
Genetic connective tissue and metabolic disorders (Ehlers Danlos, Marfans, Porphyria, Sickle Cell and others): Ehlers-Danlos and Marfans are both life-threatening genetic disorders that affect the body’s connective tissue. Connective tissue holds all the body’s cells, organs and tissues together. It also plays an important role in helping the body grow and develop properly. Connective tissue is found throughout the body; these syndromes can affect many different parts of the body causing wide-spread pain. Porphyria and sickle cell disease are both hereditary diseases of the blood, and both cause wide-spread severe pain and neurological symptoms during an acute crisis. Both can cause long term damage to the internal organs and nervous system.
Post-Viral Encephalopathy/Neuropathy- Post-viral permanent damage to the brain and nervous system. Often the body launches a continuous auto-immune attack after a viral infection causing further neurological damage and pain syndromes including various neuropathies. The auto-immune response can also cause further damage to multiple organ systems, depending on the system that is targeted by the response.
Traumatic Brain Injury (TBI): Injury to the brain from physical trauma from an outside source, blows to the head, falls, blast injuries and auto accidents. Exposure to toxins, tumors and strokes can also cause traumatic brain injury. Similar in effect to viral encephalopathy, the body often launches a continuous auto-immune attack which causes further neurological damage and pain syndromes.
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