Chronic Pain

Front 1

What are the 4 groups of afferent fibers that carry information to the brain?

Give function of each:

Back 1

- Aα: proprioception

- Aβ: mechanical stimulation

- Aδ: sharp pain

- C: dull pain

Front 2

Name several chemical mediators between neurons that signal pain. (7)

Back 2

1) Serotonin

2) Substance P
3) Prostaglandins
4) Kinins

5) Cytokines

6) Chemokines

7) ATP

Front 3

What nerve fiber type detects cold?

Back 3

Aδ

Front 4

What nerve fiber type detects heat?

Back 4

C

Front 5

Where are the cell bodies of primary afferents located?

Back 5

Dorsal Root Ganglia (DRG)

Front 6

What is the most common excitatory neurotransmitter associated with sensory afferents?

Back 6

Glutamate

Front 7

Where do pain fibers cross when ascending to the brain?

Back 7

Anterior white commissure

Front 8

What spinal tract do pain nerves travel?

Back 8

Spinothalamic tract

Front 9

Where in the medulla do ascending lateral axons terminate?

Back 9

Ventromedial medulla

Front 10

At what nucleus in the ventromedial medulla do pain axons terminate?

Back 10

Reticular formation

Front 11

In which nucleus are opioid enkephalins present?

Back 11

Periaquaductal grey

Front 12

What mass can form as a result of repeated axonal injury?

Back 12

Neuroma

Front 13

What atypical receptor can present on injured axons with repeated damage?

Back 13

Alpha-adrenergic receptors

Front 14

What signs and symptoms suggest radicular pain? (5)

Back 14

- Subjective back pain
- Paresthesia over a dermatome
- Weakness
- Diminished reflexes
- Positive straight-leg test

Front 15

What enzyme do steroids inhibit to stop inflammation related to back pain?

Back 15

phospholipase A2

Front 16

Which fiber type can methylprednisone block?

Back 16

C-fibers

Front 17

When should an epidural steroid injection (ESI) be reassessed post-Op?

Back 17

2-3 weeks afterward

Front 18

What steroid is recommend for cervical ESI?

Interlaminar? (3)

Lumbar? (2)

Back 18

Cervical: dexamethasone

Interlaminar: methylprednisone, triamcinolone, or betamethasone

Lumbar: Betamethasone or triamcinolone

Front 19

Why use different steroids at different vertebral levels?

Back 19

Bulky particle steroids (like methylprednisone) last longer but can occlude blood vessels.

Front 20

What is rhizotomy?

Back 20

Destruction of nerve roots

Front 21

What are 3 treatments for sacroiliac joint syndrome?

Back 21

1) Intra-articular steroid injections

2) RF denervation

3) Surgical fixation

Front 22

Where is pain felt in piriformis syndrome?

Back 22

The buttock

Front 23

How does piriformis syndrome pain differ from sciatica?

Back 23

In piriformis syndorme, pain starts in the buttock but only radiates to the greater trochanter, where in sciatica, it can radiate down the leg

Front 24

What movements aggravate pain in piriformis syndrome? (3)

Back 24

- Hip flexion

- Hip adduction

- Hip internal rotation

Front 25

How is myofacial pain diagnosed? (4)

Back 25

- Palpable taut band

- Exquisite tenderness

- Twitch response from manipulation

- Loss of ROM

Front 26

What is the treatment for myofacial points?

Back 26

Cold spray and digital manipulation or injection of local anesthetic

Front 27

How does myofacial pain differ from fibromyalgia?

Back 27

Fibromyalgia pain is symmetrical

Front 28

What are the pharmacologic treatments for fibromyalgia? (4)

Back 28

- Tramadol

- Duloxetine

- Pregabalin

- Sedative

Front 29

What are 3 the standard treatments for post-herpetic neuralgia?

Back 29

- Nortriptyline

- Tramadol

- Gabapentin

Front 30

What class of drugs is standard Tx for diabetic neuropathy?

Name two.

Back 30

Anticonvulsants: gapapentin & pregabalin

Front 31

What is CRPS?

Back 31

Complex Regional Pain Syndrome

Front 32

What are the risk factors for CRPS? (2)

Back 32

- Female sex

- Nerve injury

Front 33

How does pain in CRPS relate to intensity of injury?

Back 33

Pain is usually exagerrated (hyperalgesia)

Front 34

What is the difference between Type 1 & Type 2 CRPS?

Back 34

Type 2 follows actual nerve damage

Front 35

What pharmacological treatments are available for CRPS? (2)

Back 35

- Gabapentin

- Memantine

Front 36

What is the MoA of memantine?

Back 36

NMDA-antagonist

Front 37

What are treatments HIV neuropathy? (3)

Back 37

- Vitamin supplements
- Lamotrigine

- Gabapentin

Front 38

How often is phantom pain sensed in amputees?

Back 38

A few times a month

Front 39

What 4 drugs can be used to Tx phantom pain?

Back 39

- Opioids

- Gabapentin

- an NMDA antagonist

- Antidepressant

Front 40

What is the mainstay treatment for cancer pain?

Back 40

Opioids

Front 41

What neurolytic chemical is used in a celiac ganglion block?

Back 41

Phenol

Front 42

At what vertebral level is a needle inserted to block the celiac ganglion?

Superior hypogastric plexus?

Back 42

Celiac: T12-L1

SHP: L5-S1

Front 43

What ganglion can be blocked to alleviate perineal cancer pain?

Back 43

Ganglion impar (Walther's ganglion)

Front 44

Which opioid is the standard drug for cancer pain?

Back 44

Morphine

Front 45

What risk is associated with methadone use?

Back 45

QT-prolongation leading to Torsades de pointes

Front 46

What action from another drug on P450 can increase the chances of QT-prolongation caused by methadone?

Back 46

P450 inhibition

Front 47

Name 3 so-called weak opioids.

Back 47

- Codeine

- Hydrocodone

- Tranadol

Front 48

What makes tramadol an attractive drug to use for pain control? (3)

Back 48

- Low abuse potential

- Low constipation

- Minimal risk of respiratory distress

Front 49

What 2 anticonvulsants are indicated for trigeminal neuralgia?

Back 49

- Carbamazepine

- Lamotrigine

Front 50

What 3 anticonvulsants are indicated for post-herpetic neuralgia?

Back 50

- Gabapentin

- Pregabalin

- Topiramate

Front 51

What 2 drugs are indicated for spinal cord injury pain?

Back 51

- Amitriptyline

- Gabapentin

Front 52

What drug is indicated for central post-stroke pain?

Back 52

Lamotrigine

Front 53

What drug is indicated for pain associated with Guillain-Barré syndrome?

Back 53

Gabapentin

Front 54

Which anticonvulsants has an adverse reaction of hyponatremia and low thyroid hormone concentration?

Back 54

oxycarbazepine

Front 55

How are lidocaine patches dosed?

Back 55

one per day for 12 hours x 3 days

Front 56

What term is used for oral lidocaine?

Back 56

Mexiletine

Front 57

What is discography in pain management?

Back 57

Injecting dye into a vertebral disc and checking to leaks by x-ray

Front 58

What is IDET?

Back 58

Intradiscal electrothermal therapy: burning of the disc to cause fibrosis to contract the disc

Front 59

How are patients prepped for discography or IDET?

Back 59

PPx Abx

Front 60

What is vertebroplasty?

Back 60

Injection of polymethylmethacrylate (PMMA) in a vertebral compression fracture

Front 61

What can occur if cement leaks into paravertebral veins or bone marrow after percutaneous vertebral augmentation procedure?

Back 61

PE

Front 62

What can occur if vertebral cement leaks into the neural foramen?

Back 62

radiculopathy

Front 63

What neurotransmitter is increased as a result of spinal cord stimulation by implantable device?

Back 63

GABA

Front 64

Is spinal cord stimulation a viable option for a patient with CRPS?

Back 64

Yes

(It helps pain but doesn't improve functionality.)

Front 65

What are first-line opioids used for intrathecal pumps? (2)

Back 65

- Morphine

- Hydromorphone

Front 66

What is the trade name of hydromorphone?

Back 66

Dilaudid