Advanced | Chronic Pain and Anesthesia Flashcards
Following a vaginal hysterectomy in the lithotomy position under general anesthesia, a patient has numbness of the lateral aspect of the left calf and medial half of the dorsum of the left foot. On physical examination she has footdrop and the toes cannot be extended. Which nerve is most likely to be involved?
(A) Common peroneal nerve
(B) Deep peroneal nerve
(C) Posterior tibial nerve
(D) Saphenous nerve
(E) Sciatic nerve
(A) Common peroneal nerve
The most likely effect of a celiac plexus block for an abdominal operation is:
(A) bowel distention
(B) hypotension
(C) incisional analgesia
(D) muscle relaxation
(E) urinary retention
(B) Hypotension
TRUE or FALSE
The local application of methylprednisolone blocks transmission of C fibers but not Aβ fibers
TRUE
- Only C fibers.
Barash |9th edit
Which of the following would have the LEAST effect in the treatment of lumbosacral radicular pain?
A. Carbamazepine
B. NSAID
C. Epidural steroid
D. Duloxetine
A. Carbamazepine
Physical therapy, NSAIDs, acetaminophen, and short courses of muscle relaxants are effective first-line agents in treating spine pain.
- Antiepileptics are not effective in treating low back pain or lumbosacral radicular pain.
- Carbamazepine is a carboxamide derived anti-epileptics.
Duloxetine was noted to be superior to placebo in treating the neuropathic component of chronic low back pain.
- Epidural steroid injections (ESIs) may be considered for patients
with spine pain that do not respond to noninterventional management
Barash | 9th edit
In terms of epidural steroid injections, which of the following approach will provide the steroid injection closest to the nerve root?
A. Interlaminar (IL) approach
B. Transforaminal (TF) approach
C. Posterior laminar approach
B. Transforaminal (TF) approach
Epidural steroid injections (ESIs) may be considered for patients
with spine pain that do not respond to noninterventional management.
Steroids have antinociceptive and anti-inflammatory effects related to
phospholipase A2 inhibition.
Epidural placement via an interlaminar (IL) approach deposits steroid into the posterior epidural space whereas the transforaminal (TF) approach traverses the intervertebral foramina to access the anterolateral epidural
space, which deposits steroid closer to the nerve root
Barash | 9th edit
The maximum number of epidural steroid injection is:
A. twice only, then consider adjuvants
B. maximum of 3 doses
C. one dose only, then reassess
D. no limit as long as clinically responding
B. maximum of 3 doses
Barash | 9th edit
This epidural steroid injection poses the highest risk of complications such as vasospasm or occlusion:
A. Methylprednisolone
B. Betamethasone
C. Triamcinolone
D. Dexamethasone
A. Methylprednisolone
Barash | 9th edit
Which of the following is NOT expected to be a side-effect of epidural steroid injection?
A. Vasospasm
B. Infection
C. Potentiation of the hypoglycemic effect of insulin
D. Suppression of hypothalamic pituitary adrenal axis
E. Bone density reduction
C. Potentiation of the hypoglycemic effect of insulin
- It clinically REDUE the hypoglycemic effect of insulin in DM patients.
Barash | 9th edit
True/False
These lowest effective steroid doses, or their pharmacologic equivalent, should be employed for ESIs to reduce adverse effects.
TRUE
Barash | 9th edit
This is the primary determining factor for the development of vasospasm or occlusion in epidural steroid injection:
A. Particulate
B. Dosage
C. Site of injection
D. Strength of steroid
A. Particulate
Barash | 9th edit
Cervical IL Epidural steroid injection should be performed at:
A. C7 - T1
B. C3 - C4
C. C4 - C5
D. C5 only
A. C7 - T1
Barash | 9th edit
Epidural steroid injection is clinically considered to be INEFFECTIVE in which of the following conditions?
A. Acute radicular symptoms
B. Chronic lumbar radiculopathy
C. Spinal stenosis
D. Herniated disc
B. Chronic lumbar radiculopathy
ESIs are more effective in patients with acute radicular symptoms; they are not effective in patients with chronic lumbar radiculopathy.
The efficacy of ESIs in spinal stenosis, when combined with local anesthetic, may last up to 3 months.
The evidence for epidural local anesthetic alone in spinal
stenosis, without steroid, is low but may be entertained in view of the side effects of steroids.
Barash | 9th edit
30 year old male is scheduled for interventional pain management. He is presently complaining of low back that radiates to the ipsilateral posterior thigh and usually terminates at the knee. On PE, paraspinal tenderness and reproduction of pain with extension–rotation maneuvers of the back is prominent. Which is the MOST likely diagnosis?
A. Facet syndrome
B. Piriformis Syndrome
C. Herniated disc
D. Myofascial Pain Syndrome
A. Facet syndrome
Barash | 9th edit
Based on guidelines and literatures, can you treat Facet Syndrome with ESI (epidural steroid injection)?
YES.
Although there are no published studies regarding the response to ESI, the author believes the efficacy of ESI for the treatment of facet syndrome.
Barash | 9th edit
A 40 year old male is complaining of buttock pain with or without radiation to the ipsilateral leg. The buttock pain usually extends from the sacrum to the greater trochanter of the femur. Prolonged sitting, as in driving or biking, or rising from a sitting position aggravates the pain. Neuro-examination is negative. Which of the ff is the most likely diagnosis?
A. Facet syndrome
B. Piriformis Syndrome
C. Herniated disc
D. Myofascial Pain Syndrome
B. Piriformis Syndrome
Barash | 9th edit
Each of the following is a complication of stellate ganglion block EXCEPT
(A) brachial plexus block
(B) diplopia
(C) local anesthetic-induced seizure
(D) recurrent laryngeal nerve palsy
(E) subarachnoid block
(B) diplopia
Which of the following complications of caudal anesthesia with 0.25% bupivacaine is more likely in children than in adults?
(A) Intravascular injection
(B) Neurotoxicity
(C) Profound motor block
(D) Systemic toxicity
(E) Total spinal block
(E) Total spinal block
It is a painful regional syndrome characterized by the presence of active trigger point in skeletal muscle. This trigger point can be observed as a palpable “TAUT” band and manipulation of the trigger point, by digital pressure or by penetration with a needle, may
induce a “twitch” response.
A. Facet syndrome
B. Piriformis Syndrome
C. Herniated disc
D. Myofascial Pain Syndrome
E. Postherpetic Neuralgia
D. Myofascial Pain Syndrome (Fibromyalgia)
Barash | 9th edit
A 40 year old female came in at the pain clinic for what seem to be a Myofascial Pain Syndrome or Fibromyalgia. Which of the following has the LEAST important role in the treatment of this patient?
A. Duloxetine
B. Pregabalin
C. Amitriptyline
D. Morphine
D. Morphine
Barash | 9th edit
Which of the following is NOT considered a type of neuropathic pain?
A. Post-herpetic neuralgia
B. Diabetic Neuropathy
C. Myofascial Pain Syndrome
D. Phantom Pain
C. Myofascial Pain Syndrome
Barash | 9th edit
Based on efficacy, which of the following is ideally the first choice for neuropathic pain
syndromes?
A. TCA
B. Opioid
C. Pregabalin
D. Epidural steroid injection
A. TCA
Based on efficacy, antidepressants are the first choice for neuropathic pain syndromes, followed by opioids, tramadol, and gabapentin/pregabalin.
What should be the best choice of pain control in a patient with history of substance use disorder (SUD)?
A. TCA
B. Opioid
C. Gabapentin
D. Epidural steroid injection
E. Local anesthetic
C. Gabapentin
When quality of life, side effects, prevention of substance use disorder (SUD), and
regulatory issues are considered in addition to pain relief, then
gabapentin/pregabalin may be the preferred first-line agents.
Barash | 9th edit
TRUE or FALSE
Intrathecal methylprednisolone
with lidocaine DO NOT play a role in the management of post-herpetic neuralgia
FALSE
Intrathecal methylprednisolone
with lidocaine, given once a week for four administrations, appears to be more effective in relieving PHN compared with intrathecal lidocaine or no treatment.
A 78-year-old patient is scheduled for an amputation of the proximal third of his left leg. He has a long history of diabetes mellitus, managed with metformin alone for years. Considering the potential side effects of various treatment options, which medication would be the most appropriate for managing the expected diabetic neuropathy in this patient?
A. Gabapentin plus nortriptyline
B. Duloxetine
C. Opioid
D. Milnacipran
E. Both B and D
E. Both B and D
The antiepileptics gabapentin and pregabalin appear to be effective in the management of DPN, with the efficacy of gabapentin enhanced by the addition of controlled-release morphine or nortriptyline.
The TCAs are more effective than SNRIs but given their more favorable side-effect profile, duloxetine is the most widely prescribed agent for DPN.
- SNRI’s that are most commonly recommended by The European Federation of Neurological Sciences Task Force and the International Association for the Study of Pain (IASP) are DULOXETINE and MILNACIPRAN.
Barash | 9th edit