Félix E. Sarria Deheza, Pablo Sonzini Astudillo, Jorge F. García Pinna

GENERAL pain is a universal symptom, in the sense that no human being passes his life without experiencing it in multiple and varied circumstances.

References to pain fill the history of man in theology, literature, medicine, philosophy, art, etc. The greatest thinkers such as Cicero, Pliny, Seneca, Petrarch and many others who touched on the subject of man wrote about it. Cicero stated: “The pain, if severe, is brief; if long, it is light ”; and also: “Remember that great pain ends death; that the little ones are interrupted lowith frequent intervals of tranquility, and that we know how to control medium suffering. "

Pain is an essentially subjective symptom and full of connotations, and perhaps for this reason it is often difficult to interpret it well. Historically, and up to the present time, it has been and is instrumented for martyrdom and revenge, derision, threat or intimidation. It is twinned in many ways with death itself and for many believers it assumes a meaning of redemption.

Pain controls or limits many activities of man and puts him in a reality that demands efforts and sacrifices and challenges him to heroism, compassion, which is a source of solidarity, resignation, austerity in the face of excess, prudence and the order. How much danger it is that man considers it a simple biological fact, ideally suppressible!

Medicine is rooted in the anthropological concept and seeks the interpretation and relief of pain in a methodical diagnostic elaboration that enables the achievement of health and the prolongation of life, and thus allows individual and social fulfillment in well-being.

The subject of pain has been taken up with growing interest in all fields and, despite the progress made, innumerable aspects remain to be clarified. It is even the subject of the recent and last apostolic letter of the current Pontiff, “Salvific mission of pain”, in one of whose paragraphs he expresses: “The pain of others invokes without another pause another world, that of human love in feelings and works "

The entire primitive brain is involved in the pathophysiology of pain. The cerebral cortex, on the other hand, is responsible for the painful location, the accumulated experiences of that sensation, the forms of behavior against them, and therefore the particular subjectivity in different circumstances. From here depend the different manifestations or interpretations of the symptom that we analyze in special situations, such as dementia, hypnosis, general organic weakness, cultural degree, lifestyle, occupation or trade, combat or sports competition, the particular religious feeling, etc.

Disease pain is only possible in organisms because they have different receptors, pathways and attached nerve centers. It is the way in which the disease is often revealed to consciousness, but it does not define precisely, in a categorical way, its origin, severity and other relationships. Hence the importance of the lengthy examination that the doctor performs, especially the interrogation, against a symptom loaded with so much subjectivity.

Acute and chronic pain. In whatever location is considered, the pain can be acute or chronic. The first is of recent and abrupt appearance, with a tendency to reach its maximum intensity soon. The second, on the other hand, originates from imprecise circumstances, more or less distant or as an aftertaste of a previous acute pain, with oscillations in its rigor and without reaching the levels of the previous one. Acute pain behaves like a protective alarm signal. Chronic is usually an integral symptom of a more complex picture that configures a certain disease. Chronic pain arouses obsessive fears and ideas, which provoke manifestations of anxiety and depression against a background of prolonged suffering. Acute pain can obviously become chronic, and vice versa, chronic pain will sometimes exacerbate.

Superficial pain and deep pain. The superficial painit is located in the skin and immediate structures. It is frequently caused by physical or mechanical noxas such as heat or cold, cuts, erosions, etc. It also occurs in neurodermal diseases such as herpes zoster or other central neurological diseases (thalamic syndrome), or conduction pathways, in which a variant of superficial pain occurs called hyperesthesia or hyperalgesia, which means painful perception. stimuli that are not usually capable of causing that sensation. This is due to the lowering of the pain threshold in these central and nerve pathway diseases. Two types of superficial pain have been described according to their characteristics, and in general they are called stabbing one, burning the other. The first one is sharp, intense, short and therefore fast; it is located in the place and coincides exactly in time with respect to the stimulus of aggression that originates it; Quickly informs about the time and place and is useful in the defense reaction. The second or burning is more diffuse, slow and follows the previous with some delay; It has been linked to other paresthesias such as burning, itching, tingling, etc. The component of both superficial pains has been called "Lewis double reaction".

The deep pain , in turn, is somatic when originating in muscles, nerves, bones and joints, or on the walls of body cavities. It can be localized, but in general it is rather diffuse, imprecise and with a tendency to extend over time. Some describe it as a mortifying weight or pressure. Deep somatic pain often disables normal activity, and movements and attitudes take on characteristic modalities that aid diagnosis.

Deep pain is visceral when it comes from the internal organs, which, due to congestion, edema or inflammation, become very sensitive to stimuli such as traction, bloating, anoxia, ischemia, etc. Very often it is accompanied by general neurovegetative reactions such as sweating, nausea, vomiting, hypotension, paleness, etc. Sometimes it is uncharacteristic and therefore offers difficulties for diagnosis; in other cases, on the other hand, it adopts very defined modalities with respect to its intensity, irradiation, concomitant signs, etc., which lead to the diagnosis. Sometimes it is repeated identically in successive episodes and in these cases it is very well recognized by the patient. Visceral pain is often associated with somatic pain, as it causes muscle contractions or metamerically irradiates,referred pain . In the same way, it is associated with superficial pains of the cutaneous sectors linked to the medullary segments that receive afferent nerve fibers from the viscus in question.

Organic pain and psychogenic pain. Finally, it is necessary to differentiate what organic pain is as opposed to psychogenic pain. The first includes all those just described, in which it is generally possible to identify and diagnose the real cause of the symptom in coincidence with the general picture of the patient.

In psychogenic pain, the desired cause is not found and, on the other hand, special characteristics are evident in the personality of the patient.

Often the definition is difficult and the observation must be prolonged before concluding in the correct diagnosis.

It must be accepted, however, that in organic pain there is an important psychic component and also that, without being psychogenic, there are fleeting, fleeting pains, produced by banal causes such as bad movement, intestinal cramps due to flatulence, muscle cramps, etc., which do not properly configure disease either and which all individuals experience almost daily.

Pain anatomy and physiology

Stimuli capable of producing pain. In the skin, the stimuli that produce pain are those that injure the tissues, such as punctures, cutting wounds, burns, freezing, etc., although these have little effect if applied to the hollow viscera, since they respond with pain against to other types of stimuli, such as bloating, ischemia, spasm, inflammation of the mucosa and traction on the mesos.

In cardiac muscle, the only source of pain is ischemia, while in the striatum it can also be induced by tears of the connective sheaths, necrosis, and hemorrhage.

The arteries are sensitive to punctures and inflammation of their robes, to traction and to dis-tension.

The joints, on the other hand, are insensitive to punctures and sections, and produce pain when the synovium is inflamed or filled with blood or fluid under tension.

Threshold for pain. This is the name given to the minimum intensity of a stimulus capable of being recognized as pain. It is supposed to be roughly the same for ordinary people; it is diminished by inflammation and increased by local anesthetics, as well as by lesions of the central nervous system and centrally acting analgesics.

Distraction, suggestion, and hypnosis work by drawing attention away from the painful component.

Pain receptors. At the level of the skin, they are arranged, according to their location, in two plexuses: a superficial one, located in the upper part of the dermis, and a deeper one, located in the same dermis.

The hairy areas of the skin have free nerve endings and other more complex basket-shaped ones that surround the follicle. Hairless areas, such as palms and soles, also have more distinct receptors.

A single stimulus, however limited, simultaneously stimulates several nerve endings, since each receptor terminal covers a determined area that overlaps with the adjacent ones.

In the deep structures reside free nerve endings and specialized receptors, but the density at the terminals is lower than in the skin, and can be stimulated in isolation, which explains the different quality of the painful sensation of the deep tissues, which give rise to a deaf and diffuse algia.

Each free nerve ending is capable of perceiving more than one modality of sensation, such as touch, temperature, and pain; This has been demonstrated in the cornea, where the only sensitive terminals are the free nerve endings. On the other hand, specialized receptors, such as the Krause, Ruffini, Pacini and Meissner corpuscles, sensitive to heat, cold, pressure and touch, respectively, when faced with intense stimuli, respond with pain.

The quality and intensity of a stimulus depends on three variables: the relative specificity of the terminations, the number of stimulated terminations, and the variation in the rate of discharge, which originate a "pulse train" whose temporo-spatial dispersion gives it its characteristic particular, constituting the "nervous message".

The encryption mechanism in terminals and decryption in centers is based on the adequate, subtle and surprisingly effective use of these variables.

Receptor stimulation mechanism.

The nerve endings are stimulated by:

1. a) Direct tissue tension on the nerve endings, such as the pain caused by the distension of a hollow viscus or the plucking of a hair.
2. b) The action of chemical mediators, corresponding to substances released by damaged tissues that stimulate receptors, such as acetylcholine, serotonin, histamine, bradykinin and other polypeptides, to which are added the concentration changes of the potassium ion and the changes in the acidity of certain tissues.
3. c) Very often, chemical factors work together with tissue tension and cause pain.

Types of fibers that lead pain. Ordered according to their decreasing thickness, three types of fibers are distinguished: A, B, and C. In turn, fibers A, which are myelinated, are subclassified into alpha, beta, gamma, and delta.

C fibers are the only unmyelinated, and are the finest. Neural conduction velocity is known to be proportional to the square root of the axon diameter. It is for this reason that transmission in the latter type of fibers is done much more slowly. The response threshold of the different types of fibers to the stimulus is in inverse relation to their diameter, and therefore C fibers are the more difficult to stimulate.

The conduction of pain-related stimuli is almost exclusive to the A delta and C fibers, but it must be borne in mind that they not only transmit painful impulses. Delta fibers carry fast impulses to the brain and give rise to the "living" or "sharp" elements of pain, which last for a short time and disappear. Fibers C, more numerous in the peripheral nerves, follow a more complex, slowly ascending path, causing a more dull and persistent type of pain. The A-fiber system, on the other hand, normally exerts an inhibitory action on the fibers. C. A delta fibers induce sensations that are located more precisely topographically, while C fibers record the sequelae of tissue damage.

We can find both types of fibers in the periosteum, the fascia, the vascular walls and the deep sensitive planes of the skin. Only A delta fibers are found in the subepithelial cutaneous plane.

Pathways of pain conduction. The sensory fibers have their neuronal body in the posterior nodes and their proximal ends pass through the posterior roots in an order, such that the thickest are internal, and the finest are unmyelinated, more external.

Upon entering the medulla, before penetrating the posterior horn, they branch into Lissauer's marginal zone into two branches, one ascending and the other descending, which pass through a few spinal segments.

The A delta fibers traverse Rolando's gelatinous substance synapsing at the base of the posterior horn. The axons of this second neuron cross in front of the duct of the ependyma and rise directly to the thalamus as part of the lateral spinothalamic bundle, characterized by conduction of rapid painful sensations, temperature and touch (Fig. 5-1).

Fibers C, after penetrating the posterior root, can choose different paths:

1. a) Synapse in the marginal zone of Lissauer, ascending the brain through a series of short connections that make up the Lissauer beam.

1. b) Address Rolando's gelatinous substance, and synapse in this area with chains of neurons from the gray and white substance of the anterolateral medullary region

These two described beams configure the multisynaptic ascending system (SAM) , which ascends slowly, causing a more dull and persistent type of pain,

The fibers that transmit the painful stimulation of the head are led by the fifth pair or trigeminal nerve, which originates from its superior maxillary, inferior maxillary, and ophthalmic branches, which join the neurons of the Lissauer bundle and the gelatinous substance. de Rolando at the level of the trigeminal spinal nucleus. From there, other neurons carry the message to the thalamus through known pathways or penetrate the central gray matter, passing to the reticular formation of the brain stem and connecting widely with the thalamus, hypothalamus, cerebral cortex, and base ganglia. (fig. 5-2).

In addition, the ear, pharynx, larynx and paranasal sinuses convey their painful sensations to the neuroaxis through the cranial nerves IX and X (glossopharyngeal and pneumogastric).

At the mesencephalic level, both the spinothalamic beams and the 5th pair cross the protuberance and the peduncles as part of the external or lateral lemniscus, ending in the thalamus, in the ventrobasal nuclear complex.

In this way, many collaterals are emitted that detach from the bundles to pass to the reticular substance of the trunk, whose neurons join the SAM fibers forming a center of diffuse gray substance that connects to all areas of the cortex, being able to generate different responses to sensory stimuli, including activation of the vegetative nervous system and emotional reactions.

As regards the thalamus, the paleothalamus must be distinguished from the neothalamus. The ventrobasal complex, which belongs to the neothalamus and receives fast-conducting fibers, is directly related to different points in the body, emitting fibers that radiate to the primary sensory areas of the cortex, which have a topographic disposition that reflects that of the thalamus. On the other hand, the SAM neurons that end in the oldest paleothalamus have no relation to specific points in the economy, but they do have a relationship with the rest of the thalamus, so they receive information from everywhere. The paleotalamus connects widely with the cortex; with the limbic system, which has to do with memory and emotion; and with the ganglia of the base, in relation to the control of movement. Under normal conditions,

There is no antagonism between thalamus and cortex; on the contrary, both act complementing each other.

Direct cortical stimulation does not induce pain, although it allows locating the precise place of damage or stimulus, making possible the intervention of memory and emotion, the latter in relation to the limbic system.

Cortical areas related to pain are known as:

1. a) Sensitive area 1, located in the ascending or retrorollandic parietal gyrus, which is the most highly differentiated sector.

1. b) Sensitive area 2, located on the upper lip of Silvio's fissure, forming a coarser system.

Both sensory areas receive the projection of visceral and somatic input.

Each region of the body is represented in the homolateral cortex in a reduced form, and in the contralateral one in a more extensive way.

The autonomic nervous system is also related to pain, and this relationship is verified as follows:

1. a) From visceral and non-visceral structures come afferent fibers that reach the posterior root ganglion, and from there to the posterior medullary horn, where they synapse with connecting neurons and where an interaction between somatic and autonomous neurons is manifested.

1. b) The connecting neurons can ascend to vegetative centers of the reticular formation of the trunk and the hypothalamus, or return to the periphery activating neurons and generating the vegetative reflex arc.

1. c) The roads take roads similar to SAM.

1. d) In the reticular formation there are sympathetic and parasympathetic areas.

1. e) From the hypothalamus, the anterior area is parasympathetic and the posterior sympathetic. The hypothalamus connects with the anterior and medial nuclei of the thalamus, with the cortex and with the limbic system, thus allowing the integration of the quality, meaning and location of stimuli, endowing them with emotional charge and involving memory.

Gate control. The impulses that arrive through the thick A delta fibers are, at first, activators of the T cells or neurons of the posterior horn or second neuron, whose cylindro-axis will form the spinothalamic beam. The small neurons of the gelatinous substance would constantly exert an inhibitory action on the T cells while the thick afferent fibers would activate these neurons, thus enhancing such inhibition. While the fine fibers would in turn exert an inhibitory action on the inhibitor cells themselves, resulting in an inhibition of the inhibition, known as "facilitation".

Furthermore, the impulses transmitted by these thin C fibers are direct excitators for T cells.

The stimuli that permanently reach the posterior horns by both groups of fibers, open and close the entrance according to the type of stimulation, its intensity and its frequency. During sustained stimulation, the greater adaptation or the progressive reduction of the response of the thick fibers, allows the predominance of the thin fibers that open the entrance to the impulse from the T cells to the centers, and in turn, from the centers, descend fibers that can close the input by blocking impulses at that level. This explains the inhibition of pain of central origin in the case of great psychic excitement. This theory explains some painful phenomena such as diabetic neuropathy and postherpetic neuralgia, where selective degeneration of thick fibers has been demonstrated,

The impulses that the posterior cords follow are transmitted so quickly that they can not only prepare cortical neurons for the arrival of stimuli, but also, through corticospinal fibers, influence intercalar, activating and inhibiting neurons, before cells Don't get active. Thus, diverse mental activities cause descending impulses that act on: the entire neuroaxis and hinder or facilitate the transmission of painful impulses by closing or opening the entrance to them. This is also known as grid theory (Fig. 5-3).

Modulators. The neurotransmitter A delta and C fibers have substance P, which is found in significant concentrations in the posterior horns of the medulla. It is synthesized by ganglion cells and transported to the intraspinal axonal terminals by means of "axonal flow". These substances by the first neuron are modulated by the action of Rolando's gelatinous substance interneurons, which release enkephalins with the ability to block the release of substance P at that site.

Encephalins are two pentapeptides that differ only in the terminal amino acid. They are found in high concentration in the posterior horn of the medulla, the trigeminal nucleus, and in sensitive areas of the brain. The only known function of these opioid peptides would be to inhibit the release of substance P, binding to morphinic receptors on the presynaptic membrane of the first neuron in the pain pathway.

Other morphinomimetic substances are endorphins, alpha, beta and gamma. They have a greater analgesic action than enkephalins and of a longer duration. Beta endorphin is highly concentrated in the anterior and middle lobes of the pituitary, in nerve endings of the hypothalamus, and appears to have a broader action than that of enkephalins.

They have been found elevated in the cerebrospinal fluid of schizophrenic patients, inhibit gastrointestinal peristalsis, alter heart rate, and cause respiratory depression, prolactin release, and catatonia.

Another substance, anodinine, which is chemically different from endogenous opiates, has been isolated with a longer analgesic action, which also works by interfering with opiate receptors.

All of these substances are likely to play an important modulating role in downstream inhibitory mechanisms, as these mechanisms have been shown to be activated by morphine and inhibited by naloxone.

Segmental sensory innervation. For a quick orientation regarding the root distribution of dermatomes, the following should be remembered fundamentally:

The face and anterior portion of the skull are innervated by the trigeminal; the nape of the second cervical pair; the neck by the third party; shoulders by the fourth and fifth cervical pairs; the thumb and the radial edge of the forearm by the sixth cervical pair; the ulnar border of the forearm and the little finger by the first dorsal pair; the nipple by the fifth dorsal; the navel by the tenth; the groin through the first lumbar; the genito-sacral areas by the third, fourth and fifth sacral pairs. The intrathoracic viscera are innervated by the first to fourth dorsal pairs, while the sixth to eighth pairs innervate the superior intra-abdominal organs (Fig. 5-4, A and B).

HEADACHE

Definition and generalities. Headache or headache are actually synonymous terms; both mean headache and etymologically come from the Greek kepkaleé (head) and algos (pain). Headache is an apocope and has been used more predominantly in modern times.

It is probably one of the most frequent symptoms at any age. A large number of individuals consider it an inalienable discomfort to the contingencies of the activity and their existence elapses without consulting the doctor, and ingesting popular pain relievers. In consultations, in turn, it occupies a proportionally high place and its vulgarity is the reason why it is often not paid enough attention. It is necessary to carry out an adequate interrogation and examination to obtain a correct qualification of the problem. This allows the physician to limit complementary studies, which are very expensive, on the other hand, to cases that are really justified by the clinical examination. Expansive tumor causes are the least frequent and it can be said that in the consultation of a clinical physician with abundant clientele, they do not exceed ten in their entire professional life, but other causes do not, mainly vascular or tension headaches, which may number in the thousands. In conclusion, all headache patients should be thoroughly questioned and examined; some of them will need to undergo specialized examinations.

Pain-sensitive head structures and mechanisms of their production.The sensitive cephalic structures are external to the skull and also intracranial. Among the former are practically all the tissues that cover the skull, mainly the arteries and even the periosteum. Among the second are also, first, the cerebral and doral arteries; then the large venous sinuses and their tributaries; some sector of the dura »mother in the base; the fifth, ninth, and tenth cranial nerves, and the first three cervical nerves. Stimuli acting above the store of the cerebellum cause pain in the anterior half of the skull, through the trigeminal; On the other hand, those that act below the store of the cerebellum, cause pain in the back of the skull through the glossopharyngeal, pneumogastric and the first three cervical nerves.

The pain mechanisms are due to traction, compression, and inflammation, and the consequent displacements that the aforementioned sensitive structures undergo due to these causes, with irritation of the nerve endings that are their own, or of the neighboring nerves. Dilation of the intra or extracranial arteries is probably the most frequent mechanism of pain, due to stimulation of its own nerve endings and due to the strains or tractions they cause. They occur in exposure to heat or sun, fever, hypoxia, alcoholic ingestion, and following the first stage of vasoconstriction in migraine.

The other frequent mechanism is the contracture of the nape muscles, produced by various causes such as nervous tension, vicious and sustained positions at work or secondary to intracranial processes that give pain.

Interrogation

Headache as a symptom is often undervalued, or, conversely, it raises exaggerated fears by referring to known serious cases. For its correct interpretation it is necessary to give the interrogation the greatest importance, as in all pathologies, but with more sagacity and depth since it is, as we have said, a particularly subjective symptom, adorned with multiple opinions and personal nuances and linked, rather than others to emotional, environmental and character situations. ^ influence of learning and environment is transcendent. There are individuals in whom pain is a common theme as an expression of concerns, present or future; in others, however, it is an exceptional or disqualified observation.

When the patient makes his story, already confident in the task undertaken, imbued with the transcendence of the accuracy of his own data, and while questions and answers flow, it is the moment in which the practitioner internalizes the personality in question Which is the first step to the proper interpretation of all that follows.

The anxious personality turns his fears, insecurities and worries towards somatic manifestations, which are frequently headaches and neck pain. He defines them in a very particular imprecise way, and thus speaks of dullness, pressure, weight, burning or dizziness. These references fluctuate with variations in the anxious state.

Depression with its many shades of pessimism, sadness, hopelessness, lack of energy, apathy, also causes the transfer of psychic suffering to physical pain, which is often headache. Both situations, anxiety and depression, carry a component of hypochondria that can be defined as an exaggerated, unjustified and morbid concern for health. It is a very frequent alteration and difficult to discard. It has been said that more than 10% of medical consultations are of this nature. Headache with the hidden or recognized idea of ​​fear of disease is a modality of this pathology. In these people there is also the possibility of magnifying at dramatic levels what is not really significant.

In hysteria, the patient makes an unconscious conversion of his disorder and sometimes becomes aggressive towards the doctor, accusing him of not knowing how to interpret his disorders.

The schizoid temperament has been defined as the characteristic personality of certain headaches, especially the typical migraine. These are detailed, perfectionist individuals, with a disguised desire to excel and a super normal self-worth, who also frequently obey reality without being sufficiently recognized by the environment around them. In dementia or oligophrenia, the deterioration makes patients with true painful pathology expressionless and indifferent.

Methods have been devised to objectify personality variations. Among them, one of the best known is the IMPM (Minnesota multiphasic inventory of personality) cited by Bond, which allows, in pain assessment, to establish the “profiles of personality ”Another is the method of Professor Hans Eysenck.

Simultaneously with this recognition of the patient's personality, which we intend to achieve throughout our conversation, we are methodically obtaining the precise data that will allow us to characterize the symptom. In this regard, it is useful to leave to the initiative of the patient the description of his discomfort, in his own words and with the guidance of the doctor, who knows how to grasp the knots of the story and pay special attention to the useful elements of the exhibition. In this way, the headache symptom will appear as the main reason for the consultation, or, on the contrary, it will arise from a second instance and with all its importance, among a set of other references that initially seemed to predominate (for example: vertigo , nausea, vomiting, visual disturbances, etc.). It may be reported as a fact present at the time of the consultation or that has already passed more or less time ago, but which has left a concern because of its importance or its repetition. Therefore, the interrogation strives to require data on "how is" or "how was" the discomfort experienced. For this it is useful to investigate the following parameters:

Antiquity

Continuity or periodicity

Time relationships

Frequency

Duration

Intensity

Location

Age and Sex

Concomitant symptoms

Morbid background

Family background

Antiquity. If the symptom is new, we cannot prejudge how it will behave in the future, but it forces us to be cautious in its assessment. If, on the other hand, it is lifelong, or several years, or more than a year at least, and has generally retained its characteristics, it is possible that it is not serious and that it is probably a form of migraine or tension headache.

Continuity or periodicity. The appearance of pain in an episodic form repeated and at variable intervals, but which sometimes become conspicuously regular, is characteristic of chronic migraine and tension headaches. The opposite of this characteristic is continuity and this is the framework for most of the injury cases, some of them, therefore, serious; but they can also be functional, preferably linked to the psychopathic personalities described. Finally, there are isolated pictures, which occasionally appear, from time to time in life, such as headache or histamine migraine or Horton's syndrome.

Time relationships.There are hourly links in the different types of headache. The one that begins in the early hours of the morning and is attenuated at dusk is typical of migraine or high blood pressure. The pain that awakens the patient at night after the first hours of sleep is characteristic of Horton's syndrome. Headache that starts in the morning after several hours of activity is the way brain tumors usually appear. Of course, these are rare and that there are many banal circumstances that also adopt this modality. The headache that appears at the end of the working day, usually occurs in those caused by muscle contracture and in those due to eye conditions. Those of paranasal cavity processes are relieved by getting up in the morning, and then the pain intensifies.

Regarding the days of the week, it has been repeatedly reported that there are headaches that systematically occur on rest days (Saturdays and Sundays) or at the beginning of the holidays. This occurs in numerous cases of migraine and is triggered by the nervous relaxation that occurs when ignoring the usual occupations and concerns.

Frequency. From the point of view of the interrogation, it will be necessary to ask if it has been experienced many times, or several times, or if it is the only and first episode. It goes without saying that in a patient with habitual headache, a new event may occur, with different characteristics, which would classify him in a different noxa than the previous one. Migraines and tension headaches appear regularly on a daily, weekly or monthly basis.

Duration. In the headache diagnosis, the duration is especially important in the case of the typical migraine, which lasts from a few hours to one or two days; also in the grouped migraine, in which it manifests a few hours. In other cases it is maintained while the cause is in force and therefore does not help too much to differentiate them. Migraine itself is sometimes prolonged into a kind of migraine disease.

Intensity.There are very intense headaches that, if present at the time of questioning, are more evident by the expression and attitude of the patient than by their description. If it has already passed, the mere memory of the symptom and its story, annoy the patient. The intensity of the headache is, in general, not an element of judgment to rate the severity of the cause that causes it. The exception is the most intense of all, which corresponds to the rupture of an intracranial aneurysm. It is very abrupt at the beginning and continues continuously until the resolution of the process. Smells that are very intense, but with a more gradual onset, are those that accompany meningitis, high fever and many crises of typical migraine and grouped migraine. The symptoms that complete the clinical picture help define the diagnosis. The other headaches are of medium intensity, so they cannot be characterized. This occurs even in tumors, which only in special circumstances acquire a more painful expression, such as when they are appreciably enlarged or complicated by intratumoral hemorrhage, or in its terminal phase, in which a paroxysmal headache that lasts from a few seconds usually occurs. up to thirty minutes, of an unbearable nature and that heralds coma or death.

Location.In questioning it is very important to be able to pinpoint the predominant location of the pain. None of them is pathognomonic of a certain disease, but it is a very guiding fact. Headache with a half head is very common, once on one side and others on the opposite (right episodes tend to predominate), almost always with a tendency to be anterior, temporary, frontal and retro or supraorbital. Because of this unilateral characteristic, this type of headache has been called hemicrania or migraine. This same headache sometimes becomes bilateral and ends with an occipital component, due to an added contracture of the corresponding muscles. This picture is that of the typical vascular migraine. There are fixed unilateral pains on the same side, which, despite suggesting migraine, obey processes of another nature, for example,

Frontal headaches may be due to benign diseases such as sinusitis or ocular processes, or be a late manifestation of supratentorial tumors. Frontooccipital pain occurs in arterial hypertension or in feverish toxyinfectious processes; in the first case they are more important in the morning and are attenuated in the afternoon, exempting the inverse in the second case. Persistent and moderate occipital pain can exist from other causes, such as the involvement of the first two cervical vertebrae. The pain caused by infratentoriais tumors of the posterior fossa in a late phase also correspond to this location.

Retroauricular pain is usually due to inflammatory processes in the ear, with or without mastoid involvement; they are also the expression of tumors of the cerebellopontine angle and acoustic neurinoma; in the first case it is late, in the second early.

From what we see, the location of the pain is often evidence of processes far from the place where it manifests itself. In other circumstances it coincides with the proximity of the lesion, as occurs in subarachnoid hemorrhage, trauma, in some tumors, or in the arteritis of the temporal artery. Headaches have been cited so far from their apparent cause, such as those that accompany distension of the bladder or rectum.

Age and sex. It is known that migraines tend to lessen and disappear over the years. Headaches that appear and increase with age in the fifth or sixth decade are due to high blood pressure, occlusive cerebrovascular conditions, and temporal arteritis. Regarding sex, the frequency of vascular headaches coinciding with the menstrual period and its attenuation during pregnancy and after menopause have been noted. Histamine migraine or Horton's syndrome occurs four times more frequently in men than in women . Concomitant tunings. They will be listed at the end of this section when the different clinical entities in which the headache habitually intervenes as a fundamental or important symptom are briefly described.

Morbid history. As in any medical history, past illnesses must be analyzed, even more so if they are valid in the present, especially those that refer to neurological, vascular, infectious, allergic or toxic diseases (alcohol, tobacco). Ophthalmological, oral and otorhinolaryngological conditions cause headache with marked frequency.

Family background. Given the incidence of the symptom and the number of conditions that produce it, it is very difficult for the patient to ignore references to any of the types of headache in the ancestors, collaterals or descendants. However, it is in the typical migraine that the family memory is easily evoked and with defined characteristics. High blood pressure is a guiding fact in the background.

Summary of the most common pathologies in which headache is predominant.

It is not the purpose of this work to enunciate a detailed classification such as that of the Committee for the Clarification of Headaches of the National Institute of Neurology and Blindness of the United States of America. In addition, and with different criteria, many have been proposed. From all of them we extract the ones that in our opinion and experience encompass most of the headaches seen in medical practice.

Following this criterion, and linking it to the predominant production mechanism, we deal with:

Headache vascular headaches

Typical migraine

Common or atypical migraine

Histamine migraine or grouped Horton syndrome

Basilar artery migraine

Ophthalmoplegic migraine

Hemipiegic migraine

Abdominal migraine

Non-migraine vascular headaches

Arterial hypertension

Fever

Headache from alcoholism, toxic or drugs

Headache from hypoxia, from heights

Headache in occlusive cerebrovascular vasculopathies

Headache in temporal arteritis

Tension headache or muscle contraction

Combined, vascular and muscle contraction headache

Headache from intracranial processes

Meningeal irritation headache

Headache from intracranial hemorrhages

Headache in intracranial tumor or cystic expansive processes

Headache in brain abscesses

Headache from ophthalmological, otorhinolaryngological, dental and cervical spine diseases

Headache in cranial neuralgias.

In general, all other headaches fall within one of the statements and by the same mechanisms.

1. Headache vascular headaches

1. a) Typical migraine.Ratifying what we have already mentioned, hereditary factors and temperamental modalities of the perfectionist or schizoid type take on great importance in this condition. In its pathophysiology, the action on certain circumscribed vascular areas of the brain is attributed to substances such as serotonin, which is produced at different levels, mainly in the cells of the chromaffin system of the intestinal mucosa or the kidneys, and then is carried by the platelets and metabolized with the intervention of the enzyme monoamine oxidase. Other polypeptides, such as neurokinin, would act in situ due to their vasomotor action. The same is true of norepinephrine and prostaglandins. In summary, there are still many doubts about the true origin of migraine crises. It seems proven, instead, that this recurrent process begins with vasoconstriction in the territories of the internal carotid, to which the premonitory symptoms obey; that this is followed by vasodilation, which frequently corresponds to branches of the external carotid artery, sometimes on one side but also on the opposite side, and it is in this phase that the headache is installed with all its intensity; and that finally there is an edematous infiltration of the vascular wall and its vicinity, which explains the residual manifestations that sometimes last up to several days. It is then a cranial vascular dysfunction, in which the same mechanisms are caused by different sometimes contradictory circumstances, such as sudden disgust, tiredness, relaxation at rest, cold, careful occupation,

The foreboding symptoms we referred to are called auras, and are sensory, sensory, motor, neurovegetative, and psychic. The most common are visuals in the form of scintillating scotomas, which usually appear as luminous circles or fortification spectra (teicopsy), or hemianopic moments. Paresthesias appear in the perioral areas or in one of the hands. Pariases and involuntary clonic movements are also seen mainly in the hands, which sometimes causes the fall of a seized object. Cold sensations with paleness, urination, instability, or muscle weakness may occur. From the psychic point of view, insecurity or dullness. After a few minutes to half an hour the headache breaks, usually unilateral (more frequent on the right), retroocular and temporal, other times more generalized, intense, pulsating, which increases with coughing or stooping, accompanied by photophobia, nausea and vomiting that seem to alleviate the condition. The whole process lasts a few hours, although it can last 24 hours or more, it forces the patient to seclude himself in his room and, when it passes, he leaves a feeling of fatigue, but other times, conversely, the patient at that moment feels euphoric. , lucid, with an exaggerated appetite, contrasting with the previous situation. The visual manifestations, so characteristic of the described prodromal phase, should not be confused with other diseases, especially when they first appear. Such situations may refer to tumors of the occipital lobe, in which reductions of the visual field occur; intracranial arteriovenous aneurysms, in which case the auras, similar to those of migraine, are prolonged in the headache stage and beyond; and also in glaucoma in which, together with retroocular headache, visual phenomena appear in the form of colored halos or transitory or prolonged defects.

1. b) Common or atypical migraine. It has been considered as the most frequent variety. In general, it obeys the same causes, mechanisms and modalities as the previous one. They can alternate crises of this type with those. The prodromes may not exist in a defined form, the headache is more generalized and the duration is longer.

1. c) Histamine or grouped migraine or Horton's syndrome. It has been described as many times within headaches as segregated from them. It is characterized by being more common in males, of great intensity, unilaterally located around the orbit and with frontal, temporal and malar propagation. The crises last between 20 and 40 minutes and occur during the night waking the patient. This picture repeats for several days or weeks and disappears for years. It is accompanied by eye congestion and tearing, nasal obstruction and runny nose, redness, and increased cheek temperature, all on the same side as the pain. It is very common that it is triggered by the ingestion of alcohol.

1. d) Migraine of the basilar artery.This variety appears in girls and women under the age of 30, usually coinciding with menstruation. It receives this name for evoking lesions of the basilar artery and the fact that vasomotor phenomena occur in that territory. It is characterized by starting with a sudden total or partial blindness, of short duration, which however can last for two or three hours and also present dysarthria, tinnitus, hearing loss, vertigo, and perioral and limb paresthesias. Headache starts soon after of the prodromes and when it is located it is preferably occipital and other times generalized. The duration lasts for one or two days. Family history is not lacking. Cases have been described with fleeting loss of consciousness, but without seizures or sphincter relaxation.

1. e) Ophthalmoplegic migraine. This is the name given to the headache accompanied by ocular manifestations, which means the involvement of some or all of the oculomotor nerves: common ocular motor, pathetic motor and external ocular motor. It is characterized by complete or partial ophthalmoplegia and therefore can present with palpebral ptosis, disorders of convergence and accommodation, and mydriasis. This form of headache is rare and appears in patients in whom the usual condition is that of a typical migraine. Ophthalmoplegia occurs hours after the headache has started. It disappears promptly or can last up to several days. Its presence requires a lengthy differential diagnosis with respect to aneurysms of the bifurcation of the internal carotid artery or the posterior cerebral artery.

1. f) Hemiplegic migraine. It is a rare form of headache. Hemiplegia is not usually complete and more affects the upper limbs, lasting no more than twenty-four hours. The appearance of these rare types of migraine depends on the place where the stated vasomotor phenomena occur.

1. g) Abdominal migraine. It usually occurs in children and young people with a headache and a family history. It is characterized by pain in the upper abdomen, coinciding or not with headache and other symptoms of it. It is accompanied by abdominal bloating, vomiting and constipation.

2. Non-migraine vascular headaches

1. a) Headache of arterial hypertension It is less frequent than the beliefs of the common people attribute. Not all headache in hypertension is due to this disease. High especially high diastolic blood pressure levels of more than 120 mm of mercury are required. The location is mostly occipital and the patient usually wakes up with a headache. Its production has been incriminated to the increase of prostaglandins, due to its cerebral vasodilatory action.

1. b) Headache of febrile processes. Whatever the origin of fever, headache is a very frequent accompanying symptom. It does not imply involvement of the central nervous system by the causative agent. It occurs by vasodilation and is generalized, although mainly frontal.

1. c) Toxic alcohol headache, medications. Alcohol penetrates by diffusion into the bloodstream and into the various tissues very quickly. In the cranial structures it produces headache by vasodilation. Its mechanism has been attributed to histamine action. Other toxins such as industrial solvents, fixatives, acids (osmic), carbon monoxide, etc., would act by similar mechanisms. Medicines such as derivatives of nitroglycerin, other vasodilators, reserpine, etc., produce generalized headaches and also hemicrania.

1. d) Hypoxia headache, from the heights, hypoglycemic. In hypoxic states, as in the accumulation of carbon dioxide, vasodilation occurs and secondarily edema of the wall, which causes headache. It is common for this symptom to manifest itself more in the morning when waking up, due to less pulmonary ventilation during sleep. The intimate mechanisms of production are controversial today. Headache is also one of the main symptoms of altitude sickness, along with dyspnea, gastric fullness, nausea. Hypoglycemia also causes vasodilation and edema.

1. e) Headache in occlusive cerebral vasculopathies. Various authors have described headache in these processes as an early symptom, prior to occlusive evidence. The most accepted explanation is the activation of a collateral circulation, called to supply the occluded sector. the location has value to determine the affected vessel, for example, it is bifrontal in the occlusion of the basilar artery, or occipital in the case of the vertebral.

1. f) Headache in temporal arteritis It is a disease that appears in the sixth or seventh decade of life. It can occur at younger ages and take other arteries than the temporal one, in the skull or anywhere in the body. It is a giant cell granulomatous arteritis, which affects all the arterial layers, causing its thickening and eventual occlusion. The inflammatory process spreads to the periartery and sometimes includes neighboring veins and nerves. Its etiology is unknown and is interpreted as collagen disease. It begins with general prodromes of fever, decline, weight loss. The headache located in the artery path is then installed in the temporal region. This artery is felt inflamed and hardened. The initial pain that occurs in the chewing act is very common.

3. Tension headache or muscle contraction

Anxious personality is characteristic and presents as a reaction to stress. It is quite frequent. It begins gradually and in the same way tends to disappear. It is not as intense, but its persistence is mortifying. It is rather bilateral with a tendency to be diffuse. Its predominant location is in the neck and occipital muscles, but it can extend to the supraorbital ones. It lasts from hours to several days or weeks and is repeated according to moods. If relaxation can be promoted, the relief is striking.

4. Combined vascular and muscle contraction headache

The type just described can be alternated with migraine episodes. In addition, in the latter there is an added component of muscle contracture.

5. Headache from intracranial processes

1. a) Headache from meningeal irritation. Painful sensitivity of the meninges and pain mechanisms and pathways have already been discussed. Headache in these cases is preceded by symptoms that are common to the prodromes of infectious diseases. The onset of headache is gradual and then acquires great intensity, accompanied by fever, photophobia and stiff neck. There are many viral and bacterial agents that produce it. Meninges can also be irritated in certain diagnostic procedures such as pneumoencephalography or myelography. Pain is exacerbated by coughing, laughing, or sneezing. Two classic signs of exploration are Brudzinsky's (flex the head on the sternum), and Kernig's (extend the leg, with the thigh flexed on the abdomen).

1. b) Headache due to intracranial hemorrhage.The most intense and dramatic is subarachnoid hemorrhage caused by rupture of arterial aneurysms. It occurs quickly and sometimes starts being unilateral, and then becomes general. It is accompanied by photophobia, stiff neck, Kernig sign and in some cases loss of consciousness is installed. Other times, depending on the location, aphasia, monoparesis, hemiparesis, seizures, simple or combined paralysis of the third, fourth, fifth and sixth cranial nerves are added. Paralytic mydriasis denounces the location of the aneurysm in the posterior communicating artery. The formation of a carotid-cavemose fistula, due to rupture of an internal carotid aneurysm, can cause a pulsatile exophthalmos with a murmur over the eye. Spinal tap is a critical diagnostic method of exposing bleeding.

Head trauma is the cause of extradural bruising.

The rupture of the middle meningeal artery is the usual origin, forming a hematoma that compresses and displaces the brain with serious consequences, such as the hernia of the temporal lobe by the tentorial hiatus. It starts with an intense and progressive headache. These are the cases in which, after the "lucid interval", drowsiness and subsequent loss of consciousness may occur. Mydriasis usually appears on the same side.

Subdural hematomas are also generally traumatic. They are less bulky than the extradural, their progression is slow and they originate rather from venous ruptures. They can get complicated as extradurals do.

Spontaneous intracerebral hemorrhages in hypertensive patients generally start suddenly, with severe headache, the location of which is usually occipital and then generalize. In the evolution and according to the site of the affected brain, aphasia, paralysis, alteration of consciousness, respiratory changes, fever occur, with extreme severity of the patient.

1. c) Headache in expansive intracranial cystic or immoral expansive processes.It has already been said that headache in these processes is usually a late symptom and not the most significant. However, it is frequent that people suffering from headaches have the obsessive idea of ​​this pathology until the doctor manages to convince them otherwise. More frequent in these cases are usually mental deterioration, focal signs such as seizures, paralysis or circumscribed paresis, eye manifestations, etc. In some locations, however, or when they grow excessively, or infiltrate sensitive structures, or are complicated by vascular involvement or intratumoral hemorrhage, they do acquire a relevant intensity and modalities that can make them confuse with other headaches. In general we can say that the pain coincides with the location of the process that causes it, but in other cases it acquires special characteristics as in the following examples: posterior fossa tumors hurt in the occipital area and neck and it is possible that they produce visual phenomena and vomiting; the supratentorial formations locate the headache in the frontal region; pituitary tumors hurt in the frontotemporai and retroorbital regions and are accompanied by alterations attributable to the involvement of the optic nerve with deterioration of the visual field and others; Third ventricular tumors produce sudden headaches due to valve mechanisms with these changes in position, etc. pituitary tumors hurt in the frontotemporai and retroorbital regions and are accompanied by alterations attributable to the involvement of the optic nerve with deterioration of the visual field and others; Third ventricular tumors produce sudden headaches due to valve mechanisms with these changes in position, etc. pituitary tumors hurt in the frontotemporai and retroorbital regions and are accompanied by alterations attributable to the involvement of the optic nerve with deterioration of the visual field and others; Third ventricular tumors produce sudden headaches due to valve mechanisms with these changes in position, etc.

1. d) Headache in brain abscesses. It is usually precocious and similar in many respects to the symptoms caused by the other expansive processes. It is accompanied by the elements of the infectious picture, including fever.

6. Headaches from ophthalmological, otorhinolaryngological, dental and cervical spine diseases

1. a) Headache in ophthalmology. There are multiple causes that cause it and the need for a comprehensive eye examination in headache patients is well known to doctors. The pain, although, prevails in the eyes, their envelopes and orbits, spreads to the frontal region and is also generalized. It is an organ with abundant receptors that follow the path of the trigeminal ophthalmic branch. The diseases that cause it are: the refractive vices that are accompanied by fatigue of the eye muscles (asthenopia), as seen first in astigmatism; the inflammatory processes of the various structures of the organ; tumors of the eye, and increased infraocular pressure mainly in acute glaucoma. In some cases they are very similar to migraine attacks.

1. b) Headache in otorhinolaryngological processes.The innervation of the ear, nostrils, and sinuses is extremely rich and constitutes multiple pathways of pain. It depends on branches of the trigeminal, facial, glossopharyngeal, pneumogastric, and upper cervical nerves. The pain is due, in most cases, to acute processes easily identifiable by the direct location in the affected organs. In the ear they are usually very intense and radiate to neighboring areas or become generalized. It is important to consider the referred otalgia when the local injury is not demonstrated. In these cases, it comes from various origins such as dental, sinus conditions, temporomaxillary arthropathies, laryngopharyngeal ulcerations, thyroiditis, etc., which must be carefully investigated, especially when the pain is more chronic and progressive. Regarding sinus processes, pain is more frequent in acute cases and is located coincidentally with the affected sinus. It is rare in chronic sinusitis, except in the ethmoid or sphenoid, in which its location is retroorbital, sometimes pulsating, and is confusing with migraines. Nasal pain is also due to acute inflammatory processes and usually coincides with sinus pain.

1. c) Headache in conditions of the cervical spine.This aspect has been the subject of opinions as disparate as that of those who attribute much of the headaches to spinal problems and that of others who deny it at all. It is common for symptoms to transpose the anatomical limits of the neck, based on the extension of the sensory roots to the skull through the Arnold sub-occipital nerve, derived from the second cervical pair, which is distributed in the posterior half of the head, and the sensory root of the first cervical pair, questioned by some, but which today is known to be distributed throughout the frontal and anterior region of the skull. The processes that stimulate pain respond to inflammatory or degenerative lesions of the vertebroilgamentous or disc structures, with their muscular repercussion on euro logic. It is more difficult to explain them for diseases of the vertebral arteries. They are located in the occipital region, appear already in the morning, are not very intense and are aggravated by forced movements of the neck, cough, sneeze or swallowing. Rubbing noises often appear on head turns. Usually they are bilateral and when they are unilateral it is necessary to strive to rule out more significant organic lesions.

7. Headache in cranial neuralgias

There are several pictures described depending on whether the nerves are involved and whether it is just one or one of its branches, or several are combined simultaneously. They have in common that they are often idiopathic or also virotic, sometimes with herpetic manifestations.

The most characteristic of these neuralgias is the trigeminal neuralgia, also called "tic douloureux", due to the grimaces and expressive gestures that the pain starts from the patient. Other salient features are that of presenting with brief and repeated crises lasting from one to sixty minutes, appearing abruptly, starting with preferential stimulation of certain areas called "trigger points". The sick, people over 50 years of age, defend themselves and prevent themselves from making any movement that triggers pain, such as chewing or just talking. The affected pathways are the second and third branches of the trigeminal. The pain spreads like a current from the wing of the nose through the jaws to the ear. Between one crisis and another the discomfort disappears.

Glossapharyngeal neuralgia, with similar characteristics, takes the tonsils, jaws, root of the tongue and even the ear. That of the geniculated ganglion can be accompanied by facial paralysis and herpes zoster in the ear, then being called Ramsav Hunt syndrome. Other neuralgias may correspond to branches of the pneumogastric such as the superior larynx, or the vidian nerve, or the petrous nerves.

Auxiliary diagnostic methods

Once the semiological stage has been completed in front of the patient, based on the interrogation and examination, with the contribution of specialists, as has been noted, it is necessary to resort, when the case advises, to laboratory controls, among which is at some point of importance, lumbar puncture for observation of the cerebrospinal fluid.

If a subsequent ordering should be suggested, the electroencephalography will begin, which provides fundamental elements of diagnostic characterization and lesional location. Plain skull radiography illustrates osteolytic or osteoblastic alterations, or bone deformities such as the example of the sella turcica. Cerebral arteriography is highly demonstrative in terms of displacements caused by processes that take place or vascular abnormalities such as arterial or arteriovenous aneurysms; it also detects total or partial obstructions. Computed axial tomography is a highly accurate method of injury determination. Pneumoencephalography, which has its indications, is, however, less used nowadays due to the advance of the previous ones. Radioisotopic scintillation provides elements that multiply in examinations combined with axial tomography. Other non-invasive techniques, such as Doppler ultrasound, provide information about the cephalic arterial circulation.

THORACIC PAIN

Identifying the nature and significance of localized pain in the chest is a very frequent diagnostic problem, and the doctor must distinguish those that are trivial from those that are serious. It can be said that the pains that originate from involvement of the components of the chest wall are generally of good prognosis, and in these cases the pain manifests itself as an isolated symptom. On the contrary, those generated by visceral compromise tend to be more serious, and frequently appear accompanied by other local and general manifestations.

Brief anatomical overview. The thoracic cage has inside the lungs, which are surrounded by the pleurae and separated from each other by the mediastinum, which is a thick septum that includes the other thoracic viscera. It extends from the sternum to the rachis, and from the base of the neck to the diaphragm; It is arbitrarily divided into four spaces, namely: superior, anterior, middle and posterior mediastinum.

The superior mediastinum is bounded downward by a plane perpendicular to the sternal angle and the inferior border of the fourth dorsal vertebra; it houses the upper portion of the thymus, the brachiocephalic venous trunks, the superior vena cava, the aortic arch, and its three main branches, the trachea, esophagus, phrenic nerve, vagus nerves with the recurrent left branch, the cardiac nerves and thoracic duct.

The anterior mediastinum has the thymus and connective tissue.

The middle mediastinum includes the heart and great vessels within the pericardial sac, and the phrenic nerves that descend between the pericardium and the pleura.

The posterior mediastinum, located behind the pericardium, gives way to the descending aorta, esophagus, vagus nerves, thoracic duct, posterior intercostal vessels, azygos major and minor veins, and splanchnic nerves.

Some chest structures are known to lack pain sensitivity, such as the visceral pleura, pulmonary parenchyma, visceral pericardium, parietal as well (except the lower portion adjacent to the diaphragm), lymph nodes, and endocardium.

The remaining thoracic structures have sensitive nerve endings that generate pain, such as the skin, muscles, periosteum, intercostal nerves, parietal pleura, bronchi, esophagus, diaphragm, myocardium, arteries, breasts, and to a lesser extent. degree the endosteum. f The type of innervation that characterizes the different components of the thorax must be taken into account in order to interpret the particular characteristics of the pain originating in each one of them.

Breast tenderness is driven by the 2nd, 3rd, 4th, 5th and 6th intercostal nerves; the fibers of the 2nd intercostal nerve have a connection with the brachial plexus. There are other fibers that ascend from the infraclavicular regions carrying painful sensations through the 2nd and 3rd cervical nerves.

The sensory fibers of the trachea, bronchi, and esophagus run entirely through the vagus nerves.

Those that originate in the parietal pleura, intercostal muscles and in the skin, cross the chest wall as part of the intercostal nerves. The diaphragmatic pleura, in its anterior peripheral portion and in the posterior third, receives fillets from the 5th and 6th intercostal nerves, while the central part receives fibers from the phrenic nerve, like the lower portion of the parietal pericardium adjacent to the diaphragm.

The painful fibers that arise in the heart pass through the cardiac plexus, penetrate the five or six upper thoracic sympathetic nerves and from them through the communicating branches to the corresponding spinal ganglia. Others travel through the inferior, middle, and superior cardiac nerves to the cervical sympathetic nodes, and there is evidence that some neurons emit fibers from the superior cervical ganglion to the Gasserian ganglion. However, most of the sensory fibers that originate in the heart go through the lower cervical sympathetic node (stellate node) and the two or three upper thoracic nodes.

The sensations of chest pain transmitted by the vagus nerve arrive at the bulb and those that pass through Gasser's ganglion penetrate through the bulge, while the rest »enter the spinal cord through fibers that pass through the root ganglia and, after forming the posterior roots are transmitted to neurons in the posterior horns. Fibers for somatic and visceral pain share these pathways; In this way, impulses from visceral nerve endings reach the same reception site in neurons of the posterior horn as impulses from somatic origin, which explains why visceral pain will be perceived in the somatic region with which it shares a final common way.

Interrogation

Individuals who complain of chest pain may present to the doctor in many different ways, some with very severe acute pain that impresses as seriously ill, as in acute myocardial infarction, pulmonary embolism, pneumonia, and in the dissecting thoracic aortic aneurysm; Other individuals seem to be in good health and have permanent pain or pain in brief episodes, but more tolerable, that allow them to coexist with their discomfort in their daily activities, as happens with angina, esophagitis, intercostal neuritis and psychogenic chest pain.

During the interrogation, the doctor must internalize the patient's personality, identifying the patient with hypochondriacal features, who, due to morbid fear of the disease, will magnify banal pain; also those who are obsessive, compulsive and meticulous, who live in permanent conflict with the rest of the individuals and over time, characterizing them as type A personality. These individuals are known to have a higher incidence of coronary heart disease.

The detailed history of this subjective phenomenon, pain, will sometimes allow us to make the diagnosis with questioning only, as in the case of angina, which has very particular characteristics; in other cases it will be necessary to resort, to establish the origin of the pain, to other elements of judgment such as the patient's history, physical examination, radiology laboratory. resting, stress and dynamic electrocardiogram (Holter), echocardiogram, gamma camera radioisotope studies, hemodynamics and angiography, etc. You should always consider:

Location

Irradiation

Character

Intensity

Duration

Time of appearance

Triggers

Factors that aggravate or alleviate it

Concomitant symptoms

Location . The doctor will analyze the location in all cases, immediately imagining, vis-à-vis the pain, the visceral anatomy of the region; however, you should not forget that it can also be irradiated or referred from neighboring or distant organs.

Taking into account the location, the most frequent is pain of the precordial region, which is limited upwards by the sternal handle, downwards by the line that passes through the xiphoid appendix, on the right by a line parallel to the sternal rim located 2-3 cm from it, and to the left along a line drawn from the apex to the sternal manubrium. It includes the topographic view of the mediastinum, its corresponding chest wall, and also the mediastinal pleurae.

It is the location that perhaps arouses greater concern to the patient, due to the immediate deduction he makes of a possible heart disease, the danger of which he does not ignore. It is the classic area of ​​onset of ischemic heart pain, pericarditis, dissecting aortic aneurysm, and esophageal spasm. It is very rare that in these pathologies the pain begins in another area.

The pains located in the rest of the chest, anterolateral, posterior and apical regions, are the consequence of problems of the components of the wall and the parietal pleura.

The stabbing pain of pneumonia and lung infarction manifests in these regions when they irritate the parietal pleura. Apical pain can sometimes be a consequence of involvement of the brachial plexus, as occurs in thoracic operculum syndrome.

Irradiation . Knowledge of the mode of irradiation of chest pain will often help to detect its nature, since some viscera have particular modalities based on their different innervation.

Pain located at the thoracoabdominal border with radiation to the neck and shoulder is characteristic of irritation of the diaphragmatic pleura and also of the diaphragmatic peritoneum, via the phrenic nerve.

Precordial pain with the same irradiation as the previous one is characteristic of pericardial involvement.

The precordial pain that radiates to the shoulder, to the inner edge of the arm to the flexion of the elbow, and to the last two fingers of the left hand, is typical of angina pectoris; so is high radiation to the neck, chin, jaw, ear, and nape.

Precordial chest pain that radiates back to the back is common in dissecting aortic aneurysm.

Character . It is very important to keep this in mind. Retrosternal pain with oppressive or constricting sensation, reported many times by patients with a clenched fist in the precordial region (Levine's sign), is described as having ischemic origin. The same sensation is known to occur in massive pulmonary thromboembolism and also in esophageal spasm.

Another characteristic type of pain is that of acute side pain or wound sensation, which usually characterizes the irritation of the parietal pleura as a consequence of pneumonia or lung infarction.

Intensity , It is not easy to estimate the magnitude of a pain; It can be underestimated in those with difficulties in expressing themselves, such as in a patient with aphasia or in one with a greatly reduced IQ; on the other hand, it can be overrated in the hypochondriac.

In any case, it is recognized as intense pain that which is unbearable for the patient and forces him to rest, as can happen with precordial pain from acute myocardial infarction, although it is not known that there are silent infarctions, especially in diabetic patients .

Intense pains are characteristic in the dissecting aortic aneurysm; also after an attack of vomiting or instrumental manipulation in the acute rupture of the esophagus.

In pericarditis there may be intense pain, but it tends to respond more than the previous ones to pain relievers, the same as in the case of pneumonia and lung infarction.

Mild or bearable pain that allows you to live with it is found in acute bronchitis and in most pain originating from the chest wall.

Moderate pain such as angina or epidemic pleurodynia is located at an intermediate level.

Duration . There are prolonged chest pain as in the case of pleural irritation from pneumonia, herpes zoster, acute mastitis, and acute pericarditis.

Intermittent precordial pain, which is brief in duration, is described as that oppressive retrosternal pain that rarely lasts less than one, nor more than ten minutes, characteristic of angina pectoris.

The pain of acute myocardial infarction exceeds ten minutes and persists for several hours.

Time of appearance . It often helps, in many cases, to determine the time of appearance; for example: the presence of oppressive precordial pain that wakes the patient from sleep, always at the same time, is characteristic of Prinzmetal's angina or variant angina. The onset of pain, studying electroencephalogram patients, has been associated with the period of rapid eye movements (REM sleep).

Triggers, aggravating factors and those that relieve pain . When the patient suffers from constrictive precordial pain that appears regularly when walking quickly and disappears a few minutes after stopping, it suggests angina. Exposure to cold, emotions, intercourse, smoking a cigarette, etc., also produce the same triggering effect, because in these situations there is an imbalance between supply and demand of oxygen to the myocardium.

The Valsalva maneuver, which consists of performing a forced expiration with a closed glottis, relieves anginal pain due to a reduction in the venous return with a decrease in the tension of the myocardial wall, lowering the oxygen demand. Absorption of sublingual nitroglycerin also produces the same effect, but it is necessary to keep in mind that this drug also relieves pain from esophageal spasm and biliary colic due to smooth muscle relaxation.

Post-esthetic pain that is aggravated by changes in posture, during deep inspiration, sometimes with swallowing, and that remits when sitting or leaning forward, suggests acute pericarditis.

Pain as a side stitch that increases with deep inspiration, with coughing, sneezing, and yawning indicates irritation of the parietal pleura and usually occurs in pneumonia or lung infarction. This pain diminishes or ceases when the effusion appears and also adopting the lateral decubitus on the diseased hemithorax, which immobilizes the rib cage thereby causing abdominal breathing.

Low precordial pain that occurs with lying down or leaning forward, that decreases or ceases with antacids, is characteristic of reflux esophagitis.

Inquiring about trauma, effort and sudden movements should not be omitted, looking for the cause of possible chest wall injuries, as well as the intake of caustics and very hot foods that can produce acute esophagitis.

Concomitant symptoms. The analysis of the symptoms that accompany the pain, usually helps to further characterize its nature; For example: that individual who manifests a band chest pain, who does not tolerate the rubbing of clothing and reports the appearance of dermal lesions with vesicles, configures the classic picture of herpes zoster.

When chills, fever, cough, expectoration and dyspnea are associated with the appearance of stabbing pain in the side, it leads to pneumonia. A similar painful picture accompanied by dyspnea, cough and hemoptoic expectoration in a patient with heart failure or during an immediate postoperative period or with thrombophlebitis of a lower limb, suggests a pulmonary embolism with a pulmonary infarction.

Constrictive retrosternal pain associated with epigastric burning sensation, dysphagia, and regurgitation of food is suggestive of esophagitis with esophageal spasm.

When intense retrosternal pain, sudden onset and radiating to the back, is associated with neurological deficit or acute pain in a cold and pale upper limb, it leads to a dissecting thoracic aortic aneurysm.

Personal information. Sex and age are data that serve as orientation; Thus, precordial pain in a person under thirty years of age and in women throughout their fertile life is highly unlikely to be due to coronary heart disease.

Morbid history. Analysis of the patient's history is very helpful; Currently, numerous factors are known that, when present in isolation, produce a higher incidence of development of atherosclerotic disease at all levels, such as hyperlipoproteinemias, high blood pressure, diabetes mellitus, smoking, obesity, sedentary lifestyle, hyperuricemia, stress, etc. Thus, in relation to a patient who manifests pain suggestive of myocardial ischemia, the association with one or more risk factors further confirms the suspicion.

A history of long-standing arterial hypertension is frequent in patients with aortic dissecting aneurysm, except in cases of Marfan syndrome or idiopathic median cystic necrosis.

Patients with systemic lupus erythematosus often develop pericarditis or pleurisy; on the other hand, the development of herpes zoster is common in immunosuppressed patients.

Summary of pathologies in relation to the characteristics of chest pain

The different types of chest pain are arranged in three groups, according to the origin of the pain, namely:

Pains originating in the chest wall.

Pains originating in the thoracic viscera.

Pains of extrathoracic origin that are referred or irradiated to the chest.

1. Pains originating in the chest wall

The pains produced by involvement of the sensitive components of the chest wall are called somatic pains, and include neuralgia, radicular pain, ostalgia, arthralgia and mastalgia.

1. a) Neuralgia. It is a consequence of irritation 4 of the intercostal nerves secondary to neuritis, trauma, toxins, infections, and compression of the nerve.

In neuritis, the pain usually starts suddenly, is located in the intercostal space, is throbbing, burning, and in severe cases it has paroxysms when the patient breathes deeply, coughs, or moves; sometimes it can be located in the precordial region. The patient accurately locates the site of pain along the intercostal nerve path; Paroxysms are produced by gentle pressure, especially near the vertebrae, in the axillary lines or near the parasternal lines (Vaileix points).

Herpes zoster is a characteristic form of irritation of the posterior roots that produces an acute inflammatory dermatosis characterized by vesicles arranged in clusters, and is frequent in chronically ill and cancerous subjects. The herpetic lesion may be preceded by intense burning in the nerve path, developing a strip of cutaneous hyperesthesia; The pain can be disabling and persists for many weeks, even after the skin lesions have healed, extending from the spine to the anterior midline. A chickenpox-like virus that would cause severe hemorrhagic inflammation in the spinal ganglia has been isolated from the lesions, while degeneration of its fibers is noted in the peripheral nerves.

Chronic intercostal neuralgia is described by the sliding of the eighth, ninth, and tenth costal cartilages on either side, as the fibrous inserts loosen, causing trauma to the intercostal nerve. The pain is dull and mild, tolerated for years; sometimes it is paroxysmal and very intense, and is triggered by palpation over the lesion.

1. b) Root pain.It means irritation of the posterior roots of the spinal cord, caused by toxins or infections (radiculitis), but usually results from mechanical irritation of the posterior root, secondary to deformities or spinal compressions. In hypertrophic osteoarthritis, the bone spurs adjacent to the conjunction holes can irritate the roots as the spine moves. Narrowing of the intervertebral spaces by compression of the pulpy discs can cause compression of the nerve trunks. It is known that in thoracic operculum syndrome radicular pain occurs that is referred to the chest wall, due to compression of the brachial plexus between the clavicle and the first rib, or due to the presence of a cervical rib or the anterior scalene muscle .

The radicular pain is usually lancinating, sometimes with stitches in the spinal region; it is aggravated by pastural changes such as getting up, torsion of the trunk, mobilization of the arms, etc. The pain often refers to the anterior and lateral walls of the chest, and can be sharp, although it is often dull. This same pain, when radiating to the sternum and shoulders, can sometimes be mistaken for angina, and careful questioning in these cases reveals a history of back pain.

Pain in the upper part of the anterior and posterior aspects of the chest sometimes results from irritation of the posterior dorsal roots and also from cervical disorders, since the nerves of the major and minor pectorals, the suprascapularis, the rhomboids and the serratus major they originate in the lower cervical segments and when irritated they can produce pain in the thorax.

Spine radiography is helpful, and shows skeletal abnormalities that produce radicular pain; however, it should be noted that there are sometimes bone abnormalities that are not accompanied by symptoms.

1. c) Myalgia. Muscle irritation is a frequent cause of somatic pain; it appears to be a tissue that only causes dull pain.

Inflammation and pain can occur in many different situations such as trauma, bruising, general infections, trichinosis, myositis, ossifying, etc.

An incessant or paroxysmal cough, intense, often causes pain in the intercostal muscles.

Myositis can cause pain on palpation, which often reveals nodules and muscle tightening.

Exercise of untrained muscles of the shoulder girdle causes myalgia.

In a large group of soldiers, it has been observed that distension of the pectoralis minor muscle can cause localized pain in the anterior chest wall in the muscle area, without irradiation.

1. d) Ostalgia. Bone pain originates from the sensory nerve endings, very abundant in the periosteum and less in the endosteum; consequently, there may be painless osteopathy when the mentioned structures are not involved.

The involvement of the periosteum produces intense pain, very well localized; On the other hand, chronic diseases that affect the bone marrow and the endosteum cause pain of variable intensity and poorly localized.

Trauma with or without a fracture to the ribs and rachis produces intense pain due to involvement of the periosteum, as does osteomyelitis that causes periostitis.

In aneurysmal syphilitic aortitis, gradual erosion of the sternum occurs, generating constant, localized and intense pain; This can also occur from mediastinal tumors such as Hodgkin's disease and lymphosarcoma. There may be dull, severe pain in cases of metastasis to the dorsal vertebrae and ribs, prostate carcinoma, breast carcinoma, and hypernephromas. In many cases these lesions are not visible on radiographs, but must be suspected due to the intensity of the symptoms and the presence of cancer elsewhere; at these stages they can be detected by bone scintigraphy with technetium 99 labeled with MDP.

It is known that in leukemia and multiple myeloma there may be ostalgias that are accentuated by compression of the sternum and ribs.

1. e) Arthralgia. The involvement of the chondrocostal and sternoxyphoid joints generates chest pain; It can be inflammatory, rheumatic or traumatic in nature.

Costoperichondritis, described by Tiemann, is characterized by being very painful; It produces a visible tumor, sensitive to palpation, located on the upper or lower edge of the affected cartilage and respects the anterior aspect. On a careful examination it can simulate angina. Tietze syndrome is quite frequent and is characterized by pain at the level of one or more rib cartilages, always on the same side, which increases with exertion, cough and deep inspirations, simulating pleuritic pain. It is accompanied by a sensitive swelling of the affected cartilage, and takes several months to resolve completely.

1. f) Mastalgia. The integuments of the mammary gland have the ability to accurately locate superficial painful stimuli. The patient usually easily identifies pain caused by skin incisions, boils, bruises, swelling of areolas, and nipple cracks.

The parenchyma appears insensitive, except when stromal distension occurs, due to cancer or inflammatory injury, as in acute postpartum mastitis, and can sometimes generate severe pain (Fig. 5-5). However, there are bulky tumors that do not cause pain.

Mastodynia is a frequent cause of breast pain; It usually begins progressively over months or years, frequently worsens before menstruation, and is located in the super-external quadrant of the breast, which is hard and sensitive to palpation. Jerking or movements of the breast exacerbate the pain. The gland presents insufficient lobular development with an increase in the pericanalicular stroma, epithelial proliferation and changes that form cysts and adenosis.

2. Pains originating in the thoracic viscera

They are called visceral pain and include tracheobronchial, pleural, pericardial, esophageal, mediastinal pain, heart pain, and aortic pain.

1. a) Tracheobronchial pain. In acute tracheitis there is high retrosteinal pain with a burning sensation, which is aggravated by coughing and diffuses to the projection sites of the source bronchi.

Embedding of a foreign body, for example a fish bone, in the upper portion of the trachea causes pain on the front of the neck. Inflammatory and neoplastic lesions of the main bronchial tubes accurately locate pain on the anterior side of the chest. Tracheobronchial pain is then assumed to refer to sites in the neck or anterior portion of the chest that correspond to the same level as the areas of irritation of the airways.

1. b) Pleural pain. When stimulated, pain-responsive fibers originating from the parietal pleura produce sharply localized, cutting, intense pain, exacerbated by respiratory movements, coughing, sneezing, and spinal movements.

If the affected pleura is the lowest, the pain may radiate along the edge of the ribs to the upper quadrants of the abdomen.

Pleural pain decreases or ceases when the effusion appears and when the patient adopts lateral decubitus on the diseased hemithorax.

If the pleuritis is interlobular, the pain is in the girdle and accompanies the path of the pulmonary fissures.

The mediastinal pleura produces retrosternal pain that radiates to the neck, and in the diaphragmatic pleuritis pain is experienced at the thoracoabdominal border, with irradiation to the neck and shoulder.

Pleural pain is seen in acute fibrinous pleurisy complicating inflammatory lung diseases such as pneumonia, manifesting early with a side stitch and chills. But if the process is central, the pain appears late, when, with increasing size, the focus reaches the parietal pleura. In children, it is possible that the pain is perceived in the corresponding hemiabdomen through the intercostal nerves, generating the possibility of a confusion that has even led to laparotomies for alleged acute appendicitis.

Chest radiography is indisputably helpful in diagnosis, which will show a medium-density shadow that classically adopts a triangular vertex shape facing the mediastinum.

Pulmonary thromboembolism with lung infarction is manifested by intense, sudden pleural pain and progressive dyspnea, acceleration of the pulse, and distress. At first, chest radiography frequently shows no significant abnormalities, pulmonary scintigraphy being of great diagnostic value, and the determination of the ventilation / perfusion ratio, of great sensitivity, which will show areas without arterial perfusion with normal ventilation.

In healthy men, spontaneous pneumothorax usually occurs, characterized by severe pain in the upper and external portion of the chest wall, accompanied by dyspnea. Possibly the pain is due to the existence of adhesions that become tense when the lung rapidly collapses; It should be noted that it can occur without pain.

Chest radiography shows a transparent field with no lung structures.

When the parietal pleura is invaded by neoplastic tissue, constant pain occurs due to irritation of the sensory endings. When invading the superior costovertebral sinus (Pancoast tumor), carcinoma of the apex of the lung produces apical and shoulder pain, and involves the brachial plexus, also causing intense radicalgias.

In addition, it invades the lower cervical ganglion or stellate ganglion and generates sympathetic symptoms, either by excitation (Pourfour du Petit syndrome) with mydriasis, exophthalmia and increased palpebral fissure, or by paralysis (Bernard-Horner syndrome) with miosis, endophthalmia and decreased palpebral fissure.

1. c) Pericardial pain. It only appears in acute inflammatory processes, with or without effusion, and if the pericarditis is not inflammatory the pain is minimal or nil.

The phrenic nerves carry sensory fibers from the lower portion of the parietal pericardium adjacent to the diaphragm.

In acute pericarditis the pain is precordial, and to the left of the sternum, and substernal pain is also common. Sometimes it is intense and is confused with that of myocardial infarction. In part, the pain appears to originate from the adjacent pleura in close contact, which is why it increases with coughing, swallowing, deep breathing, and postural changes. It radiates to the neck and shoulder due to irritation of the phrenic nerve (Fig 5-6).

When the effusion is voluminous, the pain is relieved in the genupectoral or ma-hometana prayer position or in the Blechmann position, flexing the trunk on the thighs and resting the head on a pillow placed on the knees.

Some patients feel synchronous pain with the heartbeat. On physical examination, the presence of a pericardial rub usually confirms the origin of the pain.

On the electrocardiogram, changes in repolarization appear, characterized by diffuse ST-segment elevation and diffusion of the T wave on some occasions.

The echocardiogram clearly shows, when there is pericardial effusion, an echo-free space between the visceral and parietal pericardial sheets.

1. d) Esophageal pain. The esophageal mucosa is more sensitive to pain in the upper portion; acid regurgitated from the stomach produces a burning sensation in the upper thoracic and cervical region, without sensations in the lower part of the esophagus.

Organ distension causes constrictive pain, and the higher it is, the higher the retrosternal pain and its dorsal projection will be.

Heartburn is a painful sensation of retrosternal burning near the heart, after swallowing a food; it is of short duration and is attributed to regurgitation of the gastric contents and insufficiency of the cardia to open immediately after swallowing.

In acute esophagitis there is pain when swallowing, retrosternal, radiating to the back; It can be acute by foreign bodies and caustics, or chronic, which is frequently observed in alcohol islands and in smokers.

Esophageal carcinoma is painless in itself, except if it is complicated by esophagitis.

Esophageal spasm produces intense, paroxysmal retrosternal pain radiating to the neck and shoulders, accompanied by respiratory distress, tachycardia, and sweating, as in angina. It generally occurs after swallowing and concentric tightness can be detected on the barium-contrast radiograph, which clarifies the diagnosis.

The class and location of esophageal pain may be inconclusive; however, the presence of other symptoms such as dysphagia and regurgitation suggests esophageal disease.

1. e) Mediastinal pain. The mediastinal lymph nodes affected by Hodgkin's disease may not cause pain unless nerve fibers are involved, thanks to the elasticity of the tissues that limit them and their non-invasive nature. Alcohol intake is known to cause pain in the affected area, mediastinum or bone, but the pathogenesis of this phenomenon is unknown. It occurs even with small amounts of alcohol and lasts from 30 to 60 minutes, the time it takes for most of the alcohol to oxidize.

However, many mediastinal tumors produce vague retrosternal pain, along with cough and dyspnea.

Spontaneous mediastinal emphysema causes excruciating pain, triggered by rupture of a thinned alveolus and by air breaking through the planes of detachment into the mediastinum: it is usually accompanied by pneumothorax. It begins with the patient standing still and is manifested by precordial pain that radiates to the nape of the neck and shoulders, lasts for hours, and a characteristic crackling synchronous with the heartbeat is heard.

1. f) Heart pain. The heart muscle is insensitive to palpation, but it is a source of pain when the irrigation through the coronary arteries does not provide the oxygen required by the myocardium, motivating the accumulation of metabolites of acid reaction (substance P, described by Levis) that stimulate the termi -sensitive nations. This type of pain is known as ischemic pain, distinguishing angina and myocardial infarction.

Angina pectoris can be defined as paroxysmal precordial chest pain, which is normally due to a transient imbalance between oxygen delivery to and demand for the myocardium.

It appears suddenly during an effort, a fast march, an emotion, in full di-managerial work, during intercourse, smoking a cigarette and in exposure to the cold. It is located in the retrosternal region, the patient describes it by applying the claw hand on the sternum (Levine's sign), it radiates to the shoulder, inner edge of the arm, forearm and two last fingers of the left hand. Radiations to the neck, chin, ears, and nape of the neck are fairly specific (Fig. 5-7).

The patient, surprised by the pain, remains immobile, and the pain subsides completely in a few minutes.

Cigarette can trigger anginal crisis because carbon monoxide produced in combustion binds to hemoglobin by shifting the dissociation curve of oxyhemoglobin to the left, thus reducing oxygen delivery to the tissues. Furthermore, nicotine absorbed through the lung and mucosa increases heart rate, systolic and diastolic pressure, and cardiac output, by releasing endogenous catecholamines, increasing the oxygen demand of the heart muscle.

Angina peaks rapidly with the absorption of sublingual nitroglycerin, because it is a powerful smooth muscle diatlator and produces a decrease in coronary vascular resistance, increasing coronary irrigation in the normal man; however, it has less influence on flow in patients with advanced disease.

It is probable that the efficacy of nitroglycerin is due to a reduction in the work of the heart with accumulation of blood in the venous bed, thus decreasing the return, and due to a drop in general vascular resistance, reestablishing a more favorable relationship between supply, by increased coronary irrigation, and demand, by decreased cardiac work.

Angina pectoris is a symptom, not a disease. Angiographic studies detect coronary heart disease in more than 90% of cases, but there are other processes that can cause it, such as obstruction of the left ventricular outflow channel due to valvular aortic stenosis, or subaortic muscular stenosis, or severe arterial hypertension and in addition, aortic insufficiency, anemia and severe hypoxia. These circumstances are accompanied by an increase in the oxygen demand of the myocardium and in the last two by a decrease in the contribution.

Severe systolic hypertension of the right ventricle, in pulmonary embolism and pulmonary hypertension, can lead to anginal pain, possibly as a consequence of subendocardial ischemia of the right ventricle.

To confirm the diagnosis, the effort axis electrocardiogram is available, which can give classic signs such as negative ST segment elevation, suggestive of coronary heart disease; This non-invasive technique is simple and inexpensive; it is used en masse and has an overall sensitivity of close to 60%. The most advanced gamma camera techniques, such as the thallium perfusion study and the technetium 99 radiocardiogram, have a sensitivity greater than 90%.

Cinecoronary angiography is the technique that shows the state of the arterial tree and allows the detection of narrowing or obstruction sites with precision. Because it is a bloody method, it has specific indications for doing it.

There is anginal pain, known as variant or Prinzmetal angina, that appears at rest and generally always at the same time, and that is possibly more intense and prolonged than that of exertional angina pectoris. It is due to an acute decrease in the supply of oxygen to the myocardium by isolated coronary spasm or spasm added to an atherosclerotic lesion.

The data collected is generally very accurate, and the bloodless technique used for diagnosis is the 24-hour dynamic electrocardiogram, in which, during the crisis, typical changes such as ST segment elevation are recorded. Cinecoronariography may or may not show occlusive disease of the coronary vessels.

A third category of angina is unstable angina, which is characterized by progression of pain in stable exertional angina or recent onset angina. Pain occurs during both exertion and rest.

Acute myocardial infarction is a serious clinical syndrome, resulting from a poor coronary irrigation that causes the death of the cells of a sector of the myocardium. It is characterized by more intense and prolonged pre-cordial pain than angina pectoris, often accompanied by nausea, vomiting, diaphoresis, and dyspnea. It usually lasts an average of several hours and does not spoil with nitroglycerin. The irradiation of pain is equal to that of angina pectoris. However, there is a great diversity of symptoms, and it is known that in a significant percentage of cases, especially in the elderly and diabetics, painless or silent heart attacks can occur.

Infarction can occur as a consequence of occlusion of a coronary artery by acute thrombosis, subintimal hemorrhage, or rupture of an atheroma plaque, but it can also be observed without coronary occlusion.

On the electrocardiogram there are useful signs of myocardial necrosis for diagnosis, such as the appearance of the Q wave, in this case being called a transmural infarction; other times there are only changes in repolarization, such as negative ST segment elevation and negative T wave, and in these circumstances we speak of non-transmural infarction.

Studying the electrocardiographic correlation with findings at autopsy, it has been shown that there are transmural infarcts with only changes in repolarization and also the inverse, that is, non-transmural Q wave infarcts.

Another sign of necrosis is an increase in the serum level of certain enzymes such as creatine phosphokinase (CPK), which exists in high concentration in the heart and skeletal muscle; it increases rapidly reaching maximum values ​​after 24 hours. There are three varieties of CPK; MM is from skeletal muscle, BB is from the brain, and MB is from the heart muscle.

The determination of the MB variety, which is specific to the heart muscle, is useful for the diagnosis of acute myocardial infarction in those patients in whom damage to the skeletal muscle occurred, such as occurs immediately after surgery or injection intramuscular.

Glutamic oxalacetic transaminase (TGO) reaches its maximum level 48 hours after the infarction. It exists in high concentration in the myocardium, skeletal muscle, liver, brain, and kidney.

Lactic dehydrogenase (LDH) is found in various tissues, and increases in the serum level are usually not specific for a diagnosis of heart attack. The gamma camera study, using technetium pyrophosphate, detects the presence of a myocardial infarction in the acute stage.

1. g) Aortic pain. Clinically, the most easily identified aortic pain is that of a dissecting aneurysm.

The pain starts abruptly and becomes unbearable, unlike that which occurs in myocardial ischemia, which progressively increases in intensity.

It is accompanied by a feeling of tearing, it can radiate towards the neck, characteristically to the back, and also to flanks or legs depending on the location. It is a constant pain with paroxysms; During the attack, patients can lie down, get up, squirm in bed looking for relief, which contrasts with the behavior of the patient with a myocardial infarction, which remains immobile. Sometimes there are manifestations of collapse. There are cases of brief and mild pain that are mistaken for angina. When the dissection compromises the lumen of the cerebral arteries, neurological pictures are produced.

Most patients have a history of long-standing systemic arterial hypertension, except in cases of Marfan syndrome or idiopathic median cystic necrosis.

It is common to misdiagnose it as an acute myocardial infarction, with the caveat that the infarction is a known complication of the dissecting aneurysm when it involves the ostium of a coronary artery. A chest radiograph shows an aneurysmal aorta, and a definitive diagnosis is made with an arteriogram.

3. Pains of extrathoracic origin that are referred or irradiated to the chest

1. a) Psychogenic chest pain. Psychogenic pain is included here considering it to be of extrathoracic origin, product of the imagination.

It usually occurs in anxious and hypochondriacal patients, in most cases female. It is located in the precordial region and would inframamaría, with a stinging sensation, other times oppression. It is usually prolonged, unrelated to effort, and is experienced after an activity or at sunset.

Associated symptoms include sighs, sadness, irritability, and easy crying.

Some find pressure sensitivity of the left fourth chondrocostal joint. No other signs were detected on the examination, nor in the complementary studies.

1. b) Chest pain originating from abdominal viscera. Approximately 10% of patients suffering from chest pain have conditions in the abdominal cavity, responsible for the painful manifestations.

One of the most frequent is the distension of the splenic flexure of the colon, which radiates pain to the left hemithorax and is relieved by bowel movements and gas elimination.

Subphrenic abscess and hemoperitoneum, due to irritation of the diaphragmatic peritoneum, radiate pain to the shoulder (Kehr sign).

In acute pancreatitis, many times after a large meal, sudden epigastric pain appears, radiating to the left rib margin, reaching the scapula on the same side. Pain and early shock often suggest a heart attack.

Gastric ulcers of small curvature neighboring the cardiac and posterior ones, as well as diaphragmatic hernia, may be accompanied by pain radiating to the chest, with a constrictive sensation that generates confusion with angina pectoris.

In acute cholecystitis and biliary colic, pain may be irradiated to the back, scapula, and right shoulder.

ABDOMINAL AND PELVIAN PAIN

Recognizing the meaning of abdominal pain in time is a serious and difficult responsibility that the acting doctor must assume. Subtracting significance from its early evaluation, and underestimating its importance, can lead, and unfortunately still leads, to trigger catastrophes in the ab-domen.

As in all regions of the economy, abdominal and pelvic pain require a correct interpretation; but perhaps as in none of them, this evaluation must be done early.

To begin, a brief review of the anatomy of the wall and the abdominopelvic cavity will be made, completed with an analysis of the anatomical mechanism of abdominal pain.

It will be seen what causes pain at this level, analyzing abdominal and pelvic algia as isolated symptoms and in relation to the symptoms and signs that accompany them, to finish, completing the topic, with the study of diagnostic auxiliary procedures and of the main syndromes of abdominal pain.

Brief anatomical overview. Viewed from the outside, the abdominal wall is described as having two faces or walls: the posterior and the anterolateral.

The posterior wall has an axis, the vertebral column an ​​upper limit, the twelfth rib, another lower, the iliac crest, and some lateral borders, the posterior axillary lines, It forms a solid muscle mass, known as the lumbar fossa, composed of the muscles width of the abdomen, the square of the loins and the paravertebral muscle groups.

It has two weak points, without great medical significance: the Grynfelt ring and the JL Petit triangle.

The most extensive and relevant anterolateral wall, less solid and consistent, limits above with the costal rim and the xypho-costal angle, below with the pubis, the crural arcade and the anterior iliac spines, and laterally with the posterior axillary lines. It is entirely occupied by the anterior rectus muscles and the wide muscles of the abdomen. It has weak points of great anatomical and surgical importance, such as the inguinocrural region, the umbilical region, the alba line and the Spieghel line.

If a horizontal line is drawn at the level of the costal ridge, another one that joins the two anterior and superior iliac spines, and two vertical lines projecting down the midpoint of the clavicle, the anterolateral wall of the abdomen will be divided into compartments of much semiological importance. Thus, in the midline, from proximal to distal, the epigastrium, mesogastrium and hypogastrium are distinguished, while, on each side, also from cephalad to caudal, the hypochondrium, flank and iliac fossa can be observed, to the right or to the left, depending on which side of the midline it is located.

Imaginatively, the projection on these quadrants of the different hollow and solid viscera of the abdominal content must be remembered; in the epigastrium, keep in mind the semilunar space of Traube, corresponding to the gastric chamber; the cystic point, the precise place where the gallbladder hurts, at the junction of the navel with the hemiciavicular line; and the Chauf-fard-Rivet pancreaticocolledocian zone, delimited by a line that goes from the navel to the xiphoid appendix and by another than the same navel with the mid-axillary line in the approximate projection of the sixth rib.

If the cavity of the abdomen is penetrated, it is noted that it also decomposes into compartments, namely: the insertion of the transverse mesocolon in the posterior abdominal wall, successively crossing the second duodenal portion and the entire extension of the anterior face of the pancreas, It divides the 1st abdominal cavity into a supramesocolic and an inframesocolic half. The supramesocolic compartment contains the liver, gastric and splenic cells. The gastric cell is located in front of the retrocavity of the omentum, which has the pancreas as the posterior aspect and the diaphragm as the roof.

In turn, the inframesocolic half is divided, by the insertion of the ascending and descending mesocolons and the root of the mesentery, into parietocolic and mesentericocolic compartments, right and left, respectively.

The vast majority of the viscera are completely covered with peritoneum, but others are retroperitoneal, such as the kidney and ureters, the pancreas and the second duodenal portion; preperitoneal, like the bladder; or extraperitoneal, such as the lower half of the rectum.

The pelvic cavity continues insensitively upwards with the abdominal cavity, and is delimited laterally, in front and behind by the bony pelvis, made up of the coxal and sacrococcyx bones. The lowest point of the entire cavity is in the pelvis, and it is the Douglas cul de sac, between the bladder and rectum in men, and between the rectum and uterus in women. Fluids discharged into the abdomen converge with great frequency, although alternatively these collections can drain into the interhepatho-diaphragmatic or subphrenic space, into the subhepatic space, into the transcavity of the omentum, or in the direction of the mesentericocolic or parietocolic compartments.

Anatomical mechanism of the production of abdominal pain. The initial stimulus intended to produce pain must, of course, be of sufficient intensity to trigger it. But it must, on the other hand, necessarily come up with a receptor capable of capturing it and a nervous transmission system that takes it to the cerebral cortex and brings back a motor response.

The parietal peritoneum and skin, which are the most exquisitely sensitive points on the abdominal wall, direct their stimuli towards the cerebrospinal pathway that leads them to the ganglia of the posterior roots, from where they penetrate the posterior horn. From this point a second neuron starts, crossing from the posterior horn to the contralateral side of the medulla and ascending the spinothalamic bundle, passing to the posterior central nucleus of the thalamus. Here the third neuron is born, ending in the posttrollar gyrus of the cortex.

In the thalamus, connections are established with higher integrating planes where painful stimuli are interpreted, which can be integrated at three levels: the superior, the cortex, the intermediate, the thalamus, which interrelates with the cortex to discriminate location and intensity; and the lower one, the quadrigeminal tubercles and the hypothalamus.

Visceral stimuli are transmitted by the visceral afferent fibers of the splanchnic nerves that concur with the sympathetic nerves to the ganglia of the posterior roots through the white communicating branches, penetrating the posterior horn with the somatic neurons, which they accompany in all their way.

What stimuli cause pain in the abdomen. It is important to remember where abdominal pain can be triggered, and what kinds of stimuli trigger it.

The parietal peritoneum is very sensitive to minimal aggression; its response to mechanical, thermal, or chemical stimulation is entirely comparable to that of the skin, and much more important than that of the remaining layers of the abdominal wall. Without going any further, a simple puncture of the abdomen without anesthesia generates very intense painful responses when passing through the skin and the parietal peritoneum, while it is well tolerated when passing through the subcutaneous cell, fascia and muscles. This painful threshold is shortened with fear, as in the immediate preoperative period, in children and in the faint-hearted, and it becomes higher in stressful situations, such as in war or fighting.

The visceral peritoneum that covers the hollow viscera has very little painful response. The same is not the case with the peritoneal capsules of envelope of the massive organs, such as the Glisson's capsule of the liver and the spleen capsule, which respond painfully to stimulation. These envelopes can be attacked from within, by post-traumatic hemorrhages, edema, inflammation or sudden increase in the size of the parenchyma, or from the outside, by trauma of all kinds.

The hollow viscus itself has no painful response to external aggression. What hurts in these organs is the chemical irritation of the mucosa, with acids or alkalis, for example, the distension of the walls by gases, liquids or pressurized feces, and the tension exerted on the mesos by pulling them, trying to mobilize the organs. The vascular occlusion of the arteries supplying these viscera also causes ischemic pain, known as "abdominal angina".

As a practical conclusion, it can be said that any abdominal surgical intervention can be carried out without anesthesia, if contact with the parietal peritoneum, chemically irritating the mucosa, straining the intestinal lumen, dividing the mesos or interrupting its irrigation is avoided.

Characterization of abdominal pain

In front of a patient with abdominal or pelvic pain, the examiner is obliged to characterize this pain, regardless of the signs or symptoms that may accompany it.

The analysis of abdominal pain due to its characteristics rests on four pillars: evolution, type, intensity and location.

1. Evolution. It involves investigating the appearance of pain, its changes over time and the way it ends.

A pain of recent appearance has greater importance and eventual severity than another of older dates; she must incline to think about acute abdominal pathology, and forces her to follow it closely in the course of hours. The appearance of pain should always be investigated in relation to possible triggers, such as intake, trauma, effort, sudden appearance of hernias, etc.

The changes over time of the pain itself have enormous significance in the abdomen. It is good practice, in front of a sudden onset abdominal pain and short evolution, hospitalize the patient and observe if this pain calms or increases with the course of hours. Very often, pain that spontaneously decreases in intensity does not respond to emergency surgical pathology.

The way to end or calm the pain is very valuable. It is necessary to investigate whether it is spontaneous or if it is verified with vomiting, ingestion, in analgesic positions, with rest or effort, or with the administration of analgesics or antispasmodics.

2. Types of pain. Depending on its modality, abdominal pain can be dull or sharp, and these two, in turn, can be colic or permanent. The dull pain can be at the same time permanent and relatively tolerable. It manifests in the abdomen as an oppression or heaviness, and is due to the moderate distension of the hollow viscera or the capsules of the solid organs.

The acute pain is alive, much more dramatic, dramatic, intense; it reminds the patient of “pinpricks” or “stabs”, it is accompanied by neuro-vegetative manifestations, such as sweating, trembling, goose bumps or paleness, and is usually caused by significant bloating of the hollow viscera or by physical, chemical or septic irritation of the peritoneum.

The cramping pain is one that "comes and goes"; the patient describes it as "cramps," or as something that appears, gradually increases and gradually gives way to disappear. Sometimes it does not go away completely, and it simply flares up or decreases in an episodic or cyclical way, configuring subintrant colic . Colic pain usually calms with the administration of antispasmodics, it is accompanied in its exacerbations by multiple neurovegetative manifestations, the patient is observed to look for analgesic positions and sometimes change them permanently, and responds especially to irritation or injury of the hollow viscera such as small intestine or colon. The permanent pain is l which remains unchanged in its features along hours.

3. Intensity. According to its magnitude or intensity, the pain is classified as mild, moderate, intense and intolerable.

Mild pains are perceived by most normal individuals. Fasting epigastralgia due to irritation of the gastric mucosa or abdominal pain due to moderate distension are frequently observed.

In normal physiological situations such as premenstrual or ovulation, moderate or intermediate pain can be observed .

The intense pain of biliary colic, acute appendicitis or abdominal trauma leads the patient to the consultation, while the intolerable pain , observed in pancreatitis, for example, compromises the general condition and requires immediate therapy.

4. Location. An abdominal pain can manifest as localized or generalized.

Generalized pain usually indicates evidence of several hours of evolution and is more serious.

Localized pain appears in the debut of acute symptoms and guides the doctor in the search for the diagnosis.

Thus, epigastric pain appears at the beginning of appendicitis, and in conditions of the gallbladder, pancreas, stomach and duodenum. The painful mesogastrium refers to a condition of the small intestine. The hypogastrium "hurts" when the bladder and the annexes are damaged. The right hypochondrium reveals liver or biliary pain.

If there is pain in the flanks and lumbar fossae, one should look for, apart from muscular pathology of the area, nephroureteral affections, and bear in mind, if the pain is right, the projection to that region of the pain caused by the abrupt distension of the airway. main bile.

Each segment of the colon causes pain in the quadrant of the wall on which it is projected. Malignant tumors that close the intestinal lumen, producing occlusion, distend the proximal portions of the colon with respect to the lesion, and it is these that hurt; this is why a sigmoid tumor rarely hurts in the left iliac fossa, and is evidenced by pain in the right iliac fossa, a witness to cecum distension.

The concept of referred pain and radiated pain should also be clarified here.

The referred pain is a painful sensation at the level of the skin that appears accompanying acute or severe visceral pathologies, such as abdominal angina or appendicular syndrome; It usually calms with the local anesthetic injection of the affected integument, and it is accompanied or not by a true concomitant visceral pain.

If a pain affects two quadrants simultaneously, we are in the presence of irradiated pain . Thus, an acute vesicular picture hurts in the epigastrium and right hypochondrium, but it radiates, runs to the ipsilateral lumbar fossa; and the pain in the right iliac fossa of the appendicular syndrome itself radiates to the thigh on the same side.

Abdominal pain according to the symptoms or signs that accompany it

A correct and systematic analysis of the data provided by abdominal pain, studied as an isolated symptom, provides elements of enormous value for the purposes of shaping a syndrome. But comparing these data with those provided by the signs or symptoms that usually accompany it, greatly increases the possibility of getting it right.

In the case of the infant who suggests pain with crying, the location of the pain and the structuring of the syndrome are only addressed with the contribution of concomitant signs. The old man sometimes does not experience pain, and if he feels it, it is usually typical, deformed, exaggerated or minimized depending on the circumstances; In this case, the accompanying signs or symptoms are by far more important than the pain itself. Mentally ill patients often suffer irrelevant pain for the purpose of diagnosis, and the same occurs with simulators, the faint-hearted and the hysterical, in which the accompanying signs and symptoms provide the necessary data.

To analyze the symptoms and signs that accompany abdominal pain, the data provided by the interrogation and examination are separated into five groups:

Personal information

Signs relating to general condition

Digestive manifestations

Urinary or genital manifestations

Abdominal signs

1. Personal data. Those listed below will be considered:

1. a) The sex and age of the patient are the first general data to consider in a carrier of abdominal pain. Much of the pathology is predominantly distributed in both sexes and in certain age groups. Biliary lithiasis, for example, prevails in women over 40 years of age. The infant, due to its thin walls and short omentums, generalizes its peritonitis more quickly.

1. b) Hereditary history is of particular importance, since there are many pathologies related to abdominal pain, such as colon cancer, the incidence of which is higher in certain families.

1. c) The origin forces to consider regional pathologies.

1. d) The profession should not be underestimated either. since there are occupational diseases, such as lead poisoning, that simulate an acute abdomen.

1. e) Race , like racial types, must be included in a general context. Sickle cell disease, which occasionally causes acute pseudoabdominal disease, is unique to blacks, while familial Mediterranean fever, or "maladie vedette," which occurs with severe abdominal pain, is frequently described in Arabs.

1. f) Personality is a highly valuable fact, but it should not induce to discard disease due to the fact that the patient is an anxious, hysterical or hypochondriac. It must be taken into account, but in moderation.

1. g) Toxic habits , such as alcoholism and drug addiction, should not be underestimated.

2. Signs related to the general state. Among them, and due to their importance, we can mention the following:

1. a) Nutritional status The patient must be classified as obese, edematous, dysproteinemic, cachectic, emaciated, etc., from admission. It is here that the data "weight loss", little, much, in a short or long period of time, contributes to the diagnosis. There are patients who never weigh themselves, but who have noticed that their clothes fit or fit looser than before, which should be reported as data. In those who have lost a lot of weight and suffer from abdominal pain, it is essential to rule out a digestive neoplasm.

1. b) Fever . It must be investigated, correctly analyzed as an isolated sign, and incorporated as a valuable element to the pain symptom. It should be investigated in its equivalents, chills, or tachyphygmia.

1. c) Dehydration . It is suspected due to the presence of oliguria, dry skin and mucosa or decreased skin turgor, and should never be superficially analyzed or forgotten.

1. d) Apnea . It is evidenced by waxy pallor of the skin or mucosa, by tachyphygmia, by arterial hypotension or sensation of lipothymia and is confirmed by the laboratory; it has a lot of value as a member of the abdominal pain syndrome. Different acute or chronic abdominal processes usually have it as a fundamental sign. Sometimes anemia alone accompanied by another sign of value, such as amenorrhea or diarrhea, for example, indicates the safe path to a diagnosis of acute abdominal pathology, such as ectopic pregnancy, or chronic, such as cancer of the blind. The mere observation of a blood smear, with the finding of morphological alterations in erythrocytes (sickle cells), allows the diagnosis of abdominal pain crises that accompany certain hemoglobinopathies.

1. e) Jaundice . Sometimes unequivocally manifested by the yellowish color of the skin, mucosa and conjunctiva, other larvae and incipient, evidenced by coluria, is another valuable fact.

3. Digestive manifestations. They have undoubted value if they are integrated with the other elements that accompany abdominal pain; they are never pathognomonic of a single pathology and generally concur integrating dissimilar syndromes. They should always be collected, described and analyzed in relation to the other symptoms and signs that accompany abdominal pain, and as with the pain itself, studied according to its intensity, its periodicity, its chronology, its time of evolution and its relationship or not with meals.

Such manifestations are, fundamentally:

1. a) Vomiting . Vomiting should be known by its prodromes: nausea, the popular "gagging" and belching; for its type: easy, difficult, in "projectile"; for its content: gastric, nutritional, bilious, hematic or stercoráceous; and in relation to pain: if it calms it, provokes it, or exacerbates it. It is important to integrate it with the rest of the signs or symptoms that woo abdominal pain. Hematemesis or vomiting blood sometimes does not appear, observing only its equivalent, the mane or elimination of black stool.

1. b) Diarrhea . It acquires great value if it accompanies pain in a chronic way; it is trivial or banal if it is recent or temporary; and its meaning is aggravated if it has mucus, foam, pus or blood in its content. Diarrhea can integrate the sign "changes in defecation habit", considered an alarm symptom, as well as pushing and tenesmus, which must be taken into account.

4. Urinary or genital manifestations. If dysuria or voiding burning, hematuria or macroscopic or microscopic presence of blood in the urine, and urinary frequency accompany abdominal pain, they quickly orient towards the urinary nature of the same, as does the observation of "grits" in the sediment.

The presence of abnormal vaginal discharge, leucorrhoea , metrorrhagia , hypermenorrhea , polymenorrhea or sinusorrhagia in women should lead one to think of gynecological pathology in relation to pain.

The alterations of the female sexual cycle should never be overlooked in the analysis of abdominal pain, especially if it is sharp and short evolution. The rupture of ovarian follicles usually causes brief hemorrhages in the middle of the cycle, and complicated ectopic pregnancies are preceded by amenorrhea before rupture. Every woman with abdominal pain should be questioned about her sexual cycles, her pregnancies, abortions, contraception and the date of her last menstruation.

5. Abdominal signs. The basic pillars of the examination of the abdomen, that is, inspection, palpation, percussion, and auscultation, provide signs of enormous value that help to identify the abdominal syndrome, which will ultimately lead to diagnosis.

In a patient with abdominal pain, simple inspection can objectify fundamental data, such as jaundice, dehydration, symmetrical or asymmetric bloating, the presence of scars, collateral circulation, hernias, or the observation of atypical spots such as the halo of Halstead present in severe pancreatitis, which alone make or contribute to the diagnosis.

The drum can be objectified neumoperitoneos into pierced hollow viscera, hipertimpanismo in the presence or mattness bag distended exaggerated in the tumor masses. Fist-percussion is positive in acute urinary conditions, such as nephritic colic.

The auscultation careful abdomen allows recognize noises in normal healthy hydroaerial abdomen, signs of fighting mechanical occlusion and abdominal silence paralytic ileus.

The probing surface and deep in abdominal pain, which in acute cases must be complemented with a rectal simultaneous, known as maneuver ano-parieto-abdominai of Yodice-Sammartino allow objectify a soft on the trivial processes belly, locate accurately the painful points, and make evident the different degrees of peritoneal compromise, depending on whether there is hypertone, defense or contracture. The contracture or "plank belly", is the total rigidity of the wall of the abdomen, objective to the simple inspection, that allows to see the relief of the spasmodized abdominal muscles, and speaks of a total involvement of the abdominal cavity, for example, in the case of generalized peritonitis.

The defense is the painful reaction to palpation, which is complicated by the reflected contraction of the muscles of one or more quadrants and marks a lesser degree of peritoneal commitment, whose initial stage is objectified by the hypertonic evident the start of peritoneal pictures and manifested by a painful defense reflex when testing deep palpation in the affected area. It is the typical case of provoked pain, which also appears in front of other types of stimuli, such as coughing, crying or movement. A sign of involvement of the peritoneum, which sometimes, as in the case of hematic effusions in the cavity, does not accompany the different degrees of parietal hypertone, is also peritonism., or sudden decompression pain, which should always be investigated in acute symptoms and is manifested by an intense painful reaction when decompressing the belly after a deep and sustained palpation. It appears in the peritonitic processes and also in the presence of distended handles.

Auxiliary procedures to study abdominal pain

There is no doubt that a complete interrogation of the patient with abdominal or pelvic pain, completed with a correct and exhaustive physical examination, which in acute cases must always be accompanied by a digital rectal examination, a gynecological examination and the measurement of axilorectal differential temperature, provides all the data necessary to develop a syndrome and more than half of those required for a diagnosis.

On many occasions, it is very difficult to confirm or rule out a diagnostic presumption without resorting to the help of complementary methods, which, as such, are only collaborators in the implementation of a correct semiological method.

These complementary methods can be differentiated according to their simplicity or complexity, although lately it is preferred to classify them according to whether they are invasive or non-invasive.

Non-invasive methods are better for being bloodless and for having a high specificity index, although in many cases their indication is postponed when opting for more aggressive, but less expensive, procedures.

Laboratory . It is the first spring to actuate in the path of diagnosis.

From the routine examinations, the cytologist detects anemias, which in chronic pain conditions force to rule out neoplasms, and in acute ones, hemorrhages or peritoneal hematic effusions. It can show polyglobulia index of eventual hemopathies or splenopathies causing pain, and alterations in the leukocyte formula, or changes in the number of leukocytes or platelets that guide or concur with the diagnosis. The diagnosis of a leukemia through cytological examination, would like an acute pseudoabdomen that is sometimes associated with this pathology.

The erythrocyte sedimentation rate , or erythrocyte sedimentation rate, provides a nonspecific finding, since its increase is not characteristic of a single disease; however, it is very useful because it indicates the existence of an active pathological process with inflammation or destruction of the tissues.

An elevated glycemia or uremia can guide the diagnosis of acute pseudoabdomen, non-surgical pathology, and collaborate in the evaluation of the prognosis in a patient with abdominal condition.

A simple urine test rules out or detects urinary tree disease, showing germs, pus, blood, debris, metabolites and even neoplastic cell flaps, fungi or parasites.

The patient with abdominal pain, carrier of eventual liver pathology, should be studied, apart from the aforementioned analyzes, of great value in these cases, with laboratory measurements such as transaminases (glutamic pyruvic and glutamic oxalacetic), the prothrombin time , the proteinogram by electrophoresis , bilirubinemia and enzyme dosages or tests of more limited use, such as bromosulfonphthalein, gamma glutamyl transpeptidase, lacticodehydrogenase, 5-nucleotidase and others.

If it is desired to investigate extrahepatic biliary hypertension, the dosages of bilirubin (indirect, conjugated and total), in addition to alkaline phosphatase and cholesterol , must be added to those already requested.

The acute involvement of the pancreas is investigated by determining the amylases in blood and urine, plus calcaemia , which, added to elements of value in the routine laboratory, collaborate with the diagnosis.

The laboratory also provides data by examining the stool , which can detect the presence of fungi, parasites or bacteria, in addition to showing hidden blood.

Fecal matter, urine, and blood can be cultured , thus collaborating in the diagnosis, prognosis, and therapeutics of the patient.

There are other procedures, today less applied than ever, such as gastric acidimetry or duodenal sounding, which contribute to the study of abdominal pain.

Radiology . It is the second spring that is launched on the path of diagnosis, of enormous significance, sometimes forceful, in patients with pain in the abdomen or pelvis.

The most elementary and perhaps the most important stage of radiological diagnosis is plain or direct radiography , which should always be requested of the chest and abdomen, if possible with the patient standing, or at least sitting.

The chest X-ray is used to rule out processes that hurt thoracic or abdominal crunches processes that coexist with, and sometimes to expose exclusive pathologies of the abdomen. Thus, a pneumoperitoneum can be seen in hollow viscera perforations, abnormal elevations of a hemidiaphragm in subphrenic collections, pleural effusions in acute conditions of the pancreas, or the presence of pleuropulmonary pathologies as a reflection of the same processes in the abdomen, for example, pulmonary metastases from Malignant digestive processes or evidence of pulmonary hydatidosis, which may well coexist with the same pathology at the hepatic, splenic or peritoneal level.

The examination of the diaphragm is complemented by radioscopy or direct functional examination, which will reveal paresis or paralysis.

The abdominal plain film contributes in turn essential data such as liver calcifications, pancreatic, spleen, bile, mesenteric, arterial, peritoneal or urological; presence of air where it should not be found, such as pneumoperitoneum, retroneumoperitoneum, pneumobilia or subcutaneous emphysema, which alone can make the diagnosis; effacement of the psoas edges; or difficulties in the digestive transit, evidenced by images such as bloating, plaster sign, "herring skeleton" image, segmental strains of the large intestine or presence of air-fluid levels that sometimes, by themselves, guide therapeutic behaviors.

Direct radiology is completed with contrasted radiological procedures , which for the digestive tract are the barium esophagus-gastro-duodenum-enteric transit, the colon by ingestion and the colon by enema, which, perfected by technical details such as evacuation, insufflation and Other devices have developed the so-called "double contrast" of air and barium, which sometimes achieves a correct impression of the mucosa and reveals incipient pathologies.

The extrahepatic bile ducts are studied with oral cholecystography, which normally allows us to view the gallbladder, its morphology and its pathologies. and with endovenous cholecystocholangiography , which impresses the gallbladder and hepatocolledocus. The second is usually indicated when the first is negative, configuring the sign of “excluded gallbladder”, and both, in rare cases, are complemented by transpaietohepatic cholangiography and endoscopic retrograde cholangiopancreatography .

The urinary system is always examined with a direct x-ray of the abdomen, but the urinary tract is studied using the excretion urogram or descending pictogram, minute or not, completed with a pre- and post- voiding cystography , and if necessary with an ascending pyelography.

The aortography by lumbar puncture or by catheterization, and horn variants the selective arteriography , allowing catheterized each arterial trunk abdomen with absolute specificity, and even embolizarlos substances, is reserved for a minimum of cases, as it is a method bloody, highly complex, which is gradually being replaced by less aggressive ones.

Endoscopy . In its old variant, rigid endoscopy , or in its most modern and flexible form, fiber optic endoscopy allows direct scans, photography and biopsy or brushing for cytology, the esophagogastroduodenal mucosa, the entire large intestine, and in some very specialized much of the mobile portion of the small intestine. It also collaborates in channeling the biliopancreatic route.

Laparoscopic procedures , today, also with the help of cold light and fiber optics, provide examinations of the abdomen equivalent to those provided by a laparotomy, make a diagnosis, allow biopsy, and sometimes practice small therapeutic gestures.

Ultrasound and computed axial tomography . They are bloodless methods reserved for problem cases and for those in which the described methodology does not approximate the diagnosis sufficiently.

In good hands, both procedures exhibit a very high level of fidelity and accuracy, grouping together with the techniques of "diagnostic imaging" . Its indication is limited by its complexity and its high cost, but it increases permanently due to the precision of the data they provide. Ultrasonography is less expensive than computed tomography, and both procedures may or may not be reinforced with the addition of contrast medium in the digestive tract or the urinary tree.

Summary of pathologies

The correct interpretation of pain in the abdomen is of tremendous importance. The first conclusion that a seasoned examiner must reach is whether or not that pain responds to an acute condition. Secondly, if you suspect that it is an acute abdominal or pelvic episode, you are obliged to rule out or certify that this condition may be an emergency surgical case. It is here that the therapeutic indication to explore the abdomen is sometimes considered before advancing towards the diagnosis, and it is here where the experienced doctor is frequently heard saying: "I do not know what it is, but I do know that it must be explored" . And it is only then when, suspected or ruled out the acute picture, considered or eliminated the possibility of emergency surgery,

The clinical sense of opportunityin the diagnosis and eventual therapeutic indication it is something that comes with experience and over the years; But the young professional, and even the student, must keep these principles in mind and be aware of the presence or absence of an acute condition with all its implications. Thus, the symptoms and signs called "of alarm", such as recent onset pain, fever, vomiting, tachyphygmia, hypotension, lipotimia, "in crescendo" pain, hypertonicity, defense, contracture, bloating, color or jaundice, non-emission of gases and disappearance of liver dullness on percussion, must be estimated, analyzed and investigated with the responsibility that these signs deserve, and with the obligation to make a first determination, which is not to let the patient leave, least of all with symptomatic therapy .

It is in this way that the painful symptoms of the abdomen are divided into acute and non-acute, with those who debut more abruptly and spectacularly being called acute and that, in some cases, may require immediate surgical therapy.

If a pain is identified as “not acute”, it is appropriate to evaluate its characteristics and its concomitant signs and symptoms, to finally implement the auxiliary methods of diagnosis and thus recognize its origin, since, as will be seen, each organ “ it hurts ”in a particular way.

Abdominal pain in different organs

Liver . This organ generally hurts in the presence of acute viral hepatitis, or liver congestion from congestive heart failure; It usually hurts exceptionally when there are liver metastases from digestive malignancies, and sometimes due to the distension of its capsule by trauma, cysts, or bruising. The pain is usually dull and located in the right hypochondrium, and can increase considerably until it becomes intolerable, as occurs in acute heart failure.

Spleen . Very rare pathologies, such as splenic infarction, generate pain in the left hypochondrium due to injury to this organ; analogously to what happens in the liver, but more rarely, it hurts in the presence of heart failure or portal hypertension. There are hemopathies that cause splenomegaly, also responsible for this vague pain.

Gallbladder . The stones are the most frequent cause of pain in this organ, configuring the picture known as "biliary colic". It is an intense pain, that comes and goes, that appears after the intake of cholecystokinetics, such as sauces, fats, fried, spicy, alcohol, chocolates or sausages, which occupies the epigastrium and right hypochondrium, it radiates in "hemicinturon" to the right lumbar fossa and depending on its severity or complications, can last long or become permanent, and may be accompanied by nausea, food vomiting, gastric or bilious, fever, chills, coluria, jaundice, defense or contracture in the right hemiabdomen. It usually calms with antispasmodics and digestive rest, or needs more aggressive therapeutic measures, including surgical, depending on its seriousness.

Stomach and duodenum . Two causes cause pain in these organs: acidic chemical irritation of the mucosa, which occurs in ulcers and gastritis or duodenitis, and bloating, which appears in pyloric syndrome, aerophagia, and acute gastric dilatation . The distension of the stomach hurts in a dull way, with a feeling of fullness in the epigastrium, which appears tense and tympanic, and which hinders the respiratory movements and the flexion of the body on itself, calming with vomiting or belching.

Ulcerative syndrome causes pain that can wake the patient at midnight or manifest on an empty stomach; recalls a stab in the epigastrium, is penetrating, permanent, and is accompanied by a feeling of emptiness, hunger or languor; it is described in skinny, anxious, thorough, and obsessive individuals known as carriers of the "ulcerative personality" although ulcers frequently appear in totally different individuals. This pain usually calms with the intake, especially alkaline, and in its complications it can be accompanied by vomiting, which can be food, gastric and even hematic, or disappear in the perforation pictures, if we remember the principle “the perforated vomits inside” .

Small intestine , The most common cause of pain in the small intestine, which is caused by the traction of its mesos and the distension of its light, is enteric colic, which responds to enteritis, generally manifested by explosive diarrhea, intense Colic-type pain, with varied neurovegetative manifestations, a feeling of nausea, a soft stomach, and a marked increase in airborne noise. The pain extends to all quadrants of the abdomen, usually appears with fever, and responds very well to digestive rest and the administration of antispasmodics.

The small intestine is usually a seat in addition to occlusive or sub-occlusive pictures, which cause intense pain. The factors responsible for these occlusive syndromes are firstly postoperative flanges; then complicated hernias; beyond, foreign bodies, such as stones in the gallstone ileus, hairs in the trichobezoar, and poorly chewed vegetables in the phytobezoar; and finally the small intestine tumors, of exceptional appearance. He will return, with two acute pictures, to describe the occlusive syndrome.

Large intestine . Constipation and low occlusive conditions cause distension of the colon, which triggers pain. It is a dull pain, with spaced colic, accompanied by the lack of gas emission and asymmetric abdominal distension.

As mentioned before, the pain rarely appears in the abdominal quadrant that corresponds to the affected portion, but what usually hurts is the proximal area with respect to the point that causes the occlusion.

Urinary tract. The kidney and ureter, due to lithiasis, malformations, infections and sometimes tumors, hurt in the form of "renal colic" or "nephritic colic". It is an intense painful picture, which is installed in the lumbar fossa of the affected side, radiates to the flank and ipsilateral iliac fossa, and can be run to the hypogastrium, inguinal region and genitalia, as well as to the inner aspect of the thigh. It is accompanied by macro or microscopic hematuria, sometimes pyuria and fever, and frequently causes abdominal distension and significant reflex ileus. The doctor finds a patient who changes position permanently, who turns on the bed or stands up and walks, complaining of very intense pain, exacerbated by fist-percussion. This pain responds well to antispasmodics or local heat, such as subjecting the patient to a hot immersion bath,

Pancreas. Acute pancreatitis causes very intense and severe pain, of periumbilical location, which seriously compromises the general state, incoercible vomiting and shock are almost permanent guests. Gallstones and alcoholism are the most frequent determinals; It is a pain that goes through the belly like a lunge, it is accompanied by elevation of amylases, first the urinary, of leukocytosis and radiological signs such as Del Campo's ileus, on direct radiography of the abdomen and left pleural effusion on radiography of chest. It is often confused with myocardial infarction pain and perforated ulcer pain, and is sometimes accompanied by signs that darken the prognosis, such as jaundice, the halo of periumbilical cyanosis described by Halstead, or elevated blood glucose. which coexists in these cases with a decrease in amylases. It does not respond quickly to common pain relievers and is often rebellious even to the administration of morphine.

Cecal appendix . It only hurts in the course of acute appendicitis, which begins with epigastric pain, nausea, and vomiting, accompanied by fever, which usually exhibits marked evidence of axilorectal thermal dissociation. The pain runs over the hours to the right iliac fossa, and can be easily masked by the administration of pain relievers and antibiotics. Depending on its evolution, hypertone, defense and contracture may appear successively, and the laboratory will show leukocytosis with neutrophilia and normal erythrocyte sedimentation in the beginning. Acute appendicitis should always be considered in the presence of abdominal pain.

Female internal genitalia . The uterus, tubes, and ovaries often ache in the presence of septic salpingoovarites, or in severe acute surgical conditions, such as complicated ectopic pregnancy, or torsion of a pedicled ovarian cyst. The pain appears in the hypogastrium or in both iliac fossae, and the syndrome must be structured taking into account the presence or absence of the urogenital symptoms or signs that were opportunely mentioned. Under no circumstances can the history of lipothymia or short-term amenorrhea be underestimated in the analysis of this pain.

Pelvic and abdominal pain in acute conditions

The symptoms of acute surgical abdominal pain are grouped into a small number of syndromes, known as peritonitic, hemorrhagic, occlusive, and ischemic, which represent most of the pathologies that may require immediate surgery.

Sometimes a Husma pathology can present with two or more of the mentioned syndromes, which makes the diagnosis more difficult and darkens the future of the patient.

Peritonitic syndrome . It appears in the complications of appendicitis, cholecystitis and acute pancreatitis, and is very evident and dramatic in the perforation of the hollow viscera, such as the stomach, duodenum, cecal appendix, Meckel's diverticulum, small intestine or colon, constituting a variant of it, perforative syndrome .

This condition hurts due to septic or chemical irritation of the parietal peritoneum, and is characterized by a sudden onset, fever, compromise of the general state, toxic or septic facies, abdominal defense or contracture, abdominal silence on auscultation, severe pain on sudden decompression and vomiting, which completely disappears in the perforation.

Priapism is usually seen in some cases, and in others the relief of the contracted muscles in the abdominal wall is seen.

Radioscopy of the chest shows diaphragmatic paresis and direct radiography can reveal a pneumoperitoneum. Direct abdominal radiography sometimes shows the "plaster sign," typical of severe peritonitis.

The laboratory will show leukocytosis with neutrophilia and accelerated erythrocyte sedimentation, and will collaborate with its tests to investigate the probable cause of peritonitis and its eventual complications.

Abdominal puncture, at the left Mc Burney point, usually confirms the diagnosis.

Hemorrhagic syndrome . It is usually an indication of extremely urgent surgery, and it is observed in trauma with ruptured liver or spleen, in complicated ectopic pregnancies and in bleeding ovarian follicles, as well as in Asuro aneurysm of the abdominal aorta.

It is a pain of sudden appearance, which recognizes a traumatic antecedent, immediate or not as recent as in two-stage hemorrhage of the spleen, or that is preceded by a short-term amenorrhea, or that is triggered around half of the female sexual cycle .

It is accompanied by tachyphigmia, low blood pressure, severe pale skin and conjunctivae, and recent lipotimia or feeling of fainting.

The belly is always soft and with preserved intestinal transit; There is severe pain on sudden decompression and omalgia, due to phrenic irritation, known as Kehr's sign.

The hemoperitoneum is corroborated by abdominal puncture, or of the posterior vaginal cul-de-sac, or by peritoneal puncture-lavage.

The laboratory does not usually reveal anemia if the bleeding is of a very short evolution, and gives the clinic its full role.

Occlusive syndrome . It accompanies clogged or strangled hernias, tumors of the small intestine and colon, postoperative flanges and foreign body endoluminal obstacles, already mentioned.

Apart from suffering pain, which is colic, the patient does not pass gas, vomits food, gastric fluid, bilious or porous if the occlusion is high, and only vomits late if the ileocecal valve is incontinent in low occlusions.

The belly is soft, practically painless on palpation, very sensitive to sudden decompression, and very tympanic on percussion, the "signs of struggle" being evident when auscultating.

Inspection will allow observation of distended loops crawling under the wall and asymmetries in the lower occlusions, and will verify the presence of old scars or hernial tumors.

Simple or direct radiology will reveal the typical hydro-air levels and will show whether the distended loops correspond to the small or large intestine, the latter case in which the bari-tated enema may indicate the site of the occlusion.

Ischemic syndrome . It is a painful picture of the abdomen that appears abruptly due to thrombosis in old pan-arteriosclerotics, or due to embolism in patients with atrial fibrillation or digitized, or as a complication of aortic surgery, which compromises the lower mesenteric circulation.

It is a very intense, shocking pain, with distension of the belly in shell and frequently accompanied by proctorrhagia.

Less severe symptoms, without shock, are usually described in the same patients, known as "abdominal angina" and caused by ischemia. Pain is characteristically postprandial. The patient avoids the intake and consequently loses weight. Presents the radiological sign of the thumb or "thumb-print" in the colon by enema. The diagnosis is usually suspected because of the history.

Acute abdominal pictures of medical treatment

The doctor who faces an acute abdominal picture must decide quickly whether or not it is a surgical emergency, in which case, quite often he decides to practice the so-called "exploratory laparotomy", since it is not uncommon that with the usual methods it is not possible to arrive at the diagnosis.

However, there is a group of diseases that in their crises simulate acute abdominal symptoms, and that with certain frequency lead the surgeon to unnecessary laparotomies, if not aggravating their pathology.

These are, following Harrison:

Metabolic causes

Exogenous:

“Black widow” spider bite

Lead poisoning and others

Endogenous:

Uremia

Diabetic acidosis

Porphyrias

Allergic factors

Neurogenic causes

Tabes dorsal

Herpes zone or zoster

Causalgia and others

On the other hand, it should not be forgotten that trauma or tumor affecting the abdominal wall, or bleeding from the epigastric artery with hematoma of the rectus sheath, can simulate an acute peritoneal picture, which is investigated by examining the patient while pushing or pushing, such as sitting or inflating a balloon, which pinpoints the location of the condition.

CERVICODORSOLUMBAR PAIN

The spine, consisting mainly of the spinal column (vertebrae and pulpy discs) and the muscles, ligaments, fascia, and nerves associated with it, has the multiple and significant function of being the support axis on which practically all movements and attitudes depend; of being shock absorbing and elastic of the greatest adaptability and resistance by virtue of the arrangement of its balance lines and the automatic, imperceptible, and incomparable plasticity of the mentioned structures; and of being also a protective conduit for the neuroaxis and the nerves that emerge from it and the basic support column for all the organs and their envelopes.

The spinal nerves that leave the medulla along its entire length receive two confluents, an anterior motor root and a posterior sensory root. Very soon the nerve thus formed is divided into an anterior and a posterior primary branch that are already mixed, motorized and sensitive. Shortly before forking, they give a small recurring branch that innervates the medullary meninges. The distribution territories of both main branches coincide with their anterior or posterior denomination, and therefore most of the dorsal and lumbar pains depend on the posterior branches. The described anatomy also explains the referred pains of injuries of tributary organs of the anterior branches. Several spinal nerves come together to form plexuses as occurs at the top with the brachial plexus,

The sensory innervation of the muscular, ligamentous, fascial, periosteal, vascular, and meningeal structures is rich in pain receptor fibers. Vertebral bone, cartilage, and nuclei pulposus are apparently not.

The stimuli that cause pain come from inflammation, stretching, distension, tearing, concussion, incision, chemical irritation, bleeding, etc.

Any process that alters the functional balance mentioned above causes, in addition to its direct effect on the tissues, additional muscle contractions that try to compensate for the altered balance and cause fatigue pain. This occurs in exaggerated efforts, vicious attitudes and in a wide range of pathologies within which we can mention: congenital anomalies (spondylolisthesis, sacralization of the fifth lumbar vertebra, horizontalization of the sacrum, spina bifida, flat foot, unequal leg length , etc.), trauma, inflammatory diseases (spondyloarthritis), degenerative (spondyloarthrosis), infectious (brucellosis, tuberculosis, meningitis, etc.), primitive or metastatic neoplasms. The alteration, secondary to various processes, which constitutes the herniated disc pulposus, It is the cause of severe spinal pain. Pain referred from thoracic or abdominopelvic diseases has already been mentioned in the corresponding sections. The characteristics of thoracolumbar pain are not too categorical in the interrogation to establish a diagnosis, and this depends on the concomitant symptoms and the examination of the patient.

PAIN OF MEMBERS

The same considerations regarding pain and its characteristics, expressed in the previous sections, apply to the extremities. Due to the fact that they are especially vulnerable to accidents, we exclude the extensive chapter that includes fractures, dislocations, sprains and other injuries of the different structures, due to the obvious identification of their causes and their well-known diagnostic methodology. However, a distant traumatic history is important, due to the sequelae it can leave.

The most frequent pains in the extremities correspond to joint and periarticular pain, and among these to the shoulder in the upper limb and the knee in the lower limb, and in this order, hip, wrist, ankle, elbow and small joints of the fingers. Venous vascular pain from chronic venous insufficiency, arterial, neurological, and finally muscular and bone pain follows in order of frequency.

Some anatomical data. Superior member. It is known that this extension of the shoulder girdle is divided into four parts, the shoulder, the arm, the forearm and the hand. It is further understood that his motor and sensory innervation comes from the brachial plexus and that arterial blood reaches him through the subclavian branch of the aortic arch on the left and from the brachiocephalic trunk on the right.

The anatomical structures of the upper limb that can hurt or have to do with pain are:

The bones: clavicle and shoulder blade in the shoulder, humerus in the arm, ulna and radius in the forearm, carpus, metacarpus and phalanges in the hand.

The joints: of the shoulder or glenohumeral, of the elbow, of the wrist, of the bones of the forearm to each other and of the bones of the hand to each other.

Muscles and their tendons: most often the deltoid and supraspinatus in the shoulder, the biceps tendon in the biceps slider of the humerus, the long supinator tendon in the forearm, and the long flexor and short flexor tendons of the thumb at height wrist.

The synovial pockets, of which the subacromial and the subdeltoid stand out.

The sliding and synovial tendons of the flexors and extensors of the hand.

The anterior and posterior annular ligaments of the carpus, sometimes responsible for compression phenomena.

The superficial veins, known as the superficial radial, median, and superficial ulnar veins in the forearm, and cephalic and basilic in the arm.

The homonymous, axillary, humeral, radial, ulnar satellite arteries and their veins, their collateral branches and anastomotic systems such as the peritroclear and perichondyle circles, and the superficial and deep palmar arches.

There are also spaces, regions or anatomical points of the upper limb that are in some way related to pain:

The supraclavicular hollow, not specifically located in the upper limb, is of great importance because it is where the first half of that hourglass, which is the brachial plexus, sits, in turn in relation to the scalenes, the subclavian vessels, the pleural dome and the starry ganglion.

The axillary pyramid, with its four faces, its vertex and its base, which contains all the terminal branches of the brachial plexus, clustered around the vein and axillary artery.

The epitrócleo-olecraneano channel, which in contact with the integuments on the posterior side of the elbow.

On the other hand, this review cannot be concluded without knowing the cutaneous territories of the sensory branch of each terminal of the brachial plexus, namely:

The shoulder is almost entirely innervated by the circumflex.

In the arm, the palmar aspect, the circumflex and the accessory of the internal cutaneous brachial are distributed, which also supplies the dorsal aspect along with the radial aspect.

The dorsal and ventral portions of the forearm correspond on the outside to the radial and musculocutaneous, and on the inside to the internal cutaneous brachial.

The hand is divided between the median, radial, and ulnar nerves (Fig. 5-9, A and B).

Lower limb . It is a prolongation of the pelvic girdle and is subdivided in turn into the gluteal, thigh, leg and foot regions.

In addition to the blood provided by some extrapelvic branches of the hypogastric, the irrigation of the lower limb comes from the femoral artery, which after a short journey is subdivided into superficial and deep. The first crosses the Scarpa triangle and when it reaches the Hunter duct it becomes a popliteal, which after transposing the rhomboidal space of the same name and crossing the ring of the soleus, is divided into two terminals, the anterior tibial and the tibiofibular trunk. The anterior tibial crosses underneath the anterior annular ligament of the tarsus, becoming called the pedia, while the tibioperonéus trunk, after a short journey, is subdivided into the peroneum and posterior tibial, ending in the interosseous and plantar arteries,

As for the bones, it is the hip and the sacrococcyx that make up the pelvic girdle; the bulky femur is the axis of the thigh, while the tibia and fibula are for the leg. The foot is made up of the tarsus, the meta tarsus and the phalanges.

Of the joints, the hip and knee joints are of interest. The latter, with its cruciate ligaments and its inter-articular menisci, is a frequent source of painful symptoms.

Among the extensions of the sinus vial, the subquadricipital serous pouch, partially covered by the patella, and the pretibial serous pouch, below the fat package of the knee stand out.

The deep venous system is a satellite and the same name as the arterial, and the superficial one is divided into two groups, the internal saphenous and the external saphenous. The latter circulates on the posterior aspect of the leg and deepens at the level of the popliteal rhombus, while the internal saphenous vein originates in front of the tibial malleolus, has its route through the internal aspect of the limb throughout its entire length, and deepens at the level of the Scarpa triangle by piercing the cribriform fascia.

The anatomical spaces and points that cannot be omitted when considering pain are:

1. a) Scarpa's triangle, due to its vascular content and the emergence, at its level, of the two superficial branches of the crural nerve.
2. b) The popliteal rhombus, because at this level the division of the major sciatic nerve is verified and by the presence in it of the popliteal vessels.
3. c) The Hunter Channel.
4. d) The soleus ring.
5. e) The anterior annular ligament of the tarsus.
6. f) The palpation sites of the pedio pulses, at the level of the projection of the dorsal aspect of the first two metatarsals, and the posterior tibial, behind the tibial malleolus.

In turn, the entry into the gluteal region of the terminal branch of the sacral plexus, the greater sciatic, below the pelvic pyramidal muscle should be remembered; its posterior trajectory in the thigh, following the rough femoral line and in relation to the biceps and the great adductor; and its division, in the upper angle of the popliteal hollow, into the internal and external popliteal sciatics.

The latter ends at the level of the head of the fibula, while the internal one crosses the ring of the soleus to be called the posterior tibial and follows the path of its homonymous artery, ending next to the internal side of the Achilles tendon,

Regarding the sensory territories of the skin of the lower limb, it should be remembered that the thigh region is distributed between the collateral and terminal branches of the lumbar plexus, except on the posterior aspect, where a large part receives innervation from the minor sciatic, that extends to the popliteal skin.

The musculocutaneous, peroneal, cutaneous and saphenous nerves ensure the sensitivity of the leg and part of the foot, which are also addressed by the plantar and tibial nerves (Fig. 5-10, A and B),

Joint and periarticular pain

Superior members. They will be described first, with emphasis on some specially recognized entities. Due to the anatomical nature and the obvious location, it is more didactic to proceed in this way than by the deductive method previously used. It is necessary to specify that a joint can hurt in isolation, which is more common in large or small injuries such as those that recur in daily work or sports, in cases of osteoarthritis and more rarely in infections (tuberculosis, brucellosis, gono , meningo, pneumo or staphylococcus) and in neoplastic processes. Other times there are several or many painful joints, as is common in rheumatic diseases, in which pain acquires different modalities with respect to simultaneity, symmetry, etc., which will be analyzed in the corresponding chapter.

Shoulder pain. It is one of the most frequent, mainly in the male sex, in adulthood and more on the right side. It is also common to recognize that in most cases it is due to periarticular injuries, especially tendinitis and bursitis. The pain appears and then gradually increases reaching its maximum intensity in days or weeks; other times it does so abruptly. It is located on the anterior and superior aspect of the joint, but sometimes it is difficult to pinpoint the painful site correctly, since it extends to the entire region, it soon radiates to the scapula, arm and even to the fingers. The first time it is noticed, it coincides with some abduction or rotation of the arm. In serious cases it occurs throughout the day, causing activity limitation even for minor actions such as combing or dressing, and also during the night, when the patient reports that he cannot find a position to fall asleep, neither on the affected shoulder nor on the opposite. The arm tends to become immobilized by contraction of the muscles surrounding the joint. The most frequent causes are calcifying tendonitis of the supraspinatus, subdeltoid or subacromial bursitis, bicipital tendinitis and capsulitis. The prolongation of this picture leads to two complicated situations, one is that of the "frozen shoulder", immobile due to pain and contracture, and the other is the psychic depression produced by the mortifying persistence of the disease. The other causes of shoulder pain are inflammations of various origins, trauma, infections, dislocations, rheumatic or systemic diseases, degenerative and more rarely tumor, metabolic or referred.

Elbow joint pain . It is less frequent and occurs gradually or abruptly. It obeys causes similar to those listed for shoulder. There are two modalities of special mention: a) epicondylitis, with pain in the insertion area of ​​the long supinator tendon in the epicondyle and that extends to the lower third of the humerus or distally on the external aspect of the forearm; It is called "tennis elbow" and is due to traumatic fascial tears, and b) epicrocleitis in the external sector, a condition called "golf player's elbow". 

Wrist pain. The rheumatic cause is more frequent than in the shoulder and elbow. The wrist also presents very characteristic and painful periarticular processes, among which the “ganglion” can be mentioned, which is a cystic appearance bulge due to synovial hernias. Other times the pain is located in the tendons of the short extensor and the long abductor thumb, in the area that configures the anatomic snuffbox, constituting "De Quervain's tenosynovitis", in which the pain increases when the patient deviates the wrist ulnarly, especially if you previously pinch the thumb with the other fingers. The third characteristic wrist pain is the one that radiates to the first three fingers and to the outer edge of the fourth and other times to the entire upper limb, mainly at night. 

Pain in the small joints of the hands . It offers some remarkable features in terms of location, such as that of the carpometacarpal joint of the thumb, which is common in women who do it and is mainly caused by osteoarthritis; Another elective seat of this process is the distal interphalangeal ones. Proximals, on the other hand, and metacarpophalangeal pain in rheumatic diseases, especially in rheumatoid arthritis. The pain in the distal part of the palms of the hands is attributable to stenosing tenosynovitis of the flexor tendons, which sometimes produce the so-called trigger finger. 

Finally, the combined picture of periarthritis shoulder pain is mentioned, as described above, and localized manifestations in the hand consisting of pain, palmar retraction, tendon tenosynovitis, edema and vasomotor disorders with subsequent atrophy. This whole process has been called "shoulder-hand syndrome". Sometimes it occurs secondary to vascular-cerebral diseases or myocardial infarction. 

Lower limbs . When analyzing pain in the lower limbs, those that originate from trauma and accidents with their multiple variants will be ignored, as they are enough to fill an entire chapter of medicine. 

Hip. Pain is a frequent occurrence and, contrary to what is stated regarding the shoulder, it is due more to joint than periarticular conditions. Among them is distinguished the pain of coxarthrosis, generally of a degenerative nature (other times due to the repetition of small traumas), which occurs at various ages, but mainly after 50 years. It begins insidiously with the movements, intermittently, disappearing at rest. Then it becomes continuous and disabling, also referring to the outer side of the thigh and knee. It radiates from the beginning to the groin and gluteus medius. In other cases the pain comes from rheumatic or systemic diseases, from the so-called aseptic necrosis or from septic arthritis. In the latter case, and due to the little extensibility of the capsule, the patient defends himself by adopting positions such as flexing the thigh in abduction and external rotation. Other pains are peri-articular and respond to trochanteric bursitis and gluteus medius tendinitis. 

Knee . Aside from its traumatic vulnerability in sports and work, it is also the seat of arthrosic, rheumatic and infectious processes that cause pain. Osteoarthritis begins and continues to dominate on one side, but soon becomes bilateral and seriously compromises gait. In advanced cases, joint deformity and the noises produced in the movements are notorious. Other causes of severe knee pain are synovial effusions or hemarthrosis, the latter in hemopathies such as hemophilia. Periarthritis pain usually manifests as subrotull bursitis; or of the anserine pocket in the antero-internal zone, below the articular interline and coincident with the insertion site of the tendons of the so-called goose leg. 

Foot . The joint processes that produce pain are similar to those described for other locations, especially the hand, but there are also several circumstances whose particularities are worth noting. Walking and wearing shoes cause pain favored by preexisting or acquired anatomical defects, among which we can mention the flat foot, the fall of the transverse arch of the foot, the heel spur, or the hallux valgus. A well-known pain is from the metatarsophalangeal joint of the big toe, periodically appearing, sometimes seasonal, in relation to excesses or eating disorders, and with a higher incidence in men and certain racial types. 

It is the "podagra" that is observed in gout and that can coincide with accumulation of uric acid. Achilles tendon pain results from nonspecific, traumatic, or rheumatic tendinitis or bursitis. The persistent pain that is located on the inner edge of the foot is usually due to compression of the posterior tibial nerve by the corresponding inflamed annular ligament, which passes through the tarsal tunnel. Heel pain that radiates forward is usually caused by tears in the plantar fascia and is accentuated during gait and hyperextension of the foot. Pain that appears at the level of the head of the fourth metatarsal or in the fourth space, during walking or in the standing station, sometimes of a paroxysmal nature, may be due to what is called Morton's syndrome, attributed to a neuroma of the interdigital nerve. 

Vascular pain 

Pain caused by disease of the blood vessels in the limbs can be classified, by its presentation, as persistent or intermittent. 

1. Persistent vascular pain. Among them the following are distinguished: 

Pain of pretrophic rest, ischemic ulcer and gangrene

Acute arterial occlusion pain

Ischemic neuropathy pain

Arteritis pain

Pain from chronic venous insufficiency and pain from phlebitis

Lymphedema and lymphangitis pain

1. a) Pain of pretrophic rest, ischemic ulcer and gangrene. It exists in patients with severe occlusive arterial disease; It is considered as a sign of gravity and indicates that the blood supply is insufficient to meet the nutritional needs of the skin. It can be located on one or more toes, but many times it is distributed throughout the rest of the foot and leg. It is very severe and the patient gets partial relief when he places the leg in a decline and with the heat, but the elevation of the limb and the cold increase the intensity. The patient usually sleeps with the legs hanging off the edge of the bed and, if it is intense, it is impossible for him to fall asleep, which forces the use of opiates to achieve temporary relief. 

1. b) Pain from acute arterial occlusion. Thrombus fragments originating from the heart or aneurysm and atheromatous material from an ulcer often cause strokes that occlude the lumen of the arteries. In half of the patients there is an abrupt onset of pain that rapidly reaches its maximum intensity, located beyond the site of the embolism in the affected limb. In other cases it starts and develops insidiously over one or several hours, and may be preceded by paresthesias. It is associated with muscle weakness and sometimes with paresis of the affected segment. On examination, the limb is pale and cold with a net Emittal distal to the occlusion, and pulses cannot be detected. 

1. c) Ischemic neuropathy pain. There are alterations in the peripheral nerves due to atherosclerosis of the major vessels, producing a distal sensory and motor neuropathy that seems to depend on an inadequate blood supply and even on a nerve infarction.

It produces severe pain in the feet, sometimes as pricks and other times burning, with paroxysms, especially at night, lasting minutes or hours. It is usually accompanied by paresthesias, and ischemic neuropathy can be symmetric or asymmetric depending on the location of the arterial disease. 

1. d) Pain from arteritis. Acute arteritis is generally mildly painful when the condition is located in the extremities, characterized by dull pain when the artery is compressed, while chronic arteritis is usually painless unless the involvement of the lumen of the vessel generates ischemic pain. as occurs in thromboangiitis obliterans. 

1. e) Pain from chronic venous insufficiency and phlebitis. Patients with chronic venous insufficiency may suffer dull pain in the affected leg of different intensity, which usually appears when they have been standing for a long time, and which usually relieves and disappears when lying down with the lower limbs elevated.

Deep phlebitis produces moderate pain that is attributed to venous congestion; sometimes it calms down simply by elevating the affected limb and usually subsides with commonly used pain relievers. When the superficial veins are affected, the process is also accompanied by moderate pain that increases with palpation, as occurs in chemical thrombophlebitis in the upper limbs by intravenous injection of drugs and in varicose vein thrombosis in the lower limbs. 

1. f) Lymphedema pain and lymphangitis. Lymphedema produces no pain per se, except when it is complicated by cellulite. Lymphangitis, characterized by an erythematous line on the skin that extends proximally from an infected lesion, generates mild pain that is accentuated by palpation.

2. Intermittent vascular pain. These include the following:

Raynaud's phenomenon pain

Erythromelalgia pain

Intermittent claudication pain

1. a) Pain from Raynaud's phenomenon . This phenomenon is characterized by the appearance of sequential changes in the color of the fingers, generally of the hands, produced by exposure to cold or emotional stress; classically, they are first pale, then cyanotic, and finally blush appears. These changes reflect intense arteriospasm. Sometimes the patient experiences finger pain, and when it exists it is more likely to be a Raynaud's phenomenon secondary to pathologies such as thromboangiitis obliterans, cryoglobulinemias, scleroderma and thoracic operculum syndrome. 

1. b) Erythromelalgia pain . It is a rare condition characterized by having episodes of burning pain at the tips of the fingers or toes involved; other times it is described as pinpricks that appear when the limb is resting very warm. Lasts minutes or hours, is more intense the higher the temperature of the skin, and is relieved or relented by stepping on cold surfaces or otherwise cooling the affected limb. It is accompanied by reddened and hot skin.

1. c) Intermittent claudication . It is a very specific symptom that indicates an inadequate supply of the arterial blood necessary for muscle contraction. The pain only appears during exercise and subsides immediately upon stopping the effort, without the need to adopt changes in posture

The patient feels constrictive pain that forces him to stop; other times he expresses it as a cramp or a jerk; it is generally preceded by feeling tired.

The distance walked or the magnitude of the effort that has been made when the pain appears helps to estimate the degree of arterial disease. The claudication site is also of value, because it indicates that the level of occlusion is in the arterial segment proximal to pain (Fig. 5-11).

Most of the time it is a consequence of atherosclerotic arterial occlusive disease, but it can also occur in thromboangitis obliterans and in thoracic operare syndrome; In the latter, there is compression of the subclavian artery that causes the corresponding upper limb to give way. Claudication is also seen in patients with normal arteries, but who breathe a very poor oxygen atmosphere, or in those with severe anemia.

It should be differentiated from intermittent pseudoclaudication that occurs by compression of the cauda equina in the case of a narrow spinal canal, which produces pain similar to that of intermittent claudication but can also be triggered by movements of the spine, and calms gradually making post-rural changes.

Neurological pain in the extremities

The anatomical knowledge of metamers and the scheme of dermatomes is important; also the distribution of the nerves, as briefly stated at the beginning of this section.

Neurological injuries can cause suppression of the painful sensation and, on the contrary, cause intense pain. Whatever the etiological or anatomical origin, pain has three components that are common to the different levels of injury to the peripheral nerve pathways: a) the acute, burning, intense character, referring to the corresponding superficial territories; b) a second deep, persistent and deaf element, which becomes more evident when the first is interrupted or attenuated, which occurs intermittently; and c) a third component that is cutaneous hyperalgesic in nature, which makes the slightest touch very annoying, prompting the patient to adopt a series of preventive measures. This is explainable since, at whatever level the injury occurs, it involves the compromise of pathways that refer to the central and cortical nervous system, a certain innervation zone. There are probably antidromic impulses that justify the skin disorders observed

Regarding the upper limbs medullary pain is rare, but not radicular in nature due to cervical spine injuries, usually multiple osteoarthritis, or herniated disc. In the case of osteoarthritis, several roots can be affected, 6th, 7th and 8th bilaterally, and in this case the pain symptom generalizes from the shoulder to the hand. In the second situation, a single root is generally affected unilaterally, and therefore the pain is limited to the corresponding territory, which in the hand is the thumb for the 6th, the index and middle for the 7th, and the annular and pinky in the case of the 8th root. Neck movements, mainly hyperextension and straining, coughing and sneezing, increase this type of root pain. It usually extends to the occipital and scapular regions and appears by a sudden movement of the neck (braking in the car, for example), or rather slowly and progressively; it falls over with cephalic traction, which is very characteristic. Other sensory or motor symptoms often accompany pain, such as paresthesias, paresis, or muscle atrophy. Less common causes than those listed may be responsible for the symptom, such as compression from tumors, traumatic jerks, or inflammatory processes.

Pain due to brachial plexus injury that occurs in thoracic opérenlo syndrome is very characteristic and has already been mentioned in this chapter. Of the components of the syndrome, the most striking and worrying for the patient is pain. It is located on the anteroexternal aspect of the shoulder, extending above to the supraclavicular fossa, below to the anterior aspect of the arm, and then to the hand along the ulnar border. When installed, it usually becomes permanent, but has significant paroxysmal episodes and intensifies after hours of regular work or exercise. It is common that it is influenced by the fact of carrying hanging packages from the hands such as bags, briefcases, etc. It also occurs in women after housework. Lifting your shoulders in imitation of indifference denotes pain relief. Accompanying symptoms and causes of the syndrome have already been noted.

Pain is a prominent symptom of neuritis, spreading in the corresponding territories. It can affect them individually or as a whole, and in this case it constitutes polyneuritis. Some are related to the trade and are due to repeated microtraumas that even affect the vasa nervorum, as seen in those who handle jackhammers or other machinery or clap their hands.

In the lower limbs, pain of medullary origin (tumor or not) is more frequent than that reported for the upper limbs . Its location depends on the level and therefore on the roots involved. It is usually intense as in the case of horsetail tumors. In people who are past the middle age of life, a pain of lumbar location and lower limbs has been described, both in anterior and posterior territories of the legs and thighs, of a continuous or intermittent nature; sometimes as a painful fatigue, which intensifies with walking or when the standing station is prolonged, forcing the change of position and seeking anti-allergic attitudes with the body leaning forward. This may be due to narrowing syndrome of the spinal canal.

The pain of herniated lumbar disc very often begins abruptly with an effort and forces the patient to be "bent", immobilizing him. It is intense, sharp, usually affects only one root and only one side. It is located in the lumbosacral zone and is most frequently irradiated by the gluteal region and then by the territory of the sciatic nerve, whose roots are the most commonly affected.

This territory corresponds to the posterior aspect of the thigh and the leg up to the foot. The pain intensifies with walking, and with efforts that involve contraction of the lumbar muscles such as coughing, sneezing, defecation, etc. There are certain maneuvers that provoke stretching of the nerve and increase pain of sciatic origin (Lasegue). This same picture can be caused by neuritis, trauma, spondyloarthritis, etc.

Other neuralgias, that is, pains of nervous origin in the lower limbs, are those that occur in the testicular area and the superointema region of the thigh with a burning sensation, permanent, intense, which is due to lesions of the genitofemoral nerve due to surgical trauma of the groin region. It has been called testicular neuralgia.

Meralgia paresthetica is a similar but localized picture on the anterolateral aspect of the thigh, due to injuries to the lateral femorocutaneous nerve.

Other painful neuropathies will be described in the corresponding chapter, and they are due to infectious, toxic (stem, alcohol), deficiency causes (avitaminosis B), metabolic (diabetes), etc. The blasting crises, such as paroxysmal "electric current", of the tabes dorsalis are very characteristic.