SANS Pain Flashcards
Seorang wanita berusia 24 tahun mengeluh adanya rasa nyeri seperti terbakar pada bagian distal tungkai dan kaki kanan. Hasil pemeriksaan fisik didapatkan bengkak kemerahan pada kaki kanan dengan warna kepucatan yang persisten setalah palpasi. manakah diagnosis dibawah ini yang benar?
A. Sindrom nyeri regional kompleks
B. Radikulopati lumbal kronis
C. Fenomena Raynaud
D. Sindrom tarsal tunnel
E. Skleroderma
A. Sindrom nyeri regional kompleks
These are all cardinal signs of complex regional pain syndrome (CRPS), previously known as reflex sympathetic dystrophy or RSD. This patient’s right foot (and distal leg) are somewhat swollen and red, when compared to the left side. In addition, the examiner’s hand leaves a blanched imprint on the dorsum of the foot. Lastly, the nails on the affected foot are also somewhat dystrophic. The examiner should also look for changes in hair growth on the toes of the affected foot, also commonly seen in CRPS. Chronic lumbar radicuopathy may present with neuropathic pain which is difficult to distinguish from RSD, but the changes in limb color and temperature would be difficult to reconcile with radiculopathy. Moreover, the trophic nail changes are not typical for radiculopathy. Connective tissue disorders such as scleroderma and Raynaud’s phenomenon may present with color changes, trophic nail/skin changes as well as temperature changes, but these disorders are not typically accompanied by the neuropathic-type pain seen in CRPS. Lastly, neural compression syndromes such as tarsal tunnel syndrome, need to be excluded in patients presenting with distal limb pain; these pain syndromes are typically much more focal in the distribution of the affected nerve and are not usually accompanied by the plethora of skin and nail changes seen in CRPS.
Seorang pria berusia 37 tahun dengan nyeri hebat pada tangan kirinya yang didahului dengan kecelakaan motor dimana pasien mengalami avulsi pleksus brachialis traumatis. Setelah dua tahun lewat, pasien masih memiliki yang disebut “flail arm” dengan tidak adanya bukti fungsi kembali normal. Terapi medikamentosa telah dinyatakan gagal menyembuhkan gejalanya. Manakah dibawah ini yang menjadi terapi terbaik untuk nyeri pada pasien :
A. Membuat lesi pada zona radiks dorsalis
B. Neurotisasi dari segmen denervasi saraf
C. Neurotomi pada segmen yang terkena
D. Pemasangan implan yang menstimulasi sumsum tulang belakang (Spinal cord stimulator)
E. Pemasangan implan yang memompa morfine (morphine pump)
A. membuat lesi pada zona radiks dorsalis
Dorsal root entry zone lesion successfully treats brachial plexus avulsion pain in 50-70% of cases in the long term. It is one of the few ablative procedures with long-term benefit in nonmalignant pain. It should be reserved for patients who do not have any evidence of recovery of function over the long term. Neurotization procedures are unlikely to add any benefit at this late stage. In addition, they would not treat the patient’s pain and are reserved for restoration of useful function. Similarly, neurotization surgery does not address the source of the pain which appears to be in the dorsal root entry zone. Intrathecal morphine does not offer any benefit, as pain of this type tends to be unresponsive to opiates. Electrical stimulation is also unlikely to work, as it requires integrity of the nervous system in order to facilitate conduction of the electrical impulses.
Seorang wanita berusia 45 tahun dirujuk dengan keluhan kelumpuhan mendadak, nyeri ditusuk-tusuk pada bagian dasar lidah dan regio tonsil pada bagian kiri. Nyeri dapat hilang dengan pengolesan kokain pada pilar-pilar tonsil. Hasil pemeriksaan neurologis dalam batas normal. CT scan pada otak dan dasar tengkorak serta MRI dari otak dalam batas normal. Nyeri pada pasien paling mungkin disebabkan oleh?
A. Neuralgia glossofaringeal
B. Sindrom Eagle
C. Neuralgia trigeminal
D. Meningioma pada sudut CPA
E. Neuralgia genikulatum
A. neuralgia glossofaringeal
Except for the location, glossopharyngeal neuralgia (GN) is similar to trigeminal neuralgia in that the typical pain is severe, intermittent, and lancinating. In some patients the pain may radiate to the ear and be confused with geniculate neuralgia. GN is far less common than trigeminal neuralgia and is most often idiopathic in nature. Similar to trigeminal neuralgia, it has been suggested that the primary cause of GN is vascular compression in the region of the root entry zone. The posterior inferior cerebellar artery is the most commonly implicated vessel. Glossopharyngeal neuralgia is less commonly related to secondary causes. Eagle’s syndrome is a condition where an elongated styoid process produces extracranial compression of the 9th nerve. Tumors may also cause secondary GN. When trigeminal neuralgia is related to tumor in the CP angle, it is most likely a benign lesion such as a meningioma or schwannoma. However, when GN is related to a tumor in the region of the jugular foramen, the lesion is more likely to be malignant.
Division of the glossopharyngeal nerve and the upper 1/3 of the vagus nerve is a highly effective treatment for glossopharyngeal neuralgia. Careful testing may reveal diminished sensation over the pharynx, reduction of the gag reflex on the affected side, and absence of taste on the posterior third of the tongue; there is rarely any significant long-lasting clinical effect on swallow. Alternatively, patients with glossopharyngeal neuralgia may be treated with microvascular decompression in the event there is obvious evidence of vascular compression. Percutaneous RF lesioning of the nerve in the jugular foramen has been described but is associated with a high risk of injury to the vagus nerve. Similar problems are associated with extracranial sectioning of the nerve due to the proximity of the tenth nerve and the jugular bulb. Caudalis DREZ might be considered as a last resort in persons who remain with intractable pain following intradural rhizotomy, but this would not be considered a primary surgical therapy.
Seorang wanita berusia 45 tahun dirujuk dengan keluhan kelumpuhan mendadak, nyeri ditusuk-tusuk pada bagian dalam saluran telinga kiri. Hasil pemeriksaan neurologis dalam batas normal. CT scan pada otak dan dasar tengkorak serta MRI dari otak dalam batas normal. Pengobatan medikamentosa telah gagal pada kondisi pasien. Manakah dibawh ini yang merupakan pilihan operasi terbaik untuk pasien?
A. Ablasi Nucleus caudalis DREZ
B. Pelepasan prosessus styloidal
C. Rhizotomi intradural pada bagian saraf kranialis 9 dan 1/3 bagian saraf kranialis 10
D. Dekompresi mikrovaskuler dari nervus trigeminus
E. Intradural section pada nervus intermedius
E. Intradural section pada nervus intermedius
This patient had geniculate (nervus intermedius) neuralgia, and the operation should target the nervus intermedius itself. Nervus intermedius is a small sensory branch of the facial nerve, and surgical treatments for geniculate neuralgia usually involve either microvascular decompression of this nerve, or intradural sectioning of this rootlet.
Division of the glossopharyngeal nerve and the upper 1/3 of the vagus nerve is a highly effective treatment for glossopharyngeal neuralgia. Careful testing may reveal diminished sensation over the pharynx, reduction of the gag reflex on the affected side, and absence of taste on the posterior third of the tongue; there is rarely any significant long-lasting clinical effect on swallowing. Alternatively, patients with glossopharyngeal neuralgia or trigeminal neuralgia may be treated with microvascular decompression of the affected nerve in the event there is obvious evidence of vascular compression. The treatment of Eagle Syndrome consists of removal of the elongated styloid process that is compressing the extracranial portion of the glossopharyngeal nerve. Nucleus caudalis DREZ might be considered as a last resort in persons who remain with intractable pain following less invasive treatments, but this would not be considered a primary surgical therapy.
Seorang pria 48 tahun yang telah menjalani lima kali operasi pada saraf lumbal setelah cedera yang berhubungan dengan pekerjaan, datang ke klinik anda mengeluh adanya nyeri punggung belakang yang hebat. Dalam kesehariannya, pasien mengonsumsi Morfin 300 mg/hari dan memakai duragesic patch. Pasien menyebutkan obat tersebut kurang adekuat untuk meredakan nyeri dan selama lima tahun terakhir, kebutuhannya akan obat meningkat drastis. Manakah dibawah ini yang dapat mendeskripsikan keadaan pasien :
A. Addiksi Narkotika
B. Toleransi narkotika
C. Ketergantungan narkotika
D. Malingering
B. Toleransi narkotika
Chronic use of oral opioids is almost always associated with tolerance. In some cases, the tolerance may be therapy-limiting. However, addiction– or chemical dependence – is defined as psychological dependence, and should be differentiated from tolerance. Unlike patients exhibiting tolerance to opioids, chemically-dependent patients typically seek multiple medications from multiple prescribers, and often fail to maintain stable relationships with their physicians. Intrathecal narcotic therapy does not obviate tolerance and certainly does not prevent addiction.
Seorang wanita berusia 55 tahun yang secara medis mengalami nyeri tenggorokan dan telinga yang hebat dan berat serta refrakter, dipicu dengan memakan makanan padat. Pilihan tindakan operasi yang tepat adalah dengan dekompresi dari bagian ;
A. Nervus glossofaringeal
B. Nervus intermedius
C. Nervus trigeminus
D. Bagian bawah nervus vagus
E. Nervus hipoglossus
A. Nervus glossofaringeal
Glossopharyngeal neuralgia (GN) is severe, intermittent, lancinating pain that causes sharp, stabbing pulses of pain in the back of the throat and tongue, the tonsils, and the middle ear. GN is far less common than trigeminal neuralgia and is most often idiopathic in nature. In some cases GN can be caused by vascular compression in the region of the root entry zone. The posterior inferior cerebellar artery is the most commonly implicated vessel. Tumors of the region of the jugular foramen may also cause secondary GN.
Division of the glossopharyngeal nerve and the upper 1/3 of the vagus nerve is a highly effective treatment for glossopharyngeal neuralgia. Post-operative testing may reveal diminished sensation over the pharynx, reduction of the gag reflex on the affected side, and absence of taste on the posterior third of the tongue, however there is rarely any significant long-lasting clinical effect on swallow. Alternatively, patients with glossopharyngeal neuralgia may be treated with microvascular decompression if is obvious evidence of vascular compression. Caudalis DREZ might be considered as a last resort in persons who remain with intractable pain following intradural rhizotomy.
Pasien dengan nyeri ekstremitas bawah telah berhasil diterapi selama 6 bulan dengan pemberian morfin 35 mg/hari melalui “Intrathecal pump”. Sekarang pasien datang dengan peningkatan intensitas nyeri ekstremitas bawah dan baal. Hasil pemeriksaan fisik didapatkan hiperrefleksia baru pada ekstremitas bawah. Apakah yang paling mungkin menjelaskan penyebab gejala terbaru pasien :
A. Pump overinfusion
B. Patahnya kateter intrathecal
C. Ketergantungan morfin
D. Morfin induced myelotoxicity
E. Catheter-tip granuloma
E. Catheter-tip granuloma
Catheter-tip granuloma formation is an unusual, but potentially catastrophic complication of chronic, intrathecal opiate administration. The growth of these sterile, inflammatory masses at the tip of the catheter is thought to be related to local chemical irritation from high dose, high concentration opiates (FIGURE). These masses have been reported mostly with intrathecal morphine, but there have been occasional reports of their formation with other opiates as well. Single case reports of granulomas in the setting of baclofen therapy have also been published, but it is not clear that these cases are similar in pathophysiology to those masses forming with opiate therapy. Symptoms of catheter-tip granuloma typically consist of increased pain and the onset of new neurological deficits. The appearance of upper motor neuron signs should alert the clinician of a progressive myelopathy, and the possibility of a catheter-tip granuloma as its cause.
A fractured catheter or pump overinfusion typically manifest with withdrawal symptoms or sedation, respectively. Note that the specific onset of hyper-reflexia in this case precludes the possibility that the increased pain is simply due to a fractured catheter. Finally, while myelotoxicity may manifest with increased pain, neurological deficit and upper motor neuron signs, this is an extremely rare event, and is usually seen only in cases in which non-commercial preparations of morphine are contaminated with neurotoxic byproducts.
Pada diagram dibawah ini, angka berapakah yang menunjukkan target pada tindakan cordotomy?
A. 3
B. 2
C. 1
D. 4
E. 5
D. 4
Cordotomy consists of surgical interruption of the anterolateral spinothalamic tract (4). Knowledge of spinal cord tract organization is paramount for the safe performance of ablative procedures for pain, such as cordotomy. It can be performed either percutaneously at C1, or by an open procedure in the thoracic spinal cord. Care must be taken during this procedure to stay ventral to the dentate ligament, which separates the dorsally located corticospinal tract (3) from the spinothalamic tract. The dorsal root entry zone (2) is the target for DREZ lesioning procedures, and the midline pain pathway (1) is the target for the midline myelotomy for visceral pain. The ventral white decussation (5) contains fibers from both spinothalamic tracts and is the target for commissural myelotomies.
Pemasangan lead “spinal cord stimulator” perkutaneus telah dilakukan tetapi gagal karena adanya pembentukan jaringan parut pada epidural. Agar dapat mengobati nyeri neuropatik pada ekstremitas bawah pasien, anda memutuskan untuk melakukan prosedur pemindahan lead. Tempat paling mungkin untuk laminektomi adalah?
A. C1-2
B. T10-11
C. T7-8
D. L2-3
B. T10-11
Placement of spinal cord stimulator for relief of lower extremity pain should be performed over the lumbar enlargement of the spinal cord, which is approximately at the T10-T11 level. This area affords the highest likelihood of stimulating the dorsal aspect of the spinal cord with minimal stimulation of the dorsal roots. Stimulating below the tip of the spinal cord is therefore not helpful. Similarly, stimulating the spinal cord above the lumbar enlargement is likely to be associated with significant radicular stimulation with minimal dorsal column stimulation. Stimulation at C1-2 may be performed for upper extremity symptoms. While stimulation at this site may yield stimulation within the lower extremities as well, it is less pronounced than the stimulation in the arms.
Pembuluh darah yang paling mungkin terjadi kontak patologis dengan nervus glossofaringeal pada neuralgia glossofaringeal adalah :
A. Arteri serebri posterior
B. Arteri serebelli infero-posterior
C. Arteri serebelli superior
D. Arteri rekuren Heubner
B. Arteri serebelli infero-posterior
The posterior inferior cerebellar artery lies in close vicinity to the normal glossopharyngeal nerve. This is most frequently evident on MRI studies. Occasionally the vertebral or the anterior inferior cerebellar artery may contribute to glossopharyngeal neuralgia.
Apakah susunan tipikal pada serabut saraf dalam ganglion trigeminal?
A. V1 inferomedial, V3 superolateral
B. V1 superolateral, V3 inferomedial
C. V1 superomedial, V3 inferolateral
D. V1 inferolateral, V3 superomedial
C. V1 superomedial, V3 inferolateral
V1 is superomedial and V3 inferolateral in the trigeminal (Gasserian) ganglion. The trigeminal nerve enters Meckel’s cave and forms the trigeminal ganglion within it. The somatotopic arrangement of the fibers of the trigeminal nerve recapitulates the postganglionic divisions of the nerve: V1, which exits through the superior orbital fissure; V2, which exits inferiorly and more laterally through the foramen rotundum; and V3, which exits at the lateral extent through the foramen ovale. It is through the foramen ovale that percutaneous approaches to the Gasserian ganglion are performed, since it is the opening in the skull base that offers the easiest access to Meckel’s cave via the percutaneous route. This somatotopic organization is important to keep in mind when performing such operations for trigeminal neuralgia.
Manakah prosedur dibawah ini yang paling baik pada nyeri kanker yang refrakter secara medis?
A. Spinal cord stimulation
B. Kordotomi anterolateral
C. Punctate midline myelotomy
D. Membuat luka pada zona masuk radiks dorsalis
C. Punctate midline myelotomy
The best treatment of cancer-related pelvic and rectal pain is a punctuate midline myelotomy. The treatment of cancer-related pelvic and rectal pain is extremely challenging. The pain pathway from visceral organs is particularly difficult to access, and for a long time was thought to be poorly localized. In 1997, Dr. Haring Nauta reported on a novel midline pain pathway located within the dorsal columns, which appeared to subserve pain neurotransmission from the pelvic viscera. Subsequent experimental models have confirmed the existence of this pathway, and success in relief of pelvic pain has been reported following the lesioning of this pathway.
Anterolateral cordotomy is usually reserved for extremity pain related to neoplastic invasion of the plexus or peripheral nerves. Visceral nociception does not travel in the anterolateral funiculus. Pelvic pain is therefore not likely to be relieved by lesioning of the anterolateral spinothalamic tract. Spinal cord stimulation may stimulate the midline pain pathway, but the amplitudes required to penetrate the cord substance to this depth usually result in too broad a stimulation of the rest of the cord. Dorsal root entry zone lesioning is usually reserved for brachial plexus avulsion pain or transitional zone pain following spinal cord injury. It has no demonstrated effect in the treatment of pelvic pain.
Anda menemukan seorang pasien di klinik anda dengan quadriplegia komplit sekunder akibat injury pada saraf tulang belakang di C6. Dia mengeluhkan nyeri hebat di daerah rektum. Pada pemeriksaan fisik, mulai segmen dibawah C7, pasien sudah tidak dapat merasakan apa-apa. Manakah terapi paling baik untuk kasus di atas :
A. Spinal Cord stimulation
B. Kordotomi thoracal
C. Deep brain stimulation
D. Amitriptilin dan/atau karbamazepin
E. Morphine pump intrathecal
D. Amitriptilin dan/atau karbamazepin
This patient’s rectal pain is likely a manifestation of his spinal cord injury. Such pain is poorly responsive to spinal cord stimulation. In addition, intrathecal morphine therapy is unlikely to be successful and should not be tried in the absence of attempts at medical therapy. A surgical cordotomy does not address midline visceral pain. The literature regarding deep brain stimulation for such pain is relatively sparse. Use of antidepressants (such as amitriptyline) and anticonvulsants (such as carbemazapine) is associated with some success in treating neuropathic pain syndromes including those associated with a complete neurological injury.
