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
A patient is scheduled for amputation of the third metatarsal. A tourniquet will not be used during the procedure. The most effective anesthesia will be provided by block of which of the following nerves?
(A) Femoral
(B) Common peroneal and tibial
(C) Sural and deep peroneal
(D) Sural and tibial
(E) Tibial, saphenous, and deep peronea
(B) Common peroneal and tibial
Phantom pain is caused by both peripheral and central
factors. Which of the following is increased in activity with respect to the peripheral mechanism of this neuropathology?
A. C fiber
B. a-delta fiber
C. a-beta fiber
D. B fiber
A. C fiber
Phantom pain is caused by both peripheral and central factors.
- Peripheral mechanisms include neuromas, an increase in C fiber
activity, and sodium channel activation.
Central mechanisms include
abnormal firing of spinal internuncial neurons and supraspinal involvement
secondary to the development of new synaptic connections in the cerebral cortex.
TRUE or FALSE
Complex regional pain syndrome (CRPS) is considered nociplastic in nature and is directly due to nerve damage.
FALSE
Complex regional pain syndrome (CRPS) is now considered nociplastic in nature, caused by ongoing inflammation and damage of tissues, in contrast to neuropathic pain, which is due to nerve damage.
Which of the following is NOT considered a risk factor for the development of CRPS?
A. Previous trauma
B. Nerve injury (for causalgia)
C. Previous surgery
D. Male sex
E. Female sex
D. Male sex
Females are considered risk factor.*
30 year old female with previous history of nerve injury due to traumatic amputation. She was diagnosed with CRPS. If Ketamine is to be infused, which of the following should be serially monitored during the course of treatment?
A. liver enzymes
B. creatinine clearance
C. blood sugar
D. tryptase level
A. liver enzymes
30 year old female with previous history of nerve injury due to traumatic amputation. She was diagnosed with CRPS. Which of the following treatment modalities will LEAST likely be effective?
A. Phenol neurolysis
B. Spinal cord stimulation
C. Acetaminophen
D. Memantine
E. Ketamine
C. Acetaminophen
Which one is preceded by a nerve injury?
A. CRPS I
B. CRPS II
B. CRPS II
The clinical features of CRPS type II are the same as in CRPS type I except there is a preceding nerve injury in CRPS II.
CRPS is a clinical diagnosis but with BUDAPEST criteria, the specificity and sensitivity is very high.
The celiac plexus is a collection of ganglia that innervates all abdominal viscera except for the:
A. left side of the colon
B. mid-transverse colon
C. pancreas
D. gall bladder
A. left side of the colon
A 54-year-old man receives 25 ml of a 50% alcohol and 0.25% bupivacaine solution for celiac plexus block. During the next 20 minutes, blood pressure decreases from 130/75 mmHg to 85/55 mmHg. Which of the following is the most likely cause?
(A) Intravascular injection
(B) Retroperitoneal hemorrhage
(C) Splanchnic vasodilation
(D) Subarachnoid blockade
(E) Tension pneumothorax
(C) Splanchnic vasodilation
Complications from celiac plexus block include retroperitoneal hematoma, reactive pleurisy, hiccups, hematuria, abdominal
aortic dissection, transient motor paralysis, and paraplegia.
Paraplegia and transient motor paralysis may be due to spasm of the lumbar segmental arteries that perfuse the spinal cord, direct vascular or neurologic injury, or
retrograde spread to the nerve roots or spinal cord.
After carefully crafting your plan of celiac plexus block. You decided to give the neurolysis via the antecrural space with which of the following volume?
A. 30 ml
B. 10 ml
C. 15 ml
D. 5 ml
The dosages of the neurolytic agents are 30 to 50 mL for the antecrural space, 15 to 30 mL for the retrocrural space, and 10 to 15 mL on each side for splanchnic nerve blockade.
- There appears to be no difference in efficacy between approaches to celiac plexus blockade.
ANTERIOR CRURA 30 -50 ml
RETRO CRURA 15 - 30 ml
SPLANCHNIC 10 -15 ml
Neurolysis application to the distal third of vagina is MOST effective with which of the following approach?
A. Ganglion impar block
B. Celiac plexus block
C. superior hypogastric plexus block
D. Inferior hypogastric plexus block
A. Ganglion impar block
Which of the following opioid lacks an active metabolite and highly associated with torsades de pointes?
A. Morphine
B. Hydromorphone
C. Methadone
D. Meperidine
C. Methadone
Which of the following has the LEAST histamine releasing activity?
A. Fentanyl
B. Morphine
C. Oxymorphone
D. Meperidine
A. Fentanyl
- Actually, fentanyl do not have the histamine releasing activity.
A 10 year old was admitted to the PACU after an uneventful surgery. 2 hours post-op, He complained of pain at the surgical site. The anesthesia resident upscaled the opioid and gave IV bolus. After several minutes, the pt complained with the same pain score but this time with pruritus and nausea vomiting. Which of the following opioid was most likely used?
A. Codeine
B. Morphine
C. Alfentanil
D. Buprenorphine
A. Codeine
Barash | 9th edit
Which of the following is recommended 1st line pharmacologic treatment for NEUROPATHIC PAIN?
A. TCA
B. Weak opioid
C. Strong opioid
D. Capsaicin 8%
A. TCA
- First-line medication recommendations for neuropathic pain include antiepileptics, SNRIs, and TCAs.
- Second-line recommendations included capsaicin 8% patches, topical lidocaine, and tramadol.
- Botulinum toxin A and opioids are third-line medications, but strong opioids have been linked
to worsened outcomes
The following is considered a second-line recommendation for the treatment of neuropathic pain EXCEPT:
A. Codeine
B. TCA
C. SNRI
D. Tramadol
D. Tramadol
- First-line medication recommendations for neuropathic pain include antiepileptics, SNRIs, and TCAs.
- Second-line recommendations included capsaicin 8% patches, topical lidocaine, and tramadol.
- Botulinum toxin A and opioids are third-line medications, but strong opioids have been linked to worsened outcomes.
What is the primary reason why SNRI’s are more commonly used for neuropathic pain compared to TCA?
READ
5% lidocaine patch delivers:
A. 700 mg of lidocaine
B. 500 mg of lidocaine
C. 250 mg of lidocaine
D. 150 mg of lidocaine
A. 700 mg of lidocaine
The analgesic effect of spinal cord stimulation is primarily thru:
A. Intensity theory
B. Sensitivity theory
C. Gate control theory
D. Neuromatrix
C. Gate control theory
The analgesic effect of SCS may involve the gate control theory,
neurotransmitter modulation in the spinal cord affecting pain pathways and suppression of sympathetic activity, with antidromic activity and supraspinal mechanisms also playing roles.
It is hypothesized that SCS increases the input of large nerve fibers, thus closing the “gate” at the substantia gelatinosa
of the dorsal horn of the spinal cord.
Which of the following is clinically considered to be a 1st line analgesia treatment thru the use of Intrathecal drug delivery (IDD)?
A. Preservative free morphine
B. Fentanyl plus local anesthetics
C. Baclofen
D. Preservative free Hydromorphone
A. Preservative free morphine
Intrathecal drug delivery (IDD) enables opioids and other analgesics to be directly deposited near the spinal cord receptors, resulting in analgesia at lower doses
The top indication for IDD has historically been spinal pain, though recent guidelines recommending lower doses of opioids have translated to
decreased utilization in chronic noncancer pain.
IDD allows the drug to be
directly deposited near the spinal cord receptors, bypassing the blood–brain
barrier and the first-pass effect encountered by systemic medications.
Hence, medications that have limited blood–brain barrier permeability and medications whose target receptors are in the spinal canal can be delivered more efficiently and at significantly lower doses.
HIV-related sensory
neuropathy would MOST likely respond to which of the following?
A. Lamotrigine
B. Mexilitine
C. Lidocaine
D. Tramadol
A. Lamotrigine
Lamotrigine is effective in treatment of HIV polyneuropathy, pain from
SCI, trigeminal neuralgia, and central poststroke pain.
The most common
side effect is rash, and use of lamotrigine is limited by the risk of Stevens–
Johnson syndrome.
- Mexiletine is an oral analog of lidocaine and can treat the pain of diabetic neuropathy, thalamic stroke, spasticity, and myotonia with modest
efficacy however it is not well tolerated by most patients.
