Question of the Month – October 2019 Written by Tim Casias, MDUniversity of Wisconsin, American Family Children's Hospital Which of the following intra-operative pain treatments has been shown to enhance post-operative analgesia following multilevel posterior spinal fusion in an otherwise healthy teenager with no other pain co-morbidities? A) Lidocaine infusion B) Methadone intravenous C) Ketamine infusion D) Remifentanil infusion Time's up
Question of the Month – September 2019 Written by:Genevieve D’Souza, MDStanford University A 16 year old boy presents to the pediatric chronic pain clinic with 5 month history of daily headaches. Onset of headaches correlated with the start of 9th grade in a new high school. His headache is in the occipital area radiating to the top of his head bilaterally. His grades have dropped significantly as he is absent 2-3 days/week and comes home early from school the other days. He reports being stressed from missing all the school work and now having to make up all the work. He reports difficulties in falling asleep and is playing videogames for 2-4 hrs at night as he can’t fall asleep. He was trialed on triptans and gabapentin but had to discontinue them due to side effects. Review of the chart reveals a normal MRI of the head. On examination, he has a normal neurological exam with positive bilateral occipital neuralgia. He has been taking acetaminophen every 4 hours and ibuprofen every 6 hours, in scheduled fashion. Which option would not be the recommended next step in management? A. Recommend discontinuation of daily acetaminophen/NSAIDS to prevent medication overuse headache. B. Consider administration of bilateral occipital nerve blocks for occipital neuralgia. C. Formal referral to rest of the multidisciplinary chronic pain team in order to incorporate lifestyle modification, sleep hygiene skills, acupuncture, and referral to a psychologist. D. Continue daily acetaminophen and ibuprofen, and also add triptans. Time's up
Question of the Month – August 2019 Written by: Deepa Kattail, MD MHS FAAP McMaster University, Hamilton, Ontario, CanadaA 15 year old girl presents to the pediatric chronic pain clinic as referral from the family doctor. She complains of widespread musculoskeletal pain in her back, neck, shoulders, arms. Her mother is quite tearful and describes how much the pain has disrupted her daughter's life. She was previously a straight A student but now is struggling in school and misses at least one day of school per a week for the last one year. The patients also reports feelings of sadness and crying. Review of the chart reveals normal MRI of the spine, xray of bilateral arms also normal. On examination, she was tender in the areas of pain complaints but was otherwise grossly normally neurologically and had no issues with radicular pain symptoms. She has been prescribed NSAIDs by her family doctor. She is asking for help with pain management. What would be the best next step in managing this patient's pain? A. Prescribe enteral oxycodone to be taken as needed for pain. B. Provide epidural steroid injections for treatment of her back pain. C. Consider an interdisciplinary approach to pain management, including referral to psychologist and physiotherapist to further investigate multifactorial causes of pain. D. Decline referral, this patient would be best treated by a mental health program. Time's up
Question of the Month – July 2019 Written by: Sam Nia, MDUMass Memorial Medical Center, Worcester, MA You are covering the pediatric acute pain/ regional service and are called to the bedside in the holding area to evaluate a 7 month old female who is scheduled to undergo a right cleft lip and cleft palate repair. The patient’s parents are extremely concerned about perioperative opiate use for this patient and would prefer the patient receive the least amount of opiates possible. The patient has no other significant medical and prenatal history. You are asked if there are any regional anesthesia options available for their child. Which regional technique, if any, could be used in this case? A. Sphenopalatine Ganglion block using lidocaine-soaked pledgets in the nares B. Glossopharyngeal nerve blocks using landmark technique C. Suprazygomatic Maxillary Nerve blocks with ultrasound guidance D. There is no regional technique that could help in this situation Time's up
Question of the Month – June 2019 Written by: Bob Wilder, MD The Mayo Clinic, Rochester, MN A 15-year-old girl developed an acute viral intestinal illness several months ago with nausea, vomiting and diarrhea. These symptoms resolved in 7 – 10 days, but she has had postprandial right upper quadrant abdominal pain since. She notes that she also hurts with exercise. A pediatric gastroenterologist has seen her and has completed a workup consisting of a normal abdominal ultrasound, an EGD that was normal both visually and by pathology. Disaccharidase levels are normal. Gastric emptying studies were also normal. Fructose breath test was normal. Abdominal radiograph shows “non-obstructive pattern with mild to moderate stool in the colon.” She may have increased pain with bearing down to have a bowel movement, but it returns to baseline thereafter. On exam the gastroenterologist states she has a “positive Carnett’s sign” in the right upper quadrant. What is a Carnett’s sign? A) Carnett’s sign is increased abdominal wall tenderness when the abdominal wall muscles are tensed. B) Carnett’s sign is pain in the right lower abdominal quadrant on palpation of the left side of the abdomen. C) Carnett’s sign refers to pain upon removal of pressure rather than application of pressure to the abdomen. D) Carnett’s sign is pain when the patient is asked to cough whilst tensing the psoas muscle. Time's up