NEURO-Chronic Pain Flashcards
Mr. Bruce is requesting increasing dose of meds, bc his symptoms are not changing. He is also experience agitation when he doesn’t have his meds. What is he experiencing?
Tolerance and Dependence
Mr. Bruce has seen multiple providers in order to fix his pain for TKR. After getting his pain stopped he stopped seeking. What is this condition?
Pseudo-addiction
no law broken
As with RX modalities what can the following TX option provide in term of Dec pain? Pharmacology ○ Physical Medicine ○ Behavioral Medicine ○ Neuromodulation ○ Interventional ○ Surgical
30% reduction
What is the workup for chronic pain lasting > 3mo
NO test for pain. Subjective ●Blood ● Imaging ● Neuro- mood ● Psych ● All usually benign if condition not previously known
What actually causes pain?
● Neuropathic- damaged nerve, gabapentin
● Musculoskeletal- trauma tear, nsaids
● Inflammatory- pressure on nerve, narcotics
● Mechanical/compressive- external
Neuropathic pain: accurate diagnosis, relieve nerve compression or medication effects. What RX is ideal?
antidepressants
Ca++ channel agents -Gabapentin and pregabalin -Changes neurotransmitter release via calcium channels
Carbamazapine
Narcotics- AVOID
Nociceptive pain: Pain *not from direct trauma on nerves but carried through peripheral nociceptors. What RX is ideal?
Acetaminophen- DEC prostaglandin NSAIDs- inhibit prostoglandin Tramadol antidepressants NO RX to relax a muscle. These are sedatives. *“Muscle relaxants” MOA – CNS Depression OPIODs- last resort
What theory supports small nerve in PNS can excite Neuron in PNS to signal pain the brain. However, another neuron can inhibited excited neurons in that signal Pain.
GATE theory
Substantia gelatinosa
What type of neurons excite nerunos in the substantia gelatinosa?
Mechanoreceptors Large Long Fast- mylinated A, delta fibers Recurrent neurons via neuron in the limbic system- endogenous analgesia
Which neuron excite the brain to produce pain?
Nociceptors
C fibers- slow, demylinated
Afibers
How do topical pain relievers works?
activates peripheral thermoceptors (Neuron S), interferes with transmission of pain signal at gate
Stimulate the gate theory via mechanorecepoters, stimulate neurons that can inhibit pain in the brain
42 yo male c/o acute exacerbation of LBP x 2 days since moving furniture. Reports L/S pain rad to right buttock worse with movement. H/o Degenrative Disc Dz, herniated disc L5-S1.
ROS consideration- incontinence, gait, foot drop sensation
PE- + SLR= lumbar radiculopathy
TX-ICE +/- heat. Acetaminophen and NSAIDs
NSAID 1-2wk
Tramadol prn, vicodin/xanax for sleep
PT
AVOID benzio, antieplitic,
NONRX- PT, yoga, stretch. MOVE
Surgery- little EBM Epidural inj+ SLR
What are DDX of LBP
Acute MSK lower back pain/strain
Right lumbar radiculopathy
Degenerative disc disease, lumbosacral
L5-S1 disc herniation without compression- d/t no gait abnormality
60 yo DM male c/o feet blisters x 3 days after using treadmill x 30 min. Previously sedentary. How would you treat?
Management of DPN
○ Glycemic control
○ Foot care
○ Treatment of pain
● *Amitriptyline (Elavil)-TCA
○ Neuromodulating agent for his neuropathy
● Other options: ○ Venlafaxine (Effexor) - SNRI ○ Duloxetine (Cymbalta) - SNRI ○ Pregabalin (Lyrica) - anticonvulsant ● NOT opiates (this is the key here)
48 yo F with knee pain related to long-standing damage to meniscus. Has advanced from OTC analgesia to Vicodin to control knee pain. Referred to orthopedics for evaluation and treatment. After arthroscopic procedure, patient reports significant, debilitating pain in extremity. Drug seeking d/t pain.
Management.
PE-general, skin, MSK
LABs- MRI +/-
Nerve conduction SNS
TX- TENs, biofeedback, spinal cord stim-implanted
TEAM approach
