ASIPP Anatomy Questions Flashcards

Question

``` 25. Which of the following nerves is not a branch of the sciatic nerve? A. Superfi cial peroneal B. Saphenous C. Deep peroneal D. Posterior tibial E. Sural ```

Answer 1

25. Answer: B | Source: Day MR, Board Review 2005

Answer 2

26. Answer: B Explanation: (Raj, Pain Review 2nd Ed., page 272) With a gastrectomy the incision may be extended up to the xiphoid process. This can be extremely painful if the catheter is placed to low. Hence T10, T12, L1 catheters may be able to cover some of the pain but it would be insuffi cient. Higher concentrations and volumes would be needed to cover the xiphoid which could put the patient at undue risk of hypotension, muscle weakness, and sensory loss. A catheter at T3 may be appropriate for thoracic surgery but not for upper abdominal surgery. Source: Shah RV, Board Review 2005

Answer 3

27. Answer: D Explanation: (Moore, Developing Human, 6/e, pp 452-456.) After closure of the neural tube, cells proliferate and establish three primitive layers: (1) the ventricular zone adjoining the central canal and ventricles; mitoses of neuronal and glial precursors continue in this zone; (2) a mantle zone consisting of cell bodies of neurons and glia that have migrated out of the ventricular zone; and (3) a marginal zone on the periphery containing the myelinated nerve processes characteristic of white matter. Closure of the neural tube begins near the midpoint of its length and proceeds in both directions simultaneously. The neurectoderm of the neural tube will give rise to neurons and some glial cells (astrocytes, oligodendroglia, and ependymal cells), but the precursors of microglia (the monocyte-macrophage lineage) migrate into the nervous system from the blood. The sensory ganglia are formed by neural crest cells that migrated before the development of mature neurons. Source: Klein RM and McKenzie JC 2002.

Answer 4

28. Answer: E Explanation: The trochlear nerve is purely a motor nerve and is the only cranial nerve to exist the brain dorsally. The trochlear nerve supplies one muscle: the superior oblique. The cell bodies that originate in the trochlear nerve are located in the ventral part of the brain stem in the trochlear nucleus. The trochlear nucleus gives rise to fi bers that cross to the other side of the brain stem just prior to exiting the pons. Thus, each superior oblique muscle is supplied by nerve fi bers from the trochlear nucleus of the opposite side. The nerve travels in the lateral wall of the cavernous sinus and then enters the orbit via the superior orbital fi ssure. It passes medially and diagonally across the levator palpebral superioris and superior rectus muscles to innervate the superior oblique. (Parent, 531) Source: Neurology Examination and Board Review By Nizar Souayah, MD and Sami Khella, MD

Answer 5

29. Answer: D | Source: Day MR, Board Review 2006

Answer 6

30. Answer: D | Source: Day MR, Board Review 2005

Answer 7

31. Answer: C Explanation: (Raj, Pain Review 2nd Ed.) A.The genitofemoral nerve is approached by inserting the needle just lateral to the pubic tubercle. The needle is advanced through the inguinal ligament. B.The iliohypogastric lies 3 cm medial to the ASIS, but the needle is aimed towards the umbilicus. C.The ilioinguinal nerve is approximately 2-3 cm medial and 2-3 cm inferior to the ASIS, but above the inguinal canal.Typically one may feel a ‘pop’ as the needle passes the internal oblique and lies between the internal oblique and transverses abdominis. D.The lateral femoral cutaneous nerve is approached 2cm medial and inferior to the ASIS but the needle is inserted below the inguinal ligament. The needle is advanced through the fascia lata with a pop and loss of resistance. Note that if you advance the needle further and feel a second pop, then you have gone through the fascia iliaca. This is approximately how one would perform a fascia iliaca block in order to avoid the femoral nerve block. Source: Shah RV, Board Review 2003

Answer 8

32. Answer: A Explanation: The arm receives sensory innervation from the brachial plexus except for the shoulder, which is innervated by the cervical plexus, and the posterior medial aspect of the arm, which is supplied by the intercostobrachial nerve.

Answer 9

33. Answer: A Explanation: The skin over the posterior part of the neck, upper back, posterior part of the scalp upto the vertex is supplied segmentally by the posterior rami of the C2 to C5. A. The Greater occipital nerve is a branch of the posterior of ramus of C2. The lesser occipital nerve is a branch of the posterior ramus of C2 and C3. Headaches due to occipital neuralgia are characterized by either continuous pain or paroxysmal lancinating pain in the distribution of the nerve. The etiology of occipital neuralgia is compression of the C2 nerve root, migraine or nerve entrapment. An occipital nerve block maybe performed as a diagnostic or therapeutic measure. Source: Chopra P. 2004

Answer 10

34. Answer: B Explanation: A.The dorsal roots convey sensation to the spinal cord. B.The axial musculature of the back receives innervation from the dorsal primary rami of the spinal nerves. D.The splanchnic nerves and gray rami communicantes are components fo the sympathetic division of the autonomic nervous sytem. E.The ventral primary rami contribute to the cervical plexus, brachial plexus, intercostal nerves, and the lumbosacral plexus.

Answer 11

35. Answer: E Explanation: A. The pterygoid venous plexus communicates with the cavernous sinus via the petrosal sinuses. B. The parietal emissary vein also communicates with the superior sagittal sinus. C. The frontal emissary vein communicates with the superior sagittal sinus via the foramen cecum. D. The basilar venous plexus communicates with the inferior petrosal sinus. E. The superior ophthalmic vein drains the region of the paranasal sinuses and is directly connected with the cavernous sinus although blood fl ow is normally away from the brain

Answer 12

36. Answer: D Explanation: Myelination in the central (CNS) and peripheral (PNS) nervous systems occurs by similar methods, although there are differences in the supportive cells responsible. A. Myelin is similar in both locations but different in the presence of Schmidt-Lanterman clefts, which only appear in the PNS and represent the presence of Schwann cell cytoplasm that is not displaced toward the periphery. This provides a continuous cytoplasmic pathway from the exterior to the interior of the myelin sheath. Myelin is an insulator and also decreases membrane capacitance. White matter is high in myelin content and is named by the presence of tracts of axons that appear white (myelinated). Gray matter represents neuron-rich areas low in myelin (e.g., cell bodies). B. Myelination occurs in both pre- and postnatal development. In the PNS, formation of myelin is initiated by the invagination of an axon into a Schwann cell. A mesaxon is formed as the outer leafl ets of the cell membrane fuse. Subsequently, the mesaxon of the Schwann cell wraps itself around the fi ber. D. In the CNS, the oligodendrocytes myelinate axons, whereas the Schwann cells conduct myelination in the PNS. Oligodendrocytes myelinate several axons at one time, whereas the Schwann cells myelinate only one axon. In the CNS, oligodendrocytes form myelin around several axon segments compared with the 1: 1 relationship between Schwann cells and axon segments in the PNS.

Answer 13

37. Answer: C Explanation: The stellate ganglion usually lies in front of the neck of the fi rst rib. C. The vertebral artery lies anterior to the ganglion as it has just originated from the subclavian artery. After passing over the ganglion, it enters the foramen and lies posterior to the anterior tubercle of C6.

Answer 14

38. Answer: D Explanation: A. The mandibular division of the trigeminal nerve, which passes through the foramen ovale, innervates the masticatory muscles responsible for clenching the jaw as well as the tensor palatini muscle, which assists in the establishment of the velopharyngeal seal. B. The other muscles of the soft palate are innervated by the pharyngeal branch of the vagus nerve, which transits the jugular foramen. C. The inferior oblique muscle of the eye is innervated by the inferior branch of the oculomotor nerve, which enters the orbit through the superior orbital fi ssure. D. The maxillary division of the trigeminal nerve, which passes through the foramen rotundum, is entirely sensory. Damage to this nerve results in sensory deprivation over the maxillary region of the face and loss of the sneeze refl ex. E. The orbicularis oris and buccinator muscles are innervated by the facial nerve, which transits the stylomastoid foramen

Answer 15

39. Answer: E Explanation: The occiput receives sensory innervation from the occipital nerves, which are terminal branches of the cervical plexus.

Answer 16

40. Answer: C Explanation: Ref: Crews. Chapter 14. Acute Pain Syndromes. In: Practical Management of Pain. 3rd Edition. Raj et al, Mosby, 2000, page 178. Source: Day MR, Board Review 2003

Answer 17

41. Answer: A Explanation: The common fi bular (peroneal) nerve bifurcates into superfi cial and deep branches. The deep fi bular nerve innervates all muscles of the anterior compartment of the leg. The superfi cial fi bular nerve emerges from the deep fascia and descends in the lateral compartment, where it innervates the peroneus longus and brevis muscles before dividing into median dorsal cutaneous and intermediate dorsal cutaneous nerves, which supply the distal third of the leg, dorsum of the foot, and all the toes. The saphenous nerve (the terminal branch of the common femoral nerve) distributes cutaneous branches to the anterior and medial aspects of the leg as well as to the dorsomedial aspect of the foot. The sural nerve follows the course of the lesser saphenous vein and becomes the lateral sural cutaneous nerve to supply the anterolateral aspect of the foot. Source: Klein RM and McKenzie JC 2002.

Answer 18

42. Answer: C

Answer 19

43. Answer: D Explanation: D. The rib cage is covered both internally and externally by thin layers of deep fascia. The inner layer, consisting of loose areolar tissue called the endothoracic fascia, lines the internal aspect of the thoracic cage. This layer of facia covers the inner surface of the intercostal muscles and intervening ribs, along with the subcostal and transversus thoracis muscles andthe diaphragm. It lies between the parietal pleura and the thoracic cage.

Answer 20

44. Answer: E Explanation: All other muscles of the larynx are innervated by the recurrent laryngeal nerve.

Answer 21

45. Answer: E | Source: Day MR, Board Review 2006

Answer 22

46. Answer: E Explanation: (Bonica, 3rd Ed., page 970) C7 has a transverse process but no foramen for transmitting the vertebral artery. In fact the stellate ganglion (C7-T1) is posterior to the artery at this level. C3, C5, C6 all have transverse processes that transmit the vertebral artery. C1 does have a long transverse process that is longer than other vertebral bodies. It also has a vertebral artery foramen. Upon leaving this level, the vertebral artery migrates posteriorly and medially. Source: Shah RV, Board Review 2005

Answer 23

47. Answer: C | Source: Boswell MV, Board Review 2005

Answer 24

48. Answer: A Explanation: (Raj, Pain Review 2nd Ed., page 292-3) The medial branch of the exiting spinal nerve sends a branch to the facet joint at its level and to one level below. In older studies some have demonstrated and ascending branch of the dorsal ramus that innervates the level above. However, this is not true as far as board exams go. In this case the medial branches of the L3 and L4 nerves innervate the L4-5 zygapophyseal joint. Expect some permutation of this kind of question Source: Shah RV, Board Review 2005

Answer 25

``` 49. Answer: A Explanation: (Bonica, 3rd Ed., page 1480, fi gure 75-9) The conus ends at: T12: 6% T12-L1: 18% L1: 30% L1-L2: 24% L2: 22% L3: rarely Source: Shah RV, Board Review 2005 ```

Answer 26

50. Answer: C | Source: Day MR, Board Review 2005

Answer 27

51. Answer: B Explanation: (Bonica, 3rd Ed., page 372) The vertebral endplates are fl at in the lumbar spine, but are concave and convex. All of the other statements are true. The joints of Luschka or the uncovertebral joints are degenerative clefts. Source: Shah RV, Board Review 2005

Answer 28

52. Answer: E Explanation: The posterior spinal arteries are paired; they arise from the posterior inferior cerebellar arteries and have 25 to 40 radicular arteries. The anterior spinal artery is a single midline artery that arises from the union of a branch of each vertebral artery. It descends in front of the anterior longitudinal sulcus of the spinal cord. This single artery is also fed by numerous radicular arteries.

Answer 29

``` 53. Answer: E Explanation: (Bonica, 3rd Ed., page 975) Canal sagittal dimensions get progressively narrower from the upper to lower cervical spine; the narrowest location is at C5-6. C1-C3: 21 mm (16-30) C4-C6: 18 mm (14-23) Source: Shah RV, Board Review 2005 ```

Answer 30

54. Answer: C Explanation: The deep peroneal nerve innervates the short extensors of the toes and the skin of the web space between the great and second toe. The deep peroneal nerve is blocked at the ankle by infi ltration between the tendons of the anterior tibial and extensor hallucis longus muscle.

Answer 31

55. Answer: C | Source: Day MR, Board Review 2005

Answer 32

56. Answer: A Source: Raj P, Pain medicine - A comprehensive Review - Second Edition

Answer 33

57. Answer: D Explanation: D. The odontoid process (dens) of the axis, the second cervical vertebra, is the remnant of the body of the fi rst cervical vertebra (atlas). Developing from a separate ossifi cation center, it fused to the body of the axis. The fact that there is no intervertebral disk between the atlas and axis probably facilitates the fusion. The dens, projecting from the superior surface of the axis, provides a pivot about which rotation occurs at the atlantoaxial joint. Fracture and posterior dislocation of the dens may crush the spinal cord with fatal results.

Answer 34

58. Answer: B Explanation: B.The 7th costal cartilage articulates with the sternum at the lateral margin of the xiphisternal junction. The articulation between the xiphoid process and the inferior border of the sternal body is a cartilaginous structure that ossifi es later in life.

Answer 35

59. Answer: B Explanation: Reference: Gray’s Anatomy, Thirteenth American Edition. Pages 696-699. The vertebral arteries originate from the subclavian arteries and ascend anterior to the transverse processes of the seventh cervical vertebrae. They then ascend through the foramina transversaria from C6 to C1. The C7 vertebral body does not have a foramen transversarium. The arteries then exit the C1 foramina transversaria and turn medial to course through the foramen magnum where they ascend and combine to form the basilar artery which perfuses the brain. Just above the foramen magnum, the vertebral arteries give rise to the paired posterior spinal arteries. Further cephalad, at the approximate level of the medulla oblongata, the paired vertebrals give rise to the descending, single anterior spinal artery. The vertebral arteries are always lateral to the atlanto-axial joints since they must pass through the laterally-situated foramina transversaria at C1 and C2. From the foramen transversarium of C1 to the foramen magnum, the vertebral arteries pass posterior to the atlanto-occipital joints within the suboccipital triangle. There course from C1 to the foramen magnum may be somewhat tortuous and unpredictable. The vertebral arteries are always anterolateral with respect to the cervical neuroforamina since they are coursing through the foramina transversaria. Source: Schultz D, Board Review 2004

Answer 36

60. Answer: A | Source: Day MR, Board Review 2006

Answer 37

61. Answer: B Explanation: (Bonica 3rd Ed., page 971)

Answer 38

62. Answer: C Explanation: The musculocutaneous nerve arises from the lateral cord of the brachial plexus and carries fi bers from the root of C5, C6, and C7. The nerve proceeds obliquely downward between the axillary artery and the median nerve. The nerve pierces the coracobrachialis muscle while giving off branches to it, and it descends further between the biceps and brachialis muscles to supply both of them. The lateral cutaneous nerve of the forearm is the sensor continuation of the muscular cutaneous nerve innervates the skin from the elbow to the wrist and covers the entire forearm from the dorsal to the ventral midline. The coracobrachialis muscle is a forward elevator of the arm. The biceps is a forearm supinator, especially if the elbow fl exed at 90 degrees. Isolated lesions of the musculocutaneous nerve are rare. Such lesion could cause weakness of elbow fl exion again resistance in a fully supinated hand, possible arm elevation weakness, arm pain and radial forearm parasthesia. (Brazis, 9-10; Staal, 31-33) Source: Neurology Examination and Board Review By Nizar Souayah, MD and Sami Khella, MD

Answer 39

63. Answer: D | Source: Day MR, Board Review 2006

Answer 40

64. Answer: D Explanation: D. The tip of the styloid process lies approximately halfway between the angle of the mandible and the mastoid process and provides a bony landmark for blockade of the glossopharyngeal nerve. The glossopharyngeal nerve exits the jugular foramen at the base of the skull to emerge slightly posterior and medial to the styloid process. It proceeds inferiorly to innervate the posterior one-third of the tongue as well as part of the throat and nasopharynx as far down as the pharyngoesophageal junction at the level of the cricoid cartilage.

Answer 41

65. Answer: A | Source: Racz G. Board Review 2003

Answer 42

66. Answer: B Explanation: The blood supply to the spinal cord is primarily three longitudinally running arteries – two posterior spinal arteries and one anterior spinal artery. The Anterior Spinal artery supplies approximately 80% of the intrinsic spinal cord vasculature. It is formed by the union of a branch from the terminal part of each vertebral artery. It actually consists of longitudinal series of functionally individual blood vessels with wide variation in lumen size and anatomic discontinuations. The spinal cord has three major arterial supply regions: 1. C1 to T3: Cervicothoracic region 2. T3 to T8: Mid thoracic region 3. T8 to the Conus: Thoracolumbar region There is a poor anastomosis between these three regions. As a result the blood fl ow at the T3 and T8 levels is tenuous. In spinal stenosis, especially in the lower cervical region, the Anterior Spinal artery may be compressed by a dorsal osteophyte and a herniated nucleus pulposus leadingto the Anterior Spinal Syndrome (loss of motor function). There are two posterior spinal arteries that arise from the posterior inferior cerebellar arteries. The three longitudinal arteries are reinforced by ‘feeder’ arteries. They are spinal branches of the cervical, vertebral posterior intercostal, lumbar and lateral sacral arteries. Approximately 6 or 7 of these contribute to the anterior spinal artery and another 6 or 7 to the posterior spinal arteries, but at different levels. The largest of these arteries is known as the radicularis magna or the artery of Adamkiewicz. Source: Chopra P, 2004

Answer 43

67. Answer: C Explanation: The medial wall of the cavernous sinus contains the abducens nerve, the internal carotid artery and the sympathetic fi bers of the carotid plexus. The lateral wall contains the oculomotor and trochlear nerves, and the ophthalmic and maxillary divisions of the trigeminal nerve. (Afi fi and Bergman, 240) Source: Neurology Examination and Board Review By Nizar Souayah, MD and Sami Khella, MD

Answer 44

68. Answer: C Explanation: The trigeminal nerve is a mixed nerve. It subserves the sensory innervation of the ipsilateral side of the face and the ipsilateral muscles of mastication (masseter, temporalis, and pterygoids). The sensory nucleus of the trigeminal nerve extends from the midbrain to the upper cervical cord: (a) The mesencephalic nucleus subserves proprioception and deep sensation from the tendons and muscles of mastication. (b) The main sensory nucleus (located in the pons) subserves light touch. (c) The spinal nucleus (which extends from the pons to the upper cervical cord and is divided into segments that correspond to concentric dermatomes around the mouth) subserves pain and temperature. The trigeminal nerve supplies sensation to the ipsilateral side of the face via three branches: the ophthalmic division (which innervates the frontal, lacrimal, and nasociliary areas), the maxillary division (which innervates the cheek and lower eyelid), and the mandibular division (which innervates the lower lip, the tongue, the mandible, except for the angle of the mandible). The motor nucleus lies medially to the main sensory nucleus and sends axons to the mandibular division of the trigeminal nerve. All division of the trigeminal nerve converge at the Gasserian ganglion which lies in Meckel’s cave of the temporal bone. (Afi fi and Bergman, 173-175) Source: Neurology Examination and Board Review By Nizar Souayah, MD and Sami Khella, MD

Answer 45

69. Answer: D Explanation: The sciatic nerve is a mixed nerve that carries fi bers from L4 to S3 and leaves the pelvis through the sciatic foramen below the piriform muscle. The nerve then curves laterally and downward beneath gluteus maximus muscle and runs on the dorsal side of the femoral bone to terminate at the proximal part of the popliteal fossa to divide into the tibial nerve medially and the peroneal nerve laterally. Within the sciatic nerve, as proximal as the gluteal region, the fi bers of the tibial and peroneal nerves are arranged into two separate divisions: The medial and the lateral trunks, respectively. The medial part of the nerve innervates the adductor magnus and the hamstring muscles, except for the short head of the biceps femoris (it is the only thigh muscle supplied by the lateral peroneal division). The hamstring muscles are fl exors of the knee joint and include the semimembranosus muscle, the semitendinous muscle, and the short and long heads of the biceps femoris. (Staal, 117-118) Source: Neurology Examination and Board Review By Nizar Souayah, MD and Sami Khella, MD

Answer 46

70. Answer: E Explanation: The diaphragm has three large openings (the aortic, esophageal, and vena caval apertures) and a number of smaller ones that transmit the superior and middle splanchnic nerves. E. The aortic aperture is the lowest and most posterior of the large openings and approximates the level of the T10 vertebra. This aperture also transmits the thoracic duct and occasionally the azygous and hemiazygous veins.

Answer 47

71. Answer: C | Source: Racz G. Board Review 2003

Answer 48

72. Answer: D Explanation: With advancing age, there is reduced caliber of the spinal canal due to arthritic changes. There is decreased water and glycoprotein content of intervertebral disks, with decreased height of vertebral bodies. (Ref. 1, pp. 455–456; Ref. 2, p. 590) Source: Neurology for the Psychiatry specialty Board Review By Leon A. Weisberg, MD

Answer 49

73. Answer: D Explanation: The nervus intermedius is the sensory and parasympathetic division of the facial nerve. It carries preganglionic parasympathetic fi bers to the submaxillary ganglion and tothe pterygopalatine ganglion. It receives sensory fi bers from the geniculate ganglion. This ganglion receives fi bers that carry taste sensation from the anterior two-thirds of the tongue and afferents from the mucosae of the pharynx, nose, and palate.(Afi fi and Bergman, 166- 167) Source: Neurology Examination and Board Review By Nizar Souayah, MD and Sami Khella, MD

Answer 50

74. Answer: D Explanation: The orbicularis oculi controls eye closure and is innervated by the facial nerve.Eye opening is controlled by the levator of the lid, which is innervated by the oculomotor nerve. (Brazis, Masdeu, and Biller, 271-272) Source: Neurology Examination and Board Review By Nizar Souayah, MD and Sami Khella, MD

Answer 51

75. Answer: C Explanation: Reference: Gray’s Anatomy, Thirteenth American Edition. Pages 964-971. The spinal cord receives its’ blood supply from three longitudinal arteries: 1. a single anterior spinal artery 2. two posterior spinal arteries The anterior spinal artery forms intracranially anterior to the medulla oblongata, from the junction of two anterior spinal branches, one derived from each of the two vertebral arteries. From its’ origin, it descends anterior to the spinalcord to the tip of the conus medullaris. The diameter of the anterior spinal artery is greatest at the cervical and lower thoracic regions with the smallest diameter along the midthoracic zone from T3-T9. This region of the cord is considered the “vulnerable zone” with respect to circulation. The branches of the anterior spinal artery that penetrate the cord parenchyma are end arteries and do not anastomose further. The spinal cord receives segmental arteries bilaterally at every level that enter the spinal canal through the neuroforamina, accompanying the spinal nerve roots. These segmental arteries supply blood to the dorsal and ventral nerve roots. In the cervical region these segmental arteries may originate from the vertebrals or from other cervical arteries. In the thoracic region, the segmental arteries originate from the posterior intercostal arteries which branch directly from the aorta.In the lumbar region,they branch from the lumbar arteries. In addition, the anterior spinal artery is reinforced at a number of segmental levels by feeder arterial branches from these segmental arteries. These arteries are called anterior medullary feeder arteries. There is an average total of 8 anterior medullary feeder arteries (inclusive of all spinal levels bilaterally) the largest of which is the great anterior medullary artery or artery of Adamkiewicz. The total number of anterior medullary feeder arteries varies from 2 to 17 in different individuals with an average of 3 in the cervical region, 3 in the thoracic region and 2 in the lumbar region. The artery of Adamkiewicz typically enters the cord on the left side (77% of specimens) anywhere from T7 to L4 (most commonly at T9 to T12). In the cervical region, the largest anterior medullary feeder enters at C4-5 or C5-6. Source: Schultz D, Board Review 2004

Answer 52

76. Answer: A Explanation: The patient described in this vignette has a pure motor defi cit. The right pronator quadratus is weak because of paresis of forearm pronation. Also there is paresis of the fl exor digitorum profundus I & II and the fl exor pollicis longus because of loss of fl exion of the terminal phalanges of the second and third fi ngers, and the thumb, respectively. All of these muscles are innervated by an anterior interosseous nerve. The characteristic feature of a lesion of this nerve is the inability to make a circle with the thumb and index fi nger. (Staal 55-56) Source: Neurology Examination and Board Review By Nizar Souayah, MD and Sami Khella, MD

Answer 53

77. Answer: A Explanation: A. The madibular nerve emerges from the cranial cavity by way of the foramen ovale to enter the infratemporal fossa. In the infratemporal fossa the mandibular nerve divides into its terminal branches. Madibular nerver supplies the lower jaw, tongue, and lower teeth, the buccal surface of the cheek, and the skin overlying the lower jaw, the temporal region, and the anterosuperior two-thirds of the surface of the external ear. C. The maxillary nerve leaves through the foramen rotundum

Answer 54

78. Answer: B | Source: Sizer et al - Pain Practice - March & June 2004

Answer 55

79. Answer: E Explanation: The gasserian ganglion, also known as the trigeminal ganglion,is formed from many midpontine rootlets as they pass into the posterior cranial fossa and cross the superior border of the petrous bone to enter the recess called Meckel’s cave, or the trigeminal cave. In this recess (Meckel’s cave or trigeminal cave), the posterior two thirds of the ganglion are covered by dura. The anterior one-third is not covered by dura, and it is from this portion of the ganglion that the three major divisions of the trigeminal nerve (ophthalmic, maxillary, and mandibular) exit. When performing a trigeminal ganglion block, if the needle has punctured the dura of Meckel’s cave, a very small amount of local anesthetic may result in rapid loss of consciousness or cardiac arrest.

Answer 56

80. Answer: D Explanation: The Rexed laminae in the dorsal horn of the spinal cord are important in the modulation and transmission of nociceptive stimuli. A, B. Laminae I and II receive dense projections from the brainstem nuclei. Small diameter primary afferents also terminate primarily in laminae I and II. Myelinated primary afferent neurons and those from the brainstem involved in modulation of pain perception in laminae I and II also project to the deeper laminae such as V. D. Lamina V has a high concentration of wide dynamic range cells, which play an active role in the phenomenon of central sensitization.

Answer 57

81. Answer: C | Source: Racz G. Board Review 2003

Answer 58

82. Answer: B Explanation: There are 5 nerves that supply the ankle and foot: 1. Posterior tibial nerve 2. Sural nerve 3. Superfi cial nerve 4. Deep peroneal nerve 5. Saphenous nerve These nerves are superfi cial at the level of the ankle and are easy to block. The posterior branch of the tibial nerve gives rise to the medial and lateral plantar nerves, which supply the plantar surface of the foot.

Answer 59

83. Answer: E | Source: Day MR, Board Review 2006

Answer 60

84. Answer: E | Source: Shah RV, Board Review 2003

Answer 61

85. Answer: B Explanation: The structures in the neck from medial to lateral are the recurrent laryngeal nerve, carotid artery, vagus nerve, internal jugular vein, and phrenic nerve.

Answer 62

86. Answer: E Explanation: The spinal artery arises from the posterior branch of the segmental artery close to the intervertebral foramen and divides into three terminal branches: posterior, intermediate, and anterior. A. The posterior branches help supply the spinal dura and the tissues of the epidural space. B. The intermediate (middle) branches supply the dura of the associated nerve roots.Their radicular branch can pierce the dura and help supply the spinal cord. E. The anterior branches supply the vertebral bodies along with other spinal structures.

Answer 63

87. Answer: D Explanation: The artery of Adamkiewicz, also known as arteria radicularis magna, is one of the feeder arteries for the anterior spinal artery. Damage to this artery by any means or particular injection can lead to ischemia in the thoracolumbar region of the spinal cord. The origin of this artery is variable. In 60% of the cases, it is described to arise from T9 to T12. In 14% of cases, it is described to originate from T5 to T8. In 20% of the cases, it is described to originate below L1.

Answer 64

88. Answer: E | Source: Day MR, Board Review 2006

Answer 65

89. Answer: B | Source: Day MR, Board Review 2005

Answer 66

90. Answer: A | Source: Day MR, Board Review 2006

Answer 67

91. Answer: D Explanation: The facial nerve leaves the pons and travels with the vestibulocochlear nerve through the internal auditory canal. (Parent, 154-168) Source: Neurology Examination and Board Review By Nizar Souayah, MD and Sami Khella, MD

Answer 68

92. Answer: B Explanation: A. The facial nerve lies superfi cial on the face. B. The location of the glossopharyngeal nerve in the tonsillar bed places it in jeopardy during tonsillectomy. C, D. The hypoglossal and lingual nerves pass well inferior to the tonsillar bed.

Answer 69

93. Answer: D

Answer 70

94. Answer: C Explanation: A. The mandibular nerve leaves through the foramen ovale. B.The maxillary nerve leaves the cranial cavity through the foramen rotundum.Following here it traverses the pterygomaxillary fossa to enter the fl oor of the orbit at the inferior orbital fi ssure. The maxillary nerve primarily supplies the upper jaw, lateral nasal wall, and most of the nasal septum.

Answer 71

95. Answer: C | Source: Day MR, Board Review 2006

Answer 72

96. Answer: D Explanation: D. An obturator nerve block is achieved by placement of the needle 1 to 2 cm lateral to and below the pubic tubercle. After contact with the pubic bone, the needle is withdrawn and walked cephalad to identify the obturator canal.

Answer 73

97. Answer: D | Source: Racz G. Board Review 2003

Answer 74

98. Answer: A Explanation: The point of entrapment of the median nerve in carpal tunnel syndrome lies under the fl exor retinaculum. The fl exor retinaculum forms the roof of the carpal tunnel, whereas the carpal bones and their connective tissue components form the fl oor of the carpal tunnel.In Guyon’s canal, the hamate, and the pisiform bones are sites of compression of the ulnar nerve at the wrist. Rarely, radial nerve compression occurs at the level of the styloid process, just proximal to the wrist. (Staal, 56-66) Source: Neurology Examination and Board Review By Nizar Souayah, MD and Sami Khella, MD

Answer 75

99. Answer: E | Source: Day MR, Board Review 2006

Answer 76

100. Answer: E Explanation: The radial nerve arises from the posterior cord of the brachial plexus and comprises fi ber from spinal levels C5 to C8. After descending posterior to the axillary artery, the nerve courses posterior to the humerus in the spinal groove. It is at this site that the nerve is more often damaged by the compression. (Staal, 35) Source: Neurology Examination and Board Review By Nizar Souayah, MD and Sami Khella, MD

Answer 77

101. Answer: D | Source: Day MR, Board Review 2006

Answer 78

102. Answer: B | Source: Day MR, Board Review 2006

Answer 79

103. Answer: C Explanation: References: Waldman, Interventional Pain Management, Second Edition; Chapter 42, pp. 446-452 Gray’s Anatomy, Thirteenth American Edition, pp. 333- 335. Zygapophyseal or facet joints are true synovial joints and share characteristics with other synovial joints including: 1.The contiguous bony surfaces of the joints are covered with hyaline cartilage 2.The joint is surrounded by a fi brous joint capsule 3.The inner surface of the joint is lined by a synovial membrane which secretes synovial fl uid to lubricate the joint 4.The joints contain intra-articular meniscoids (of uncertain signifi cance) which are attached to the joint capsule Zygapophyseal joints are posterior spinal structures with the nerve root and neuroforamen anterior to the joint. The most cephalad zyg joint is C2-3 and the most caudal is L5- S1. The atlanto-axial and atlanto-occipital joints (C1-2 and C0-1 respectively) are unique and fundamentally different from zyg joints in that they are anterior spinal structures with the nerve root exiting posterior to the joint. These two most cephalad spinal joints are therefore not considered zygapophyseal joints and do not have sensory innervation from medial branch nerves like the true zyg joints. Source: Schultz D, Board Review 2004

Answer 80

104. Answer: A Explanation: The long thoracic nerve arises from the motor roots of C5, C6, and C7. It courses downward through and in front of the medial scalenus muscle and further descends dorsal to the brachial plexus along the medial axillary wall to innervate the serratus anterior muscle. The suprascapular nerve innervates the supraspinatus and infraspinatus. The dorsal scapular nerve innervates the rhomboid and levator scapulae. (Parent, 276; Staal 19) SOURCE: Souayah, N, and Khella S; Neurology Examination & Board Review; McGraw-Hill, New York. Source: Neurology Examination and Board Review By Nizar Souayah, MD and Sami Khella, MD

Answer 81

105. Answer: A Explanation: The lingual nerve is a branch of the mandibular division. The posterior auricular is part of the cervical plexus, the spinal accessory is CN XI, and the occipital is from C2 and C3 Source: Trescot AM, Board Review 2003

Answer 82

106. Answer: E Explanation: E. Cerebrospinal fl uid formed in the choroid plexus circulates in the subarachnoid space and is absorbed by the venous sinuses through the arachnoid villi, some of which project into the superior sagittal sinus. Cerebrospinal fl uid protects the nervous system from concussions and mechanical injuries and is important for metabolism. A, B, C, D. It circulates slowly through the ventricles of the brain and through the meshes of the subarachnoid space.

Answer 83

107. Answer: D Explanation: In approximately 90% of cases the dorsal root ganglion (DRG) lies in the middle zone of the intervertebral foramen, directly below the pedicle. In approximately, 8% of cases it is inferolateral and in 2% of cases it is medial to the pedicle. The center of the DRG lies over the lateral portion of the intervertebral disc in some cases. The size of the DRG increases from L1 to S1 and then progressively decreases till S4. The DRG at S1 is 6mm in width. The DRG contains multiple sensory cell bodies. It is the site for production of neuropeptides: Substance P, Eukephalin, VIP (Vasoactive Intestinal peptides), and other neuropeptides. The DRG is a primary source of pain when it undergoes mechanical deformity as by an osteophyte, herniated nucleus pulposus or stenosis. It also produces pain when it undergoes an infl ammatory process either by infection or chemical irritation from a herniated nucleus pulposus, release of local neuropeptides or local vascular compromise. Source: Chopra P, 2004

Answer 84

108. Answer: B Explanation: B. The dorsal pedal artery, a continuation of the anterior tibial artery, passes onto the dorsum of the foot between the tendons of the extensor hallucis longus and extensor digitorum longus muscles. The dorsal pedal pulse may be palpated here before the artery passes beneath the extensor hallucis brevis muscle. E. The posterior tibial artery passes behind the medial malleolus, where the posterior tibial pulse is normally palpable. Source: Klein RM and McKenzie JC 2002.

Answer 85

109. Answer: B Explanation: A. From the ventricular zone, astrocytes, oligodendrocytes, and neurons differentiate. Ultimately, the cells that remain in the ventricular zone become the ependymal cells that line the central canal. B. The white matter of the adult CNS is derived from the marginal zone of the developing neural tube. The most peripheral zone is the marginal zone, which contains the myelinated axons of the developing motor neurons (adult white matter). C. The mantle zone forms the grey matter, where cell bodies of differentiating motor neurons are located. Source: Klein RM and McKenzie JC 2002.

Answer 86

110. Answer: C Explanation: The axillary nerve originates from the posterior fascicle of the brachial plexus and carries fi bers from C5 and C6. It innervates the deltoid muscle and teres minor muscle. The axillary nerve sends a sensory branch, the lateral brachial cutaneous nerve, to the skin of the upper outer surface of the arm mainly in the deltoid region. An axillary nerve lesion results in weakness of arm abduction in the horizontal position against resistance.The fi rst 30 degrees of abduction of the upper arm from the trunk is performed by the supraspinatus muscle, which is innervated by the suprascapular nerve, not by the axillary nerve. There is also weakness of the horizontal upper arm retraction against resistance with sensory loss in the skin area overlying the deltoid muscle.The axillary nerve is often involved in neuralgic amyotrophy, and in about ten percentof cases it is affected in isolation. (Parent, 275 – 277; Staal, 27-29) Source: Neurology Examination and Board Review By Nizar Souayah, MD and Sami Khella, MD

Answer 87

111. Answer: B Explanation: A. The periosteum is an important connective tissue layer surrounding the bone of the skull. This layer retains osteogenic potential even in the adult. B. The dura mater contains the venous sinuses and is composed of dense connective tissue and possesses very limited osteogenic potential. The dura mater is one of the three protective layers that comprise the meninges surrounding the brain and spinal cord. In the spinal cord, the dura is separated from the periosteum by the epidural space. C.The thin subdural space lies between the dura mater and the arachnoid. D. The arachnoid is composed of a weblike avascular connective tissue that forms villi for the reabsorption of cerebrospinal fl uid (CSF) into the venous sinuses found in the dura. The subarachnoid space contains the CSF, which is formed both by ultrafi ltration of the blood and transport across the epithelial lining of the choroid plexuses. E. The pia covers the brain and spinal cord as a delicate, vascular connective tissue. It lines the perivascular spaces through which blood vessels penetrate the CNS.

Answer 88

112. Answer: D Explanation: (Moore, Anatomy, 4/e, pp 698-699.) The upper and lower subscapular nerves innervate the subscapularis muscle, which is the only muscle of the rotator cuff group that medially rotates the arm. The lower subscapular nerve also innervates the teres major muscle, which is not part of the rotator cuff group. The suprascapular nerve innervates the supraspinatus and infraspinatus muscles that abduct and laterally rotate the arm, respectively. The teres minor muscle, innervated by the axillary nerve, also laterally rotates the arm. The thoracodorsal nerve, originating from the posterior cord between the upper and lower subscapular nerves, innervates the latissimus dorsi muscle. Source: Klein RM and McKenzie JC 2002.

Answer 89

113. Answer: D Explanation: A, D. The vertebral arteries usually arise from the subclavian arteries and ascend through the transverse foramina of the sixth to the fi rst cervical vertebrae but not the seventh. They enter the cranium through the foramen magnum after which they join to form the basilar artery. B. The hypoglossal nerves leave the cranium via the anterior condylar (hypoglossal) canals, C. The posterior condylar canals transmit emissary veins. E. The basilar artery terminates by bifurcating into the posterior cerebral arteries.

Answer 90

114. Answer: D Source: Raj P, Pain medicine - A comprehensive Review - Second Edition

Answer 91

115. Answer: C Explanation: The lumbar arteries supply the vertebrae at various levels. Each lumbar artery passes posteriorly around the related vertebra and supplies branches into the vertebral body. The terminal branches form a plexus of capillaries below each endplate. The disk is a relatively avascular structure. Nutrition to the disk is by diffusion from the endplate capillaries and blood vessels in the outer annulus fi brosus. Passive diffusion of fl uids into the proteoglycan matrix is further enhanced by repeated compression of the disk by repeated fl exion-extension of the spine associated with activities of daily living which pumps fl uid in and out of the disk. Source: Chopra P. 2004

Answer 92

116. Answer: E Explanation: E. The carotid tubercle (Chaussignac’s tubercle) lies 2.5 cm lateral to the cricoid cartilage. It is a part of the transverse process of the C6 vertebra and can be easily palpated anteriorly. The carotid tubercle is an important landmark for stellate ganglion blocks. Source: Chopra P. 2004

Answer 93

117. Answer: C Explanation: A, B. It originates in 14% of cases between T5-T8. In a small percentage of cases (15%) the take off is higher at T5. In this case the slender contribution from the iliac artery enlarges to compensate for the increased blood fl ow to the lumbar portion of the cord and the conus. C. The artery of Adamkiewicz originates on the left between the T8 and L3 level in most cases. This is the largest of the feeder arteries that supplies the anterior spinal artery. The artery of Adamkiewicz enters through an intervertebral foramen between T8 and L3 to supply the lumbar enlargement. It originates in 60% of cases between T9-T12. D, E. It originates below L1 in 20% of cases. Source: Chopra P, 2004

Answer 94

118. Answer: D Explanation: D. The stellate ganglion is the inferior cervical ganglion. The cervicothoracic ganglion is frequently formed by the fusion of the inferior cervical ganglion and the fi rst thoracic ganglion. It is located anteriorly on the neck of the fi rst rib and the transverse process of the C7 vertebra. It is oval in shape and 1 inch long by 0.5 inch wide. The ganglion is bound anteriorly by the subclavian artery, posteriorly by the prevertebral fascia and the transverse process, medially by the longus colli muscle and laterally by the scalene muscle. The classical Stellate ganglion block is done one level above the location of the Stellate ganglion (it lies at the C7 level and the block is done at the C6 level). E. The vertebral artery travels anteriorly over the stellate ganglion at C7 but at C6 the artery moves posteriorly. Source: Chopra P. 2004

Answer 95

119. Answer: E Explanation: A. The capillary endothelium is nonfenestrated, which also adds to the barrier. B. Microglia function as brain macrophages and are involved in antigen presentation and phagocytosis. C. Astrocytes form foot processes around the brain capillaries. D. Surrounding the CNS is a basement membrane with a lining of astrocyte foot processes; this forms the glia limitans, which also contributes to the integrity of the blood-brain barrier. E. The blood-brain barrier is formed primarily by occluding junctions (zonulae occludentes) between endothelial cells that compose the lining of brain capillaries.

Answer 96

120. Answer: D (4 Only) Explanation: 1. The femoral nerve originates from lumbar plexus. 2. The obturator nerve originates from lumbar plexus. 3. Lateral femoral cutaneous nerves arise from the lumbar plexus. 4. The sciatic nerve gives multiple branches: the common peroneal deep and superfi cial peroneal, posterior tibial, and sural.

Answer 97

121. Answer: B (1 & 3) Explanation: 1. The greater occipital nerve is a branch of the posterior ramus of C2. 2. The lesser occipital nerve is part of the cervical plexus. 3. Total spinal anesthetics has occurred after occipital nerve blocks, due to subarachnoid injection. 4. The occipital nerve is a pure sensory nerve. Source: Trescot AM, Board Review 2003

Answer 98

122. Answer: E (All) Explanation: References: Bogduk, Clinical Anatomy of the Lumbar Spine and Sacrum, Third Edition, Churchill Livingston 1997 pp. 133-135 Lord, Barnsley, Bogduk; Cervical Zygapophyseal Joint Pain in Whiplash Injuries in Cervical Extension-Flexion Whiplash Injuries, George Malanga MD Editor, Hanley and Belfus Medical Publishers, 1998 pp. 309-310 With respect to the zygapophyseal joint, each joint is innervated by two medial branch nerves, one originating from the dorsal ramus of the same segmental level and one originating from the dorsal ramus above the level. For example, the C4-5 zygapophyseal joint is innervated by the C4 and C5 medial branches and the L4-5 zygapophyseal joint is innervated by the L3 and the L4 medial branches. With respect to the medial branch nerves, each medial branch originates from the dorsal ramus of the spinal nerve and sends an ascending branch to innervate the joint above and a descending branch to innervate the joint below. Which medial branch nerves innervate which zygapophyseal joints can be a source of confusion since numbering in the cervical spine is different from the numbering in the thoraco-lumbar spine. The numbering convention associating spinal nerve roots within neuroforamina is different above and below C7-T1. The C4 nerve root (and C4 medial branch) exits the C3-4 neuroforamen whereas the L4 nerve root (and L4 medial branch) exits the L4-5 neuroforamen. Things change from a numbering perspective at C7-T1 since the C8 nerve root exits the C7-T1 foramen Above C7-T1 (from C2-3 to C6- 7)the exiting spinal nerve root has the same number as the last number of the foramen (i.e. C6 exits the C5-6 foramen).Beginning at the T1-2 neuroforamen, the exiting nerve root carries the same number as the fi rst number of the foramen (T1 nerve root exits T1-2 foramen). With respect to medial branches, the C8 medial branch innervates the C7-T1 joint and the T1-2 joint. The T1 medial branch innervates the T1-2 and the T2-3 joints. And the L3 nerve root innervates the L3-4 and L4-5 joints. 1. The medial branches of C4 through C8 typically lack cutaneous distribution and follow the following course: The dorsal ramus of the segmental nerve at each level gives rise to the medial branch with that segmental number which in turn innervates the zyg joint above and below i.e. the C4 spinal nerve exits the C3-4 foramen and gives rise to the C4 medial branch which sends a branch cephalad to innervate the C3-4 zyg joint and caudad to innervate the C4-5 zyg joint. 2. The medial branch of L5 is located in the groove between the sacral ala and the superior articulating process of S1. 3. The C3 medial branch is the fi rst clinically signifi cant medial branch with respect to radiofrequency denervation of the zyg joints. The C3 medial branch is unique in that it has a large superfi cial, cephalad branch called the “third occipital nerve”and a smallerdeep and more caudal branch which is called the medial branch of C3. The third occipital nerve originates from the C3 dorsal ramus and courses directly posterior across the lateral aspect of the C2-3 zyg joint which it innervates. The C3 medial branch also originates from the C3 dorsal ramus but courses caudally to cross the lateral waist of the C3 4. The medial branch of C2 is large and is called the greater occipital nerve. The C2 medial branch (greater occipital nerve) supplies sensory-motor innervation to the occiput and may also send a communicating branch caudally to contribute to the innervation of the C2-3 zyg joint. articular pillar in similar fashion to the courses of the C4-C8 medial branches. The C3 medial branch innervates the superior aspect of the C3-4 zyg joint. Source: Schultz D, Board Review 2004

Answer 99

123. Answer: B | Source: Day MR, Board Review 2006

Answer 100

124. Answer: C | Source: Day MR, Board Review 2006

Answer 101

125. Answer: C (2 & 4) Explanation: 1. In the lumbar region the intervertebral disks constitute about 30 percent of the length of the column as compared with 20 to 25 percent in the thoracic and cervical regions. 2. Each intervertebral disk is composed of a tough fi brocartilaginous ring (the annulus fi brosus) and a pliable intergelatinous mass (the nucleus pulposus). The colloidal gel of the nucleus pulposus is a mucopolysaccharide that can imbibe external fl uid and maintain its intrinsic water balance. 3. At birth the disk contains 88 percent water, but it dehydrates with age and trauma. 4. The superior and inferior plates of the disks are the end plates of the vertebral bodies, which are composed of articular hyaline cartilage in direct contact with and adherent to the underlying resilient bone of the vertebral body.

Answer 102

126. Answer: B (1 & 3) Explanation: 1. Intercostal nerves differ from other spinal nerves in that each pursues an independent course. 2. The intercostal nerves are distributed chiefl y to the thorax and abdomen. 3. Except for the fi rst intercostal nerve, they do not enter into the formation of plexuses. 4. The smaller posterior primary divisions diverge from their anterior counterparts and run posteriorly to supply the muscles and skin of the back through medial and lateral branches.

Answer 103

127. Answer: C (2 & 4) Explanation: Six extraocular muscles control the movements of the eye. The four rectus muscles (superior, medial, inferior, and lateral) originate from a common tendon ring that encircles the optic foramen. 1. The lateral rectus muscle is innervated by the abducens or 6th cranial nerve while the superior oblique muscle receives innervation from the trochlear or 4 th cranial nerve. 2. The oculomotor or third cranial nerve innervates the superior, medial, and inferior rectus muscles as well as the inferior oblique and levator palpebrae superioris muscles. 3. The superior oblique muscle originates above and medial to the optic foramen, while the inferior oblique muscle originates medially from the periosteum of the lacrimal bone. 4. The oculomotor or third cranial nerve innervates the superior, medial, and inferior rectus muscles as well as the inferior oblique and levator palpebrae superioris muscles.

Answer 104

128. Answer: A (1, 2, & 3) Explanation: 1. Pain referred to the penis may be due to neuralgia of the ilioinguinal nerve. 2. Pain referred to penis may be due to neuralgia of iliohypogastric nerve. 3. Pain referred to penis may be due to neuralgia of genitofemoral nerve. 4. Lateral femoral cutaneous neuralgia (meralgia paresthetica) usually causes pain in the lateral thigh without radiation to the penile shaft. Source: Kahn CH, DeSio JM. PreTest Self Assessment and Review. Pain Management. New York, McGraw-Hill, Inc., 1996.

Answer 105

129. Answer: A | Source: Day MR, Board Review 2006

Answer 106

130. Answer: E (All) Explanation: Reference: Bonica’s Management of Pain, Third Edition, pp. 210-215 Cell bodies of preganglionic sympathetic fi bers lie primarily in the intermediolateral cell column of the spinal cord from T1 to L2. The preganglionic axon fi bers course out of the spinal cord in the ventral root, course a short distance within the segmental spinal nerve and then exit the spinal nerve via the white rami communicantes. The white rami carries the preganglionic sympathetic fi bers to the sympathetic ganglia which consist of postganglionic cell bodies and are located in the prevertebral regions from the high cervical spine to the sacrum. Preganglionic fi bers may ascend or descend within the sympathetic chain for several levels before synapsing in the ganglion with the cell body of the post-ganglionic fi bers. The postganglionic sympathetic axons are then transmitted out of the ganglion by the gray rami communicantes where these axons travel with the spinal nerves to their end organs mainly blood vessels, sweat glands and hair follicles. Source: Schultz D, Board Review 2004

Answer 107

131. Answer: A (1, 2, & 3 ) Explanation: An action potential occurs when an electrical, mechanical, or chemical stimulus increases neural membrane permeability to ion infl ux. 1. In myelinated nerves, the action potentials occur at the nodes of Ranvier and impulses are rapidly conducted by saltatory conduction. - In nonmyelinated nerves, the action potentials occur along the length of the axon. Such continuous conduction is much slower than the saltatory conduction of myelinated fi bers. 2. The resting transmembrane potential is around -90μV with high membrane permeability to potassium (K+) and limited sodium (Na+) permeability. 3. Sodium channels are present only at the nodes of Ranvier. 4. Increasing stimuli alter the membrane potential, the membrane becomes much more permeable to Na+. This causes sodium to fl ow in and potassium ions to fl ow outward. Chloride ion diffuses freely through the membrane in response to changes in polarity. - The opening and closing of K+ channels in response to stimuli is responsible for the depolarization and repolarization phases of the action potential. An ion channel, for example, enlarges during the depolarization phase (+60 to 70 μV). After depolarization, the Na+ channels lose their increased permeability to Na+, and K+ is pumped back into the cells during repolarization. The potential gradually returns to resting transmembrane potential. - The resting potential is maintained by diffusion of intracellular K+ out of the cell through partially open K+ channels.

Answer 108

132. Answer: B (1 & 3 ) Explanation: 1. The sphenopalatine ganglion receives sensory input from a variety of nerves, including the trigeminal nerve. 2. It is a sympathetic ganglion. 3. Has been blocked to treat cluster headache. 4. It has efferents to the stellate ganglion, but does not cause a Horner’s syndrome. Source: Trescot AM, Board Review 2003

Answer 109

133. Answer: D (4 Only) Explanation: References: Mercer, The Ligaments and Anulus Fibrosus of Human Adult Cervical Intervertebral Discs, SPINE 1999;24:619 Bogduk, Clinical Anatomy of the Lumbar Spine and Sacrum, Third Edition, Churchill Livingston 1997, Chapter 2, pp. 26-29 1. The lumbar intervertebral discs function as load bearing shock absorbers whereas the cervical discs accommodate rotational motion of the cervical spine but do not bear signifi cant weight. - Therefore the anatomic structure of the lumbar and cervical discs is very different from each other. 2. The lumbar disc annulus consists of approximately 20 concentric lamellae of collagen fi bers that uniformly surround the nucleus pulposus with alternating oblique orientations slanted to approximately 65 degrees. - These lamellae are thicker in the anterior and lateral portions of the disc and thinner at the posterior disc margin. 3. The cervical anulus is crescentic, being thick anteriorly but tapering in thickness laterally as it approaches the uncovertebral region. There is no defi nable nucleus in the adult cervical disc. Posteriorly, the anulus fi brosus is not multilaminated like the anterior anulus of cervical discs or the posterior anulus of lumbar discs, nor does it consist of obliquely orientated fi bers. It is represented only by a thin set of vertically running fi bers. 4. In the lumbar disc, the gray rami communicantes innervates the anterior and anterolateral portions of the disc whereas the sinuvertebral nerve innervates the posterior disc annulus Source: Schultz D, Board Review 2004

Answer 110

134. Answer: D (4 Only) | Source: Sizer Et Al - Pain Practice March & June 2003

Answer 111

135. Answer: A (1, 2, & 3) Explanation: 1. The brachial plexus may be blocked through interscalene approach. 2. The brachial plexus may be blocked through supraclavicular approach. 3. The brachial plexus may be blocked through infraclavicular or axillary approach. 4. Cervical transforaminal is utilized for epidural block – individual nerves may be blocked, but not the plexus. Source: Trescot AM, Board Review 2003

Answer 112

136. Answer: A (1, 2, & 3 ) Explanation: (Raj, Pain Review 2nd Ed.) Ankle blocks typically refer to blockade of the deep and superfi cial peroneal nerves, posterior tibial nerves, sural nerve, and saphenous nerve. The superfi cial peroneal, sural, saphenous are superfi cial to the fascia, whereas the deep peroneal and posterior tibial are deep to the fascia. The superfi cial peroneal and deep peroneal nerves are branches of the common peroneal nerve. The deep peroneal is medial to the dorsalis pedis artery. The posterior tibial nerve, a branch of the tibial nerve, lies in the tarsal tunnel, anterior to the posterior tibial artery and posterior to the fl exor hallicis longus. The saphenous nerve is a branch of the femoral nerve. The obturator supplies the hip adductors and sensation to a small area over the distal medial thigh. Source: Shah RV, Board Review 2003

Answer 113

137. Answer: A (1, 2, & 3 ) Explanation: Each ligamentum fl avum consists of yellow elastic tissue attached to the anterior and inferior surfaces of the lamina above and to the posterior superior surface of the lamina below. 1 & 3. Ligamenta fl ava is thin in the cervical region, thicker in the thoracic region, and thickest in the lumbar region. 2. The ligamenta fl ava connect the laminae of adjacent vertebrae. 4. The fi bers of the ligamenta fl ava are oriented perpendicularly to the laminae to which they are attached.

Answer 114

138. Answer: E (All) Explanation: The Chiari II malformation is a complex anomaly with skull, dura, brain, spinal, and spinal cord manifestations. This disorder is almost invariably associated with myelomeningocele. The Chiari II malformation is the most common serious malformation of the posterior fossa. The frequency is approximately 1 case per 1000 population in the United States. Source: Boswell MV, Board Review 2004

Answer 115

139. Answer: E (All) | Source: Racz G. Board Review 2003

Answer 116

140. Answer: D (4 Only) Explanation: The glossopharyngeal and sphenopalatine are mixed nerves. The spinal accessory is a motor nerve and the occipital is a sensory nerve. Source: Trescot AM, Board Review 2003

Answer 117

141. Answer: C | Source: Day MR, Board Review 2006

Answer 118

142. Answer: C (2 & 4) Explanation: (Raj, Practical Management of Pain, 3rd Ed., page 618) 1. The trachea and bronchial tree send afferent input through the vagus and upper thoracic sympathetics (T2-7) and is pain radiates to the sternum. 2. The visceral pleura has no pain sensation. 3. The parietal pleura transmits pain along somatic nerves, such as the brachial plexus (C8,T1), intercostal nerves (T1-12), and phrenic nerves (C3-5). 4. The lung parenchyma is pain insensitive. Source: Shah RV, Board Review 2005

Answer 119

143. Answer: D (4 Only) Explanation: 1. The intraarticular ligament consists of a short fl at band of fi bers attached at one end to the crest separating the two articular facets on the head of the rib and at the other end tothe intervertebral disk. 2. The superior costotransverse ligament is attached to the superior border of the neck of the rib and passes laterally to the lower border of the neck of the transverse process immediately above. 3.The radiate ligament connects the anterior part of the head of each rib with the sides of the bodies of two adjacent vertebrae and the intervertebral disks between them. 4. The lateral costotransverse ligament passes from the apex of the transverse process of the vertebra to the rough and nonarticular portion of the tubercle of the corresponding rib.

Answer 120

144. Answer: B (1 & 3) | Source: Nader and Candido – Pain Practice. June 2001

Answer 121

145. Answer: B (1 & 3 ) Explanation: 1. They exit the spinal canal through the intervertebral foramina and immediately split into dorsal and ventral rami. - The dorsal rami pass posteriorly to innervate the paraspinal muscles and skin. 2. Thoracic spinal nerves form intercostal nerves – not cervical 3. Spinal nerves are derived from the union of the corresponding ventral and dorsal roots of the spinal cord. 4. The ventral rami combine to form plexuses at cervical and lumbosacral levels. The thoracic spinal nerves from the intercostal nerves.

Answer 122

146. Answer: A (1, 2, & 3 ) | Source: Rozen. Pain Practice: SEP 2001

Answer 123

147. Answer: A (1, 2, & 3) | Source: Boswell MV, Board Review 2005

Answer 124

148. Answer: A (1, 2 & 3) Explanation: Raj and Patt. Chapter 11. Visceral Pain. In: Pain Medicine: A Comprehensive Review, 2nd Edition, Raj, Mosby, 2003 Source: Boswell MV, Board Review 2005

Answer 125

149. Answer: C (2 & 4) | Source: Boswell MV, Board Review 2005

Answer 126

150. Answer: C (2 & 4) Explanation: 1. The bladder is innervated by the pelvic splanchnics (pain afferents with parasympathetics from the sacral roots). 2. Superior hypogastric plexus block is indicated for ovarian pain. 3. The vulva is innervated by somatic fi bers that travel with pudendal nerves. 4. Superior hypogastric plexus block is indicated for kidney pain. Source: Boswell MV, Board Review 2005

Answer 127

.151. Answer: B | Source: Day MR, Board Review 2005

Answer 128

152. Answer: B Explanation: (Bonica, 3rd Ed., pages 971-976) The average spinal cord diameter from C2-6 is about 10 millimeters and below C6 it is 7-9 millimeters. With neck extension, the posterior longitudinal ligament relaxes and the anterior longitudinal ligament stretches. The ligamentum fl avum looks like shingles on a roof: they span the anterior inferior surface of the cephalad lamina to the posterior superior margin of the caudad lamina. They are elastic and stretch laterally to reinforce the anterior aspect of the zygapophyseal joints. The lateral atlanto-axial joints contribute to rotation (the ‘NO’ joint) and the atlantooccipital joint contributes to fl exion-extension (nodding, the ‘YES’ joint). Source: Shah RV, Board Review 2005

Answer 129

153. Answer: D Explanation: (Bonica, 3rd Ed., page 969) The atlas or C1 vertebra does not have a body. It is a solid ring of bone with two lateral pillars; the upper and lower surfaces articulate with the occiput and C2 vertebra respectively. The short anterior arch of C1 articulates with the odontoid process of C2 in the vertical plane. The C2 vertebra has four articulating surfaces. Excluding those two already mentioned, the inferior facet articulates with the superior facet of C3 and the posterior aspect of the dens articulates with the transverse alar ligament. The C3 and C7 vertebral bodies have only two each. The intervertebral disc and the uncinate processes are not true articular surfaces. Source: Shah RV, Board Review 2005

Answer 130

.154. Answer: B (1 & 3) Explanation: (Raj, Pain Review 2nd Ed., page 229-231, Netter’s Anatomy Atlas) The correct order is least occipital nerve (C3), greater occipital nerve (C2), lesser occipital (C2-3), greater auricular nerve (C2-3), auriculotemporal (V3), supraorbital (V1), and supratrochlear(V1). Source: Shah RV, Board Review 2005

Answer 131

155. Answer: A (1, 2, & 3 ) Explanation: 1. The somatic fi bers of the pudendal nerve are derived from the anterior primary divisions of the S2, S3 and S4 nerves. 2. The pudendal nerve leaves the pelvic cavity by passing through the greater sciatic foramen inferior to the piriformis muscle, between it and the coccygeal muscle. 3. The sympathetic fi bers of pudendal nerve are contributed by the sacral portion of the sympathetic pain. 4. The pudendal nerve trunk divides into three main branches: the inferior hemorrhoidal nerve, the perineal nerve, and the dorsal nerve to the clitoris (or to the penis).

Answer 132

156. Answer: D (4 only) Explanation: (Raj, Practical Management of Pain, 3rd Ed., page 620- 621) 1. Although Tietze’s syndrome is synonymous with costochondritis (infl ammation of the anterior joints corresponding to articulation between the sternum/manubrium and ribs), it is specifi c for a unilateral anterior chest pain involving the 2nd and 3rd anterior costal cartilages. A better term would be costochondral pain. This pain develops following blunt chest trauma, coughing due to upper respiratory infections,and overuse (washing windows or painting). It can be confused with myocardial infarction. 2. It affl icts patients of all ages, but usually those less than 40 years of age. 3. Bulbous swellings may persist for several months and point tenderness over the costochondral joints are common. Treatment is conservative: NSAIDS, TENS, local infi ltration, hot/cold packs, electroacupuncture. True costochondritis refers to infl ammation and arthritides of the costochondral joints at multiple locations. This affl icts elderly patients, but the treatment is similar to Tietze’s syndrome. Source: Shah RV, Board Review 2005

Answer 133

157. Answer: C (2 & 4) Explanation: 1. The laminae of lumbar vertebrae are broad, short, and strong. - The body of the vertebra is large and is wider transversely than anteroposteriorly and a little thicker anteriorly than posteriorly. 2. The lumbar vertebrae are the largest of the true immovable vertebrae and are also large in comparison to their own vertebral canal. 3. The lumbar vertebral (spinal) canal is triangular and is larger than the thoracic canal but smaller than the cervical canal. 4. The lumbar vertebral (spinal) canal is triangular and is larger than the thoracic canal but smaller than the cervical canal.

Answer 134

158. Answer: A (1,2, & 3) Explanation: (Raj. Pain Review 2nd Ed., page 313, Bonica 3rd Ed., page 938) Ramsay-Hunt syndrome is the reactivation of herpes zoster in the geniculate ganglion and can lead to ear and facial pain, rash over the face, hearing loss, and balance diffi culties. 1. The otalgic variety of geniculate neuralgia is known. 2. Pain can occur in the ear and radiate to the face. 3. It can be lesioned alone or in conjunction with the following cranial nerves: VI, XI, XII. 4. Surgical exposure of the nervus intermedius is more diffi cult than performing trigeminal or glossopharyngeal nerve sectioning. Additional cranial nerves that may be sectioned include VII, VIII, IX, and X. Source: Shah RV, Board Review 2005

Answer 135

159. Answer: D (4 only) Explanation: (Raj, Practical Management of Pain 3rd Ed., page 580) 1, 2, 3. The trigeminal ganglion is commonly thought of as only a sensory neural structure, but in reality it provides motor innervation to the muscles of mastication: masseter, medial and lateral pterygoids, temporalis, mylohyoid and anterior belly of the digastric muscles. The temporomandibular joint is innervated by the maxillary nerve. 4. The facial nerve provides muscle innervation to the muscles of the face and taste sensation vis a vis chorda tympani. Recall the pneumonic:’To Zanzibar By Motor Car’, which describes the branches of the facial nerve. The buccinator is innervated by the buccal nerve. Temporalis Zygomatic Buccal Marginal Mandibular Chorda Tympani Source: Shah RV, Board Review 2005

Answer 136

160. Answer: B (1 & 3) Explanation: 1. The epidural space is bound anteriorly by the posterior longitudinal ligament and the vertebral bodies, and laterally by the pedicles and intervertebral foramina. 2. In the lumbar region, the epidural space is triangular with the apex of the triangle corresponding to the posterior midline of the vertebral canal. 3. Posterior boundaries of the epidural space include the laminae and ligamenta fl ava, while its inferior boundary is its continuation with the sacral canal. 4. The size of the epidural space varies greatly. The anterior portion is the narrowest (approximately 1 mm).

Answer 137

161. Answer: A (1, 2, & 3 ) Explanation: 1, 2 & 3. Insertion sites are located by reference to a line that joins the tip of the mastoid process with Chassaignac’s tubercle of C6, which is palpated at the level of the cricoid cartilage. - The deep cervical plexus is composed of the C2-C4 spinal nerves as they emerge from the foramina in the cervical vertebrae. 4. The posterior border of the sternocleidomastoid muscle is the major point of reference used in performing blockade of the superfi cial cervical plexus.

Answer 138

162. Answer: C (2 & 4)

Answer 139

163. Answer: C (2 & 4) | Source: Nader and Candido – Pain Practice. June 2001

Answer 140

164. Answer: E (All) Explanation: The muscles of the abdomen are divided into an anterolateral group and a posterior group. The anterolateral group is composed of four fl at muscular sheets that form the anterior abdominal wall. These muscles include the internal and external obliques; the transversus and rectus abdominis; and the cremaster and pyramidalis muscles, which are involved in suspending the testes and tensing the midline tendinous raphe of the abdominal wall, respectively.

Answer 141

165. Answer: B (1 & 3) Explanation: Reference: Gray’s Anatomy, Thirteenth American Edition. Page 127- 130. 1. The anterior spinal column consists of vertebral bodies and intervertebral discs. 2. The spinal canal lies between the anterior column and the posterior elements and transmits the spinal cord and below L2, the cauda equina. - The pedicle connects the lamina to the vertebral body, thus connecting the posterior and anterior spinal structures. - The pars interarticularis is part of the lamina between the superior and inferior articular processes. 3. The posterior elements consist of spinous processes, lamina, zygapophysial (facet) joints and posterior spinal ligaments (supraspinous, infraspinous and ligamentum fl avum). 4. The dens (odontoid process) is the tooth-like projection of the C2 vertebral body (the axis) that juts upward into the anterior arch of C1 (the atlas). Source: Schultz D, Board Review 2004

Answer 142

166. Answer: A (1, 2, & 3 ) Explanation: 1. The supraorbital nerve innervates the eye. 2. The occipital nerve transmits the referred pain. 3. Infraorbital nerve innervates the eye. 4. The mandibular nerve innervates the lower jaw. Source: Trescot AM, Board Review 2003

Answer 143

167. Answer: A ( 1, 2, & 3) Explanation: 1. The plexus is situated in the epigastrium just anterior to the crura of the diaphragm. 2. The entire plexus lies posterior to the stomach and the omental bursa not anterior. 3. The celiac plexus is composed of two or more large aggregates of ganglion cells, the right and left celiac ganglia, a number of smaller ganglia, and a dense network of parasympathetic and sympathetic efferent and afferent fi bers that enmesh these ganglia. 4. The plexus is situated anterior to the body of fi rst lumbar vertebra not posterior.

Answer 144

168. Answer: D (4 Only) Explanation: Bogduk, Clinical Anatomy of the Lumbar Spine and Sacrum, Third Edition 1. The pars interarticularis is a part of the lamina which connects the superior and inferior articular processes. 2. Spondylolysis is the term used to describe a pars defect. - Spondylolysis was originally thought to be a defect caused by failure of union between two ossifi cation centers in the vertebral lamina. - Recent evidence however clearly shows that spondylolysis is an acquired defect caused by a fatigue fracture of the pars interarticularis. 3. Pars defects are not necessarily painful and are present in approximately 10% of asymptomatic individuals. - Nonetheless, in the presence of a pars defect, the posterior spinal elements are disconnected from the anterior spinal column and constitute a “fl ail segment”. - This may cause motion instability and the forward movement of one vertebral body on another known as spondylolisthesis. - The pars defect itself is innervated with free nociceptive nerve endings and certainly has the potential to be painful. - It has been suggested that infi ltration of the pars defect may help to determine whether or not it is involved in pain generation. - However, no studies have established how often a pars defect is the cause for back pain. 4. Fluoroscopically, the pars interarticularis is represented by the neck of the “Scotty dog” and a pars defect appears as a “collar” on the dog’s neck. Source: Schultz D, Board Review 2004

Answer 145

169. Answer: C (2 & 4) Explanation: 1. Vagus nerves do not innervate the diaphragm. 2. The diaphragm’s peripheral muscular fi bers are supplied by the 6th to the 11th or 12th intercostal nerves. 3. Lumbar plexus does not innervate the diaphragm. 4.The most central portion of the diaphragm is innervated by the phrenic nerves, which arise from the two cervical plexuses (C3-C5).

Answer 146

170. Answer: B (1 & 3) Explanation: (Raj, Practical Management of Pain 3rd Ed., page 618) The visceral afferent fi bers of the heart are transmitted through the vagus, cervical ganglia (middle and inferior cervical nerves), and the upper fi ve thoracic ganglia (thoracic cardiac nerves)…all of which send input to the central nervous system via T1-5. Source: Shah RV, Board Review 2005

Answer 147

171. Answer: A (1, 2, & 3 ) Explanation: 1. The posterior primary division provides sensory fi bers to periosteum. 2. The posterior primary division provides sensory fi bers to cutaneous and muscular structures. 3. The posterior primary division provides sensory fi bers to facet joints. 4. The sinuvertebral nerves supply posterior longitudinal ligament and other structures within the spinal canal.

Answer 148

172. Answer: B (1 & 3) Explanation: 1. Supratrochlear nerve is a branch of ophthalmic division of trigeminal nerve. 2. Infratrochlear nerve is a branch of maxillary nerve (DR M CHECK) 3. Frontal nerve is a branch of ophthalmic division of trigeminal nerve. 4. Auriculotemporal nerve is a branch of mandibular nerve. Source: Shah RV, Board Review 2003

Answer 149

173. Answer: B (1 & 3) | Source: Nader and Candido – Pain Practice. June 2001

Answer 150

174. Answer: C (2 & 4) Explanation: Reference: Gray’s Anatomy, Thirteenth American Edition. Pages 345- 350. 1. The posterior spinal ligaments consist of the supraspinous, the interspinous and the ligamentum fl avum. The supraspinous is the most superfi cial and connects the apices of the spinous processes from the C7 to the sacrum. The interspinous ligament connects adjacent spinous processes with one another and is interposed between the supraspinous and the ligamentum fl avum. The ligamentum fl avum is markedly elastic and connects the lamina of one segment to the adjacent lamina. The ligamentum fl avum is the roof of the dorsal epidural space. 2. The posterior longitudinal ligament runs the length of the spinal column from the axis to the sacrum. This ligament is within the spinal canal and is just anterior to the spinal cord and anterior epidural space. The posterior longitudinal ligament separates the intervertebral disc annulus from the spinal canal. - The anterior longitudinal ligament lies on the ventral surface of the vertebral bodies extending from the axis to the sacrum. 3. The layers of the spinal canal consist of the dura mater, the arachnoid and the pia mater. The dura is a substantial fi brous tissue that is the inner boarder of the epidural space. - Once the dura is penetrated the needle tip enters a potential space called the subdural space. This space is fi lled with a small amount of serosanguinous fl uid. The subdural space is often transcended entirely with quick penetration of the thin and closely apposed arachnoid membrane which allows access to the cerebrospinal fl uid compartment. The pia mater is closely adherent to the spinal cord and the CSF fl ows between the pia and the arachnoid. 4. The epidural space is a circular space which surrounds the spinal canal and its contents.Posteriorly in the midline, the dura is the fl oor of the epidural space and the ligamentum fl avum is the roof. Source: Schultz D, Board Review 2004

Answer 151

175. Answer: A (1, 2, & 3 ) Explanation: 1, 2 & 3. Branches of the maxillary nerve within the pterygopalatine fossa include the pharyngeal branch to the mucosa of the pharynx, the greater palatine branch to the mucosa of the posterior palate, the nasopalatine branch to the septal mucosa through the incisive canal to the anterior hard palate, and the superior alveolar branch to the second and third maxillary molars. 4. The inferior alveolar nerve is a sensory branch of the mandibular nerve that supplies the mandibular teeth,body of the mandible, and labial gingiva anterior to the bicuspid teeth

Answer 152

176. Answer: C (2 & 4) Explanation: 1. The parietal pleura is supplied by the intercostal nerves at its lateral aspects, by the T1 spinal nerve at its apex, and by the phrenic nerves on the diaphragmatic surface. 2. The visceral pleura is supplied by sympathetic fi bers that have a vasomotor function. 3. It has afferent fi bers that do not have a nociceptive function, making it insensitive to noxious stimuli. 4. Visceral pleura receives parasympathetic fi bers through the pulmonary plexuses.

Answer 153

177. Answer: C (2 & 4) Explanation: 1. A trigeminal nerve block at the foramen ovale can result in anesthesia to the eye. 2. The mandibular nerve block at the coronoid will include the lingular nerve which gives sensation to the tongue resulting in loss of sensation. 3. A trigeminal nerve block at foramen ovale can result in subarachnoid injection. 4. The mandibular nerve block at coronoid notch will block the mental nerve which innervates the chin. Source: Trescot AM, Board Review 2003

Answer 154

178. Answer: A (1, 2, & 3) Explanation: 1. In adults the spinal cord ends at L1-L2. 2. The sympathetic nerve fi ber originates in the intermediolateral grey column of the T1-L2 spinal segments. 3. The spinal canal originates at the foramen magnum and terminates at the sacral hiatus. 4. The dural sac terminates at S2 in adults – not S4.

Answer 155

179. Answer: A (1, 2, & 3 ) Explanation: The supraspinous ligament, interspinous ligament, and ligamentum fl avum are traversed, after which continued advancement places the needle in the epidural space. 1. The supraspinous ligament is a strong, fi brous cord that connects the spinous processes from the C7 vertebra to the sacrum. The needle passes through this ligament during an interlaminar epidural injection. 2. The ligamentum fl avum connects the laminae of adjacent vertebrae. The needle passes through this ligament during an interlaminar epidural injection. 3. The interspinous ligaments are thin and membranous and connect adjoining spinous processes, extending from the root to the apex of each process. The needle passes through this ligament during an interlaminar epidural injection. 4. The posterior longitudinal ligament extends from the axis to the sacrum and passes over the dorsal surface of the bodies of the vertebrae and the intervertebral disks. - Although the posterior longitudinal ligament is the anterior boundary for the epidural space,it is not traversed when an epidural injection is performed. - It will only be traversed if the needle went through the spinal cord.

Answer 156

180. Answer: E (All) Explanation: - There are eight nerves involved in processing sensory information to the scalp. - Four sensory nerves pass in front of the ear to the scalp: the supratrochlear and supraorbital nerve from V1 (ophthalmic branch of trigeminal); the zygomaticotemporal nerve from V2 (maxillary branch of trigeminal); and the auriculotemporal nerve from V3 (mandibular branch of trigeminal). -Four nerves pass behind the ear: the great auricular nerve and the greater, lesser, and least occipital nerves from the cervical plexus. - All eight nerves converge toward the vertex of the scalp. 1. Supraorbital nerve from ophthalmic branch of trigeminal also passes in front of ear. 2. Auriculotemporal nerve, a branch of mandibular branch of trigeminal nerve also passes in front of the ear. 3. Supratrochlear nerve from ophthalmic branch of trigeminal passes in front of the ear. 4. Zygomatico temporal nerve from maxillary branch of trigeminal also passes in front of the ear.

Answer 157

181. Answer: B (1 & 3) Explanation: 1. The sacral canal is the continuation of the lumbar spinal canal. It communicates laterally with the anterior and posterior sacral foramina. 2. The volume of the sacral canal, including the sacral foraminal extensions, varies between 12 and 65 mL with a mean of about 30 to 34 mL. 3. The canal contains the fi ve sacral nerve roots and the coccygeal nerve, which constitute the cauda equina. Sacral canal also contains the fi lum terminale, which exits through the sacral hiatus to attach to the back of the coccyx. 4. Inferiorly, the sacral canal terminates at the sacral

Answer 158

182. Answer: A (1, 2, & 3 ) Explanation: The abdomen contains three large plexuses composed of prevertebral sympathetic ganglia, parasympathetic fi bers from the vagus or sacral parasympathetics, and visceral afferent fi bers. 1 The celiac plexus innervates the abdominal viscera. 2. The inferior hypogastric plexus also supplies the pelvic viscera. 3. The superior hypogastric plexuses supply the pelvic viscera. 4. Esophageal plexus is not (T-T5) abdominal autonomic plexus

Answer 159

183. Answer: E (All) Explanation: 1. The brainstem is the most caudal portion of the brain and consists of the medulla (myelencephalon), pons (metencephalon), and midbrain (mesencephalon). 2. The brainstem is roofed by the fourth ventricle. 3. The brain stem is bounded rostrally by the thalamus. 4. The brain stem is bounded ventrally by a fl at bone called the clivus. - It is bounded dorsally by the fourth ventricle and cerebellum caudally by the spinal cord.

Answer 160

184. Answer: E (All) Explanation: Sympathetic fi bers can be blocked at all locations. Raj, Practical Management of Pain, 3rd edition, page 655

Answer 161

185. Answer: D (4 Only) Explanation: 1. Cell bodies of preganglionic sympathetic neurons lie within the intermediolateral gray of spinal cord segments (T1-L2). 2. Lumbar ganglia lie on the anterolateral surface of the respective vertebrae. 3. Axons from these preganglionic neurons pass by way of anterior spinal roots and rami communicantes to reach paravertebral ganglia of the sympathetic chain. 4. Paravertebral ganglia are segmentally arrayed in bilateral vertical rows extending from the second cervical vertebra to the coccyx.

Answer 162

186. Answer: B (1 & 3 ) Explanation: 1. The superior hypogastric plexus is situated in front of the bifurcation of the abdominal aorta,the body of the fi fth lumbar vertebra, and the promontory of the sacrum. 2. Superior hypogastric plexus often lies in the extraperitoneal connective tissue, often to the left of the midline - not to the right. 3. In addition to the sympathetic fi bers that descend to form the superior hypogastric plexus, the superior hypogastric plexus contains parasympathetic fi bers derived from the pelvic splanchnic nerves, which ascend from the inferior hypogastric plexus. 4. The superior hypogastric plexus is formed by the union of branches from the aortic plexus with contributions by the L3 and L4 splanchnic nerves.

Answer 163

187. Answer: C (2 & 4)

Answer 164

188. Answer: B (1 & 3)

Answer 165

189. Answer: C (2 & 4)

Answer 166

``` 190. Answer: A (1, 2, & 3) Explanation: SINGLE SYSTEM EXAMINATION MUSCULOSKELETAL * Primary - Musculoskeletal * Other - Constitutional - Neurological - Cardiovascular – Peripheral - Lymphatic - Skin - Psychiatric NEUROLOGICAL * Primary - Neurological * Other - Constitutional - Musculoskeletal - Cardiovascular - Eyes ```

Answer 167

191. Answer: C (2 & 4) Explanation: Five nerves are blocked when performing an ankle block. The saphenous, superfi cial peroneal, and sural nerves are all sensory below the ankle. 1. The posterior tibial nerve causes fl exion of the toes by stimulating the fl exor digitorium brevis muscles and abduction of the fi rst toe by stimulating the abductor hallucis muscles. - The posterior tibial nerve is sensory to most of the plantar part of the foot. 2. Saphenous nerve below ankle does not contain motor fi bers. 3. Stimulation of the deep peroneal nerve causes extension of the toes by stimulating the extensor digitorum brevis muscles. - The deep peroneal nerve has a small sensory branch for the fi rst interdigital cleft. 4. Sural nerve below ankle does not contain motor fi bers.

Answer 168

192. Answer: A (1, 2, & 3 ) Explanation: 1. By way of the intervertebral foramina at each level, the vertebral plexus communicates with thoracic and abdominal veins. - Marked increases in intraabdominal pressure may compress the inferior vena cava while distending the epidural veins and increasing fl ow up the vertebrobasilar plexus. 2. The major portion of this plexus lies in the anterolateral part of the epidural space, out of reach of a correctly placed epidural needle. 3. Epidural veins are large and valveless. They are part of the internal vertebral venous plexus, which drains the neural tissue of the spinal cord, CSF, and the bony spinal canal. 4. Epidural veins are large and valveless. They are part of the internal vertebral venous plexus, which drains the neural tissue of the spinal cord, CSF, and the bony spinal canal.

Answer 169

193. Answer: A (1, 2, & 3) Explanation: 1. The internal branch of the superior laryngeal nerve provides sensory innervation to the larynx above the vocal cords. 2. The external branch of the superior laryngeal nerve provides sensory innervation to the anterior subglottic mucosa. 3. The recurrent laryngeal nerve provides sensory innervation to the larynx below the vocal cords. 4. Glossopharyngeal nerve does not provide sensory innervation to the larynx. It provides sensory innervation to tongue and pharynx. (DR M NEED TO CHECK FOR ACCURACY)

Answer 170

194. Answer: A (1, 2, & 3 ) | Source: Nader and Candido – Pain Practice. June 2001

Answer 171

195. Answer: A (1, 2, & 3) Explanation: There are four main nerves in the lower extremity: the sciatic, femoral, obturator, and lateral femoral cutaneous. 1, 2. The sciatic nerve is the largest of the four and divides into the posterior tibial nerve and common peroneal nerve at the popliteal fossa. 3. The common peroneal nerve divides further into the deep and superfi cial peroneal nerves. The tibial nerve divides into the posterior tibial and sural nerves. - Thus, four of the fi ve nerves that provide sensory innervation to the ankle arise from the sciatic nerve: deep peroneal, superfi cial peroneal, posterior tibial and sural. 4. The saphenous nerve is a branch of the femoral nerve

Answer 172

196. Answer: D (4 Only) Explanation: 1. The cricothyroid muscle is an intrinsic muscle of the larynx. 2. The cricothyroid is innervated by the external branch of the superior laryngeal nerve of the vagus. 3. The cricothyroid is innervated by the external branch of the superior laryngeal nerve of the vagus. 4. The cricothyroid muscle is the only intrinsic muscle of the larynx that tenses the vocal cords. - All other intrinsic muscles of the larynx receive motor innervation from the recurrent laryngeal nerve.

Answer 173

197. Answer: B (1 & 3)

Answer 174

198. Answer: A (1, 2, & 3)

Answer 175

199. Answer: A (1, 2, & 3 ) Explanation: 1. Needle trajectory should aim superiorly toward the anterior aspect of the external auditory meatus (in a lateral view). 2. In the coronal plane the needle should be in the directionof the mid-pupillary line. 3. The needle is inserted 2 – 2.5 cm lateral to lips. 4. The mandibular notch is used for the infrazygomatic sphenopalatine ganglion block Source: Shah RV, Board Review 2003

Answer 176

200. Answer: E (All) | Source: Raj P, Practical Management of Pain, 3rd Ed.

Answer 177

201. Answer: D (4 Only) | Source: Rozen. Pain Practice: SEP 2001

Answer 178

202. Answer: A (1, 2, & 3 ) Explanation: 1. Early in life, the blood supply to the disk is from the periphery as well as from vessels in the bodies of adjacent vertebrae, which grow through the cartilaginous plates and run toward but do not reach the nucleus pulposus. 2. After 3rd decade intervertebral disk receives nutrients by diffusion of solutes, lymph and other fl uids through the cervical portion, the vertebral end plate, and the annulus fibrosus. 3. Intervertebral disk receives nutrition by alternating compression and relaxation of the elastic container. 4. Shortly after birth, the vascular supply begins to diminish and by the third decade of life, the disk is almost avascular. Source: Kahn and Desio

Answer 179

203. Answer: C (2 & 4) Explanation: - The fi rst seven pairs of the 12 ribs are known as the vertebrosternal ribs. They connect dorsally with the vertebral column and ventrally with the sternum by means of costal cartilages. - The remaining fi ve pairs are “false” ribs and consists of two types. The 8th to 10th ribs have their cartilages attached to the cartilage of the rib above (vertebrochondral). 2 & 4. The 11th and 12th ribs are free at their anterior extremities and are referred to as fl oating or vertebral ribs because they do not attach to the sternum.

Answer 180

204. Answer: C (2 & 4) Explanation: 1. The PLL is broad throughout the length of the vertebral column until it reaches the L1 vertebral level, where it begins to narrow progressively so that at the L5-S1 interspace it is one half its original width. 2. The posterior longitudinal ligament (PLL) extends along the posterior surface of the body of the vertebra from the cervical axis to the sacrum. 3. The PLL is composed of longitudinal fi bers that are denser and more compact than those of the anterior longitudinal ligament. 4. It contributes to the anterior wall of the vertebral canal.

Answer 181

205. Answer: D (4 Only) | Source: Sizer Et Al - Pain Practice March & June 2003