1. Complete the following statements about pain:

G7 p.548:40mm

a. Three types of pain are

     i. n _____

nociceptive

     ii. d _____

deafferentation

     iii. s _____ m _____

sympathetically maintained

b. Two types of nociceptive pain are

     i. s _____

somatic

     ii. v _____

visceral

c. Two sites of electrical stimulation for pain in deep brain are

     i. peria _____ _____

periaqueductal gray

G7 p.567:135mm

     ii. periv_____ _____

periventricular gray

2. Complete the following statements about craniofacial pain syndromes:

G7 p.549:83mm

a. Tic convulsif is g _____ neuralqia plus h_____ spasm.

geniculate; hemifacial

b. Ramsay Hunt syndrome is p _____ q _____ n _____.

postherpetic geniculate neuralgia

c. Tolosa-Hunt syndrome is s_____ o _____ f _____ i _____.

superior orbital fissure inflammation

d. Raeder neuralgia is p_____ n _____.

paratrigeminal neuralgia

3. Characterize craniofacial pain syndromes.

G7 p.549:120mm

Hint: sunct

a. s _____ _____

short lasting

b. u _____

unilateral

c. n _____ _____ with

neuralgiform headache

d. c _____ _____ and

conjunctival injection

e. t _____

tearing

f. brief—about _____

2 minutes

g. near the_____

eye

h. occurs_____ _____per day

multiple times

     i. affects_____

males

4. Complete the following regarding primary otalgia:

G7 p.550:40mm

a. It may have its origin from which nerves?

fifth, seventh, ninth, tenth, and occipital nerves

b. Cocainization of the pharynx producing pain relief suggests_____ _____ instead of primary otalgia.

glossopharyngeal neuralgia

c. Treatment includes

     i. medicines: T_____, D_____, and b_____

Tegretol, Dilantin, and baclofen

     ii. surgical procedures of decompression by m_____ d_____ or sectioning n_____ f_____ of the n_____ i_____ and n_____ and t_____ CN

microvascular decompression (MVD), nerve fibers, nervus intermedius, ninth and tenth CN

5. Characterize trigeminal neuralgia (TGN).

G7 p.551:120mm

a. The incidence is _____.

4/100,000

b. The percentage of multiple sclerosis (MS) patients who have TGN is _____%.

2%

c. The percentage of bilateral TGN patients who also have MS is _____%.

18%

d. It is pathophysiologically caused by _____.

ephaptic transmission from large myelinated A fibers to poorly myelinated A delta and C fibers

e. It is caused

     i. most commonly by _____ _____ _____

superior cerebellar artery (SCA)

     ii. or _____ _____ _____ _____

persistent primitive trigeminal artery

     iii. or _____ _____.

basilar artery

6. Complete the following statements about craniofacial pain syndromes:

G7 p.552:80mm

a. What should the neurologic exam be in a patient with trigeminal neuralgia?

entirely normal

b. How effective is Tegretol?

pain relief in 69%

c. What if Tegretol has no effect?

The diagnosis of trigeminal neuralgia is suspect.

d. What is the second drug of choice for trigeminal neuralgia?

baclofen (Lioresal)

e. The two special precautions needed with the use of this medication are as follows:

     i. It may be_____.

teratogenic

     ii. Don’t _____ _____.

stop abruptly

7. Medicines for trigeminal neuralgia include the following:

G7 p.552:155mm

a. a_____

amitriptyline (old)

b. b_____

baclofen

c. c_____

carbamazepine, clonazepam, capsaicin

d. D_____

Dilantin

e. E_____

Elavil

f. g_____

gabapentin

g. L_____

Lamictal

h. o_____

oxcarbazepine

8. Oxcarbazepine

G7 p.553:20mm

a. aka_____

trileptal

b. is metabolized into_____.

carbazepine

c. It is useful because patients can tolerate _____ _____.

higher doses

9. What is the basis upon which percutaneous procedures treat trigeminal neuralgia?

G7 p.553:167mm

a. They destroy_____ _____,

nociceptive fibers

b. which are_____ _____

A Δ and C

c. and preserve_____,

touch fibers

d. which are_____ _____.

A α and β

10. Which treatment procedure is most helpful in trigeminal neuralgia in multiple sclerosis patients?

percutaneous techniques (Microvascular decompression [MVD] does not work well for multiple sclerosis [MS] patients with trigeminal neuralgia [TGN].)

G7 p.553:167mm

11. State the benefits of percutaneous microcompression (PMC).

G7 p.554:175mm

a. Patient can choose to avoid_____ _____.

major surgery

b. With multiple sclerosis and trigeminal neuralgia treatment

     i. Which procedure is best?

balloon PMC

     ii. Does it respond to microvascular decompression?

not well

c. Occurrences of intraoperative hypertension are_____.

less with PMC than with radiofrequency

d. Reports of intracranial hemorrhage?

none reported with PMC

12. Answer the following concerning trigeminal neuralgia (TGN) and microvascular decompression (MVD):

G7 p.554:175mm

a. True or False. It is appropriate for an older age group.

false (not to be used on persons over 65)

b. True or False. It may produce anesthesia dolorosa.

false (It does not occur with MVD.)

c. It has a mortality rate of _____%.

1%

d. It has a major neurologic morbidity of _____%.

1 to 10%

e. It has a failure rate of_____%.

20 to 25%

f. True or False. It is the procedure of choice in MS patients.

false (MS patients do not respond to MVD.)

g. What is the procedure of choice in MS patients?

percutaneous microcompression (PMC) (i.e., balloon)

h. What is the recurrence rate in MS patients?

50% in 3 years with percutaneous techniques

13. Complete the following about TGN and the benefits of stereotactic radiosurgery:

G7 p.555:78mm

a. Complete pain relief is achieved in_____%.

65%

b. There is significant pain reduction in an additional _____%.

15 to 30%

14. Complete the following about TGN and electrode positioning:

G7 p.556:140mm

a. Positioning for percutaneous approach

     i. lip:_____

lateral to lip 2 to 3 cm

     ii. eye:_____

medial aspect of pupil

     iii. ear:_____

3 cm anterior to external auditory meatus

b. X-ray landmarks

     i. anteroposterior (AP)—submental vertex, aim for_____

foramen ovale

     ii. lateral x-ray, aim for_____

10 mm below floor of sella along clivus

15. Characterize complications of radiofrequency trigeminal rhizotomy.

G7 p.558:55mm

a. masseter weakness_____%

24%

b. anesthesia dolorosa_____%

4%

c. neuroparalytic keratitis_____%

4%

d. oculomotor paresis_____%

2%

e. How would you identify pterygoid muscle weakness?

     i. ask patient to_____

open mouth

     ii. chin deviates to side of_____

weak pterygoid

16. Describe microvascular decompression (MVD) complications.

G7 p.561:150mm

a. mortality_____%

0.22 to 2%

b. morbidity_____%

1 to 10%

c. hearing loss_____%

3%

d. infarction_____%

0.6%

e. success rate_____%

75 to 80%, approximately 60% of original group

17. Complete the following about supraorbital and supratrochlear nerves:

G7 p.562:115mm

a. They arise from the_____nerve.

Frontal

b. The larger of the two is the_____.

supraorbital

c. It exits the orbit via the_____notch.

supraorbital

d. It is located within the_____third of the orbital roof.

medial

e. Which nerve is most medial?

supratrochlear

18. Complete the following about supraorbital neuralgia (SON):

G7 p.563:36mm

a. True or False. SON can be differentiated from trigeminal neuralgia.

true

b. SON lacks_____zones.

trigger

c. SON lacks_____ _____-like pain.

electric shock

19. Characterize glossopharyngeal neuralgia.

G7 p.563:100mm

a. Pain is located in

     i. base of t_____ = g_____and

tongue = glosso

     ii. t_____ = p_____

throat = pharyngeal

b. Other symptoms

     i. h_____

hypotension—vagus

     ii. s_____

syncope

     iii. c_____ a_____

cardiac arrest

20. Describe glossopharyngeal neuralgia.

G7 p.563:110mm

a. The incidence is_____ in_____ persons.

1 in 1,775,000 (1/70 as frequent as trigeminal neuralgia; trigeminal neuralgia occurs 4/100,000 [i.e., 1/25,000])

b. Pain occurs in t_____, b_____ of t_____, e_____, n_____

throat, base of tongue, ear, neck

c. Treatment includes

     i. medicine: c_____

cocainization

     ii. surgery: m_____ d_____

microvascular decompression

     iii. section of n_____ and u_____ t_____ of t_____ n_____

ninth and upper third of tenth nerve

21. Complete the following concerning geniculate neuralgia:

G7 p.563:180mm

a. Pain is located_____.

deep in the ear, eye, cheek

b. It is called_____.

prosopalgia

c. If there are herpetic lesions this is called R_____ H_____ s_____.

Ramsey Hunt syndrome

d. If combined with hemifacial spasm it is called t_____ c_____.

tic convulsif

e. Treatment

     i. medicine_____

same as trigeminal neuralgia

     ii. surgery_____ _____

microvascular decompression of seventh nerve

     iii. What vessel is involved?

AICA—compressing sensory and motor roots of seventh nerve

22. Complete the following about herpes zoster:

G7 p.564:120mm

a. The etiologic agent is h_____ v_____ z_____ v_____.

herpes varicella zoster virus

b. It involves the eye in_____%.

10%

c. Pain lasts_____.

2 to 4 weeks

d. Long-term pain persists in_____%,

10%

e. called p_____ n_____.

postherpetic neuralgia

f. Vesicles and pain run in the

     i. distribution of the d_____

dermatome

     ii. not the p_____ n_____.

peripheral nerve

g. Treatment is with

     i. c_____ and

capsaicin

     ii. a_____.

amitriptyline

23. Complete the following about postherpetic neuralgia:

G7 p.465:105mm

a. With an acute attack of herpes zoster, you may treat with e_____ or i_____ i_____.

epidural or intercostal injection

b. For acute treatment use

     i. a_____ or

acyclovir

     ii. v_____

valacyclovir

c. For postherpetic neuralgia use

     i. Z_____ (c_____)

Zostrix (capsaicin)

     ii. N_____(g_____)

Neurontin (gabapentin)

     iii. E_____ (a_____)

Elavil (amitriptyline)

d. Start treatment with

     i. I_____ p_____, which is

lidocaine patches

G7 p.465:170mm

     ii. better tolerated in the_____.

Elderly

G7 p.465:155mm

24. Usual maximum oral narcotic dose tolerated is_____.

MS contin (up to 300 to 400 mg/day)

G7 p.567:95mm

25. Name intracranial ablative procedures to treat the following pains:

G7 p.567:157mm

a. cancer pain: m_____ t_____

medial thalamotomy (stereotactic procedure used for nociceptive cancer pain)

b. head, neck, face pain: s_____ m_____

stereotactic mesencephalon lesion 5 mm lateral to aqueduct at level of inferior colliculus; diplopia may occur

c. suffering from pain: c_____

cingulotomy—bilaterally (modifies affect use MRI— recurs in approximately 3 months)

26. Matching. Match the procedure and its application (some have more than one).

G7 p.567:170mm

Applications for pain from:

spinal cord injuries; post-laminectomy pain; pelvic pain with incontinence; at or below C5; head, face, neck, upper extremity; bilateral below diaphragm; causalgia; bilateral below thoracic dermatomes; avulsion injuries; not for cancer pain

Procedure:

a. stereotactic mesencephalotomy

b. cordotomy

c. spinal intrathecal

d. sacral cordotomy

e. sympathectomy

f. commissural myelotomy

g. dorsal root entry zone (DREZ)

, ,

h. spinal cord stimulator

,

27. Complete the following concerning cordotomy:

G7 p.568:80mm

a. Your objective is to interrupt the fibers of the_____ _____ _____ _____ on the side_____ to the pain.

lateral spinal thalamic tract; contralateral

b. Cordotomy is the procedure of choice for_____ pain below the_____ dermatome.

unilateral; C5

c. Two ways to perform cordotomy are

     i. _____

open

     ii. _____

percutaneous

d. Loss of automatic breathing can occur after_____ _____and is called_____ _____.

bilateral cordotomy; Ondine curse

e. What is the cutoff percentage on pulmonary function test before patients can undergo cordotomy?

50%

28. Answer the following about pain procedures:

G7 p.568:165mm

a. What kind of patients are candidates for cordotomy?

terminally ill patients

b. On which side should the cordotomy be performed?

contralateral to the pain

c. What happens to impedance as the needle penetrates the cord?

jumps from 300 to 500 ohms to 1200 to 1500 ohms.

d. What response should stop cordotomy from being performed?

muscle tetany upon stimulation

e. If you look at the eye what will you learn?

if there is a Horner syndrome ipsilaterally the procedure is satisfactory

f. What percent will have pain relief?

94%

29. Answer the following concerning commissural myelotomy:

G7 p.570:75mm

a. What is the indication for commissural myelotomy?

bilateral or midline pain

b. What is the rate of complete pain relief after commissural myelotomy?

60%

c. What is the special requirement for intrathecal morphine?

preservative-free 0.9% saline

30. Answer the following regarding central nervous system (CNS) narcotic administration:

G7 p.571:88mm

a. Requirement for implantation of a morphine pump is_____ _____ _____.

preoperative testing dose

b. _____ _____ can shorten the delay time for a morphine pump to function; otherwise the relief may not occur for_____.

Bolus infusion; days

c. Is meningitis common after pump placement?

no

d. Is respiratory failure common after pump placement?

no

31. Complete the following concerning spinal cord stimulation:

G7 p.572:175mm

a. Site of spinal cord stimulation is the_____ _____.

dorsal column

     i. The most common indication is _____ _____ _____.

postlaminectomy pain syndrome

G7 p.573:28mm

     ii. It is not usually indicated for_____ _____.

cancer pain

b. Two kinds of electrodes are

     i. p_____-like

plate

G7 p.573:60mm

     ii. w_____-like

wire

32. Complete the following regarding deep brain stimulation:

G7 p.575:15mm

a. Periventricular stimulation will be beneficial for_____pain.

nociceptive

b. A lesion at the_____ _____ _____ _____can help phantom limb pain.

dorsal root entry zone

c. Rate of recurrence after thalamotomy for pain is_____% in_____.

60% in 6 months

33. Complete the following about dorsal root entry zone (DREZ) lesions:

G7 p575:45mm

a. They are useful for_____pain.

deafferentation

b. They result from nerve root_____.

avulsion

c. They most commonly occur from_____accidents.

Motorcycle

d. For such an injury, pain relief can be expected in_____%.

80 to 90%

G7 p575:115mm

34. Complete the following about thalamotomy:

G7 p.575:143mm

a. It is used_____.

rarely

b. Target is the_____thalamus.

medial

c. Cancer pain control occurs in_____%

50%

G7 p.575:143mm

d. but by 6 months only in_____%.

20%

e. Neuropathologic pain control is successful in only_____%.

20%

35. Complete the following statements about causalgia:

G7 p.576:54mm

a. Triad to diagnose causalgia

     i. a_____ d_____

autonomic dysfunction

     ii. b_____ p_____

burning pain

     iii. t_____ c_____

trophic changes

b. What is the cause of major causalgia?

high-velocity missile injury

c. Allodynia is pain induced by_____ _____.

non-noxious stimulus

d. Signs of causalgia are

     i. tapered_____

fingers

     ii. hands are_____and_____

cold and moist

     iii. touching causes_____

pain

     iv. also known as_____

allodynia

G7 p.576:170mm

e. Current name for causalgia is_____ _____ _____ _____.

complex regional pain syndrome (CRPS)

36. Complete the following statements about causalgia:

G7 p.577:84mm

a. Medical treatment for causalgia uses_____ _____.

tricyclic antidepressants

b. A common agent used for intravenous injection for causalgia is_____.

guanethedine

c. Surgical sympathectomy may relieve the pain of causalgia in_____%.

90%

G7 p.577:103mm