Pain Management in Neurology Flashcards

A patient with refractory chronic migraine is being considered for occipital nerve stimulation (ONS). What is the theoretical basis for its analgesic effect?

Answer: Direct stimulation of the trigeminal nucleus caudalis via convergent pathways

ONS modulates the trigeminocervical complex where occipital afferents converge with trigeminal pain signals, reducing migraine pain through neuromodulation.

Which cognitive-behavioral therapy (CBT) technique is specifically evidence-based for catastrophizing in chronic pain patients?

Answer: Cognitive restructuring targeting pain-related helplessness and magnification

Cognitive restructuring directly addresses the three components of pain catastrophizing — magnification, rumination, and helplessness — with the strongest evidence base.

A 70-year-old patient with chronic pain requires analgesic therapy. Which analgesic is considered LEAST appropriate in elderly patients due to risk of anticholinergic effects and CNS toxicity?

Answer: Meperidine (pethidine)

Meperidine is contraindicated in elderly patients because its active metabolite normeperidine accumulates causing seizures, tremors, and CNS toxicity; it is on the Beers Criteria.

Ketamine's analgesic mechanism in chronic pain states primarily involves:

Answer: NMDA receptor antagonism reducing central sensitization

Ketamine blocks NMDA receptors, interrupting the glutamate-driven central sensitization and wind-up that perpetuate chronic pain states.

In evaluating a patient for chronic pain, the Waddell signs are used to identify:

Answer: Behavioral or psychosocial contributions to low back pain presentation

Waddell signs are non-organic behavioral indicators suggesting psychosocial factors influencing pain presentation, not proof of malingering.

Which finding on skin punch biopsy would confirm a diagnosis of small-fiber neuropathy (SFN) as the cause of burning extremity pain?

Answer: Reduced intraepidermal nerve fiber density (IENFD) below the 5th percentile

Reduced IENFD on skin punch biopsy, typically from the distal leg, is the gold standard pathological confirmation of small-fiber neuropathy.

A patient with spinal cord injury at T6 develops pain below the level of injury. This is best classified as:

Answer: Central neuropathic pain at-level and below-level SCI pain

Pain below the level of a spinal cord injury is classified as central neuropathic pain arising from the injured spinal cord itself, distinct from peripheral or nociceptive mechanisms.