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(Steele) Anesthesia Pharm Grayson (Spring 2023) > Pain Pathways (Exam II) > Flashcards

Pain Pathways (Exam II) Flashcards

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1
Q

Differentiate the sensory-discriminative & motivational-affective aspects of pain.

A
  • Sensory-discriminative - Ascending pathways and the perception of pain (location, intensity, sensation, etc.)
  • spinothalamic and trigemino-thalamic –> cerebral cortex –> perception of pain
  • Motivational affective - responses to painful stimuli (Ex. arousal, reflexes, endocrine responses, and emotional changes)
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2
Q

What is nociception?

A
  • The experience of pain through a series of complex neurophysiologic processes.
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3
Q

What are the four stages of pain perception?

A
  1. Transduction (tissue level, nerve endings)
  2. Transmission (via nerves)
  3. Modulation (via spinal cord, PNS and CNS)
  4. Perception (CNS, Thalamus)
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4
Q

Where does the modulation of pain impulses occur?

A
  • Dorsal horn of the spinal cord
  • Can be inhibitory or excitatory
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5
Q

What drugs are used to affect the transduction of pain?
What specifically is being affected by these drugs?

A
  • Local anesthetics & NSAIDs
  • Peripheral nociceptors
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6
Q

What drugs are used to affect the transmission of pain?
What specifically is being affected by these drugs?

A
  • Local anesthetics
  • Αδ (A-delta) and C fibers
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7
Q

What drugs are used to affect the modulation of pain?
What specifically is being affected by these drugs?

A
  • LA’s, opioids, ketamine, α2 agonists
  • Afferent fibers of the dorsal horn
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8
Q

What drugs are used to affect the perception of pain?
What specifically is being affected by these drugs?

A
  • General anesthetics, opioids, α2 agonists
  • Brain
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9
Q

Where does the modulation of pain impulses occur?

A. Thalamus
B. Dorsal Horn
C. Cortex
D. CNS

A

B. Dorsal Horn

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10
Q

Where are nociceptors located?

A
  • Skin
  • Muscles
  • Joints
  • Viscera
  • Vasculature
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11
Q

What characterizes afferent C-fibers?

A
  • Unmyelinated
  • Pain from heat (burning) & sustained pressure
  • Slow (less than 2 m/s)
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12
Q

What characterizes A-fibers?

A

-Myelinated
- Type I: Aβ & Aδ (heat, mechanical, chemical)
- Type II: Aδ (heat)
- Fast (>2 m/s)

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13
Q

What chemical mediators of pain are targeted with spinal anesthetics?

A

Peptides

  • Substance P
  • Calcitonin
  • Bradykinin
  • CGRP
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14
Q

Which chemical mediator is released first in response to injury?

A
  • Bradykinin
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15
Q

What chemical mediators of pain are inhibited by NSAIDs?

A

Lipids
- Prostaglandins
- Thromboxanes

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16
Q

What chemical mediators of pain are inhibited by cannabis?

A

Lipids
- Endocannabinoids

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17
Q

What can be found on the pain pathway after transmission and before modulation?

A

The Dorsal Root Ganglion

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18
Q

Receptors and channels found in the DRG and the Peripheral Terminals (7)

A
  • Purinergic
  • Metabotropic
  • Glutamatergic
  • Tachykinin
  • TRPV I
  • Neurotrophic
  • Ion Channels
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19
Q

What is sensitization?

A
  • Decreased pain threshold (likely due to upregulation of receptors)
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20
Q

Differentiate hyperalgesia and allodynia.

A
  • Hyperalgesia - ↑ pain sensations to normally painful stimuli.
  • Allodynia - perception of pain to things that aren’t normally painful.
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21
Q

What characterizes primary hyperalgesia?

A

Hyperalgesia at original site of injury.

  • Lower pain threshold
  • Spontaneous pain
  • Increased response to suprathreshold stimuli
  • Expansion of receptive field
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22
Q

What characterizes secondary hyperalgesia?

A
  • Sensitization of CNS → hyperalgesia from uninjured skin surrounding injury only from mechanical stimuli.
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23
Q

What area of the brain accounts for the perception (location & intensity) of pain and is also called the forebrain?

A
  • Somatosensory Cortex I & II (SI & SII)
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24
Q

What is the relay center for nociceptive and sensory activity?
How does sensory activity travel from this area to the cerebrum?

A
  • Spinal Dorsal Horn
  • Ascending pathways
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25
What areas of the brain may depress or facilitate the integration of painful information in the spinal dorsal horn?
- **PAG** - Peraqueductal Gray Matter - **RVM** - Rostral Ventral Medulla
26
The perception of motivational-affective pain components are found where?
Limbic Cortex and Thalamus
27
What are the 2 main parts of the brain stem?
- **PAG** - Peraqueductal Gray Matter - **RVM** - Rostral Ventral Medulla
28
Where are afferent C-fibers located in the spinal column?
- Dorsal horn: Lamina I & II
29
What is another name for Lamina II? What drugs work here?
- Substantia gelatinosa - Opioids
30
Where are the NK-1 receptors found?
On Laminae III and IV where **substance P** is used
31
What NT is targeted when using spinal anesthesia?
**Substance P**
32
Gate open part of theory, pain is projected to the ____ regions
**supraspinal brain**
33
What nerve fibers are associated with an "open-gate" for pain? What nerve fibers can shut this gate?
- Aδ & C-fibers = **open** - Aβ fibers = **closed**
34
Aβ fibers are? They are found in?
Large, myelinated, and faster Laminae I, IV, and VII in ventral horn
35
What receptors does ketamine target for pain modulation?
- NMDA
36
The excision of what structure would result in the complete loss of perception of pain?
Amygdala *Bonus points if you just said the whole brain you degenerate*.
37
What neurotransmitters propagate excitatory transmissions in the spinal column?
- Glutamate - Calcitonin - Neuropeptide Y - Aspartate - Substance P
38
What neurotransmitters propagate inhibitory transmissions in the spinal column?
- GABAA - Glycine - Enkephalins - NorEpi - Dopamine
39
What are the four ascending pain pathways?
- Spinothalamic - Spinohypothalamic - Spinomedullary - Spinobulbar
40
What information is carried by the spinothalamic pathway? What laminae are used?
- Pain, Temp, & Itch - Laminae I, VII, and VIII
41
What information is carried by the spinobulbar pathway? What laminae are used?
- Behavior towards pain - Laminae I, V, and VII
42
What information is carried by the spinohypothalamic pathway? What laminae are used?
- Autonomic, neuroendocrine & emotional aspects of pain - Laminae I, V, VII, & X.
43
What part of the supraspinal pathway differentiates where pain is coming from?
Forebrain: S1 & S2 (Somatosensory cortex 1 & 2)
44
What supraspinal areas deal with the emotional/motivational aspects of pain?
The limbic system: - Anterior cingulate cortex (ACC) - Insular Cortex (IC) - Amygdala
45
Where do the descending inhibitory tracts originate? Where do they then synapse at?
- PAG (periaqeueductal gray matter) - Synapse at dorsal horn
46
What neurotransmitters are increased with exercise? What part of the pain tract are they a part of?
- Endorphins - Enkephalins - Serotonin The supraspinal descending inhibitory tracts
47
How do inhibitory tracts inhibit the propagation of painful stimuli?
**Hyperpolarizing Aδ & C fibers** - ↓ release of substance P - ↑ pK⁺ and inhibiting Ca⁺⁺ channels
48
Where does the pain inhibiting impulse originate from in the descending inhibitory tracts?
PAG-RVM areas
49
What are two aspects of the descending pathways of pain modulation?
Descending **Inhibition** Pathway (DI) Descending **Facilitation** Pathway (DF)
50
When is pain considered chronic rather than acute?
- If > 3 - 6 months - If pain persists beyond tissue healing
51
Who is at increased risk of neuropathic chronic pain?
- Cancer patients - Diabetics
52
What are the two types of neuropathic pain?
Allodynia and hyperalgesia
53
What is the treatment for chronic neuropathic pain? (4)
- Cannabis - Opioids - Amitriptyline - Gabapentin *All situation dependent*
54
How is visceral pain characterized? What examples were given in lecture?
- Diffuse and poorly localized - referred to somatic sites - skin and muscles
55
Causes of visceral pain
Ischemia stretching of ligaments spasms distention
56
What is complex regional pain syndrome?
- Variety of painful issues **following an injury** - IE: Spontaneous pain, allodynia, hyperalgesia, edema
57
When can babies begin to perceive pain?
23 weeks | Lower pain threshold and exaggerated responses
58
How does pain affect the GI/GU system?
- ↑ SNS = ↑ sphincter tone and ↓ peristalsis = **N/V, ileus, distension**, etc. - Stress ulcers --> aspiration | N/V - intraop could be from gasses, Post op could be from pain
59
How can the effects of pain in the cardiovascular system be summarized?
↑ SNS *↑BP, HR* Myocardial ischemia Myocardial irritability Compromised LV ↓ CO
60
What hormones experience a decrease in response to chronic pain?
**Anabolic Hormones** - Insulin - Testosterone
61
What are the pulmonary effects of chronic pain?
- Shallow breathing → **atelectasis and pneumonia.** - Intrapulmonary shunting - impaired coughing
62
What hormones experience an increase in response to chronic pain?
**Catabolic hormones** - Catecholamines - Cortisol - Glucagon
63
Pain effects on the hematologic system
- platelet adhesiveness - Reduced fibrinolysis - hypercoagulability
64
Immune responses to pain
Stress related - Leukocytosis - Depressed reticuloendothelial system - increased infection

(Steele) Anesthesia Pharm Grayson (Spring 2023) (20 decks)

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