Lippincott's Anesthesia Review: 1001 Questions and Answers

Chapter 9. Pain Management

Thomas Halaszynski

    1.   At what time frame following the postsurgical period does persistent postsurgical pain become defined as being “chronic pain”?

          A.   1 to 2 weeks

          B.   3 to 4 weeks

          C.   1 to 2 months

          D.   6 to 12 months

    2.   Both surgical trauma and anesthetic administration techniques can modulate which of the following human stress responses?

          A.   Neuroendocrine

          B.   Metabolic

          C.   Inflammatory

          D.   All of the above

    3.   Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used as part of “multimodal” analgesic therapy; some of the potential advantages include all of the following, except

          A.   Decreases opioid requirements

          B.   Can decrease postoperative pain intensity

          C.   Indirect effect of decreasing opioid-related side effects

          D.   Can improve wound healing

    4.   Type(s) of symptomatic pain conditions that best describes “chronic” pain often includes

          A.   Neuropathic pain alone

          B.   Nociceptive pain alone

          C.   Neuropathic or nociceptive pain

          D.   Somatic or visceral pain

    5.   At what levels does the modulation of pain by electrical stimulation result in the activation of inhibitory fibers?

          A.   Nociceptor level alone

          B.   Spinal cord level alone

          C.   Only within the brain

          D.   All of the above

    6.   Activation of which of the following mechanisms and/or pathways best describes “central sensitization” at the level of the spinal cord?

          A.   Second-order wide dynamic range neurons

          B.   Dorsal horn neuron

          C.   Spinal cord reflexes

          D.   All of the above

    7.   A 26-year-old female undergoes a left stellate ganglion block for treatment of complex regional pain syndrome of the left hand. Twenty minutes after the block is placed, skin temperature in the left arm rises from 33 to 36.5°C. Venous engorgement of the left arm and hand, left eye papillary constriction, and drooping of the eyelid are observed. The pain is not relieved. Which of the following can best explain the block failure?

          A.   Pain-carrying fibers originated from right stellate ganglion

          B.   Pain-carrying fibers originated from middle cervical ganglion

          C.   Pain-carrying fibers originated from inferior cervical ganglion

          D.   Pain-carrying fibers originated from second thoracic ganglion

    8.   Chronic pain indications for insertion of a spinal cord stimulator include all of the following, except

          A.   Phantom pain

          B.   Complex regional pain syndrome

          C.   Chronic visceral pelvic pain

          D.   Compartment syndrome pain

    9.   The term used to best describe the PAIN condition “perception toward ordinary non-noxious stimulus as being painful” is

          A.   Hyperalgesia

          B.   Anesthesia dolorosa

          C.   Hypalgesia

          D.   Allodynia

  10.   Incorrect statement related to the definition of an abnormal sensation is

          A.   Dysesthesia is an abnormal sensation with or without a stimulus

          B.   Paresthesia is abnormal sensation without a stimulus

          C.   Neuralgia is due to abnormality in nerve roots

          D.   Hyperesthesia is an abnormal sensation of exaggerated response to mild stimulation

  11.   Which of the following clinical diagnoses best describes deafferentation pain?

          A.   Herniated disk

          B.   Amputation

          C.   Neuropathic pain

          D.   Diabetic neuropathy

  12.   Gasserian ganglion block is most commonly used for neuropathic pain located in which of the following nerve distributions?

          A.   Facial nerve

          B.   Trigeminal nerve

          C.   Glossopharyngeal nerve

          D.   Vagal nerve

  13.   Major excitatory neurotransmitters responsible for pain modulation include all the following, except

          A.   Substance P

          B.   Glutamate

          C.   Somatostatin

          D.   Aspartate

  14.   All the following are inhibitory neurotransmitters in the pain pathway, except

          A.   Norepinephrine

          B.   Adenosine

          C.   Serotonin

          D.   Calcitonin gene-related peptide

  15.   Incorrect statement regarding secondary hyperalgesia is

          A.   It is caused by neurogenic inflammation

          B.   It is associated with Lewis’ triple response

          C.   It is increased by injection of local anesthetics

          D.   It is increased by application of capsaicin

  16.   Types of pain disorders that are commonly treated using “sympathetic blockade” include all of the following, except

          A.   Complex regional pain syndrome

          B.   Phantom limb pain

          C.   Postherpetic neuralgia

          D.   Acute pain due to pelvic exenteration

  17.   Systemic responses of the human body that can develop secondary to symptoms of acute pain include all of the following, except

          A.   Hypertension and tachycardia

          B.   Increased work of breathing

          C.   Urinary retention

          D.   Increased peristalsis

  18.   A 56-year-old man presented to his primary care physician with a complaint of right buttock and right leg pain along with numbness and tingling sensations. He was subsequently diagnosed with a piriformis syndrome (trapped nerve). The nerve(s) responsible for this diagnosis is/are

          A.   Femoral and saphenous nerves

          B.   Ilioinguinal nerve

          C.   Sciatic nerve

          D.   Obturator and femoral nerves

  19.   A 56-year-old patient with a past medical history of hypertension, diabetes, and alcohol abuse presents to the operating room for a right-elbow open reduction internal fixation, secondary to a motor vehicle accident that occurred 24 hours ago. On postoperative day 1, the patient complains of right fourth and fifth digit numbness and minor pain. A diagnosis of cubital tunnel syndrome has been made. The nerve most likely to be involved is

          A.   Median nerve

          B.   Ulnar nerve

          C.   Radial nerve

          D.   Musculocutaneous nerve

  20.   Incorrect statement regarding myofascial pain is

          A.   Myofascial pain is associated with muscle discomfort (pain, stiffness, weakness, spasm)

          B.   Patient may have several trigger points producing pain upon stimulation

          C.   Systemic diseases such as connective tissue disease may cause myofascial pain

          D.   Myofascial pain is never associated with autonomic dysfunctions

  21.   The diagnosis of fibromyalgia includes all of the following, except

          A.   Minor pain

          B.   Pain lasts more than 3 months

          C.   No other pathologies can explain or contribute to the pain

          D.   Frequent association with psychiatric diagnosis

  22.   Common causes for lower back pain include all of the following, except

          A.   Lumbosacral strain

          B.   Degenerative disk disease

          C.   Myofascial syndromes

          D.   Fibromyalgia syndrome

  23.   A 68-year-old male presents to his primary care physician’s office with a major complain of back pain radiating into the gluteal region and pain in the distribution of the plantar surface of the foot on the same side. The patient’s physical examination reveals decreased plantar flexion of the foot. An MRI will most commonly show a herniated disk at

          A.   L2–L3

          B.   L3–L4

          C.   L4–L5

          D.   L5–S1

  24.   Disk herniation at L4–L5 of the vertebral column often presents with all of the following clinical symptoms, except

          A.   Diminished dorsiflexion of the foot

          B.   Quadriceps femoris muscle weakness

          C.   Posterior-lateral thigh pain

          D.   Dorsal foot pain between first and second toes

  25.   Facet syndrome is characterized by all the following, except

          A.   Pain relieved by local anesthetic injection of the medial branches of the posterior rami of spinal nerves

          B.   Pain relieved by an intra-articular injection of the zygapophyseal joints

          C.   Pain can be exacerbated by overextension and lateral rotation of back

          D.   Pain is sympathetically mediated

  26.   Incorrect statement regarding neuropathic pain is

          A.   It includes pain associated with stroke, spinal cord injury, and diabetic neuropathy

          B.   It is not associated with low back pain or multiple sclerosis

          C.   Neuropathic pain can be paroxysmal

          D.   Neuropathic pain can be associated with hyperpathia

  27.   Regarding the treatment of neuropathic pain, the correct statement is

          A.   Narcotics is the most effective and “first-line” treatment option

          B.   It is most optimally treated with multimodal therapies

          C.   Sympathetic blockade will eliminate all neuropathic pain

          D.   Spinal cord stimulator is not an effective therapy

  28.   Pathological features of complex regional pain syndrome include all the following, except

          A.   It is sympathetically mediated

          B.   It is often associated with documented nerve injury

          C.   It is only associated with major injuries (never from minor procedures)

          D.   It is not associated with evidence of skin color, hair, and temperature changes

  29.   Incorrect statement regarding treatment of complex regional pain syndrome (CRPS) is

          A.   Efficacious treatment with multimodal therapy early in the diagnosis (within 1 month of symptom) is most effective

          B.   It responds well to sympathetic blockade

          C.   If not treated properly and in a timely fashion, CRPS can result in functional disability

          D.   Patients need to refrain from physical therapy until the pain syndrome is resolved

  30.   Possible complications to disclose when obtaining an anesthesia consent from a patient prior to performance of a celiac plexus block include all of the following, except

          A.   Postural hypotension and lightheadedness

          B.   Constipation and urinary retention

          C.   Vena cava and aortic vascular injury

          D.   Retroperitoneal hemorrhage

CHAPTER 9 ANSWERS

    1.   C.   Persistent postsurgical pain is defined as chronic pain that continues beyond the usual recovery period of 1 to 2 months following surgery (well past the normal convalescence period expected for a particular/specific surgical procedure). Chronic pain is defined as pain that has lasted longer than 3 to 6 months, though some other investigators have placed the transition from acute to chronic pain at 12 months. The incidence of persistent postsurgical pain can often exceed an incidence of 30% after certain high-risk/surgically invasive procedures such as amputations, thoracotomy, mastectomy, and inguinal hernia repair. Acute pain will typically last less than 30 days, chronic pain to more than 6 months duration, and subacute pain lasts from 1 to 6 months. A popular alternative definition of chronic pain involving no arbitrarily fixed durations is “pain that extends beyond the expected period of healing.”

    2.   D.   Many perioperative factors can produce significant influence toward amplifying or decreasing the surgical stress response(s) such as neuroendocrine, metabolic, and inflammatory changes. These factors can be further modified by patient-specific contributions such as anxiety/depression, surgical history, surgical technique (open vs. laparoscopy), and anesthetic techniques (general vs. regional).

    3.   D.   NSAIDs have not only many of the above-identified advantages, but also several potential side effects that the practitioner must remain cognizant of such as risk of gastrointestinal bleeding, renal injury, and the potential to impair wound healing.

    4.   C.   Chronic pain is most often defined as neuropathic and/or nociceptive in nature. Chronic pain may be divided into nociceptive pain—caused by activation of nociceptors—and neuropathic pain—caused by damage to or malfunction of the nervous system. Neuropathic pain is divided into peripheral (within the peripheral nervous system) and central (originating from the brain/spinal cord). Peripheral neuropathic pain is often described as burning, tingling, electrical, stabbing, and/or pins and needles sensation(s). Nociceptive pain is divided into superficial or deep, and deep pain into deep somatic and visceral pain. Superficial pain is initiated by activation of nociceptors in the skin or superficial tissues. Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, and muscles, and is described as dull, aching, poorly-localized pain. Visceral pain originates in the internal organ system(s) of the body. Visceral pain may be well-localized, but often is difficult to locate, and several visceral regions can produce “referred” pain when damaged or inflamed, where the sensation is located in an area distant from the site of pathology or injury.

    5.   D.   Modulation of pain can happen centrally or peripherally. It can occur at the nociceptor level peripherally or centrally either in the spinal cord or in supraspinal structures. These modulation effects can be either inhibitive or facilitative. In the brain and the spinal cord, much of the information from the nociceptive afferent fibers results from excitatory discharges of multireceptive neurons. Pain information in the central nervous system is controlled by ascending and descending inhibitory pathways (using endogenous opioids or other endogenous substances). In addition, a powerful inhibition of pain-related information occurs in the spinal cord. These inhibitory systems can be activated by brain stimulation and peripheral nerve stimulation. However, pain is a complex perception that is influenced also by prior experience and by the context within which the noxious stimulus occurs. This sensation is also influenced by emotional state.

    6.   D.   Central sensitization is an enhancement in the function of neurons and circuits in nociceptive pathways, caused by increases in membrane excitability and synaptic efficacy as well as reduced inhibition and is a manifestation of the plasticity of the somatosensory nervous system in response to activity, inflammation, and neural injury. Central sensitization is responsible for hyperalgesia and there are three mechanisms that have been identified at the level of spinal cord: (1) windup of second-order wide dynamic range neurons, (2) dorsal horn neuron receptor field expansion, and (3) hyperexcitability of flexion reflexes.

    7.   D.   The stellate ganglion (cervicothoracic ganglion or inferior cervical ganglion) is a sympathetic ganglion formed by the fusion of the inferior cervical and first thoracic ganglion. Stellate ganglion is located at the level of C7 (seventh cervical vertebra), anterior to the transverse process of C7, superior to the neck of the first rib, and just below the subclavian artery. Complications of stellate block include intravascular injection, intrathecal/epidural injection, bleeding, pneumothorax, brachial plexus involvement, local anesthetics spread to recurrent laryngeal nerve, and osteomyelitis or mediastinitis (rarely).

    8.   D.   A spinal cord stimulator is a device used to exert pulsed electrical signals to the spinal cord to control chronic pain, and additional applications include use in some motor disorders. Spinal cord stimulation is most effective for neuropathic pain, of which some common indications include sympathetically mediated pain, phantom limb pain, ischemic pain due to peripheral vascular disease, peripheral neuropathies, and visceral pain. Compartment syndrome pain often requires urgent evaluation and possible need for emergency fasciotomy.

    9.   D.   Hyperalgesia is an exaggerated response to noxious stimuli, an extreme and exaggerated reaction to a stimulus which is normally painful. Anesthesia dolorosa is pain in area that has no sensation, is pain felt in an area (usually of the face) that is completely numb to touch with the pain described as constant, burning, aching, or severe. Hypalgesia equals reduced sensitivity to pain, the opposite of hyperalgesia. Allodynia is defined as pain due to a stimulus that does not normally provoke pain. Temperature or physical stimuli can provoke allodynia (which may feel like a burning sensation) and can often occur after injury.

  10.   C.    Dysesthesia is an abnormal sensation with or without a stimulus and is defined as an unpleasant, abnormal sense of touch and often presents as pain (may also present as an inappropriate, but not discomforting, sensation). Dysesthesia is caused by lesions of the nervous system (peripheral or central) and involves sensations (spontaneous or evoked) such as burning, wetness, itching, electric shock, and pins and needles. Dysesthesia can include sensations in any bodily tissue, including most often the mouth, scalp, skin, or legs. Paresthesia is abnormal sensation without a stimulus with a sensation of tingling, tickling, prickling, pricking, or burning of a person’s skin with no apparent long-term physical effect. The manifestation of a paresthesia may be transient or chronic. The most familiar kind of paresthesia is the sensation known as “pins and needles” or of a limb “falling asleep.” Neuralgia is pain sensation in the distribution of a nerve or a group of nerves (radiculopathy is pain secondary to nerve roots pathologies). Neuralgia is pain in one or more nerves caused by a change in neurological structure or function of the nerves rather than by excitation of healthy pain receptors. Neuralgia falls into two categories: central neuralgia (the cause of the pain is located in the spinal cord or brain) and peripheral neuralgia. Hyperesthesia is exaggerated response to mild stimulation or a condition that involves an abnormal increase in sensitivity to stimuli of the sense.

  11.   B.    Deafferentation pain is a type of neuropathic pain that is associated with loss of sensory input from the periphery to the central nervous system, such as phantom limb pain. It is the interruption or destruction of the afferent connections of nerve cells (e.g., in animal experiments, deafferentation demonstrates the spontaneity of locomotor movement by the freeing of a motor nerve from sensory components).

  12.   B.    The gasserian ganglion is formed from two roots that exit the ventral surface of the brainstem at the midpontine level, and these roots pass in a forward and lateral direction in the posterior cranial fossa across the border of the petrous bone. They enter a recess called Meckel cave, which is formed by an invagination of the surrounding dura mater into the middle cranial fossa. The dural pouch that lies just behind the ganglion is called the trigeminal cistern and contains cerebrospinal fluid. The gasserian ganglion is canoe-shaped, with the three sensory divisions—the ophthalmic (V1), the maxillary (V2), and the mandibular (V3)—exiting the anterior convex aspect of the ganglion. A small motor root joins the mandibular division as it exits the cranial cavity via the foramen ovale. The gasserian ganglion contains the cell bodies of sensory fibers of trigeminal nerve. This procedure called a gasserian ganglion block to treat facial pain is where a small amount of local anesthetic (with or without steroid) is injected onto the part of the nerve supply to the face called the gasserian ganglion (located to the back of the face between the ear and eye socket).

  13.   C.    Substance P, glutamate, aspartate, and ATP are among the major excitatory molecules responsible for pain modulation. Somatostatin, acetylcholine, and endorphin are among the major inhibitory mediators of pain.

  14.   D.    Norepinephrine, adenosine, and serotonin are among the major inhibitory neurotransmitters in the pain cascade. However, calcitonin gene-related peptide is an excitatory neurotransmitter.

  15.   A.    Secondary hyperalgesia is defined as an increase in pain sensitivity when a noxious stimulus is delivered to a region surrounding, but not including, the zone of injury (increased pain sensitivity outside of the area of injury or inflammation). Secondary hyperalgesia, also known as neurogenic inflammation, is associated with local redness, tissue edema, and sensitization to noxious stimuli. Local anesthetics injection or capsaicin topical application can diminish these reactions. Secondary hyperalgesia is a centrally mediated condition that may occur due to injury or disease in an area of the body. Secondary hyperalgesia is due to central neuron sensitization and requires continuous nociceptor input from the zone of primary hyperalgesia for its maintenance. Secondary hyperalgesia implies only mechanical hyperalgesia (e.g., allodynia and pin prick).

  16.   D.    Certain chronic pain conditions are sympathetically maintained and will respond to sympathetic blockade, such as complex regional pain syndrome, phantom limb pain, postherpetic neuralgia, and trigeminal neuralgia. However, acute pain secondary to pelvic exenteration surgery, although very difficult to treat, is typically not mediated sympathetically and does not usually respond well to a sympathectomy.

  17.   D.    One of the many reasons acute pain needs to be managed properly is its systemic effects, which include hypertension, tachycardia, and increased minute ventilation, can promote ileus and urinary retention, along with the release of catabolic hormones.

  18.   C.    Piriformis syndrome is a neuromuscular disorder that occurs when the sciatic nerve is compressed or otherwise irritated by the piriformis muscle, causing pain, tingling, and numbness in the buttocks and along the path of the sciatic nerve descending down the posterior lower thigh and into the leg. The sciatic nerve can be trapped at the sciatic notch and cause impingement syndromes (buttocks and leg pain).

  19.   B.    The cubital tunnel is a channel that allows the ulnar nerve to travel over the elbow and is bordered by the medial epicondyle of the humerus, the olecranon process of the ulna, and the tendinous arch joining the humeral and ulnar heads of the flexor carpi ulnaris. Cubital tunnel syndrome is a condition brought on by increased pressure on the ulnar nerve at the elbow, typically against medial epicondyle where the ulnar nerve passes. This can occur due to chronic compression of this nerve, positional or due to inappropriate cast/splint placement.

  20.   D.    Myofascial pain syndromes are associated with muscle symptoms such as spasm, pain, weakness, and stiffness, and associated with autonomic dysfunction (e.g., vasoconstriction). The trigger points can spontaneously resolve, but may continue on and become latent and activated at a later time. Myofascial pain needs to be ruled out in patients with chronic lower back pain as trigger points in quadratus lumborum, and gluteus medius muscles can be the cause for it. Some systemic diseases such as connective tissue disease can cause myofascial pain. Poor posture and emotional disturbances might also instigate or contribute to myofascial pain. The diagnosis of myofascial pain is by the pain and existence of trigger points.

  21.   A.    Fibromyalgia is characterized by chronic widespread pain and allodynia (a heightened and painful response to pressure). Its exact cause is unknown, but believed to involve psychological, genetic, neurobiological, and environmental factors. Fibromyalgia symptoms are not restricted to pain. Other symptoms can include debilitating fatigue, sleep disturbances, and joint stiffness. The American College of Rheumatology diagnosis criterion indicates that the pain be at least moderate to severe in scale: Widespread Pain Index (WPI) score of 7 or higher and the Symptom Severity (SS) scale score of 5 or higher. Another category of criteria to diagnose fibromyalgia includes a WPI of 3 to 6 along with an SS scale score of 9 or higher. The other two criteria for diagnosis include chronic conditions and absence of other coexisting chronic pain disorders. Treatment includes pregabalin (Lyrica), duloxetine (Cymbalta), and milnacipran (Savella) to identify a few options.

  22.   D.    Chronic lower back pain is one of the top reasons for physician office visits and also one of the greatest reasons for work absence. Lumbosacral strain, degenerative disk disease, and myofascial syndromes are the most common causes, and fibromyalgia is not typically associated with a diagnosis of lower back pain.

  23.   D.    Disk herniation at L5–S1 is the most common location of vertebral disk pathology presenting as back pain (affects the S1 nerve root). Patients often have associated gluteal pain and numbness along with pain/paresthesia in the posterior thigh, posterolateral calf, lateral dorsum, and undersurface of the foot. Physical examination will also identify a diminished plantar flexion of the ankle on the affected side.

  24.   B.    Disk herniation at L4–L5 is a very common location for such pathology and affects the L5 nerve root. Patients may present with pain and paresthesia anywhere along the dermatome distribution of the L5 nerve root (lateral thigh, anterolateral calf, medial dorsum of the foot, particularly between the first and second toes). The symptoms of quadriceps femoris muscle weakness would be secondary to pathology of nerve roots L2–L4.

  25.   D.    Facet joints are formed by the superior and inferior processes of each vertebra. Facet syndrome is a syndrome in which the zygapophyseal joints (synovial diarthroses, from C2 to S1) cause back pain. Fifty-five percent of facet syndrome cases occur in cervical vertebrae, and 31% in the lumbar area. Facet syndrome can progress to spinal osteoarthritis, which is known as spondylosis. Back pain secondary to degenerative changes in the facet (zygapophyseal) joints is also called facet syndrome. It is characterized by near midline pain that may radiate to the gluteal region, thigh, and knee. Facet syndrome symptoms may worsen by hyperextension or lateral rotation of the back. Confirmative test is pain relief offered by intra-articular injection of local anesthetics or blockade of the posterior ramus medial nerve branch.

  26.   B.    Neuropathic pain is pain caused by damage or disease that affects the somatosensory system. Neuropathic pain along with components of neuropathic pain can be associated with several chronic diseases such as diabetes, stroke, spinal cord pathology, postherpetic neuralgia, multiple sclerosis, cancer pain, or low back pain. Neuropathic pain is often described as “wax and wane” types of pain symptoms (e.g., comes and goes), burning, and electrical, as described by patients. Allodynia or hyperalgesia can often be associated with neuropathic pain.

  27.   B.    Neuropathic pain can be very difficult to treat effectively and often requires multiple therapeutic modalities for treatment. These include anticonvulsants, antidepressants, antiarrhythmics, α2-adrenergic agonists, topical agents, and analgesics (nonsteroidal anti-inflammatory drugs and opioids). Sympathetic blocks as well as spinal cord stimulation work for certain patients resistant to pharmacological interventions.

  28.   D.    Complex regional pain syndrome (CRPS), formerly called reflex sympathetic dystrophy or causalgia, or reflex neurovascular dystrophy or amplified musculoskeletal pain syndrome, is a chronic systemic disease characterized by severe pain, swelling, and changes in the skin. CRPS is expected to worsen over time. Some forms of CRPS are sympathetically maintained and are therefore responsive to sympathetic blockade. CRPS type 2 is associated with documented nerve damage/injury, but not CRPS type 1. CRPS can be associated with either minor or major surgical procedures or injuries. When the autonomic nervous system is involved, additional signs and symptoms can include sweating (sudomotor changes), color, and skin temperature changes, along with trophic changes of the skin, hair, and nails. Motor strength and range of motion of the extremity may also be affected.

  29.   D.    The general strategy in CRPS treatment is often multidisciplinary, with the use of different types of medications combined with distinct physical therapies. Physical therapy plays a central role in the multimodal treatment of CRPS. Therapy is facilitated with sympathetic blockade or intravenous regional blocks. Physical therapy typically consists of active movement without weights and desensitization therapy. If not treated in timely fashion, CRPS can result in functional disability. The incidence of a cure is about 90% with effective multimodal therapy initiated within 1 month of symptoms.

  30.   B.    Potential complications of a celiac plexus block include postural hypotension from the visceral sympathectomy and vasodilation due to the local anesthetic injection. Both the vena cava and the aorta are in close proximity and susceptible to intravascular injury/injection. Other potential complications include a pneumothorax, retroperitoneal hemorrhage, injury to the kidneys or pancreas, and sexual dysfunction. The visceral sympathetic chain is in close proximity, and blockade may result in unopposed parasympathetic activity that may lead to increased gastrointestinal motility and diarrhea.