Overall Pain Burden

= Chronic pain affects ~20% adults worldwide (~1.5B people) and ~50M US adults (20M high-impact).

1. Nociceptive Pain  = Pain from actual/potential tissue damage via intact somatosensory system.

• Prevalence: ~30–40% adults worldwide | ~100M US Subtypes: Somatic (skin, muscle, bone) vs Visceral (organs).
  Mediators: Prostaglandins, bradykinin, substance P. Examples: Osteoarthritis, appendicitis, fractures.
  
  

2. Neuropathic Pain = Pain from lesion or disease of somatosensory nervous system.

• Prevalence: ~7–10% worldwide | 8–10% US Mechanisms: Ectopic discharges, maladaptive plasticity, central sensitization.

• Biomarkers: NaV1.7/NaV1.8 sodium channel mutations, glial activation.

• Examples: Diabetic neuropathy, post-herpetic neuralgia, radiculopathy.
  
  

3. Nociplastic Pain = Pain from altered nociception without clear tissue damage or nerve lesion.

• Prevalence: ~20% worldwide | ~10–15% US Mechanisms: Central sensitization, impaired descending inhibition, abnormal pain modulation. Associated Syndromes: Fibromyalgia, irritable bowel syndrome, tension-type headache. Neuroimaging: Abnormal thalamic–cortical connectivity, altered μ-opioid receptor binding.
  
  

4. Mixed Pain  = Overlap of nociceptive, neuropathic, and/or nociplastic processes.

• Prevalence: ~30–50% of chronic pain cases | ~40% US   

• Examples: Low back pain (mechanical + nerve compression), cancer pain, post-surgical pain.  

5. Other Specialized Categories =

• Inflammatory Pain = Driven by immune mediators (TNF-α, IL-1β, NF-κB). Seen in RA, Crohn’s, gout. (~3–5% worldwide | ~5–7% US)

• Functional Pain = Clinical symptom without proportional pathology, overlaps with nociplastic.

• Psychogenic/Idiopathic Pain = Pain disproportionate or unexplained by pathology, influenced by psychiatric or biopsychosocial factors (~5–10%).
  
  

📌 Key Concept:

• Nociceptive = damage signal 

• Neuropathic = nerve injury 

• Nociplastic = altered processing 

• Mixed = overlapping mechanisms

Disc Bulge (DB) – Mild <3 mm, Moderate 3-5 mm, Severe >5 mm | ICD-10: M51.26 (L), M50.30 (C), M51.24 (T)

Disc Herniation (DH) – Protrusion 2-6 mm, Extrusion >6 mm | ICD-10: M51.26 (L), M50.20 (C), M51.24 (T)

Central Canal Stenosis (CCS) –   C10 ... L12 

C-spine <10 mm (severe), 10-13 mm (moderate)

L-spine <12 mm (severe), 12-15 mm (moderate) | ICD-10: M48.02 (C), M48.04 (T), M48.06 (L)

Foraminal Stenosis (FS) – Significant narrowing <3 mm | ICD-10: M99.33 (C), M99.34 (T), M99.35 (L)

Facet Hypertrophy (FH) – Thickening >3 mm | ICD-10: M47.812 (C), M47.814 (T), M47.816 (L)

Ligamentum Flavum Hypertrophy (LFH) – Thickening >2-4 mm | ICD-10: M47.12 (C), M47.14 (T), M47.16 (L)

Spondylolisthesis (SPL) – Grade I: 0-25%, Grade II: 26-50%, Grade III-IV: >50% | ICD-10: M43.12 (C), M43.14 (T), M43.16 (L)

Spondylosis (SP) – Degenerative disc changes with osteophytes (1-3 mm) | ICD-10: M47.812 (C), M47.814 (T), M47.816 (L)

Osteophyte Complex (OC) – Bone spurs contributing to narrowing | ICD-10: M25.78 (C/T/L)

Thoracic Kyphosis (TK) – Hyperkyphosis >40-45° curvature | ICD-10: M40.09

Lumbar Lordosis Abnormality (LLA) – Loss of normal curvature | ICD-10: M40.56

Thoracic/Lumbar Radiculopathy (TR/LR) – Nerve root compression | ICD-10: M54.16 (L), M54.14 (T), M54.12 (C)

Cervical Myelopathy (CM) – Spinal cord compression | ICD-10: M47.12

 ****    Important Reminder - FOR REFERENCE ONLY

SEEK INSTRUCTIONS FROM YOUR DOCTORS    ****

***For Spine AND HIP INJECTIONS - here are instructions to stop bloodthinners. 

For SI joint injections - no need to stop your blood thinner. 

Do not stop taking your anticoagulant until you have been cleared to do so by the medical provider prescribing that medication.

Anticoagulants

• Coumadin (warfarin): Stop 5 days before procedure; INR must be obtained on the day of the procedure.

• Pradaxa (dabigatran): Stop 4 days before procedure.

• Eliquis (apixaban): Stop 3 days before procedure.

• Xarelto (rivaroxaban): Stop 3 days before procedure.

• Bevyxxa (betrixaban): Stop 6 days before procedure.

Antiplatelets / Platelet Inhibitors

• Aspirin / Excedrin (any dose “baby” or otherwise): Stop 7 days before procedure.

• Plavix (clopidogrel): Stop 7 days before procedure.

• Effient (prasugrel): Stop 10 days before procedure.

• Ticlid (ticlopidine): Stop 5 days before procedure.

• Pletal (cilostazol): Stop 2 days before procedure.

NSAIDs (Nonsteroidal Anti-inflammatory Drugs)

• Advil (ibuprofen): Stop 1 day before procedure.

• Arthrotec (diclofenac): Stop 1 day before procedure.

• Indomethacin: Stop 2 days before procedure.

• Lodine (etodolac): Stop 2 days before procedure.

• Mobic (meloxicam): Stop 4 days before procedure.

• Aleve (naproxen): Stop 4 days before procedure.

• Relafen (nabumetone): Stop 6 days before procedure.

• Feldene (piroxicam): Stop 10 days before procedure.

Supplements

• Fish oil: Stop 6 days before procedure.

• Garlic: Stop 7 days before procedure.

• Vitamin E: Stop 7 days before procedure.

• Turmeric: Stop 7 days before procedure.

Again, confirm these timelines with the provider who prescribed your medication.

**** Recordatorio importante - SOLO PARA REFERENCIA

BUSQUE INSTRUCCIONES DE SU MÉDICO ****

Para inyecciones en la columna vertebral Y la cadera – aquí están las instrucciones para suspender anticoagulantes.

Para inyecciones en la articulación sacroilíaca (SI) – no es necesario suspender su anticoagulante. 

No deje de tomar su anticoagulante hasta que haya sido autorizado por el proveedor médico que le recetó ese medicamento.

Anticoagulantes

• Coumadin (warfarina): Suspenda 5 días antes del procedimiento; el INR debe obtenerse el día del procedimiento.

• Pradaxa (dabigatrán): Suspenda 4 días antes del procedimiento.

• Eliquis (apixabán): Suspenda 3 días antes del procedimiento.

• Xarelto (rivaroxabán): Suspenda 3 días antes del procedimiento.

• Bevyxxa (betrixabán): Suspenda 6 días antes del procedimiento.

Antiplaquetarios / Inhibidores de Plaquetas

• Aspirina / Excedrin (cualquier dosis “baja” o normal): Suspenda 7 días antes del procedimiento.

• Plavix (clopidogrel): Suspenda 7 días antes del procedimiento.

• Effient (prasugrel): Suspenda 10 días antes del procedimiento.

• Ticlid (ticlopidina): Suspenda 5 días antes del procedimiento.

• Pletal (cilostazol): Suspenda 2 días antes del procedimiento.

AINEs (Antiinflamatorios No Esteroides)

• Advil (ibuprofeno): Suspenda 1 día antes del procedimiento.

• Arthrotec (diclofenaco): Suspenda 1 día antes del procedimiento.

• Indometacina: Suspenda 2 días antes del procedimiento.

• Lodine (etodolaco): Suspenda 2 días antes del procedimiento.

• Mobic (meloxicam): Suspenda 4 días antes del procedimiento.

• Aleve (naproxeno): Suspenda 4 días antes del procedimiento.

• Relafen (nabumetona): Suspenda 6 días antes del procedimiento.

• Feldene (piroxicam): Suspenda 10 días antes del procedimiento.

Suplementos

• Aceite de pescado: Suspenda 6 días antes del procedimiento.

• Ajo: Suspenda 7 días antes del procedimiento.

• Vitamina E: Suspenda 7 días antes del procedimiento.

• Cúrcuma: Suspenda 7 días antes del procedimiento.

Most Common Types of Pain =  

LBP - HAs - Joint - Neuropathic - FBM - Whiplash (acute) 

Neck - Abd/Pelvic - Post-Op - CA - Dental/Face | PAIN RESEARCH

XRAY  MRI  EMG  NCV | Cracking Joints | Sciatic N. | 

1️⃣ Lower Back Pain (Most Common) | ~30-40% of adults at some point in life | Leading cause of disability worldwide | Causes: Muscle strain, herniated discs, arthritis (Spine | Knee), spinal stenosis.

DX:  Spinal Stensosis - Cervical  Lumbar 

LUMBAR -   FACET  MBB  RFA | ESI (LESI w/o ctr)  |TFESI |SACROILIAC JOINT|CAUDAL

CERVICAL- FACET  MBB  RFA | ESI (CESI w/o ctr) |ONB | TPI |TH-ESI   

2️⃣ Headaches & Migraines | ~15-20% of the population regularly [Tension 40% / Migraine 10% ]  | Includes tension headaches, migraines, cluster headaches | Causes: Stress, dehydration, neurological disorders, hormonal changes.  WHIPLASH (HEADACHE) | 

3️⃣ Joint Pain (Arthritis & Osteoarthritis) | ~25% of adults | Common in knees, hips, hands, shoulders | Causes: Aging, wear-and-tear, autoimmune conditions (rheumatoid arthritis).

NON-STEROID TREATMENTS

Topical Treatments

1. CBD/THC Topicals – Apply 2–3 times daily as needed (20–30 mg per dose).

2. Diclofenac Gel (Voltaren 1%) – Apply 2–4 g up to four times daily.

3. Capsaicin Cream (0.025–0.1%) – Apply 3–4 times daily (initial burning sensation expected).

Therapies & Physical Treatments

4. Acupuncture – 1–2 sessions per week (based on response).

5. TENS Therapy – Use 15–30 min per session, up to 2–3 times daily.

6. Paraffin Wax Therapy – Heat wax to 125–130°F, dip hands 5–10 times, wrap, and leave for 15–20 min, repeat daily or as needed.

7. Hand Exercises – 5–10 min, twice daily (stretching, grip strength, and mobility drills).

Supplements & Natural Remedies

8. CBD - OTC is supplement - buy only at a reviewed, reputable company - usually 25-50 mg per dose 2-3x per day

9. Omega-3 (Fish Oil, EPA/DHA) – 1,000–3,000 mg daily.

10. Curcumin (Turmeric w/ Black Pepper Extract) – 500–1,500 mg daily, divided into 2–3 doses.

11. Collagen Peptides – 5–10 g daily (powder or capsules).

12. Magnesium Lotion (or Oral Supplement) – Apply 1–2 times daily OR take 200–400 mg magnesium glycinate orally.

LUPUS | LIVING WITH LUPUS | ANTI-INFLAMMATORY DIET  | RESEARCH = CANNABIS AND AUTOIMMUNE DZ CANNABIS AND LUPUS   

LUPUS AND DIET  | LUPUS + NUTRITION |  

4️⃣ Neuropathic Pain (Nerve Pain, Sciatica, Neuropathy) | ~10-15% of the population | Includes sciatica, diabetic neuropathy, post-herpetic neuralgia, carpal tunnel syndrome | Causes: Diabetes, nerve compression, injury, chemotherapy.

NEUROPATHY

5️⃣ Musculoskeletal Pain (Fibromyalgia, Myofascial Pain, Chronic Pain Syndrome) | ~10-12% of adults | Widespread pain, often linked to stress or nervous system dysfunction | Causes: Muscle overuse, central nervous system disorders, psychological stress.

6️⃣ Neck Pain | ~10-12% of adults | Often work-related or posture-related | Causes: Poor posture, whiplash, arthritis, disc herniation.

7️⃣ Abdominal & Pelvic Pain (IBS, Endometriosis, Menstrual Pain) | ~10-15% of the population | Common in women and people with digestive disorders | Causes: Inflammatory conditions, hormonal imbalances, digestive disorders.

8️⃣ Post-Surgical & Post-Traumatic Pain | ~10-15% of surgery patients | Can develop into chronic pain | Causes: Nerve damage, scar tissue formation, inflammation.

9️⃣ Cancer Pain | ~30-50% of cancer patients (70-90% in late-stage cases) | Often severe and persistent | Causes: Tumor growth, nerve compression, chemotherapy side effects.

🔟 Facial & Dental Pain (TMJ, Toothache, Trigeminal Neuralgia) | ~5-10% of the population | Often related to nerve disorders or jaw misalignment | Causes: Tooth decay, jaw misalignment, nerve dysfunction (trigeminal neuralgia).

Whiplash Sciatica  THORACIC MBB 

New Pt Visits = [ Less than 15min x last # (ex What time duration is 99205?  5x15 = 75; 74-60.  ]  

99202 │ Strtfrwd    │ 15–29 min | 99203 │ Low │ 30–44 min  

99204 │ Moderate │ 45–59 min | 99205 │ High │ 60–74 min 

 
Established Patient Visits = [ less than 10 min x last #  (ex what time duration is 99214?  4x10 = 40;  39-30.]  

99212 │ Strtfrwd    │ 10–19 min | 99213 │ Low │ 20–29 min 

99214 │ Moderate │ 30–39 min | 99215 │ High │ 40–54 min

Prolonged Services

• +99417 │ Add-on │ 75–88 min

• G2212 │ Add-on │ 89+ min

NOTES: 

• 99417: A CPT code used by healthcare providers in the United States to bill for extra time spent with a patient beyond the standard duration of the primary E/M service.

• Add-on: This refers to the nature of the code itself. It is a secondary code that must be billed in addition to a primary E/M service code, not on its own.

• Requirements: To use this code, a provider must have spent at least 15 minutes of documented time beyond the total time required for the highest-level E/M service on the same date.

• Use case: A provider might bill a standard E/M code like 99215 for a typical established patient visit, and then add-on 99417 to cover significant extra time spent discussing a complex issue or coordinating care