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Regional > Pain Pathway > Flashcards

Pain Pathway Flashcards

1
Q

Epicritic Sensation

A

Light touch, pressure, temperature discrimination.
Low threshold receptors
Large myelination

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2
Q

Protopathic Sensation

A

Noxious- Pain sensation
Detected by high threshold receptors
Conducted by smaller lightly myelinated alpha-delta and unmyelinated C nerve fibers

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3
Q

What fibers conduct Protopathic sensation ?

A

Lightly myelinated alpha-delta and Unmyelinated C fibers

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4
Q

Pain

A

Unpleasant sensory or emotional experiences
Associated with actual of potential tissue damage
Or described as such damage

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5
Q

Nociception

A

Neural response to traumatic or noxious stimuli.

* All nociception produces pain but not all pain results from nociception .

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6
Q

Classifications of pain

A

Classified by

1) Pathophysiology: Nociceptive or neuropathic
2) Etiology : Arthritis or Cancer
3) Affected area: Headache or Lower back
* Classification drive the course of treatment

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7
Q

What is Nociceptive pain caused by?

A

Activation or Sensitization of peripheral nociceptors that transduce the noxious stimuli

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8
Q

What does neuropathic pain result from ?

A

Injury or acquired abnormalities of either peripheral or central neural structures

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9
Q

Gender and age and pain perception

A

There are differences in pain perception, experiences and coping strategies related to gender and age .

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10
Q

Acute Pain : A)cause and B)characteristic?

A

A) Caused by noxious stimulation due to : 1) injury 2) disease process 3) abnormal fx of muscle/viscera
B) Almost always Nociceptive = serves to 1) detect 2) localize 3) limit tissue damage .

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11
Q

4 physiological process involved in pain :

A

Transduction :
Modulation: Inhibition or intensify
Perception: Pain
Transmission :

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12
Q

Somatic pain

A

Superficial vs Deep
Superficial : skin, SubQ, mucous membrane; well localized, sharp , pricking , throbbing, burning .
Deep Somatic : Muscles, tendons, Joints, Dull, aching, less localized

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13
Q

Visceral Pain

A

Disease process or abnormal function of internal organ and it’s covering ( parietal pleura, pericardium, peritoneum )

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14
Q

How many visceral pain subtypes and describe ?

A

True localized
Localized parietal
Referred visceral
Referred parietal

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15
Q

True localized (Visceral subtype )

A

Dull, diffused, usually midline causes N/V/sweating/changes in BP & HR

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16
Q

Fibromyalgia

A

1) WPI score of 7 or higher or
Symptom Severity Scale (SS) of 5 or higher or
WPI of 3 to 6 + SS of 9 or higher
2) Symptoms at similar level for at least 3 months
3) Absence of disorder that would otherwise explain the pain.

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17
Q

Chronic pain that persists beyond the usual course of an acute disease or after a reasonable time for healing to occur

A

Chronic pain . Healing can vary 1 to 6 months. Chronic may be Nociceptive , neuropathic or mixed .

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18
Q

True or False. Chronic pain may be neuropathic , Nociceptive or mixed

A

True

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19
Q

A distinguished factor of pain is that …

A

Psychological mechanisms or environmental factors frequently play a major role

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20
Q

First order neuron Pain fibers initiated in the head are carried by

A

CN 5, 7, 9 and 10

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21
Q

Tract of Lissaeur

A

Pain fibers can ascend or descend 2- 3 segments on the track of Lissaeur before synapsing with second order neuron in the gray matter of the ipsilateral dorsal horn .

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22
Q

Second order neuron terminates in

A

The Thalamus

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23
Q

Spinothalamic Tract lies

A

In the anterolateral white matter of the spinal cord , classically considered the major pain pathway , is and ascending tract

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24
Q

Spinothalamic tract divided into the

A

1) Lateral spinothalamic tract

2) medial spinothalamic tract

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25
Q

Lateral spinothalamic tract aka neospinothalamic project mainly into____and carries____

A

The ventral posterolateral thalamus;

discriminative aspects of pain such as: location, intensity , duration

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26
Q

Medial Spinothalamic projects to____and is responsible for mediating the ______

A

The Medial Thalamus; autonomic and unpleasant emotional perception of pain

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27
Q

Spinomesenphalic tract may be important in activating_____because it _______

A

Anti-Nociceptive descending pathways ; has some projections to the peri-aquaductal gray

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28
Q

Third order neuron located_____sends fibers_____and the _______respectively.

A

In the thalamus; to somatosensory area I & II in the postcentral gyrus of the parietal cortex ; superior wall of the Sylvian fissure

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29
Q

Nociceptor types (3)

A

Mechanonociceptors= pinch and pinprick
Silent Nociceptors= only in presence of inflammation
Pymodal mechanoheat nociceptors = more prevalent and respond to excessive pressure , extremes of temperature >42C and <40C + to substances : bradykinins , histamine , serotonin (5 HT), H+, K+, some prostaglandins , capsaicin, and possibly ATP. They are slow to adapt to strong pressure and display heat sensitization

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30
Q

Pymodal mechanoheat nociceptors???

A

more prevalent and respond to excessive pressure , extremes of temperature >42C and <40C + to substances : bradykinins , histamine , serotonin (5 HT), H+, K+, some prostaglandins , capsaicin, and possibly ATP. They are slow to adapt to strong pressure and display heat sensitization

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31
Q

Cutaneous Nociceptors

A

1) both somatic and visceral .

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32
Q

Cornea and Tooth pulp unique because

A

Almost always innervated by Nociceptive A-delta and C fibers.

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33
Q

Deep somatic

A

Less sensitive to noxious stimuli than cutaneous BUT more they easily sensitized by inflammation.
Deep somatic pain is : dull and poorly localized .
Their nociceptors are in the Joint capsules and Muscle . They respond to 1) mechanical 2) chemical 3)thermal stimuli

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34
Q

Visceral organs are insensitive tissue that mostly contain ——noiciceptors

A

Silent

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35
Q

Heart , lung, bile ducts have specific nociceptors vs most other organs( ex: intestine ) are innervated by

A

Polymodal Nociceptors that respond to 1) smooth Muscle spasm 2) Ischemia 3) inflammation.

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36
Q

Polymodal Nociceptors do not respond to

A

Cutting, burning , crushing that occurs during surgery.

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37
Q

____lack nociceptive receptors totally. However, ______do contain nociceptors

A

A few organs such as brain ; Meningeal coverings

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38
Q

Somatic and Visceral nociceptors are free nerve endings of _________neurons whose cell bodies lie in the ______. BUT visceral nociceptors travel with the ______to reach the viscera .

A

Primary afferent; dorsal horn ; efferent sympathetic nerve fibers to reach the viscera.

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39
Q

Afferent activity from ***enters the spinal cord between

A

T1 and L2

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40
Q

Nociceptive C fibers of trachea, larynx , esophagus travel with vagus to enter the

A

Nucleus solitarius of the brainstem

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41
Q

Afferent fibers from the _____are transmitted into the spinal cord via ______nerves at S_ to S_ nerve roots .

A

Bladder, prostate, rectum, cervix, urethra, genitalia ; parasympathetic ; S2-S4

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42
Q

Chemicals mediators of pain (3)

A

1- Excitatory Amino Acids: Glutamate (most important AA) & Aspartate
2-Excitatory Neuropeptides: Substance P and Calcitonin gene-related peptide
3-Inhibitory Amino Acids: Glycine and GABA

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43
Q

Substance P and CRGP , histamine from ____5HT from ____and is a potent____ and attracts leukocytes

A

Histamine: from Mast cells
5HT : From platelets
Potent vasodilator
Can cause direct post ganglionic discharge bc it sends collateral fibers to paravertebral sympathetic ganglia .

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44
Q

Modulation of Pain: Primary Hyperalgesia

A

Exaggerated response to pain at the site of injury .
Increased excitability of nocicpetors lead to Peripheral sensitization of polymodal C fibers and High Threshold mechanoreceptors that leads to primary hyperalgesia.

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45
Q

Secondary Hyperalgesia : mechanism

A

Increased pain response evoked by stimuli outside the area of injury . Release of Substance P into the spinal cord removes the magnesium block on the NMDA receptors = allows glutamate to bind to NMDA.
Repetitive C fiber stimulation to the WDR neurons in the dorsal hormone lead to Wind up central sensitization = secondary hyperalgesia.

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46
Q

Secondary Hyperalgesia has …does not have …manifested by

A

Also called neurogenic inflammation . By Substance P

1) Red flushing , local tissue edema , sensitization to noxious stimuli.
2) Does not have skin denervation.
3) Manifested by triple response of Lewis: red flush around the side of injury(flare), local tissue edema, and sensitization to noxious stimuli .
* can be produced by electrical stimulation of a sensory nerve, diminished by LA. Capsaicin = depletes Substance P = diminishes neurogenic inflammation.

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47
Q

Transduction

A

The event whereby noxious thermal, chemical, mechanical stimuli are converted into action potential .
*Conversion of Noxious stimuli into action potential .

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48
Q

Referred Visceral pain pattern - central diaphragm

A

C4

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49
Q

Lungs referred pain

A

T2-T6

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50
Q

Aorta

A

T1- L2

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51
Q

Heart

A

T1-T4

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52
Q

Esophagus

A

T3- T8

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53
Q

Radiculopathy

A

Functional abnormality of one or more nerve roots

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54
Q

Second order neuron can be either

A

Nociceptive specific or Wide Dynamic Range ( WDR) neurons.

55
Q

Nociceptive specific serve only ..

A

Noxious stimuli and are arranged in Lamina 1.

56
Q

WDR neurons found in Lamina ___, ___, and ____; receive____&____afferent input from__,__,and__. Are most abundant in ____but are found throughout ______

A

Lamina IV, V, VI
Receive both noxious and non-noxious afferent input from A beta, A delta and C-Fibers .
In Lamina V
The dorsal horn .

57
Q

Hyperpathia

A

Presence of hyperesthesia , allodynia and hyperalgesia usually associated with overreaction and persistence of the sensation after the stimulus .

58
Q

Anesthesia

A

Absence of all pain sensation

59
Q

Allodynia

A

Perception of an ordinarily non-noxious stimuli as pain

60
Q

Hyperesthesia

A

Increased response to MILD stimulation

61
Q

Hyperalgesia

A

Increased response to NOXIOUS stimulation

62
Q

First order neuron synapse on

A

Second order neurons in the dorsal horn primarily in Laminas I , II, V where they release excitatory amino acids and neuropeptides.

63
Q

Neuralgia

A

Pain in distribution of a nerve or a group of nerves

Sciatic, neuropathy, diabetes, chicken pox(shingles in adults )

64
Q

Lamina I aka Marginal Layer

A

Input from Ad and C fibers

Somatic nociception, thermoreception

65
Q

Lamina II aka SUBSTANTIA Gelatinosa

A

Input C and Ad fibers

Somatic nociception and thermoreception.

66
Q

Lamina V aka Nucleus proprius WDR neurons

A

A-beta,A-delta and C fibers

Visceral and somatic nociception and mechanoreception

67
Q

Lamina 8 and 9 aka motor horn

A

A-Beta

Motor

68
Q

Lamina VII aka intermediolateral column

A

Input : Blank !

Sympathetic

69
Q

Lamina I and II

A

Somatic nociception thermoreception

70
Q

Lamina 4 and 6

A

Mechanoreceotion
4= a beta abd a delta
6- a beta

71
Q

Lamina 7

A

Sympathetic

72
Q

Lamina 5

A

Visceral and somatic nociception and mechanoreception

A beta Adelta and C

73
Q

Table 47-5

A

Gprotein» Phospholipase C—PIP2= DAG( Proteine kinase C) and IP3 ( release of ca++)»Phopholipase A2&raquo_space; changes phosphatidylcholine PC to arachidonic acid (AA)= Cox: PG, PCC, Thromboxanes and lipoxygenase= leukotrienes

74
Q

Complications Mandibular nerve and its branches block

A

Intravascular injection, Subrachnoid injection and Horner’s syndrome and motor block of muscles of mastication .

75
Q

3 mechanisms

A

Wind-up and sensitization of second order neuron
Receptor field expansion
Hyper-excitability

76
Q

Stimulation of the peri aqueducts gray mater (PAG) provides

A 
Widespread analgesia in humans .
Receptors 
1)Serotogenic
2)Opioid: Mu, Delta , Kappa
3)
77
Q

Acute Pain , what type of stress response

A

Neuroendocrine stress response that is proportional to pain intensity .

78
Q

Moderate to Severe acute role in Morbidity and Mortality

A

Regardless of site of the acute pain, can affect the function of nearly every organ and may adversely affect perioperative M&M.

79
Q

CV effects of acute pain

A

A)HTN, Tachycardia , enhanced myocardial irritability and increased SVR.
B)CO increase in normal patient but decreased in pt with poor ventricular function.
C) Beacause of increased O2 demand can precipitate or worsen MI.

80
Q

respiratory effects of Acute Pain

A

1) Increase O2 consumption + CO2 production = body increases the minute ventilation
2) Increased min. Vent. = Increased WOB esp in patient in underlying lung dx \
3) Guarding/ splinting = decreased pul. Fx
4) decreased chest wall movement = decreased Tidal Vol. & FRC =actelectasis, intrapulmonary shunting= hypoxemia , less commonly hypoventilation **
5) reduced Vital capacity = can’t cough & clear secretions

81
Q

GI and GU effects

A

N/V/C are common
Increased sphincter tone & decreased urinary/ intestinal mobility = ileus and urinary retention
Worsening of pulmonary aspiration & stress ulceration bc hyper secretion of Gastric acid

82
Q

Endocrine effects

A

Stress increased catabolic hormones : catecholamines, glucagon, cortisol
Decreases anabolic hormones: Insulin, Testosterone
Development neg nitrogen balance, carbohydrate intolerable, increased lipolysis

83
Q

Entrapment syndrome

A

Neural compression wherever a nerve comes through an anatomically narrowed passage. Can involve sensory, motor, or mixed .

84
Q

Diagnosis of entrapment syndrome

A

Confirmed by electromyography and nerve conduction studies
Treatment with analgesic and temporary immobilization
For complex regional pain = sympathetic block
Refractory symptoms = surgical decompression

85
Q

Myofascial Pain

A

Aching muscle pain, spasm, weakness, stiffness, occasionally autonomic dysfunction . Due to repetitive microtrauma
Develop discrete trigger points in one or more muscles of connective tissue
Tight roppy bands overlying the muscle .
Autonomic dysfunction causes vasoconstriction and pyloerection
Radiates in a FIXED pattern, that does not follow dermatomes

86
Q

Diagnosis of Myofasical pain

A

By palpating trigger points . Common areas are : 1) level or scapulae 2) Masseter
3) Quadratus Lumborum 4) gluteus medius muscle .

87
Q

Treatment of Myofascial Pain

A

They resolve spontaneously, but may have latent trigger points
Trigger point injections LA : 1- 3 ml
Massage .stretch therapy
Topical spray : Fluocarbone and ethyl Chloride
Ultrasound S therapy

88
Q

Fibromyalgia diagnosis is by

A

Rule out

89
Q

3 criteria that suggests Fibromyalgia

A

1) Widespread Pain index of 7 or >; or SS scale of 5 or > ; or SS scale 3-6 + WPI 9 or >
2) Symptoms Present at similar levels for at least 3 months
3) absence of another disorder that would otherwise explain it

90
Q

Treatment for Fibromyalgia

A

Cardiac conditioning

Pregabalin ( Lyrica) , duloxetine (Cymblata ) , Milnacipran (Savella).

91
Q

Contraindication to NSRI Serotonin and NE reuptake inhibitor

A

Relative and abosolute contraindications:

1) hypersensitivity
2) other CNS drugs : MOAI,
3) hepatic and Kidney impairment
4) uncontrolled narrow angle glaucoma
5) suicidal ideation

92
Q

Spinal Stenosis

A

Pain radiates to the 1)butt 2)thighs and 3)legs

93
Q

Spinal Stenosis

A

Advanced Age
Degeneration of Nucleus Polposus = reduce disc height
Osteophyte formation at end plates of the adjoining vertebral bodies .
Exercise makes it worse
Relived by rest .

94
Q

Facet Syndrome Radiates where ?

A

Pain may be near midline or may Radiates to 1) Gluteal 2) Thigh 3) Knee 4) associated with muscle spasm .
Is dermatome *

95
Q

Facet syndrome is

A

Degenerative changes in the facet joints produce back pain .

96
Q

What exacerbates Facet Syndrome

A

Hyper extension and lateral rotation of the spine

97
Q

Spondylolisthesis

A

Anterior displacement of one vertebra body on the next due to disruption of the posterior element .

98
Q

Spondylosis

A

Dirsrupstion of pars interarticularis

99
Q

Acetaminophen ( Paracetamol )

A

Antipyretic , analgesic
Inhibits prostaglandins
3000mg/day limit
Lacks anti inflammatory

100
Q

What meds potentiate Acetaminophen toxicity

A

Barbiturates
Isoniazid
Zidovudine

101
Q

Complication of neuraxial anesthesia

A 
Urinary retention
Cardiac arrest 
High Spinal 
Total Spinal 
Anterior Spinal artery syndrome 
Horner’s Syndrome
102
Q

Who gets TNS most?

A

Male , Outpatient and Lithotomy
Occurs after resolution of spinal anesthesia
Hyperbaric Lidocaine . 5%

103
Q

TNS pain

A

Resolves spontaneously after several days
Pain that radiates to the legs with NO motor or sensory deficit
LA concentration dependent

104
Q

Cauda Equina Syndrome

A

Bowel and Bladder dysfunction with multiple nerve root injury
Lower Upper

105
Q

Complications related to needle/catheter placement

A 
Inflammation Archoiditis 
PDPH or Dural puncture : 
Bleeding : Epidural/intraspinal hematoma 
Catheter sheering/retention 
Backache 
Infection : Meningits, Epidural abcess 
Misplacement of needle: inadequate anesthesia, unintended subdural block, intravascular injection 
Neural Injury : cauda equina ,
106
Q

Drug toxicity

A

LA systemic toxicity
TNS
Cauda Equina Syndrfom

107
Q

What is High Neural Block

A

Exaggerated Dermatomal spread of neural blockade

108
Q

What causes High neural Block

A

Excessive dose
Failure to reduce the dose
Sensitivity or spread of LA

109
Q

S&S of High neural Block

A

Dyspnea
Upper Exytremity weakness
Nause Hypotension
Bradycardia

110
Q

Transduction

A

Noxious thermal, chemical , mechanical are converted into action potential

111
Q

Somatic Pain

A

Type of acute pain classified as superficial or deep .
Superficial Somotic : Nociceptive input from Skin, SubQ, Mucous Membranes, Sharp Throbbing , Burning .
Deep Somatic Pain : arising from muscle, joints, tendons,

112
Q

Tranmission

A

Action Potential is conducted through the nervous system via the 1st,2nd, and third order neuron

113
Q

Radiculopathy

A

Functional abnormality of 1 or more nerve roots

114
Q

First order neuron

A

Synapse on Second order neuron in the dorsal horn at Lamina I, II, and V where they release excitatory amino acids and neuropeptides

115
Q

Second order neurons

A

Synapse with third order neurons in the thalamus and sends projections to the internal capsule and the corona radiata . To the post central gyrus of the cerebral cortex.
Can be Nociceptive specific or Wide range Neurons

116
Q

Nociceptive specific serves only

A

Noxious stimuli

Neurons are in Lamina 1

117
Q

WDR are found in

A 
Lamina 4, 5, and 6 
Receive noxious and non-noxious afferent input 
Input from A-beta, A-Delta, C fiber 
Most abundant in lamina V 
Found throughout the dorsal horn
118
Q

Hyperpathia

A

Presence of Hyperalgesia, allydonia and parathesia associated with overreaction, persistence on the sensation after the stimulus .

119
Q

Anesthesia

A

Absence of all pain sensation

120
Q

Analgesia

A

Presence of pain perception

121
Q

Lateral Spinothalamic Tract aka Neospinothalamic tract

A

Ventral posterolateral nucleus of thalamus

122
Q

Neospinothalamic tract also called

A

Lateral Spinothalamic tract , carries to ventral posterolateral of the thalamic nucleus .
Carries discriminative aspect of pain : Location, Intensity & Duration

123
Q

Medial Spinothalamic tract also called

A

Paleo Spinothalamic tract projects to the medial thalamus

Mediated the autonomic and unpleasant perception of pain

124
Q

Modulation occurs

A

Peripherally at the Nociceptor, in the spinal cord , and supraspinal structures
Can either inhibit or intensify

125
Q

Trigemmenal Nerve Block Principle Indications

A

Trigemminal neuralgia

Intractable facial cancer pain

126
Q

Ophtalmic nerve Block

A

Avoid denervation related- keratitis , only the supraorbital branch is blocked . Ophthalmic division itself itself is not blocked
Put LA at supraorbital notch , which is located at supraorbital ridge above the pupil

127
Q

Supratrochlear branch can also be blocked

A

With LA at the superior Medial corner of the orbital ridge .

128
Q

Maxillary nerve and its branches

A

Needle is inserted between the zygomatic arch and the notch of the mandible.
Both maxillary and sphenopalatine (ptegolatine) ganglia are usually anesthetized
Potential for hemorrhage is serious !!!!

129
Q

Mandibular nerve Block

A

Mouth slightly open :8-10 cm 22 g needle between the zygomatic arch and the Mandibular notch. Contact the pterygoid plate , partially withdraw and angle sup and post toward the ear .

130
Q

Mandibular block complications

A

1) accidental IV injection
2) Subarchnoid injection
3) Horner’s syndrome
4) Motor Block of muscles of mastication
* **Facial nerves may unintentionally be blocked during block of Mandibular

131
Q

Facial nerve block indication and complications

A

1) relief spastic contraction of facial muscles
2) Herpes Zoster if facial nerve
Anterior of mastoid process , beneath the external meatus, midpoint of the Mandibular ramus.
Put LA just below the stylomastoid process
COmplications : needle past styloid bone = too deeply= may black glossopharyngeal and vagal nerves
Aspirated bc : 1) facial nerve 2) Carotid artery 3) internal Jugular

132
Q

Complication of Glossopharyngeal

A

Pain due to cancer of the base tongue, epiglottis , or palatine tonsils.

133
Q

Complication of Glossopharyngeal Block

A

Dysphasia and vagal blockade resulting in ipsilateral vocal cord paralysis and tachycardia.
Block of the accessory nerve and hypoglossal nerves causes ipsilateral paralysis of the trapezius muscle and the tongue
Careful aspiration is necessary to prevent intravascular injection

Regional (4 decks)

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