Chronic Pain

Question 1

Diffuse pain for greater than 3 months withOUT objective evidence of joint or muscle inflammation?

Answer 1

Fibromyalgia - a diagnosis of exclusion

Question 2

Block for chronic pelvic pain unresponsive to opioids? What level?

Answer 2

Superior hypogastric plexus block - retroperitoneal structure from lower third of L5 to the upper third of S1

Question 3

Nerve block for sharp, electric, burning pain to the vagina or rectum that is exacerbated by sitting? What level?

Answer 3

Pudendal nerve block: S2-S4

Question 4

Spinal cord stimulators are not effective for which type of pain?

Answer 4

nociceptive pain

SC stimulators are effective relief of neuropathic pain

Question 5

Indications for spinal cord stimulators?

Answer 5

Failed back surgery syndrome (mixed pain syndrome with both neuropathic and nociceptive pain)

Refractory angina pectoris

Peripheral vascular dz when critical limb ischemia becomes inoperable

CRPS Type 2 (Causalgia)

Question 6

The medial branch nerve (facet block) innervates what structures?

Answer 6

facet joint
multifidus muscle
interspinous ligament

Question 7

Most effective means of preventing PHN from herpes zoster?

Answer 7

prior vaccination with varicella vaccine

Question 8

Definition of allodynia?

Answer 8

pain from nonpainful/nonnoxious stimuli

Question 9

Definition of hyperalgesia?

Answer 9

increased response to painful stimuli

Question 10

Definition of anesthesia dolorosa?

Answer 10

Pain in a region that should be absent of sensation

Question 11

Appropriate relief after a diagnostic block to help identify if a neurolytic block will provide benefit?

Answer 11

30-80% pain relief

Can last hours to days for local anesthetics; and days to months for local anesthetics with steroids

Question 12

Neurogenic claudication and radicular pain that improves with flexion of the spine?

Answer 12

Spinal stenosis improves with flexion i.e. walking uphill or squatting

Question 13

3 stages of CRPS

Answer 13

stage 1: muscle cramps, increased sweating, and hyperesthesia
stage 2: severe/diffuse pain, hard swelling, coarse or scant hair, brittle/cracked nails, spotty osteoporosis of bone and the beginning of muscle wasting
stage 3: IRREVERSIBLE wasting of tissue

Question 14

first line treatment for phantom limb pain?

Answer 14

No clear first line treatment identified for this population. Frequently used: opioids, antidepressants (TCAs/nortryptiline/despramine), anticonvulsants, gabapentin and pregabalin, and memantine (oral NMDA receptor antagonist).

Other treatments: TENS, deep brain stimulation, spinal cord stimulation, acupuncture, sympathetic blockade and mirror therapies

Acetaminophen NOT effective!

Question 15

Methadone acts at what receptors?

Answer 15

opioid, NMDA, and SSRI

Question 16

Risk factors for the development of postop peripheral neuropathies?

Answer 16

male sex
extremes of weight
pre-existing neuro symptoms
diabetes mellitus
peripheral vascular disease
alcohol dependence
tobacco use
arthritis

**opioid dependence is NOT a risk factor

Question 17

What type of pain fibers do TENS units stimulate?

Answer 17

Large afferent epicritic fibers (gate theory)

Question 18

What to block in chronic pelvic pain vs chronic perineal pain?

Answer 18

Chronic pelvic: superior hypogastric

Chronic perineal: ganglion impar block (Walther’s ganglion)

Question 19

Pathognomonic for cauda equina syndrome?

Answer 19

Saddle anesthesia (S3-S5)

Question 20

Best región to test L5?

Answer 20

Lateral side of 2nd toe

Question 21

Best place to test L4?

Answer 21

Knee and medial side of big toe

Question 22

Best place to test L3?

Answer 22

Medial lower thigh

Question 23

Best place to test L2?

Answer 23

Medial or lateral UPPER thigh

Question 24

Best place to test L1?

Answer 24

Along inguinal ligament