Ch 11 - Pain Medicine: Pain Syndromes

Question 1

Description of Nociceptive/Somatic pain

Answer 1

Deep somatic pain: dull/aching
Superficial somatic pain: sharp, pricking
Burning, localized, reproducible

Question 2

Description of Visceral pain

Answer 2

Crampy and dull

Vague in location

Question 3

Description of Neuropathic/Central pain

Answer 3

Burning, tingling, shooting, stabbing, electric-like

May be associated with numbness, tingling

Question 4

What is the cause of nociceptive/somatic pain?

Answer 4

noxious perception from tissue damage mediated by the somatic nervous system

Question 5

What is the cauase of visceral pain?

Answer 5

Organs mediated by ANS

Question 6

What is the cause of neuropathic/central pain?

Answer 6

Lesion or dysfunction in CNS or PNS

Question 7

What is myofascial pain?

Answer 7

Localized and referred soft-tissue pain that can exhibit sensory, motor, and autonomic symptoms arising from myofascial trigger point

Question 8

What is a myofascial trigger point?

Answer 8

hyperirritable point within a taut band of skeletal muscle or fascia that is painful on compression

Question 9

What is Complex regional pain syndrome (CRPS)?

Answer 9

neuropathic pain disorder affects one or more extremities and usually occurs following a physical injury

Question 10

What are the types of CRPS?

Answer 10

CRPS I: without nerve damage

CRPS II: nerve damage

Question 11

Medications used for CRPS

Answer 11

NSAIDs, antidepressants, anticonvulsants, opioids (limited data), topical dimethyl sulfoxide (DMSO), and oral N-acetylcysteine (NAC)

Question 12

What procedure can be useful in CRPS?

Answer 12

Sympathetic nerve blocks

Question 13

Describe CRPS pain

Answer 13

Continuing pain, allodynia, or hyperalgesia in which the pain is disproportionate to any known inciting event

Question 14

What can be signs of CRPS?

Answer 14

edema, changes in skin blood flow, or abnormal sudomotor activity in the region of pain

Question 15

What is Interstitial cystitis?

Answer 15

Chronic inflammatory condition of the bladder’s submucosal and muscular layers

Question 16

What is a Hunner’s ulcer?

Answer 16

Patches of broken skin on the bladder wall

Present in 10% of interstitial cystitis

Question 17

Describe K+ sensitivity test

Answer 17

Positive if patient experiences pain with urinating K+/water vs water from bladder alone

Question 18

What is first line treatment for interstitial cystitis?

Answer 18

Patient education
Diet modification
Stress modification

Question 19

What is second line treatment for interstitial cystitis?

Answer 19

PT
Oral medications (amitriptyline, cimetidine, hydroxyzine, pentosan polysulfate)
Bladder instillations (DMSO, heparin, lidocaine)

Question 20

What is third line treatment for interstitial cystitis?

Answer 20

Treatment of Hunner’s ulcers (laser, fulguration,
triamcinolone injection)
Hydrodistention (low pressure, short duration)

Question 21

What is fourth line treatment for interstitial cystitis?

Answer 21

Neuromodulation (sacral or pudendal nerve)

Question 22

What is fifth line treatment for interstitial cystitis?

Answer 22

Cyclosporine A, Botulinum toxin

Question 23

What is sixth line treatment for interstitial cystitis?

Answer 23

Surgical intervention (urinary diversion, augmentation, cystectomy)

Question 24

What is Irritable bowel syndrome (IBS)?

Answer 24

Abd pain or discomfort for 6 mo & at least 3x/mo for the last 3 mo w/o other cause

Question 25

What are symptoms of Irritable bowel syndrome (IBS)?

Answer 25

``` Chronic abdominal pain Discomfort Bloating Urgency to move bowels Tenesmus Alteration of bowel habits Improvement of pain with bowel movement ```

Question 26

What comorbidities are associated with Irritable bowel syndrome (IBS)?

Answer 26

HA Fibromyalgia Depression Chronic fatigue syndrome

Question 27

Tx of IBS

Answer 27

Diet modification Psychotherapy Probiotics Oral medications (fiber supplements, laxatives) Antidiarrheals (loperamide) Antispasmodics (hyoscine, cimetropium, pinaverium) Antidepressants (TCAs, SSRIs), or Amitiza (lubiprostone)

Question 28

What do the sacral nerves provide sensory and motor innervation to?

Answer 28

Anorectal region and motor innervation to the external anal sphincter and levator ani muscles

Question 29

Which viscera are innervated by S1-4?

Answer 29

Bladder Urethra External genitalia

Question 30

What is a Presacral neurectomy used for?

Answer 30

Midline chronic dysmenorrhea that is unresponsive to medical management

Question 31

What is a Presacral neurectomy?

Answer 31

Total transection of the presacral nerves, superior hypogastric plexus, lying within the boundaries of the interiliac triangle

Question 32

What is a LUNA procedure?

Answer 32

Under laparoscopy, uterus is anteverted with a uterine manipulator and the uterosacral ligaments, which carry nerve fibers, are identified and transected close to their cervical attachment.

Question 33

What is Piriformis syndrome?

Answer 33

Compression or irritation of the sciatic nerve by the piriformis muscle, resulting in pain, numbness, and tingling in the buttocks that may radiate into the thigh and lower leg

Question 34

What kind of pain is present in 30% of HIV patients?

Answer 34

Peripheral neuropathic pain

Question 35

Which HIV medications can cause peripheral neuropathy?

Answer 35

didanosine and stavudine

Question 36

What can contribute to HA in HIV patients?

Answer 36

Cryptococcal meningitis | Zidovudine

Question 37

What can cause abdominal pain in HIV patients?

Answer 37

Mycobacterium avium complex [MAC] infection

Question 38

What is a common first symptom of MS?

Answer 38

Optic neuritis | Usually resolves in 7 to 10 days

Question 39

What is the most common pain syndrome in MS?

Answer 39

Neurogenic: dysesthesias, often occurs in legs | Lhermitte’s sign

Question 40

Describe pain in peripheral vascular disease

Answer 40

``` Intermittent claudication: calf pain on exercise Critical limb ischemia: pain at rest Aching Cramping Burning in feet, calves or thighs ```

Question 41

What is chronic pain in sickle cell disease typically secondary to?

Answer 41

AVN (hips > shoulders > ankles)

Question 42

What can be seen on x-ray of the spine with chronic back pain in sickle cell disease?

Answer 42

Fish mouth appearance of spine

Question 43

What is Rheumatoid arthritis?

Answer 43

systemic disease characterized by inflammation of the membranes lining the joints and synovium

Question 44

What is the cause of pain in RA?

Answer 44

Synovitis Usage related joint pain secondary to weakness Secondary arthritis

Question 45

Describe symptoms of Ankylosing Spondylitis

Answer 45

Pain and stiffness in SI, low back and buttock that is gradual over weeks to months Pain unilateral, bilateral or alternating Worse in the mornings and at night

Question 46

What can improved the symptoms in Ankylosing Spondylitis (AS)?

Answer 46

Warm shower | Light exercise

Question 47

Describe the epidemiology of Fibromyalgia patients

Answer 47

``` Female-to-male ratio of 3:1 >50 years of age Low educational level Low socioeconomic status Living in rural areas ```

Question 48

What is the mechanism of Fibromyalgia?

Answer 48

CNS sensitization that leads to “disordered afferent processing” and increased levels of excitatory neurotransmitters (glutamate, substance P) and/or low levels of inhibitory neurotransmitters (5HT, NE, GABA)

Question 49

What are the symptoms of Fibromyalgia?

Answer 49

``` Multifocal pain Fatigue Insomnia Cognitive or memory problems Psychological distress ```

Question 50

How is Fibromyalgia diagnosed?

Answer 50

Tenderness at 11 or more of 18 specific tender point sites (pressure at 4 kg/cm2).

Question 51

What are pharmacologic treatments of Fibromyalgia?

Answer 51

1. TCAs and cyclobenzaprine shown to be efficacious in RCTs 2. Pregabalin (FDA approved in 2007) 3. Duloxetine (FDA approved in 2008) 4. Milnacipran (FDA approved in 2009)

Question 52

What are nonpharmacologic treatments of Fibromyalgia?

Answer 52

1. Exercise 2. Behavioral medicine 3. Educational approaches