Pain Flashcards
Type of pain
nociceptive pain;
1- somatic: well localized. Described as sharp, stabbing, aching or cramping.,> inflammation or nerve compressions Tx interrupting the nociceptive pathway
2- visceral: poorly localized. Poor response to primary pain medications
— deafferentation pain: poorly localized. crushing, tearing, tingling or numbness 🐜 , burning dysesthesia numbness often with lancinating pain, and hyperpathia. Unaffected by ablative procedures🚫💊
||sympathetically maintained” causalgiaCRPUS
Neuropathic pain
PDN and PHN is typically burning and aching, is continuous, and is characteristically refractory to medical and surgical treatment.
TX Tricyclic antidepressants 💊 Amitriptyline
MOA serotonin re-uptake blocker➡️ dose amitriptyline (Elavil®) 75 mg daily;
Starting dose 12.5–25 mg PO q hs
Max dose 150 mg / d
SE anticholinergic effects and orthostatic hypotension, especially in the elderly ▶️ 🔽 by titration
CI 🚫❌ 🧓🏼 IHD
Gabapentin 💊
Indication : PHN , DNP CRPS , pot OP , migraine , neuropathy
SE dizziness and somnolence ( during titration, often diminish with time). Ataxia, fatigue, peripheral edema, confusion and depression
Dose ;
titration 300 mg on Day 1, 300 mg BID on Day 2, and 300 mg TID on Day 3
Starting ➡️ 100 mg HS
Max ▶️ 1800 mg/d divided TID. T
Anti seizure dose 3600mg/ d no benefit for neuropathic pain 🚫
Oxcarbazepine💊
150 mg PO BID.
trigeminal neuralgia: 300 mg PO BID, increase by 600 mg/d q week. Usual dose: 450- 1200 mg
MAX 2400 mg/ d
SE Rapidly metabolized to carbamazepine, s hyponitermia
Trigminal neuralgia
SCA on REZ (REDLICH-Obersteiner zone )
deafferentation pain
1st line carbamazepine, phenytoin, baclofen…
glossopharyngeal neuralgia
Pain at toung and pharynx
Artery AICA
CN VII
tic convulsif
geniculate neuralgia + hemifacial spasm
AICA
superior laryngeal neuralgia
laryngeal pain and occasionally pain on the auricle
PICA , VA
CN X
geniculate neuralgia
1otalgia and deep prosopalgia
AICA
VA VII
herpes zoster PHN
continuous , p a. Painfull vesicles and crusting followed pain pain resolve
Peak age 40-60
Ophthalmic > spinal segment
Cause ; VZV lies dormant in the sensory ganglia (dorsal root ganglia of the spine, trigeminal (semilunar) ganglion for facial involvement) ➡️ if 🔽immunity, HZV erupt ▶️ inflammation ➡️ later fibrosis
Sx
🔥 pain , allodynia🔽 relief by pressure , cotnious no pain-free intervals
Distribution unilateral chest or on V1
If ophthalmic division, called ▶️ herpes zoster ophthalmicus)
Pain resolve usually resolves after 2–4 weeks
When pain presisr > 1 m after vesicular eruption ▶️ called PHN
If presist > 6 m unlikely to resolve
Tx ; acute 🚨 epidural or paravertebral somatic (intercostal) nerve block
antiherpetic drugs💊 🔽 duration of pain and incidence of PHN , SE thrombocytopenia
Intrathecal steroid ▶️ methylprednisolone (60 mg) + 3% lidocaine (3 ml) given once per week for up to 4 weeks, reported good to excellent pain relief for up to 2 years.
Surgery;
1- nerve block temporary
2- cordotomy
3- rhizotomy retrogasserian for face
4- neuroectomy sympathetectomy
5- DREZ 🔼 recurrence
6- spinal cord or motor cortex stimulation
Ramsay-Hunt syndrome
Reactivating of HZV
Other name herpes zoster oticus).
🔺ipsilatral facial plasy + ear pain , vesicle face and 👂
short-lasting unilateral neuralgiform headache SUNCT
Trigminal neuropathic pain
Male
Age 20-70
Brief (< 2 minutes) pain (burning, stabbing or shock-like) usually near the eye, occurring multiple times per day.
V1
🔺 ptosis, conjunctival injection, lacrimation, rhinorrhea, hyperemia.
lacrimation and conjunctival injection 🔺> vs Trigminal
Raeder’s) paratrigeminal neuralgia
Horner syndrome + trigemin
Tolosa-Hunt syndrome (
painful ophthalmoplegia
orbital pseudotumor
🔺 proptosis, pain, and EOM dysfunction
atypical facial pain (AFP) (prosopalgia)
constant pain, hyperactive autonomic dysfunction, hypesthesia to pinprick.
Otalgia
5th, 7th ( (nervus intermedius, chorda tympani, geniculate ganglion) ) , 9th, or 10th cranial nerves or the occipital nerves. ▶️ were involve
Primary unilateral
🔼 cold and 💧
Sx hearing loss , tinnitus,vertigo
🔽 relive by cocainization or nerve block ➡️ pharyngeal tonsils suggests glossopharyngeal neuralgia
Tx 1st line ➡️ carbamazepine, phenytoin, baclofen…)
2nd line ➡️ suboccipital exploration of the 7th (nervus intermedius) and lower CN , or MVD
sectioning the nervus intermedius, the 9th and upper 2 fibers of 10th nerve, and a geniculate ganglionectomy (
if glossopharyngeal neuralgia is strongly suspected, ➡️ just 9th and upper 2 fibers of 10th)+ geniculate ganglionectomy
Supraorbital neuralgia SON
frontal nerve and are 2 of the 5 branches of V1 (ophthalmic division of the trigeminal nerve)
Larger branch SON
Exite supraorbital notch or foramen,
Common women 👩🦰 at 40 - 50
unilateral pain in the distribution of the supraorbital nerve
tenderness in the region of the supraorbital not
temporary relief with nerve block.
Type SON primRy or 2ry ▶️ truma , chronic compression goggles👓
TX same STN
Supratrochlear neuralgia (STN)
nerve exits the orbit without a foramen
pain in the more medial forehead
relief on blockade of the supratrochlear nerve alone.
Complex regional pain syndrome (CRPS)
Other names causalgia (reflex sympathetic dystroph)
Def ▶️ disproportionate pain syndrome caused by nerve damage and resultant sympathetic dysfunction. 46 It may arise from direct injury to a nerve (type 1), or indirectly due to damage to surrounding tissue (type 2).
🔺 🔥 pain , autonomic dysfunction, and trophic changes ++ allodynia
Sign pic
Type ;;
II ➡️ major causalgia)follows nerve injury with high velocity , missile injury
I ➡️ AKA reflex sympathetic dystrophyRSD or causalgia minor) denoted less severe after non-penetrating trauma.
Associated post CTS releas , spine surgery
Pathogenis ➡️ norepinephrine released at sympathetic terminals + with hypersensitivity secondary to denervation or sprouting
MCC Nerve ➡️➡️ ulnar and sciatic nerves
Tx tricyclic, sympathetic nerve block or Iv , sympathectomy, spinal cord stimulation
