Honorio T. Benzon

Physical Examination of the Patient With Pain

Abstract This chapter highlights the importance of a systematic, targeted, physical examination in the evaluation of patients with pain and describes each of the components in detail. General observations are made as soon as the practitioner encounters the patient and are followed by an assessment of their mental status before delving into the musculoskeletal portion of the examination. This includes inspection, palpation, and range-of-motion testing. Next the neurologic portion of the examination is performed and involves strength, sensation, and reflex testing. Finally targeted provocative maneuvers are performed before integrating the findings in the context of the history to generate a differential diagnosis.

Postmeningeal puncture headache and spontaneous intracranial hypotension

Abstract Meningeal puncture headache (MPH), commonly known as postdural puncture headache (PDPH), is an orthostatic bilateral headache following meningeal puncture. The headache can be associated with other symptoms, like neck stiffness, nausea, vomiting, visual changes, auditory changes, and mental status changes. It usually presents within 24–48 hours after a meningeal puncture and resolves within 7 days but in rare cases may persist for months. The incidence of developing a headache after a meningeal puncture depends on the needle size, the design of the needle tip, and the orientation of the bevel during meningeal puncture. The smallest practical needle diameter with a noncutting tip is associated with the lowest risk of MPH. Independent risk factors of MPH include the female gender, pregnancy, falling in the age group of 20–50 years of age, and having a low body mass index. Treatment of MPH should be balanced by the understanding that 85% of MPHs last less than 5 days and that MPHs are rarely associated with significant morbidity. Thus initial therapy should be conservative relying on hydration and medications. An epidural blood patch (EBP) is the gold standard in treating MPH not responding to conservative management.Spontaneous intracranial hypotension (SIH) is a syndrome with symptoms similar to MPH in a patient with no history of meningeal puncture. Computed tomography myelography (CTM) is the diagnostic procedure of choice to show the location and extent of CSF leak in SIH. EBPs are the treatment of choice. Several EBPs may be required.