Repetera-utvalda

Question 1

2 major Indications for SCS

Answer 1

• Failed back surgery syndrome
• Complex regional pain syndrome

Question 2

SCS mindre vanliga indikationer

Answer 2

• DM neuropathy
• Refractory angina pectoris
• Intercostal neuralgia (ex efter thoracothomy)
• Postherpetic pain
• Painful limb ischemia from inoperable peripheral vascular disease

Question 3

SCS - “functional indications”

Answer 3

• bladderdysfunction
• dystonia
• spastic hemiparesis

Question 4

DBS - pain indication

Answer 4

• deafferentation pain syndromes
• nociceptive pain syndromes
  (*) cluster headaches

Question 5

Types of electrical stimulation for pain modulation

Answer 5

DBS - thalamus (VPM, VPL), Periaqueductal grey matter, Periventricular grey matter

SCS- hela spinalkanalen. från C2-C5 o ned.

Question 6

Intracranial ablative procedures for pain

Answer 6

• Cingulotomy bilaterally
• stereotactic mesencephalotomy - for unilateral head, neck, face and UE pain.

Question 7

Spinal ablative surgical procedures (7)

Answer 7

• Cordectomy - open or percutaneous
• Commissural myelotomy - bilateral pain
• Punctate midline myelotomy - visceral cancer pain
• DREZ lesions - for SCI pain and deafferation pain from root avulsion.
• Dorsal rhizotomy
• Dorsal root ganglionecomy (extraspinal procedure)
• Sacral cordotomy. for pelvic pain if (förutsatt att) the patient have colostomy or ileostomy

Question 8

When is cordotomy used?

Answer 8

for unilateral aching pain below nipple (C5) in a terminally ill patient

Question 9

When is comissural myelotomy used?

Answer 9

for bilateral or midline pain primarily below thoracic level. Incl abdomen, pelvis, perineum and LE.

Question 10

What is a DREZ lesion?

Answer 10

Dorsal root entry zone (DREZ) lesioning is a type of surgery for nerve pain that is used when conservative treatments have not alleviated the patient’s symptoms. This surgery may treat sensory nerve damage by destroying the area where damaged nerves join the central nervous system.

Question 11

What is comissural myelotomy?

Answer 11

Midline or commissural myelotomy is a procedure in which the decussating fibers of the spinothalamic tract are interrupted as they cross in the anterior white commissure of the spinal cord.

Question 12

When is commissural myelotomi an option?

Answer 12

In intractable pain associated with malignancy in the abdominal or pelvic region.

Question 13

When is DREZ indicated?

Answer 13

he dorsal root entry zone (DREZ) lesioning procedure is a treatment for severe pain caused by nerves that have been torn away (avulsed) from the spinal cord or, less commonly, by spinal cord injury. DREZ lesioning may be appropriate when nonoperative pain therapies have not provided relief.

Question 14

What parts can be difficult to reach w SCS?

Answer 14

Midline truncal stimulation between neck and low back pain.

Question 15

SCS: Var ska elektroder placeras för posterior column stimulation och hur upplevs det?

Answer 15

De läggs alltid i dorsal epidural space and give a tingling paresthesia overlaying the area of pain.

Question 16

What are the two ways to introduce electrodes in SCS?

Answer 16

• Tuohy needles, inserted via puncture
• Paddles, inserted via laminotomy.

Question 17

How is the effect/success of an SCS determined?

Answer 17

ALWAYS several day trial period with an external generator before the patient fill out a VAS.
Success= more than 50% pain reduction.

Question 18

SCS: What does IPG mean?

Answer 18

implanted pulse generator.

Question 19

DBS: for deafferentation pain syndromes

Answer 19

• sensory thalamus: VPM or VPL
  For chronic neuropathic pain, 40-50% reduction in 20-60% of patients.

Question 20

DBS: for nociceptive pain syndromes

Answer 20

PVG (perivenricular grey matter)
PAG (periaqueductal grey matter)

Response rate about 20%

Question 21

DREZ lesion

Answer 21

laminectomy over involved segments.
Microscope. Find rootlets above and below.
Lesions created IPSILATERAL to the avulsed nerve root/s.
Radiofrequency current -75 degreeds celsius 15s per lesion (or knife blade).

Question 22

What is cordotomy?

Answer 22

Interruption of lateral spinothalamic tract fibers in the SC.

Question 23

How much painrelief is needed in an intrathecal vs an epidural administration?

Answer 23

5-10 x more in intrathecal.

Question 24

According to Patric Blomstedt and Marwan Hariz, which are the two preferred targets for DBS in Parkinsons disease?

Answer 24

1. The subthalamic nucleus 2. Globus Pallidus interna

Question 25

Which is the ONE absolute preferred target for Parkinssons disease and why is it not always ok to use?

Answer 25

The STN - Subthalamic nucleus. Not always ok if the pt is too old, with cognitive decline or relevant depression. The patient cannot either have medically resistant axial symptoms, such as balance and gait disturbance.

Question 26

Which are the preferred targets for tremors?

Answer 26

zona inserta and Vim.

Question 27

What is the most common side effect of DBS regardless of brain target?

Answer 27

Dysarthria

Question 28

With progression of Parkinssons disease, some features of the disease become less responsive to DBS. What symtoms?

Answer 28

The nondopaminergic axial features.

Question 29

shunt or ETV?

Answer 29

1. AGE? under 1 mo -0% 1 - 6 mo -10% 6mo-1year - 20% 1y - 10 y - 40% over 10 y - 50% 2. Type of hcph? * post infectious - 0% * MMC, non-tectal tumor, post IVH - 20% * aq-stenosis, tectal tumor - 30% 3. Previous shunt? yes - 0% no - 10%

Question 30

The ETV success score is validated for predicting chance of success 6 months after ETV surgery. What does it mean to score 40% or less on the scale?

Answer 30

It means a very low chance of success.

Question 31

What does it mean to have a score over 80% in the ETV success score?

Answer 31

A better chance to succeed with ETV than shunting from the outset.

Question 32

What is the overall successrate for ETV in non-tumoral aqueduct stenosis pt?

Answer 32

60-94%.

Question 33

What 2 nerves from the median nerve needs to be looked out for?

Answer 33

1. Palmar cutaneous branch. 2. **Recurrent motor branch to the thumb.**

Question 34

Elecrtrodiagnostic criteria for the ulnar neuropathy at the elbow?

Answer 34

Not all criteria need to be present and a needle EMG is not needed. * Absolute MN conduction velocity under 50m/s from elbow to above elbow. * Drop of conduction velocity with more than 10m/s in the underarm compared to above elbow. * Amplitude of compound motor action potential normally decreases by distance, but a drop of more than 20% is abnormal. mer sägs men detta är core.

Question 35

Where is the ski incision in a ulnar decompression?

Answer 35

around and below the medial condyle.

Question 36

What is a pancoast tumor?

Answer 36

most often due to bronchogenic ca. Situated close to the brachial plexus * Atrophy of hand muscles * Horner syndrome Radiating pain.

Question 37

How can preganglionic injuries be differentiated from postganglionic?

Answer 37

-proximal or distal to the dorsal root ganglion- Pre ganglionic: * horner syndrome * Wing scapula - long thoracic nerve injury --serratus anterior * Rhomboid paralysis - dorsal scapular nerve * PSeudomeningocele on MRI associated to root avulsion and associated neuropathic pain. EMG - cannot be done until 3 weeks after injury to get a any findings.

Question 38

What does EMG find to suggest preganglionic injury?

Answer 38

* Denervation potentials in paraspinal muscles due to loss of neural input. The posterior ramus of of the spinal nerve originates just distal to the dorsal root ganglion. * Normal sensory nerve action potential - SNAP- preganglionic injuries leave the dorsal ganglion sensory bodies and the distal axon intact. A normal SNAP can therefore be recorded proximally EVEN IN AN ANESTHETIC REGION!

Question 39

Which is the most common lack of function due to a birth brachial plexus injury?

Answer 39

Upper plexus injuries. C5 and C6 and sometimes C7 too.

Question 40

What is a surgical option for birth upper plexus injuries (C5-7)

Answer 40

Nerve transfer if no antigravity in deltoid, bicep or tricep at 3 mo age.

Question 41

What structures are enclosed in the area of a thoracic outlet syndrome?

Answer 41

* The subclavian artery and vein * brachial plexus.