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MSK Week 6 > ICL 7.2: Acute & Chronic Pain > Flashcards

ICL 7.2: Acute & Chronic Pain Flashcards

1
Q

what are the risk factors for pain?

A
  1. older > younger
  2. female > male
  3. socioeconomic = low education level, income, housing status, and unemployment
  4. comorbidities = obesity and depression
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2
Q

what are the most common types of pain?

A
  1. headache
  2. back pain
  3. neck pain
  4. hip/knee
  5. abdominal
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3
Q

what is the psychosocial impact of pain?

A

Negative effects on health perception, relationships, social interactions

Increased depressive symptoms

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4
Q

what is the economic impact of pain?

A
  1. cost of direct medical care (physical therapy, inpatient services, pharmacy)
  2. additional ancillary services
  3. lost work productivity
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5
Q

what are the differences of pain in men and women?

A

WOMEN
1. more likely to experience pain

  1. higher levels of pain
  2. more likely to use analgesics
  3. persistent pain

MEN
1. consume more opioids

  1. more die from OD
  2. more likely to dropout and terminate outpatient treatment
  3. higher pain threshold
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6
Q

how do you assess pain

A
  1. HPI
  2. PE
  3. ordering tests
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7
Q

what’s the most important of an HPI in relation to pain?

A
  1. time
acute = less than 3 months
chronic = more than 3 months
  1. onset

what were they doing when it started?

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8
Q

what is somatic pain?

A

poorly defined boundaries, fluctuates in size

dull, achy

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9
Q

what is radicular pain?

A

narrow band-like boundary, longitudinally in the lower limb

shooting, electric

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10
Q

what sign is concerning about someones pain?

A

pain that is not relieved by rest should be really concerning

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11
Q

what do you do during a PE for pain?

A
  1. Palpation for tenderness
  2. Assessing active and passive range of motion
  3. Neurologic
    - Sensory deficits
    - Motor deficits
    - Reflexes
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12
Q

what diagnostic tests an you do for pain?

A

not recommended if pain is less than 4-6 weeks

they’re used to corroborate clinical findings but they’re often unlikely to show significant pathologies; HPI and PE are much more useful

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13
Q

what test is best for lower back pain?

A

MRI

it’s the gold standard for determining etiology of LBP and radicular pain

it gives you the best resolution of spinal canal, cord, neural foramina, NRs, disc spaces

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14
Q

what is a pro of x-rays over CT and MRI?

A

they show you dynamic change!

you can ask someone to flex and extend and see the limb in both positions

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15
Q

what are some of the electrodiagnostic tests you can do?

A
  1. Electromyography (EMG)
  2. Nerve Conduction Velocity (NCV)
  3. Somatosensory Evoked Potentials (SSEPs)

these are useful when features are inconclusive or indistinguishable from peripheral neuropathy

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16
Q

what are red flags of pain?

A

conditions which may pose significant threat to life or neurologic function

they 100% require further diagnostic testing

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17
Q

what are the various red flags of pain?

A
  1. younger than 20 or over 50

< 20: Congenital/developmental anomalies

> 50: Prone to neoplasms, fractures, infections

  1. duration of symptoms (chronic or acute)
  2. constitutional symptoms

fever, chills, malaise, night sweats, weight loss

  1. systemic illness (cancer, IVDA, transplant)
  2. incontinence, saddle anesthesia, bilateral neurologic symptoms
  3. history of trauma
  4. unrelenting pain
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18
Q

which symptoms are a sign of cauda equine syndrome?

A

incontinence, saddle anesthesia, bilateral neurologic symptoms

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19
Q

A 30 year old man reports new onset back pain that started 2 weeks ago when helping a friend move furniture off of a truck. He reports the pain worsens with activity, but significantly improves with rest. Reports pain is located in the lower back, and does not radiate down the legs. Which of the following would be the best next step in managing this patient?

A

reassurance

pain hasn’t been going on for long, improves with rest, and isn’t very severe

there’s no red flags!

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20
Q

what is radiculopathy?

A

nerve root damage

21
Q

what is radiculitis?

A

inflammation of nerve roots

22
Q

what is radicular syndrome?

A

it’s a broad category that suggests clinical signs and symptoms secondary to pathology/dysfunction of sensory spinal nerve roots or dorsal root ganglion

23
Q

what’s the etiology of radicular syndrome?

A
  1. lesions of intervertebral disc
  2. degenerative spinal disorders
  3. lesions involving the spinal nerve, DRG or plexuses

entrapment neuropathies (piriformis and ischial tunnel syndrome), generate pain in multiple dermatomes of peripheral nerve

24
Q

what are the clinical features of radicular syndrome?

A
  1. Pain

Sharp, shooting, lancinating

  1. Paresthesias
  2. Numbness; loss of sensation
  3. Weakness

Gait disturbances, reduced muscle strength, diminished reflexes

  1. Travels along narrow band
25
Q

what is spinal stenos?

A

clinical syndrome with neurogenic claudication or radicular pain due to narrowing of spinal or nerve root canal and compression of its elements

it can be congential vs. acquired or central vs. lateral

26
Q

what is acquired spinal stenosis?

A

due to things like:

  1. disc degeneration
  2. disc bulging
  3. facet joint hypertrophy
  4. thickening of ligamentum flavum
  5. osteophyte formation
27
Q

what is central stenosis?

A

causes compression of NR of cauda equina

28
Q

what is lateral stenosis?

A

causes compression of exiting spinal NRs

29
Q

what are the clinical features of spinal stenosis?

A
  1. neurogenic claudication
  2. radicular pain
  3. axial pain

patients tend to walk with a stooped posture, decrease range of lumbar extension but the pain is relieved by sitting down or pushing a walker/shopping cart

note: unilateral symptoms usually indicate lateral stenosis

30
Q

what is neurogenic claudication?

A

a sign of spinal stenosis

radiating pain, posterolateral aspect of thighs and legs

sorse with walking and lumbar extension

relieved by sitting down, pushing a walker/shopping cart

31
Q

how do you diagnose spinal stenosis?

A

MRI or CT

MRI will show you pathologic lesions

CT will show bony abnormalities or lateral recess

32
Q

what is facet syndrome?

A

facet = synovial joint composed of the superior and inferior articular processes of vertebrae

the facet joint is innervated by the medial branch of the posterior ramus at the same level and from one level above

can cause patients to have shopping cart sign

33
Q

what causes facet syndrome?

A

some causes may include systemic inflammatory arthritis, synovitis, synovial cysts, infections

34
Q

what are the clinical symptoms of facet syndrome?

A
  1. unilateral or bilateral pain
  2. worsens with spinal extension, twisting, prolonged standing/upright posture
  3. relieved with forward flexion, walking, and rest
  4. NO neurologic findings
35
Q

what is post-laminectomy syndrome?

A

a syndrome of pain following surgery –> patients with persistent or worsened pain/symptoms after surgery

36
Q

what are the causes of post-laminectomy syndrome?

A
  1. prolonged trauma to the nerve/region prior to surgery, inability to heal
  2. surgical trauma to the nerve/region during surgery
  3. scar tissue formation after surgery
  4. structural changes of the spine after surgery
37
Q

what conditions can post-laminectomy syndrome lead to?

A
  1. radiculopathies
  2. facet joint arthropathy and pain
  3. spinal stenosis
  4. neuralgia
  5. chronic low back pain
38
Q

A 52 year old woman reports pain that is worst in the “small of the back”. The pain worsens with standing and improves with leaning forward. She notes that during grocery shopping, she finds herself leaning forward onto the cart to prevent persistent pain. Which of the following is the most likely diagnosis?

A

more information is needed

it could be lumbar spinal stenosis, lumbar facet pain or lumbar post-laminectomy syndrome because they all have the shopping cart sign

for spinal stenosis you’d expect shooting radicular pain

39
Q

how does acute pain effect the body?

A

acute pain leads to changes in neural function

persistent noxious signaling in the periphery leads to enduring maladaptive neuroplastic changes at the dorsal horn and higher CNS structures, releasing neurotropic factors

maladpative brain remodeling which leads to alterations in the corticolimbic circuitry

so we need to stopacute pain to reduce development into chronic pain

40
Q

what are the conservative medication treatment options for pain?

A
  1. NSAIDs
  2. acetaminophen
  3. corticosteroids
  4. muscle Relaxants
  5. neuropathic Medications like antidepressants and anticonvulsants
41
Q

what are the conservative therapy treatment options for pain?

A
  1. Exercise/Weight Loss
  2. Physical Therapy
    Traction
    Manual therapies
  3. Chiropractic Care
    Manipulation (questionable safety)
  4. Psychological Therapy
    Behavioral Therapy
    Biofeedback
42
Q

what are the conservative alternate therapy treatment options for pain?

A
  1. heat
  2. cryoptherapy
  3. electricity
  4. orthotics
  5. work rehab
  6. chinese medicine; acupuncture and herbal medicine
43
Q

what are the interventional treatment options for pain?

A
  1. intra-articular joint injections
  2. epidural steroid injections (interlaminar or transforaminal approach)
  3. peripheral nerve blocks
  4. radio frequency ablation of nerves
44
Q

what are the advancds interventional options for pain?

A
  1. spinal Cord Stimulation
  2. peripheral Nerve Stimulation
  3. intrathecal Drug Delivery Devices
  4. minimally Invasive Lumbar Decompression (MILD)
  5. interspinous Spacer
  6. kyphoplasty/Vertebroplasty
45
Q

what are the surgical treatment options for pain?

A
  1. surgical discectomy

2. surgical decompression

46
Q

what is surgical discectomy?

A

necessary in cases of cauda equina syndrome, progressive motor deficits

microdiscectomy has been reported to be better than traditional discectomy

47
Q

what is surgical decompression?

A

remove posterior aspect of the spine and put it screws and rods –> wide laminectomy, removing spinal laminae and ligamentum flavum from pedicle to pedicle

laminotomy, removes smaller area –> preserves spinal stability and high rate of restenosis

48
Q

what are good prognostic factors of a patient returning to work following spine injury?

A
  1. younger, native, highly educated with high income
  2. married, stable social networks, self-confident, low levels of disease severity
  3. long working history with job
  4. employer that care and wishes for patient to return to job
  5. returning to work within 2-3 months

MSK Week 6 (10 decks)

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