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Cuccurullo Book > Ch 11 - Pain Management: Interventional procedures > Flashcards

Ch 11 - Pain Management: Interventional procedures Flashcards

1
Q

What form of radiation comes from x-ray?

A

Electromagnetic, ionizing radiation

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2
Q

What are the adverse effects of radiation exposure?

A

Carcinogenesis
Radiation burns
Cataract formation

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3
Q

How can you minimize practitioner radiation exposure?

A

Lead apron
Thyroid shield
Lead glasses
Keep extremities far from fluoro machine

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4
Q

What can be used to monitor cumulative radiation exposure?

A

Film badge dosimeter worn outside of the lead protection should be utilized to monitor cumulative radiation exposure

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5
Q

How can you minimize patient radiation exposure?

A

X-ray tube far away from patient so larger area exposed to smaller radiation
Image intensifer close to patient to optimize image quality and minimize scatter radiation
Collimation (narrow x-ray beam) reduces direct and scatter radiation
Pulse mode rather than continuous exposure

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6
Q

What is the MOA of local anesthetics?

A

Reversibly blocking the sodium channels in nerve and muscle membranes

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7
Q

What signs of CNS toxicity from local anesthetic?

A 
Mild—Lightheadedness/dizziness
Perioral numbness
Blurred vision
Tinnitus
Tremors
Shivering
Severe—tonic-clonic seizures, respiratory depression/arrest
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8
Q

What signs of Cardiac toxicity from local anesthetic?

A

Arrhythmias (conduction blocks, ventricular dysrhythmias)

Myocardial depression

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9
Q

When local anesthetics are injected into the subarachnoid space, what is effected first?

A

Sympathetic nerves first (motor nerves last)

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10
Q

What can Intravascular anesthetic injection of local anesthetic cause?

A

Adverse cardiovascular effects

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11
Q

What is the recommended max dose of Bupivacaine (without Epi)?

A

2.5 mg/kg, not to exceed 175 mg

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12
Q

What is the recommended max dose of Lidocaine (without Epi)?

A

4.5 mg/kg, not to exceed 300 mg

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13
Q

What is the recommended max dose of Ropivacaine?

A

5 mg, not to exceed 200 mg

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14
Q

What is the recommended max dose of Procaine?

A

7 mg/kg, not to exceed 350–600 mg

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15
Q

What is the MOA of decreasing pain with corticosteroids?

A

Cause direct inhibition of C-fiber neuronal membrane excitation and induce synthesis of a phospholipase A2 inhibitor, thereby preventing release of substrate for prostaglandin synthesis.

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16
Q

Which steroids have no mineralocorticoid activity?

A

Dexamethasone
methylprednisolone
triamcinolone
betamethasone

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17
Q

Which steroids can increase blood glucose with glucocorticoid activity?

A

dexamethasone and betamethasone

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18
Q

Which steroid is non-particulate?

A

Dexamethasone sodium phosphate

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19
Q

What can happen with intravascular injection of particulate steroid?

A

Embolic infarction of the spinal cord and brain

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20
Q

How can urticaria after spine injection be treated?

A

Benadryl
Vistaril
Cimetedine
Ranitidine

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21
Q

How can facial and laryngeal edema after spine injection be treated?

A

Epinephrine
IVF for hypotension
ACLS protocol

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22
Q

How can bronchospasm after spine injection be treated?

A

Oxygen
Beta-agonist inhalers
Epinephrine
IVF for hypotension

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23
Q

How can hypotension with tachycardia after spine injection be treated?

A

Reverse Tendelenburg
IVF
Epinephrine

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24
Q

How can hypotension with bradycardia after spine injection be treated?

A

Reverse Tendelenburg
IVF
Atropine

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25
Q

How can severe HTN after spine injection be treated?

A

Nitroglycerin

Phentolamine in pheochromocytoma

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26
Q

How can seizures after spine injection be treated?

A 
Secure airway
Oxygen
Diazepam or midazolam
Phenytoin
ACLS protocol
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27
Q

How can pulmonary edema after spine injection be treated?

A

Oxygen
Diuretics
Consider IV morphine use
Transfer to ICU

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28
Q

What are early symptoms of early local anesthetic toxicity?

A

Perioral and tongue paresthesias
Dizziness
Orthostasis

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29
Q

What are early symptoms of early local anesthetic toxicity?

A 
Muscle twitching
Drowsiness
CNS depression
Respiratory depression
Tonic-clonic seizures
Bradycardia
Hypotension
Cardiac arrhythmia (conduction block)
Cardiac arrest
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30
Q

How is local anesthetic toxicity treated?

A

ACLS protocol
Cardiac arrhythmia treatment
Lipid emulsion therapy

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31
Q

What are side effects of corticosteroids from spine injection?

A 
HA
Insomnia
Facial erythema rash 
Pruritus
Dizziness
Low grade fever
Transient hyperglycemia
HTN
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32
Q

When are epidural steroid injections indicated?

A

Cervical or lumbar radicular symptoms with correlation on MRI/CT and/or EMG

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33
Q

What is the infrapedicular or “safe triangle” approach for lumbar transforaminal ESI?

A

Endpoint for needle is inferior to the 6 o’clock position of the pedicle in the upper 1/3 of the neuroforamen

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34
Q

What are the borders of the “safe triangle” in lumbar TF ESI?

A

Superior base: line parallel to inferior border of the pedicle
Height: lateral edge of vertebral body
Hypotenuse: spinal nerve root

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35
Q

What are the borders of the Kambin’s triangle?

A

Inferior Base: caudal vertebral body
Height: traversing nerve root
Hypotenuse: exiting nerve

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36
Q

What is the approach for an interlaminar injection?

A

Midline or paramedian approach

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37
Q

What type of needle is used for an interlaminar injection?

A

18-or 20-gauge Tuohy or Crawford needle connected to a loss of resistance (LOR) syringe

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38
Q

What are the ligaments that are passed through for an interlaminar injection?

A

supraspinous ligament → interspinous ligament →

ligamentum flavum

39
Q

Where is the needle advanced for a caudal injection?

A

Sacral hiatus

40
Q

Why should the needle not be advanced higher than the S3 level during a caudal injection?

A

Dural sac typically ends at the S2 level

41
Q

What levels can be treated with a cadual injection?

A

Superiorly up to the L4–L5 or L5–S1 levels

42
Q

What is considered a positive response for medial branch block (MBB)?

A

> 80% pain relief post-procedure

43
Q

Where is the needle aimed during a cervical MBB?

A

Articular pillars of the vertebra

44
Q

Where is the needle aimed during a lumbar MBB?

A

Groove b/w the superior articular process and transverse process (where the medial branch lies)

45
Q

How should the needle tip be positioned in conventional RFA ablation?

A

Parallel to the target medial branch nerve to produce optimal nerve lesioning

46
Q

What are complications of RFA?

A 
Spinal nerve lesioning (causing paralysis, neuropathic pain)
Increased pain
Vasovagal reaction
Bruising
Ataxia (lesion to third occipital nerve) 
Neuritis
Dropped head syndrome 
Infection 
Bleeding
47
Q

What type of joint is the sacroiliac joint?

A

Diarthrodial joint

48
Q

Where is the needle directed in an SI joint injection?

A

Inferior border of the joint at a point where the anterior and posterior joint lines overlap

49
Q

What is a Discography?

A

Diagnostic procedure in which a spinal disc is pressurized to establish or rule out a diagnosis of discogenic pain

50
Q

Where is the needle advanced in Discography?

A

Anterior to the superior articular process of the inferior vertebral body and advanced slightly into the disc

51
Q

What technique can be used to decrease risk of infection in Discography?

A

Double needle technique
Pre-procedure IV
Intradiscal antibiotics

52
Q

What are the risks of Discography?

A

Infection (diskitis, osteomyelitis, abscess)
Accelerated disc degeneration
False positive results
Increased pain

53
Q

What information should be gathered regarding pain response in Discography?

A

Pain Level
Character
Location

54
Q

What is a normal opening disc pressure?

A

5-25 psi

55
Q

What does a disc manometry of >30 psi indicate?

A

Needle tip is in annulus fibrosis

56
Q

What does a disc manometry of >50 psi indicate?

A

Excessive pressure can result in false positive results

57
Q

Disc annulus sensitivity in chemical discs is indicated by pain at what psi?

A

Concordant pain response at 15 psi above opening

pressure

58
Q

Disc annulus sensitivity in mechanical discs is indicated by pain at what psi?

A

Concordant pain response at 15 to 50 psi above

opening pressure

59
Q

Disc annulus sensitivity in indeterminate discs is indicated by pain at what psi?

A

Pain provocation at 51 to 90 psi above opening pressure (should not be considered clinically significant)

60
Q

Disc annulus sensitivity in normal discs is indicated by pain at what psi?

A

No pain provocation

61
Q

Where do Presynaptic sympathetic fibers arise?

A

Intermediolateral cell column horn of the spinal cord from T1–L2 levels and leave the CNS via the ventral roots

62
Q

Where do post-ganglionic axons travel?

A

Unmyelinated and leave the paravertebral ganglia via the gray rami communicantes and exit via the segmental spinal nerves

63
Q

What is the stellate ganglion compromised of?

A

Lower cervical sympathetic and upper thoracic ganglia

64
Q

Where is the stellate ganglion located?

A

Anterolateral to the C7 vertebral body

65
Q

Where does the stellate ganglion receive parasympathetic input and transmits sympathetic output to?

A

head, neck, heart, and upper extremities

66
Q

What is the clinical landmark for injection target for stellate ganglion block?

A

Chassaignac tubercle (carotid tubercle) of the C6 vertebral body

67
Q

What anatomic abnormality lead to an incomplete stellate ganglion sympathetic blockade?

A

Anomalous intrathoracic pathways known as Kuntz’s nerves can bypass the stellate ganglion

68
Q

What are indications for stellate ganglion blocks?

A

Chronic facial and/or cervicobrachial pain syndromes
CRPS type I or II
Vascular and sympathetically-mediated HAs
Vascular insufficiency/vaso-occlusive diseases
Neuropathic pain syndrome
Post-herpetic neuralgia, Trigeminal neuralgia
Neuropathic orofacial pain
Phantom limb pain
Hyperhidrosis

69
Q

What are complications of stellate ganglion blocks?

A 
Ipsilateral Horner’s syndrome
Hoarseness
Paralysis
Dyspnea
intravascular/intrathecal: seizures and cardiac arrhythmias
Infection
Hematoma
Local organ injury
70
Q

How many pairs of thoracic sympathetic ganglia are there?

A

10 (sometimes 11)

71
Q

What is the innervation of the cardiac plexus?

A

T1-4

72
Q

What is the innervation of the celiac ganglion?

A

T5-T12

73
Q

What does the aortic plexus provide innervation to?

A

lower abdominal viscera

74
Q

Celiac plexus receives sympathetic and parasympathetic fibers from which nerves?

A

SNS: greater, lesser and least splanchnic nerves
PNS: vagus nerve

75
Q

What are indications for celiac plexus block?

A 
Sympathetically mediated thoracic, chest wall, upper abdominal viscera pain
Hyperhidrosis
Intractable cardiac arrhythmia
Prinzmetal’s angina
Raynaud’s disease
Upper extremity CRPS
Post-thoracotomy pain
Acute herpes zoster
Post-herpetic neuralgia 
Post-mastectomy phantom breast pain
76
Q

What are complications of celiac plexus block?

A

ipsilateral Horner’s syndrome
Pneumothorax
Infection
Temporary intercostal neuritis

77
Q

What are indications for Superior Hypogastric plexus block?

A

Chronic pelvic pain from gynecologic, colorectal, or

genitourinary cancer

78
Q

Where is the Superior Hypogastric plexus located?

A

Lower 1/3 of the L5 vertebral body in from the anterolateral border of L5 bilaterally

79
Q

What are the landmarks for Superior hypogastric plexus block?

A

L4 and L5 spinous processes are identified and needle insertion sites are 5 to 7 cm lateral to the midline at the level of L4–L5 interspace

80
Q

What indicates proper needle depth in the lateral view during Superior hypogastric plexus block?

A

Smooth posterior contour corresponding to the anterior psoas fascia

81
Q

Where do sacral nerves provide innervation to?

A

Sensation: anorectal region
Motor: external anal sphincter and levator ani muscles

82
Q

What visceral innervation does S1-S4 provide?

A

Bladder
Urethra
External genitalia

83
Q

How do spinal cord stimulators (SCS) utilize the Gate Control Theory?

A

Introducing external neuromodulation in the form of non-painful electrical signals from percutaneous electrodes placed over the dorsal columns

84
Q

How is SCS stimulation increased?

A

Amplitude
Frequency
Pulse width
Supine position

85
Q

What are indications for SCS?

A 
Failed back surgery syndrome
Discogenic pain refractory to conservative and surgery
CRPS
Arachnoiditis
Painful peripheral neuropathy
Refractory angina pectoris
Non-operable ischemic pain
Migraine HA
86
Q

Where are SCS electrodes inserted?

A

Cervical: Below T1-T2 vertebral body
Lower body: T12-L1 or L1-2
Upper extremity: T2-3 or T3-4

87
Q

Where should SCS electrodes be placed to maximize electrode stability?

A

2 segments below target so 3 inch of lead body lies within epidural space

88
Q

Which patients are considered candidates for implanted drug delivery system device?

A

Chronic intractable pain with known pathophysiology who failed maximal medical and/or surgical therapy

89
Q

What are requirements prior to implanted drug delivery system device placement?

A

Patient sensitive to infused agent
Favorable Psychological evaluation
Life expectancy >3 months

90
Q

What are routes of administration of implanted drug delivery system device?

A

Intrathecal vs epidural

91
Q

What are disadvantages of intracthecal route for implanted drug delivery?

A

HA
Neural injury
Supraspinal spread

92
Q

What are advantages of intracthecal route for implanted drug delivery?

A

Requires lower dosage
Less systemic effect
No catheter tip dural fibrosis

93
Q

What are complications of implanted drug delivery system device placement?

A 
Infection
Skin erosion from hardware
Pump failure
Catheter kinking, migration and obstruction
Catheter tip granuloma formation

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