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Anaesthesiology
Chronic Pain Management
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
14 sections · 187 slides
Overview
- Scope of this topic
- Roadmap
- Key points of this topic
- Further key points
Anatomy, physiology and neurochemistry of pain processing
- Primary afferent fibres
- Primary afferent fibres and their function
- A-beta fibres
- Nociceptors: A-delta and C fibres
- First pain and second pain
- Sodium channels in pain sensing
- Transient receptor potential channels
- Neurochemistry of the primary afferent
- Transmitters released in the dorsal horn
- Entry of primary afferents into the spinal cord
- Rexed laminae of the spinal grey matter
- Layers of the spinal dorsal horn
- Somatic versus visceral C fibre termination
- Nociceptive projection neurons
- Ascending pathways
- Spinothalamic tract
- Spinohypothalamic, limbic and cortical connections
- Descending pain inhibition
- Rostral ventral medulla and dorsolateral pontine tegmentum
- Higher cortical processing
- Roles of the cortical pain regions
Transition from acute to chronic pain
- Failure of adaptation in pain sensation
- Peripheral and central sensitisation
- From injury to a chronic pain state
- Neuroma formation after nerve injury
- Humoral factors and tumour necrosis factor alpha
- Phenotypic switch of A-beta fibres
- Interaction of central and peripheral mechanisms
- Definitions used in pain medicine
Spine pain and radicular pain syndromes
- Causes of spine pain
- Herniated disc and radicular pain
- Chemical radiculitis
- Rationale for epidural steroid injections
- Limits on epidural steroid use
- Transforaminal epidural injection
- Interlaminar versus transforaminal approach
- Technique-related complications of epidural steroids
- Systemic effects of injected steroid
- Lowest effective steroid doses
- Central nervous system injury after epidural steroids
- Particle size of injectable steroids
- Particulate versus nonparticulate steroid
- 2015 safety recommendations for epidural steroid injections
Facet joint syndrome
- Clinical features of facet syndrome
- Medial branch block of the lumbar facet joints
- Facet joint injection with contrast
- Steroid dose in facet intra-articular injection
- Outcomes of facet radiofrequency ablation
Buttock pain: sacroiliac joint and piriformis syndromes
- Clinical features and provocative tests of sacroiliac joint syndrome
- Sacroiliac joint injection
- Injection treatment of sacroiliac joint dysfunction
- Cranial spread of contrast at the sacroiliac joint
- Denervation of the sacroiliac joint
- Water-cooled radiofrequency denervation targets
- Piriformis syndrome: presentation
- Aggravating factors and examination in piriformis syndrome
- Confirmatory signs in piriformis syndrome
- Treatment of piriformis syndrome
Myofascial pain syndrome and fibromyalgia
- Features of myofascial pain syndrome
- Injection and needling of trigger points
- American College of Rheumatology criteria for fibromyalgia
- Neurochemistry of fibromyalgia
- Treatment of fibromyalgia
Neuropathic pain syndromes
- Acute herpes zoster
- Antiviral drugs and vaccination
- Drug treatment of postherpetic neuralgia
- Combination therapy and drug ranking
- Diabetic painful neuropathy: epidemiology and pathophysiology
- Pathophysiology of diabetic neuropathy
- Management of diabetic painful neuropathy
- HIV-related sensory neuropathy
- Phantom limb pain
- Prevention and treatment of phantom limb pain
- Complex regional pain syndrome: definition
- Risk factors and features of CRPS
- Drug treatment of complex regional pain syndrome
- Interventional treatment of complex regional pain syndrome
Cancer pain and neurolytic sympathetic blocks
- Types of cancer pain and their responsiveness
- Management of cancer pain and use of opioids
- Anatomy of the celiac plexus
- Retrocrural versus anterocrural celiac plexus neurolysis
- Approaches and guidance for celiac plexus block
- Splanchnic nerve block under fluoroscopy
- Neurolytic agents and volumes
- Celiac plexus block under computed tomography
- Complications of celiac plexus block
- Superior hypogastric plexus block
- Ganglion impar block
Pharmacologic management of pain
- Morphine
- Hydromorphone
- Methadone: advantages
- Methadone: risks
- Oxycodone and fentanyl
- Oxymorphone, buprenorphine and hydrocodone
- Weak opioids: codeine
- Tramadol
- Tapentadol and equianalgesic doses
- Opioids and driving
- Opioids in chronic non-cancer pain
- Risks of opioid therapy
- Predictors of opioid misuse
- Buprenorphine-naloxone therapy
- Drug tiers for neuropathic pain
- Mechanism of antiepileptics in neuropathic pain
- Other ion channel actions of antiepileptics
- Conditions in which antiepileptics are proven
- Gabapentin and pregabalin
- Lamotrigine, topiramate and oxcarbazepine
- Mechanisms of tricyclic antidepressants in pain
- Side effects of tricyclic antidepressants
- Serotonin-noradrenaline and selective serotonin reuptake inhibitors
- Choosing between antidepressant classes
- Number needed to treat for tricyclics
- Daily dosages of commonly used antidepressants and anticonvulsants (mg/day)
- Lidocaine 5% patch
- Capsaicin 8% patch
- Mexiletine
- Cannabinoids in chronic pain
- Recommended drugs for chronic pain syndromes
Interventional techniques
- Contrast media for interventional pain procedures
- Safe use of gadolinium contrast
- Intradiscal electrothermal therapy
- Biacuplasty and the basivertebral nerve
- Vertebral endplates as a pain source
- Lumbar spinal stenosis
- Minimally invasive lumbar decompression
- MILD compared with surgical decompression
- Vertebral compression fractures
- Vertebroplasty and kyphoplasty technique
- Balloon kyphoplasty of the thoracic spine
- Complications of vertebral augmentation
- Evidence for vertebroplasty and kyphoplasty
Neuromodulation and intrathecal drug delivery
- Mechanism of spinal cord stimulation
- Approved indications for spinal cord stimulation
- Trial before permanent stimulator implantation
- Placement of spinal cord stimulator electrodes
- Evidence for spinal cord stimulation
- Waveform modifications in spinal cord stimulation
- Spinal cord stimulation in complex regional pain syndrome
- Peripheral nerve stimulation: open versus percutaneous
- Peripheral nerve field stimulation
- Dorsal root ganglion stimulation
- Rationale for intrathecal drug delivery
- Intrathecal needle placement under fluoroscopy
- Connecting the intrathecal catheter to the pump
- Patient selection for intrathecal drug delivery
- Drugs used in intrathecal delivery
- Intrathecal catheter tip granuloma
- Intrathecal delivery in non-cancer pain
- Complications of intrathecal drug delivery systems
Summary and takeaways
- Summary of the pain pathway
- Summary of syndrome management
- Summary of drugs and interventions
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- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition