What is the recommended workup for a 54-year-old female patient with chronic neuropathic pain and muscle spasms in her hips and legs?

Comprehensive Pain Assessment for Neuropathic Pain in a 54-Year-Old Female

A comprehensive pain assessment for this patient should include a simple pain scale measurement, detailed pain characterization, physical examination focusing on neurological findings, and appropriate diagnostic testing to identify the underlying etiology of her neuropathic pain and muscle spasms.

Initial Pain Assessment

Pain Scale and Characterization

• Use a 0-10 numeric rating scale to quantify pain intensity 1
• Document pain location (hips, legs, back) and distribution pattern (symmetrical vs. asymmetrical)
• Record pain quality descriptors (the patient describes "neuropathic pain," bone/joint pain)
• Note temporal patterns:
  • Previously sporadic, now daily occurrence
  • Worse upon waking with muscle spasms
  • Pain exacerbated by lying on side
  • Current treatments (lidocaine patches, ibuprofen) providing diminishing relief

Functional Impact Assessment

• Sleep disruption (difficulty finding comfortable position, tossing and turning)
• Mobility limitations (difficulty rising from bed)
• Sitting intolerance due to back spasms
• Activities that trigger or worsen pain (heavy lifting, squatting, fatigue, stress)

Physical Examination Components

Neurological Examination

• Assess for sensory deficits (numbness, tingling, hyper/hypoesthesia) 1
• Evaluate muscle strength in lower extremities 1
• Test deep tendon reflexes
• Assess for signs of nerve root compression (straight leg raise test)
• Evaluate gait and balance 1

Musculoskeletal Examination

• Assess hip and leg range of motion 1
• Evaluate for muscle spasms and tenderness
• Perform functional tests: squat depth, single-leg balance, and step-down tests 1
• Assess for joint swelling, tenderness, or deformity

Diagnostic Workup

Laboratory Testing

• Complete blood count
• Comprehensive metabolic panel
• Inflammatory markers (ESR, CRP)
• Screen for reversible neuropathy causes: HbA1c, vitamin B12, folate, TSH 1
• Consider autoimmune panel if indicated

Imaging Studies

• MRI of spine with and without contrast to:
  • Rule out compressive lesions
  • Evaluate for nerve root enhancement/thickening 1
  • Assess for degenerative changes or stenosis

Additional Testing (Based on Initial Findings)

• Electromyography (EMG) and nerve conduction studies to evaluate polyneuropathy 1
• Consider lumbar puncture if inflammatory or infectious etiology suspected
• DEXA scan if osteoporosis is suspected 1

Pain Classification

Determine the type of pain to guide treatment:

• Neuropathic pain (burning, tingling, shooting)
• Nociceptive pain (aching, throbbing)
• Mixed pain syndromes
• Muscle spasm-related pain

Contributing Factors Assessment

• Evaluate for potential causes of neuropathic pain:
  • Previous cancer treatment (chemotherapy-induced peripheral neuropathy) 1
  • Diabetes or prediabetes 1
  • Vitamin deficiencies
  • Autoimmune conditions
  • Spinal pathology
• Review current medications for potential side effects causing or exacerbating pain
• Assess psychological factors (anxiety, depression, catastrophizing) 1

Common Pitfalls to Avoid

1. Failing to distinguish between different pain types (neuropathic vs. nociceptive)
2. Not assessing for reversible causes of neuropathic pain
3. Overlooking the impact of sleep disruption on pain perception
4. Focusing only on pharmacological management without addressing physical and psychological factors
5. Inadequate follow-up to assess treatment response

Treatment Planning Based on Assessment

After completing the assessment, treatment should be tailored to the identified pain mechanisms:

1. For confirmed neuropathic pain:

   • First-line: Gabapentin (titrate to 2400 mg/day in divided doses) 1
   • Alternative: Pregabalin (start 75 mg twice daily, titrate as needed) 2
   • For inadequate response: Consider duloxetine 1

2. For muscle spasms:

   • Physical therapy with stretching exercises 1
   • Consider muscle relaxants if appropriate 3

3. Non-pharmacological approaches:

   • Physical activity program 1
   • Consider acupuncture for pain relief 1
   • Cognitive behavioral therapy if psychological factors contribute 1

By following this comprehensive assessment approach, the underlying cause of the patient's pain can be identified and appropriate treatment initiated to improve her quality of life and function.