Pain – Flashcard
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Nerve fiber types and sensory/motor function: 1) A alpha 2) A beta 3) A gamma 4) A delta 5) B 6) C
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1) Proprioception, motor 2) Touch, pressure 3) Muscle spindle (muscle tone) 4) Pain, cold temperature, touch 5) Preganglionic autonomic 6) Dull pain, warm temperature, touch
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Nerve fiber types from largest to smallest
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A alpha A beta A gamma A delta B C
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Nerve fiber types from fastest to slowest
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A alpha A beta A gamma A delta B C
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What kind of pain do different nerve fibers convey?
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1) A delta: sharp, stabbing, well localized pain (somatic) 2) C: dull, aching, poorly localized pain (visceral)
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3 types of pain
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1) Somatic 2) Visceral 3) Neuropathic
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Pain pathway (excitatory)
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A delta and C nerve fibers ---> sustantia gelatinosa (dorsal horn) ---> release subtance P, somatostatin, VP, endophin ---> spinothalamic tract ---> thalamus ---> cortex
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Definition of pain terms: 1) Allodynia 2) Hyperalgesia 3) Hyperesthesia 4) Hyperpathia 5) Anesthesia dolorosa 6) Dysesthesia 7) Hypoalgesia 8) Neuralgia 9) Paresthesia
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1) Pain to a stimulus that is not normally painful 2) Inreased pain to a normally painful stimulus 3) Increased sensitivity to stimulation 4) Syndrome of abnormally painful reacion to stimulus 5) Pain in an area that is numb to touch (trigeminal neuralgia) 6) Unpleasant abnormal sensation 7) Decreased pain to a normally painful stimulus 8) Pain in a nerve distribution 9) Abnormal (not unpleasant) sensation
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Diffrence between CRPS I and CRPS II
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CRPS I: no major nerve damage (reflex sympathetic dystrophy) CRPS II: major nerve damage (causalgia)
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Diagnostic criteria for CRPS I
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1) Presence of initiating noxious event or a cause of immobilzation (actual nerve injury for CRPS II) 2) Pain, allodyina, hyperalgesia disproportionate to inciting event 3) Edema, change in skin blood flow, decreased motor activity 4) No other cause
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Hallmark symptoms of CRPS by stage
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1) Acute (weeks): wam, swollen, red, dry skin 2) Dystrophic (months): edematous, discolored, cold, clammy skin 3) Atrophic (> 4 months): atrophic, tight/shiny skin with decreased range of motion
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CRPS treatment
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1) Physical therapy 2) Drugs: TCA (amytirptaline), gabapentin, mild opioid, steroids, NSAID 3) Sympathetic block: stellate ganglion block, lumbar sympathetic block 4) Somatic block (if sympathetic fails): brachial plexus, epidural, spinal) 5) Spinal cord stimulator 6) TENS 7) Biofeedback
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Sympathetic supply to upper extremity
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T2-T9: synapse with stellate ganglion
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Anatomic landmarks for stellate ganglion block
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1) Transverse process of C7 2) Neck of 1st rib 3) C6 tubercle at level of cricoid (Chassaignac's tubercle) when using the anterior paratracheal technique
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Indications for stellate ganglion block
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1) CRPS 2) Refractory angina 3) Phantom limb pain 4) Vascular insufficiency 5) Hyperhydrosis
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Side effects/risks of stellate ganglion block
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1) Vertebral artery injection 2) Horner's synrome (ptosis, miosis, anhydrosis) 3) Phrenic nerve paralysis 4) Recurrent laryngeal nerve paralysis (hoarseness, lump in throat) 5) Hematoma 6) Brachial plexus injury 7) Pneumothorax 8) Epidural/spinal injection 9) Esophageal perforation
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Position of lumbar plexus for block
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Anterior lateral aspect of L2 vertebral body
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Test to determine success of sympathetic block
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Incrased skin temperature 2C
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Nerve distribution of trigeminal neuralgia
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Maxillary branch of trigeminal nerve (V2)
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Treatment of trigeminal neuralgia
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1) Drugs: carbamazepine, phenytoin, baclofen, gabapentin 2) Surgical: microvascular decompression, nerve lesion (glycerol, radiofrequency) 3) Gasserion ganglion (trigeminal ganglion) block
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Treatment of phantom limb pain
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1) Drugs: opioids, anticonvulsants, antidepressants, pregabalin, memantine, calcitonin 2) TENS 3) Deep brain stimulator 4) Spinal cord stimulator 5) Sympathetic block (stellate ganglion, lumbar) 6) Acupuncture
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Anatomic location of celiac plexus
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L1 vertebral body, lateral to aorta
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Celiac plexus is formed by which nerves?
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Greater and lesser splanchnic nerves
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Celiac plexus block anatomic landmarks
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L1 vertebral body
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Celiac plexus block: 1) Distribution 2) Indications
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1) Stomach to mid transverse colon 2) Cancer (visceral pain)
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Complication of celiac plexus block
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1) Diarrhea 2) Hypotension 3) Paraplegia 4) Local anesthetic toxicity 5) Organ puncture 6) Pneumothorax
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Superior hypogastric plexus block: 1) Distribution 2) Indications
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1) Descending colon, rectum, testes, penis, prostate, perineum, vulva, vagina, uterus, urethra and bladder 2) Chronic pelvic pain, cancer
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Anatomic landmarks for superior hypogastric plexus block
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Anterior to L4-5
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Hallmark of myofascial pain syndrome
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1) Muscle trigger points 2) Widespread aching
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Hallmark of fibromyalgia
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1) Pain in 11 of 19 trigger points 2) Widespread pain 3) Fatigue/waking unrefreshed 4) Cognitive symptoms 4) Somatic symptoms in general (headache, weakness, bowel problems, nausea, dizziness, numbness/tingling, hair loss) 5) Other causes ruled out 6) Symptoms for at least 3 months
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Treatment of fibromyalgia
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Amytriptyline (TCA) Duloxetine (SNRI) (NOT NSAIDS)
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Order in which nerve fibers are blocked with local anesthetics
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Small myelinated (B) > small unmyelinated (C, A delta) > large myelinated (A gamma, beta, alpha) > large unmyelinated Pain, temperature, touch, proprioception, skeletal muscle tone.
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Site of action of intrathecal opioids
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Substantia gelatinosa in dorsal horn spinal cord
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Primary barrier to opioid transfer from epidural space to spinal cord
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Arachnoid mater
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Epidurally administered opioid penetration into the spinal tissue depends on what?
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Lipid solubility (highly lipid soluble = high uptake by epidural fat and veins and poor arachnoid penetration)
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What is meralgia paresthetica
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Lateral femoral cutaneous nerve numbness
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Most common distribution for post-herpatic neuralgia
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Thoracic Trigeminal
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Treatment of postherpetic neuralgia
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Capsaicin (poorly tolerated for acute zoster) Lidoderm patch TCAs (amitriptyline), SSRI, duloxetine Gabapentin Opioids Sympathetic block (only useful in acute attack of zoster) Antiviral (only if given within 72 hours of onset of zoster)
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Phenol versus ethanol for neurolytic block
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1) Phenol: painless, shorter acting, hyperbaric 2) Ethanol: painful, longer acting, hypobaric
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Causes for increased risk of post dural puncture headache
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1) Age < 40 2) Female 3) H/o post dural puncture headache 4) Low BMI 5) Cutting/beveled needle (vs. pencil point) 6) Needle bevel perpendicular to spine
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How does TENS therapy work
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Activates larger neurons to override C fiber activation (gate-control theory)
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Indications for spinal cord stimulator
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1) Failed Back Syndrome 2) Radicular pain syndrome or radiculopathies resulting in pain secondary to FBSS or herniated disk 3) Postlaminectomy pain 4) Multiple back operations 5) Unsuccessful disk surgery 6) Degenerative Disk Disease (DDD)/herniated disk pain refractory to conservative and surgical therapies 7) Peripheral causalgia 8) Epidural fibrosis 9) Arachnoiditis or lumbar adhesive arachnoiditis 10) Complex Regional Pain Syndrome (CRPS) I or II
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Indications for TENS therapy
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1) Neurogenic pain: phantom limb pain, sympathetically mediated pain (CRPS), postherpetic neuralgia, trigeminal neuralgia, pain after spinal cord injury 2) Musculoskeletal pain: Rheumatoid arthritis and osteoarthritis, acute postoperative pain, acute posttraumatic pain. 3) Visceral pain and dysmenorrhea 4) Diabetic neuropathy 5) Angina pectoris 6) Urge incontinence 7) Control nausea in patients undergoing chemotherapy
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Indications for intrathecal pain pump
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1) Chronic intractable pain (morphine) 2) Severe chronic pain (zicinotide - CCB) 3) Spasticity (baclofen)
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When length of time is diagnostic of chronic pain
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6 months of ongoing pain
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How to obtain history evaluation of pain
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1) Nature of pain (sharp, stabbing, dull, throbbing) 2) Intensity 3) Location/radiation 4) Duration 5) Aggravating/alleviating factos "NILDA"
