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BR 3rd Ed > 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-agnoist 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
How can severe HTN after spine injection be treated?
Nitroglycerin | Phentolamine in pheochromocytoma
26
How can seizures after spine injection be treated?
``` Secure airway Oxygen Diazepam or midazolam Phenytoin ACLS protocol ```
27
How can pulmonary edema after spine injection be treated?
Oxygen Diuretics Consider IV morphine use Transfer to ICU
28
What are early symptoms of early local anesthetic toxicity?
Perioral and tongue paresthesias Dizziness Orthostasis
29
What are early symptoms of early local anesthetic toxicity?
``` Muscle twitching Drowsiness CNS depression Respiratory depression Tonic-clonic seizures Bradycardia Hypotension Cardiac arrhythmia (conduction block) Cardiac arrest ```
30
How is local anesthetic toxicity treated?
ACLS protocol Cardiac arrhythmia treatment Lipid emulsion therapy
31
What are side effects of corticosteroids from spine injection?
``` HA Insomnia Facial erythema rash Pruitis Dizziness Low grade fever Transient hypergylcemia HTN ```
32
When are epidural steroid injections indicated?
Cervical or lumbar radicular symptoms with correlation on MRI/CT and/or EMG
33
What is the infrapedicular or "safe triangle" approach for lumbar transforaminal ESI?
Endpoint for needle is inferior to the 6 o'clock position of the pedicle in the upper 1/3 of the neuroforamen
34
What are the borders of the "safe triangle" in lumbar TF ESI?
Superior base: line parallel to inferior border of the pedicle Height: lateral edge of vertebral body Hypotenuse: spinal nerve root
35
What are the borders of the Kambin's triangle?
Inferior Base: caudal vertebral body Height: traversing nerve root Hypotenuse: exiting nerve
36
What is the approach for an interlaminar injection?
Midline or paramedian approach
37
What type of needle is used for an interlaminar injection?
18-or 20-gauge Tuohy or Crawford needle connected to a loss of resistance (LOR) syringe
38
What are the ligaments that are passed through for an interlaminar injection?
supraspinous ligament → interspinous ligament → | ligamentum flavum
39
Where is the needle advanced for a caudal injection?
Sacral hiatus
40
Why should the needle not be advanced higher than the S3 level during a caudal injection?
Dural sac typically ends at the S2 level
41
What levels can be treated with a cadual injection?
Superiorly up to the L4–L5 or L5–S1 levels
42
What is considered a positive response for medial branch block (MBB)?
>80% pain relief post-procedure
43
Where is the needle aimed during a cervical MBB?
Articular pillars of the vertebra
44
Where is the needle aimed during a lumbar MBB?
Groove b/w the superior articular process and transverse process (where the medial branch lies)
45
How should the needle tip be positioned in conventional RFA ablation?
Parallel to the target medial branch nerve to produce optimal nerve lesioning
46
What are complications of RFA?
``` 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
What type of joint is the sacroiliac joint?
Diarthrodial joint
48
Where is the needle directed in an SI joint injection?
Inferior border of the joint at a point where the anterior and posterior joint lines overlap
49
What is a Discography?
Diagnostic procedure in which a spinal disc is pressurized to establish or rule out a diagnosis of discogenic pain
50
Where is the needle advanced in Discography?
Anterior to the superior articular process of the inferior vertebral body and advanced slightly into the disc
51
What technique can be used to decrease risk of infection in Discography?
Double needle technique Pre-procedure IV Intradiscal antibiotics
52
What are the risks of Discography?
Infection (diskitis, osteomyelitis, abscess) Accelerated disc degeneration False positive results Increased pain
53
What information should be gathered regarding pain response in Discography?
Pain Level Character Location
54
What is a normal opening disc pressure?
5-25 psi
55
What does a disc manometry of >30 psi indicate?
Needle tip is in annulus | fibrosis
56
What does a disc manometry of >50 psi indicate?
Excessive pressure can result in false positive results
57
Disc annulus sensitivity in chemical discs is indicated by pain at what psi?
Concordant pain response at 15 psi above opening | pressure
58
Disc annulus sensitivity in mechanical discs is indicated by pain at what psi?
Concordant pain response at 15 to 50 psi above | opening pressure
59
Disc annulus sensitivity in indeterminate discs is indicated by pain at what psi?
Pain provocation at 51 to 90 psi above opening pressure (should not be considered clinically significant)
60
Disc annulus sensitivity in normal discs is indicated by pain at what psi?
No pain provocation
61
Where do Presynaptic sympathetic fibers arise?
Intermediolateral cell column horn of the spinal cord from T1–L2 levels and leave the CNS via the ventral roots
62
Where do post-ganglionic axons travel?
Unmyelinated and leave the paravertebral ganglia via the gray rami communicantes and exit via the segmental spinal nerves
63
What is the stellate ganglion compromised of?
Lower cervical sympathetic and upper thoracic ganglia
64
Where is the stellate ganglion located?
Anterolateral to the C7 vertebral body
65
Where does the stellate ganglion receive parasympathetic input and transmits sympathetic output to?
head, neck, heart, and upper extremities
66
What is the clinical landmark for injection target for stellate ganglion block?
Chassaignac tubercle | (carotid tubercle) of the C6 vertebral body
67
What anatomic abnormality lead to an incomplete stellate ganglion sympathetic blockade?
Anomalous intrathoracic pathways known as Kuntz’s nerves can bypass the stellate ganglion
68
What are indications for stellate ganglion blocks?
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
What arecomplications of stellate ganglion blocks?
``` Ipsilateral Horner’s syndrome Hoarseness Paralysis Dyspnea intravascular/intrathecal: seizures and cardiac arrhythmias Infection Hematoma Local organ injury ```
70
How many pairs of thoracic sympathetic ganglia are there?
10 (sometimes 11)
71
What is the innervation of the cardiac plexus?
T1-4
72
What is the innervation of the celiac ganglion?
T5-T12
73
What does the aortic plexus provide innervation to?
lower abdominal viscera
74
Celiac plexus receives sympathetic and parasympathetic fibers from which nerves?
SNS: greater, lesser and least splanchnic nerves PNS: vagus nerve
75
What are indications for celiac plexus block?
``` 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
What are complications of celiac plexus block?
``` ipsilateral Horner’s syndrome Pneumothorax Infection Temporary intercostal neuritis ```
77
What are indications for Superior Hyogastric plexus block?
Chronic pelvic pain from gynecologic, colorectal, or | genitourinary cancer
78
Where is the Superior Hyogastric plexus located?
Lower 1/3 of the L5 vertebral body in from the anterolateral border of L5 bilaterally
79
What are the landmarks for Superior hyogastric plexus block?
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
What indicates proper needle depth in the lateral view during Superior hyogastric plexus block?
Smooth posterior contour corresponding to the anterior psoas fascia
81
Where do sacral nerves provide innervation to?
Sensation: norectal region Motor: external anal sphincter and levator ani muscles
82
What visceral innervation does S1-S4 provide?
Bladder Urethra External genitalia
83
How do spinal cord stimulators (SCS) utilize the Gate Control Theory?
Introducing external neuromodulation in the form of non-painful electrical signals from percutaneous electrodes placed over the dorsal columns
84
How is SCS stimulation increased?
Amplitude Frequency Pulse width Supine position
85
What are indications for SCS?
``` Failed back surgery syndrome Discogenic pain refactory to conservative and surgery CRPS Arachnoiditis Painful peripheral neuropathy Refefactory angina pectoris Non-operable ischemic pain Migraine HA ```
86
Where are SCS electrodes inserted?
Cervical: Below T1-T2 vertebral body Lower body: T12-L1 or L1-2 Upper extremity: T2-3 or T3-4
87
Where should SCS electrodes be placed to maximize electrode stability?
2 segments below target so 3 inch of lead body lies within epidural space
88
Which patients are considered candidates for implanted drug delivery system device?
Chronic intractable pain with known pathophysiology who failed maximal medical and/or surgical therapy
89
What are requirements prior to implanted drug delivery system device placement?
Patient sensitive to infused agent Favorable Psychological evaluation Life expectancy >3 months
90
What are routes of administration of implanted drug delivery system device?
Intrathecal vs epidural
91
What are disadvantages of intracthecal route for implanted drug delivery?
HA Neural injury Supraspinal spread
92
What are advantages of intracthecal route for implanted drug delivery?
Requires lower dosage Less systemic effect No catheter tip dural fibrosis
93
What are complications of implanted drug delivery system device placement?
``` Infection Skin erosion from hardware Pump failure Catheter kinking, migration and obstruction Catheter tip granuloma formation ```

BR 3rd Ed (92 decks)

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