Neuropathic pain

Question 1

Pain initiated or caused by primary lesion or dysfunction in nervous system

Answer 1

Neuropathic pain

Question 2

an unpleasant abnormal sensation whether spontaneous or evoked

Answer 2

Dysethesia

Question 3

_______ may be caused by:
1. virus (i.e. herpes zoster, shingles)
2. demyelinating disease (i.e. multiple sclerosis)
3. trauma, injury, surgery
4. dental extractions, root canal therapy, dental
implant placement, restorative procedures
5. Idiopathic

Answer 3

Neuropathic pain

Question 4

What nerve is most commonly injured nerve? 2nd?

Answer 4

IAN 64.4%
Lingual nerve 28.8%

Question 5

Does neuropathic pain respond to opiods?

Answer 5

Not as responsive

Question 6

What type of drug can be used to treat neuropathic pain?

Answer 6

Anticonvulsants

Question 7

Paroxysmal or constant pain typically with sharp, stabing, itching, or burning character in the distribution of a nerve

Answer 7

Neuralgia

Question 8

• a form of neuropathic pain that is characterized by
  the following features:
  1. Paroxysmal, brief (seconds to a few minutes), shock-like or
  lightning-like pain that follows a peripheral or cranial nerve
  distribution and can spread to adjacent areas in the course of
  the attack
  2. Typically, there is no objective neurologic deficit in the
  distribution of the affected nerve
  3. Attacks can be provoked by non-painful stimulation
  (allodynia) of trigger zones (i.e. flossing elicits gingival pain)
  4. A refractory period follows attacks; the duration of the
  refractory period shortens as the disease progresses

Answer 8

Neuralgia

Question 9

 Dull, continuous, aching or burning pain in the oral
cavity or teeth or jaw evolving eventually into
trigeminal neuralgia (TN)
 Pain duration varies widely from hours to months
 Pain may go into remission
 This brief, milder pain is sometimes suspected to
have a dental origin and unnecessary dental
procedures have been performed in many cases.

Answer 9

Pre-trigeminal neuralgia

Question 10

The International Association for
the Study of Pain (IASP) defines
TN as sudden, usually unilateral,
severe, brief, stabbing or
lancinating, recurrent episodes of
pain in the distribution of one or
more branches of the fifth cranial
(trigeminal) nerve

Answer 10

Trigeminal neuralgia (TN)

Question 11

Pathophys of _____:
* Most cases of this are caused
by compression of the trigeminal nerve root, usually
within a few millimeters of entry into the pons
* Compression by an aberrant loop of an artery or vein
is thought to account for 80 to 90 percent of cases.
* Other causes of nerve compression include
* vestibular schwannoma (acoustic neuroma)
* Meningioma
* epidermoid or other cyst,
* saccular aneurysm or AV malformation

Answer 11

trigeminal neuralgia (TN)

Question 12

Causes ectopic firing of nerve due to demyelination disrupting normal
nerve transmission.

Answer 12

Focal demyelination

Question 13

Clincial features of ____:
* The pain tends to occur in paroxysms and is
maximal at or near onset.
* The pain
* “electric shock-like” or “stabbing“
* typically does not awaken patients at night.
* lasts from several seconds to minutes, but may occur
repetitively
* A refractory period of several minutes during which a paroxysm
cannot be provoked is common due to nerve repolarization
* may also be a co-existing continuous, deep, dull pain.
* V2 and/or V3 are involved more frequently than V1
* unilateral in most cases
* Facial muscle spasms can be seen with severe pain
especially the masseter muscle
can be precipitated by dental procedures (i.e.
root canal therapy, dental extraction)
 Trigger zones may be present
 Triggers can be light touching, chewing, talking,
brushing teeth, cold air, smiling, shaving, washing
face and/or grimacing.
 Episodes may last weeks or months, followed by
pain-free intervals or remission of pain for years.
 Recurrence is common

Answer 13

Trigeminal neuralgia

Question 14

A. At least 3 attacks of unilateral facial pain fulfilling
criteria B and C
B. In ≥1 divisions of trigeminal nerve, with no radiation
beyond trigeminal distribution
C. Pain has ≥3 of the following 4 characteristics:
1. recurring in paroxysmal attacks lasting from a fraction
of a second to 2 minutes
2. severe intensity
3. electric shock-like, shooting, stabbing or sharp in
quality
4. precipitated by innocuous stimuli to affected side of
face
D. No clinically evident neurological deficit
E. Not better accounted for by another ICHD-3 diagnosis

Answer 14

13.1.1 Classical trigeminal neuralgia

Question 15

What imaging should be order in TN to rule out any serious brain lesions?

Answer 15

MRI or MRA

Question 16

 Destroys portions of the nervous system to block
transmission of nociceptive information.
 Nociception: a complex series of electrochemical
events that occurs between a site of active tissue
damage and the perception of pain.

Answer 16

Neuroablative procedure

Question 17

 acute inflammation caused by varicella zoster virus (chickenpox)
 Multiple, painful vesicular skin or mucosal eruptions
 Occurs in cutaneous areas supplied by the cranial or spinal nerve
ganglia inflamed by the virus causing necrosis & hemorrhage
 Pain subsides within weeks typically but can last months to years then
classified as Post-herpetic neuralgia

Answer 17

Herpes Zoster

Question 18

 Commonly affects:
 1. torso if spinal nerves involved
 2. trigeminal nerve(V1) if cranial nerves involved and may cause
blindness and palsies affecting CN III, IV, VI.
 3. facial nerve (VII) causing facial weakness, hearing loss, tinnitus.
 4. C2 & C3 causing pain over posterior head.
 Treatment: anti-virals and steroids as soon as possible. Pain
medications to manage pain.

Answer 18

Herpes zoster

Question 19

What. meds should be used to treat HZ?

Answer 19

Antivirals and steroids

Question 20

 a common form of chronic neuropathic pain
 Risk of developing PHN increases with age & affects
60% of patients > 60 years old
 A pain developed during the acute phase of HZ and
recurring or persisting for more than 3 months after
the onset of the HZ.
 Risk factors: age, female, prodrome, etc.
 a genetic component may contribute to the varied
susceptibility of some patients to developing PHN
after an attack of HZ.

Answer 20

Post herpetic neuralgia

Question 21

Clinical characteristics of ______
 a constant, deep, aching/burning pain; a brief,
intense shooting pain with hyperalgesia or allodynia
with light touch producing pain (80-90%).
 May be superimposed brief stabbing exacerbations of
pain
 sensory deficits in the affected dermatomes as well as
pigmentary changes and scarring.

Answer 21

Post herpetic neuralgia

Question 22

Management of ________
Systemic
 a SNRI/TCAs, such as
amitriptyline/nortriptyline
 Gabapentin/pregabalin
may be as effective as TCAs with
fewer contraindications
 Lyrica
 Opioids
 Steroids
 NSAIDs
Topicals
 5% lidocaine patches
 NSAID gel or cream
 Shingles gel:
 Amitriptyline (2%)
 Ketoprofen (10%)
 Tetracaine (4%)
 Deoxy d-glucose

Answer 22

Management of PHN