Pain

Question 1

Type of pain

Answer 1

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

Question 2

Neuropathic pain

Answer 2

PDN and PHN is typically burning and aching, is continuous, and is characteristically refractory to medical and surgical treatment.

Question 3

TX Tricyclic antidepressants 💊 Amitriptyline

Answer 3

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

Question 4

Gabapentin 💊

Answer 4

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 🚫

Question 5

Oxcarbazepine💊

Answer 5

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

Question 6

Trigminal neuralgia

Answer 6

SCA on REZ (REDLICH-Obersteiner zone )

deafferentation pain
1st line carbamazepine, phenytoin, baclofen…

Question 7

glossopharyngeal neuralgia

Answer 7

Pain at toung and pharynx
Artery AICA
CN VII

Question 8

tic convulsif

Answer 8

geniculate neuralgia + hemifacial spasm
AICA

Question 9

superior laryngeal neuralgia

Answer 9

laryngeal pain and occasionally pain on the auricle
PICA , VA
CN X

Question 10

geniculate neuralgia

Answer 10

1otalgia and deep prosopalgia
AICA
VA VII

Question 11

herpes zoster PHN

Answer 11

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

Question 12

Ramsay-Hunt syndrome

Answer 12

Reactivating of HZV
Other name herpes zoster oticus).
🔺ipsilatral facial plasy + ear pain , vesicle face and 👂

Question 13

short-lasting unilateral neuralgiform headache SUNCT

Answer 13

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

Question 14

Raeder’s) paratrigeminal neuralgia

Answer 14

Horner syndrome + trigemin

Question 15

Tolosa-Hunt syndrome (

Answer 15

painful ophthalmoplegia

Question 16

orbital pseudotumor

Answer 16

🔺 proptosis, pain, and EOM dysfunction

Question 17

atypical facial pain (AFP) (prosopalgia)

Answer 17

constant pain, hyperactive autonomic dysfunction, hypesthesia to pinprick.

Question 18

Otalgia

Answer 18

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

Question 19

Supraorbital neuralgia SON

Answer 19

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

Question 20

Supratrochlear neuralgia (STN)

Answer 20

nerve exits the orbit without a foramen

pain in the more medial forehead

relief on blockade of the supratrochlear nerve alone.

Question 21

Complex regional pain syndrome (CRPS)

Answer 21

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