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Neurology Y2 > L17 - Pain > Flashcards

L17 - Pain Flashcards

1. Revise peripheral and central neural pathways that subserve pain 2. Learn about localisation in pain syndromes - ranging from small fibre peripheral neuropathy to thalamic infarction 2. Understand complex regional pain syndromes and phantom limb phenomenon. 3. Know difference between primary and secondary head aches. 4. Understand that primary headache disorders differ from other types of pain and are managed differently, and know the important types of primary headache - migraine, cluster

1
Q

Definition of pain?

A

Unpleasant sensory, emotional experience associated with actual or potential tissue damage

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2
Q

Hyperalgesia

A

Increased response to stimulus that is normally painful

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3
Q

Dysaesthesia

A

An unpleasant abnormal sensation, whether spontaneous or evoked

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4
Q

Hypoalgesia

A

Diminished response to a normally painful stimulus.

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5
Q

Analgesia

A

Absence of pain in response to stimulation that normally is painful

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6
Q

Hyperaesthesia

A

Increased sensitivity to stimulation, excluding special senses

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7
Q

Hypoaesthesia

A

Diminished sensitivity to stimulation, excluding special senses

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8
Q

Hyperpathia

A

An increased sensitivity with increasing threshold to repetitive stimulus.

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9
Q

Paraesthesia

A

An abnormal sensation whether spontaneous or evoked

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10
Q

Allodynia

A

Pain resulting from stimulus (light touch) that does not normally elicit pain

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11
Q

Briefly summarise the types of pain

A 
Nociceptive pain 
- somatic (relating to body)
- visceral (organs)
Neuropathic pain 
- sympathetic, peripheral, central
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12
Q

What is nociceptive pain?

A

Usually acute, develops in response to a specific situation.

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13
Q

What are nociceptors and their role?

A

Nociceptors - specialised nerve cells

Detect noxious stimuli

  • extreme heat
  • cold
  • pressure
  • pinching
  • chemicals
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14
Q

Examples of Noxious stimuli?

A

Noxious stimulus - potentially tissue damaging event.

  1. Mechanical
    - pinching, other tissue deformation
  2. Thermal
    - high / low temp
  3. Chemical
    - acid / irritant
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15
Q

What is neuropathic pain?

A

Caused by damage or disease affecting somatosensory nervous system.
- primary lesion or dysfunction in nervous system

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16
Q

Describe peripheral neuropathic pain?

A

Peripheral

  • Aberrant regeneration of neurones may cause them to become unusually sensitive.
  • May develop spontaneous pathological activity.
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17
Q

State the different fibres in primary afferent neurones?

A

C - Fibre
A(delta)- Fibre
A(beta) - Fibre

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18
Q

C - Fibre

A

Smallest
Un-myelinated
Slow, diffuse, dull pain

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19
Q

A(delta) - Fibres

A

Still small
Activated by mechanical and thermal stimuli.
Cause rapid, sharp, localised pain.

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20
Q

A(beta) - Fibres

A

Large diameter
Highly myelinated
sensation- light touch, non-noxious

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21
Q

Role of noradrenaline in pain?

A

Involved with descending modulation of pain

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22
Q

Role of Substance P in pain?

A
  1. Identified in C-Type sensory nerve ending.
  2. Associated with inflammation.
  3. Can be synthesised and released from immune cells such as macrophages and eosinophils.
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23
Q

Role of glutamate in pain?

what is glutamate important in?

A
  1. Glutamate = main excitatory neurotransmitter in mammal nervous system.
  2. Involved in central sensitisation
  3. Glutamate important:
    - brain development
    - learning
    - memory storage
    - nociceptive processing
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24
Q

What is central sensitization?

A

Development and maintenance of chronic pain.

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25
Q

Nociceptive processing

A

Perception of pain sensations

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26
Q

Give examples of symptoms of loss of sensation?

A

Negative (loss of sensation)

  • touch
  • vibration
  • proprioception (perception or awareness of position and movement of body)
  • pain
  • temp
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27
Q

Examples of symptoms which involve gain of a sensation?

A

Positive

  • burning
  • shooting
  • hyperalgesia (increased sensitivity to pain)
  • Paresthesia
  • allodynia
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28
Q

Paresthesia

A

Abnormal dermal sensation with no apparent physical cause.

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29
Q

What pathways does the spinothalamic tract consist of?

A

Anterior

Lateral

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30
Q

What information is carried in the anterior spinothalamic tract?

A

Crude touch

ACT

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31
Q

What information is carried in the lateral spinothalamic tract?

A

Pain and temperature

32
Q

Where does the decussation of the spinothalamic tract occur?

A

Level of spinal cord.

Not the brain stem like

  • dorsal column-medial lemniscus pathway
  • lateral corticospinal tract
33
Q

Describe the fibres of the lateral spinothalamic tract?

A

Composed of:

  • fast-conducting, sparsely myelinated A(delta) fibres.
  • slower, unmyelinated C fibres
34
Q

Which fibres carry sensory information in the anterior spinothalamic tract?

A

A(beta) fibres carry sensory info pertaining to crude touch from the skin.

35
Q

Where does a lower motor neuron lesion affect?

A

Nerve fibres travelling from :

  1. ventral horn…
  2. to anterior grey column of spinal cord…
  3. to relevant muscles….
36
Q

Flaccid paralysis

A

Paralysis accompanied by loss of muscle tone.

37
Q

What are symptoms of a lower motor neurone lesion?

A
  1. Muscle paralysis
  2. Fasciculations
    - –> caused by increased receptor conc on muscles to compensate for lack of innervation.
38
Q

What reflex is often missing when patient has lower motor neuron lesion?

A

Plantar reflex (babinski)

  • elicited when sole of foot is stimulated with a blunt instrument.
  • in a normal patient plantar reflex causes a downward response

An upward response = babinski response, can identify disease of spinal cord and brain in adults.

39
Q

Mononeuropathy

A

One nerve involved

40
Q

Mononeuropathy multiplex

A
  1. Asymmetrical damage to single nerves.

e. g Right arm and left leg affected

41
Q

Polyneuropathy

A

Symmetrical

common cause: diabetes, although alcohol can also be a factor

42
Q

What is a common cause of mononeuropathy?

A

Carpal tunnel syndrome

43
Q

Common cause of mononeuropathy multiplex?

A

Diabetes

Vasculitis

44
Q

What is multiple sclerosis?

A

Condition that affects your brain and spinal cord.

  • Immune system attacks myelin
  • forms lesions
  • disrupts messages traveling along nerve fibres
45
Q

State some examples of patterns of damage to nerves?

A
  1. Wallerian degeneration
  2. Segmental demyelination
  3. Axonal degeneration
46
Q

Wallerian degeneration

A
  • Active process of degeneration.
  • Nerve fibre cut.
  • Part of axon distal to injury degenerates.
  • Axonal degeneration followed by:
  • —> degradation of myelin sheath
  • —> infiltration by macrophages.
47
Q

Describe segmental demyelination?

A
  • Focal degeneration of myelin sheath, sparing axon.
  • Often immune mediated or inflammatory in origin.

CIDP
- chronic inflammatory demyelinating polyneuropathy

48
Q

Describe axonal degeneration?

A

Can occur with age >60 y/o

Starts distally.

Common cause:
- diabetes, alcohol, toxins

49
Q

Briefly describe causes of mononeuropathy?

A
  1. Trauma
  2. Entrapment / compression
  3. Infection
  4. Systemic illnesses:
    - diabetes mellitus
    - sarcoidosis
    - vasculitis
    - leprosy
50
Q

Recap: Diabetes Mellitus

A

Type 1: body cannot produce insulin needed to control BG.

Type 2: body cannot produce enough insulin, insulin ineffective.

51
Q

Sarcoidosis

A

Disease involving abnormal collections of inflammatory cells that form lumps known as granulomas.
- develop on organs, usually lungs and skin

52
Q

Leprosy

lmao ice-age, diego’s got the L word

A

Caused by Mycobacterium Leprae.

Disfiguring pale skin sores.

Nerve damage:

  • loss of feeling in arms and legs
  • muscle weakness

v. long incubation period, almost 3 to 5 years.

53
Q

Briefly state 4 ways of Polyneuropathy classification?

A
  1. Distribution
    - symmetrical vs asymmetrical, proximal vs distal
  2. Functional disturbance
    - motor, sensory, autonomic, mixed
  3. Mode of onset
    - acute, subacute, chronic
  4. Pathological process
    - axonal, demyelinating
54
Q

Briefly describe the pathophysiology of diabetic polyneuropathy?

A
  • Poor glycaemic control
  • accumulation of sorbitol and fructose in axon/ schwann cells
  • occlusion of nutrient vessels supplying nerves
55
Q

Describe Varicella Zoster?

where does it stay dormant?

A

DNA herpes zoster virus.

Stays dormant within the dorsal root after initial infection.

56
Q

Sciatica

A

Irritation of the sciatic nerve causing pain.

- pain in lower back to behind the thigh, radiating down below the knee.

57
Q

What is the most common cause of sciatica?

A

Prolapsed disc.

58
Q

Describe the SLR test for sciatica?

A

SLR - straight leg raise
Patient supine, clinician lifts leg until patients complain.
Degree of hip flexion may indicate condition

59
Q

What is Syringomyelia

A

Development of fluid filled cyst in spinal cord.

60
Q

Describe clinical features associated with Syringomyelia?

A
  • Dissociated sensory loss of pain and temperature.
  • Wasting and weakness of small muscles of hand.
  • Winging of scapula
61
Q

Explain the ‘cape like’ distribution of pain in syringomyelia?

A

Compression of area of decussation of spinothalamic tract.

- dysfunction of fibers that pass through the anterior white commissure.

62
Q

What is Horner’s syndrome?

A

Rare disorder characterized by:

  • constricted pupil (miosis)
  • drooping of upper eyelid (ptosis)
  • absence of sweating of face (anhidrosis)
  • shrinking of eyebacll into body cavity that protects eye (enophthalmos)
63
Q

What is complex regional pain syndrome?

A

Poorly understood condition where a person experiences persistent severe and debilitating pain.
- skin of affected body part can become so sensitive, slight touch or bump or even change in temp can cause intense pain

64
Q

Describe type 1 CRPS?

Complex regional pain syndrome

A

aka: Reflex sympathetic dystrophy

Occurs after an illness or injury that didn’t directly damage nerves in affected limb.

65
Q

Describe type 2 CRPS?

A

Causalgia

- defined nerve injury

66
Q

State some symptoms of CRPS?

A 
Pain - burning, allodynia. hyperalgesia 
Loss of hair, nail changes, oedema and shininess 
Warm or cold limb 
Sweating 
Tremor
67
Q

Describe phantom limb pain?

A

Common in patients post amputation.

Sensation body part is still present.

68
Q

What is the difference between primary and secondary headaches?

A

Primary
- no underlying cause
Secondary
- cause, underlying abnormality

69
Q

Examples of primary headaches?

A

Migraine

Cluster headache

70
Q

Trigeminal autonomic cephalalgias

A

Group of headache disorders characterised by attacks of moderate to severe unilateral pain in head or face.

71
Q

Give examples of some secondary headaches?

A

Thunderclap headache

Hydrocephalus as a result of raised intracranial pressure.

72
Q

Pyrexia

A

Rise in body’s core temp.

Reduces severity of illness by preventing bacteria and viruses from multiplying.

73
Q

Describe a migraine

A

Pulsatile, unilateral, moderate-severe headache which builds up over 1-2hrs

74
Q

What is a cluster headache?

A

Relatively short but EXTREMELY SEVERE neuropathic pain every day for weeks or months at a time.

75
Q

Describe Trigeminal neuralgia?

A

Neuropathic pain in the distribution of the trigeminal nerve (usually 2nd and 3rd)
- persistent dull ache of the face

76
Q

Neuralgia

A

Severe, shooting pain occuring due to a damaged or irritated nerve.

Neurology Y2 (24 decks)

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