Chapter 3. Pain Pathophysiology Flashcards
1
Q
91. Common causes of acute abdominal pain in adults include (A) intussusception in an adolescent patient (B) abdominal aortic aneurysm in an adult population, which most likely presents with excruciating abdominal pain (C) diabetic ketoacidosis in an elderly patient without a previous history of diabetes (D) drug-induced pain from polypharmacy that is rarely a cause of abdominal pain in the elderly (E) interstitial cystitis
A
- (C) Diabetic ketoacidosis needs to be ruled out (in
addition to myocardial infarction, pneumonia,
pyelonephritis, and inflammatory bowel disease)
as a cause of abdominal pain. The most common
cause of abdominal pain in infants is intussusception.
Although abdominal aortic aneurysms,
which are a manifestation of atherosclerosis, do
occur in an adult population, they usually do not
present with specific clinical symptom of abdominal
pain. Finally, drug-related abdominal pain is
very common in the elderly
2
Q
- A 35-year-old woman has right arm pain.
Which of the following statements regarding
her pain is true?
(A) It is more likely she will have arterial thoracic outlet syndrome than neurogenic thoracic outlet syndrome
(B) If it began in the ulnar nerve distribution after an injury to the ulnar nerve, she may have complex regional pain
syndrome (CRPS) type I
(C) If she also has pain radiating into her occiput, she may have involvement of the sensory portion of the C1 nerve
(D) If she has clawing of the small finger, the median nerve is likely involved
(E) The ulnar nerve is commonly compressed at the cubital tunnel
A
- (E)
A. The majority of cases of thoracic outlet
syndrome are categorized as neurogenic
thoracic outlet syndrome.
B. CRPS type II is when an identifiable neural
injury is present.
C. The first cervical nerve does not have a
sensory branch.
D. Ulnar neuropathy often has clawing of the
small finger.
3
Q
- You suspect a patient is having cluster headaches.
The most convincing evidence of this type of
headache would be if
(A) the patient is female
(B) although it is worse on the right side of the head, the symptoms are usually bilateral
(C) the headaches are occurring at the same time each night
(D) the patient is having a rebound headache due to excessive use of medication and the most likely underlying recurring headache is a cluster headache
(E) the patient is urinating frequently and
has blurry vision
A
- (C)
A. Cluster headaches occur predominantly in
males.
B. Cluster headaches occur unilaterally and
are accompanied by lacrimation, nasal congestion,
conjunctival injection, and ptosis.
Patients tend to get clusters of headaches
occurring the same time daily (often at night).
C. Patients tend to get cluster headaches the
same time daily (often at night).
D. Patients with rebound headaches are often
overmedicating an underlying migraine
headache.
E. Patients with cluster headache do not routinely
experience polyuria or changes in
visual acuity.
4
Q
- Which of the following statements about migraine
headache is true?
(A) Recent evidence has supported the notion that cortical spreading depression is the mechanism of migraine headache
(B) Activation of cortical spreading depression
has become an interesting target for preventive migraine treatment
(C) Current evidence shows a clear causal relationship between cardiac right-toleft shunt (RLS) and migraine headaches
(D) Migraine pathophysiology involves the trigeminovascular system but not central nervous system (CNS) modulation of the pain-producing structures of the
cranium
(E) More than 90% of migraineurs have auras
A
- (A)
A. The recent discovery of multiple point
mutations in familial hemiplegic migraine
has led to the suggestion that migraine and
its variants may be caused by a paroxysmal
disturbance in ion-translocating mechanisms.
Mutations associated with familial
hemiplegic migraine render the brain more
susceptible to prolonged cortical spreading
depression caused by either excessive synaptic
glutamate release or decreased removal of
glutamate and potassium from the synaptic
cleft, or persistent sodium influx.
B. Suppression of cortical spreading depression
has become an interesting target for
preventive migraine treatment. Prolonged
treatment with β-blockers, valproate, topiramate,
methysergide, or amitriptyline
reduced the number of potassium-evoked
cortical spreading depressions and elevated
the electrical stimulation threshold for
the induction of cortical spreading depression
in rats. Recent imaging studies in
patients suffering from migraine without
aura also points to the presence of silent
cortical spreading depression as an underlying
mechanism. Repeated waves of
cortical spreading depression may have
deleterious effects on brain function, and
perhaps cause silent ischemic lesions in
vulnerable brain regions such as the cerebellum
in susceptible individuals.
C. There is an association between RLS and
migraine. The relationship between RLS
and migraine is further supported by the
disappearance and improvement of migraine
symptoms after closure of the foramen ovale.
Nonetheless, the mechanism as well as the
question about causality of this association
has to be further elucidated.
D. Migraine pathophysiology has been
demonstrated to involve the trigeminovascular
system and CNS modulation of the
pain-producing structures of the cranium.
5
Q
- A patient you are seeing recently began experiencing
low-back pain. You suspect zygapophysial
joint arthropathy as the primary cause of the
symptoms. Which of the following can be said
about this disease process?
(A) Predisposing factors include spondylolisthesis
and old age; however, degenerative
disc pathology is not a risk factor
(B) The key to diagnosing zygapophysial
joint arthropathy is the historic and
physical examination
(C) An accepted method for diagnosing
pain arising from the lumbar facet joints
is with low-volume intra-articular or
medial branch blocks because of the low
false-positive rate
(D) Cadaveric studies of the facet joints in
patients with suspected arthropathy
have revealed histologic changes
(E) Its clinical presentation is characterized
as a radicular pattern
A
- (D)
A. The onset of lumbar facet joint pain is usually
insidious, with predisposing factors
including spondylolisthesis, degenerative
disc pathology, and old age.
B. The existing literature does not support the
use of historic or physical examination findings
to diagnose lumbar zygapophysial
joint pain.
C. The most accepted method for diagnosing
pain arising from the lumbar facet joints is
with low-volume intra-articular or medial
branch blocks, both of which are associated
with high false-positive rates.
D. Histologic studies of the facet joints in
patients with suspected arthropathy have
revealed pathology.
6
Q
- Which of the following statements regarding
postmastectomy neuromas is true?
(A) In general, neuromas are palpable
(B) Neuromas form with mastectomy but
usually not with lumpectomy
(C) Neuromas are most likely the cause of a
painful scar
(D) Resection should not be considered for
an intercostal neuroma
(E) None of the above
A
- (C)
A. Neuromas can form whenever peripheral
nerves are severed or injured. Macroneuromas
consist of a palpable mass of
tangled axons unable to regenerate to their
target, fibroblasts, and other cells, whereas
microneuromas contain small numbers of
axons and may not be palpable.
B. Both mastectomy and lumpectomy leave a
scar in which neuromas can form. Chronically
painful scars can develop after mastectomy
and lumpectomy, and abnormal
neuronal activity originating in neuromas
or entrapped axons within this scar tissue
is the likely mechanism of such pain.
Neuroma pain may be more common following
lumpectomy than mastectomy.
C. Axons entrapped within these scars
can cause spontaneous pain and severe
mechanosensitivity.
D. Anecdotal reports suggest that resection of
intercostal neuromas may alleviate chronic
pain after breast cancer surgery.
7
Q
- You suspect nerve root impingement in the cervical
spine. Which of the following physical
findings would support this diagnosis?
(A) You suspect C1 nerve root involvement and the patient has numbness over the occiput
(B) You suspect C6 nerve root involvement and the patient has loss of the biceps reflex
(C) You suspect C7 nerve root involvement and the patient has loss of strength in the deltoid
(D) Carpal tunnel syndrome (CTS) would
be excluded by a normal examination of
the abductor pollicis brevis (APB)
(E) You suspect C8 nerve root involvement
and the patient has numbness in the lateral
aspect of the forearm
A
- (B)
A. The C1 nerve root has no sensory component.
B. C6 radiculopathy can be accompanied by
a loss of bicep reflex.
C. With C7 nerve roots, paresis affects the finger
and wrist flexors and extensors. The triceps
reflex is also innervated by the C7
nerve root; the deltoid is innervated by C5,
C6 nerve roots.
D. Although the median nerve (which is affected
in CTS) innervates the APB as well as the
opponens pollicis, a normal motor examination
does not exclude the possibility of CTS.
8
Q
98. Which is the following statements regarding neck pain is true? (A) Peer reviewed literature suggests that there may be short-term benefit derived from treatment with acupuncture (B) Neck pain following an acceleration/deceleration injury most commonly involves the lower cervical spine (C) If you suspect an acute cervical disc herniation, it is important to ask about bowel and bladder incontinence because of the risk of cauda equina syndrome (D) A patient with neck pain alone may meet the criteria for fibromyalgia (E) CTS cannot have associated neck pain
A
- (A)
A. Peer-reviewed literature suggests that
acupuncture is effective in the short-term
management of low-back pain, neck pain,
and osteoarthritis involving the knee.
However, the literature also suggests that
short-term treatment with acupuncture
does not result in long-term benefits. Data
regarding the efficacy of acupuncture for
dental pain, colonoscopy pain, and intraoperative
analgesia are inconclusive. Studies
describing the use of acupuncture during
labor suggest that it may be useful during
the early stages, but not throughout the
course of labor. Finally, the effects of
acupuncture on postoperative pain are
inconclusive and are dependent on the timing
of the intervention and the patient’s
level of consciousness.
B. Upper cervical pain is most common with
involvement of the suboccipital area as
well as the C2-3 dermatomes.
C. In cauda equina syndrome, there is acute
loss of function of the neurologic elements
below the termination of the spinal cord.
This occurs at the level of the lumbar spine.
D. In 1990, the American College of Rheumatology
(ACR) established criteria for classifying
patients with fibromyalgia which
consists of tenderness in 11 of 18 standardized
tender points. Only six to eight are located
in the neck and associated structures.
E. CTS can have associated neck pain.
9
Q
- Which of the following statements regarding
fibromyalgia is true?
(A) Two central criteria for fibromyalgia are
chronic widespread pain (CWP) defined
as pain in all four quadrants of the body
and the axial skeleton for at least
2 years, and the finding of pain by 25-kg
pressure on digital palpation of at least
11 of the 18 defined tender points
(B) It is generally agreed that abnormal
CNS mechanisms are responsible for all
of the symptoms of fibromyalgia
(C) There are both primary and secondary
fibromyalgia syndromes
(D) Fibromyalgia symptoms generally
resolve if a rheumatic process is identified
and treated appropriately
(E) Most of fibromyalgia patients are male
A
- (C)
A. The two operational criteria are chronic
widespread pain (CWP) defined as pain in
all four quadrants of the body and the axial
skeleton for at least 3 months, and the finding
of pain by 4-kg pressure on digital palpation
of at least 11 of 18 defined tender
points.
B. The exact pathogenesis of fibromyalgia has
not been cleared up yet, but according to
the currently held view a variety of biological,
psychological, and social factors play a
role in the manifestation of the disorder.
Among other things, inflammatory, traumatic,
and immunological processes; static
problems; endocrine disorders; and depressions,
anxiety conditions, and stress factors
are thought to trigger the syndrome. Adysfunction
of the central affective and/or
sensory pain memory may possibly be at
work in the different illnesses mentioned
above, which then results in fibromyalgia
pain.
C. In principle, fibromyalgia can be categorized
as primary or secondary fibromyalgia. In
primary fibromyalgia, which is much more
common than the secondary type, even the
most careful work-up will not reveal any
definitive organic factor triggering the syndrome.
With secondary fibromyalgia, on the
other hand, the underlying disease, such as
inflammatory rheumatic processes or collagenosis
can be diagnosed with relative
ease.
D. Symptoms associated with fibromyalgia
often do not disappear when the rheumatic
processes have subsided, suggesting that
some central mechanisms may be responsible
for the persistence of generalized pain
and hyperalgesia, possibly due to a disorder
of the central affective pain memory
and/or the memory of sensory pain or else
to latent peripheral immunological processes.
It is precisely this coexistence of pain and
hyperalgesia in secondary fibromyalgia
associated with systemic inflammatory
rheumatic diseases, which proves that pain
and sensitivity to pain cannot be separated
strictly in fibromyalgia.
10
Q
- Which of the following statements regarding
endometriosis is true?
(A) The etiology is unclear but it has recently
been demonstrated that retrograde
menstruation is most likely not the
cause
(B) Oral contraceptives tend to exacerbate pain symptoms
(C) The “gold standard” diagnosis of the disease remains magnetic resonance imaging (MRI) of the abdomen
(D) If endometriosis is diagnosed at the time of laparoscopy, laparoscopic surgery should be the first choice of treatment
(E) Endometriosis pain does not follow menstrual cycle
A
- (D)
A. Endometriosis is the presence of endometrial
glands and stroma outside the endometrial
cavity and is a common cause of pelvic
pain. The etiology is unknown, although
the theory of retrograde menstruation is the
prevailing theory.
B. Oral contraceptives, androgenic agents,
progestins, and gonadotropin-releasing
hormone (GnRH) analogs have all been
used successfully in treating the symptoms
of endometriosis.
C. The “gold standard” of diagnosis is
laparoscopy with direct visualization.
D. If endometriosis is diagnosed at the time of
laparoscopy, laparoscopic surgery should
be the first choice of treatment, especially
in women of reproductive age with an
endometrioma.
11
Q
- A 28-year-old female enters your clinic with
upper extremity symptoms. You suspect thoracic
outlet syndrome because
(A) she fractured her clavicle and developed
symptoms afterward
(B) she has had sensory symptoms along
her lateral forearm for some time
(C) radiographs confirm she does not have
cervical ribs
(D) she has symptoms consistent with a
chronic upper trunk brachial plexopathy
(E) all of the above
A
- (A)
A. The most frequently fractured bone in the
body is the clavicle and the most common
cause is a fall or blow on the point of the
shoulder. In most instances, clavicular fractures
do not involve nearby structures, and
their healing is uneventful, except for possibly
some residual deformity. Occasionally,
however, the blood vessels and the brachial
plexus elements situated between the midportion
of the clavicle and the first thoracic
rib are injured secondarily. This generally
occurs in adults, most often following
midshaft displaced fractures. This type of
neurovascular injury often is referred to as
traumatic TOS.
B. The majority of patients report having had
sensory disturbances for long periods
before that point. The earliest and most common symptoms are intermittent aching
or paresthesias along the medial arm and
forearm, sometimes extending into the
medial hand and fingers. Hand cramping
with use sometimes appears later in the
course. Although these symptoms, particularly
the intermittent aching, may be present
for years, they rarely are bothersome
enough to cause the patient to seek medical
care.
C. Plain cervical spine radiographs are important
for diagnosis of thoracic outlet syndrome.
Typically, a rudimentary cervical
rib or an elongated C7 transverse process is
found ipsilateral to the affected limb.
Cervical ribs frequently are present bilaterally,
and often the one on the contralateral,
uninvolved, side is larger. This is inconsequential,
however, because the cervical ribs
themselves do not compromise the proximal
lower trunk axons; instead, it is a radiolucent
band extending from the tip of the
rudimentary cervical rib to the first thoracic
rib that does so. In some patients, cervical
ribs are difficult to visualize unless special
radiograph views are used.
D. This rare disorder manifests as a very
chronic lower trunk brachial plexopathy,
most commonly caused by congenital
anomalies.
12
Q
- A 55-year-old homeless woman presents to the
emergency room (ER) by ambulance in an
unconscious state. The emergency medical technician
(EMT) reports discovering the patient
while she was experiencing a grand mal seizure.
She has no identifying information and is unaccompanied
in the ER. An examination of the
woman reveals that she has bilateral mastectomies.
When the patient wakes up, she reports
having severe pain in her ribs and along her
spinal column that is getting progressively
worse. Which of the following statements is true?
(A) Bisphosphonates not only can treat the
bony metastases of breast cancer but can
reverse osteonecrosis of the jaw often
seen in this type of cancer
(B) A large number of patients with breast
cancer have osteolytic metastatic disease
involving the bony skeleton
(C) Placebo-controlled trials with oral or
intravenous (IV) bisphosphonates have
shown that prolonged administration
can reduce the frequency of skeletonrelated
events by 80%
(D) Hypercalcemia is the most frequent
symptom of bone metastases
(E) This patient’s most significant issue is
most likely opiate dependence
A
- (B)
A. Bisphosphonates are effective for the management
of hypercalcemia of malignancy
and bone metastases. This group of drugs
has improved the quality of life in many
patients with proven efficacy in limiting pain
and skeleton-related events. Osteonecrosis of
the jaws is a recognized complication of bisphosphonate
therapy.
B. In some studies, up to 75% of patients with
breast cancer will have metastatic disease.
The bony skeleton is frequently involved.
On radiologic examination, these metastases
are predominantly osteolytic.
C. Placebo-controlled trials with oral or IV bisphosphonates
have shown that prolonged
administration can reduce the frequency of
skeleton-related events by 30% to 40%.
D. Pain is the most frequent symptom of
bone metastases and can significantly alter
the quality of life of cancer patients.
Hypercalcemia classically occurs in 10% to
15% of the cases.
E. This patient likely has a history of breast
cancer and now may have diffuse metastases
in both her brain and skeletal system.
She requires a detailed evaluation.
13
Q
- Which of the following statements is true
regarding arthritis?
(A) The biologic precursor to gout is elevated
serum glutamic acid levels
(B) In psoriatic arthritis the distal interphalangeal
joints are regularly involved
(C) The onset of polyarthritis in rheumatoid
arthritis (RA) is usually rapidly progressive
and initially affects the small joints
of the hands and feet
(D) Inflammatory markers such as the erythrocyte
sedimentation rate (ESR) or
C-reactive protein (CRP) are abnormal
in about 95% of patients with early RA
(E) None of the above
A
- (B)
A. The biologic precursor to gout is elevated
serum uric acid levels (ie, hyperuricemia).
B. In psoriatic arthritis, the distal interphalangeal
joints are regularly involved. The
disease can also focus on the larger joints
of the lower extremities.
C. The onset of polyarthritis in RA is insidious
in about three-quarters of patients and
initially affects the small joints of the hands
and feet (metacarpophalangeal, proximal
interphalangeal and metatarsophalangeal
joints) before spreading to the larger joints.
D. Inflammatory markers such as the ESR or
CRP are normal in about 60% of patients
with early RA.
14
Q
- Apatient enters your office complaining of leg
pain after having a sural nerve biopsy. Which of
the following statements is true about this type
of complex regional pain syndrome (CRPS)?
(A) Increased tremor has been documented
in the context of this type of CRPS
(B) This is most likely CRPS type I
(C) This type of CRPS has been described to
occur after stroke
(D) The CNS does not appear to be involved
in the pathophysiology of CRPS
(E) All of the above
A
- (A) This is most likely a case of CRPS type II.
A. CRPS is a painful disorder that develops as a
disproportionate consequence of traumas.
These disorders are most common in the
limbs and are characterized by pain (spontaneous
pain, hyperalgesia, allodynia); active
and passive movement disorders (including
an increased physiological tremor); abnormal
regulation of blood flow and sweating;
edema of skin and subcutaneous tissues;
and trophic changes of skin, organs of the
skin, and subcutaneous tissues.
B. CRPS type I (previously known as reflex
sympathetic dystrophy) typically develops
after minor trauma with no obvious or
a small nerve lesion (eg, bone fracture,
sprains, bruises, skin lesions, or surgery).
C. CRPS type I can also develop after remote
trauma in the visceral domain or even
after a CNS lesion (eg, stroke). Important
features of CRPS type I are that the severity of symptoms is disproportionate to the
severity of trauma and pain has a tendency
to spread distally in the affected limb. The
symptoms are not confined to the innervation
zone of an individual nerve. Thus, all
symptoms of CRPS type I may be present
irrespective of the type of the preceding
lesion.
D. Research is beginning to uncover that the
CNS is actively involved in CRPS pathophysiology.
Nerve cells, microglia, and
astrocytes all may be involved.
15
Q
- Which of the following statements is true regarding
pain in the context of human immunodeficiency
virus (HIV)/acquired immunodeficiency
syndrome (AIDS)?
(A) Distal symmetrical polyneuropathy is
the most common peripheral nerve disorder
associated with HIV
(B) Headache is the second most common
of the AIDS-related pain syndromes
(C) Progressive polyradiculopathy is most
commonly associated with herpes virus
(D) Kaposi sarcoma has been shown to
cause muscular pain but not bone pain
(E) None of the above
A
- (A)
A. Distal symmetrical polyneuropathy is the
most common peripheral nerve disorder
associated with HIV.
B. Headache is the most common of the
AIDS-related pain syndromes. Common
causes include cerebral toxoplasmosis.
C. Progressive polyradiculopathy is most commonly
associated with cytomegalovirus
infection. Symptoms include flaccid paralysis
and pain with sensory disturbance.
D. Kaposi’s sarcoma can cause both muscular
and bone pain through infiltration.
16
Q
- Which of the following statements about central
pain is correct?
(A) Central pain occurs with stroke and
spinal cord injury (SCI) but not with
multiple sclerosis
(B) In syringomyelia, central pain is often
the first symptom of the disease
(C) The pathophysiology of pain associated
with SCI has yet to be completely elucidated,
but supraspinal pathways, not
spinal pathways, are most likely
involved
(D) After injury to the CNS, it is the denervated
synaptic sites that serve an
inhibitory role preventing the development
of central pain
(E) All of the above
A
(B)
A. Central pain affects people with strokes,
spinal cord injuries, and multiple sclerosis.
It can also occur after neurosurgical procedures
on the brain and spine. The mechanism
is thought to be because of disruption
of spinothalamocortical transmission.
B. Pain may occur with syringomyelia, and it
may precede any other sign of the disease
by many years.
C. The pathophysiology of SCI has yet to be
completely elucidated, but both spinal and
supraspinal pathways may be involved.
D. Partial or total interruption of afferent
fibers results in the degeneration of presynaptic
terminals and an alteration in function
and structure. Denervated synaptic sites
may be reinnervated by other axons and
previously ineffective synapses may become
active (unmasking). Excitation spreads to
neighboring areas and supersensitivity
occurs, producing an abnormal firing pattern
that may depend on stimulation or
may occur spontaneously. This sequence of
events explains many of the symptoms of
central pain, including dysesthesia (abnormal
firing pattern), spontaneous shooting
pain (paroxysmal burst discharges),
evoked pain from nonpainful stimuli, diffusion
of the evoked abnormal sensation,
and the long-term failure of neurosurgical
treatment.
17
Q
- A 35-year-old female with chronic low-back
pain comes to see you in your office for the
first time. You immediately notice her unusual
affect and behavior. Which of the following
statements is true?
(A) Patients with somatization disorder,
hypochondriasis, factitious physical disorders,
and malingering may have pain
complaints as part of their illness
(B) Malingerers, by definition, are not consciously
aware of their motivation
(C) Other psychiatric disorders, such as
depression, anxiety, and panic attacks,
may strongly influence chronic pain
without directly causing it; posttraumatic
stress disorders do not usually impact a
pain complaint
(D) One of the main differences between
pain associated with malingering and
pain associated with anxiety is that in
malingering, complaints or symptoms
go beyond what should be expected
from a specific disease process
(E) None of the above
A
- (A)
A. Common psychiatric conditions that often
feature pain as part of the illness are somatization
disorder, hypochondriasis, factitious
physical disorders, and malingering.
B. One of the ways to distinguish between
these condition is whether there is conscious
awareness (or lack of awareness) of
both motivation and symptom production.
Malingerers have a conscious awareness
and motivation for a pain complaint.
C. Other psychiatric disorders may strongly
influence chronic pain without directly
causing it—depression, anxiety, panic, and
posttraumatic stress disorders.
D. Chronic pain complaints often reflect or are
influenced by psychiatric factors. Physicians
commonly encounter “illness-affirming
behaviors” in which patient complaints or
symptoms go beyond what should be
expected from a specific disease process.
This is true of both anxiety and malingering.
18
Q
- Apatient is referred to you by a dentist friend.
This patient is having pain in and around her
mouth on one side. Which of the following
statements is true?
(A) Primary burning mouth syndrome is a
chronic, idiopathic intraoral pain condition
that is not accompanied by clinical
lesions; some consider it a painful
neuropathy
(B) Increasing evidence suggests that very
few cases of trigeminal neuralgia that
are classified as idiopathic are caused by
compression of the trigeminal nerve by
an aberrant loop of artery or vein
(C) About 40% of patients with multiple
sclerosis develop trigeminal neuralgia
(D) Trigeminal neuralgia can occasionally be
present over the occiput
(E) All of the above
A
- (A)
A. Primary burning mouth syndrome is a
chronic, idiopathic intraoral pain condition
that is not accompanied by clinical lesions
but some consider it a painful neuropathy.
The symptoms are often described as continuous,
spontaneous, and often intense
burning sensation in the mouth or tongue.
B. Increasing evidence suggests that 80% to
90% of cases that are technically still classified
as idiopathic are caused by compression
of the trigeminal nerve close to its exit from
the brainstem by an aberrant loop of artery
or vein.
C. Less than 10% of patients will have symptomatic
disease associated with an identifiable
cause other than a vascularcompressive
lesion—usually a benign tumor or cyst—or
multiple sclerosis. About 1% to 5% of
patients with multiple sclerosis develop
trigeminal neuralgia.
D. Trigeminal neuralgia, by definition, has to
be in the distribution of the trigeminal
nerve (not the distribution occipital nerve).
Trigeminal neuralgia is defined as paroxysmal
attacks of pain lasting from a fraction of
a second to 2 minutes that affect one ormore
divisions of the trigeminal nerve. Diagnostic
criteria for classic trigeminal neuralgia:
• Pain has at least one of these characteristics:
intense, sharp, superficial, or stabbing precipitated
from trigger areas or by trigger factors.
• Attacks are similar in individual patients.
• No neurological deficit is clinically evident.
• Not attributed to another disorder.
19
Q
- A patient is referred to you with facial pain.
Which of the following statements is true?
(A) The pain of glossopharyngeal neuralgia
is very similar to that of trigeminal neuralgia
but affects anterior two-thirds of
the tongue, tonsils, and pharynx
(B) Giant cell arteritis is a vasculitic condition
that can lead to visual loss but has
never been reported in a case of stroke
(C) Cervical carotid artery dissection most
commonly presents with neck, head, or
facial pain
(D) Pure facial pain is rarely associated with
sinusitis alone
(E) None of the above
A
- (C)
A. The pain of glossopharyngeal neuralgia is
very similar to that of trigeminal neuralgia
but affects posterior-third of the tongue,
tonsils, and pharynx.
B. Giant cell arteritis is a common systemic
vasculitis in the elderly. It is commonly
associated with visual loss and strokes, so it
must be diagnosed and treated aggressively.
Temporal artery biopsy is the gold standard
in the diagnosis of giant cell arteritis.
Steroids are a common mode of treatment.
C. Cervical carotid artery dissection most
commonly present with head, facial, or
neck pain. Other commonly seen symptoms
include Horner syndrome, pulsatile
tinnitus, and cranial nerve palsy.
D. Pure facial pain is most often caused by
sinusitis and the chewing apparatus, but
also a multitude of other causes.
20
Q
- A 47-year-old woman comes into the ER complaining
of a vague sense of nausea and heart
palpitations. She has a history of chronic refractory
angina. Which of the following statements
regarding chest pain is false?
(A) In acute coronary syndrome men are
more likely to present with chest pain,
left arm pain, or diaphoresis and
women may present with nausea
(B) To consider the diagnosis of cardiac syndrome
X, this patient would have to
have an abnormal coronary arteriography
(C) Controlled studies suggest that in
patients with chronic refractory angina,
spinal cord stimulation (SCS) provides
symptomatic relief that is equivalent to
that provided by surgical or endovascular
reperfusion procedures, but with a
lower rate of complications and
rehospitalization
(D) The mechanism of action of spinal cord
stimulation in treating angina is not yet
completely defined
(E) None of the above
A
- (B)
A. There are gender differences in the presentation
of acute coronary syndrome. Men
are more likely to present with chest pain,
left arm pain, or diaphoresis. Nausea is
more common in women.
B. Cardiac syndrome X is angina-like chest
pain in the presence of a normal coronary
arteriography. Although symptoms in
cardiac syndrome X are often noncardiac,
a sizable proportion of patients have
angina pectoris due to transient myocardial
ischemia.
C. Despite sophisticated medical and surgical
procedures, including percutaneous endovascular
methods, a large number of
patients suffer from chronic refractory
angina pectoris. Improvement of pain relief
in this category of patients requires the use
of adjuvant therapies, of which spinal cord
stimulation (SCS) seems to be the most
promising. Controlled studies suggest that
in patients with chronic refractory angina,
SCS provides symptomatic relief that is
equivalent to that provided by surgical or
endovascular reperfusion procedures, but
with a lower rate of complications and
rehospitalization. Similarly, SCS proved
cost effective compared to medical as well
as surgical or endovascular approaches in a
comparable group of patients.
D. Using SCS for the treatment of angina is
still met with reluctance by the medical
community. Reasons for this disinclination
may be related to incomplete understanding
of the action mechanism of SCS.
