Pain Flashcards
What is fibromyalgia?
Fibromyalgia is a complex pain syndrome associated with widespread pain, sleep disturbances, fatigue, and depression
Diagnostic criteria for fibromyalgia:
1) Widespread pain index (WPI) ≥ 7 and symptom severity (SS) scale score ≥ 5
or WPI 3 - 6 and SS scale score ≥ 9.
2) Symptoms present for at least 3 months
3) No other disorder that would explain the pain
What is memantine?
Memantine is an NMDA antagonist that may be used in the treatment of CRPS.
What is CRPS? How does it present? Diagnosis? How can it be treated? Side effects of the treatment?
Complex regional pain syndrome is separated into types I and II according to the inciting event.
Type I s usually caused by a trivial injury, sprain, crush injury, or burn
Type 2: is caused by a traumatic injury to a MAJOR NERVE trunk such as significant orthopedic trauma, gunshot injuries, or knife wounds.
With either diagnosis, patients may develop burning pain and allodynia. Both syndromes are also characterized by autonomic dysfunction, which presents with localized temperature changes, cyanosis, and/or edema. If the disease progresses without treatment, the skin can become glossy, smooth, and hairless
Diagnostic criteria for CRPS I may include clinical signs and symptoms, in conjunction with a diagnostic sympathetic blockade. treatment goals include serial sympathetic blocks
Along with the risk of intravascular, epidural, and intrathecal injections, a fairly significant percentage of male patients undergoing bilateral blockade may develop ejaculatory problems. This is due to the sympathetic dependence of the ejaculatory mechanism
What is allodynia?
allodynia (pain to non-noxious stimuli)
what does chronic opioid use do to cortisol levels?
Sexual side effects of chronic opioids?
Body temp with chronic opioid use?
Addisonian symptoms?
It decreases them
these changes may lead to male/female infertility, reduced libido, galactorrhea, and menstrual changes.
A decrease in body temperature is commonly seen. Addisonian symptoms (e.g. orthostatic hypotension, muscle weakness, and hyperpigmentation) may also be observed due to reduced cortisol levels.
Phantom limb pain is what type of pain? Treatment:
Neuropathic (central). Legion of the somatosensory nervous system. Treatment: opioids, gabapentin, SC stimulators, antidepressants
Where is the celiac plexus located? Which nervous systems does it house? Possible complications of celiac plexus block?
Retroperitoneal T12-L1. House PS and SNS. Complications-diarrhea, orthostatic hypotension, retroperitoneal hemorrhage, hepatitis, aortic dissection and paraplegia. Why would anyone do this again?
TCA Side effects: And TCAs are good for-
Dry mouth, difficult urination and sedation
Good for neuropathic pain
What effects OPIOID spread on the epidural space?
Most affected by lipophilicity. Very lipophikic will att and the less lipophilic ones will spread (morphine)
Acidic drugs bind to:
ALbumin
Basic drugs bind to:
Acidic AAG
Protein binding signifies what with drugs:
Duration of action
What is Anesthesia dolorosa?
Numbness and pain in an area that lacks sensation-usually seem after a trigeminal nerve block
Discogenic pain is often described as _____. Pain can be relieved by:
Most references state that discogenic pain will increase with anything that
Decreased with standing, increased with bending/sitting
Pain relieved by: pain is often relieved by a lateral recumbent position.
discogenic pain will increase with: increases intradiscal pressure – sitting, flexion, sneezing, or coughing.
Jeopardy style: With this there is often a positive straight leg test and there may be associated weakness.
What is acute disc herniation?
Pain due to spinal stenosis:
What increases it?
Spinal stenosis pain-is it worse walking uphill or downhill?
aching with shooting pain or “pins and needles” sensation. They are increased with walking or anything that requires an incline and decreased with sitting. Although walking exacerbates spinal stenosis pain, patients may tolerate walking uphill more than walking downhill.
When you hear of people with morning back pain-who do you think of?
People with ankylosing spondylitis
Pt has a headache-when do you want to get imaging, and once you do-which type of imaging are you going to get?
In a patient presenting with headache and focal neurological symptoms, diagnostic imaging should be obtained. MRI is preferred over CT as it is able to diagnose posterior fossa and dural based abnormalities with higher sensitivity.
Those that have a recent change in headache pattern, a history of seizures, or focal neurologic findings might benefit from diagnostic testing.
What is paroxysmal hemicrania? How does it compare to migraine headaches and cluster headaches?
Paroxysmal hemicrania is a rare form of headache that has similar characteristics of pain and symptoms as cluster and migraine headaches. The difference between paroxysmal hemicrania, as opposed to cluster and migraine headaches, is that they are shorter in duration, occur more frequently, are more common in females, and they respond absolutely to indomethacin.
What are these symptoms of?
- Severe, unilateral headache that is supraorbital or temporal in location and can last between 20-30 minutes in duration
- Ipsilateral conjunctival injection and/or lacrimation
- Ipsilateral nasal congestion and/or rhinorrhea
- Ipsilateral eyelid edema
- Ipsilateral forehead and facial sweating
- Ipsilateral miosis and/or ptosis
Paroxysmal Hemicrania
What is myofascial pain syndrome?
Give an example of someone that would have it as far as their symptoms
Can it ever go dormant?
characterized by trigger points in skeletal muscles often secondary to repetitive use or trauma. The area of pain is localized but will cause radiation of pain in a characteristic non-dermatomal pattern upon palpation.
A 22-year-old male presents to the pain clinic with right upper back and neck pain. He is a collegiate basketball player and noted that the pain started after being struck in the head during a layup shot. This caused significant stretching of his neck to the left. The pain is described as dull and achy and gets worse with use. The pain is limiting his involvement in weight training and practice. On physical exam, you note tenderness in the lower right neck/upper back above the scapula with increased muscle tension.
Dormancy: Myofascial pain syndromes can become dormant with only tenderness to the site but reactivate with repeat trauma and stress.
Treatment for myofascial pain syndrome:
What’s seen in myofascial pain syndrome in trigger point injections
Treatment includes application of cold sprays such as ethyl chloride to relax the muscle and allow for implementation of stretching exercises and physical therapy. Soft tissue therapy such as massage and ultrasound is also of benefit. Interventional management can include dry needling and injections of local anesthetic. During trigger point injections, reproduction of pain radiation pattern or muscle twitch are seen.
Can you have autonomic dysfunction in myofascial pain syndrome? What about spontaneous EMG activity?
Dermatomal radiation of pain?
Yes-piloerection and vasoconstriction can occur with myofascial pain syndromes. spontaneous EMG activity can be seen in the affected region.
Characterized by a non-dermatomal radiation of pain.
Cardiac events and carbamazepine:
Cardiac events noted with carbamazepine toxicity include widening of the QRS complex (A), prolonged QT interval, ventricular arrhythmias, tachycardia, and hypotension (B) (from direct myocardial depression)
Neurologic symptoms and carbamazepine? myosis or mydriasis and why?
Neurologic changes include altered mental status, delirium, and a paradoxical reduction in seizure threshold (C). Nystagmus (D) and mydriasis are commonly noted.
Anticholinergic effects and carbamazepine:
Anticholinergic effects also include hyperthermia, flushing, dry mouth, and urinary retention.
symptoms of carbamazepine and calling a center vs side effects and calling a center:
The severity of symptoms at the time of initial contact with the poison control center correlates with outcome severity for children and adults. However, the amount of time between ingestion and poison control center contact does not appear to alter the correlation between initial severity of symptoms and final outcome severity.
Acute herpes zoster will initially present in which dermatome? Which dermatomes are more common after that?
Acute herpes zoster typically affects thoracic nerve roots, followed in descending order by: ophthalmic division of the trigeminal nerve (V1), maxillary division of the trigeminal nerve (V2), cervical spinal roots, and sacral spinal roots (least common)
Neuropathic pain: We don’t understand completely, but what are some components:
Peripheral-Inflammation, repair mechanisms, and adjacent tissue reactions can lead to hyper-excitability in afferent nociceptors (peripheral sensitization).
Central: This evokes central neurons that are innervated by the nociceptors to undergo functional changes (central sensitization).
Afferent pathway damage: Neuropathic pain states occur following injury to the afferent pathway.
What is post-herpetic neuralgia, and what are risk factors:
What decreases the incidence? What has nothing at all to do with it?
Postherpetic neuralgia is defined as pain persisting 30 days after the disappearance of the varicella/zoster rash and occurs with an overall incidence of 10-15%. Risk factors for the development of PHN include increased age (PHN incidence can be as high as 30-50% in elderly patients), female gender, increased pain or sensory abnormalities during the acute phase, a more severe skin lesion during the acute phase, and the presence of a prodrome.
VAccination decreases the incidence, and ethnicity has noting at all to do with it.
Why does upper extremity stuff never happen wiht celiac blocks?
Upper extremity injury does not occur because the approach to blocking the celiac plexus is approximately at the level of the first lumbar vertebra.
Side effects of celiac plexus block:
Celiac plexus neurolytic blocks are performed for chronic, intractable abdominal pain originating from most of the viscera. Adverse effects include hypotension, diarrhea, hiccups, pleurisy, retroperitoneal bleeding, abdominal aortic dissection, transient motor paralysis, and paraplegia.
The INR of 1.5 thing applies to which types of blocks?
Neuraxial, so if you were going to do a block in a compressible area (like intercostal) a higher INR wouldn’t really matter
What is a neurolytic block? What are the 5 criteria needed in order to reasonably do one of these?
A step further than a diagnostic block.
Five criteria for the use of neurolytic blocks are (all 5 needed):
1) The presence of severe pain
2) The failure of less invasive techniques to relieve the pain
3) The presence of well localized pain
4) The relief of pain with diagnostic local anesthetic blocks
5) The absence of adverse side effects after diagnostic blocks
Sympathetic blocks and Herpes Zoster vs Post-Herpetic neuralgia:
What is the treatment for PHN? Spinal cord stimulators?
Sympathetic blocks may be beneficial for acute herpes zoster infection but are NOT effective (C) for postherpetic neuralgia (PHN).
The treatment of PHN includes anticonvulsants, tricyclic antidepressants, lidocaine patches, topical capsaicin, opiates, and tramadol.
Spinal cord stimulators are also effective in PHN refractory to medical treatment.
What all does tramadol do?
ramadol has also proven effective in the treatment of PHN. It is a μ-opioid receptor agonist, NMDA antagonist, and norepinephrine and serotonin reuptake inhibitor. Tramadol also has a lower addiction profile relative to opioids which makes it attractive for providers to prescribe.
When are spinal cord stimulators contraindicated? Is this relative or absolute contraindication?
Absolute contraindications for spinal cord stimulators?
Spinal cord stimulators are relatively contraindicated in the setting of cognitive and psychological disability that interferes with proper usage and understanding of the device. (somatoform disorder)
Relative contraindications: Spinal cord stimulation is relatively contraindicated in the setting of major untreated psychological disease, substance abuse, and lack of social support.
Absolute contraindications for spinal stimulation include (but are not limited to): sepsis, coagulopathy, previous surgery or trauma obliterating the spinal canal, localized infection, and spinal bifida.
Where is the stellate ganglion located?
Possible complications of stellate ganglion block:
How would you think that there was an injection in the artery vs an injection intravenously? Bupi and this concept?
The stellate ganglion is located at the fusion of the inferior cervical and first thoracic ganglions at the level of the C7 transverse process. Subarachnoid injection, intraneural injection, pneumothorax, esophageal perforation, and chylothorax are other possible complications.
B/c with stellate ganglion block, a smaller amount is used, and the toxic dose for intrarterial injection (e.g. in the vertebral or carotid arteries) is lower due to a higher concentration of local anesthetic in the neurovascular tree.Injection of local anesthetic into the vertebral artery can result in CNS toxicity even at low doses due to the high local concentration. Bupivacaine, due to its potency and lipid-solubility, can cause CNS toxicity at lower doses than many other local anesthetics.
LAST and dosing of local anesthetics-lower doses=probs in which system vs higher doses?
Local anesthetic systemic toxicity occurs in a dose dependent fashion, with symptoms of lightheadedness, tinnitus, and numbness of the tongue occurring at lower doses followed by CNS toxicity and then progressing to CV toxicity at higher doses. Symptoms of CNS toxicity include seizures and unconsciousness.
Does fentanyl have active metabolites?
What is the deal with opioid induced neurotoxicity?
Who usually develops it, how long does it take to develop it?
No Opioids with active metabolites are more likely to cause symptoms and when development occurs the patient should stop the offending agent and be rotated to another agent.OIN can occur with any opioid, however those with active metabolites tend to be responsible more often - meperidine, codeine, morphine, and to a smaller extent hydromorphone. Neither fentanyl nor methadone has active metabolites and these opioids are least likely to cause neurotoxicity.
Which opioids do NOT have active metabolites?
Fentanyl and methadone
Does naloxone treat opioid induce neurotoxicity?
Would you add a benzo in OIN?
No.n addition, if the patient has severe neurologic symptoms and the clinician is concerned with development of seizures, they may start a trial of benzodiazepine to increase the seizure threshold. This may make the neurologic symptoms more pronounced in some patients thus needs to occur carefully and in selected patients.
How can someone go from having lower extremity regional complex pain syndrome to having failure of ejaculation? Why?
Lower extremity complex regional pain syndrome (CRPS) is treated with serial lumbar plexus sympathetic blocks which can be complicated by ejaculatory problems in males, particularly when bilateral blocks are performed.. This is due to the sympathetic dependance of the ejaculatory mechanism.
Complex regional pain syndrome types:
With either type, what symptoms can they have? What’ll happen if they progress w/out treatment?
Type I (formerly known as reflex sympathetic dystrophy or RSD) is usually caused by a TRIVIAL injury, sprain, crush injury, or burn Type II (formerly known as causalgia) is caused by a traumatic injury to a MAJOR NERVE TRUNK such as significant orthopedic trauma, gunshot injuries, or knife wounds. With either diagnosis, patients may develop burning pain and allodynia (pain to non-noxious stimuli). Both syndromes are also characterized by autonomic dysfunction, which presents with localized temperature changes, cyanosis, and/or edema. If the disease progresses without treatment, the skin can become glossy, smooth, and hairless
Diagnostic criteria for CRPS I:
signs, symptoms, and relief with a sympathetic block (upper or lower)
Treatment for CRPS:
Which medications do NOT work?
Any role for spinal cord stimulators?
Medications utilized in the treatment of CRPS, but with inconsistent success, include α-adrenergic blocking agents, calcium channel blockers, tricyclic antidepressants, and anticonvulsants. Surgical and neurolytic sympathectomies may also be performed for specific patients. Spinal cord stimulation has proven effective in the treatment of CRPS. Opioids are rarely effective or helpful in the management of CRPS.
methadone-Is it lipophilic? Metabolized by what? Excreted by what? Where does methadone work?
Because it is lipophilic, a considerable amount of tissue distribution occurs. Methadone undergoes hepatic metabolism and some renal excretion. Methadone works in the central nervous system on the mu, delta, and kappa receptors.
Methadone vs morphine-which one has the longer half life? Which one is easier to titrate?
Methadone, methadone is easier to titrate
What is TENS therapy? What theory is it based on?
Transcutaneous electrical nerve stimulation (TENS) uses low voltage electrical pulses to stimulate the nervous system and is used for a variety of pain syndromes. TENS can be used in a several different clinical settings: a physicians office, during physical therapy, and even for home use in selected patients. TENS therapy is based on the gate theory of pain where afferent input from large epicritic fibers competes with input from small pain fibers.
What is the GATE theory?
With the gate theory, it is proposed that second-order neurons at the level of the spinal cord dorsal horn act as a “gate” through which noxious stimuli must pass to reach higher centers in the brain and be perceived as pain. If these same neurons receive input from other sensory fibers entering through the same set of neurons in the spinal cord, the non-noxious input can effectively close the gate, preventing simultaneous transmission of noxious input. Thus, the light touch of rubbing an injured region or the pleasant electrical stimulation of TENS closes the gate to the noxious input of chronic pain.
When should TENS be used?
The device should only be used under medical supervision for adjunctive therapy and should not be intended for use as a substitute for pain medications and other pain management therapies”. Broader indications for TENS therapy include acute pain, musculoskeletal pain, neurologic pain, phantom limb pain, chronic pain and during the perioperative period
Contraindications for TENS:
Contraindications include patients with demand-type pacemakers, patients with known cardiac dysrhythmias, undiagnosed pain syndromes with unknown etiology, and mentally incompetent patients. There are differing thoughts on TENS therapy during pregnancy – some resources state it is safe following the first trimester while other sources consider it contraindicated throughout pregnancy due to the theoretical risk of premature labor. The FDA has not approved TENS use during pregnancy
