Question of the Month Archives - Page 11 of 15 - Society for Pediatric Pain Medicine

Question of the Month – October 2020

Welcome to your Question of the Month - October 2020

Ingy Iskander MD
Assistant Instructor
UT Southwestern Medical Center and Children's Medical Center

You have been asked to perform a stellate ganglion block on a 17-year-old male with complex regional pain syndrome. To avoid radiation exposure and in order to visualize the neurovascular anatomy you decide to perform the block under ultrasound guidance. Below is the image you obtain:

Which letter represent the best location for local anesthetic deposition:

Question of the Month – January 2020

Patricia Richardson, PhD
Pediatric Pain Psychology Postdoctoral Fellow
Stanford University

A 16-year-old girl presented with widespread musculoskeletal pain and headaches. Symptoms were treated with medication management and outpatient physical therapy (PT). Several months into follow-up, the patient was not making progress, continued to report elevated pain, and had stopped attending school. It was revealed that she was not taking prescribed medication or engaging in PT because she did not think these services would be helpful. Her life was further complicated by ongoing stress related to poor familial relationships and her parents’ impending divorce.

Addressing complex family dynamics that may be contributing to symptom presentation and undermining treatment progress

Supporting medication and physiotherapy adherence by developing intrinsic motivation for the patient to take medications as prescribed

Commence report to child protective services for parental medical neglect

Teach the child pain self-management techniques to directly reduce pain intensity

Support acquisition of academic accommodations (e.g. 504 plan or individualized education plan) that allow the patient to remain at school

Question of the Month – November 2019

Written by Ben Ekstrom MD, FAAP
Center for Pain Relief

A 15-year-old, otherwise healthy female gymnast presents to the pediatric chronic pain clinic with a six-month history of low back pain. The pain has been getting progressively worse over time and is not associated with any radicular symptoms. There was no significant injury prior to the onset of pain. She has been missing practices with increasing frequency. Her mood and academic performance are beginning to be impacted by the back pain. You suspect she may have developed lumbar spondylolysis. With regards to this disease, which of the following is NOT true?

A. Plain film oblique radiographs, magnetic resonance (MR) imaging, radionucleotide bone scan, and axial helical computed tomography (CT) can all detect spondylolysis.

B. Surgical stabilization may be needed for high grade spondylolisthesis.

C. Sports which require repeated hyperextension, such as gymnastics, football, and weight lifting, are associated with increased risk of pars interarticularis fracture.

D. This patient should be referred immediately to physical therapy for active lumbar extension resistive/strengthening exercises.

E. Imaging should be considered in all children who have had back pain for more than 1 month, or in whom signs or symptoms of serious pathology are present.

Question of the Month – October 2019

Question of the Month – September 2019

Written by:
Genevieve D’Souza, MD
Stanford 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 9^th 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.

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