Pain study guide (highlighted) Flashcards
Epicritic sensations are what kind of sensations?
light touch, pressure, proprioception and temperature discrimination
Epicritic sensations are characterized by?
conducted by?
characterized by low threshold receptors and are generally conducted by large myelinated nerve fibers
Protopathic sensations (pain) are detected by what kind of receptors? conducted by what type of nerve fibers?
detected by high-threshold receptors and conducted by smaller, myelinated a-delta and unmyelinated C nerve fibers.
Nociception’s do they all produce pain?
Yes, all nociception produces pain, but not all pain results from nociception.
Describe Chronic pain?
Chronic pain is pain that persists beyond the usual course of an acute disease or after a reasonable time for healing to occur. This healing can vary from 1 to 6 months. Chronic pain may be nociceptive, neuropathic or mixed. A distinguishing factor of chronic pain is that psychological mechanisms or environmental factors frequently play a major role.
2nd order neurons:
The spinothalamic tract?
Classically considered the major pain pathway. It lies anterolaterally in the white matter of the spinal cord. It is an ascending tract
Spino-mesencephalic tract?
may be important in activating anti-nociceptive, descending pathways because it has some projections to the peri-aqueductal gray
Third order neurons?
Located in the thalamus & send fibers to somatosensory areas I & II in the postcentral gyrus of the parietal cortex & the superior wall of the sylvian fissure, respectively.
What is unique about the cornea and tooth pulp?
they are almost exclusively innervated by nociceptive Aẟ & C fibers.
generally insensitive tissues that mostly contain silent nociceptors.
Visceral organs
Most other organs such as the intestines are innervated by what kind of nociceptors?
polymodal
polymodal nociceptors respond to what kind of pain stimulation? (think intestines)
smooth muscle spasm, ischemia, and inflammation
polymodal nociceptors such as in the intestines, these receptors generally do not respond to what kind of stimulation?
cutting, burning, or crushing that occurs during surgery.
The brain lacks nociceptors totally, however what covering of the brain does contain nociceptors?
meningeal covering
somatic nociceptors and visceral nociceptors both are free nerve endings of primary afferent neurons whose cell bodies lie in the?
dorsal horn
Main excitatory NT is?
Glutamate
exaggerated response to pain at the site of injury would be described as?
Primary hyperalgesia
Describe 2ndary hyperlgesia?
increased pain response evoked by stimuli outside the area of injury.
s/s of secondary hyperlgesia?
red flushing, local tissue edema, and sensitization to noxious stimuli. Does not have skin denervation.
Acute pain is typically associated with?
neuroendocrine stress response that is proportional to
pain intensity.
CV effects of acute pain would be?
Cardiovascular effects are often prominent and include hypertension, tachycardia, enhanced myocardial irritability, and increased systemic vascular resistance.
Cardiac output increases in most normal patients but may decrease in patients with compromised ventricular function. Because of the increase in myocardial oxygen demand, pain can worsen or precipitate myocardial ischemia.
Does acute pain increase or decrease total body oxygen consumption and carbon dioxide production?
increases both, leading to an increase in min. ventilation.
If you have acute pain and an abdominal or throacic incision what typically occurs?
compramised pulmonary function do to guarding or splinting of the are (less deep breaths are going to take place)
decreased movement of the chest wall due to acute pain in this area will lead to?
reduced tidal volume and FRC, promoting atelectasis, intrapulmonary shunting, hypoxemia, and, less commonly, hypoventilation.
increased work of breathing due to acute pain is common in patients who have?
underlying lung disease
reductions in vital capacity due to acute pain leads to?
impaired coughing and clearing of secretions.
endocrine effects of acute pain?
Stress increases catabolic hormones (catecholamines, cortisol, and glucagon) and decrease anabolic hormones (insulin and testosterone).
Hematological effects of acute pain?
Stress mediated increases in platelet adhesiveness, reduced fibrinolysis, and hypercoagulability have been reported
What is the Wong-baker FACES scale?
Designed for children >3yr, useful for those populations who have difficulty communicating
Various faces on the graph (smiling = no pain; to extremely unhappy = worst possible pain) describe the pain
What is entrapment syndrome?
syndromes caused by neural compression wherever a nerve comes through an ANATOMICALLY NARROWED PASSAGE, and can involve sensory, motor, or mixed nerves
How do you diagnose entrapment syndrome?
confirmed by electromyography and nerve conduction studies
Describe Myofacial pain?
Syndromes characterized by aching muscle pain, spasms, stiffness, weakness, and occasionally autonomic dysfunction. Patients develop discrete “TRIGGER POINTS” of tenderness in one or more muscles or connective tissues.
How is a diagnosis of fibromyalgia made?
diagnosis is by rule out!
There are “3” criteria that suggest the diagnosis of fibromyalgia, what are they?
High pain score
Symptoms present for at least 3 months
Absence of another disorder that would otherwise explain the pain
what drugs are approved for the treatment of fibromyalgia? (3)
pregabalin (Lyrica)
duloxetine (Cymbalta)
milnacipran (Savella)
what medications should NOT be used for fibromyalgia?
The internet states Glucocorticosteroids such as prednisone and cortisone are contraindicated.
90% of disc herniations occur at what two levels?
L5-S1 of L4-L5.
describe spinal stenosis?
Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in onset and improve with bending forwards.
What is Spondylolisthesis
spinal condition that affects the lower vertebrae (spinal bones). This disease causes one of the lower vertebrae to slip forward onto the bone directly beneath it. It’s a painful condition but treatable in most cases
Spondyloptosis is?
term to denote grade V spondylolisthesis - a vertebra having slipped so far with respect to the vertebra below that the two endplates are no longer congruent. It is usually anterolisthesis of L5 on S1 but can be seen elsewhere - rarely
Ankylosing spondylitis is?
(a form of arthritis) is a familial disorder associated with histocompatibility antigen HLA-B27.
- Presents as low back pain with early morning stiffness in YOUNG patient, usually MALE
- Pain has gradual onset, and may improve with activity
- After few months to years, the pain intensifies and is associated with progressively restricted movement of the spine.
diagnosis of ankylosing sondylitis, what do you see on xray?
bamboo-like spine
MOST common syndrome seen with diabetic neuropathy?
peripheral polyneuropathy= symmetric numbness (“stocking and glove” distribution), paresthesia, dysesthesias, and pain
How is a tension headache described?
• Described as tight bandlike pain or discomfort that is often associated with tightness in the neck muscles
Is a tension headache typically unilateral or bilateral?
More often bilateral
Describe a cluster headache? Where do they occur in the head? how often do they occur in what time period? what is the pain like? how long do they last?
classically unilateral and periorbital
occurring in clusters of one to three attacks a day over a 4- to 8-week period.
The pain is described as a burning or drilling sensation that may awaken the patient from sleep. Episodes lasts 30–120 min.
what kind of block can help cluster headaches?
sphenopalatine block
Trigeminal neuralgia is also known as what?
TIC DOULOREUX
Tell me about Acetaminophen?
an oral analgesic and antipyretic agent. IV prep (Ofirmev) for inpatient use.
It inhibits prostaglandin synthesis but lacks significant anti-inflammatory activity. Acetaminophen has few side effects but is hepatotoxic at high doses
What two drugs fall under the category of Serotonin and NE re-uptake inhibitors (SNRIs)?
Milnacipran
Duloxetine (Cymbalta)
What two drugs fall under the category of Serotonin and NE re-uptake inhibitors (SNRIs)?
Milnacipran
Duloxetine (Cymbalta)
(both used for fibromyalgia)
Absolute and relative contraindications for the use of SNRIs would include?
known hypersensitivity, usage of other drugs that act on the central nervous system (including monoamine oxidase inhibitors), hepatic and renal impairment, uncontrolled narrow-angle glaucoma, and suicidal ideation.
Commonly used neuroleptics for fefractory neuropathic pain?
fluphenazine, haloperidol, chlorpromazine, and perphenazine
Theraputic action of neuroleptic meds?
therapeutic action appears to be due to blockade of dopaminergic receptors in mesolimbic sites.
Neuroleptics exert blockade in nigrostriatal pathways (as well as mesolimbic sites) which blocks dopaminergic receptors (MOA) BUT this can produce undesirable side effects, what would those be?
can produce undesirable extrapyramidal side effects, such as mask-like facies, a festinating gait, cogwheel rigidity, and bradykinesia
Neuroleptics exert blockade in nigrostriatal pathways (as well as mesolimbic sites) which blocks dopaminergic receptors (MOA) BUT this can produce undesirable side effects, what would those be?
can produce undesirable extrapyramidal side effects, such as mask-like facies, a festinating gait, cogwheel rigidity, and bradykinesia.
Some patients also develop acute dystonic reactions such as oculogyric crisis and torticollis.
Long term side effects with the use of neuroleptics (used for refractory neuropathic pain)?
Long-term side effects include akathisia (extreme restlessness) and tardive dyskinesia (involuntary choreoathetoid movements of the tongue, lip smacking, and truncal instability.
Tizanidine (Zanaflex) what kind of med is it, and what is it used for?
centrally acting α 2 -adrenergic agonist used in the treatment of muscle spasm in conditions such as multiple sclerosis, low back pain, and spastic diplegia.
Flexeril/cycloenzaprine is an atispasmodic, what is it’s MOA?
MOA is unknown
Baclofen what kind of drug is it and what is it used for?
GABA-b agonist
particularly effective in the treatment of muscle spasm associated with multiple sclerosis or spinal cord injury when administered by continuous intrathecal drug infusion.
Baclofen discontinuation?
Abrupt discontinuation of this medication has been associated with fever, altered mental status, pronounced muscle spasticity or rigidity, rhabdomyolysis, and death.
Glucocortioids are they helpful in pain management?
extensively used in pain management for their antiinflammatory and possibly analgesic actions.
Excessive use of glucocortioids can cause?
Excess glucocorticoid activity can produce hypertension, hyperglycemia, increased susceptibility to infection, peptic ulcers, osteoporosis, aseptic necrosis of the femoral head, proximal myopathy, cataracts, and, rarely, psychosis
patients with diabetes who use glucocorticoids may have what (even after one dose)?
elevated blood glucose
what syndrome can you develop with excessive glucocorticoids use?
Cushing’s syndrome
excessive mineralocorticoid activity can do what to your electrolytes?
cause sodium retention and hypokalemia, and can precipitate CHF
Why is dexamethasone becoming the preferred cortcosteroid for injection procedures and where are these procedures on the body?
relatively small size of its suspension particles.
it is preferred in relatively vascular ares such as the head and neck region.
describe acute pain?
caused by noxious stimulation due to injury, a disease process or abnormal function of a muscle or viscera. It is usually nociceptive, which serves to detect, local and limit tissue damage.
describe visceral acute pain?
due to disease process or abnormal function involving an internal organ or its covering (parietal pleura, pericardium, or peritoneum)
when pain fails to resolve because of either abnormal healing or inadequate treatment it becomes?
chronic pain
• majority of neurons send the proximal end of their axons into the spinal cord via the dorsal (sensory) spinal root at each cervical, thoracic, lumbar, and sacral level. What order neuron is this?
first order neuron
Some unmyelinated afferent C-fibers have been shown to enter the spinal cord via ventral nerve (motor) root, revealing why some continue to feel pain after transection of dorsal nerve root (rhizotomy) and report ventral root stimulation pain. what order neuron does this describe?
first order neurons
What type of pain can affect the function of nearly every organ and may adversely affect perioperative morbidity and mortality?
acute pain
Complication of a mandibular nerve block?
Accidental intravascular injection, subarachnoid injection, Horner’s syndrome.
what kind of nerve block might you use for a patient who has pain due to cancer?
glossopharyngeal nerve block
What nerve block might you use for a patient (to treat or diagnose) with occipital headaches?
Occipital nerve block
what never block is used for painful conditions arising from the shoulder (most commonly arthritis and bursitis)?
suprascapular nerve block
What block can be used to interrupt sympathetic innervation of an extremity?
Bier block
describe transduction?
The event whereby noxious thermal, chemical, or mechanical stimuli are converted into action potential.
most abundant in lamina V describes what order neurons?
2nd order neurons
describe superficial somatic pain?
due to nociceptive input arising from skin,subcutaneous tissues and mucous membranes. Well localized and described as a sharp, pricking, throbbing or burning sensation
Describe deep somatic pain?
arises from muscles, tendons, joints or bones. Dull aching quality and is less well localized
Radiculopathy?
Functional abnormality of one or more nerve roots
Nociceptive pain?
Caused by activation or sensitization of peripheral nociceptors (specialized receptors that transduce noxious stimuli)
The final common pathway, which results from the integration of painful input into the somatosensory and limbic cortices. Describes what?
perception
Parethesia is described as?
Abnormal sensation perceived without an apparent stimulus
Pain in the distribution of a nerve or a group of nerves -
Sciatic, neuropathy, diabetes, chicken pox (shingles in adults) describes what?
neuralgia
What is hyperalgesia?
INCREASED RESPONSE TO NOXIOUS STIMULATION
Tell me the difference between analgesia and anesthesia?
analgesia is the absence of pain PERCEPTION.
anesthesia is the absence of ALL PAIN SENSATION
what is allodynia?
Perception of an ordinarily non-noxious stimulus as pain
-Something that causes pain that wouldn’t normally cause pain!
A-delta and C fibers are examples of what order neuron?
first order neurons
Most common forms of acute pain include?
post-traumatic, postoperative, and
obstetric pain as well as pain associated with acute medical illness, such as MI,
pancreatitis, and renal calculi
Pain involving what areas is frequently referred to the neck and shoulder?
referred visceral pain of the peritoneum or pleura over the central diaphragm
what is Hyperpathia?
Presence of hyperesthesia, allodynia, and hyperalgesia usually associated with overreaction, and persistence of the sensation after the stimulus
what is described: Projects mainly to the ventral posterolateral
nucleus of the thalamus and carries discriminative aspects of pain, such as location, intensity, and duration.
Lateral spinothalamic tract
What is described:
Projects to the medial thalamus and is
responsible for mediating the autonomic and unpleasant emotional perceptions of pain.
Medial spinothalamic tract
Pain fibers originating from the head are carried by what nerves?
Trigeminal V
Facial VII
Glossopharyngeal IX
Vagus X
Pain fibers can ascend or descend how many spinal cords segments?
What tract are they in when ascending and descending?
what occurs after the ascending and descending?
Pain fibers may ascend or descent 1-3 spinal cord segments in Lissauer’s tract before
synapsing with second-order neurons in gray matter of the ipsilateral dorsal horn.
This tract carries discriminative
aspects of pain, such as location, intensity, and duration?
Lateral spinothalamic (neospinothalamic) tract
This tract is responsible for mediating the autonomic and
unpleasant emotional perceptions of pain?
Medial spinothalamic (paleothalmic) tract
which nociceptors only respond to inflammation?
silent nociceptors
which nociceptors respond to pinch and pinprick?
mechanociceptors
Histamine is released from? (3)
mast cells
basophils
platelets
serotonin is released from? (2)
mast cells
platelets
What is the triple response of Lewis?
part of secondary hyperalgesia
red flush around the site of injury (flare)
local tissue edema
sensitization to noxious stimuli
what causes the “triple response of lewis”?
antidromic release of substance P
The neural origin of the “triple response of Lewis” is supported by what three findings?
i. It can be produced by electrical stimulation of a sensory nerve
ii. It is not observed in denervated skin
iii. It is diminished by injection of a local anesthetic
what does GABA and glycine do to pain?
function as inhibitor of pain directly to the spinal cord.
Do patients with chronic pain have the neuroendocrine stress response to pain?
it is attenuated or absent in most patients with chronic pain (unlike those with acute pain)
What type of pain is associated with systemic neuroendocrine stress response?
acute pain
Pain located at proximal forearm and palmar surface of the first three digits (pronator syndrome), what muscle?
pronator teres muscle
what weight do intervertebral discs bear?
at least 1/3 of the weight of the spinal column
DDD most commonly affects what section of the spine and why?
lumbar spine because it is subjected to the greatest motion and bc the posterior longitudinal ligament is thinnest at L2-L5
what procedure may provide long-term analgesia for patients with facet joint disease?
Medial branch rhizotomy
is spinal stenosis a disease of younger populations or advancing age?
advancing age
What exactly is spinal stenosis?
Degeneration of the nucleus pulposus reduces disc height and leads to osteophyte formation (spondylosis) at the endplates of adjoining vertebral bodies
treatment for tension headache?
NSAIDS, tylenol, caffeine
