neuropathic pain Flashcards

Question

Pre-trigeminal neuralgia  Pain duration

Answer 1

 Pain duration varies widely from hours to month Pain may go into remission

Answer 2

This brief, milder pain is sometimes suspected to have a dental origin and unnecessary dental procedures have been performed in many cases

Answer 3

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 4

* The annual incidence of TN is 4 to 13 per 100,000 people * 15,000 new cases occur in the US each year. * TN is one of the most frequently seen neuralgias in the elderly. * incidence increases with age * Onset after age 50, although may occur in the second and third decades or, rarely, in children. * male to female ratio is about 1:1.5

Answer 5

* Most cases of trigeminal neuralgia (TN) 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. | superior cerebellar aa

Answer 6

* vestibular schwannoma (acoustic neuroma) * Meningioma * epidermoid or other cyst, * saccular aneurysm or AV malformation

Answer 7

loss of Aa elasticity with age cause friction rub leading to demyleination

Answer 8

* The pain of TN 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

Answer 9

 TN 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, brushing or flossing teeth.  Episodes may last weeks or months, followed by pain- free intervals or remission of pain for years.  Recurrence is common

Answer 10

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 11

1. Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) 2. Cluster-tic syndrome 3. Giant Cell Arteritis 4. Multiple sclerosis 5. Other neuralgias

Answer 12

Magnetic resonance imaging (MRI) or magnetic resonance angiography (MRA) of the brain * MRI should be obtained in the following groups to rule out a mass lesion or multiple sclerosis: * Patients with sensory loss * Young patients (under the age of 40) * Patients with bilateral symptoms * Patients who do not respond to conservative therap

Answer 13

carb is classic but has CBC implications so oxcarb preffered, baclofen is adjunct

Answer 14

 Microvascular decompression  Radiofrequency rhizotomy  Glycerol rhizolysis  Balloon compression  Gamma knife radiosurgery – NON-INVASIVE  Peripheral neurectomy (not recommended)

Answer 15

Gamma Knife Radiation- better for elderly Use of mri to located nn and aa compressing it before measuring head contours for neuroablative procedure

Answer 16

Neuroablative Procedure: non-invasive  Destroys portions of the nervous system to block transmission of nociceptive information.

Answer 17

 Compression of the trigeminal nerve root at or near the dorsal root entry zone by a blood vessel (usually the superior cerebellar artery)  Segmental demyelination of A-beta and A-delta fibers at the site of vascular compression  Generation of ectopic impulses and spreading of these impulses to adjacent neurons through ephaptic transmission (cross-talk)

Answer 18

Microvascular Decompression Surgery can improve Trigeminal Neuralgia pain

Answer 19

 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 20

 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 1.

Answer 21

anti-virals and steroids as soon as possible. Pain medications to manage pain.

Answer 22

* (CDC) recommends that appropriate adults 50 or older get vaccinated to help prevent Shingles. * Shingrix (recombinant zoster vaccine) the preferred vaccine over ZOSTAVAX to help reduce your risk of getting Shingles in the future

Answer 23

 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**

Answer 24

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 25

 a constant, deep, aching/burning pain; a brief, intense shooting pain with hyperalgesia (an increased response to a stimulus that is normally painful) or allodynia (pain due to a stimulus that does not normally provoke pain) ( with light touch producing pain (80-90%).  May be superimposed brief stabbing exacerbations of pain

Answer 26

 sensory deficits in the affected dermatomes as well as pigmentary changes and scarring.  Major degenerative changes occur in afferent pathways with loss of axons and myelin in peripheral sensory nerves.  Both peripheral and central mechanisms are involved in PHN

Answer 27

systemic and topical

Answer 28

 a SNRI/TCAs, such as amitriptyline/nortriptyline  Gabapentin/pregabalin may be as effective as TCAs with fewer contraindications ** Lyrica**  Opioids  Steroids  NSAIDs

Answer 29

 5% lidocaine patches  NSAID gel or cream – Diclofenac  Sodium topical gel 1%  Shingles gel:  Amitriptyline (2%)  Ketoprofen (10%)  Tetracaine (4%)  Deoxy d-glucose

Answer 30

Persistent idiopathic facial pain (PIFP) A. Facial and/or oral pain fulfilling criteria B and C B. Recurring daily for >2 h per day for >3 mo C. Pain has both of the following characteristics: 1. poorly localized, and not following distribution of a peripheral nerve 2. dull, aching or nagging quality D. Clinical neurological examination is normal E. Dental cause excluded by appropriate investigations F. Not better accounted for by another ICHD-3 diagnosis

Answer 31

* PIFP is best defined as persistent pain in apparently normal teeth or adjacent oral tissues * (phantom tooth pain, idiopathic toothache, idiopathic odontalgia, facial migraine, atypical facial neuralgia, and atypical facial pain have been used in the past) * Affects women in the fourth or fifth decade (peri- menopausal or menopausal) * Previously called Atypical Toothache

Answer 32

1. traumatic injury 2. various routine dental procedures such as endodontic therapy, apicoectomy, tooth extraction, periodontal surgery, or implants. 3. can even follow seemingly innocuous dental procedures such as crown preparation, drilling of dentin and periodontal scaling

Answer 33

AO is more likely to develop in a tooth that was painful immediately prior to any dental intervention

Answer 34

 Odontogenic toothache  Myofascial trigger point pain  Pre-Trigeminal neuralgia  Neurovascular toothache (facial or midface migraine, cluster headache)  Maxillary sinusitis  Neuritic toothache  Temporomandibular disorder (TMD)

Answer 35

 Obtain a thorough history  eliminate any odontogenic cause  R/O a myofascial trigger point, trigeminal neuralgia, neurovascular toothache due to facial or midface migraine or cluster headache(episodic and throbbing or pulsating), tooth pain from a maxillary sinusitis / neuritic toothache/  PIFP frequently arises spontaneously and is not related to functional demands. However, the tooth may be sensitive to pressure and a patient may complain of pain on eating

Answer 36

Clinical photographs of a patient undergoing various tests. A. The intraoral cotton swab test. B. The intraoral pinprick test. C. The intraoral spatula test using hot or cold.

Answer 37

anti epileptic can stabilize nn membrane

Answer 38

 Viscous Lidocaine  Topical Ketamine ** Zostrix (OTC) – contains capsaicin- depletes substance P**  NOTE: These medications may be combined & used in a stent as a medication delivery system.  Stent covers sensitive gingival tissue.

Answer 39

* characterized by an intraoral burning sensation for which no medical or dental cause can be foun

Answer 40

psychiatric disorders such as depression – xerostomia (from drugs, connective tissue disease, or age) – nutritional deficiencies (vitamin B12, iron, folate, zinc, vitamin B6) so blood tests needed first to rule out vitamin deficiency – allergic contact stomatitis- (i.e. denture acrylic or nickel clasps) – geographic tongue – candidiasis – diabetes – denture-related pain – thyroid abnormalities – menopause

Answer 41

 predominantly affects women especially post-menopausal due to decreased estrogen

Answer 42

 30 - 50 % improve spontaneously  The frequency of burning mouth syndrome are unknown  Topical amitriptyline troches (4mg) dissolve in mouth up to 3x/day  Klonopin (clonazepam) (sedating)

Answer 43

A. Oral pain fulfilling criteria B and C B. Recurring daily for >2 h per day for >3 mo C. Pain has both of the following characteristics: 1. burning quality 2. felt superficially in the oral mucosa D. Oral mucosa is of normal appearance and clinical examination including sensory testing is normal E. Not better accounted for by another ICHD-3 diagnosis

Answer 44

 Oral pain represents the cardinal symptom of BMS  Type of pain is a prolonged “burning” sensation  Distribution of the burning sensation is nearly always bilateral but it does not follow anatomical landmarks  Most common site is anterior two-thirds and tip of the tongue.

Answer 45

 Anterior hard palate, mucosal aspect of lower lip, and mandibular alveolar regions are also affected.  Buccal mucosa and floor of mouth rarely involved.  Many patients complain of burning in more than one intraoral area at the same time

Answer 46

 Gradual with no known precipitating factors  Sudden and linked to a preceding dental procedure (tooth cleaning, filling or a new denture), upper respiratory infection or a course of antibiotics

Answer 47

The timing of the symptoms is variable.  Some patients complain of continuous discomfort throughout the day  Others find that it gradually increases during the day and reaches maximum intensity by evening  Pain usually remits nightly during sleep

Answer 48

medication only:  Clonazepam (“topical”)  Alpha-lipoic acid  Tricyclic anti- depressants: (Amitriptyline) oral or as a troche 4mg tid  Gabapentin  Pregablin

Answer 49

 Severe paroxysmal, lancinating pain that radiates to the throat, ear, teeth and tongue  Rare, unilateral condition  Affects males > age 50 years  Triggered by movement in the tonsillar region by swallowing or coughing  Due to a lesion in the petrosal and jugular ganglion of CN IX  Branches of carotid artery can trigger a vasovagal response (i.e. BP, cardiac output, altered respiration)

Answer 50

 Known as nervus intermedius neuralgia, Ramsay Hunt’s syndrome  Painful disturbance of the sensory portion of the Facial nerve - CN VII  Causes lancinating pain in the middle ear and the auditory canal  Treatment: Methyl prednisone (10mg) start with 80mg dose, then taper by 10 mg every 3 days until 20 mg dose. Maintain pt on 20mg for 14 days then taper off.

Answer 51

 Elongation or ossification of the stylohyoid ligament  Symptoms: sore throat, dysphagia, otalgia, glossodynia, headache or vague pain in the neck  Pain may occur with swallowing, talking, chewing, turning the head to the contralateral side, yawning  Usually unilateral, constant, deep, throbbing or aching  Exam: includes palpation of the stylohyoid area to attempt to reproduce pain & turning head to side  Radiograph: reveals elongated stylohyoid process  Refer to Ear, Nose & Throat (ENT) specialis