Pain

Question 1

Chemical mediators, ______and _____ is released from pancreatic ______ neurons and can lead to visceral cancer pain

Answer 1

Substance P and calcitonin gene-related peptide (CGRP)

vagal afferent neurons

Question 2

The pancreas has sensory innervation via ___

Answer 2

vagal branches
and
axons from splanchnic nerves and celiac plexus

Question 3

Central alpha-2-receptor agonists cause (analgesia/pain)

Answer 3

analgesia

- sympatholysis

Question 4

Lumbar sympathetic block targets the _______, along the anterolateral border of the lumbar vertebrae. _____ muscle is located posteromedial to the ganglia, and is often injected by contrast.

Answer 4

lumbar sympathetic ganglia

Psoas major

Question 5

Most common indication for epidural steroid injection is ____

Answer 5

1. Radicular pain caused by herniated disk
2. Spinal stenosis

*Radicular pain responds favorably to ESI

Question 6

Cauda equina syndrome affects ____ dermatomes

Answer 6

S3-S5

- saddle anesthesia

Question 7

(True/False) localized pain is nototoriously difficult to treat

Answer 7

True

- TENS, ESI do not have good results

Question 8

Why is treating phantom limb pain so difficult?

Answer 8

Lack of RCTs

Question 9

Order from most to least common nerves affected by herpes zoster

Answer 9

1. Thoracic
2. Opthalmic division of trigeminal n (V1)
3. Maxillary division of trigem n. (V2)
4. Cervical spinal roots
5. Sacral spinal roots

Question 10

Patients with trigger point myofascial pain often have _____.

Answer 10

Painful limitation of ROM
Spasm
Stiffness
Weakness

Question 11

What pain syndrome is associated with hypermobile muscles and can be made worse with trigger point injections??

Answer 11

Fibromyalgia

Question 12

How do TCAs provide analgesia in non-cancer related pain? (4)

Answer 12

1. SSRI
2. NMDA antagonist
3. mu-opioid receptor agonist
4. Na-K channel blocker

Question 13

TCAs are mu-opioid receptor (agonists/antagonists)

Answer 13

agonists

*naloxone is a mu-opioid receptor antagonist

Question 14

Lower extremity complex regional pain syndrome (CRPS)
- (autonomic dysfunction, burning pain, cyanotic, edematous, glossy skin ect)
is treated with_______

Answer 14

serial lumbar plexus sympathetic block

Question 15

Common side effect of serial lumbar plexus sympathetic block

Answer 15

Failure of ejaculation
(not erectile dysfunction)
- sympathetic dependence of ejaculation

Question 16

Why is diarrhea associated with celiac plexus block?

Answer 16

(T5-T12): Supplies innervation to all intraabdominal organs and most of bowel

Question 17

_______ is an NMDA antagonist that may be used in the treatment of CRPS

Answer 17

Memantine

Question 18

How does NAC work against acetaminophen toxicity?

Answer 18

N-acetylcystine: provides cysteine for replenishment of hepatic stores, which enhances elimination pathway

Question 19

(True/False) Epidural steroid injections for lumbar radiculopathy have a direct correlation duration of symptoms. The Longer the disorder, the better it works.

Answer 19

False
- inverse

The more acute the symptoms, the higher predictor of success

Question 20

Inhibitory neurotransmitters: inhibit central nociceptor terminals -> reducing excitatory transmitter release

Answer 20

Glycine
- acts at spinal levels

GABA
- acts at higher levels

Question 21

Cation channel gating or excitation occurs as a result of ____ stimulation of ______ in peripheral tissues

Answer 21

noxious stimulation of the primary afferent neurons (ie. nociceptors)

Question 22

Excitatory neurotransmitters that lead to opening (gating) of cation channels in the presynaptic nociceptor terminals

Answer 22

Glutamate,
substance P,
calcitonin gene-related peptide

Question 23

Patients from (higher/lower) socio-economic backgrounds are more sensitive to pain

Answer 23

lower

• worse coping mechanisms
• worse understanding

Question 24

The stellate ganglion is made of the ______ and _____ sympathetic ganglia and lies in close proximity to the carotid artery, internal jugular vein, lung, and brachial plexus

Answer 24

Inferior cervical

First thoracic sympathetic ganglia

Question 25

Side effects of stellate ganglion block

Answer 25

1. Vasovagal reactions - need to differentiate form intravascular, epidural, spinal injections 2. Horner syndrome - Ptosis, miosis, anhidrosis, enopthalmos

Question 26

______ is the most common complication of celiac plexus blockade. It is most often used for ____

Answer 26

``` #1: Orthostatic hypotension - splanchnic vasodilation by sympatholysis #2: diarrhea ``` Pain caused by unresectable pancreatic cancer

Question 27

When there is impingement of the spinal CORD itself that results in functional impairment such as weakness, numbness, or abnormal reflexes, the diagnosis is (radiculitis/myelopathy)

Answer 27

Myelopathy *radiculitis indicates inflammation of spinal NERVE ROOT, which may lead to pain in that nerve's distribution WITHOUT weakness

Question 28

When there is impingement of the spinal NERVE ROOT that results in nerve pain with functional impairment such as weakness, numbness, or abnormal reflexes, the diagnosis is (radiculopathy/myelopathy)

Answer 28

Radiculopathy *myelopathy is at the spinal cord, not the spinal nerve root

Question 29

Herpes zoster can cause blindness in immunocompromised pts if the ______ nerve is affected

Answer 29

trigeminal nerve

Question 30

Meds approved for fibromyalgia

Answer 30

Duloxetine - SNRI, additional antinociceptive effect Milnacipran - SNRI, additional antinociceptive effect Pregabalin - a-2/delta calcium channel modulator

Question 31

How does neuraxial fentanyl work and why is it so fast?

Answer 31

activation of mu receptors in the substantia gelatinosa in the dorsal horn of the spinal cord - where they inhibit release of excitatory neurotransmitters (substance P and glutamate)

Question 32

What is more concerning, lipophilic fentanyl or hydrophilic morphine/hydromorphone

Answer 32

Hydrophilic - ascend in CSF to reach resp centers of the brainstem - also works at dorsal horn of SC *lipophilic opioids work at dorsal horn of SC and through systemic absorption

Question 33

Epidural (hydromorphone/fentanyl) has less cephalic spread

Answer 33

fentanyl - more lipophilic, and absorbed systemically by surrounding fat - the more lipophilic, the shorter its duration in the epidural space *hydromorphone and morphine is hydrophilic

Question 34

First order neurons secrete _____ in the dorsal horn as a chemical mediator of pain signaling.

Answer 34

Substance P

Question 35

Wind-up phenomenon

Answer 35

exponentially progressive increase in firing of neurons w/ repeated stimulation

Question 36

a ________ is the next step for failed medical management of complex regional pain syndrome

Answer 36

one sided diagnostic sympathetic block | - sympathectomy alone w/o analgesia

Question 37

What is complex regional pain syndrome?

Answer 37

syndrome that produces spontaneous pain - Hyperalgesia or allodynia and is associated with autonomic dysfunction Type 1: no nerve damage - trivial injury, sprain, burn Type 2: nerve damage present (usually to major nerve trunk) - traumatic injury, gsw, knife wound

Question 38

a ________ is the last resort for treating complex regional pain syndrome and is indicated for refractive neuropathic pain rather than nociceptive pain

Answer 38

Spinal cord stimulator | - short electrical bursts to dorsal column of spinal cord

Question 39

Thigh dermatomes - L1 - L2 - L3

Answer 39

- L1: Along inguinal ligament - L2: Medial/lateral upper thigh - L3: Medial/lateral lower thigh (does not include knee)

Question 40

Thigh dermatomes - L4 - L5 - S1

Answer 40

- L4: lateral lower thigh, knee, and 1/2 of big toe - L5: Lateral calf and toes 1.5-4 - S1: 5th toe

Question 41

How does pKa affect local anesthetics?

Answer 41

Associated with speed of onset of drug | - sodium bicarb can be added to LA

Question 42

_______ is the best tx for a pt with an acute lumbosacral radiculopathy

Answer 42

NSAIDs

Question 43

In pt with an acute lumbosacral radiculopathy, what should be done first, imaging or treatment?

Answer 43

Conservative treatment - then CT or MRI if needed - XR does not pick up soft tissues like herniated disc

Question 44

Neuropathic pain occurs following injury to (afferent/efferent) pathways and involve (central/peripheral) mechnanisms.

Answer 44

afferent -> hyper-excitability Both central and peripheral components

Question 45

How does gabapentin and pregabalin work?

Answer 45

a-2-delta ligands that bind the subunit on VG calcium channels -> prevent release of nociceptive neurotransmitters

Question 46

For electrical pain signals to pass, the NMDA receptor must be open. What are common NMDA receptor antagonists?

Answer 46

Ketamine Nitric oxide Methadone

Question 47

Sympathetic plexus blocks are ideal interventions for patients with _______ refractive to medical therapy. A good marker of successful sympathetic block is ________.

Answer 47

regional neuropathic pain with sympathetic mediation Increase in limb temp by 2-3 degrees Celsius as blood vessels dilate

Question 48

Most common cause of seizure immediately after LA injection during a stellate ganglion block?

Answer 48

Vertebral or carotid artery injection

Question 49

The stellate ganglion is located at the level of _____ transverse process. The stellate ganglion block is often used in the tx of _____

Answer 49

C7 - fusion of the inferior cervical and first thoracic ganglions Complex regional pain syndrome

Question 50

Bupivacaine, d/t its ______ can cause CNS toxicity at lower doses than many other local anesthetics

Answer 50

potency and lipid-solubility

Question 51

Local anesthetics belonging to the (ester/amide) class, more commonly result in hypersensitivity reactions d/t their ______

Answer 51

Ester PABA metabolite

Question 52

The nerve supply to the lower extremity is derived from the _____ and ____ plexus

Answer 52

Lumbar and sacral

Question 53

The lumbar plexus gives rise to ______ nerves

Answer 53

Femoral n Obturator n Lateral femoral cutaneous n

Question 54

The sacral plexus gives rise to ______ nerves

Answer 54

Posterior cutaneous n of the thigh Sciatic n

Question 55

A sciatic peripheral nerve block covers _____

Answer 55

cutaneous innervation to posterior thigh and all of the leg and foot below the knee, EXCEPT medial strip supplied by saphenous n.

Question 56

The saphenous nerve supplies sensation to ___

Answer 56

skin on the medial side of the leg and foot

Question 57

Second order neurons describe transmission of pain signals from _____ to ____

Answer 57

dorsal horn of the spinal cord contralateral spinothalamic tract to thalamus

Question 58

TENS is a useful treatment of ______ and involves electrical stimulation of _____ to inhibit signaling of ________ fibers.

Answer 58

Myofascial pain syndrome - acute and chronic Large diameter A-beta cutaneous mechanoreceptors to inhibit signaling of A-delta and C pain fibers

Question 59

Are the analgesic effects of TENS reversible?

Answer 59

Yes - with naloxone | - implies mu-receptor agonism, central and peripheral

Question 60

______ involves osteoarthritic degeneration, causing axial back pain that may radiate to ipsilateral buttocks or thigh. Pain worsened with spinal hyperextension and lateral rotation. Achy in nature, not electrical. Not associated with numbness, weakness, or tingling.

Answer 60

Facet syndrome / Facet arthropathy

Question 61

Cons of PCA vs On-request Opioid

Answer 61

PCA: - More pruritus - more respiratory depression if PCA + continuous

Question 62

(True/False) application of TENS electrodes on the contralateral limb has shown successful analgesia

Answer 62

True

Question 63

THe superior hypogastric plexus is found at ___

Answer 63

L5 anterior to the aortic bifurcation

Question 64

The ________ block targets the sympathetic fibers that innervate the pelvic organs and is therefore effective in treating chronic pelvic pain

Answer 64

superior hypogastric block

Question 65

in early complex regional pain syndrome (CRPS), _____ block may be indicated

Answer 65

Lumbar sympathetic block | -plexus: L2-L5

Question 66

The suprascapular nerve is derived from _____ via the brachial plexus

Answer 66

C5-C6

Question 67

Chronic shoulder pain d/t arthritis can be managed with _____ nerve bloc.

Answer 67

Suprascapular nerve block

Question 68

Post-stroke pain, paresthesias, and allodynia are likely a result of _____

Answer 68

thalamic pain syndrome | - d/t latent brain plasticity after a thalamic injury

Question 69

Inhibitory neurotransmitters

Answer 69

Glycine and y-aminobutyric acid (GABA)

Question 70

Nociceptors consists of ___ and ___ fibers with cell bodies located in the trigeminal and dorsal root ganglia

Answer 70

A-delta C fibers

Question 71

Chronic opioid therapy has profound effects on adrenal and gonadal axes leading to which effects on hormones?

Answer 71

Increased 1. prolactin Decreased 2. testosterone 3. Estrogen 4. Cortisol 5. LH 6. FSH

Question 72

What is coccydynia?

Answer 72

Chronic pain syndrome that occurs from traumatic and nontraumatic causes - fractures - child birth - tumors