ASIPP Pain States Questions Flashcards
1
Q
- Characteristics of diffuse idiopathic skeletal hyperostosis
(DISH) include:
A. Extensive degenerative disease
B. Traumatic insult.
C. Cystic in presentation.
D. Osteophytosis without evidence of disk space narrowing
or sclerosis.
E. Posterior calcifi cation in four contiguous vertebrae
A
- Answer: D
Source: Helms CA. Fundamentals of Skeletal Radiology.
W.B. Saunders Co., 1995; p. 117.
2
Q
447. Which of the following is the most sensitive to visceral stimuli? A. Serosal membranes B. Solid visceral organs C. Walls of hollow organs D. Ligamentous structures E. Mesentery
A
- Answer: A
Source: Day MR, Board Review 2004
3
Q
448. Which of the following has been targeted as the cause of ischemic muscle pain? A. Substance P B. Potassium ion C. Leukotrienes D. Adenosine E. Histamine
A
- Answer: D
Source: Day MR, Board Review 2004
4
Q
449. The spinal pathway theorized to be involved in the pathogenesis of central pain is: A. Spinothalamic tract B. Posterior spinocerebeller tract C. Anterior corticospinal tract D. Fasciculi propii E. All of the above
A
- Answer: A
Source: Day MR, Board Review 2004
5
Q
450. Seventy percent of cervical radiculopathies caused by disc impingement involve the following nerve root: A. T1 B. C7 C. C6 D. C5 E. C4
A
- Answer: B
Explanation:
B. 70% of cervical radiculopathies involve C7.
C. 20% of cervical radiculopathies involves C6.
A, D & E. Only 10% of cervical radiculopathies involve the
nerve roots other than C6, C7.
6
Q
451.Based on burn depth classifi cation, which type/types is/are painful? A. 1st degree B. 2nd degree C. 3rd degree D. 1st and 2nd degree E. 1st, 2nd, and 3rd degree
A
- Answer: D
Explanation:
Ref: DeLoach and Stiff. Chapter 18. Burn Patient. In: Pain
Management and Regional Anesthesia in Trauma. 1st
Edition. Rosenberg, Grande, Berstein. W.B. Saunders,
1999, page 302.
Source: Day MR, Board Review 2003
7
Q
452. What is the most common etiology of brain central pain? A. Neoplasm B. Arteriovenous malformation C. Stroke D. Multiple sclerosis E. Syringobulbia
A
- Answer: C
Source: Day MR, Board Review 2004
8
Q
453. A 40-year-old man develops depressed mood, anhedonia, initial and terminal insomnia, loss of appetite, signifi cant weight loss, and sexual dysfunction. The clinical features of the patient’s psychiatric illness suggest dysfunction of the A. Frontal lobes B. Pituitary C. Hippocampus D. Hypothalamus E. Corpus Callosum
A
- Answer: D
Explanation:
D. Clinical studies of patients with major depressive
disorders indicate that an intrinsic regulatory defect
involving the hypothalamus underlies the disorder. It also
involves the monoamine pathways.
The hypothalamic modulation of neuroendocrine activity
has been implicated, as have been the neurotransmitter
systems of serotonin and norepinephrine, in major
depression. The evidence suggests a major role for the
heritability of such neurochemical disorders.
A, B, C & E. The frontal lobes, the pituitary, the
hippocampus, and the corpus callosum are related to the
emotions, memory, and neural communications.
However, they do not play a major role in the depressive
disorders as does the hypothalamus.
Source: Ebert 2004
9
Q
- The best description of the relationship between pain and
psychiatric disorders is which of the following?
A. There are low rates of psychiatric illness in patients with
chronicpain.
B. Medically ill patients are much more likely to have psychiatric
illness.
C. Psychiatric illnesses preclude the possibility of clinically
important medical illnesses(pain).
D. There is no relationship between pain, medical and
psychiatric disorders.
E. All the patients with chronic pain will also suffer with
somatization disorder
A
- Answer: B
Source: Cole EB, Board Review 2003
10
Q
- Neurological level of a C6 nerve root involvement is
identifi ed by the following:
A. Weakness in the wrist extension, loss of sensation in the
lateral arm, and biceps refl ex suppression
B. Weakness of shoulder abduction, pain in the lateral
forearm, and suppression of brachioradialis refl ex
C. Weakness of wrist extension, pain in the lateral forearm,
thumb, and index fi nger, and suppression of brachioradialis
refl ex
D. Weakness of wrist fl exion and fi nger extension, pain
in the thumb and index fi nger, loss of sensation in
the thumb and index fi nger, and triceps refl ex suppression
E. Weakness of wrist extension, pain in the lateral arm,
and brachioradialis refl ex suppression
A
- Answer: C
Source: Hoppenfeld S. Orthopaedic Neurology. A
Diagnostic Guide to Neurologic Levels. Philadelphia,
LWW, 1997.
11
Q
- A young man with ankylosing spondylitis complains of
neck, occipital, and shoulder pain. He denies any history
of recent trauma or febrile illness. The most likely cause
of his pain is:
A. Compression fracture of C2
B. Cervical osteomyelitis
C. Atlantoaxial subluxation
D. Epidural hematoma
E. Cervical disc herniation C4/5
A
- Answer: C
Explanation:
Patients with ankylosing spondylitis may have erosion of
the odontoid or destruction of the transverse ligament,
which may allow C1 subluxation on C2.
Patients will complain of neck, occipital, and shoulder
pain. The subluxation is usually mild in these patients.
Plain radiographs and MRI should be obtained to confi rm
the diagnosis.
Treatment is symptomatic.
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
12
Q
457. Unilateral sacroiliac joint erosion or sclerosis would be characteristic of: A. Osteoporosis B. Psoriasis C. HNP L5-S1 D. Reiter’s syndrome E. Piriformis syndrome
A
- Answer: D
Source: Helms CA. Fundamentals of Skeletal Radiology.
W.B. Saunders Co., 1995; p. 125.
13
Q
458. Ramsay Hunt syndrome (herpes zoster oticus) occurs when herpes zoster involves the: A. Gasserian ganglion B. Sphenopalatine ganglion C. Ciliary ganglion D. Geniculate ganglion E. Trigeminal nerve
A
- Answer: D
Explanation:
Ramsay Hunt syndrome develops from a herpes zoster
infection involving the geniculate ganglion.
Zoster lesions of the external ear and oral mucosa on the
ipsilateral side are usually observed.
The syndrome can present as a deep, painful sensation primarily behind the ear between the pinna and mastoid
process and radiating to the face, ear, neck, and occipital
areas.
Source: Raj (Pain Review, 2nd Ed., page 236)
14
Q
- A 54-year old man complained of back pain after heaving
lifting. Two weeks later, he had diffi culty walking on his
heels, and increased pain in the lower back, buttock, and
dorsum of the foot. Straight leg raising was positive at
50°. Likely diagnosis is:
A. L3 radiculopathy
B. L4 radiculopathy
C. L5 radiculopathy
D. S1 radiculopathy
E. L3/4 disc herniation
A
- Answer: C
15
Q
460. Diagnosis of CRPS may be performed: A. typical personality B. recent surgery C. exclusion of other likely diagnosis D. psychological testing E. drug intake profi le
A
- Answer: C
Source: Racz G. Board Review 2003
16
Q
- A female patient presents with gluteal and leg pain. The pain is exacerbated when the patient lies down on the
affected side or with crossed legs. Physical examination
revealed local trochanteric tenderness with iliotibial
band tightness and tenderness. The most likely diagnosis
is:
A. Piriformis syndrome
B. Trochanteric bursitis
C. Lumbar radiculopathy
D. Sacroiliitis.
E. Osteoarthritis of hip
A
- Answer: B
Explanation:
Trochanteric bursitis or gluteal fasciitis may be seen in
approximately 25% of the patients with back pain
predominantly in women.
Etiology is typically unknown. However, one may fi nd leg
length difference, abnormal gait, muscle tightness,
osteoarthritis of the hip or spine, and occasional trauma.
Signs and symptoms:
Gluteal and leg pain, 64%
Pain lying on affected side or with crossed legs, 50%
Local trochanteric tenderness, frequently with iliotibial
band tightness and tenderness
Differential diagnosis of trochanteric bursitis includes
osteoarthritis of hip, lumbar radiculopathy, and septic
bursitis.
Source: Cole & Herring. Low Back Pain Handbook
17
Q
- A young female patient presents with buttock and leg
pain. She also reported occasional low back pain and
severe dyspareunia. Physical examination showed pain
on resisted external rotation and abduction of hip. The
likely diagnosis in this patient is:
A. Severe osteoarthritis of hip
B. Piriformis syndrome
C. Lumbar disc herniation
D. Trochanteric bursitis
E. Sacroiliac joint arthritis
A
- Answer: B
Explanation:
B. The description above indicates piriformis syndrome:
Piriformis muscle originates medially from the inner
surface of the sacrum and exits the pelvis through the
greater sciatic foramen and attaches to the greater
trochanter of the femur.
The innervation is from the fi rst and second sacral nerves
(S1 and S2).
Buttock and nerve pain or pseudosciatica resulting from
compression or infl ammation of sciatic nerve as it courses
under or through piriformis muscle in buttock is the
mechanism.
There is no particular group at risk.
Minor trauma to piriformis may result in muscle
contraction or infl ammation.
Pseudosciatica or buttock and leg pain is the most
common symptom.
Low back pain is seen in 50% of the patients.
Dyspareunia is seen in 23%.
Piriformis muscle tenderness may be found transrectally
or transgluteally.
There is pain on resisted external rotation and abduction of hip.
There is also pain on internal rotation of hip.
The piriformis should be assessed above and below 90° of
hip fl exion.
Reproduction of symptoms in combination with forceful
internal rotation of the fl exed thigh is referred to as
Freiberg’s sign.
If you add adduction, it is called Bonnet’s sign.
The pace maneuver also assesses weakness and pain with
resisted abduction and external rotation of the thigh. This
is done with the patient in the seated position.
Tenderness may present throughout the length of the
piriformis
Differential diagnosis includes lumbar radiculopathy and
sacroiliitis.
Source: Cole & Herring. Low Back Pain Handbook
18
Q
- In a patient whose headaches are positional and are
associated with diplopia, vertigo, tinnitus, nystagmus,
hearing loss, photophobia, nausea, and vomiting the
diagnosis is:
A. Cervicogenic headache
B. Intractable migraine with aura
C. Episodic cluster headache
D. Post-dural puncture headache
E. Non-intractable migraine without aura
A
- Answer: D
19
Q
464. The usual site of herniation of a cervical intervertebral disk is: A. Posterior B. Lateral C. Postero lateral D. Anterior E. Antero lateral
A
- Answer: C
Explanation:
The uncinate processes are bony protrusions located
laterally from the C3 to C7 vertebrae. They prevent the
disc form herniating laterally. The posterior longitudinal
ligament is the thickest in the cervical region. It is 4 to 5
time thicker than in the thoracic or lumbar region. The
nucleus pulposus in the cervical disc is present at birth but
by the age of 40 years it practically disappears. The adult
disc is desiccated and ligamentous. It is mainly composed
of fi brocartilage and hyaline cartilage. After the age of 40, a
herniated cervical disc is never seen because there is no
nucleus pulposus. The most common cervical herniated
nucleus pulposus (HNP) occurs between the C6 to C7
(50%) and followed by the C5 to C6 (30%)
Source: Chopra P. 2004
20
Q
- Which of the following statements is true?
A. Pneumothorax is a common complication of thoracic
epidural.
B. Thoracic facet pathology can refer pain to the scapular
region
C. The intercostal nerve innervates only the scapular
region
D. Noncardiac chest pain is purely psychogenic
E. There is no risk of pneumothorax with a simple trigger
point injection
A
- Answer: B
Explanation:
Pneumothorax is a risk from rib blocks and trigger point
injections. The thoracic facets refer to the scapular region,
but the intercostal nerve can refer into the anterior chest.
There are multiple causes of noncardiac chest pain.
Source: Trescot AM, Board Review 2004
21
Q
466. Lower esophageal pain can be relieved by blocking spinal nerve roots at which levels? A. T2 - T3 B. T2- T5 C. T5- T8 D. T8 - T9 E. T8- T10
A
- Answer: C
Explanation:
Ref: Raj. Chapter 43. Thoracoabdominal Pain. In:
Practical Management of Pain. 3rd Edition, Raj et al,
Mosby, 2000, page 620
Source: Day MR, Board Review 2003
22
Q
467. Thoracic pain can come from all of the following EXCEPT: A. intercostal nerves B. myofascial trigger points C. thoracic or cervical facets D. lung tissue E. atlanto-axial joint
A
467. Answer: E Explanation: All of the above are causes of thoracic pain except Altantoaxial Joint Source: Trescot AM, Board Review 2004
23
Q
468. What is the lifetime prevalence of radicular pain? A. 0.2% B. 2% C. 10% D. 20% E. 80%
A
- Answer: B
Source: (Bonica, 3rd Ed., page 1528)
24
Q
- The affective dimensions of the pain response include
A. Increase in pain tolerance
B. Disruption of appetitive and arousal drive states
C. Memory loss
D. Sharp, shooting pain
E. Dermatomal sensory loss
A
- Answer: B
25
Q
- A 65-year old man with a history of chronic back pain
has been a patient for 5 years, receiving 3-4 months relief
from epidural steroid injections before pain increases to
the level where repeat injection is required. Following
6 weeks after epidural, he presents to the clinic with the
complaint of a recent increase in his pain. The pain is
constant and is exacerbated by movement. NSAIDS,
bedrest, and narcotics failed to help. There was no
history of fever. The L4 and L5 vertebrae were tender to
palpation. There was also paraspinal muscle spasm. No
motor or sensory defi cits were present. The most likely
diagnosis entertained in this patient:
A. Vertebral osteomyelitis
B. Spinal stenosis
C. Herniated disc
D. Paget’s disease
E. Epidural abscess
A
- Answer: A
Explanation:
The symptoms described in the question are consistent
with the diagnosis of vertebral osteomyelitis. Clinical
features include persistent, localized pain with heat,
swelling, tenderness, and erythema over the involved bone.
Fever may be low-grade or absent. Diagnosis can be made
by history, physical examination, radiographic studies of
the spine, bone scan, blood cultures, erythrocyte
sedimentation rate, complete blood count, needle
aspiration of the intervertebral disc space, or biopsy of
infected bone. Staphylococcus aureus is the most common
causative organism, but gram-negative bacteria can also
cause osteomyelitis (most common in a urinary tract
infection) (Bonica, pp 393-394).
26
Q
471.Which of the following statements best described
Conversion Disorder?
A. Involves one or more symptoms or defi cits affecting
voluntary motor or sensory function that suggest a
neurological or other general medical condition.
B. Psychological factors are not judged to be associated
with the symptom or defi cit because the initiation or
exacerbation of the symptom or defi cit follows confl
icts with healthcare professionals.
C. Patients intentionally produce or feign symptoms and
defi cits to call attention to themselves.
D. Symptoms or defi cit can after appropriate investigation
be fully explained by a culturally sanctioned behavior
or experience.
E. It generally develops in late life.
A
- Answer: A
Source: Cole EB, Board Review 2003
27
Q
- Spondylolysis is defi ned as:
A. Dysplasia of the L5/S1 facet joints
B. Forward slippage of vertebral body
C. Traumatic degeneration of posterior elements
D. Isthmus defect without vertebral slippage
E. Pathologic dissolution of the facet joint
A
472. Answer: D Explanation: Spondylolysis is a pars defect without vertebral body slippage Source: Boswell MV, Board Review 2005
28
Q
- A 41-year-old man presents with spastic legs, bilateral
extensor plantar refl exes, hyperrefl exia and loss of
sensation (position sense and vibration) of the lower
extremities. Choose correct diagnosis:
A. Upper motor neuron disease
B. Lower motor neuron disease
C. Myelopathy
D. Radiculopathy
E. Broca’s aphasia
A
- Answer: C
Explanation:
A. Upper motor neuron (UMN) disease (above the level of
the corticospinal synapses in the gray matter) is
characterized by spastic paralysis, hyperrefl exia, and a
positive Babinski refl ex (everything is up in UMN
disease).
B. Lower motor neuron (LMN) disease (below the level of
synapse) is characterized by fl accid paralysis, signifi cant
atrophy, fasciculations, hyporefl exia, and a fl exor (normal)
Babinski refl ex (everything is down in LMN disease).
C. Myelopathy causes severe sensory loss 0 posterior
column sensation (position sense and vibration),
spasticity, hyperrefl exia, and positive Babinski refl exes.
D. A radiculopathy occurs with root compression from a
protruded disk that causes sensory loss, weakness, and
hyporefl exia in the distribution of the nerve root.
E. Broca’s aphasia (left inferior frontal gyrus) is a
nonfl uent expressive aphasia (Broca’s should remind you
of broken speech); Wernicke’s aphasia (left posteriorsuperior
temporal gyri) is a receptive aphasia because
patients lack auditory comprehension (Wernicke’s should
remind you of wordy speech that makes no sense).
(Source: Seidel, 5/e, p 798.)
29
Q
474. The superior hypogastric plexus is: A. a collection of para sympathetic nerves B. innervates the foregut C. blocked to treat pelvic pain D. may cause lumbar radiculopathy E. performed under fl uoroscopy at L2
A
- Answer: C
Explanation:
The superior hypogastric plexus is a collection of
sympathetic nerves that innervate the pelvis and is blocked
to treat pelvic pain. They are not involved in lumbar
radiculopathy.
Source: Trescot AM, Board Review 2004
30
Q
- The uncommon Sluder’s neuralgia characterized by severe
pain in the face blow the eyebrows primarily involves the
A. Gasserian ganglion
B. Sphenopalatine ganglion
C. Ciliary ganglion
D. Geniculate ganglion
E. Trigeminal nerve
A
- Answer: B
Explanation:
Sluder’s neuralgia, also known as sphenopalatine ganglion
neuralgia, is an uncommon facial neuralgia characterized
by severe pain in the face below the eyebrows.
The pain is unilateral, constant, and boring.
The cause of Sluder’s syndrome is thought to be
involement of the sphenopalatine ganglion from an
irritation such as sinusitis.
Source: Raj, P
31
Q
476. A patient with hallux valgus develops lateral displacement of the extensor and fl exor hallucis longus tendons. CHOOSE CORRECT DIAGNOSIS: A. Hammer toe B. March fracture C. Genu valgum D. Genu varum E. Bunion
A
- Answer: E
Explanation:
(Seidel, 5/e, p 732.) Improper footwear results in lateral
deviations of the great toe, extensor, and fl exor hallucis
longus tendons (bunion formation). Hammer toe often
affects the second toe. The metatarsophalangeal joint is
dorsifl exed and the proximal interphalangeal joint
displays plantar fl exion. A stress fracture of a metatarsal is
called a march fracture. Stress fractures result in bone
resorption followed by insuffi cient remodeling due to
continued activity Stress fractures occur in the tibia as well
as the metatarsal; examination typically reveals point
tenderness and swelling. In genu varum (bowleg), the
lateral femoral condyles are widely separated when the feet
are placed together in the extended position. In genu
recurvatum, the knee hyperextends, and in genu
impressum, there is fl attening and bending of the knee to
one side with displacement of the patella. Pes planus is a
fl attened longitudinal arch of the foot, often called fl at
foot.
Morton’s neuroma causes pain in the forefoot that radiates
to one or two toes with tenderness between the two
metatarsals. The pain may be further aggravated by
squeezing the metatarsals together.
32
Q
477. Which of the following is innervated by the T1 nerve root? A. Thumb B. Index finger C. Lateral biceps D. Medial arm E. Middle finger
A
- Answer: D
Explanation:
The medial arm is innervated by the intercostals brachial
nerve, and is comprised of fi bers from T1 and T2 roots.
33
Q
- A 20-year-old college student develops left shoulder
pain after jumping into a lake from a swinging rope. She
presents holding her arm beside her body (adducted) and
avoiding any shoulder movement. On examination, the
rounded contour of the shoulder is lost and the head of
the humerus is felt under the coracoid process. Which of
the following is the most likely diagnosis?
A. Inferior glenohumeral dislocation
B. Rupture of the long head of the biceps
C. Posterior glenohumeral dislocation
D. Anterior glenohumeral dislocation
E. Fracture of clavicle
A
- Answer: D
Explanation:
(Seidel, 5/e, p 720.) Glenohumeral dislocations may be
anterior, posterior, or inferior depending on the position of the head of the humerus in relation to the glenoid. The
most common dislocation is anterior (>90%)and is due to
forceful abduction, external rotation, or extension. There
is typically fl attening of the deltoid and loss of the greater
tuberosity, causing a squared-off appearance of the
shoulder. The patient is usually in severe pain and holds
the arm in slight abduction and external rotation.
Posterior dislocations are typically seen following a
seizure. Possible complications of shoulder dislocation
include damage to the axillary artery, axillary nerve
(deltoid paralysis), and brachial plexus. First-time
dislocation requires orthopedic management (surgery or
therapeutic exercise), since 80% of patients will have a
recurrence. Rupture of the long head of the biceps causes a bulge in the lower half of the arm and pain on elbow
flexion.
34
Q
479. A young, high school girl develops a painful vesicular rash around her left eye. This is followed by blurry vision that occurs only when both eyes are open. She is diagnosed with vericella zoster ophthalmicus. Which ocular motor nerve is most likely to be affected? A. Superior division of the third. B. Inferior division of the third. C. Fourth (trochlear) D. Sixth (abducens) E. Long ciliary
A
- Answer: C
Explanation:
Varicella Zoster, or herpes zoster, spreads to the face along
the trigeminal nerve. The fourth nerve is presumably
involved because it shares its nerve sheath with the
ophthalmic division of the trigeminal nerve. The third and
sixth nerves may also be involved with varicella zoster, but
this occurs much less frequently than involvement of the
fourth nerve.
Source: Anschel 2004
35
Q
- 55 year old, former sailor states that he has pain on the
right side of his face when he chews his food. It also
starts when he shaves his beard. It is a sharp, electric like
stabbing pain and not present all the time. The pain is
mostly over his right cheek and jaw. The most likely cause
of his pain is:
A. Dental caries
B. Atypical neuralgia
C. Trigeminal Neuralgia
D. Temporomandibular joint disorder
E. Atypical facial pain
A
- Answer: C
Explanation:
Trigeminal neuralgia (Tic Douloureux) is pain restricted
to the distribution of the trigeminal nerve.It can be
present in any of the three divisions - frontal (V1),
maxillary or the mandibular. The commonest to be
affected are the maxillary (V2) and the mandibular (V3).
The peak incidence is mostly between the ages of 50 years
and 70 years. The pain is intermittent with pain free
intervals. It is described as a sharp, electric, stabbing,
shooting pain. The triggers are chewing, swallowing,
talking and exposure to cold. Trigeminal neuralgia is
mostly unilateral.
Atypical neuralgias are almost always constant with very
rare pain free intervals. This is an important
distinguishing symptom with trigeminal neuralgia. The
pain burning in character and not sharp. It is not triggered
by non-noxious stimulus. It tends to affect young adults.
Source: Chopra P, 2004
36
Q
- A 43-year old male house painter reports shoulder pain
of 2 weeks duration after a half a can of paint fell onto his
right shoulder. He feels stiff and weak when attempting
to elevate his right arm overhead. When attempting to
elevate the shoulder, he does so with an overexaggerated
right shoulder shrug up to 40° and suddenly fl ops down
to his side. The most likely diagnosis is:
A. Rotator cuff tear
B. Cervical spondylosis
C. Suprascapular neuropathy
D. Brachial neuritis
E. Bicipital tendonitis
A
- Answer: A
Explanation:
Rotator cuff disorders encompasses four stages with Stage
I with edema and hemorrhage, Stage II with tendonitis,
Stage III with partial thickness tear, and Stage IV with full
thickness tear of the rotator cuff. With partial thickness
tear, there is history of tendonitis and patient can begin abduction but experiences pain or a painful arc during the
attempt. Active abduction becomes more comfortable
afterinjection of a local anesthetic and this feature helps
differentiate tendonitis or a partial tear from a complete
tear of the rotator cuff. Since the patient with a large tear
does not regain strength after the subacromial space is
anesthetized.
Full thickness tear of the rotator cuff occurs, as the fi nal
stage of the degenerative process in which the provoked
tendon succumbs to something as trivial as opening up a
stuck window or more seriously after sustaining a fall on
the shoulder or on an outstretched abducted arm. A
complete tear may also occur after greater humeral
tuberosity fracture scar or from shoulder dislocations.
Differential diagnosis includes bursitis, cervical
spondylosis, suprascapular neuropathy, and brachial
neuritis, etc.
Source: Saidoff DC, McDonough AL. Critical Pathways in
Therapeutic Intervention. Extremities and Spine. St.
Louis,Inc., 2002
37
Q
- Following a radical mastectomy, the patient is found
to have winging of the scapula when the fl exed arm is
pressed against a fi xed object. This indicates injury to
which of the following nerves?
A. Axillary
B. Long thoracic
C. Lower subscapular
D. Supraclavicular
E. Thoracodorsal
A
- Answer: B
Explanation:
A. The axillary nerve, deep in the brachial portion of the
axilla, innervates the deltoid muscle.
B. The serratus anterior muscle (protractor and stabilizer
of the scapula) is innervated by the long thoracic nerve (of
Bell), which arises from roots C5 to C7 of the brachial
plexus. During modifi ed radical mastectomy, this nerve is
usually spared to maintain shoulder function. However, its
location places it in jeopardy during the lymphatic
resection.
C. The lower subscapular nerve innervates the teres major
muscle and a portion of the subscapularis muscle.
D. The supraclavicular nerves are sensory branches of the
cervical plexus.
E. The thoracodorsal nerve, which arises from the
posterior cord of the brachial plexus, innervates the
latissimus dorsi.
Source: Klein RM and McKenzie JC 2002.
38
Q
- A middle-aged man presents with complaints of right
elbow pain. He is an avid golf player. He does not play
tennis. He tried high doses of Aspirin and Tylenol
without any signifi cant relief. Physical examination
showed resisted wrist extension with elbow extended and
radial deviation, forced passive wrist fl exion and ulnar
deviation, and forearm pronation with elbow extension
reproduced the pain in the vicinity of lateral epicondyle.
The appropriate diagnosis in this patient is:
A. Radiohumeral joint infl ammation
B. Radial tunnel syndrome
C. Posterior interosseous nerve entrapment
D. Lateral epicondylitis
E. Medical epicondylitis
A
- Answer: D
Explanation:
A. Radial humeral joint infl ammation and swelling may
occur from rheumatoid arthritis, gout, or infectious
arthritis, especially in the last if there has been a history of
injections to this area, such as repeated steroid injections
for recalcitrant tennis elbow. Swelling, if present, will
occur between the lateral epicondyle and the olecranon
process below.
B. Radial tunnel syndrome may occur concomitantly with
lateral epicondylitis and is a common cause of treatment
resistant cases. It should be considered suspect when
tennis elbow fails to respond to conservative treatment including injections.
C. Involvement of the deep radial nerve is also known as
posterior interosseous nerve entrapment. This may be
confi rmed by a tension-test. The symptoms of entrapment
of posterior interosseous nerve are similar to the radial
tunnel syndrome in which pain is over the proximal dorsal
forearm, with maximal tenderness at the site of radial
tunnel, that is 4 cm distal to the lateral epicondyle over the
posterior interosseous nerve.
D. Lateral epicondylitis, or tennis elbow, is the most
common affl iction.
E. Medical epicondylitis or pain elicited on resisted wrist
fl exion and pronation, as well as extremes of the passive
wrist extension with the forearm supination and elbow
extension and ulnar deviation eliciting the pain at the
medial epicondyle.
Source: Saidoff DC, McDonough AL. Critical Pathways in
Therapeutic Intervention. Extremities and Spine. St.
Louis,Inc., 2002.
39
Q
- An elderly woman presents with recent onset of swelling
of the right arm, neck and face. Her right jugular vein is visibly engorged and her right brachial pulse is
diminished. On the basis of these signs, her chest x-rays
might show
A. A left cervical rib
B. A mass in the upper lobe of the right lung
C. Aneurysm of the aortic arch
D. Right pneumothorax
E. Thoracic duct blockage in the posterior mediastinum
A
- Answer: B
Explanation:
(April, 3/e, p 265.) A Pancoast tumor in the apex of the
right lung may compress the right brachiocephalic vein
with resultant venous engorgement of the right arm and
right side of the face and neck. In addition, there may be
compression of the brachial artery, the sympathetic chain,
and recurrent laryngeal nerve with attendant defi cits. An
aneurysm of the aortic arch could reduce pulse pressures
as the great vessels are occluded, but it could not explain
the venous congestion.
Source: Klein RM and McKenzie JC 2002.
40
Q
- A woman presents with complaints of left shoulder
and arm pain approximately 2 years after undergoing
radiation therapy for breast cancer. Physical examination
reveals lymphedema of the left axilla and pressure over
the left supraclavicular area precipitating a sharp pain
that radiates down her left arm. The likely diagnoses is:
A. Thromboangiitis obliterans
B. Refl ex sympathetic dystrophy
C. Tumor metastasis
D. Radiation-induced plexopathy
E. Cervical radiculopathy
A
- Answer: D
Explanation:
Radiation-induced fi brosis of the connective tissue
surrounding the brachial plexus can cause compression
and ischemic neuropathy. Symptoms have developed 6
months to 20 years after radiation therapy. The patient
complains of deafferentation-type pain. It is characterized
as progressively increasing, diffuse, and burning. Other
symptoms and signs may include numbness, paresthesias,
dysesthesias, and C5/6 motor weakness. There are
signifi cant differences in symptoms in patients with
metastatic plexopathy versus radiation plexopathy. Most
patients with metastatic plexopathy develop sensory
changes in C8/T1 distribution versus C5/6 in radiation
plexopathy. Patients with metastatic plexopathy also have
a much higher incidence of Horner’s syndrome,
lymphedema, and swelling of the painful limb, and
development of epidural deposits.
Source: Bonica
41
Q
- A 20-year-old woman presents complaining of proximal
forearm pain exacerbated by extension of the wrist
against resistance with the elbow extended, She denies
trauma but is an avid racquetball player. Which of the
following is the most likely diagnosis?
A. Lateral epicondylar tendinitis
B. Medial epicondylar tendinitis
C. Olecranon bursitis
D. Biceps tendinitis
E. Long thoracic nerve early paralysis
A
- Answer: A
Explanation:
(Goldman, 21/e, pp 1559-1560.) Tennis elbow or lateral
epicondylar tendinitis is most commonly characterized by
tenderness of the common extensor muscles at their origin
(the lateral epicondyle of the humerus). Passive fl exion of
the fi ngers and wrist and having the patient extend the
wrist against resistance causes pain. Golfer’s elbow or
medial epicondylar tendinitis is a similar disorder of the
common fl exor muscle group at its origin, the medial
epicondyle of the humerus. Olecranon bursitis is an
infl ammation of the bursa over the olecranon process
caused by acute or chronic trauma (student’s elbow) or
secondary to gout, rheumatoid arthritis, or infection.
Clinically, there is swelling or pain on palpation of the
posterior elbow. Paralysis of the serratus anterior muscle
(innervated by the long thoracic nerve) causes the scapula
to protrude posteriorly from the posterior thoracic wall
when the patient is asked to push against a wall (winged
scapula).
42
Q
- A 50-year old woman with systemic lupus erythematosus
complains of fever, headache, and vomiting associated
with a depressed level of consciousness over the last 24 h.
She recently had begun taking ibuprofen as treatment for
diffuse joint pain. CSF examination revealed neutrophilia
and normal glucose. The most likely diagnosis is:
A. Bacterial meningitis
B. Drug-induced meningitis
C. Fungal meningitis
D. Viral meningitis
E. Encephalitis
A
- Answer: B
Explanation:
B. Drug-induced aseptic meningitis may be due to a
hypersensitivity reaction to drugs such as ibuprofen,
sulindac, tolmetin, trimethoprim-sulfamethoxazole,
azathioprine, penicillin, isoniazid, phenazopyridine, and
sulfonamides.
Facial swelling, urticaria, pruritus, and conjunctivitis may
also occur along with the fever, headache, vomiting, and
depressed level of consciousness.
Symptoms usually resolve rapidly after the causative drug
is eliminated.
CSF studies show predominance of neutrophils and low or
normal glucose.
Patients with lupus, Sjögren’s syndrome, or mixed
connective tissue disease have the greatest risk of
developing drug-induced meningitis.
The incidence is higher in women.
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
43
Q
488. The relationship between social and biologic processes in the causation of psychopathology has historically been classifi ed by the following terms. A. Classically conditioned B. Organic and functional C. Genetic and familial D. Neuropathologic and sociopathologic E. Psychoanalytic and dynamic
A
- Answer: B
Explanation:
The relationship between social and biologic processes has
historically been regarded by psychiatry and medicine as
organic and functional.
Organic mental illnesses have included the dementias and
the toxic psychoses.
The functional mental illnesses have included the various depressive syndromes, the schizophrenias, and the
neuroses.
The Psychoanalytic (dynamic) approaches and an
understanding of conditioning (learning) played
important roles in the evolution and development of an
integrated biobehavioral understanding of human
behavior and human biology.
44
Q
489. The most common painful symptom associated with central pain is A. Burning pain B. Dysesthesias C. Lancinating pain D. Visceral pain E. Muscle pain
A
- Answer: A
45
Q
- A unilateral throbbing headache, associated with
nausea, phonophobia, photophonia, without preceding
symptoms, would meet the IHS criteria for what type of
headache?
A. Migraine with aura
B. Migraine without aura
C. Cluster headache
D. Trigeminal neuralgia
E. Tic doloureux
A
- Answer: B
Explanation:
A. Migraines with aura are associated with preceding
symptoms.
B. Migraine without aura has symptomatology as
described.
C. Cluster headaches are usually centered over the eye.
D. Trigeminal neuralgia is usually a sharp, lancinating
pain.
E. Tic Douloureux is trigeminal neuralgia
Source: Trescot AM, Board Review 2004
46
Q
- A patient complains of morning stiffness and pain
in multiple joints, including the joints of the hand.
Subcutaneous nodules are present over the extensor
surfaces, and diagnostic tests indicate abnormal amounts
of HLA-DR4. The most likely diagnosis is:
A. Osteoarthritis
B. Rheumatoid arthritis
C. Gout
D. Degenerative arthritis
E. Fibromyalgia Syndrome
A
- Answer: B
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition
47
Q
492. The presence of what factor distinguishes CRPS II from CRPS I? A. Sudomotor changes B. An identifi able nerve injury C. Allodynia D. Sympathetically maintained pain E. Hyperalgesia
A
- Answer: B
Source: Day MR, Board Review 2004
48
Q
- A 40-year-old male presents with anterior shoulder
pain. Physical examination shows full range of motion
with painful arc present on elevation and depression
at approximately 50° on both the upswing and the
downswing. There is no muscle wasting. There is no
cuff wasting and the patient admits to a history of cuff
impingement and suspected tear of his right shoulder of
several years’ duration that was operated a year before.
There is tenderness noted in the shoulder, shoulder
abduction, and glenohumeral rotation are painful. The
likely diagnosis is:
A. Bicipital tendonitis
B. Anterior shoulder instability
C. The coracoid impingement syndrome
D. Subdeltoid bursitis
E. Glenohumeral joint arthritis
A
- Answer: A
Explanation:
The biceps, a long fusiform muscle that arises by two
heads, has no direct connection with the humerus as it
originates above the shoulder and inserts below the elbow
joint.
The long head of the biceps arises from the supraglenoid
tubercle and arches obliquely over the top of the humeral
head within the capsule of the shoulder joint.
The biceps tendon is intraarticular but extrasynovial.
The short head of the biceps arises within the
coracobrachialis from the scapulas coracoid process and
runs down the medial side of the long head of the biceps.
The two belles join as a common distal tendon shortly the
elbow joint as fl attened tendon, only to separate into two
distal insertions.
The most common cause (95% to 98%) of bicipital
tendonitis actually results as a secondary involvement of
the biceps after primary impingement or tearing of the
rotator cuff.
Proximal biceps tendonitis is evidenced by proximal
anterior shoulder pain and possibly a painful arc during
shoulder fl exion and extension while the biceps is tensed
and by tenderness in the bicipital groove on palpation.
Pain may radiate to the muscle belly or proximally, like pain from cuff impingement, radiate to the deltoid
insertion.
However, there is no radiation into the neck or distally
beyond the biceps muscle belly.
Pain is less intense during rest and worse with use.
Nighttime exacerbation is common.
Source: Saidoff DC, McDonough AL. Critical Pathways in
Therapeutic Intervention.
49
Q
494. Brachial plexopathy following breast cancer treatment is most often the result of A. Radiation therapy B. Axillary dissection C. Lymphedema D. Chemotherapy E. Metastases
A
- Answer: A
Explanation:
Radiation therapy is more likely to cause brachial
plexopathy in patients with breast cancer. In lung cancer,
plexopathy is more often due to metastatic disease.
50
Q
495. Which of the following is considered to be the least helpful treatment for spinal cord injury pain? A. Amitryptiline B. Opioids C. Marjiuana D. Massage E. Acupuncture
A
495. Answer: A Explanation: (Shah, Central Pain States Lecture; Cardenas, Pain; Warms, Clin J Pain) Source: Shah RV, Board Review 2004
51
Q
- A 42-year-old male presents with pain in the region of the
deltoid that began when he started to build a fence in his
back yard 6 weeks ago. Now his pain is sharp, followed by
a dull aching and increases when he elevates and lowers
his arm during activity. He demonstrates a midrange
painful arc when he elevates his arm. His symptoms are
provoked with resisted shoulder abduction. However, the
same test is negative when pulling on his humerus along
its long axis. What is your diagnosis?
A. External impingement with subacromiodeltoid bursitis
B. External impingement with supraspinatus tendonitis
C. Internal impingement with infraspinatus tendonitis
D. Internal impingement with supraspinatus tendonitis
E. Internal impingement with subacromiodeltoid bursitis
A
- Answer: A
Source: Sizer Et Al - Pain Practice March & June 2003
52
Q
- A 27-year-old female patient presents with glenohumeral
instability. Her imaging, demonstrates a dent in the
posterior humeral head. How would this dent be
classifi ed?
A. Bankhart Lesion
B. Bennett’s lesion
C. Gray’s Lesion
D. Hill Sach’s lesion
E. Callifi c Tendinitis
A
- Answer: D
Source: Sizer Et Al - Pain Practice March & June 2003
53
Q
- A radiological defi nition of severe spinal stenosis is:
A. Spinal canal <25% of the AP dimension of a normal
level
A
- Answer: A
Source: Day MR, Board Review 2004
54
Q
499. The most commonly used descriptor for central pain is: A. Lancinating B. Achy C. Steady D. Crampy E. Burning
A
- Answer: E
Source: Day MR, Board Review 2004
55
Q
500. Weakness, atrophy, and fasciculation in the triceps and wrist extensors would indicate stenosis at what spinal level? A. C5 B. C6 C. C7 D. C8 E. T1
A
- Answer: C
Source: Day MR, Board Review 2004
56
Q
- A 47-year-old man fell on his outstretched right hand
while rollerblading. Several days later, he develops right
wrist pain that is constant and progressive. Pain is in the
area of the anatomical snuffbox and is worse with wrist flexion, extension, and ulnar deviation. The anatomical
snuffbox is tender to palpation but there is no swelling.
Finkelstein test is negative. Which of the following is the
most likely diagnosis?
A. Cervical radiculopathy
B. Scaphoid fracture
C. Compartment syndrome
D. de Quervain’s disease
E. Boxer’s fracture
A
- Answer: B
Explanation:
A. Cervical (C6-C8) radiculopathy causes pain,
numbness, and tingling from the neck to the hand.
B. Scaphoid fractures occur as a result of a fall on an
outstretched hand.
These fractures heal poorly due to a poor blood supply in
this area.
Radiographs done early may be negative, but later
radiographs may show evidence of healing (callus
fracture).
C. Compartment syndrome is a surgical emergency and is
due to a tight cast or swelling causing compression of the
blood vessels and nerves in the forearm.
D. de Quervain’s disease or tenosynovitis of the tendon
sheath of the extensor pollicis brevis and abductor pollicis
longus causes swelling and tenderness of the anatomic
snuffbox.
This disorder is usually found in middle-aged women
who perform repetitive activity.
The Finkelstein test is positive (patient makes a fi st
around his or her own thumb; pain is produced with
adduction toward the ulnar side) in de Quervain’s disease.
E. A boxer’s fracture causes fl attening or loss of the fi fth
knuckle prominence due to displacement of the
metacarpal toward the palm. It is usually the result of
striking an object with a clenched fi st.
Source: Seidel
57
Q
- Which of the following statements concerning
spontaneous spinal epidural abscess is correct?
A. Interventional techniques present greater risk than
surgery
B. Most cases present with nonspecifi c symptoms
C. Myelography is the most appropriate diagnostic test
D. Skin structures are the usual source of infection
E. Leukocytosis is usually present
A
- Answer: E
Explanation:
Leukocytosis is usually present. MRI with gadolinium is
the most sensitive diagnostic test, although myelogram is
usually abnormal. However, spinal puncture may increase
the risk of spinal fl uid seeding of bacteria. Gram positive
organisms are most commonly cultured.
Source: Merritt’s Neurology. 10th ed
58
Q
- A 36-year-old executive of a Wall Street fi nancial company
presents with headaches for many years. The headaches
are episodic. Usually on the left side, they may occur in
the maxillary, frontal or temporal region. Each attack
lasts for approximately 2 hours. He describes the pain like
a knife being driven through the head. It often wakes him
up in the morning. The headache attacks some several
times a day. This may continue for a week at a time.
When he has an attack he is restless and unable to fi nd a
comfortable position. What is the diagnosis?
A. Tension type headache
B. Hypertensive headache
C. Subdural hematoma
D. Cluster headaches
E. Intractable Migraine with Aura
A
- Answer: D
Explanation:
A. Tension type headaches are constricting
B. Hypertensive headaches are associated with nausea,
vomiting, seizures and confusion.
- There is a sudden rate of increase of blood pressure.
- The headache is sudden, severe and unrelenting.
- Fundoscopic examination often reveals severe
hypertensive vascular changes.
C. Subdural hematomas are commonly secondary to a
trauma or anticoagulation therapy.
- There is tearing of the bridging veins.
- The headaches are chronic, mild to moderate in severity.
- Neurological changes are usually subtle.
D. Cluster headaches are unilateral, temporal, frontal or
temporal.
Cluster headaches are 6 times more common in men.
- The usually start between the 3rd and 4th decade of life.
- These are short lasting attacks that come together over a
period of time.
- They may have several attacks in a day and this may
continue for several weeks or months.
The headaches are very severe and sharp, often associated
with lacrimation and conjunctival injection.
- In contrast to migraines, these patients tend to restless
and pace up and down.
Abortive management of an acute cluster headache
includes: oxygen by face mask, ergotamine (nasal) or
sumatriptan.
- Preventive treatment is recommended because of the
severity of the attacks. A short course of steroids, lithium
verapamil and/or valproic acid can be used.
E. Intractable migraine with aura is associated with one or
more fully reversible symptoms.
Source: Chopra P, 2004
59
Q
- Buttock pain that is reproduced by internal rotation of
the femur suggests pain arising from the:
A. Hip joint
B. Spinal nerve
C. Piriformis muscle
D. Obturator neuralgia
E. Tensor fascia lata
A
- Answer: C
Explanation:
Pain reproduced by internal rotation of the femur suggests
piriformis syndrome, because the piriformis muscle
externally rotates the hip; stretch on the muscle may
aggravate pain. External rotation induced pain suggests
hip joint or sacroiliac joint dysfunction.
60
Q
- A patient has been scheduled for a block to differentiate
somatic versus visceral pain. Appropriate blocks include:
A. Thoracic paravertebral block
B. Thoracic epidural block with 2% lidocaine
C. Splanchnic nerve block
D. Intercostal nerve block – T4-T9
E. Intercostal nerve block – T8-T10
A
- Answer: C
61
Q
506. Which of the following describes the location of pain relief following a percutaneous cordotomy performed at T3? A. Contralateral side at T6 and below B. Contralateral side T3 and below C. Ipsilateral side at T3 and below D. Ipsilateral side atT6 and below E. Bilaterally at T6 and below
A
- Answer: A
Explanation:
STT fi bers cross within several segmental levels. Clinical
and experimental evidence indicate that the uppermost
level of analgesia is several segments (perhaps as many as
5) caudad to the level of the cordotomy.
Source: Bonica’s Management of Pain, 2nd edition, page
54.
62
Q
- A middle aged woman in late 50’s presents with a one year history of weakness and diffi culty with walking, with
no signifi cant pain. Exam fi ndings include weak, wasted
muscles with spasticity, fasciculations, extensor plantar
responses, and hyperrefl exia. Most likely diagnosis is:
A. Dorsal spinal root disease
B. Ventral spinal root disease
C. Arcuate fasciculus damage
D. Motor neuron disease
E. Purkinje cell damage
A
- Answer: D
Explanation:
Motor neuron disease in the anterior horns of the spinal
cord and damage to the corticospinal tracts or motor
neurons contributing axons to the corticospinal tracts
would account for these neurologic signs. Damage to the
dorsal spinal root would be expected to produce sensory,
rather than motor, defi cits and would produce arefl exia,
rather than hyperrefl exia, at the level of the injury.
Damage to the ventral spinal roots would produce
weakness and wasting, but no spasticity or hyperrefl exia
would develop.
Purkinje cell damage would be expected to produce ataxia
without substantial weakness. The accurate fasciculus
connects elements of the cerebral cortex not involved in
the regulation of strength or motor tone.
Source: Anschel 2004
63
Q
- A 45 year old lady with a long standing history for
migraines with aura which has been well controlled with
rizatriptan, states that she has been having a constant
headache which has not responded to any of her usual
medications. The headache started a month ago and has
progressively increased during this time. Last week she
slipped and fell twice. What is the next best step?
A. Lumbar puncture for CSF
B. Increase the dose of Rizatriptan
C. MRI of the head
D. Aspirin
E. Intramuscular Demerol
A
- Answer: C
Explanation:
Any change in the character of headache must raise the
suspicion of a new organic pathology. Conditions that are
red fl ags in headaches are:
New neurologic symptoms, papilledema or change in the
level of consciousness.
New onset of headache.
A slow but crescendo increase in headache over weeks or
months.
Significant change in the character or pattern of a
preexisting headache.
Unexplained fever, neck rigidity.
Increase in headache with exertion as in coughing, bowel
movement or after sexual intercourse.
The differential diagnosis of change in the character of a
headache or a new onset headache maybe subarachnoid or
subdural headache, brain tumor, meningitis, glaucoma,
stroke, internal carotid artery dissection, sinusitis,
idiopathic intracranial hypertension, hypertensive
encephalopathy.
A. Lumbar puncture is contraindicated in the presence of a
raised intracranial pressure.
C. An MRI of the head is one of the most sensitive tests
that can be done to rule out intracranial pathology as in a
space occupying lesion.
Ref: Robbins
Source: Chopra P, 2004
64
Q
509. A 48-year-old man presents with spastic paralysis, hyperrefl exia, and an extensor plantar refl ex. Choose correct diagnosis: A. Upper motor neuron disease B. Lower motor neuron disease C. Myelopathy D. Radiculopathy E. Broca’s aphasia
A
- Answer: A
Explanation:
A. Upper motor neuron (UMN) disease (above the level of
the corticospinal synapses in the gray matter) is
characterized by spastic paralysis, hyperrefl exia, and a
positive Babinski refl ex (everything is up in UMN
disease).
B. Lower motor neuron (LMN) disease (below the level of
synapse) is characterized by fl accid paralysis, signifi cant
atrophy, fasciculations, hyporefl exia, and a fl exor (normal)
Babinski refl ex (everything is down in LMN disease).
C. Myelopathy causes severe sensory loss 0 posterior
column sensation (position sense and vibration),
spasticity, hyperrefl exia, and positive Babinski refl exes.
D. A radiculopathy occurs with root compression from a
protruded disk that causes sensory loss, weakness, and
hyporefl exia in the distribution of the nerve root.
E. Broca’s aphasia (left inferior frontal gyrus) is a
nonfl uent expressive aphasia (Broca’s should remind you
of broken speech); Wernicke’s aphasia (left posteriorsuperior
temporal gyri) is a receptive aphasia because
patients lack auditory comprehension (Wernicke’s should
remind you of wordy speech that makes no sense).
(Source: Seidel, 5/e, p 798.)
65
Q
- The celiac plexus:
A. can safely and reliably performed by an anterior approach.
B. innervates the entire gastrointestinal tract
C. commonly used to treat the pain of pancreatic cancer
D. commonly used to treat pelvic pain
E. may b
A
- Answer: C
Explanation:
The celiac plexus innervates the forgut, and can be approached from an anterior or posterior approach to
treat pancreatic pain. Pelvic pain of a sympathetic origin
may be treated with a superior hypogastric plexus
injection
Source: Trescot AM, Board Review 2004
66
Q
- The treatment of epicondylitis includes the following:
A. Absolute rest with no activity
B. Ice massage for 20 minutes, three times a day in the
acute stage and the use of heat during acute or subacute
stages
C. Weekly steroid injections
D. Stretching regimen to gain length in the extensor supinator
muscle mass
E. Strengthening with gradual concentric, as well as eccentric
exercises
A
- Answer: E
Explanation:
A. Selecting rest preferably will avoid stressful activity
until the pain has subsided. However, pain free
movements are encouraged. Excessive activity or early
return to activity may direct excessive stress to healing
scar tissue. Activities that involve strong, repetitive
grasping, such as hammering or tennis playing, should be
restricted until there is minimal pain on resisted isometric
wrist extension and little or no pain when the tendon is
passively stretched. In the acute stage, the total rest may be
achieved by immobilization of the wrist, hand, and fi ngers
in a resting splint. However, the splint may be removed
several times a day, so that the patient can gently and
slowly actively move the wrist into fl exion, the forearm
into pronation, and the elbow into extension to maintain
the muscle and tendon extensibility.
B. Ice massage for 20 minutes is recommended. Elevation
and compression are not necessary because appreciable
swelling does not occur.
C. Steroid injections are recommended if all other
modalities of treatments fail. However, these are
administered with the intent of providing pain relief only
to allow progressional rehabilitation effort. Thus, some
believe that healing may occur through rehabilitation but
not from steroid injection. However, there is no evidence
to prove or disprove this assumption.
D & E. Strengthening and stretching regimen is
recommended.
Other treatment modalities include:
- High-voltage galvanic stimulation
- Gradual return to activity
- Anti-infl ammatory medications
- Local anti-infl ammatory treatment
- Iontophoresis or phonophoresis with hydrocortisone
cream and dy lidocaine or dexamethasone injection may
also be helpful.
Source: Saidoff DC, McDonough AL. Critical Pathways in
Therapeutic Intervention. Extremities and Spine. St. Louis,
Inc., 2002
67
Q
512. Myofascial pain is an example of A. A central pain state B. Neuropathic pain C. Psychogenic pain D. Somatic pain E. Visceral pain
A
- Answer: D
68
Q
- A 52-year-old nurse has a history of low back pain for 2 months. She states the pain started after she lifted a heavy
patient at work. It is a nagging pain that worsens with
bed rest. She has tried nonsteroidal antiInfl ammatory
agents without any relief and has continued to work. She
has a past medical history signifi cant for breast cancer 8
years ago and, except for a recent 10-lb weight loss, has
been well since her lumpectomy. Her neurologic exam
and straight-leg raising test are normal. The rest of her
physical examination is unremarkable. Which of the
following is the most likely diagnosis?
A. Lumbosacral strain
B. Metastatic breast cancer
C. Disk herniation of L5-S1
D. Spondylolysis
E. Spondylolisthesis
A
- Answer: B
Explanation:
Lower back pain is a very common complaint. The
differential diagnosis includes soft tissue problems
(muscles and ligaments), disk problems (prolapse), facet
problems (degenerative joint disease), spinal canal disease (spinal stenosis), and vertebral body diseases
(osteoporosis causing a compression fracture, infection,
metastatic disease, spondylolisthesis).
A. A lumbosacral strain is an injury to a ligament or
muscle; it may mimic disk disease, but the neurologic
exam and straight-leg raising test generally remain
normal.
B. Even though radiologic studies are needed to make a
defi nitive diagnosis, the leading diagnosis with her history
of breast cancer and weight loss is metastatic disease to
the lumbosacral area.
Pain made worse by lying down or at night may be a sign
of malignancy or infection.
C. Patients with disk herniation at L5-S1 may present with
S1 nerve root compression The patient is unable to stand
on her toes and has an absent Achilles refl ex (S1).
The straight-leg raising test is positive.
D. Spondylolysis is a defect of a lumbar vertebra (lack of
ossifi cation of the articular processes) and rarely causes
symptoms.
E. Spondylolisthesis occurs when the vertebra slips
forward from its position and is generally a consequence
of spondylolysis
It is usually asymptomatic.
69
Q
- Renal changes in the kidney in a patient with diabetes
mellitus of 30 years duration may result in which of the
following:
A. Decreased permeability to plasma proteins
B. Enhanced selectivity of the fi ltration barrier
C. Hyperalbuminemia
D. A generalized increase in osmotic pressure
E. Compensatory secretion of aldosterone
A
- Answer: E
Explanation:
(Kumar, 6/e, pp 446, 570. McKenzie and Klein, p 341.
Junqueira, 9/e, p 362.) In patients who have suffered from
diabetes mellitus for many years there is compensatory
release of aldosterone. The initial change is the thickening
of the glomerular basement membrane. The separation of
laminae rarae and densa is obliterated, which results in a
loss of selectivity of the fi ltration barrier. This causes the
loss of protein from the blood to the urine (proteinuria).
The liver adjusts to the proteinuria by producing more
proteins (e.g., albumin). After continued proteinuria, the
liver is unable to produce suffi cient protein, which results
in hypoalbuminemia. This leads to an overall decrease in
osmotic pressure. The result is edema as fl uid leaves the
vasculature to enter the tissues. The movement of fl uid
from the vasculature to the tissues results in reduced
plasma volume and decreased glomerular fi ltration rate
(GFR). The overall effect is further edema because of
compensatory release of aldosterone coupled with reduced
GFR and the already existing edema. These renal changes
are known as nephrotic syndrome. The foot processes are
affected in many diseases, such as diabetes mellitus, that
lead to nephrotic syndrome. Loss of anionic charge and
fusion of the foot processes result in the obliteration of the
fi ltration slits.
Source: Klein RM and McKenzie JC 2002.
70
Q
515. What percentage of spinal cord injury patients have central pain? A. 90% C. 8-40% D. 50-60% E. 60-70%
A
- Answer: C
Explanation:
(Shah, Central Pain States Lecture)
Source: Shah RV, Board Review 2004
71
Q
516. A treatment of rib fracture pain may include: A. intercostal nerve block B. thoracic sympathetic block C. trigger point injections D. splanchnic nerve block E. costochondral injection
A
- Answer: A
Explanation:
A. Intercostal and thoracic epidural blocks are used to treat
rib fracture pain.
B. Thoracic sympathetic blocks are usually effective for
upper extremity pain.
C. Trigger point injections are ineffective in managing
pain due to fractured rib.
D. Splanchnic nerve blocks are for abdominal pain.
E. Costo-chondral injections are ineffective in managing
pain due to fracture rib.
Source: Trescot AM, Board Review 2004
72
Q
- Spondylolisthesis, is a anterior offset of S1 on L5. Grade
II spondylolisthesis would be best described as:
A. 25% but less than 50% in length of the S1 end plate
B. Less than 20% of the length of the S1 end plate.
C. Parallel axial line in place.
D. 50% to 75% in length of the S1 end plate.
E. Greater than 75% in length of the S1 end plate
A
- Answer: A
Source: Helms CA. Fundamentals of Skeletal Radiology.
W.B. Saunders Co., 1995; p. 87.
73
Q
- A 70-year old man complains of severe back pain in the region of L3/4, with gradual worsening of the back pain
with radiation into the lower extremity up to the knee
joint. This patient received interlaminar epidural steroid
injection for spinal stenosis at L3/4. The most likely
diagnosis in this patient is:
A. Epidural abscess
B. Anterior spinal artery syndrome
C. Discitis
D. Cauda equina syndrome
E. Epidural hematoma
A
- Answer: A
Explanation:
A. Epidural abscess is an extremely rare complication
following epidural steroid injections. However,
symptoms from an epidural abscess may not become
apparent for several days after injection has been
administered. The symptoms of epidural abscess include
severe back pain, sensory disturbances, and motor
weakness.Infections occur in 1% to 2% of spinal injections
and range from minor to severe conditions such as
meningitis, epidural abscess, and osteomyelitis. One case
of discitis following caudal epidural steroid injection also
has been reported. Severe infections are rare and occur
between 1 and 1,000 and 1 in 10,000 spinal injections.
Poor sterile technique is the most common cause of
infection. Staphylococcus aureus is the most common
infectious organism and is contracted from skin
structures. Epidural abscess presents with severe back
pain, fever, and chills with a leukocytosis developing on
the third or fourth day following the injection. Patients
with diabetes or other immunocompromising conditions
are more susceptible to infection. Epidural abscess
requires emergent surgical drainage to avoid neural
damage or other complications.
B. Anterior spinal artery syndrome due to damage to the
anterior spinal artery or the feeding artery, the artery of
Adamkiewicz, leads to ischemia in the thoracolumbar
region of the spinal cord. This syndrome is characterized
predominantly by motor weakness or paralysis of the
lower extremities.
C. Discitis from epidural steroid injections is extremely
uncommon. However, there has been a case report of this
following a caudal epidural steroid injection. Usually,
discitis from lumbar discography involves a gramnegative
arrow, is self-limited, and resolves with early
recognition and administration of appropriate antibiotics.
Symptoms are related to back pain and leukocytosis. The
most common organisms infecting the lumbar disc or
staphylococcus aureus and staphylococcus epidermatitis. Discitis usually presents as an increase in spine pain 5 to
14 days following discography. Acutely, no change in the
patient’s neurological status should be evident. An
elevated sedimentation rate will be seen within the fi rst
week to 10 days. Magnetic resonance imaging is now
considered the gold standard in the detection of discitis,
which was found to be superior to bone scan with 92%
sensitivity, 97% specifi city, and a 95% overall accuracy.
D. Cauda equina syndrome may be seen with trauma,
lumbar disc herniation, compression of tumors, or in
ankylosing spondylitis. The only absolute surgical
indication for lumbar disc herniation is the cauda equina
syndrome. This syndrome is characterized by bilateral
lower extremity weakness and pain, saddle anesthesia,
urinary retention, and diminished rectal tone.
E. Signifi cant epidural bleeding may cause the
development of an epidural hematoma. Clinically
signifi cant epidural hematomas are rare and have a
reported incidence of less than 1 in 4,000 to 1 in 10,000
lumbar epidural steroid injections. however, they may lead
to irreversible neurologic compromise if not surgically
decompressed within 24 hours. Retroperitoneal
hematomas which may occur following spinal injections if
the large vessels are inadvertently penetrated, usually are
self-limited but may cause acute hypolemma or anemia.
Epidural hematoma as an acute onset of symptomatology
with rapidly progressing neurological dysfunction. An
immediate physical examination followed by a CT or MRI
scan is essential for patients thought to have an epidural
hematoma, because early surgical intervention can limit or
even prevent permanent neurological damage.
74
Q
- An 18 year old girl presents with frequent headaches, each lasting for several days. She has to take time off from
school. She describes them as throbbing, localized to the
temporal region. They are associated with nausea and
vomiting, sensitivity to sound and light. A recent MRI was
normal. A diagnostic lumbar puncture done was normal.
The most probable cause of her headaches is:
A. Migraine without aura
B. Post dural puncture headache
C. Tension type headache
D. Temporal arteritis
E. Trigeminal Neuralgia
A
- Answer: A
Explanation:
According to the International Headache Society,
headaches are classifi ed into primary and secondary
headache disorders. The primary headache disorders
consist of:
1.Migraine with aura
2.Migraine without aura
3.Tension type headache - chronic and episodic
4.Cluster headache - chronic and episodic
Primary headaches such as migraine with or without aura,
tension-type, and cluster headache constitute about 90%
of all headaches
Migraine as defi ned by the International Headache Society
is – Idiopathic, recurring headache disorder manifesting in
attacks lasting 4 to 72 hours.
A. Diagnostic Criteria for Migraine With and Without
Aura
Migraine Without Aura
i. At least fi ve attacks fulfi lling II-IV.
ii. Headache attacks lasting 4-72 h (untreated or
unsuccessfully treated).
iii. Headache has at least two of the following
characteristics:
1.Unilateral location.
2.Pulsating quality.
3.Moderate or severe intensity (inhibits or prohibits daily
activities).
4.Aggravation by walking stairs or similar routine
physical activity.
iv. During headache at least one of the following:
1.Nausea and/or vomiting.
2.Photophobia and phonophobia.
v. At least one of the following:
1.History & physical and neurologic examinations do not
suggest headaches secondary to organic or systemic
metabolic disease).
2.History and/or physical and/or neurologic examinations
do suggest such disorder, but it is ruled out by appropriate
investigations.
3.Such disorder is present, but migraine attacks do not
occur for the fi rst time in close temporal relation to the
disorder.
Migraine With Aura
i. At least two attacks fulfi lling ii.
ii. At least three of the following four characteristics:
1.One or more fully reversible aura symptoms indicating
focal cerebral cortical and/or brain stem dysfunction.
2.At least one aura symptom develops gradually over more
than four minutes or two or more symptoms occur in
succession.
3.No aura symptom lasts more than 60 minutes. If more
than one aura symptom is present, accepted duration is
proportionally increased.
4.Headache follows aura with a free interval of less than 60 minutes. (It may also begin before or simultaneously with
the aura).
C. At least one of the following:
1.History & physical and neurologic examinations do not
suggest headaches secondary to organic or systemic
metabolic disease.
2.History and/or physical and/or neurologic examinations
do suggest such disorder, but it is ruled out by appropriate
investigations.
Such disorder is present, but migraine attacks do not occur
for the fi rst time in close temporal relation to the
disorder.
B. Post dural puncture headaches develop after a dural
puncture such as a spinal tap. The pain is usually frontal
and occipital. It becomes worse in the upright position and
is relieved signifi cantly with lying supine. Some patients
develop sixth cranial nerve palsy because of the long
intracranial course of the sixth cranial nerve.
C. The differentiation between tension-type headache
(TTH) and migraine without aura more diffi cult. Very
often both headaches coexist. Tension-type headaches are
tightening or pressing in character. They are mild to
moderate in intensity and are bilateral. Tension-type
headache are seldom associated with nausea and in most
patients Tension-type headaches are not greatly
exacerbated by physical activity.
D. Giant cell (temporal) arteritis affects the extracranial
vessels of the head and arms. There is tenderness over the
scalp. The temporal or occipital arteries are enlarged and
tender. They may have visual symptoms including
amaurosis fugax, diplopia and blindness. Most patients
also have symptoms of intermittent claudication with
chewing. A temporal artery biopsy is diagnostic.
E. Trigeminal neuralgia presents with typical lancinating,
sharp, electric like, stabbing pain.
Ref: Drugs for Pain
Source: Chopra P, 2004
75
Q
- A 67-year old white male presents with back pain,
stiffness located in thoracolumbar region with history
of dysphagia. Radiographic evidence showed fl owing
anterior calcifi cation, along four contiguous vertebrae.
The remaining evaluation was normal. The most likely
diagnosis is:
A. Lumbar facet joint pain
B. Lumbar disc herniation
C. Diffuse idiopathic skeletal hyperostosis
D. Osteoporotic fracture
E. Spondylolisthesis
A
- Answer: C
Explanation:
Diffuse idiopathic skeletal hyperostosis, also called DISH,
or Forester’s disease is probably a variant of osteoarthritis
characterized by exuberant ossifi cation of spinal ligaments.
Epidemiology
- More common with increase in age
- Observed in 10% of spine fi lms in elderly
- It is twice as common in men as women
- It is more common in Caucasians than African-
Americans
Etiology:
- Unknown, not associated with B27; may be increased in
diabetics
Signs and Symptoms
- Back stiffness in 80%
- Back pain in 50% to 60%
- Pain is typically thoracolumbar
- Dysphagia as a result of large cervical osteophytes in
approximately 20%
Diagnosis
- Flowing anterior calcifi cation along four contiguous
vertebrae
- Preservation of disc height
- No sacroiliac involvement
Treatment
- Active exercise program to optimize range of motion
- Non-steroidal anti-infl ammatory agents
- Rarely surgical removal of osteophytes
- Role of interventional techniques is not known
76
Q
- Wallenberg’s syndrome is characterized by:
A. hoarseness of voice
B. contralateral facial sensory loss
C. ipsilateral pain and temperature loss in the body
D. ipsilateral lateral gaze palsy
E. mydriasis
A
- Answer: A
Explanation:
(Shah, Pain States Lecture and Raj, Pain Mgmt Review)
Wallenberg’s syndrome is lateral medullary syndrome,
which is characterized by: Ipsilateral facial sensory loss
Contralateral pain and temperature loss in body
Ipsilateral cranial nerve defi cits
–IX, X- loss of taste
–IX, X- palatal weakness (dysphagia), vocal cord weakness
(hoarseness), diminished gag
Ipsilateral cerebellar signs
–Inferior cerebellar peduncle: clumsiness and ataxia (may
be confused with true weakness)
Source: Shah RV, Board Review 2004
77
Q
- All of the following are true regarding phantom limb pain
EXCEPT:
A. Described as burning, aching, or cramping.
B. Incidence decreases with more proximal amputations.
C. The etiology is not clearly defi ned.
D. The usual course of phantom limb pain is to remain
unchanged or to improve.
E. Neuromas are found in 20% of patients
A
- Answer: B
Explanation:
Ref: Hord and Shannon. Chapter 16. Phantom Pain. In:
Practical Management of Pain, 3rd Edition. Raj et al.
Mosby, 2000, pages 213-218.
Source: Day MR, Board Review 2003
78
Q
- A previously healthy 36-year old woman presents with a complaint of generalized muscular pain with aching in the
left buttock for 1 week, 4 weeks after left transforaminal
epidural injection at L5. The pain travels down the back
of her leg to the heel and lateral side of her foot to the
small toe. She has also noted a progressive numbness
in her legs and arms, which has worsened over the week.
On examination, walking was very diffi cult and her legs
buckled when she stood up. The most likely diagnosis is:
A. Postherpetic neuralgia
B. Brain tumor
C. Hysterical reaction
D. Guillain-Barré syndrome
E. Epidural abscess
A
- Answer: D
Explanation:
The patient has symptoms consistent with Guillain-Barré
acute infl ammatory demyelinating polyneuropathy. Pain is
a common early symptom of the disease. The patient may
complain of muscular or radicular pain or both, followed
by sensorimotor dysfunction. The pain may be severe but usually resolves as the symptoms improve. Presentation
of epidural abscess with back pain is 1-2 weeks after
injections.
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
79
Q
- A patient with cholecystic pain will often present with
pain from which somatic dermatome?
A. T1-T3 due to the ascending nature of the afferent visceral
tracts involved
B. T3 only as it overlies the affected area
C. T8 only as it overlies the affected area
D. T6-T8 as it refl ects the referred component of the upper
viscera
E. T9-T11 as it refl ects the referred component of the upper
viscera
A
- Answer: D
Source: Giordano J, Board Review 2003
80
Q
- A 65 year old man presents with symptoms of pain in
the cervical region. He also complains of radiation of his
pain along the lateral part of his right forearm He has an
MRI of the cervical region with evidence of a herniated
disc between the fi fth and the sixth cervical vertebra. The
nerve root that is most likely compressed is:
A. Fourth cervical nerve root
B. Fifth cervical nerve root
C. Sixth cervical nerve root
D. Seventh cervical nerve root
E. Eight cervical nerve root
A
- Answer: C
Explanation:
Disc herniations in the cervical region are relatively less
common than the lumbar region. In the cervical region the
C5 and C6 and C7 intervertebral disc are most susceptible
to herniation. The C6 and C7 intervertebral disk
herniation is the most common cervical disk herniations.
In the cervical region each spinal nerve emerges above the
corresponding vertebra. An intervertebral disc protrusion
between C5 and C6 will compress the sixth cervical spinal
nerve. There are seven cervical vertebra and eight cervical
spinal nerves. These patients characteristically present
with pain in the lower part of the posterior cervical region,
shoulder and in the dermatomal distribution of the
affected nerve root.
Source: Chopra P. 2004
81
Q
526. A pituitary adenoma is likely to result in A. Cushing’s syndrome B. Defi ciency in T3 and T4 C. Diabetes insipidus D. Osteoporosis E. Stunted growth or dwarfi sm
A
- Answer: A
Explanation:
(Junqueira, 9/e, pp 380-383, 394, 402-405.) Pituitary
adenomas are anterior pituitary specifi c. A corticotrophadenoma
would cause increased levels of ACTH and
stimulate excessive production of corticosteroids from the
adrenal cortex (Cushing’s syndrome). LH and FSHproducing
gonadotrophs occur but tend to result in
hypogonadism. Somatotropic tumors produce GH and
cause giantism. Prolactinomas are the most common form
of pituitary adenoma resulting in infertility, galactorrhea
(excessive production of milk), and amenorrhea. Diabetes
insipidus is caused by absence of vasopressin [arginine
vasopressin (AVP)], leading to excretion of a large
quantity of dilute fl uid (hypotonic polyuria).
Overproduction of parathyroid hormone (PTH) leads to
osteoporotic changes, but PTH is not regulated by the
anterior pituitary.
Source: Klein RM and McKenzie JC 2002.
82
Q
- A 28-year old female secretary complained for 6 months
of paresthesias and aching in the right hand. The aching
and numbness were most pronounced in the middle
fi nger. The aching, tingling, and numbness made it
diffi cult for her to sleep at night. She also noted that she
was dropping things. The most likely diagnosis is:
A. Refl ex sympathetic dystrophy
B. Pancoast syndrome
C. Ulnar neuropathy
D. Carpal tunnel syndrome
E. Radial nerve entrapment
A
- Answer: D
Explanation:
The patient’s symptoms are most consistent with carpal
tunnel syndrome,which is due to entrapment of the
median nerve at the wrist.
Prolongation of distal motor latency may be seen on EMG.
83
Q
528. The number one etiology of cord central pain is: A. Neoplasm B. Infl ammatory C. Cord infarction D. Arteriovenous malformation E. Trauma
A
- Answer: E
Source: Day MR, Board Review 2004
84
Q
529. The most common presenting symptom of rheumatoid arthritis is: A. Pain in the small joints of the hand B. Neck pain C. Knee pain D. Low back pain E. Shoulder pain
A
- Answer: B
Explanation:
Neck pain is the most common presenting symptom of
rheumatoid arthritis (RA). Approximately 50% of the
head’s rotation is at the atlanto-axial joint, the rest is at the
sub axial cervical spine. The atlanto-axial joint complex is
made up of three articulations.The axis articulates with
the atlas at the two facet joints laterally and another joint
posterior to the odontoid process. A bursa separates the
transverse band of the cruciate ligament from the dens.
Rheumatoid arthritis affects all three joints. The
articulations formed by the uncinate processes also known
as the joint of Luschka, are not true joints and do not have
synovial membrane. Hence, they are not subject to the
same changes as seen in RA.
Rheumatoid arthritis is an infl ammatory polyarthritis that
typically affects young to middle-aged women. They
present with a joint pain and stiffness in the hands. They
have a history for morning stiffness. Almost 80% of these
patients have a positive rheumatoid factor.
Source: Chopra P. 2004
85
Q
- A young patient presents with a 6-month history of
an aching right arm, which is exacerbated by carrying
heavy objects or by raising his arms over his head. No
neurologic defi cits were found. There was obliteration of
the radial pulse with arm extension and abduction. The
most likely diagnosis is:
A. Herniated nucleus pulposus
B. Brachial plexitis
C. Pancoast’s tumor
D. Thoracic outlet syndrome
E. Neurofi broma of the brachial plexus
A
- Answer: D
Explanation:
Thoracic outlet syndrome may be due to a cervical rib,
abnormal fi rst thoracic rib, hypertrophy of the scalenus
anterior, abnormal insertion of the scalenus medius, bands
in Sibson’s fascia, or costoclavicular abnormalities. There
is usually involvement of the subclavian vessels and
brachial plexus (most commonly C8-T1). The degree of
vascular and neurologic dysfunction is variable. Patients
may complain of radicular pain or a poorly localized, deep,
aching pain under the arm. Cold weather, lifting heavy
objects, working with arms over the head, and repetitive
movement may worsen symptoms. Pain may occur for
years before any neurologic symptoms or signs develop.
Diagnosis is made by physical examination and radiologic
studies of the neck and chest. Treatment is conservative if
there is no signifi cant vascular or neurologic compromise.
(Bonica).
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
86
Q
- Of those patients chronic neck pain due to whiplash,
approximately what percentage would respond to a
diagnostic intra-articular facet injections or medial
branch blocks?
A. 10%
B. 20%
C. 30%
D. 90%
E. 50%
A
- Answer: E
87
Q
- A patient with a history of breast cancer 10 years ago was
treated with a radical mastectomy and radiation therapy.
Recently she developed dull, ipsilateral arm pain and
associated swelling in the thoracic region. Your diagnosis
is:
A. Radiation plexopathy
B. Re-occurrence of cancer
C. Lymphoedema
D. Tumor invasion in brachial plexus
E. Lymphangiosarcoma
A
- Answer: E
Explanation:
Stewart-Treves Syndrome (lymphangiosarcoma) is a rare,
aggressive and cutaneous angiosarcoma often associated
with long standing lymphedema. The malignancy arises
from the endothelial cells of the lymphatic system. Most
cases arise from lymphedema induced by a radical
mastectomy in breast cancer patients with an average onset
of 5 - 15 years and an occurance rate of
88
Q
533. The sitting position that places the lowest load on the L3 disc is with the back of the chair at A. 90° without a lumbar support cushion B. 90° with a lumbar support cushion C. 110° without lumbar support D. 100° with lumbar support E. 100° without lumbar support
A
- Answer: D
Explanation:
Maximum load on the disc occurs when a person is sitting
against a 90° back rest without lumbar support. There is
slightly less load on the lumbar spine when one sits at 90°
with lumbar support. There is even less load on the
lumbar spine when the back of the chair is inclined to 110°
without lumbar support. There is least pressure on the
spine with the back of the chair at 100° with a lumbar
support (Bonica).
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
89
Q
- A 26-year-old woman presents with the chief complaint of
weakness that worsens throughout the day. She especially
notices weakness and feeling tired when chewing food.
The patient states that she feels strong on arising in the
morning but the weakness develops over the course of
the day. She also complains of her eyelids drooping and
occasional diplopia. Neurologic examination reveals
ptosis after 1 min of sustained upward gaze. Which of the
following is the most likely diagnosis?
A. Lambert-Eaton syndrome
B. Botulism
C. Myasthenia gravis
D. Multiple sclerosis
E. Friedreich’s ataxia
A
- Answer: C
Explanation:
A. Lambert-Eaton myasthenic syndrome (LEMS) is a
progressive generalized weakness that improves with
exercise and is associated with small cell carcinoma of the
lung.
Ocular bulbar muscles are spared, but patients often have
autonomic dysfunction.
B. Botulism causes rapid progressive paralysis of the
bulbar (dilated pupils) and extraocular muscles and
eventually causes skeletal and respiratory muscle
weakness.
The disorder is caused by ingestion of the exotoxin
produced by Clostridium botulinum, which blocks
acetylcholine release from nerve terminals.
C. Myasthenia gravis is fatigable weakness that primarily
affects the respiratory, bulbar, and ocular muscles.
The etiology of the disorder is autoimmune, causing
destruction of the acetylcholine receptors in the affected
muscles.
Thymic abnormalities often accompany the disorder, and
the Tensilon test (injection of edrophonium, which is an
acetylcholinesterase inhibitor) often results in
improvement of symptoms.
90
Q
- A 72-year old woman complains of a 3-year history of
progressive lower back pain with aching and numbness
radiating from the right buttock to the lateral aspect and
dorsum of his right foot. Pain is increased with walking.
She reported that leaning on a shopping cart and using
it as support for ambulation was very helpful. The most
likely diagnosis is:
A. Herniated nucleus pulposus
B. Lumbar plexopathy
C. Spinal stenosis
D. Arachnoiditis
E. Severe spondylolisthesis
A
- Answer: C
Explanation:
The patient has lumbar spinal stenosis involving the L5
and S1 nerve roots most prominently.
Spinal stenosis is a slowly progressive disease and
therefore allows for neural adaptation over time.
Shopping cart syndrome is a hallmark of spinal stenosis.
91
Q
- An obese woman presents with complaints of anterior
knee pain after running. She reported a grinding
sensation in her knee, with stiffness and pain in the
morning hours that occur following the activity for
sitting several hours each day. However, she reported
feeling better after she started running or walking.
She occasionally experiences a giving away sensation
during descent, as if she cannot rely on the affl icted leg.
Kneeling is extremely uncomfortable. There is no history
of trauma to her knee or back. Family history shows
osteoarthritis of both knees and hips in her mother and
father. Physical and neurological examination is normal.
She had no problems with the other knee except for some
grinding sensation. The most likely diagnosis:
A. Plica syndrome
B. Fat pad infl ammation
C. Patellofemoral osteoarthritis
D. Retropatellar pain syndrome
E. Chondromalacia of the patella
A
- Answer: E
Explanation:
A. Plica syndrome is synovial or embryologic remnants
presenting as folds of tissue adjacent to the patella. They
are a rare source of pain and dysfunction at the knee and
may present a challenge to differentiating from
chondromalacia. Synovial plica may prove symptomatic
and manifest as knee stiffness following sitting with the
knee bent for any length of time. Stiffness may be
experienced when attempting to get up out of this
position.The key, however, to differentiating from plica
and chondromalacia derived pain is by historically
determining when the patient experiences pain. Pain
during activity is generally seen with patellar tracking of
abnormalities such as chondromalacia or patellar
instability, whereas pain after activity is typical of
infl ammatory disorders such as synovial plica irritation.
B. Fat pad infl ammation or fi brosis, is a relatively
common problem contributing to inferior knee pain in
patients’ who have had previous knee surgery or in those
who play sports or engaging vocations that directly
traumatize this area. Pain is located immediately adjacent
to the patellar ligament and stems from the richly
innervated fad pad. If fi brosis is extensive, as it may be
following several knee surgeries or severe trauma to this
site, the retropatellar tendon bursae, as well as the
infrapatellar tendon will eventually scar down to the
proximal tibia.
C. Patellofemoral osteoarthritis represents the end
sequelae of chondromalacia and presents with symptoms
similar to chondromalacia. However, the articular surface
involvement is more advanced with subchondral bone
exposure and often has a poorer prognosis. Unlike
chondromalacia, radiographs of patellofemoral
osteoarthritis show narrowing of the joint space, sclerosis
and spurring. These patellofemoral osteophytes typically
form on the marginal areas of the femur and may be
palpated during the physical examination and viewed on
infrapatellar radiographs. These osteophytes may result in
catching and popping sensations from synovial catching,
entrapment, and irritation from these bone spurs.
Patellofemoral arthritis may show a relatively short onset
following traumatic injury or may have a more insidious
onset in patients with long-standing patellofemoral
complaints. The latter typically occurs in patients who
endure abnormal forces to the knee, such as maybe
incurred from rough sports or heavy work, over many
years.
D. Retropatellar pain, pre-parapatellar pain, and
patellofemoral stress syndrome all describe an overuse
injury characterized by peripatellar pain following acutely
or slowly from repetitive knee fl exion-extension activities
such as jumping, running or kicking. This type of patellar
disorder differs from chondromalacia in that arthroscopy evaluation of the retropatellar surface does not reveal the
typical fi brillated cartilage surfaces associated with
chondromalacia or degenerative changes following an
acute blow to the patella.
E. Chondromalacia of the patella is commonly
encountered in joggers and long-distance runners and has
subsequently been called “runners knee.” Nevertheless, the
increasing interest in sports among the general population,
patellofemoral pain has been identifi ed as the primary
complaint of knee pain. Adolescent females are often
susceptible to developing chondromalacia as well as
patellofemoral instability. Chondromalacia is literally a
pathologic description that means softening of the
articular cartilage located along the underside of the
patella and is commonly the diagnosis given to patients
with anterior knee pain. Chondromalacia is a degenerative
process believed to result from excessive loading of
articular cartilage lining the patellar facets. Articular
cartilage is loaded by compressive forces that may be
exceeded resulting in decreased diffusion of nutrients and
eventual malacia of the involved facet. Classic physical
symptoms of chondromalacia include retropatellar pain,
recurrent effusion, retropatellar crepitation,
patellofemoral grinding during the knee fl exion or
extension, and tenderness upon palpation of the patellar
facets.
Source: Saidoff DC, McDonough AL. Critical Pathways in
Therapeutic Intervention. Extremities and Spine,St.
Louis,Inc., 2002
92
Q
537. The incidence of fractured ribs found in closed thoracic trauma is: A. 10-20% B. 20-30% C. 30-40% D. 40-50% E. > 50%
A
- Answer: E
Explanation:
Ref: Sinatra and Ennevor. Chapter 19. Trauma Patient
with Thoracic and Abdominal Injuries. In: Pain
Management and Regional Anesthesia in Trauma.1st
Edition. Rosenberg, Grande, Berstein. W.B. Saunders, - page 312.
Source: Day MR, Board Review 2003
93
Q
- A 33-year-old graduate student complains of low back
pain after carrying heavy suitcases on a recent vacation
in Europe. Because of his pain, he went to a neurologist
in London who recommended bed rest and nonsteroidal
anti-infl ammatory agents. After 10 days, the back pain
resolved, but the patient comes to see you because of new
weakness of his right anterior tibialis. The rest of the
physical examination is normal. Which of the following
is the most likely diagnosis?
A. Nerve root impingement
B. Tibial stress fracture
C. Anterior compartment syndrome
D. Gastrocnemius muscle tear
E. Popliteal cyst
A
- Answer: A
Explanation:
A. Lumbar disk herniation may occur after lifting heavy
objects.
A short period of rest (“unloading the spine”) and
nonsteroidal anti-infl ammatory agents may help.
If a patient develops signifi cant neurologic defi cit after the
initial pain has resolved, the diagnosis is most likely nerve
root impingement.
B. Tibial stress fractures (shin splints) may occur due to
weight-bearing exercises or training errors. These injuries
cause anterior tibial pain after exercise but not weakness.
C. Anterior compartment syndrome occurring after
weight-bearing exercise may cause a neuropraxia of the peroneal nerve, leading to footdrop.
D. A gastrocnemius muscle tear usually occurs suddenly
after rapid dorsifl exion of the ankle and causes severe
midcalf pain.
In a few days, the calf characteristically develops a bluish
discoloration.
E. A popliteal cyst (Baker’s cyst) causes calf pain, swelling,
and knee effusion. It is often a complication of rheumatoid
arthritis and represents a diverticulum of the synovial sac
that protrudes through the posterior joint capsule of the
knee.
(Source: Goldman, 21/e, p 2187.)
94
Q
- All of the following are true regarding carpal tunnel
syndrome except:
A. Caused by compression of the median nerve by the
transverse carpal ligament.
B. History of wrist pain and paresthesias in the thumb,
index fi nger, and long fi ngers.
C. Physical examination may demonstrate atrophy of the
hypothenar eminence.
D. EMGs/NCTs may confi rm denervation of thenar musculature
E. Treatment includes splints, steroid injections, and/or
surgical release.
A
- Answer: C
Explanation:
Ref: Merkow. Chapter 16. Hand Disorders. In: Manual of
Rheumatology and Outpatient Orthopedic Disorders, 2nd
Edition. Beary; Little, Brown and Company, 1990, page 95-
96.
Source: Day MR, Board Review 2003
95
Q
- Costochondritis is characterized by all of the following
except:
A. Can mimic intrathoracic and intrabdominal disease
B. Local tenderness with palpation
C. May produce radiating symptoms
D. Presents as infl ammation of multiple costovertebral
articulations
E. Most often occurs in adults over 40 years of age
A
- Answer: D
Explanation:
Ref: Raj. Chapter 13. Miscellaneous Pain Syndromes. In:
Pain Medicine: A Comprehensive Review, 2nd Edition,
Raj, Mosby, 2003, page 121.
Source: Day MR, Board Review 2003
96
Q
541. Classic hemophilia A is associated with a defi ciency of which factor? A. V B. VIII C. IX D. X E. All of the above
A
- Answer: B
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition
97
Q
- Which of the following analgesics are least effective with
the treatment of chronic post-stroke pain?
A. Morphine
B. Mexilitene
C. Carbamazepine
D. Doxepin
E. Propanolol
A
- Answer: A
Explanation:
(Raj, Practical Mgmt of Pain, 3rd Edition, page 262)
Central post-stroke pain is diffi cult to manage. Opioids
have not been successful in managing CPSP for at least
100 years. Some authors recommend detoxifi cation. The
mainstays for treatment include anti-dysrhythmics, anticonvulsants,
and antidepressants.
Carbamazepine, doxepin, propanolol, and Mexilitene have
been demonstrated to have benefi t in CPSP
Source: Shah RV, Board Review 2004
98
Q
- A 66 year old woman presents with pain in the posterior
cervical region for the last 1 year. It radiates to the right
shoulder, lateral upper arm, and right index fi nger. She
also complains in the medial part of the right scapula
and anterior shoulder. On physical examination, she has
numbness to the index and middle fi ngers of the right
hand and weakness of the triceps muscle. The cause of
her pain is most likely:
A. Herniated nucleus pulposus of the C5 to C6 disk causing
compression of the C5 nerve root
B. Herniated nucleus pulposus of the C5 to C6 disk causing
compression of the C6 nerve root
C. Herniated nucleus pulposus of the C6 to C7 disk causing
compression of the C7 nerve root
D. Herniated nucleus pulposus of the C6 to C7 disk causing
compression of the C6 nerve root
E. Herniated nucleus pulposus of the C7 to T1 disk causing
compression of the C8nerve root
A
- Answer: C
Explanation:
The pattern of pain helps identify the cervical disk causing
the most problems. Herniated nucleus pulposus (HNP)
are more common in the lumbar region.The cervical nerve
roots exit above the vertebral body of the same segmentthe
C7 nerve root exits between the C6 to C7 vertebra.
Source: Chopra P. 2004
99
Q
- Trigeminal neuralgia
A. is also called tic doloureux
B. is characterized by sudden, sharp, stabbing facial pain
C. often has a specifi c “trigger zone”
D. may be treated with surgery, medications, or injections.
E. all of the above
A
- Answer: E
Explanation:
Trigeminal neuralgia is a devastating facial pain
characterized by sudden facial pain, and may be treated
with surgery, medications, or injections.
Source: Trescot AM, Board Review 2004
100
Q
545. A 22 year old healthy woman with a history of migraine headaches develops an intense frontal headache after eating ice cream at a party. The pain is sharp and intense. What is the most likely diagnosis? A. Frontal sinusitis B. Cold stimulus headache C. Conversion headache D. Chronic paroxysmal hemicrania E. Intractable Migraine without Aura
A
- Answer: B
Explanation:
A. A frontal sinusitis is a persistent frontal headache and
does not have an abrupt onset.
B. Cold stimulus headache start with exposure of the head
to very cold temperatures as in diving into cold water. An
intense focused pain develops in the frontal region when a
very cold food ingested. The pain lasts for a short duration
of a few minutes. It maybe in the frontal or
retropharyngeal region.
C. Conversion headaches are associated with severe
behavioral abnormalities.
D. Chronic paroxysmal hemicrania is very similar to a
cluster headache in the form that it is similar in intensity
and location. The attacks are short and frequent. They
respond well to indomethacin.
E. Intractable migraine with aura is associated with one or
more fully reversible symptoms.
Source: Chopra P, 2004
101
Q
- Which of the following is true about spinal stenosis
A. Spinal stenosis can only be diagnosed if a patient has
neurogenic claudication
B. Spondylolysis of the pars interarticularis is the most
common etiology of spinal stenosis
C. Classically, patients develop pain after walking and
must stop and stand, in order to obtain pain relief
D. Patients typically have relief of symptoms when walking
downhill
E. Urinary dysfunction is common among patients with
spinal stenosis
A
- Answer: E
Explanation:
A subset of patients with spinal stenosis have neurogenic
claudication, but most patients present with aching low
back and thigh pain. Degenerative arthritic changes of the
L4-5 facet joints and spondylosis of the L4-5 disc are the
most common etiologies of spinal stenosis.
Spondylolisthesis is also associate with these changes.
Classically, patients must sit or stoop forward in order to
obtain pain relief. Patients with vascular claudication have
to stop walking and just stand in order to get relief.
Patients have an exacerbation of symptoms when walking
downhill, due to relative spine extension.
Patients with spinal stenosis frequently have urinary
dysfunction, as evidenced by urodynamic abnormalities
(Inui Y. Spine 2004; 29(8): 869-873)
Source: Shah RV, Board Review 2004
102
Q
- A 12-year old boy complains of neck and jaw pain. He
underwent tonsillectomy 6 months ago. The pain is
exacerbated by swallowing, talking, or turning his head.
There was no evidence of infection. The most likely cause
of his persistent pain is
A. Riedel’s struma
B. Eagle’s syndrome
C. Ludwig’s angina
D. Post traumatic stress disorder
E. Infection of tonsillar bed
A
- Answer: B
Explanation:
Eagle’s syndrome, also known as stylohyoid syndrome,
occurs after tonsillectomy, rarely. This is secondary to
fi brosis developing around an elongated styloid process,
impinging on the carotid sheath. It causes pain in the
upper neck, jaw, face, ears, sternocleidomastoid, or
temporal region. Pain may be exacerbated by swallowing,
talking, or turning the head. Surgical removal of the
styloid may be necessary
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
103
Q
548. Patients with sickle cell disease can experience episodic painful crises, which are characterized by A. Hypothermia B. Normoxemia C. Acidosis D. Dehydration E. Cocaine addiction
A
- Answer: B
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition
104
Q
549. What sign is classical for multiple sclerosis? A. Hoffman’s sign B. Homan’s sign C. Lhermitte sign D. Koenig’s sing E. Brudzinski’s sign
A
- Answer: C
Source: Day MR, Board Review 2004
105
Q
550. A 62-year-old woman complains of limb discomfort and trouble getting off the toilet. She is unable to climb stairs and has noticed a rash on her face about her eyes. On examination, she is found to have weakness about the hip and shoulder girdle. Not only does she have a purplishred discoloration of the skin about the eyes, but she also has erythematous discoloration over the fi nger joints and purplish nodules over the elbows and knees. The most likely diagnosis is: A. Systemic lupus erythematosus B. Psoriasis C. Myasthenia gravis D. Dermatomyositis E. Rheumatoid arthritis
A
- Answer: D
Explanation:
This woman presents with proximal muscle weakness and
pain and a heliotrope rash about her eyes. The term
heliotrope refers to the liliac color of the periorbital rash
characteristic of dermatomyositis. This rash surrounds
both eyes and may extend onto the malar eminences, the
eyelids, the bridge of the nose, and the forehead. It is
usually associated with an erythematous rash across the
knuckles and at the base of the nails and may be associated
with fl at-topped purplish nodules over the elbows and
knees. Men with dermatomyositis are at higher than
normal risk of having underlying malignancies. Psoriatic
arthritis may be associated with reddish discoloration of
the knuckles and muscle weakness, but the heliotrope rash
would not be expected with this muscle weakness, but the
heliotrope rash would not be expected with this disorder.
The age of onset for a psoriatic myopathy is also atypical.
Similarly, the patient’s rashes are not suggestive of lupus
erythematosus, although a myopathy may occur with this
connective tissue disease as well.
Source: Anschel 2004
106
Q
551.The most common organism identified in spinal infections is A. Staphylococcus aureus B. Staphylococcus epidermidis C. Mycobacterium tuberculosis D. Pseudomonas aeruginosa E. Escherichia coli
A
- Answer: A
Explanation:
Gram positive aerobic bacteria are most commonly
isolated, and staph aureus is the most common organism.
Source: Boswell MV, Board Review 2005
107
Q
552. The most common source of spine infection is A. Genitourinary B. Dermatologic C. Respiratory D. Bowel E. Dental
A
- Answer: A
Source: Boswell MV, Board Review 2005
108
Q
553. Delayed onset of central pain after spinal cord injury is most commonly due to A. Infl ammation B. Fibrosis C. Infection D. Syrinx E. Tumor
A
- Answer: D
Source: Boswell MV, Board Review 2005
109
Q
- A 52-year-old man presents with locked-in syndrome. On neurologic examination, the patient is quadriplegic with
sensory loss and cranial nerve involvement. He is able to
respond to questions using his eyes. Choose appropriate
diagnosis:
A. Basilar artery stroke
B. Middle cerebral stroke
C. Anterior cerebral stroke
D. Transient ischemic attack
E. Posterior cerebral stroke
A
- Answer: A
Explanation:
(Tierney, 42/e, pp 962-963.) Basilar artery stroke causes
quadriplegia, sensory loss, and cranial nerve involvement;
patients may present with coma or locked-in syndrome.
Wallenberg syndrome or lateral medullary syndrome
causes an ipsilateral weakness of the palate and vocal
cords,ipsilateral ataxia, ipsilateral Horner syndrome, and
ipsilateral loss of facial pain and temperature but
contralateral loss of body pain and temperature sensation.
There is no limb weakness in Wallenberg syndrome.
Anterior cerebral stroke causes unilateral leg weakness and
sensory loss. Posterior cerebral artery stroke causes an occipital stroke and a homonymous hemianopsia. Middle
cerebral artery stroke causes hemiplegia or hemiparesis
greater in the arm than the leg, aphasia, unilateral sensory
loss, and eyes that deviate to the side of the hemispheric
lesion. Patients with lacunar infarcts may present with
different syndromes, such as dysarthria and mild
hemiparesis (clumsy-hand dysarthria). Lacunar infarcts
represent small artery occlusions; hypertension and
diabetes are risk factors for these infarcts. Patients in a
vegetative state from diffuse cortical damage have
spontaneous eye opening and movement without evidence
of awareness.
110
Q
- Acute Herpes zoster (shingles) involving the anterior
external ear canal, palate, tongue, and face is due to
reactivation of virus in which of the following ganglia?
A. Otic
B. Geniculate
C. Gasserian
D. Sphenopalatine
E. Pterygopalatine
A
- Answer: C
Explanation:
The virus involves the ganglion that forms the 5th nerve,
the gasserian ganglion. Ramsay Hunt syndrome involves
the ear, by reactivation in the geniculate ganglion, which
appears to have sensory fi bers from the pinna and
posterior external auditory canal.
111
Q
556.The mechanism of injury of a C2 traumatic spondylolisthesis is A. Flexion B. Flexion-rotation C. Compression D. Extension E. Other
A
- Answer: D
Explanation:
This fracture is also known as a hangman’s fracture; the
mechanism is hyperextension, such as might occur at the
end of a short rope tied around ones neck, with the knot
under the mandible.
Source: Boswell MV, Board Review 2005
112
Q
- A 41-year-old construction worker complains of the
sudden onset of severe back pain after lifting some heavy
equipment. He describes the pain as being in his right
lower back and radiating down the posterior aspect of his
right buttock to the knee area. He has no bladder or bowel
dysfunction. The pain has improved with bed rest. On
physical examination, the patient has tenderness in his
lumbar area with palpation. The straight-leg maneuver
with the right leg increases the back pain at 80°. The
straight-leg maneuver with the left leg also causes thigh
pain. Sensation, strength, and refl exes are normal. Which
of the following is the most likely diagnosis?
A. Nerve root compression
B. Paravertebral abscess
C. Lumbosacral strain
D. Osteoporosis compression fracture
E. Paget’s disease
A
- Answer: C
Explanation:
(Tierney, 42/e, pp 793-795.) Since the patient has no
neurologic compromise, the most likely diagnosis is back
strain. Strain is common in people in their forties. It is
exacerbated by activity and improves with rest. A straightleg
maneuver is positive for nerve root compression from
disk herniation when pain is produced at less than 70° of
elevation. Crossover pain (straight-leg maneuver of
nonpainful leg worsens pain of involved leg) is also a
strong indicator of nerve root compression, but only if
pain is produced below the knee. Paravertebral abscess
usually presents with fever and tenderness with percussion
of the affected back area. Risk factors for osteoporosis
include female gender, menopause, lack of activity, slim
body habitus, older age, inadequate calcium intake,
medications such as corticosteroids, and racial-ethnic
background (Asian and northern European descent).
Paget’s disease (osteitis deformans) is a slowly
progressing disease of bone that may be asymptomatic or
may cause bone pain, deformities (such as a large skull or
leg bowing), hearing loss, and fractures. It begins in
middle-aged men and is thought to be due to an inborn
error of metabolism causing the formation of poorly
organized bone.
113
Q
558. The hallmark that distinguishes ankylosing spondylitis from other forms of arthritis is: A. Synovitis B. Enthesitis C. Kyphosis D. Amyloidosis E. Osteoporosis
A
- Answer: B
Explanation:
Infl ammation at insertion of tendons, ligaments and fascia
on bone is an important mechanism of the spinal bony
changes
Source: Boswell MV, Board Review 2005
114
Q
559. A 61-year-old man presents with fl accid paralysis, atrophy, fasciculaions, and hyperrefl exia. Choose correct diagnosis: A. Upper motor neuron disease B. Lower motor neuron disease C. Myelopathy D. Radiculopathy E. Broca’s aphasia
A
- Answer: B
Explanation:
(Seidel, 5/e, p 798.) Upper motor neuron (UMN) disease
(above the level of the corticospinal synapses in the gray
matter) is characterized by spastic paralysis, hyperrefl exia,
and a positive Babinski refl ex (everything is up in UMN
disease). Lower motor neuron (LMN) disease (below the
level of synapse) is characterized by fl accid paralysis,
signifi cant atrophy, fasciculations, hyporefl exia, and a
fl exor (normal) Babinski refl ex (everything is down in
LMN disease). A radiculopathy occurs with root
compression from a protruded disk that causes sensory
loss, weakness, and hyporefl exia in the distribution of the
nerve root. Myelopathy causes severe sensory loss 0
posterior column sensation (position sense and vibration),
spasticity, hyperrefl exia, and positive Babinski refl exes.
Broca’s aphasia (left inferior frontal gyrus) is a nonfl uent
expressive aphasia (Broca’s should remind you of broken
speech); Wernicke’s aphasia (left posterior-superior
temporal gyri) is a receptive aphasia because patients lack
auditory comprehension (Wernicke’s should remind you
of wordy speech that makes no sense).
115
Q
- A 30-year-old woman with a history of diabetes mellitus presents with a 3-week history of hand numbness that often awakens her from sleep. The symptoms resolve
after she shakes her hands for a few minutes. On physical
examination, there is no sensory or motor defi cit of her
hands but there is a positive Tinel sign. Which of the
following is the most likely diagnosis?
A. Thoracic outlet syndrome
B. Carpal tunnel syndrome
C. Dupuytren’s contracture
D. Mallet fi nger
E. Ganglion
A
- Answer: B
Explanation:
(Seidel, 5/e, p 735.) Carpal tunnel syndrome (CTS) is the
most likely diagnosis. It is due to median nerve
compression by the transverse carpal ligament. Risk
factors for this disorder include diabetes mellitus,
pregnancy, hypothyroidism, rheumatoid arthritis,
repetitive activity, and acromegaly. The Tinel sign
(paresthesias or pain reproduced with percussion of the
volar surface of the wrist) and Phalen sign (symptoms are
reproduced by holding the wrist in passive fl exion for 1
min)may be positive. Patients may complain of pain in the
forearm, the thenar eminence, and the fi rst three digits.
Thoracic outlet syndrome usually causes medial arm pain
and paresthesia when using the arms. The presence of a
cervical rib is a risk factor for this disorder. Dupuytren’s
contracture is a fi brotic process of the palmar fascia that
causes fi xed fl exion of the ring fi nger. Mallet fi nger is a
fl exion deformity of the distal interphalangeal joint and is
generally the result of traumatic rupture of the extensor
tendon of the distal phalanx. A ganglion is a painless, fi rm
cystic mass arising from any joint or tendon sheath. A
trigger fi nger may be seen in patients with rheumatoid
arthritis. It occurs when an enlarged fl exor tendon sheath
passes through the pulleys of the digits, causing locking or
catching.
116
Q
561. A 20-year-old man presents with complaints of pain in the left hip and left proximal femur. The pain has been present for approximately 3 weeks and is increasing in severity. It is worse at night and is relieved by aspirin. There is no history of trauma or previous hip or leg problems. Which of the following is the most likely diagnosis? A. Osteosarcoma B. Paget’s disease C. Osteoid osteoma D. Chondrosarcoma E. Muscle strain
A
- Answer: C
Explanation:
(Tierney, 42/e, p 835.)
C. A history of pain that increases in severity, worsens at
night, and is relieved by aspirin suggests the diagnosis of
osteoid osteoma. This benign tumor is more common in
males than females,and patients present between20 and 30
years of age. The proximal femur is the most common site
for this tumor. Other benign tumors of bone include giant
cell tumor (osteoclastoma), osteochondroma,
chondroblastoma, and osteoblastoma.
A & D. The most common malignant tumors of bone
include osteosarcoma (45%), chondrosarcoma (25%),
Ewing’s sarcoma (15%), and malignant fi brous
histiocytoma.
Osteosarcomas commonly involve the distal femur.
Chondrosarcomas are seen in older patients (40 to 50
years old).
Osteosarcomas may be seen later in life as a complication
of Paget’s disease.
117
Q
- Duchenne muscular dystrophy is a sex-linked disorder
involving the gene responsible for the synthesis of
A. Glucose-6-phosphatase
B. Hexosaminidase B
C. Myosin
D. Dystrophin
E. Actin
A
- Answer: D
Explanation:
Duchenne dystrophy has been incontrovertibly linked to
the gene, located on the X chromosome, that makes
dystrophin. The more profound the disturbance of this
gene, the earlier the disease becomes symptomatic. The
gene for dystrophin has single or multiple deletions in
affected children. Women who are probable carriers of the
defective gene can be checked for heterozygosity and given
genetic counseling. Chorionic villus biopsy at 8 to 9 weeks
can determine if a fetus that is at risk for the deletion
actually carries it.
Source: Anschel 2004
118
Q
- The commonest cause of Trigeminal neuralgia symptoms is:
A. Infected tooth
B. Multiple sclerosis
C. Temporomandibular joint disorder
D. Compression by the superior cerebellar artery.
E. Post Therpetic Neuralgia
A
- Answer: D
Explanation:
The most common cause of trigeminal neuralgia is
mechanical compression of the trigeminal nerve as it
leaves the pons and traverses the subarachnoid space
towards Meckel’s cave. The cross compression is usually
by the superior cerebellar artery and may occasionally be
by the posterior inferior cerebellar artery, anterior inferior
or the vertebral artery.
The region of pain in the face corresponds with the region
of compression of the trigeminal nerve by the artery.
Compression of the rostral and anterior portion of the
nerve by the superior cerebellar artery causes pain in the
maxillary (V2) and mandibular divisions (V3). Pain in the
frontal (V1) division is due to compression of the
trigeminal nerve root in its caudal and posterior portions
by the anterior inferior cerebellar artery.
Multiple sclerosis is not a common cause of trigeminal neuralgia. Dental abscess, infection and
temporomandibular joint dysfunction has not been
proven to be a cause of trigeminal neuralgia.
Source: Chopra P, 2004
119
Q
564. An 35-year-old man presents with a history of low back pain that awakens him from sleep. He also complains of morning stiffness and decreased mobility. The pain does not improve with activity. Schober test is positive. What is the accurate diagnosis? A. Refl ex sympathetic dystrophy B. Ankylosing spondylitis C. Reiter syndrome D. Hypertrophic osteoarthropathy E. Charcot joint
A
- Answer: B
Explanation:
Hypertrophic osteoarthropathy is nail clubbing
accompanied by a symmetrical polyarthritis involving the
large joints and occasionally the metacarpophalangeal
joints. Hypertrophic osteoarthropathy may be seen
secondary to malignancy, endocarditis, vasculitis, and
other pulmonary and cardiac diseases. Ankylosing
spondylitis (AS) is a chronic and progressive
infl ammatory disease, seen mostly in men in their thirties,
that most commonly affects the spinal, sacroiliac, and hip
joints. It may go undiagnosed for many years, and bilateral
hip pain due to sacroiliac involvement may be clinically
undetectable. It is strongly associated with HLA-B27.
Examination of the spine usually reveals limitation in
movement; patients in advanced stages may have a
characteristic bent-over posture. Patients with AS may
present with an acute nongranulomatous uveitis and
limited chest expansion due to involvement of the
costovertebral joints. The Schober test is positive in AS
(with the patient erect, marks are made 5 cm below and 10
cm above the lumbosacral junction between the posterior
superior iliac spines; the patient bends, marks are
measured, and if the distance between the two marks
increases by less than 4 cm there is spinal immobility). The
pathogenesis of refl ex sympathetic dystrophy is unknown.
The presentation may be seen after peripheral limb injury;
early symptoms include pain in the limb and edema. This
disorder may lead to contractures. Charcot joint is a
complication of peripheral neuropathy seen in diabetic
patients. Repetitive minor trauma to the foot causes
deformities, which may lead to skin breakdown, erythema,
edema, and callus formation.
Source: Goldman
120
Q
- All of the following are true regarding diabetic peripheral neuropathy except:
A. Is Symmetric
B. Involves sensory nerves only
C. Symptoms are gradually progressive
D. The pain progresses in a proximal direction
E. Treatment includes anti-epileptic drugs and sympathetic
blocks
A
- Answer: B
Explanation:
Ref: Manning, Loar, Raj, Hord. Chapter 10. Neuropathic
Pain. In: Pain Medicine: A Comprehensive Review, 2nd
Edition, Raj, Mosby. 2003, page 78
Source: Day MR, Board Review 2003
121
Q
566. Neuropathic pain is diagnosed by: A. History B. Physical exam C. Laboratory testing D. Neurodiagnostic testing E. None of the above
A
- Answer: E
Explanation:
Neuropathic pain is a diagnosis of exclusion. There are no
single diagnostic criteria.
Source: Trescot AM, Board Review 2004 for Shah
122
Q
- A 23-year old female complains of pain when elevating
her right shoulder and when carrying her briefcase in
either hand to and from work. She also complains of
slight grinding or crunching sensation when actively
elevating her right shoulder. She admits that her left
shoulder bothers her as well, though not as much as
right shoulder. There is no history of injury. Physical
examination shows no muscle wasting. There was
pinpoint tenderness slightly inferior to the anterior
border of the acromion while the shoulder is passively
extended. She had a presence of painful resisted external
rotation and abduction, as well as during passive internal
rotation while the shoulder is elevated to 80°. The most
likely diagnosis is:
A. Impingement of supraspinatus tendon
B. Rotator cuff syndrome
C. Bicipital tendonitis
D. Cervical spondylosis
E. Acromioclavicular joint arthritis
A
- Answer: A
Explanation:
The term impingement syndrome was popularized by Charles Neer in 1972 as such. Neer Test for positive
impingement sign was popularized by Neer and Walsh
which reproduces pain in concomitant fascial grimace
when the arm is forcefully fl exed forward by the examiner,
jamming the greater tuberosity against the anteroinferior
acromial surface.
The injection of 10 mL of lidocaine in to the subacromial
space, followed by pain relief, helps confi rm the diagnosis
and rules out other causes of shoulder pain such as
acromioclavicular joint sprain and adhesiocapsulitis
which are not relieved by injection.
Source: Saidoff DC, McDonough AL. Critical Pathways in
Therapeutic Intervention. Extremities and Spine. St.
Louis,Inc., 2002
123
Q
- A 14-year-old boy presents with a history of intermittent
facial grimacing, twitching, and eye blinking since
childhood. The movements are repetitive and often
move from one part of the face to another. On physical
examination, cranial nerve, sensory, and cerebellar
examinations are normal. Motor examination reveals
frequent and quick repetitive eye blinking, nasal
twitching, and facial grimacing accompanied by an
occasional snort or grunt. Which of the following is the
most likely diagnosis?
A. Tardive dyskinesia
B. Tourette syndrome
C. Asterixis
D. Sydenham’s chorea
E. Huntington’s chorea
A
- Answer: B
Explanation:
(Tierney, 42/e, pp 979-982.) Tourette syndrome is a
disorder of repetitive progressive multiple tics involving
the face, head, and shoulders and is often accompanied by
vocal tics (i.e., grunts, snorts, involuntary swearing, or
coprolalia). Huntington’s disease is an autosomal
dominant disorder characterized by abrupt, involuntary,
nonrepetitive, jerky movements (chorea) and dementia.
Patients with tardive dyskinesia have developed
purposeless movements, such as mouth smacking tongue
protrusion, after use of a dopamine-blocking neuroleptic
drug. Asterixis is seen in patients with hepatic
encephalopathy (liver nap) renal failure and is
characterized by frequent inability to sustain wrist
extension (bye-bye gesture). Wilson’s disease
(hepatolenticular degeneration) is an autosomal recessive
disorder of copper metabolism characterized by
choreoathetosis, ataxia, cirrhosis, and corneal deposits
called Kayser-Fleischer rings. A low serum ceruloplasmin
or a high urinary copper level is found in Wilson’s disease.
Sydenham’s chorea is seen rheumatic fever.
124
Q
- Neuropathic pain is caused by:
A. direct stimulation of mechanoreceptors
B. pain receptors in the brain
C. dysfuntion in the nervous tissue itself
D. indirect stimulation of mechanoreceptors
E. Thermoreceptors
A
- Answer: C
Explanation:
Neuropathic pain results from injury or disease of the
nervous tissue itself. Although there can be central pain
states, they are not due to actual “pain receptors” in the
brain. Mechanical pain is considered nociceptive.
Source: Trescot AM, Board Review 2004 for Shah
125
Q
570. The most common psychiatric disorder seen in patients with chronic low back pain is A. Generalized anxiety disorder B. Somatization disorder C. Personality disorder D. Depression disorder E. Factitious disorder
A
- Answer: D
Source: Boswell MV, Board Review 2005
126
Q
- A 42-year-old man presents with a crush injury to his
left lower extremity. He complains of severe leg pain that
seems out of proportion to his injury. He also complains
of paresthesias of left lower extremity. Leg examination is
signifi cant for pallor and coldness. The dorsalis pedis and
posterior tibialis pulses are not palpable. Which of the
following is the most likely diagnosis?
A. Arterial insuffi ciency
B. Pelvic fracture
C. Aortic insuffi ciency
D. Aortic dissection
E. Compartment syndrome
A
- Answer: E
Explanation:
(Tintinalli, 5/e, pp 1838-1841.) The patient most likely has
compartment syndrome from elevated pressure in a
confi ned space compromising nerve, soft tissue, and
muscle perfusion. Etiologies include burn injuries, crush
injuries, and fractures. Compartment syndrome is often referred to as the disorder of Six P’s (Pain, Pallor,
Paralysis, Paresthesias, Poikilothermia, and
Pulselessness). Immediate fasciotomy and restoration of
tissue perfusion is the treatment for compartment
syndrome.
127
Q
572. Neuropathic pain may be: A. peripheral B. central C. both peripheral and central D. neither peripheral or central E. none of the above
A
- Answer: C
Explanation:
Neuropathic pain can be both central and peripheral.
Source: Trescot AM, Board Review 2004 for Shah
128
Q
573. The most common primary malignant spine tumor is A. Myeloma B. Osteosarcoma C. Chondrosarcoma D. Chordoma E. Lymphoma
A
- Answer: A
Explanation:
The 1st, 2nd and 3rd most common primary malignant
tumors of bone, in descending order, are multiple
myeloma, osteosarcoma and chondrosarcoma. Chordoma
is a malignant notochord remnant, and lymphoma is not a
primary bone tumor.
Source: Boswell MV, Board Review 2005
129
Q
574. The most common cause of thoracic radiculopathy is A. Metastasis B. Herniation C. Infection D. Diabetes E. Scoliosis
A
- Answer: D
Source: Boswell MV, Board Review 2005
130
Q
575. Absolute central lumbar stenosis is defi ned as: A. Less than 8mm diameter B. Less than 10mmdiameter C. Less than 12mm diameter D. Less than 15mm diameter E. Less than 2mm diameter
A
- Answer: B
Explanation:
The spinal canal is nearly round in shape; it is 12mm or
more in the anteroposterior diameter. Relative stenosis is
defi ned as midline sagittal diameter of <10mm.
Source: Chopra P, 2004
131
Q
576. Impingement of the L5 nerve root may cause loss of which refl ex? A. Plantar B. Patellar C. Cremasteric D. Hamstring E. Achilles
A
- Answer: D
Explanation:
Hamstring refl ex, also known as the posterior tibial refl ex
Source: Boswell MV, Board Review 2005
132
Q
577. Herniation of the C4-5 disc may cause weakness of which of the following muscles? A. Biceps brachii B. Triceps brachii C. Interosseus dorsales D. Flexor digitorum E. Extensor carpi radialis
A
- Answer: A
Explanation:
The C5 root is most commonly impinged. The best
answer is biceps, but note that the biceps is innervated by
C5 and C6. Pain radiates to the shoulder and anterior arm
and radial forearm.
Source: Boswell MV, Board Review 2005
133
Q
- During a burn debridement procedure, ketamine is
utilized as an analgesic in a twelve-year-old child. A
undesirable side effect of ketamine in the pediatric
population include:
A. Profound respiratory depression in standard analgesic
doses
B. Bradycardia and hypotension
C. Dysphoria and dream terror
D. Decrease of renal blood fl ow
E. Improved compliance in drug-dependent patients
A
- Answer: C
Source: Hansen HC, Board Review 2005 for Shah
134
Q
- Physiologic risk from traumatic injury includes:
A. Immobility, and increased risk of dermal breakdown
B. Decreased respiratory effort and resultant atelectasis
C. Increased risk of deep venous thrombosis
D. Impaired gastric motility and splanchnic circulation
E. Increased functional status
A
- Answer: D
Source: Hansen HC, Board Review 2005 for Shah
135
Q
- True statement about lateral epicondylitis are as follows:
A. Peak incidence is fourth decade
B. Associated with pain at the elbow, with radiation to the
forearm and wrist.
C. Decrease in grip strength and pain with extension of
the elbow
D. Progressive weakness and paresthesia inhibits supination
and pronation
E. Lateral epicondylitis is also called Golfer’s elbow
A
- Answer: D
Source: Hansen HC, Board Review 2005 for Shah
136
Q
- The etiology of carpal tunnel syndrome includes all of the following except:
A. Paresthesias are noted in thumb, index fi nger, and long
fi ngers, and is frequently associated with decreased
grip strength.
B. Is felt to be caused by compression at wrist by thickening
transverse carpal ligament.
C. An increase in volume or tunnel contents secondary to
tenosynovitis.
D. Alteration of the osseous margins of carpus
E. Systemic disease
A
- Answer: A
Source: Hansen HC, Board Review 2005 for Shah
137
Q
- A middle aged, mildly obese woman presents complaining
of bilateral medial right knee pain that occurs with
prolonged standing. The pain does not occur with sitting
or climbing stairs but seems to be worse with other
activity and at the end of the day. The patient denies
morning stiffness. Examination of the knees reveals no
deformity, but there are small effusions. Some mild pain
and crepitus are produced with palpation of the medial
aspect of the knees. The most likely diagnosis is:
A. Rheumatoid arthritis
B. Gouty arthritis
C. Chondromalacia patellae
D. Osteoarthritis
E. Psoriatic arthritis
A
- Answer: D
Explanation:
Osteoarthritis most often affects the weight-bearing joints
and is associated with obesity or other forms of
mechanical stress. It has no systemic manifestations. It is
more common in women, and onset is usually after the
age of 50.
Pain often occurs on exertion and is relieved with rest,
after which the joint may become stiff. Distal
interphalangeal joints may be involved, with the
production of Heberden nodes. Bouchard nodes are often
found at the proximal interphalangeal joint. Crepitus (the
sensation of bone rubbing against bone) is often felt on
examination of the involved joint. Rheumatoid arthritis is
a systemic disease of women under the age of 40. joint
involvement is usually symmetric, involving the proximal
interphalangeal and metacarpophalangeal joints. Ninetyfi
ve percent of gouty arthritis occurs in men and often
involves the great toe. Chondromalacia patellae or
chondromalacia means softening of the cartilage. Patients
present with anterior knee pain and tenderness over the
undersurface of the patella. Pain is worse when sitting for
long periods of time or when climbing stairs. Psoriatic
arthritis is an asymmetric oligoarthritis that involves the
knees, ankles, shoulders,or digits of the hands and feet and
occurs in 50% of patients with psoriasis.
Source: Tierney
138
Q
- Breakthrough pain, i.e., episodic exacerbations of pain
above an established baseline level of pain is experienced
by what percentage of patient with cancer?
A. >90%
B. 75-90%
C. 50-74%
D. 25-49%
E.
A
583. Answer: A Explanation: (Raj, Pain Review, 2nd Ed., page 110) Breakthrough pain is experienced by 93% of patients with cancer Source: Shah RV, Board Review 2005
139
Q
- Of the following, which is the correct defi nition?
A. Allodynia -pain brought on by a non-painful stimulus
B. Hyperpathia -burning, pins and needles sensation
C. Paresthesia - extreme sensitivity to noxious stimulus
D. Dysesthesia - sharp, shooting pains
E. Hyperalgesia - pain brought on by a non-painful stimulus
A
- Answer: A
Explanation:
A. Allodynia is pain brought on by a non-painful stimulus.
B. Hyperpathia is an abnormal response to a stimulus.
C. Paresthesia is a burning or “pins and needles” sensation.
D. Dysesthesia is an abnormal and disagreeable symptom.
E. Hyperalgesia is an exaggerated pain caused by a
normally painful stimulation.
Source: Trescot AM, Board Review 2004 for Shah
140
Q
- Which of the following is true of trigeminal neuralgia?
A. Like post-herpetic neuralgia, the V1 distribution is the
most affected
B. Like temporal arteritis, patients typically develop jaw
claudication with chewing
C. The pain is paroxysmal, shooting and electrical in nature
and lasts 10 to 30 minutes at a stretch
D. Pain typically lingers between episodes
E. Facial muscles innervated by cranial nerve 7 may contract during episodes
A
- Answer: E
Explanation:
(Raj, Pain Review, 2nd Ed., pages 28-39)
Trigeminal neuralgia represents painful ectopic or
ephaptic fi ring of trigeminal neurons: the ‘kindling’
phenomenon occurs when abnormal impulses in damaged
trigeminal neurons are ‘driven’ into a sensory seizure
activity by the afferent barrage from trigger zones. Several
mechanisms have been proposed. The most common is an abnormal blood vessel, such as the superior cerebellar
artery and anterior inferior cerebellar artery. Other
mechanisms include demyelinating plaques that affect the
caudalis nucleus or direct tumor infi ltration of the rootlets
(acoustic neuromas,aneurysms, angiomas,cholesteatomas)
A. Unlike PHN, V2 and V3 are the most commonly
affected.
B. Unlike temporal arteritis, the pain is not gradual and
progressive with eating.
C. Chewing rather induces paroxysmal, lancinating,
electrical shocks that last from seconds to a few minutes
(usually less than 2 minutes).
D. Patients are usually pain free between episodes.
E. Facial muscles may contract during episodes…
voluntarily. Patients grimace the face in order to
immobilize any trigger zones: tic doloreux.
Note hemifacial spasm involves compression or ephaptic
discharges of the facial nucleus which can lead to
involuntary pain contractions of facial muscles on one
side.
This is unlike the ‘voluntary’ grimacing of facial muscles
with trigeminal neuralgia.
Source: Shah RV, Board Review 2005
141
Q
586. Which of the following most commonly is associated with central pain? A. Stroke B. Epilepsy C. Brain tumor D. Spinal cord injury E. Parkinson’s disease
A
- Answer: D
Source: Boswell MV, Board Review 2005
142
Q
587.Central pain most likely requires injury to which of the following pathways? A. Posterior columns B. Corticospinal fi bers C. Spinothalamic tract D. Reticulospinal fi bers E. Mesencephalic system
A
- Answer: C
Source: Boswell MV, Board Review 2005
143
Q
588.The most common site of spinal cord lesions causing central pain is A. Brainstem B. Cervical C. Thoracic D. Lumbar E. Sacral
A
- Answer: B
Source: Boswell MV, Board Review 2005
144
Q
589.Infections of the spine most commonly involve which segments? A. Cervical B. Thoracic C. Thoracolumbar D. Lumbar E. Sacral
A
589. Answer: D Explanation: Lumber spine is involved slightly more often than thoracic spine. Source: Boswell MV, Board Review 2005
145
Q
- Patient controlled anesthesia allows all of the following
except:
A. Patient controlled administration of analgesia by demand
B. Decreased risk of normeperidine induced seizure activity
with demerol administration
C. Improved compliance with post-traumatic rehabilitation
D. Improved compliance with JCAHO fi fth pathway recommendations
E. Improved analgesia with reduced overall opioid administration
A
- Answer: B
Source: Hansen HC, Board Review 2005 for Shah
146
Q
591.The most common painful symptom associated with spinal cord injury is A. Burning B. Dysesthesias C. Lancinating D. Muscle cramps E. Visceral pain
A
- Answer: A
Source: Boswell MV, Board Review 2005
147
Q
592.The most common cause of mononeuropathy multiplex is A. Diabetes mellitus B. Temporal arteritis C. Sarcoidosis D. Systemic lupus erythematosus E. Periarteritis nodosa
A
- Answer: A
Explanation:
A. Diabetes mellitus is the most common cause of
mononeuropathy multiplex. In this disorder, individual
nerves are transiently disabled. The neuropathy usually
develops over the course of minutes to days, and the
recovery of function may require weeks to months.
B. Various rheumatoid disease and sarcoidosis produce similar clinical pictures, but temporal arteritis does not
typically lead to this type of neuropathy.
A vascular lesion is believed to be the most common basis
for this type of neuropathy. If the giant cell arteritis seen
with temporal arteritis does cause a neuropathy, it is an
optic neuropathy with resultant blindness.
Unlike the peripheral nerve injuries that develop with
mononeuropathy multiplex, this ischemic optic
neuropathy of temporal arteritis produces irreversible
injury to the affected cranial nerve.
The patient who loses vision as part of temporal arteritis
does not recover it.
148
Q
- Which of the following is not a barrier to effective pain
control in the cancer population?
A. Lack of validated instruments to assess the multidimensional
aspects of pain in a cancer patient
B. Under-reporting of pain by cancer patients
C. Fear of civil or criminal penalties due concerns by practitioners
of improperly prescribing analgesics
D. Inadequate reimbursement by payers
E. Inadequate assessment of pain and lack of knowledge of
pain therapies by practitioners
A
- Answer: A
Explanation:
A. There are several validated instrument for assessing
cancer pain:
Multidimensional Scales:
Memorial Pain Intensity Card- 100 mm VAS, pain relief
scale, mood scale, and 8-point verbal rating scale. Its utility
is its brevity
McGill Pain Inventory
Brief Pain Inventory
Unidimensional Scales:
VAS
Numerical Rating Scale- 11
B. Under-reporting by patients and families
C. Fear of over-regulation by the government
D. Inadequate reimbursement or requirements for
excessive documentation by 3rd party payers
E. Inadequate assessment by practitioners
- Lack of knowledge regarding current pain treatment by
practitioners
Source: Shah RV, Board Review 2005
149
Q
594.The most prominent areas of degeneration with Friedreich’s disease are in the A. Cerebellar cortex B. Inferior olivary nuclei C. Anterior horns of the spinal cord D. Spinocerebellar tracts E. Spinothalamic tracts
A
- Answer: D
Explanation:
Degeneration occurs primarily in the spinal cord rather
than the cerebellum or brainstem in patients with
Friedreich’s disease. Both the dorsal and ventral
spinocerebellar tracts are involved. The other spinal cord
structures exhibiting degeneration include the posterior
columns and the lateral corticospinal tracts.
Source: Anschel 2004
150
Q
- Acute pain is never well tolerated, but in which of the
following would you expect the patient to have the
greatest tolerance?
A. Early in the course of the cancer
B. Late in the course of the cancer
C. After a bone biopsy
D. Mucositis following radiation therapy
E. Abdominal distention and cramps following chemotherapy
A
- Answer: A
Explanation:
Patients may tolerate high levels of pain early in the course
of the illness because of the expectation that anti-cancer
therapy may relieve their symptoms.Late in the course
they may have increase anxiety, apprehension, and fear. Diagnostic procedures tend to be frequent in these
patients.
Since patients may be wary of the results and since bone
biopsies are frequently painful, this may not be well
tolerated. Mucositis is diffi cult to treat and will be
unpleasant. Abdominal distention and cramps, along with
nausea following chemotherapy would also be poorly
tolerated
Source: Shah RV, Board Review 2005
151
Q
- A patient with inoperable pancreatic cancer has severe
abdominal pain. A celiac plexus block failed to provide
any relief. Over a period of one month, the patient has
required higher and higher doses of fentanyl to150
mcg/hour (two 75 mcg/hr patches). You decide to proceed
with an intrathecal trial of morphine in anticipation of
placing a permanent intrathecal pump. How much would
you trial with?
A. 15 milligrams
B. 15 micrograms
C. 30 milligrams
D. 30 micrograms
E. 500 micrograms
A
- Answer: E
Explanation:
Typically the conversion ratios for different routes are as
follows:
Oral to intravenous = 3:1
Intravenous to epidural = 10:1
Epidural to intrathecal = 10:1
Also, although debatable, fentanyl to morphine the
conversion ratio is 1:100.
Thus, an appropriate trial would start with 0.5 mg or 500
micrograms. The issue of management is controversial,
since most patients with inoperable pancreatic cancer are
not expected to live more than 4-6 months. Intrathecal
pumps typically are cost-effective when the life expectancy
is greater than 4-6 months. If less than that then consider a
tunneled epidural catheter.
Source: Shah RV, Board Review 2005
152
Q
597. Which of the following is NOT a disorder of the microcirculation? A. Raynaud’s disease B. Acrocyanosis C. Livedo Reticularis D. Erythromelalgia E. Thromboangiitis obliterans
A
- Answer: E
Explanation:
A. Raynaud’s disease is a disease of the microcirculation
B. Acrocyanosis is a vasospastic disorder manifested by
persistent coldness, intense cyanosis, edema, and
hyperhidrosis
C. Livedo Reticularis is manifested by marbled mottling
of the skin with cold intolerance
D. Erythromelalgia is the opposite of acrocyanosis and
Raynaud’s disease: vasodilatation, redness, and burning
pain
E. Thromboangiitis obliterans is a non-atherosclerotic
lesion of medium sized arteries and veins in the distal leg
or arm.
- Young cigarette smoking males are almost exclusively
affected.
- The pain is symmetric and bilateral.
- Patients usually have a cold intolerance.
-The most common symptoms are instep claudication
and rest pain
Source: Shah RV, Board Review 2005
153
Q
- A 17 -year-old football player with his foot planted is
tackled from the side, causing a forced valgus bending
of the knee. On physical examination, there is tenderness
over the medial femoral condyle. McMurray test is
negative for any palpable clicks. Which of the following is
the most likely diagnosis?
A. Tear of the lateral meniscus
B. Rupture of the lateral collateral ligament
C. Rupture of the medial collateral ligament
D. Dislocation of the patella
E. Subluxation of the patella
A
- Answer: C
Explanation:
(Seidel, 5/e, pp 737-738.) The lateral and medial collateral
ligaments are on either side of the knee. Forced valgus bending of the knee may rupture the medial collateral
ligament (MCL), also called the tibial collateral ligament.
This is the most frequently injured ligament of the knee.
Patients present with pain over the medial aspect of the
knee. Injuries to the MCL may in turn tear the medial
meniscus since the MCL is attached to the medial
meniscus. Patients with medial mensical tears may
complain of locking of the knee in fl exion with activity
while walking. Injuries of the lateral (fi bular) collateral
ligament cause tenderness over the lateral knee with
palpation, but these injuries are not common. Dislocation
or subluxation of the patella is due to a great force.
Locking is common and the patella is usually displaced
laterally.
Subluxation reduces by itself, while dislocation requires
reduction.
154
Q
- Which of the following is typical of neurogenic
claudication associated with spinal stenosis?
A. Spinal canal diameter of 12 mm
B. Decreased pedal pulses
C. Leg pain with standing
D. Horner’s syndrome
E. Brachial plexus compression
A
- Answer: C
Source: Boswell MV, Board Review 2005
155
Q
- A patient presents with serve pain during resisted
shoulder abduction, along with minimal pain during
resisted external rotation. The following tendopathies
would be most likely responsible for the pain.
A. Biceps Tendinitis
B. Infraspinatus Tendinitis
C. Subscapularis Tendinitis
D. Supraspinatus Tendinitis
E. Gleno Humeral Tendinitis
A
- Answer: D
Source: Sizer Et Al - Pain Practice March & June 2003
156
Q
- When taking the history of a new headache patient, which of the following would not raise your suspicion of a
serious pathologic etiology?
A. Headache that is always in one spot
B. Relief of headache with sleep
C. Double vision with lateral gaze
D. Headache that worsens when lifting a heavy object
E. The worst headache ever
A
- Answer: B
Explanation:
(Raj, Pain Review, 2nd Ed., page 25, Table 5-1)
Several factors in a targeted headache history should raise
concern:
New headache of recent onset (‘the fi rst’)
New headache of unusual severity
Headache associated with systemic illness
Headache that peaks rapidly
Headache associated with exertion
Focal headache
Sudden change in a previously stable headache pattern
Headache associated with a Valsalva maneuver
Nocturnal headache
In this case, a headache that is in one spot may be
associated with malignancy or other intracranial
pathology. Double vision with lateral gaze implies a
neurological
abnormality, such as increased intracranial pressure.
Headache that worsens with heavy lifting implies
increased pain with transient increases in ICP (Valsalva).
The worst headache ever may signal a catastrophe such as
an aneurysm rupture or meningitis. Relief of headache
with sleep is often associated with a benign process.
Source: Shah RV, Board Review 2005
157
Q
602. The structure that is most often associated with bursitis at the shoulder is the A. Acromioclavicular joint capsule B. Glenohumeral joint capsule C. Subacromial bursa D. Subdeltoid bursa E. None of the above
A
- Answer: C
Explanation:
C. Shoulder bursitis is often the result of calcium deposits
associated with the subacromial bursa, which separates
the acromion process from the underlying supraspinatus
muscle, or within the suprajacent supraspinatus tendon.
D. The subdeltoid bursa separates the deltoid muscle from
the head of the humerus and the insertions of the rotator
cuff muscles.
Source: Klein RM and McKenzie JC 2002.
158
Q
- A 46-year old homemaker enters your offi ce holding
her right upper extremity in a guarded posture with a
complaint of an acute and worsening throbbing pain of 3
days duration in the right shoulder that is unrelieved by
rest. She provided the history that the mild pain started
approximately 4 months ago. She had tenderness over the
deltoid muscle and pain elicited when rolling over onto
the right shoulder while sleeping. There was initially a
loss of range of motion, as well as a catching and painful
sensation whenever the right arm was elevated between
75° to 100°. High doses of Aspirin helped her pain. There
was no history of trauma. The x-ray taken of the shoulder
is depicted below. The most likely diagnosis is:
A. Dystrophic calcifi cation of the shoulder
B. Massive calcifi cation of the shoulder
C. Osteoarthritis of the humerus
D. Bicipital tendonitis
E. Calcifi c tendonitis
A
- Answer: E
Explanation:
Calcifi c tendonitis of the anterior cuff is a common
disorder that demonstrates a cyclic nature of calcium
deposition and eventual absorption as the tendons heal.
Source: Saidoff DC, McDonough AL. Critical Pathways in
Therapeutic Intervention. Extremities and Spine.St. Louis,
159
Q
604. Pain referred to the right side of the neck and extending laterally from the right clavicle to the tip of the right shoulder is most likely to involve the A. Cervical cardiac accelerator nerves B. Posterior vegal trunk C. Right intercostal nerves D. Right phrenic nerve E. Right recurrent laryngeal nerve
A
- Answer: D
Explanation:
(April, 3/e, p 260.) The phrenic nerve, which arises from
cervical nerves C3 through C5, mediates sensation from
the diaphragmatic pleura and peritoneum, as well as from
the pericardium; in addition, it carries motor fi bers to the
diaphragm. Therefore, pain from the diaphragmatic pleura
or peritoneum, as well as from the parietal pericardium,
may be referred to dermatomes between C3 and C5,
inclusive. These dermatomes correspond to the clavicular
region and the anterior and lateral neck, as well as to the
anterior, lateral, and posterior aspects of the shoulder.
Source: Klein RM and McKenzie JC 2002.
160
Q
605. Waddell’s Signs are used to help identify A. Depressive disorder B. Non-physiologic signs C. Munchausen’s syndrome D. Factitious disorder E. Somatoform disorder
A
- Answer: B
Source: Boswell MV, Board Review 2005
161
Q
606.The most common cause of spinal cord-related central pain is A. Trauma B. Neoplasms C. Vascular lesions D. Surgical injury E. Inflammatory lesions
A
- Answer: A
Source: Boswell MV, Board Review 2005
162
Q
607.Which of the following plays a limited role in the management of cancer pain? A. Nalbuphine B. Choline magnesium trisalicylate C. Hydromorphone D. Amitriptyline E. Methylprednisolone
A
- Answer: A
Explanation:
The World Health Organization recommends a 3 step
ladder for cancer pain management:
Step 1: Non-opioid analgesics (Aspirin, NSAIDS,
acetaminophen) +/-Adjuvants (medications used in pain
management whose primary indication is for another
disorder)
Step 2: Weak opioids analgesics (Codeine, Hydrocodone,
Oxycodone) +/-Non-opioid analgesics Adjuvants
Step 3: ‘Strong’ opioids analgesics (Morphine,
Hydromorphone, Oxycodone, Fentanyl patch) +/-
A. Nalbuphine is a mixed opioids agonist and antagonist
that has a limited role in cancer pain for two reasons:
ceiling analgesic effect and possible induction of opioids
withdrawal in opioids tolerant patients.
B. Choline magnesium trisalicylate is a non-acetylated
salicylate that has a minimal effect on platelet function and
lower rates of GI upset compared to acetylated salicylates
C. Hydromorphone is a strong opioid agonist.
D. Amitriptyline is a tricyclic antidepressant and adjuvant
analgesic that has effi cacy in several neuropathic pain
syndromes.
E. Methylprednisolone is an adjuvant that may improve
mood and appetite, but also alleviate pain due to neural
compression or bony infi ltration
Source: Shah RV, Board Review 2005
163
Q
- After biopsy resection of a lymph node in her neck, a
23-year-old woman notices instability of her shoulder.
Neurologic examination reveals winging of the scapula
on the side of the surgery. During surgery, she probably
suffered damage to the
A. Deltoid muscle
B. Long thoracic nerve
C. Serratus anterior muscle
D. Suprascapular nerve
E. Axillary nerve
A
- Answer: B
Explanation:
Winging of the scapula most often occurs with weakness
of the serratus anterior muscle.
This is innervated by the long thoracic nerve, whose
course starts high enough and runs superfi cially enough to
allow injury to the nerve with deep dissection into the root
of the neck. The long thoracic nerve is derived from C5,
C6, and C7.
Winging is elicited by having the patient push against a
wall with the hands at shoulder level. With this maneuver,
the scapula with the weak serratus anterior will be pulled
away from the back and vertical margin of the scapula will
stick out from the back.
Injuries to the long thoracic nerve are usually unilateral
and are often due to trauma or surgical manipulation.
Source: Anschel 2004
164
Q
- A 45-year-old swimmer presents with a sore right
shoulder for nearl 12 months. He was taking nonsteroidal
anti-infl ammatory agents throughout this period with
minimal relief. Over the last several days, he has developed
pain with elevation of his arm above the horizontal and
has some loss of passive motion in external rotation and
with abduction. The pain is relieved after you inject 2 mL
of lidocaine into the subacromial space. Which of the
following is the most likely diagnosis?
A. Fracture of the surgical neck of the humerus
B. Bicipital tendinitis due to snapping
C. Cervical radiculopathy due to a herniated disk
D. Calcifi c tendinitis
E. Frozen shoulder due to a rotator cuff injury
A
- Answer: E
Explanation:
A. Fracture of the surgical head of the humerus is usually
seen in the elderly after a fall.
Swelling and ecchymosis are visible.
B. Bicipital tendinitis may be seen with overuse and
trauma, but pain is typically felt over the anterior aspect of
the shoulder and palpation of the biceps tendon in the
bicipital groove elicits tenderness.
Pain produced on supination of the forearm against
resistance (Yergason sign) confi rms bicipital tendinitis.
Lidocaine injection into the synovial sheath of the long
head of the biceps relieves pain.
C. Cervical radiculopathy typically results in decreased
sensation, strength, and refl exes all matching to one root
level of the upper extremity.
D. Calcifi c tendinitis is due to calcium deposits in the
subacromial region and is especially common in the
supraspinatus tendon near its insertion.
E. Passive range of motion (ROM) tests are performed by
the examiner, while active ROM tests are performed by the
patient. Passive ROM tests need not be done if active ROM
tests are performed adequately. The loss of passive range of
motion indicates a stiffening shoulder (frozen shoulder or
adhesive capsulitis).
The most likely etiology in this patient would be
impingement of the rotator cuff causing infl ammation,
degeneration, and possibly a tear.
The rotator cuff, which is formed by the SITS tendons of
the Supraspinatus, Infraspinatus, Teres minor, and
Subscapularis muscles, stabilizes the glenohumeral joint
and prevents upward movement of the head of the
humerus.
Injuries may occur from overhead activities including
freestyle and butterfl y-style swimming
The drop arm sign may be positive in rotator cuff tear
(abduct the arm to 180° and ask patient to bring it down
slowly; at 90° the arm will drop quickly due to weakness).
An injection of lidocaine often relieves the infl ammation
inthe subacromial space in patients with rotator cuff
tendinitis and alleviates the symptoms.
Source: Goldman
165
Q
- Retrograde release of Substance-P contributes most to
which of the following phenomena: - Co-morbidity of pain and depression
- Reduction in local concentration of cytokine(s)
- Nociceptive pain
- Neurogenic infl ammation
A
- Answer: D (4 Only)
Source: Giordano J, Board Review 2003
166
Q
- Diabetic neuropathy:
- can cause diffuse, generalized, or symmetrical polyneuropathies
- can involve sensory, motor, or autonomic nerves
- can cause focal neuropathesies
- can involve cranial nerves
A
- Answer: E (All)
Explanation:
Diabetes can cause all of these
Source: Trescot AM, Board Review 2004 for Shah
167
Q
- Which of the following statements best describes Factitious Disorders?
- There is no deliberate production or feigning of physical
or psychological signs or symptoms - External incentives for the behavior are clearly present
- It is the new term used to describe “malingering.”
- Motivation for the behavior is the desire to assume
sick role
A
- Answer: D (4 Only)
Source: Cole EB, Board Review 2003
168
Q
- Which of the following statements are true about the
evaluation of patients with chronic pain regarding their
potential for suicide? - It is safer to not directly confront patients about their
suicidal ideation because doing so may suggest to
them that suicide is a viable option. - Co-existing depression increases the relative risk.
- Participation in an established religious denomination
may increase the risk. - Work is protective so that unemployment raises the
risk.
A
- Answer: C (2 & 4)
Source: Cole EB, Board Review 2003
169
Q
- True statements regarding plexopathies include:
- Complaints of exquisite burning pain and intense allodynia
in the distribution of the nerve plexus - Treatment can include spinal cord or peripheral nerve
stimulation - Symptoms can occur days to weeks after the injury
- Frequently caused by tumor infi ltration and radiation
injury in cancer patients.
A
- Answer: E (All)
Explanation:
Ref: 1) Cherry and Portenoy. Chapter 45. Cancer Pain:
principles of Assessment and syndromes. In: Textbook of
Pain, 4th Edition. Wall & Melzack, Churchill Livingston,
1999, page 1042. Rauck. Chapter 6. Trauma. In: Pain
Medicine: A Comprehensive Review, 2nd Edition, Raj,
Mosby, 2003, page 36.
Source: Day MR, Board Review 2003
170
Q
- Burn injury reveals each of the following in initial stages
of assessment: - Obvious traumatic exposure of burn injury
- Increase in metabolic activity
- Wound involvement refl ecting suspected underlying
tissue destruction - Potentially massive fl uid loss at the site of burn
A
- Answer: C (2 & 4)
Source: Hansen HC, Board Review 2005 for Shah
171
Q
- Which of the following is most correct about the
distinction between delirium and dementia? - Both are caused by underlying acute and generally
reversible medical conditions. - Dementia has less frequent and vivid hallucinations
than delirium. - Both produce signifi cant agitation and require the ongoing
administration of antipsychotic medications. - While dementia has no clear onset, delirium has a very
specific onset.
A
- Answer: C (2 & 4)
Source: Cole EB, Board Review 2003
172
Q
- Electrical burns are characteristically:
- Determined by severity, voltage, amperage, and duration
of electrical contact - Resistance of current is an important determinant of
the extent of contact wound - Contact wound may be deceptively benign and not
reveal signifi cant underlying tissue damage - Requires both superfi cial and deep debridement
A
- Answer: A (1,2, & 3)
Source: Hansen HC, Board Review 2005 for Shah
173
Q
- Characteristics of entrapment syndromes include:
- Pain worse at night
- Unrelenting pain
- Local pain at the area of nerve entrapment
- Muscles distal to the entrapment are always painful
A
- Answer: B (1 & 3)
Explanation:
Ref: Sola, Chapter 24. Upper extremity pain. In: Textbook
of Pain, 4th Edition Wall & Melzack, Churchill
Livingston, 1999, page 571-572.
Source: Day MR, Board Review 2003
174
Q
- Epidural catheters are considered a poor choice for
control of burn pain involving the posterior thorax and
lumbar region as a result of: - Poor landmarks and diffi culty of access to proper
placement of catheter - Potential for wound infection and seeding the epidural
space of contaminant - Diffi culties with anchoring, and placement of catheter
for prolonged infusion - Increased local sensitivity to anesthetics
A
- Answer: A (1,2, & 3)
Source: Hansen HC, Board Review 2005 for Shah
175
Q
- True statements regarding Superior Mesenteric Artery
Syndroms is/are: - Recurrent, acute attacks of diffuse, colicky abdominal
pain - Tense and distended abdomen
- Can be treated with balloon angioplasty
- Does not usually require surgery.
A
- Answer: A (1, 2, & 3 )
Explanation:
Ref: Raj. Chapter 43. Thoracoabdominal Pain. In:
Practical Management of Pain. 3rd Edition, Raj et al,
Mosby, 2000, page 626.
Source: Day MR, Board Review 2003
176
Q
- Neuropathic pain:
- can be caused by axonal degeneration
- can be sympathetically mediated
- can be caused by strokes
- can be caused by spinal cord injuries
A
- Answer: E (All)
Explanation:
All of the above are true statements
Source: Trescot AM, Board Review 2004 for Shah
177
Q
622. Which of the following patients are at increased risk for developing a spinal epidural abscess? 1. Immuno compromised 2. Alcoholic 3. Diabetic 4. Intravenous drug users
A
- Answer: E (All)
Explanation:
Spinal epidural abscesses must be quickly recognized and
effectively treated due to its rapid course. S. Aureus is the
most common organism. Mass effect or thrombotic
ischemia is the typical mechanism of action. The above are
risk factors for developing this condition.
Source: Shah RV: 2003(Bonica, 3rd Ed., page 1014)
178
Q
- True statements in reference to spondylolysis and
spondylolisthesis include: - Incidence in school-aged children in 4%, increasing to
6% by adulthood - Pars defects have been found in 20% of asymptomatic
adults - Increased incidence of isthemic spondylosis is associated
with certain sports including diving, gymnastics,
wrestling, and weight lifting - Degenerative spondylolisthesis is most common at
L3/4 and more common in men
A
- Answer: B (1 & 3)
Explanation: - Incidence in school-aged children in 4%, increasing to
6% by adulthood - Pars defects have been found in approximately 7% of
asymptomatic adults.
- Pars defects are twice as common in young males but
high grade slips are 4 times more common in the girls. - Increased incidence of isthemic spondylosis is
associated with certain sports including diving,
gymnastics, wrestling, and weight lifting - Degenerative spondylolisthesis is most common at L4/5
and more common in women
History:
- Chronic, dull, aching, or cramping low back pain
- Often located along the belt line
- Exacerbated by rotation and/or hyperextension
- Underlying history of chronic repetitive motions
Physical examination
- Pain with extension
- Symptoms can be attenuated by having the patient stand
on one leg and bend backward
- Paraspinal muscle spasm
- Tight hamstrings
- Loss of lumbar lordosis
Source: Cole & Herring. Low Back Pain Handbook.
179
Q
- Mittelschmerz syndrome is usually:
- Dull aching pain
- At mid-cycle
- Lasting from minutes to hours
- Felt in both lower quadrants
A
- Answer: A (1, 2, & 3)
Source: Nader and Candido – Pain Practice. June 2001
180
Q
- The activities exacerbating pain the most in an elderly
patient with severe spinal stenosis include: - Walking uphill
- Riding a bicycle
- Bending forward
- Walking downhill
A
- Answer: D (4 Only)
Explanation:
Pain from spinal stenosis is caused by narrowing of the
spinal canal due to degenerative changes in the joints and
discs. This often results in multidermatomal leg pain in
one or both legs, buttocks, and low back. Movements that open the spinal canal, such as leaning forward (walking
uphill, riding a bicycle), will often decrease the pain.
Movements that decrease the size of the spinal canal, such
as walking downhill, will increase the pain.
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
181
Q
- True statements regarding glossopharyngeal neuralgia
include: - It is more common in adults than children
- Attacks can be associated with cardiac arrest
- It is most often described as aching and burning between
attacks - It is found to occur more frequently in patients with
tic douloureux
A
- Answer: A (1, 2, & 3)
Explanation: - Glossopharyngeal neuralgia is characterized by
paroxysms of lancinating pain in the tonsillar region, base
of the tongue, ear and ipsilateral face, neck, or scalp.
Patients are almost always older than 20. - Other symptoms that may occur during attacks are
cardiac arrhythmias (including arrest), hiccups, seizures,
coughing, stridor, and excessive salivation. - Attacks may last minutes or seconds and rarely occur at
night. The etiology is unknown. Attacks can be triggered
by swallowing or by touching the ear, face, or neck.
Patients may complain of a constant burning or dull ache
between attacks of lancinating pain. - There is no association between the incidence of tic
douloureux and glossopharyngeal neuralgia (Wall, p 713).
182
Q
- True statements about painful polyneuropathies caused
by selective small fi bre loss include the following: - Diabetes
- Amyloid neuropathy
- Hereditary sensory neuropathy
- Chronic renal failure
A
- Answer: A (1, 2, & 3)
Explanation:
Small myelinated and unmyelinated fi bre loss is found in
diabetic neuropathy, Fabry’s disease, amyloid neuropathy,
and hereditary sensory neuropathy.
Patients with these disorders may complain of a burning,
aching, lancinating pain.
Chronic renal failure is associated with large myelinated
fi bre loss, which is rarely painful.
183
Q
- A young man presents with morning back pain and
stiffness and tenderess over the sacroiliac joints.
The patient denies any previous history of eye or
genitourinary problems. On physical examination, there
is a diastolic rumbling murmur. The most likely diagnosis
in this patient is: - Rheumatoid arthritis
- Sjogren syndrome
- Reiter syndrome
- Ankylosing spondylitis
A
- Answer: D (4 Only)
Explanation:
(Tierney, 42/e, pp 825-826.) Ankylosing spondylitis
(Marie-Strumpell arthritis) is a chronic and progressive,
infl ammatory disease that most commonly affects the
spinal, sacroiliac, and hip joints. All patients have
symptomatic sacroiliitis. Other symptoms ml, include
uveitis and aortitis.Men in the third decade of life are most
frequently affected, and there is a strong association with
HLA-B27 (900 in white patients. Patients with advanced
disease present with a bent over posture. A positive
Schober test indicates diminished anterior fl exion of the
lumbar spine. Involvement of the costoveretebral joints
limits chest expansion and eye involvement may cause an
iritis. Patients with Reiter syndrome may present with a
history of conjunctivitis, urethritis, arthritis, and
enthesopathy (Achilles tendinitis). Aortitis in ankylosing spondylitis may cause aortic
insuffi ciency. The AI manifests itself early in the course of
the spinal disease and may lead to congestive heart failure.
184
Q
- Characteristic features of peripheral neuropathies
include: - Paresthesias and dysesthesias
- Sensory loss
- Loss or diminution of tendon refl exes
- Pain
A
- Answer: A (1, 2, & 3)
Explanation:
1, 2, 3. Peripheral neuropathies, regardless of their cause,
have several characteristic signs and symptoms:
paresthesias and dysesthesias, sensory loss, loss or
diminution of tendon refl exes, and impaired motor
function. - Not all peripheral neuropathies are painful, and when
pain is associated with a peripheral neuropathy, it usually
is not a distinguishing feature of the neuropathy (Wall, pp
991-995)
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
185
Q
630. The following mechanical factors are related to an impingement event at the shoulder 1. Acromion length 2. Acromion orientation 3. Os Acromiale 4. Acromian softness
A
- Answer: A (1, 2, & 3)
Source: Sizer et al - Pain Practice - March & June 2004
186
Q
- All of the following structures are essential to posterior
glenohumeral joint stability - Anterior angulation of the glenoid fossa
- Anterior-inferior glenohumeral ligament complex
- Integrity of the glenoid labrum
- Posterior glenohumeral capsule
A
- Answer: A (1, 2, & 3)
Source: Sizer Et Al - Pain Practice March & June 2003
187
Q
632. Identify all the items packaged under the Medicare outpatient prospective payment system 1. recovery room 2. supplies 3. anesthesia 4. medical visits
A
- Answer: A (1, 2, & 3)
188
Q
- Cause(s) of continued low back pain in post lumbar laminectomy syndrome include:
- epidural fi brosis
- recurrent disc herniation
- spinal instability
- facet joint arthropathy
A
- Answer: E (All)
189
Q
634. The following conditions typically produces localized symptoms 1. Subacromiodeltoid bursitis 2. Glenohumeral arthritis 3. Sternoclavicular synovitis 4. Acromioclavicular instability
A
- Answer: D (4 Only)
Source: Sizer Et Al - Pain Practice March & June 2003
190
Q
- The true statements regarding pain and spinal cord
lesions are - only incomplete spinal cord lesions can cause pain
- traumatic spinal cord lesions are the most common
cause of central pain of spinal cord origin - the development of central pain after a spinal cord lesion
depends on cord level - pain is usually produced in an area of somatosensory
loss
A
- Answer: C (2 & 4)
Explanation: - Central pain of spinal cord origin most commonly
occurs after traumatic spinal cord lesions. - Spinal cord lesions of any cause commonly result in
central pain. - The pain usually occurs in an area of spinothalamic
somatosensory loss. Central pain may also occur with
lesions that fail to produce clinically detectable
somatosensory loss. - Both complete and incomplete lesions, regardless of
cord level, can cause central pain.
Source: Kahn and Desio
191
Q
636. Which of the following medications is/are FDA approved for use in intrathecal pumps? 1. Hydromorphone 2. Baclofen 3. Clonidine 4. Morphine
A
- Answer: C (2 & 4)
Source: Day MR, Board Review 2004
192
Q
- A 55 year old woman comes into the ER with a sudden
onset of “the worst headache of my life”. She has a history
of migraines but this feels “different”. Diagnostic studies
should include: - CT scan
- CBC and sed rate
- Lumbar puncture
- EEG
A
- Answer: B (1 & 3)
Explanation:
For a possible subarachnoid bleed, a CT followed by an LP
would be appropriate. CBC and sed rate might be appropriate for temporal arteritis, and EEG for epilepsy
related migraines.
Source: Trescot AM, Board Review 2004
193
Q
638.True statements regarding Eagle’s syndrome include
which of the following:
1. Pain occurs during mandibular movement or twisting
of the neck
2. Pain never occurs spontaneously with the mouth
closed
3. The pain is stabbing in nature
4. Trigger points are present
A
- Answer: A (1, 2, & 3)
Explanation:
Eagle’s syndrome, also known as stylohyoid syndrome, is
caused by dystrophic calcifi cation of the stylohyoid
ligament. Treatment consists of surgical excision of the
stylohyoid ligament and the elongated styloid or cervical
process, if present. - Pain occurs during mandibular movement or with
twisting of the neck. - Pain is absent when the mouth is closed.
- The pain is stabbing, with radiation from the tonsil area
to the temporomandibular joint and base of the tongue. - There are no trigger points
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
194
Q
639. The glenohumeral joint capsule is reinforced by the tendons of all the following muscles 1. Infraspinatus 2. Subscapularis 3. Supraspinatus 4. Teres Major
A
- Answer: A (1, 2, & 3)
Source: Sizer Et Al - Pain Practice March & June 2003
195
Q
- During an occipital nerve block, suddenly, the patient
complains of lightheadedness and states “I don’t feel
good”. The differential diagnosis must include: - subarachnoid injection
- vertebral artery injection
- anaphylactic reaction
- Raynaud’s phenomena
A
- Answer: A ( 1, 2, & 3)
Explanation:
1 & 2. Injections into the foramen magnum or the
vertebral artery are very real and potential complications.
3.Depending on the medications, anaphylactic reactions to
the injectate (e.g. PABA allergies with multi-dose
medications) may occur. - Raynaud’s phenomena would not be related to the
injection.
Source: Trescot AM, Board Review 2004
196
Q
- Tension type headaches :
- are usually bilateral
- are not usually associated with nausea and vomiting
- may become chronic
- are described as sharp and stabbing
A
- Answer: A ( 1, 2, & 3)
Explanation:
Tension headaches are usually described as dull, bilateral
headaches associated with photophobia and phonophobia
but not nausea. They may become chronic, and they are
often associated with analgesia rebound.
Source: Trescot AM, Board Review 2004
197
Q
- The ligament systems is most responsible for stabilizing
the acromioclavicular joint in the frontal plane (ie…in
the cranial-caudal direction) is: - Acromioclavicular ligaments
- Coracoacromial ligament
- Coracohumeral ligaments
- Coracoclavicular ligaments
A
- Answer: D (4 Only)
Source: Sizer Et Al - Pain Practice March & June 2003
198
Q
- Discontinuation of tramadol can result in
- seizures
- tardive dyskinesia
- ventricular tachycardia
- cholinergic activity
A
- Answer: D (4 Only)
199
Q
644.True statements with regards to lateral epicondylitis
(tennis elbow) include:
1. Peak incidence is the fourth decade of life.
2. Characterized by pain in the lateral aspect of the elbow.
3. Physical exam reveals point tenderness of the lateral
epicondyle.
4. Usually fails to respond to conservative treatment
A
- Answer: A (1, 2, & 3 )
Explanation:
Ref: Sisto. Chapter 21. Sports injuries. In: Manual of
Rheumatology and Outpatient Orthopedic Disorders, 2nd Edition. Beary: Little, Brown and Company, 1990, page
121-122.
Source: Day MR, Board Review 2003
200
Q
- A patient presents with acute low back pain with radiation
into lower extremity with weakness of extensor digitorum
longus, and numbness on dorsum of the foot. Refl exes
were normal. The most likely diagnosis is: - L4/5 disc herniation
- L3/4 disc herniation
- L5 nerve root involvement
- S1 nerve root involvement
A
- Answer: B (1 & 3)
Explanation:
L4/5 disc herniation with L5 nerve root involvement
causes weakness of extensor hallucis longus, with
numbness on the lateral leg and dorsum of foot. However,
L5 has no refl exes
Source: Hoppenfeld S. Orthopaedic Neurology. A
Diagnostic Guide to Neurologic Levels. Philadelphia,
LWW, 1997.
201
Q
- A C4/5 disc herniation with neurological involvement
of C5 will have the following features on physical
examination: - Loss of sensation on the lateral arm
- Refl ex suppression of biceps
- Weakness of shoulder abduction
- Weakness of wrist extension
A
- Answer: A (1, 2, & 3)
Source: Hoppenfeld S. Orthopaedic Neurology. A
Diagnostic Guide to Neurologic Levels. Philadelphia,
LWW, 1997.
202
Q
647.True statements with regards to spondylolysis and
spondylolisthesis include the following:
1. Classifi cation includes dysplastic, isthemic, degenerative,
traumatic, pathological, and post surgical.
2. Isthemic is due to a lesion in pars interarticularis usually
present in the fi rst years of school with subtype
A and B
3. Degenerative are due to long-standing segmental instability
with remodeling of articular processes at the affected
level and degeneration of supporting structures
leading to loss of lumbosacral locking mechanisms
4. Pathological is due to localized or generalized bone
disease.
A
- Answer: E (All)
Source: Cole & Herring. Low Back Pain Handbook.
203
Q
- True statements about differences and similarities of
Basilar migraine and classic migraine are as follows: - Sex of the persons most often affected
- Resistance of the visual system to involvement
- Severity of symptoms
- Duration of the aura and the sequence of neurologic
defi cits and headache
A
- Answer: D (4 Only)
Explanation: - As with classic migraine, with basilar migraine women
are more susceptible than men. - Disturbances of vision are common, the aura usually
resolve within 10 to 30 min, and the headache invariably
follows, rather than precedes, the neurologic defi cits. - The visual change may evolve to complete blindness.
- The character and severity of neurologic defl ects
associated with basilar migraine are distinct. Irritability
may develop into frank psychosis. Rather than a mild
hemiparesis, the patient may have a transient quadriplegia.
Stupor, syncope, and even coma may appear and persist
for hours.
Source: Anschel 2004
204
Q
- A young female in her early 20’s presents with history of facial pain for one week on right side. She describes it as
an intense shooting pain that comes and goes. Most likely
underlying problem of this patient is: - Tolosa-Hunt syndrome
- Migraine
- Anterior communicating artery aneurysm
- Multiple sclerosis
A
- Answer: D (4 Only)
Explanation: - The Tolosa-Hunt syndrome is a presumably
infl ammatory disorder that produces ophthalmoplegia
associated with headache and loss of sensation over the
forehead.
- Papillary function is usually spared, and the site of
pathology is believed to be in the superior orbital fi ssure
or the cavernous sinus.
- It is usually not associated with trigeminal neuralgia. - Migraine has typical pattern of headaches with or
without aura. - Anterior communicating artery aneurysm produces
symptoms inconsistent with this description. - Multiple sclerosis is often associated with trigeminal
neuralgia, which is then termed symptomatic trigeminal
neuralgia because it occurs ass a symptom of another
illness. Other causes of symptomatic trigeminal neuralgia
include basilar artery aneurysms, acoustic schwannomas,
and posterior fossa meningiomas, all of which may cause
injury to the fi fth cranial nerve by compression.
Source: Anschel 2004
205
Q
- The scapulothoracic instability when exhibited during
the eccentric and or concentric phases of upper extremity
elevation is indicated with - Scapular downward rotation
- Scapular tipping
- Scapular winging
- Scapular upward rotation
A
- Answer: A (1, 2, & 3)
Source: Sizer Et Al - Pain Practice March & June 2003
206
Q
- A 35-year-old man injured his thoracic spine in a motor
vehicle accident 2 years ago. Initially he had a bilateral
spastic paraparesis and urinary urgency, but this has
improved. He still has pain and thermal sensation loss on
part of his left body and proprioception loss in his right
foot. There is still a paralysis of the right lower extremity
as well. True Statements about his status include: - This patient has Brown Sequard (hemisection) syndrome.
- In this patient, the pain and temperature abnormalities
start at one or two segments below the lesion. - The posterior column neurons decussate at the medulla.
- The lateral corticospinal tract decussates at the junction
of the midbrain and the medulla
A
- Answer: A (1, 2, & 3)
Explanation: - Hemisection of the spinal cord results in a contralateral
loss of the pain and thermal sensation due to
spinothalamic damage, and ipsilateral loss of
proprioception due to posterior column damage. There
is also an ipsilateral motor paralysis due to destruction
of the corticospinal and rubrospinaltracts as well as motor
neurons.
Complete transection of the spinal cord would cause a
bilateral spastic paralysis, and there would be no conscious
appreciation of any cutaneous or deep sensation in the
area below the transection.
Posterior column syndrome would result in a bilateral
loss of proprioception below the lesion, with relative
preservation of pain and temperature sensation.
Syringomyelic syndrome results from a lesion of the
central gray matter. Pain and temperature fi bers that cross
at the anterior commissure are affected, which may result
in bilateral loss of these sensations over several
dermatomes. However, tactile sensation is spared. The
most common cause of this type of syndrome is
syringomyelia. Trauma, hemorrhage, or tumors are other
possible etiologies. If the lesion becomes large enough,
then other spinal cord systems affected as well.
Tabetic syndrome results from damage to proprioceptive
and other dorsal root fi bers. It is classically caused by
syphilis. Symptoms include paresthesias, pain, and
abnormalities of gait. Vibration sense is most affected. - The spinothalamic system is responsible for pain and
temperature sensation.It enters the spinal cord through
the dorsal root ganglion. The second-order neurons then
ascend one or two levels as they cross in the anterior gray
commissure. Thus a lesion of the right spinothalamic tract
at the T8 spinal cord level would result in a contralateral
loss of pain and temperature on the left body beginning at
approximately T9-10 dermatome. - After the primary sensory fi ber enters the spinal cord,
the ascending branch enters the dorsal columns and travels
to the medulla. The fi bers from the legs and trunk level
medially in the fasciculus gracilis, while those from the
arm and neck travel laterally in the fasciculus cuneatus.
These fi rst-order neurons synapse in the medulla, and then
the second-order neurons decussate as the internal arcuate
fi bers and ascend in the medial lemniscus. The secondorder
fi bers synapse in the ventroposterolateral nucleus of
the thalamus, which then synapses on the somatosensory
cortex. - The lateral corticospinal tract originates primarily in
the precentral gyrus (primary motor cortex). These axons
then travel in the posterior limb of the internal capsule,
and then the middle section of the cerebral peduncle. They
enter the basal pons and continue as the pyramids in the
medulla. At the decussation of the pyramids, the lateral
corticospinal tract crosses and then continues down the
spinal cord.
Source: Anschel 2004
207
Q
- Bone pain may be characterized by which of the following
descriptions? - It can originate from the cortex and marrow
- It is transmitted by A-delta and C fi bers
- It has the highest pain threshold of the deep somatic
structures - It primarily arises from cancellous bone
A
- Answer: C (2 & 4)
Explanation: - The cortex and marrow do not receive nociceptive
fi bers. - Bone is innervated by A-delta and C fi bers that form a
plexus around the periosteum and invest the cancellous
bone. - Bone is said to have the lowest pain threshold of the
deep somatic structures. - Bone is innervated by A-delta and C fi bers that form a
plexus around the periosteum and invest the cancellous
bone.
Source: Kahn and Desio
208
Q
653. Which of the following structures may be involved in postmastectomy syndrome? 1. Chest 2. Shoulder 3. Axilla 4. Arm
A
- Answer: E (All)
Explanation: - Chest is involved in postmastectomy syndrome.
- Shoulder is involved in postmastectomy syndrome.
- Axilla is involved in postmastectomy syndrome.
- Arm is involved in postmastectomy syndrome.
Pain following mastectomy can arise after lumpectomy or
more extensive procedures. Axillary node dissection
increases the risk.
- Onset occurs from 2 weeks to 6 months and the
incidence is 5 to 20%.
- The most often cited cause is damage to the
intercostobrachial nerve, which is a branch of the 2nd
intercostal nerve, with frequent contribution from the 3rd intercostal nerve.
- Postoperative complications such as infection increase
the incidence.
Source: Bonica’s Management of Pain, 3rd edition, page
1216.
209
Q
- Which of the following can be associated with a neuropathic pain syndrome?
- Diabetes
- Mercury poisoning
- Causalgia
- Guillain-Barré syndrome
A
- Answer: E (All)
Explanation:
Certain alterations of neurologic structure and function
may result in pain. Metabolic changes of diabetes or
mercury poisoning may produce a painful peripheral
neuropathy. Viral dA mange (herpes zoster, late
poliomyelitis, and Guillain-Barré syndrome) may also
produce painful states. Trauma to peripheral nerves can
lead to neuropathic pain from neuromas, causalgia, or
phantom pain
210
Q
- True statements about trigeminal neuralgia and atypical
facial pain include the following: - Lancinating and Paroxysmal
- Associated with anesthetic patches
- The gasserian ganglion block relieves pain
- Unilateral
A
- Answer: D (4 Only)
Explanation: - Patients with trigeminal neuralgia, complain of
paroxysmal, lancinating pains.
- However, patients with atypical facial pain usually
complain of a constant, deep pain. - Progressive loss of sensation in the distribution of the
fi fth cranial nerve is seen with trigeminal neuralgia. - Gasserian ganglion block is treatment for trigeminal
neuralgia. - Atypical facial pain is often bilateral, but it may be
unilateral and fairly limited in its distribution.
- The cheek, nose, or zygomatic regions are often affected
by this idiopathic pain syndrome.
Source: Anschel 2004
211
Q
- A 68-year-old man has had severe, constant burning, and
aching in the right forehead and anterior scalp for six
weeks after an episode of herpes zoster. True statements
concerning this patient’s condition including: - It is more common in elderly patients
- The neuralgia involves supraorbital branches of the
ophthalmic division of the facial nerve - Tricyclic antidepressants often provide effective pain
relief - Opioid analgesics or the fi rst-line treatment
A
- Answer: A (1, 2, & 3)
212
Q
- Which of the following may be evident in more severe
cases of carpal tunnel syndrome? - Numbness with hand in the fl exed position
- Increased conduction velocity across the wrist crease
- Fibrillation potentials in the abductor pollicis brevis
- Atrophy of the hypothenar muscles
A
- Answer: A (1,2, & 3)
Explanation:
Conduction velocity is decreased, and involvement of the
hypothenar muscles does not occur (innervated by the
ulnar nerve).
213
Q
- The coracohumeral ligament serves as a principle
constraint to all of the following movements - Glenohumeral external rotation
- Glenohumeral fl exion
- Glenohumeral inferior translation with the arm at the
patient’s side - Glenohumeral abduction
A
- Answer: A (1, 2, & 3)
Source: Sizer Et Al - Pain Practice March & June 2003
214
Q
- True statements regarding quality of life interference with
CRPS include: - Insomnia
- unable to work or keep sustained activity
- Depression
- Hypoglycemia
A
- Answer: A (1, 2, & 3)
Source: Racz G. Board Review 2003
215
Q
- All of the following structures serve as components of the rotator cuff interval
- Coracohumeral ligament
- Subscapularis tendon
- Superior glenohumeral ligament
- Infraspinatus tendon
A
- Answer: A (1, 2, & 3)
Source: Sizer Et Al - Pain Practice March & June 2003
216
Q
661. Which of the following is directly useful for assessing pain levels in the chronic pain patient? 1. Visual analogue scale(s) (VAS) 2. Modifi ed McGill Pain Questionnaire 3. Physical examination 4. Beck’s Depression Inventory
A
- Answer: A (1, 2, & 3 )
Source: Giordano J, Board Review 2003
217
Q
- A patient presents with C7/T1 disc herniation. The expected findings are as follows:
- Weakness of fi nger fl exion
- Loss of sensation in lateral forearm and middle fi nger
- Loss of sensation in medial forearm, ring, and small
fi nger - Triceps refl ex suppression
A
- Answer: B (1 & 3)
Source: Hoppenfeld S. Orthopaedic Neurology. A
Diagnostic Guide to Neurologic Levels. Philadelphia,
LWW, 1997.
218
Q
- A young ataxic woman with a family history of Friedreich’s
disease develops polyuria and excessive thirst over the
course of a few weeks. She notices that she becomes
fatigued easily and has intermittent blurred vision. True
statements about the condition - The most likely explanation for her symptoms is Diabetes
mellitus. - The peripheral neuropathy that would be expected to
be seen with this patient develops in part because of
degeneration in Dorsal root ganglia. - This patient’s condition has been consistently linked to
a defect on Chromosome9. - If this patient has children, at Juvenile period stage of
life, they will be expected to become symptomatic if
they inherited Friedreich’s ataxia.
A
- Answer: E (All)
Explanation: - More than 10% patients with Friedreich’s disease
develop diabetes mellitus.
- A more life-threatening complication of this
degenerative disease is the disturbance of the cardiac
conduction system that often develops.
- Visual problems occur with the hyperglycemia - The peripheral neuropathy that would be expected to be
seen with this patient develops in part because of
degeneration in Dorsal root ganglia. - This patient’s condition has been consistently linked to a
defect on Chromosome 9. - If this patient has children, at Juvenile period stage of
life, they will be expected to become symptomatic if they
inherited Friedreich’s ataxia.
219
Q
- Endocrine and metabolic effects of burn injury include
the following: - Increased production of catecholamines
- Increased oxygen consumption and demand
- Decreased insulin levels
- Interleukin 2 depletion
A
- Answer: A (1, 2, & 3)
Source: Hansen HC, Board Review 2005 for Shah
220
Q
- Lumbosacral spondylosis is associated with which of the following?
- Facet arthritis
- Disc degeneration
- Ligamentous hypertrophy
- Vertebral ankylosis
A
- Answer: E (All)
Explanation:
Spondylosis may include all of these abnormalities
Source: Boswell MV, Board Review 2005
221
Q
- Migraine headaches typically:
- affect males more than females
- can be diagnosed by MRI
- are always associated with auras
- affect as many as 40 million patients
A
- Answer: D (4 Only)
Explanation:
Migraine headaches primarily affect females, can not be
diagnosed by MRI, and may not be associated with auras
(“common migraine”)
Source: Trescot AM, Board Review 2004
222
Q
- Diabetic peripheral neuropathy
- is one of the most common neuropathic pains
- affects the feet primarily
- is characterized by “die back”
- is sympathetically mediated
A
- Answer: E (All)
Explanation: - Diabetic peripheral neuropathy is the 2nd most
common neuropathy in the US behind LBP. - It primarily affects the feet and hands fi rst, and is not
common as a primarily facial pain. - It is commonly described as “die back” because of the
progressive advance cephalad. - Is sympathetically mediates.
Source: Trescot AM, Board Review 2004 for Shah
223
Q
- In a patient with 5 lumbar vertebrae and without prior
back surgery, which level(s) is/are most commonly
affl icted with spondylolisthesis - L4-5
- L2-3
- L5-S1
- T12-L1
A
- Answer: B (1 & 3)
Explanation:
L4-5 and L5-S1 are the most commonly involved levels in
the general population. Multiple etiologies can cause this but ultimately there is incompetence of the posterior
elements, ligaments, and disc.
Source: Shah R: 2003(Bonica, 3rd Ed., page 1522)
224
Q
- When comparing hemophilia A to hemophilia B, which
is true? - Only hemophilia A occurs almost exclusively in males
- Hemophilia A is associated with low factor IX level
- Chronic hemophiliac arthropathy is only associated
with A - Desmopressin is useful in hemophilia A
A
- Answer: D (4 only)
Explanation:
Hemophilia A and B are X-linked (hence, affecting almost
exclusively males), congenital bleeding disorders. Type A
is associated with low factor VIII levels. Type B is
associated with low or defi cient factor IX levels.
Hemophiliacs can develop hemorrhages that develop
hours or days after a trauma.Hemorrhage can occur in any
organ, but commonly affl ict weight bearing joints, soft
tissues, or muscles. Recurrent hemarthroses lead to
chronic joint arthritis or ankylosis. This can occur in type
A or B.
Primary therapy consists of factor replacement.
Desmopressin can be used in Hemophilia A. to boost
factor VIII levels.
Other pain therapy includes acetaminophen and opioids.
Opioids should not be given subcutaneously or
intramuscularly. Avoid NSAIDs due to their anti-platelet
effects. Non-invasive strategies such as biofeedback and
TENS should be explored.
Source: Shah RV, Board Review 2005
225
Q
- Which of the following is not true about rheumatoid
arthritis? - Initial age of presentation is over 55
- First-line therapy involves the use of tumor necrosis
factor-alpha inhibitors - Elevated rheumatoid factor levels are required for
diagnosis - Rheumatoid arthritis is typically progressive and leads
to worsening disability
A
- Answer: A (1,2, & 3)
Explanation: - Age of presentation varies from 30-50.
- Most patients have a destructive, progressive, and
disabling disease process. - Treatment goals of RA include:
- decrease infl ammation
- joint preservation
- preserve function
- resolve the pathologic process
Drug therapy includes:
- First line: Salicylates and NSAIDs (reduce pain and
swelling but do not interrupt the disease process)
- Second-line: Immunosuppressive or
immunomodulatory agents such as methotrexate,
cyclophosphamide, azathioprine, and newer TNF-alpha
inhibitors
- Third-line: Surgery - Diagnosis of RA requires 4 out of 7 of the following
criteria (note that all are weighted equally):
- Morning stiffness
- 3 or more joints are affected
- Hand joints are affected
- Symmetric arthritis
- Rheumatoid nodules
- Serum rheumatoid factor
- Radiographic changes
4.In some cases RA may be intermittent and rarely, there is
a remission.
Source: Shah RV, Board Review 2005
226
Q
671. Which of the following are associated with multiple sclerosis? 1. Trigeminal neuralgia 2. Peripheral neuropathy 3. Paroxysmal lancinating pain 4. Paresthesias with neck fl exion
A
- Answer: E (All)
Source: Boswell MV, Board Review 2005
227
Q
- Neuropathic pain treatment includes:
- antiepileptic drugs (AEDs)
- Opioids
- tricyclic antidepressants
- local anesthetics
A
- Answer: E (All)
Explanation:
All of the above are current treatments.
Source: Trescot AM, Board Review 2004 for Shah
228
Q
- Which of the following would support the diagnosis of
C5 nerve root compression? - Pain in the neck, shoulder, and lateral aspect of the
upper arm. - Pain in the neck, shoulder, and dorsal aspect of the
forearm. - Weakness of the deltoid, supraspinatus, infraspinatus,
biceps, and brachioradialis. - Numbness of thumb and index fi nger.
A
- Answer: B (1 & 3)
Explanation: - C5 nerve root compression is associated with pain in
the neck, shoulder, medial scapula, anterior chest, and
lateral aspect of the upper arm. - With C6 nerve root compression, pain is present in the
neck, shoulder, medial scapula, anterior chest, lateral
aspect of the upper arm, and also dorsal aspect of the
forearm. - With C5 nerve root compression, weakness of the
deltoid, supraspinatus, infraspinatus, biceps, and
brachioradials is observed with diminished biceps and
brachioradials refl exes. With C6 nerve root compression,
weakness of the biceps and extensor carpi radialis is
frequently observed with diminished or absent biceps
refl exes. - With C5 nerve root compression, numbness may be
observed in upper and lateral aspect of the shoulder. With
C6 nerve root compression numbness, numbness is
present in the thumb and index fi nger.
Source: Shah RV: 2003
229
Q
- Renal effects of a burn injury include:
- Decreased renal plasma fl ow
- Decreased free water clearance, sodium retention
- Decreased GFR
- Decreased myoglobin
A
- Answer: A (1,2, & 3)
Source: Hansen HC, Board Review 2005 for Shah
230
Q
- The genitofemoral neuralgia:
- causes pain in the rectum
- causes pain in the testicles or vagina
- can be mistaken for appendicitis
- the nerve runs along the psoas muscle
A
- Answer: C (2 & 4)
Explanation: - The GFN nerve innervates the testicles and vagina, not
the rectum. - The GFN nerve innervates the testicles and vagina, not
the rectum. - The ilioinguinal nerve can be mistaken for
appendicitis. - The GFN nerve runs along the psoas muscle.
Source: Trescot AM, Board Review 2004
231
Q
676.True statements regarding the cervical facet joint include:
1. Primarily innervated by C-type nociceptors.
2. Substance P has been isolated enhancing a nociception
at the joint
3. Chronic infl ammation at the joint may be contributory
of osteophytic production
4. The facet joint is a true synovial joint.
A
- Answer: E (All)
232
Q
- Which of the following is true regarding central nervous system pain?
- Spinal cord lesions are responsible for most central
pain states. - Wallenberg’s Syndrome is the most common vascular
cause of central nervous system pain. - Generally two types of central pain are noted: spontaneous
pain and hyperesthesia - The clinical features are similar whether the lesion is
located in the spinal cord, brainstem, or brain.
A
- Answer: E (All)
Explanation:
Ref: Manning, Loar, Raj, Hord. Chapter 10. Neuropathic
Pain. In: Pain Medicine: A Comprehensive Review, 2nd
Edition, Raj, Mosby. 2003, page 77.
Source: Day MR, Board Review 2003
233
Q
- The true statements regarding a spinal epidural abscess
include: - The most common symptom is back pain
- It commonly leads to radicular symptoms
- Symptoms may not occur for 1 to 2 weeks following a
medical procedure - Paraplegia can result
A
- Answer: E (All)
234
Q
- Which of the following is true regarding complex regional
pain syndrome (CRPS) - More common in males
- Most common cause is trauma secondary to accidental
injury - Triple phase bone scan alone is diagnostic of CRPS
- The mainstays of current therapeutic management are
sympathetic block and physical therapy
A
- Answer: C (2 & 4)
Explanation:
Ref: Manning, Loar, Raj, Hord. Chapter 10. Neuropathic
Pain. In: Pain Management: A Comprehensive Review, 3rd
Edition, Raj, Mosby, 2003. page 82-86.
235
Q
- In the diabetic patient, painful neuropathy occurs
- Due to loss of A-delta fi ber function
- Due to increase in A-delta fi ber function
- Due to hyper sensitization of C-fi bers
- Due to loss of C-fi ber function
A
- Answer: B (1 & 3)
Source: Giordano J, Board Review 2003
236
Q
- A 56 year old. Female patient is referred to your clinic
with a tentative previous diagnosis of polymyalgia
rheumatica. What would represent a sensible approach
to her evaluation for pain? - Addressing Immunologic parameters through the administration
of specifi c tests (eg.- ANA, SMA, RF) - Use of physical examination to assess painful areas and
articulation(s) - Use of pain scale(s) and pain diagrams
- Use of interrogative questioning to evaluate her personal
experience(s) of discomfort
A
- Answer: E (All)
Source: Giordano J, Board Review 2003
237
Q
- True statements about CRPS are as follows:
- CRPS Type II is like causalgia
- CRPS Type II is like hand shoulder syndrome
- CRPS Type I is like refl ex sympathetic dystrophy
- CRPS Type I is like neuralgia major and neuropraxia
A
- Answer: B (1 & 3)
Source: Racz G. Board Review 2003
238
Q
- Geniculate neuralgia is:
- Most often seen in middle aged patients
- Called the Ramsay Hunt syndrome when accompanied
by ipsilateral facial paralysis - less common than glossopharyngeal neuralgia
- Associated with ocular pain
A
- Answer: A (1, 2, & 3)
Explanation:
The geniculate ganglion is located in the roof of the
temporal bone. The nervus intermedius, which is a branch
of cranial nerve VII, has its cell bodies in the geniculate
ganglion.
It supplies sensory afferents to the tympanic membrane,
external auditory canal,skin in the area between the ear
andmastoid process, and some deep structures of the head
and neck. - Young to middle-aged adults are most commonly
affected. - Ramsay Hunt syndrome is geniculate neuralgia
associated with the occurrence of a herpes zoster-type
vesicular rash in the external ear and around the mastoid
area, often accompanied by ipsilateral fascial paralysis. - It is less common than glossopharyngeal neuralgia.
- Geniculate neuralgia is associated with ear pain and
neck pain – but, not ocular pain
239
Q
- Post-operative analgesia for the lower extremity may be treated effectively by:
- Epidural analgesia at the T4-8 level
- Patient controlled analgesia utilizing morphine with
the Basal and Bolus program - Ilioinguinal nerve block
- Epidural analgesia at the L2-L4 level
A
- Answer: C (2 & 4)
Source: Hansen HC, Board Review 2005 for Shah
240
Q
- The conditions causing coccygodynia include:
- Levator syndrome
- Arachnoiditis
- Pilonidal cyst
- Fracture of the L3 vertebral body
A
- Answer: A (1, 2, & 3)
Explanation:
Primary causes of coccygeal pain include sprained
ligaments, dislocation fracture, childbirth, osteoarthritis
of the coccygeal joints, and subluxation of the coccyx.
Metastases and external compression by a tumor mass
represent 2% of cases.
1, 2, 3. Referred pain may occur in patients with lumbar
disc disease, cauda equina syndrome, arachnoiditis, spinal
cord tumor, perirectal abscess or fi stula, pilonidal cyst,
pelvic infl ammatory disease or tumor, vaginismus, levator
syndrome, and psychoneurosis. - Fracture of L3 vertebral body is an unlikely source of
coccygodynia.
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
241
Q
- The ganglion of Impar:
- is associated with low back pain
- is a collection of sympathetic nerves
- causes pain down the leg
- often needs a specially bent needle to reach it.
A
- Answer: C (2 & 4)
Explanation:
The ganglion of Impar is the termination of the lumber
sympathetic chain. It is associated with pelvic and
coccygeal pain but not leg pain, and needs often specially
curved needles to reach the site.
Source: Trescot AM, Board Review 2004
242
Q
- What types of pain predominate in cord central pain?
- Spontaneous steady pain
- Evoked pain
- Spontaneous neuralgic pain
- Musculoskeletal pain
A
- Answer: B (1 & 3)
Source: Day MR, Board Review 2004
243
Q
- Factor(s) capable of inducing visceral pain is/are:
- Abnormal distension and contraction of hollow visceral
walls - Rapid stretching of the capsule of a solid visceral
organ - Ischemia of visceral musculature
- Cutting normal viscera
A
- Answer: A ( 1, 2, & 3)
Source: Day MR, Board Review 2004
244
Q
- Which of the following are components in the criteria for
establishing post-polio syndrome? - acute febrile illness during a polio epidemic
- residual, asymmetric muscle atrophy, weakness, and
arefl exia in at least one limb with normal sensation - musculoskeletal complaints
- recovery or functional stability for 15 years following
a polio illness
A
- Answer: E (All)
Explanation:
Acute polio starts with a non-specifi c viral syndrome,
during which time the virus replicates in the nasopharynx
and gut. A viremia develops and gives rise to sore throat,
headache, nausea, vomiting, and abdominal pain lasting a
few days. Patients may have signs that mimic meningitis.
Only 1-2% of cases develop a partial or complete paralytic
illness due to viral infection of the anterior horn cells. Up
to 50% of the anterior horn cells infected with the virus
undergo cell death, whereas the remainder are
dysfunctional.
Some patients recover, but may develop symptoms later.
This condition is thought to be post-polio syndrome. The
above criteria of post-polio syndrome were developed at
the NIH and should be met before a patient is classifi ed as
having post-polio syndrome.
Source: Shah RV, Board Review 2004
245
Q
690. Where are the cell bodies of visceral afferent nerves located? 1. Dorsal root ganglion of spinal nerves 2. Thoracic sympathetic ganglion 3. Ganglion of cranial nerves 4. Lumbar sympathetic ganglion
A
- Answer: B (1 & 3)
Source: Day MR, Board Review 2004
246
Q
- Glossopharyngeal neuralgia
- may be associated with bradycardia
- is associated with lancinating pain at the base of the
tongue, posterior pharynx, and tongue - microvascular decompression may be successful in
some cases - is an exclusively idiopathic neuropathic pain condition
A
- Answer: A (1,2, & 3)
Explanation:
(Shah, Pain Practice 2003; 3(3): 232-237)
Glossopharyngeal neuralgia may be idiopathic or
secondary to injury.It is associated with lancinating pain at
the base of the tongue, tonsillar fossae, posterior pharynx,
and ear. Microvascular decompression is the most
successful surgical procedure for the idiopathic variety, as
compared to other surgical techniques: neurectomy. Since the vagus nerve is intimately related to the
glossopharyngeal nerve, this syndrome may be associated
with bradycardia and hypotension. In fact, during
radiofrequency procedures,bradycardia is a potential
hazard
Source: Shah RV, Board Review 2004
247
Q
- True statements regarding sickle cell disease include: 1. Valine is substituted for glutamic acid in the sixth acid
of the beta chain of hemoglobin - With proper treatment, patients with homozygous
sickle cell disease have a normal life expectancy - Homozygous patients have all HbS, with a variable
amount of HbF (fetal globulin) - Splenectomy and hematinics have been shown to be
effective in prolonging life expectancy and decreasing
frequency of crises in patients with severe sickle cell
disease
A
- Answer: B (1 & 3)
Explanation:
Sickle cell disease is a chronic hemolytic anemia. It occurs
primarily in the black population because of genetic
transmission of a molecular lesion of hemoglobin.
- 0.15% of black children are homozygous for this trait
and manifest symptoms of sickle cell disease.
- Diagnosis of the disease is made by history, physical
examination, and blood electrophoresis. - Valine is substituted for glutamic acid at the sixth
position in the beta chain of hemoglobin.
- The sickle hemoglobin is fragile and thereby less able to
withstand the trauma of circulation, infection, and
dehydration. - Patients with sickle cell disease suffer from recurrent,
painful vaso-occlusive attacks, which may result in
progressive infarction of the liver, spleen, gallbladder, and
lungs.
- Complications associated with these crises lead to
shorter life expectancy. - Homozygotes have almost all HbS with a variable
amount of HbF (fetal hemoglobin). They have no HbA.
- Heterozygotes, patients with sickle cell trait, have more
HbA than HbS, and as such will not experience hemolysis,
painful crises, and thrombotic complications associated
with sickle cell disease. - Therapy consists of symptomatic treatment.
Splenectomy and hematinics are not helpful.
248
Q
- A woman in her sixties complains of recent onset of
unilateral temporal headaches. She has muscle and joint
aches without neck stiffness. She also complains of loss
of appetite, low-grade fever, and visual disturbances. The
most likely diagnosis is: - Migraine headaches
- Subarachnoid hemorrhage
- Venous thrombosis
- Giant cell arteritis
A
- Answer: D (4 Only)
Explanation:
The Diagnosis is Giant cell arteritis
The prevalence of giant cell arteritis (temporal arteritis)
increases after age 50 and occurs twice as often in women.
Patients complain of temporal headache of a constant,
boring quality, which may be relieved with aspirin.
They may also have symmetric arthralgias and myalgias,
general malaise, anorexia, low-grade fever, claudication of
jaw muscles, and visual loss due to ischemia of the optic
nerve and retina.
Facial and temporal artery pulsations may be absent. Blindness and stroke have occurred. Patients with giant
cell arteritis also have an increased ESR.
The diagnosis is confi rmed by temporal artery biopsy.
Treatment is with corticosteroids. In the presence of
intolerable side effects, azathioprine has been used with
some success. Patients should be on the lowest dose of
medication that will suppress the ESR, which should be
checked regularly. Rise in the ESR may indicate potential
relapse.
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
249
Q
- Which of the following is true about restless leg
syndrome? - The syndrome is rare and affl icts less than 0.5% of the
population - Uremia is strongly associated with this condition
- Leg movement is involuntary
- Patients often complain of a ‘creeping’ and ‘crawling’
sensation in their legs
A
- Answer: C (2 & 4)
Explanation: - Restless legs syndrome affl icts 2-10% of the population.
- Uremia, hyper and hypothyroidism, and diabetes are
associated with RLS.
- Additionally, CHF is associated with it also known as
Vesper’s curse (reduced cardiac compliance results in the
engorgement of epidural veins) - The motions are not involuntary, but rather the patient
describes an irresistible urge to move the legs. - Patients typically complain of unusual sensations in
their legs that can be described as ‘creeping’, ‘crawling’,
‘tingling’, and ‘itching’.
- The feeling is unlike that of the legs falling
asleep…rather the pain is deep.
Source: Shah RV, Board Review 2004
250
Q
695.True statements about painful polyneuropathies with
selective loss of large fi bres include the following:
1. Isoniazid neuropathy
2. Pellagra neuropathy
3. Hypothyroid neuropathy
4. Diabetic neuropathy
A
- Answer: A (1, 2, & 3)
Explanation:
1.Isoniazid neuropathy, pellagra neuropathy, and
hypothyroid neuropathy are all painful polyneuropathies
associated with the selective loss of neural fi bres of large
diameter. Isoniazid may cause distal numbness and
tingling followed by a deep ache or burning pain as the
myelinated fi bres are selectively damaged. Lower
extremity sensorimotor neuropathy and cutaneous
hyperesthesia may also be present.
2.Pellagra neuropathy is due to niacin defi ciency.
Sensorimotor neuropathy of the lower extremities with
painful feet, tender calf muscles, and cutaneous
hyperesthesia occurs.
3.Hypothyroid sensorimotor neuropathy is associated with
painful feet and paresthesias of the hands.
4.Diabetic neuropathy is associated with loss of small
fi bres.
251
Q
- The true statement about the pain condition(s) with the nerve block(s) include the following:
- arm pain - thoracic sympathetic block
- abdominal pain - ilioinguinal block
- abdominal pain - splanchnic block
- fractured rib - thoracic sympathetic block
A
- Answer: A ( 1, 2, & 3)
Source: Trescot AM, Board Review 2004
252
Q
- Which of the following can cause spinal stenosis?
- Short pedicles
- Spondylosis
- Disc protrusion
- Ligamentous hypertrophy
A
- Answer: E (All)
Source: Day MR, Board Review 2004
253
Q
698.True statements regarding deafferentation pain
syndromes include that they:
1. Are rarely successfully treated with narcotic agents
2. May manifest as burning, crushing, or tearing pain
3. Typically produce pain that is constant and unremitting
4. Seldom respond to neurosurgical intervention
A
- Answer: E (All)
Explanation: - Narcotic analgesics characteristically do not afford much
relief beyond their sedative and mood-altering effects. - Patients experiencing deafferentation pain commonly
complain of numbness, burning (causalgia, caustic pain),
coldness, or, in severe cases, crushing, tearing, or ripping
sensations. - Their pain is usually constant, unremitting, and
accompanied by prominent suffering. - Further destruction of neural tissue via neurosurgical
intervention rarely gives the patient lasting relief and may
result in an even more widespread deafferentation pain
state.
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
254
Q
- The differential diagnosis for intermittent claudication includes:
- Lumbar spinal stenosis
- Thromboangiitis obliterans
- Atherosclerotic obliterans
- Osteoarthritis of the hip
A
- Answer: E (All)
Source: Day MR, Board Review 2004
255
Q
700. Noninvasive technique/s to measure macro circulatory blood fl ow is/are: 1. Segmented pressure 2. Duplex scanning 3. Systolic toe pressures 4. Ankle-brachial indices
A
- Answer: E (All)
Source: Day MR, Board Review 2004
256
Q
- Thalamic pain syndrome
- was described by Dejerine and Roussy
- may follow a thalamic stroke
- a pain syndrome that develops on the hemiplegic side
- may be associated with hemiataxia and choreoathetoid
movements
A
- Answer: E (All)
Explanation:
(Raj, 3rd Edition, Practical Mgmt of Pain)
Dejerine Roussy described pain associated with a stroke,
specifi cally ‘thalamic’ pain syndrome following a thalamic
stroke. Their patients had mild hemiplegia, hemisensory
losss, astereognosis, hemiataxia, choreoathetoid
movements, and pain.
Source: Shah RV, Board Review 2004
257
Q
- Drugs associated with rebound headaches include:
- Butalbutal
- Caffeine
- Triptans
- Opioids
A
702. Answer: E (All) Explanation: All of these medicines can cause analgesic rebound headaches Source: Trescot AM, Board Review 2004
258
Q
703.What are the true statements regarding carpal tunnel
syndrome?
1. In Phalen’s test or Tinel’s sign, the median nerve is
easily depolarized when mechanically stimulated by
direct tapping over the palmaris longus tendon over
the fl exor retinaculum.
2. Positive fi ndings are present in over 90% of all cases.
3. Intercarpal pressure is greatest at 90° wrist fl exion superimposed
on ulnar deviation.
4. Pronator syndrome presents with identical symptoms
as carpal tunnel syndrome with similar fi ndings on the
nerve conduction studies.
A
- Answer: B (1 & 3)
Explanation:
Carpal tunnel syndrome is one of the most common, best
defi ned, and most carefully studied entrapment
neuropathies.
-It affects middle-aged females between 40 and 60 years of
age, that is menopausal women, a characteristic suggestive
of a hormonal aberration as a causative development of
this disorder.
-The most common cause of carpaltunnel syndrome is an idiopathic non-specifi c fl exor tenosynovitis that may
simply arise from chronic repetitive occupational stress,
both in males and females.
- Carpal tunnel syndrome may occur acutely after lunate
bone dislocation or from a Colles’ fracture and requires
immediate medical attention as to prevent acute nerve
ischemia.
Carpal tunnel syndrome may be subdivided into one of
the four categories.
- An increase in volume or tunnel content secondary to
non-specifi c tenosynovitis of the fl exor tendons within the
carpal tunnel
- Thickening or fi brosis of the transverse carpal ligament
- Alteration of the osseous modus of the carpus caused by
fractures, dislocations or arthritic joint changes
- Tumor or systemic disease
The median nerve has both sensory and motor branches.
During median nerve compression at the carpal tunnel
sensory, abnormalities usually occur fi rst only to progress
to motor involvement as the pathology evolves.
Clinical fi ndings are proportional to the degree of nerve
damage, which in turn is related to the severity of
compression and not to the duration of compression.
The differential diagnosis includes C6 radiculopathy with
refl ex changes and EMG studies showing denervation out
of the median nerve territory and sensory loss of the 6th
cervical dermatome. - Carpal tunnel is diagnosed with positive Phalen’s test
or Tinel’s sign where the median nerve is easily
depolarized when mechanically stimulated by direct
tapping over the palmaris longus tendon over the fl exor
retinaculum. - Positive fi ndings occur only in approximately 45% of
all cases. - Intercarpal pressure is greatest at 90° wrist fl exion
superimposed on ulnar deviation. - Pronator syndrome referring to compression of the
median nerve by pronator muscle as it passes through the
heads of that muscle and to a lesser extent,by fi brous
bands near the origin of deep fl exor muscles known as the
lacertus fi brosis and fl exor digitorum superfi cialis arcade,
and even less commonly by the ligament of Struthers, an
analomous structure found in about 1% of the population.
- Pronator syndrome may also be expressed with
expressed with median nerve paresthesias mimicking
those of CTS, it differs in several aspects. Night pain,
symptoms brought on by wrist movement, intrinsic
weakness of opponents and abduction movements, as well
as positive Phalen and Tinel wrist signs are not common
to this condition.
Source: Saidoff DC, McDonough AL. Critical Pathways in
Therapeutic Intervention. Extremities and Spine. St.
Louis,Inc., 2002
259
Q
704.True statements regarding spondylolysis and
spondylolisthesis include the following:
1. Spondylolysis defi nes anterior displacement of one
vertebra on another
2. Degenerative spondylolysis and spondylolisthesis occurs
due to long standing segmental instability with
remodeling of articular processes at affected level
3. MRI provides gold standard in evaluation of spondylosis
and spondylolisthesis
4. Bone scan with single-photon emission computed tomography (SPECT) is the gold standard
A
- Answer: C (2 & 4)
Explanation: - Spondylosis is fracture of the pars interarticularis.
- Spondylolisthesis is anterior displacement of one
vertebrae on another. - Plain fi lms and CT scan assist in the diagnosis.
- MRI may provide additional soft tissue information -
but not gold standard - Bone scan with single-photon emission computed
tomography is the gold standard.
Source: Cole & Herring. Low Back Pain Handbook.
260
Q
- Which of the following rarely result in central pain?
- Arteriovenous malformations
- Craniocerebral injury
- Infarction
- Craniotomy
A
- Answer: C (2 & 4)
Source: Day MR, Board Review 2004
261
Q
- Second order neurons that receive input from the viscera are located in which Rexed laminae?
- X
- V
- I
- II
A
- Answer: A ( 1, 2, & 3)
Source: Day MR, Board Review 2004
262
Q
- In which of the following would you suspect a potentially
serious cause of back pain? - elderly female that sustains minor trauma
- age >50 years old
- new onset urinary frequency
- progressive neurologic defi cit in lower extremity
A
- Answer: E (All)
Explanation:
There are several red fl ags for potentially serious
conditions causing acute low back pain. These include:
Major trauma such as motor vehicle accident
Minor trauma in an elderly or osteoporotic individual
Age >50 and
263
Q
- The severity of electrical burns is determined by which
of the following: - Duration of electrical contact
- Resistance of current at contact points, entry and exit
- Voltage
- Adipose insulation capacity
A
- Answer: A (1,2, & 3)
Source: Hansen HC, Board Review 2005 for Shah
264
Q
- Nerves of the anterior abdominal wall are entrapped by:
- the rectus abdominus muscle
- the external oblique muscle
- scar tissue
- Pfannenstiel incisions
A
- Answer: E (All)
Explanation:
All of these can entrap abdominal nerves.
Source: Trescot AM, Board Review 2004
265
Q
710. The pathophysiologic factors involved in neuropathic pain include 1. well-defi ned inhibitory mechanisms 2. poorly defi ned central pathways 3. well-defi ned nociceptive mechanisms 4. well-defi ned neurologic damage
A
- Answer: C (2 & 4)
Explanation:
Neuropathic pain is typically not biologically useful,
although the neurologic damage may be well defi ned. Its
nociceptive mechanisms, central pathways, and inhibitory
mechanisms are poorly defi ned. Pain is often appreciated
in a region of sensory defi cit.
Source: Kahn and Desio
266
Q
- Possible mechanisms for the production of neuropathic
pain include - malfunction of the “gate”
- generation of ectopic impulses by nerves
- “crosstalk” between large and small fi bers
- malfunction of central processing
A
- Answer: E (All)
Explanation:
There are four possible mechanisms for the production of
pain in peripheral nerve lesions, as proposed by Wall: - The “gate” might be closed to malfunction.
- The nerves might become mechanically sensitive and
generate ectopic impulses. - There might be “crosstalk” between large and small
fi bers. - There might be changes in the central processing.
Source: Kahn and Desio
267
Q
- Cortisol is responsible for:
- Gluconeogenesis
- Direct activation of insulin production
- Indirect action of glycolytic hormones and catecholamine
production - Interleukin 1 release
A
- Answer: B (1 & 3)
Source: Hansen HC, Board Review 2005 for Shah
268
Q
713.The benefi ts of continuous epidural analgesia after
traumatic incident to the chest wall includes:
1. Early post-injury extubation
2. Improved ventilator weaning capacity
3. Improved respiratory therapy efforts
4. Decreased potential for nosocomial chest wall infection
A
- Answer: A (1,2, & 3)
Source: Hansen HC, Board Review 2005 for Shah
269
Q
- Which of the following distinguishes Raynaud’s disease
from Raynaud’s phenomenon? - Raynaud’s disease is a progressive disorder that leads to irreversible digital gangrene requiring amputation
- Both manifest symptomatology whereby the digits
become white, blue, and then red-in this order - Only Raynaud’s phenomenon responds to a sympathetic
block - Raynaud’s disease is a primary idiopathic disorder
which can present bilaterally, whereas Raynaud’s
phenomenon is typically secondary to an underlying
disease process and unilateral
A
- Answer: C (2 & 4)
Explanation:
(Raj, Pain Review 2nd Ed., page 30)
Raynaud’s disease is a relatively common clinical problem
characterized by vasospasm of the microcirculation of the
fi ngers and is not due to any other pathologic process.
Raynaud’s phenomenon is usually secondary to an
underlying disease process, but the symptomatology is
similar. Raynaud’s phenomenon is typically unilateral and
the disease is typically bilateral. Both processes are
reversible when a sympathetic block is used or if patients
avoid the triggering stimulus, e.g., keeping the hands
warm. Although skin necrosis may develop, patients don’t
typically develop digital gangrene. The color changes may be found in both conditions: white-vasospasm, bluecyanosis,
red-reperfusion and vasodilatation.
Source: Shah RV, Board Review 2005
270
Q
- Neuralgic pain differs from nociceptive pain in that it
usually - has a delayed onset after a causative event
- less responsive to opioid administration
- has a dysesthetic component to it
- can be treated by proximal surgical interruption
A
- Answer: A (1, 2, & 3 )
Explanation:
Neural (neurogenic) pain differs from nociceptive pain in
several ways. Typically, its onset is delayed after a causative
event and it is often causalgic or dysesthetic in nature.
Neurogenic pain may respond to intravenous
administration of barbiturate-like drugs but less response
to opiates.
It is usually temporarily relieved by proximal local
anesthetic blockade but not permanently relieved by
surgical interruption at the same site.
Source: Kahn and Desio
271
Q
716. Which of the following are associated with migraine improvement in females? 1. Menses 2. First trimester of pregnancy 3. Use of birth control pills 4. Menopause
A
- Answer: C (2 & 4)
Explanation:
1 & 3. Menses and birth control pills may trigger or
worsen the intensity of headache.
2 & 4. Menopause and the fi rst trimester of pregnancy are
associated with headache improvement.
Source: Shah RV, Board Review 2005
272
Q
717. Which of the following are common with Parkinson’s Disease? 1. Pain 2. Rigidity 3. Tremors 4. Bradykinesias
A
- Answer: E (All)
Source: Boswell MV, Board Review 2005
273
Q
- Schizophrenic patients experiencing chronic painful
conditions pose signifi cant challenges for pain
practitioners because of which of the following? - Their complaints about pain are delusional and diffi
cult to assess. - They are overrepresented in chronic pain management
programs and require excessive amounts of time to
satisfactorily treat. - Current healthcare delivery models require that medical
conditions be treated separately from ongoing serious
mental disorders. - They appear to complain less about pain than patients
with other psychiatric disorders so often fail to receive
adequate medical evaluations.
A
- Answer: D (4 Only)
Source: Cole EB, Board Review 2003
274
Q
- Which of the following signs may be associated with T1
root compression - Weakness of the intrinsic muscles of the hand
- Subjective numbness in the ulnar aspect of the forearm
- Pain in the neck, medial scapula, and anterior chest
- Horner’s syndrome
A
- Answer: E (All)
Explanation:
Typical fi ndings in T1 root (i.e., T1/2 disc) compression
include pain in the neck, medial scapula,and anterior
chest;subjective numbness in the ulnar aspect of the
forearm; weakness of the intrinsic muscles of the hand;
and normal deep tendon refl exes. Occasionally, Horner’s
syndrome (miosis, anhidrosis, and ptosis) can be caused
by compression of the sympathetic nerves (Wall, p 745)
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
275
Q
- Diagnostic features of an epidural abscess include that it:
- Is most commonly caused by Staphylococcus epidermidis
- May present as severe back pain
- Will show normal myelographic fi ndings
- May present as local back tenderness
A
- Answer: C (2 & 4)
Explanation: - Staphylococcus aureus is the most common infecting
organism.
-Thus, antibiotic administration should include treatment
for a staphylococcal infection if positive cultures are not
available. - Epidural abscess generally presents with severe back
pain, local back tenderness, fever, and leukocytosis. - An abnormal myelogram with obstruction to flow of contrast medium is a common fi nding.
- Epidural abscess generally presents with severe back
pain, local back tenderness, fever, and leukocytosis.
276
Q
- True statements with regards to spinal stenosis causing
low back and lower extremity pain include the following: - Pathophysiology includes narrowing of the spinal canal
with disc, osseous thickening of bone, facet joints,
or spondylolisthesis - Narrowing of the spinal canal with thickening of the
ligamentum fl avum, association with DISH or Paget’s
disease - Venous congestion of the roots of the cauda equina
- Clinical defi nition of neurogenic claudication includes
pain relieved by standing or walking
A
- Answer: A (1, 2, & 3)
Explanation:
Spinal stenosis: narrowing of the spinal canal.
Neurogenic claudication: radiating pain or paresthesia into
buttocks and lower extremities. Pain exacerbated by
standing or walking
Pain relieved by lumbar fl exion
Radiologic evidence of spinal stenosis
Central stenosis defi ned by sagittal diameter of less than
11 mm
Lateral recess stenosis-lateral to the central canal with a
depth of less than 3 mm
Pathophysiology: narrowing of the spinal canal
Speculation of venous congestion of the roots of the cauda
equina
History: Slowly progressive increase in back and unilateral
and bilateral legs.
Symptoms are relieved by lumbar fl exion and/or sitting.
Increase in symptoms walking downhill due to increased
lumbar extension.
Shopping cart syndrome
Important to differentiate from peripheral vascular disease
by the need to have sit or bend forward to relieve
symptoms or the ability to tolerate cycling with neurogenic
claudication.
Physical Examination
Diffi cult to stand upright and knees are bent slightly
forward.
Loss of lumbar lordosis
Neurological examination may be normal but ankle jerks
may be absent
Straight leg raising is often normal. Look for
abnormalities of peripheral vascular system
Source: Low Back Pain Handbook.Cole & Herring. Low
Back Pain Handbook
277
Q
- Which of the following regarding phantom limb pain are true?
- Pain increases with time after amputation.
- The incidence of phantom pain is less than 10%.
- Pain is more common with distal amputations
- Phantom pain is not infl uenced by age or gender
A
- Answer: D (4 Only)
Explanation:
Phantom limb pain is a term used to describe painful
sensations that are perceived to originate in the amputated
portion of the extremity. In addition, patients may have
localized pain following the amputation that originates
from the stump itself. - Phantom limb pain has been reported to occur as early
as 1 week after amputation. Generally, the incidence
decreases with time. However, 60% of the amputees may
experience pain 6 months after amputation. In the fi rst
month following amputation, 85% to 97% of patients
experience phantom limb pain. One year after amputation,
approximately 60% of patients continue to have phantom
limb pain. Even though, phantom limb pain may begin
months to years after amputation, pain starting more than
1 year following amputation occurs in less than 10% of the
patients.
2.The incidence of phantom limb pain is higher than 10%.
Early literature reports the incidence of phantom limb
pain in amputees to be less than 10%. However, it is now
believed that this fi gure is artifi cially low because of the
reluctance of patients to report phantom limb pain. Large
studies have shown the incidence of phantom limb pain to
be 72% to 85%. - The incidence of phantom limb pain increases with
more proximal amputations. For example, it was reported
that phantom pain existed in 68% after hemipelvectomy,
40% after hip disarticulation, 19% after above knee
amputation, and 0% with below knee amputation. - Phantom limb pain is not infl uenced by age or gender.
There is no genetic predisposition toward phantom limb
pain, and there is no evidence that learned behavior
infl uences the incidence of it. Some studies suggest that it
may be less prevalent in the diabetic population. Further, a
predisposition to phantom limb pain has been shown in
patients of lower socioeconomic class and in those with
postoperative wound complications or frozen joints.
Reference: Hord and Shannon. Chapter 16. Phantom Pain.
In: Practical Management of Pain, 3rd Edition. Raj et al.
Mosby, 2000, page 212-213.
278
Q
- Rheumatoid arthritis would include all of the following:
- Joint space narrowing
- Soft tissue edema and swelling.
- Symmetrical presentation.
- Osteomyelitis.
A
- Answer: A (1, 2, & 3)
Source: Helms CA. Fundamentals of Skeletal Radiology.
W.B. Saunders Co., 1995; p. 120.
279
Q
- The true statements regarding endometriosis are as
follows: - Is commonly felt in the hypogastric region
- May be resolved with NSAIDs
- May result from a direct action on nerve endings
- May mimic acute appendicitis
A
- Answer: E (All)
Explanation:
Endometriosis can cause pain and tenderness by direct
action on nerve endings or by interfering with the
function of involved or adjacent organs. The pain is
characteristically worse a few days before menstruation
rather than during the early period of fl ow. Hypogastric
midcycle pain (mittelschmerz) in patients with
endometriosis can be severe for a few hours to days and
canmimic the pain of acute appendicitis.
280
Q
- Exteroceptive sensations include
- Temperature
- Vibration
- Touch
- distention
A
- Answer: B (1 & 3)
Explanation:
Exteroceptive sensations are those that arise from or
originate in sense organs in the skin or mucous
membranes and respond to external agents and changes in the environment. They may also be designated as
superfi cial sensations.
There are three major types: pain, temperature, and touch.
Source: Kahn and Desio
281
Q
- The pathology of neuropathic pain may be:
- axonal degeneration
- central sensitization
- segmental demyelination
- none of the above
A
- Answer: B (1 & 3)
Explanation:
Neuropathies may be classifi ed as axonal, segmental, or
mixed.
Source: Trescot AM, Board Review 2004 for Shah
282
Q
- At the site of injury, or at the level of tissue destruction,
pain providing infl ammatory processes is stimulated by: - Endocrine mediated responses
- Catecholamine response
- Infl ammatory mediators, bradykinin, platelet-activating
factor, prostaglandins - Elaboration of insulin, increasing the insulin to glucagon
ratio
A
- Answer: A (1,2, & 3)
Source: Hansen HC, Board Review 2005 for Shah
283
Q
- Dejerine and Roussy described which of the following
abnormalities in their patients with central pain? - Ataxia
- Asteriognosia
- Hemiplegia
- Paroxysmal pain
A
- Answer: E (All)
Source: Boswell MV, Board Review 2005
284
Q
- Treatment of pelvic pain may include:
- pudendal nerve blocks
- intercostal nerve block
- superior hypogastric block
- celiac plexus block
A
- Answer: B (1 & 3 )
Explanation:
Pudendal and superior hypogastric blocks treat pelvic
pain. Intercostal blocks treat thoracic pain, and celiac
plexus blocks treat upper abdominal pain.
Source: Trescot AM, Board Review 2004
285
Q
- Which of the following are true about tension-type
headache? - They are always bilateral
- They typically occur from 11pm to 3 am
- There is a male predominance
- Patients typically have a band-like tightness around
the scalp
A
- Answer: D (4 only)
Explanation:
(Raj, Pain Review, 2nd Ed., page 27)
The typical patient profi le of tension-type headache:
- Usually bilateral, but can be unilateral
- Possible bandlike, non-pulsatile ache or tightness in the
frontal, temporal, and occipital region
- Often has neck etiology…hence the associated term
cervicogenic headache
- Evolves over a period of hours to days and lingers; hence
unlike a migraine-which by defi nition is an intermittent
headache-tension headaches tend to be present all the time
until the exacerbating factors are removed. Exacerbating
factors include physical and psychological stress. TMJ and cervical spine disorders can also trigger a headache
- No aura
- Sleep disturbance is usually present
- Female predominance
- No hereditary pattern
Source: Shah RV, Board Review 2005
286
Q
731.Theories regarding the etiology of neuropathic pain
include:
1. Peripheral nerve injury resulting in neuromas
2. Glial scar formation secondary to CNS nerve injury
3. Spontaneous hyperactivity in the wide dynamic range
neuron after peripheral nerve injury
4. Sympathetic hyperdynamic state after an injury
A
- Answer: E (All)
Source: Trescot AM, Board Review 2004 for Shah
287
Q
- Which of the following neurologic abnormalities are
commonly seen in patients with central pain? - Loss of position sense
- Reduced light touch
- Diminished temperature sensation
- Complete numbness
A
- Answer: A (1, 2, & 3 )
Source: Boswell MV, Board Review 2005
288
Q
733. Several painful conditions have been described in patients with AIDS. These include: 1. Guillain-Barré syndrome 2. Postherpetic neuralgia 3. Encephalopathy 4. Predominant sensory neuropathy
A
- Answer: E (All)
Explanation:
Neurologic disease can be either a direct result of HIV
infection or a direct or indirect result of HIV
immunosuppression. Early clinical manifestations of HIV
encephalopathy include cognitive symptoms, behavioral
changes, and motor symptoms. Late manifestations
include frank dementia, seizures,and pyramidal tract signs.
Painful syndromes in patients with AIDS that involve the
peripheral nervous system include Guillain-Barré
syndrome, postherpetic neuralgia, and a predominant
sensory neuropathy (Raj)
289
Q
- Causes of scrotal pain include:
- Testicular cancer
- Epididymo-orchitis
- Testicular torsion
- Paraphimosis
A
- Answer: A (1, 2, & 3)
Explanation:
Scrotal pain or pain in the inguinal area is often associated
with pathology of the testicle or epididymis. A careful
history and physical examination should be performed to
rule out acute conditions such as testicular torsion,
infection of the epididymis or testicle, and fracture of a
portion of the testicle after trauma. Testicular cancer is
most common in men 20 to 40 years of age. Urinalysis
will provide information regarding infl ammatory or
infectious causes of pain. If examination of the testicle
reveals that it is elevated in the scrotum close to the
external inguinal ring, torsion exists and may be a surgical
emergency. If a portion of the testicle has been fractured in
a traumatic event, the painful necrotic portion of the
testicle may requirer excision and anastomosis of the
tunica albuginea to preserve function of the remaining
portion of the testicle. Early testicular cancer is usually
nonpainful, but it is frequently associated with
epididymitis. After appropriate treatment of the
infection/infl ammation, ultrasound and possibly a
testicular biopsy should be performed to rule out testicular
cancer. Paraphimosis is a condition in which the retracted
foreskin forms a constricting band at the base of the
glams. This may be associated with penile pain.
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review.
290
Q
- True statements in postmastectomy pain syndrome are
as follows: - The intercostobrachial nerve is rarely affected.
- Pain may be exacerbated by arm movement
- The patient complaints of tight, constricting, burning
pain in the mid back - Painful areas often include the posterior arm and
axilla
A
- Answer: C (2 & 4)
Explanation: - The intercostobrachial nerve is often affected.
- Pain may be exacerbated by arm movement.
3.The patient with postmastectomy pain may complain of
a tight, constricting, burning pain in the posterior arm,
axilla, and anterior chest wall, with the pain being
exacerbated by movement of the arm.
- Patients may respond to a combination of therapies,
including stellate ganglion blocks, thoracic epidural
blocks, transcutaneous electrical nerve stimulation
(TENS), anticonvulsants, and other medications used to
treat neuropathic pain. - Painful areas often include the posterior arm and axilla.
291
Q
- Cyclical pain:
- Usually indicates a gynecological etiology
- May be experienced during an exacerbation of a bowel
process during menstruation - May be associated with ovulation (Mittelschmerz)
- Is always of organic origin
A
- Answer: A (1, 2, & 3)
Source: Nader and Candido – Pain Practice. June 2001
292
Q
- An epidural abscess may be caused by:
- Staphylococcus aureus
- Pseudomonas species
- Gram-negative rods
- Streptococcal species
A
- Answer: E (All)
Explanation:
All the organisms listed have been known to cause
epidural abscess.
- Staphylococcus aureus is by far the most common.
293
Q
- The true statements regarding the occurrence of acute
herpes zoster (AHZ) in cancer patients include: - The location of the AHZ infection is not associated
with the site of the cancer - Patients with hematologic or lymphoproliferative cancer
have an increased incidence of AHZ - Patients receiving immunosuppressive therapies have
lower incidence of AHZ - AHZ occurs less frequently in nonirradiated areas than
in irradiated areas
A
- Answer: C (2 & 4)
Explanation: - The location of the cancer is associated with the site of
AHZ occurrence. - AHZ occurs more frequently in patients with
hematologic or lymphoproliferative cancers, and in those
patients who receive immunosuppressive therapies. - Patients with breast or lung cancer are more likely to
develop thoracic AHZ, those with head and neck cancer
tend to develop facial AHZ, and those with gynecologic or
urologic tumors frequently develop lumbar or sacral
AHZ. - AHZ also occurs most often in areas that have been
previously irradiated.
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.
