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P2 Head, Neck and Neuro > Chronic pain, brain anatomy, signalling in the NS > Flashcards

Chronic pain, brain anatomy, signalling in the NS Flashcards

1
Q

Which lobe is the precentral gyrus part of?

A

Frontal

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2
Q

What lobe is the postcentral gyrus part off?

A

Parietal

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3
Q

Where is Broca’s area?

A

On the inferior frontal gyrus

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4
Q

Which hemisphere is Broca’s more commonly found in?

A

The left

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5
Q

Which gyri is the auditory complex found on?

A

Superior temporal gyri

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6
Q

What is the function of Broca’s area?

A

Motor aspect of speech - speech associated gestures

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7
Q

What does damage to Broca’s area do?

A

Expressive aphasia- non-fluent and slow speech

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8
Q

Where is wernicke’s area found?

A

Within the auditory association cortex

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9
Q

What is the function of Wernicke’s?

A

Sensory language areas, lexical processing

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10
Q

What can damage to Wernicke’s area cause?

A

Receptive aphasia - extremely poor comprehension

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11
Q

What are the most anterior and posterior parts of the corpus callosum called?

A

Genu (anterior)

Splenium (posterior)

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12
Q

What is the rostrum of the corpus callosum?

A

The part that projects inferiorly and posteriorly from the Genu

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13
Q

Where is CSF made?

A

Choroid plexus within the ventricular system of the brain

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14
Q

How much CSF is produced per day, and what happens to it when it’s been used?

A

500ml produced per day 140ml circulates through the subarachnoid space

Reabsorbed into the venous drainage system

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15
Q

What is the function of CSF?

A

Affords mechanical and immunological protection to the brain and spinal cord

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16
Q

How does CSF pass from the lateral ventricles to the third ventricle?

A

Interventricular foramen

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17
Q

How does CSF pass from the third ventricle to the fourth ventricle?

A

Through the aqueduct of midbrain

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18
Q

Which structures make up the lentiform nucleus?

A

Putamen

Globus palidus

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19
Q

What are the three borders of the lentiform nucleus?

A

Claustrum

Anterior limb

Posterior limb

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20
Q

Which motor axons pass by the Genu of the lentiform nucleus?

A

Corticobulbar axons

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21
Q

Which axons pass by the posterior boundary of the lentiform nucleus?

A

Corticospinal axons

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22
Q

What are the three main pairs of arteries given off by the circle of Willis?

A

Anterior cerebral arteries

Middle cerebral arteries

Posterior cerebral arteries

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23
Q

Roughly what areas of the brain does the anterior, middle and posterior cerebral arteries supply?

A

Anterior - frontal and parietal

Middle - temporal

Posterior - occipital

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24
Q

Which eight, fused bones make up the cranial cavity?

A

Frontal

Occipital

Sphenoid

Ethmoid

2 x parietal

2 x temporal

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25
Q

What are the red flags of lower back pain?

A

Previous history of malignancy

Younger than 16, older than 50 with new pain

Weight loss

Prolonged steroid use

Recent serious illness

Recent significant infection

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26
Q

List some mechanical causes of lower back pain below.

A

Trauma

Muscular and ligament pain

Pustular back pain

Facet joint syndrome = ostearthritis

Lumbar disk prolapse

Lumbar spondylosis

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27
Q

Describe the anatomy of an intervertebral disk.

A

Soft gelatinous centre called nucleus pulposus, encircled by a strong, ring-like collar of fibrocartilage called the annulus fibrosis.

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28
Q

What is the main function of an intervertebral disk?

A

Shock absorption

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29
Q

What happens in an intervertebral disk prolapse?

A

Nucleus pulposus is squeezed out of place and herniated through the annulus fibrosis

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30
Q

Name some reasons an IV disk would become damaged?

A

Trauma

Effects of ageing

Degenerative disorders of the spine

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31
Q

Briefly describe pathology involved once an IV disk herniation has occurred?

A

Posterior protrusion of the nucleus pulposus towards the intervertebral foramen and its contained spinal root. Annulus fibrosis becomes thin and poorly supported by posterior or anterior ligaments at this point

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32
Q

Which regions of the spine are most commonly involved in disk herniations?

A

Cervical and lumbar

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33
Q

Where are the signs and symptoms of a disk herniations seen?

A

Localised to the area of the body innervated by the affected spinal nerve roots- includes motor and sensory

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34
Q

If the nerve roots L4, L5, S1, S2 and S3 are damaged, what condition arises?

A

Sciatica

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35
Q

Describe where the pain is felt in sciatica?

A

Spreads down the back of the leg and over the sole of the foot

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36
Q

What are the most common sensory effects from spinal root compression?

A

Paraesthesia and numbness

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37
Q

What are the most common motor effects from spinal root compression?

A

Knee and ankle reflexes may be absent or diminished

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38
Q

What are the symptoms of severe spinal disease?

A

Pain worse at rest

Thoracic pain

Fever

General malaise

Urinary retention

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39
Q

What signs and symptoms of cauda equina compression occur in severe spinal disease?

A

Bilateral leg pain

Back pain

Urinary retention

Perinatal sensory loss

Erectile dysfunction

Reduced anal tone

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40
Q

What are the layers of protection for the spinal cord?

A

Vertebrae

Vertebral ligaments

Fat and connective tissue in epidural space

Meninges

CSF

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41
Q

At what point do the spinal nerves stop being covered in meninges?

A

Once they exit the spinal column through the intervertebral foramen

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42
Q

What is the epineurium?

A

The outer covering of spinal and cranial nerves - continuous with dura mater

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43
Q

Which meningeal layer contain blood vessels? (At least in the spine :/)

A

Pia mater and dura mater

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44
Q

Describe the connective tissues of the dura mater.

A

Thick, strong, dense and irregular

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45
Q

Where does the spinal cord arise and terminate in adults and babies?

A

-Arises in the medulla oblongata

Terminates:

  • superior border of 2nd lumbar vertebrae in adults
  • L3,4 in newborns
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46
Q

What is the superior enlargement of the spinal cord, and where does it span?

A

It’s a cervical enlargement, that nerves to and from the upper limb arise from

Spans from C4 to T1

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47
Q

What is the inferior enlargement of the spinal cord, and where does it span?

A

It’s a lumbar enlargement, that nerves to and from the lower limb arise from

Spans from T11 to S2

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48
Q

What is the conical structure at the end of the spinal cord called?

A

Conus medullaris (between L1, 2)

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49
Q

What is the filum terminale?

A

Extension of pia mater that extends from conus medullaris to the arachnoid and dura mater at the coccyx- anchors spinal cord to coccyx

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50
Q

What is contained in a dorsal root ganglion?

A

Cell bodies of sensory neurons

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51
Q

What is in the white matter of the spinal cord?

A

Bundles of myelinated axons of neurons

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52
Q

What are the anterior median fissure and posterior median sulcus of the spinal cord?

A

Anterior median fissure - wide groove on ventral side

Posterior median sulcus - narrow furrow on dorsal side

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53
Q

What is contained in the grey matter of the spinal cord?

A

Dendrites and cell bodies of neurons, unmyelinated axons and neuroglia

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54
Q

What are denticulate ligaments?

A

Triangular shaped membranous extensions of the pia mater than suspend the spinal cord in the middle of the rural sheath

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55
Q

What is found in the centre of the grey commissure?

A

Central canal - contains CSF

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56
Q

What is there grey commissure?

A

Crossbar between the two lateral sides of the grey matter

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57
Q

What are nuclei?

A

Clusters of neuronal cell bodies arranged in functional groups in the grey matter

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58
Q

What parts of the spinal cord are the intermediate grey horns found in, and what do they contain?

A

Thoracic and upper lumbar Contain autonomic motor nuclei - regulate activity of cardiac muscle, smooth muscle and glands

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59
Q

What is the difference between a nerve and a track?

A

Nerves are bundles of axons in PNS Tracts are bundles of axons in the CNS

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60
Q

What are the two spinothalamic pathways?

A

Neospinothalamic tract - fast pain Palaeospinothalamic tract - slow pain

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61
Q

Outline the common course of primary afferent of the spinothalamic pathway

A

Peripheral receptor, body in the dorsal root ganglion, synapses in the lamina I+II of the dorsal horn, glutamergic

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62
Q

Outline the common course of secondary afferent of the spinothalamic pathway

A

Body in the lamina I+ II of dorsal horn Cross over to the lateral funiculus Travel through medulla In midbrain give fibres to periaqueductal grey matter and to reticular formation, to hypothalamus In thalamus synapse

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63
Q

When are nociceptors activated?

A

When the pain reaches a noxious threshold

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64
Q

Describe pain sensitization in relation to nerve fibres?

A

Continued stimulation decreases the threshold at which nociceptors respond

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65
Q

What type of pain do the C-fibres send to the brain?

A

The poorly localised, diffuse ‘second’ pain (slow and burning)- polymodal; respond to mechanical, thermal and chemical stimuli

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66
Q

Name the three neurotransmitters used by nociceptive fibres.

A

Glutamate Substance P Calcitonin gene-related peptide (CGRP)

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67
Q

Outline the common course of tertiary afferent of the spinothalamic pathway

A

Body in thalamus

Signals to the cerebral cortex

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68
Q

Describe the course of the descending inhibitory tracts

A

Originate in periaqueoductal grey matter and locus ceoruleus

Synapse in medulla and move down through the inhibitory dorsal columns to the synapse of primary and secondary afferents

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69
Q

How does a thermal stimuli activate A-delta and C-fibres?

A

Hot activates the TRPV1 receptor

Cold activates the TRPM8 receptor

Results in either cooling or warming of the body behaviours - mediated through projections to the hypothalamus

70
Q

How does a mechanical stimuli activate A-delta and C-fibres

A

High threshold

Only activated when stimuli is noxious and may cause tissue damage

71
Q

How does a chemical stimuli activate C-fibres?

A

Can be external irritation or substances released during tissue damage

72
Q

What chemicals are released when tissues are injured?

A
  • Bradykinin
  • 5-HT
  • Prostaglandins
  • Potassium ions
73
Q

How are C-fibres activated in general?

A

In response to the chemicals procured by tissues during tissue damage

  • CGRP and substance P are released
  • mast cells are simulated
  • histamine release
  • vasodilation, plasma extravasion, oedema and bradykinin release
74
Q

What happens to the activated threshold after the initial chemical release and vasodilation?

A

It is lowered to make the area more sensitive to pain

  • hyperalgesia
  • allondyia
75
Q

Are the interneurons modulating pain inhibitory/excitatory and what neurotransmitters do they use?

A

Inhibitory GABA and Glycine

76
Q

Describe how shifting towards A-beta fires in the gate control theory works.

A

C and A-delta fibres activate projection neuron firing - causing pain These can be inhibited by inhibitory interneurons A-beta firing activates the inhibitory interneuron

77
Q

How do endogenous opiods and opiates work?

A

Stimulates PAG matter in the midbrain, which sends descending, inhibitory pathways that supresses transmission of pain signals

78
Q

Names the three classes of endogenous opioids.

A

Endorphins Enkephaline Dynorphin

79
Q

Name three types of opioid receptor.

A

mu kappa delta

80
Q

How is back pain managed between the ages of 5 and 20?

A

It’s likely to be mechanical - managed with analgesia, brief rest and physiotherapy

81
Q

What is the best way to manage back pain (in any age)?

A

Physiotherapy Being as active as possible Early management

82
Q

Describe the role of the pysiotherapist in management of back pain

A

Builds up muscles to cope with problems Prevents and manages musculoskeletal disorders/other health problems Works in hospital or community Passive modalities to assist pain relief - electric stimulation Provides pain relief

83
Q

What is nociception?

A

The neural mechanism by which an individual detects the presence of a potentially tissue harming stimulus

84
Q

What are the stages of nociception?

A

Transduction Transmission Modulation Perception

85
Q

Through which type of sensory vesicle is pain felt and where they are located?

A

Free nerve endings - skin, bone, muscle, internal organs, blood vessels - not in brain

86
Q

Name the 2 levels of pain modulation

A

Spinal: gate control theory Supra-spinal: Conditioned pain modulation

87
Q

Describe the role of the hospital specialist in management of back pain

A

Further evaluates, manages and treats the underlying problem causing the back pain Cause may be mechanical, metabolic, malignant or infectious

88
Q

What is a ‘yellow flags’, when regarding back pain?

A

Psycho-social barriers to recovery

89
Q

List some yellow-flags of back pain.

A

Belief that pain is harmful and debilitating Fear - avoidance behaviours Sickness behaviours - extended rest Social withdrawal Emotional problems - constant low mood Problems at work Financial problems Overprotective family Inappropriate expectations of treatment

90
Q

What are the two different types of pain?

A

Neuropathic - nerve damage Nociceptive - tissue damage

91
Q

Describe somatic nociceptive pain.

A

Well localised - dermatomal Sharp, aching and gnawing pain Constant

92
Q

Describe visceral nociceptive pain.

A

Vague distribution, diffuse Dull, cramping and digging pain Can be periodic Causes nausea, vomiting, sweatiness, CV symptoms

93
Q

What are the symptoms of neuropathic pain?

A

Shooting Electric shock like Burning Tingling Numbness

94
Q

What kind of pain is lower back pain? (neuropathic, nociceptive)

A

Local nociceptor activation = nociceptive Compression and inflammation of nerve root = neuropathic

95
Q

What’s the difference between somatic referred back pain and radicular pain in the leg?

A

Somatic referred pain - nociceptive pain affecting large areas of the posterior thigh Radicular pain - neuropathic pain radiating down lower limb to the heel in a narrow band

96
Q

How can pain be measured?

A

NRS - numerical rating scale VAS - visual analgoue scale

97
Q

Name some of co-morbidities associated with neuropathic pain.

A

Poor appetite Anxiety Depression Difficulty concentrating Drowsiness Lack of energy Difficulty sleeping

98
Q

Describe the WHO analgesic ladder

A

1 - Paracetamol, NSAIDs 2- Codeine, dihydrocodeine 2-3 Tramadol 3 - Morphine, methadone, oxycodone

99
Q

What are the possible side effects of NSAIDs?

A

GI ulceration Bleeding Renal problems Asthma Decreased bone healing

100
Q

What criteria must be looked at before prescribing opioids?

A

Appropriate - pain model- pain patient- pain prescription

101
Q

From most to least effective, list conditions opioids can be used in.

A

Arthritis Nueropathic pain Lower back pain Visceral pain Fibromyalgia

102
Q

Name some adjuvants which can be used for neuropathic analgesics.

A

Anti-depressants Anti-convulsants Anti-arrhythimcs

103
Q

Describe the lumbar facet syndrome.

A

Lower back pain to groin, hip or thigh Worse on back extension/rotation Tender over paraspinal region

104
Q

How is lumbar facet syndrome diagnosed?

A

X-ray shows nothing local anaesthetic to medial branch of dorsal primary rami

105
Q

What is resting membrane potential?

A

Difference in charge between inside and outside of the neuron/cell at rest

106
Q

What is the typical resting membrane potential?

A

-60 mV to -70 mV

107
Q

What is equilibrium potential?

A

Membrane potential where N ions entering cell = N ions leaving cell E.g. concentration gradient moves K+ out of cell but electrical potential gradient moves K+ into cell

108
Q

What is action potential?

A

Very brief, but dramatic change in membrane potential All or nothing

109
Q

What are the stages of action potential?

A

Depolarisation Repolarisation Hyperpolarisation

110
Q

What happens during depolarisation?

A

Fast opening of voltage-gated Na channels

111
Q

What happens during repolarisation/ hyperpolarisation?

A

Slow opening of voltage-gated K channels

112
Q

Name 2 ways in which an action potential can be propagated

A
  1. along axon 2. out of axon via membrane
113
Q

What cells myelinate neurons in CNS?

A

Oligodendrocytes

114
Q

What cells myelinate neurons in PNS?

A

Schwann cells

115
Q

How does action potential propagation differ in myelinated and umyelinated neuron?

A

Myelinated: AP jumps from node to node, faster Unmyelinated: slower, cannot jump

116
Q

Name 2 disorders associated with defective myelination

A

Multiple sclerosis (CNS, autoimmune) and Guillan-Barre syndrome (PNS, inflammatory)

117
Q

Outline the steps in synaptic transmission

A
  1. AP enters presynaptic terminal 2. Ca2+ entry through voltage-gated Ca2+ channels 3. Docking of synaptic vesicles containing neurotranmitters 4. Neurotransmitter released by exocytosis 5. Neurotransmitter binds to and activates receptors on postsynaptic membrane 6. Ions enter cells Na+ = depolarisation Cl- = hyperpolarisation
118
Q

Name 5 types of neurotransmitters

A

Cholinergic Biogenic amines Amino acids Neuropeptides Miscellaneous

119
Q

Name example of cholinergic neurotransmitter

A

Acetylcholine

120
Q

Name example of biogenic amines neurotransmitters

A

Catecholamines: noradrenaline, adrenaline, dopamine 5-hydroxitryptamine

121
Q

Name example of amino acids neurotransmitter

A

Excitatory: glutamate Inhibitory: GABA

122
Q

Name example of neuropeptides neurotransmitter

A

Endogenous opioids

123
Q

Name example of miscellaneous neurotransmitter

A

Gases: NO Purines: adenosine, ATP

124
Q

Name 2 diseases that disrupt cholinergic transmission

A

Botulism (toxin prevents Ach release), Myasthenia gravis (inflammatory)

125
Q

What is temporal summation?

A

Frequency of firing of APs at one point

126
Q

What is spatial summation?

A

Firing at multiple sites combines e.g. 2 different dendrites

127
Q

What does inhibitory postsynaptic potential?

A

Moves the post-synaptic membrane further away from threshold

128
Q

What does excitatory post-synaptic potential do?

A

Brings the post-synaptic membrane closer to threshold

129
Q

Name the 2 ways in which information can spread in the nervous system

A

Divergence (one neuron signals to many, spreading the signal) and convergence (integration of many signals to one cell)

130
Q

What are the methods used to localise cerebral function?

A

Electro-encephalography (EEG) PET fMRI Transcranial magnetic stimulation (TMS)

131
Q

What is the function and role of EEG in investigating brain?

A

Records the electrical activity of the brain Investigate cognitive processes in response to a stimulus

132
Q

What is the function and role of PET in investigating brain?

A

Measures blood flow - radioactive injected Locate brain activity while performing a task

133
Q

What is the function and role of fMRI in investigating brain?

A

Measures blood flow Locate brain activity while performing a task

134
Q

What is the function and role of TMS in investigating brain?

A

Electromagnet to stimulate brain activity Interrupt brain activity while performing a task

135
Q

List the disadvantages of pain

A

CNS - anxiety, depression, sleep deprivation CVS - increased BP, HR and risk of ischaemic heart disease RESP - inhibits cough, hyperventilation GIT - nausea, vomiting Genitourinary - urinary retention, uterine inhibition Muscle - restless, immobility Metabolic - Acute catabolic stress response - cortisone, glucagon..

136
Q

Describe the Gate Control Theory of Pain

A

In absence of input local tonically active inhibitory interneuron suppresses pain pathway With strong pain, C fibres stops inhibition -> signal send to brain If Abeta fibres are also activated they reactivate the interneuron and decrease the painful stimulus

137
Q

Name compartments of the supraspinal pain neuromatrix

A

Sensory discriminative: Thalamus, Post insula Affective-motivational: Ant insula cortex, Ant mid cingulate cortex Cognitive activation: Prefrontal cortex

138
Q

Define allodynia

A

Pain from a stimulus not normally painful

139
Q

Define Hyperalgesia

A

Abnormally high levels of pain from noxious stimuli Primary - Peripheral sensitisation Secondary - central sensitisation

140
Q

What are the mediators that activate nociceptors?

A

K+ 5-HT Bradykinin H+ Histamine ATP, Adenosine

141
Q

What are the mediators that sensitise nociceptors?

A

Prostaglandins Leukotrienes Substance P Noradrenaline Neurokinin A CGRP Nitric oxide Reactive oxygen species

142
Q

Describe the mechanism of peripheral sensitization

A

Change nociceptors from high to low threshold Process continues after the initial stimulus has ended Mediators: ATP, H+, NGF, Sub P, histamine, cytokines, PGI2, bradykinin

143
Q

What are the neurotransmitters that are part of conditioned pain modulation in the CNS?

A

NA 5HT Inhibitory

144
Q

What are the red flags of lower back pain?

A

Wt loss - malignancy Fever Signs of systemic inflammatory disease Anatomical change Possible history of trauma Cauda equina syndrome Neurological signs - radiculopathy (pinched nerve)

145
Q

Outline the triple response after a mild trauma

A

Red reaction - after scratching White wheal - around the scratch Flare - redder area of the skin

146
Q

Describe the mechanism at the scratch site in triple response reaction

A

Tissue damage: K+ and prostaglandins released Plasma releases bradykinin, platelets: 5HT -> activation of free nerve endings CGRP and sub P release - activate mast cells (histamine release), dilation of blood vessels (flare), sub P (oedema)

147
Q

Describe ischaemic pain

A

Results from a lack of adequate blood supply to active tissue Release of activating and sensitizing molecules resulting in breakdown of ATP

148
Q

What are vertebral foramina?

A

All of them together form the vertebral canal

149
Q

Define transverse processes of vertebrae

A

articulate with ribs in thoracic region, junction of pedicle and lamina

150
Q

Where are the superior and inferior articulate processes?

A

At the junction of pedicle and lamina

151
Q

What do superior and inferior vertebral notches form?

A

The intervertebral foramina

152
Q

Name the outer and inner layer of intervertebral disc

A

Anulus fibrosus - outer Nucleus propulsus - inner

153
Q

Give the distribution of major ions across the membrane of a typical neuron

154
Q

Label the areas of cortical specialisation

155
Q

Label

156
Q

What is the structure and label its parts

157
Q

Label

158
Q

Describe the parts of the lentiform nucleus

159
Q

Label

160
Q

Label

161
Q

Label diagram

162
Q

Label diagram

163
Q

Label diagram

164
Q

Which centre in the medulla controls the tone of blood vessels and thus total peripheral resistance in relation to pain?

A

The rostral ventrolateral medulla

165
Q

List the signals that the rostral ventrolateral medulla integrates

A
  • From periaqueductal grey matter
  • Cerebral cortex signals
  • Paraventricular nucleus in hypothalamus
  • Nucleus of the solitary tract
166
Q

What signals does the periaqueductal grey matter receive?

A

Pain signals

167
Q

What signals and where from, where to does the paraventricular nucleus in hypothalamus receive?

A

From the rostral ventrolateral medulla and nucleus of the solitary tract

Sends signals back to both these structures and to the intermediolateral column in spinal cord

168
Q

Where from does the nucleus of the solitary tract receive signals?

A

Baroreceptors and Paraventricular nucleus of the hypothalamus

169
Q

Where does the nucleus of the solitary tract signals to?

A

Paraventricular nucleus in the hypothalamus, rostral ventrolateral medulla and Nucleus ambiguus

170
Q

What is the role of nucleus ambiguus in the total peripheral resistence during pain response?

A

Receives signals from cerebral cortex, hypothalamus and nucleus of the solitary tract

Sends signals to heart

171
Q

What are the final signals to the spinal column in the total peripheral resistance pathway?

A

The paraventricular nucleus in the hypothalamus and the rostral ventrolateral medulla signal to the Intermediolateral column in spinal cord T1-L3; than to postganglionic sympathetic nerve activity

172
Q

What are the final effective signals of the total peripheral resistance pathway?

A

Vascular tone

Renal nerves

Other viscera

P2 Head, Neck and Neuro (11 decks)

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