Nerve and Pain Flashcards
A 48-year-old man who has been managed on a stable dose of intrathecal morphine presents with sudden onset altered mental status, sweating, severe pain, and diarrhea. His airway and breathing are stable. What is the best initial diagnostic workup at this point?
a. Blood and urine cultures
b. Assessment by the Gastroenterology service
c. Head CT
d. Plain X-rays of the pump system
e. Assessment by the Addiction Medicine service
d. Plain X-rays of the pump system
You are operating on a patient with neurofibromatosis-1 that you suspect has a benign neurofibroma of the sciatic nerve, and have performed the initial exposure of the lesion, shown in the figure. What is the most appropriate maneuver at this point?
a. Perform en bloc excision of the tumor, nerve, and surrounding muscle
b. Perform direct nerve stimulation to identify a safe zone to incise
c. Excise the lesion and perform a graft repair of the nerve
d. Biopsy the lesion for frozen and permanent sections and close
e. Perform an internal debulking of lesion
b. Perform direct nerve stimulation to identify a safe zone to incise
A 35-year-old woman has been experiencing excruciating early morning headaches localized behind the right eye, associated with ptosis and ipsilateral nasal congestion, lasting approximately 20 minutes. These symptoms have been present intermittently for 10 days. She had experienced several similar episodes in the past, lasting 1 to 2 weeks, followed by a pain-free interval. What is the most effective treatment option to abort this patient’s headache once it has begun?
a. Subcutaneous sumatriptan
b. Oral dexamethasone
c. Intravenous fosphenytoin
d. Lying in bed in a dark, quiet room
e. Oral lithium
a. Subcutaneous sumatriptan
A diabetic patient with known peripheral vascular disease undergoes an anterior cervical discectomy at C4-5. The operative course is unremarkable; however, in the recovery room the patient is noted to have decreased sensation in the 4th and 5th digits of the left hand and decreased grip. What is the MOST likely diagnosis?
a. Positioning nerve injury
b. Residual muscle relaxation
c. Surgical trauma
d. Embolic stroke
e. Brachial plexus stretch injury
a. Positioning nerve injury
You are seeing a new patient with a spinal infusion pump in the Emergency Room. They report having had a pump refill at an outside institution earlier that day. No medical records are available for this patient. They are complaining of severe pain, diarrhea, nausea, and a sensation of skin crawling. On examination they show agitation, tachycardia, and vomiting. What clinical syndrome do you suspect?
a. Clonidine withdrawal
b. Ziconotide withdrawal
c. Baclofen overdose
d. Bupivicaine overdose
e. Opioid withdrawal
e. Opioid withdrawal
You are seeing an adult patient with a history of tarsal tunnel syndrome, who presents with plantar foot discomfort sparing the heel. You decide to decompress the nerve at its typical area of entrapment. Which of the following incisions would be most appropriate to do this?
a. Figure 5
b. Figure 4
c. Figure 2
d. Figure 1
e. Figure 3
a. Figure 5
What is a contraindication for bilateral percutaneous cordotomy in the treatment of chronic refractory pain?
a. Presence of mild dementia
b. Severe pulmonary dysfunction
c. Pain associated with tumor compression of a peripheral nerve
d. Unilateral upper extremity pain
e. Life expectancy of < 6 months
b. Severe pulmonary dysfunction
You are seeing a patient with neuropathic lower extremity pain. On examination, light touch provokes severe burning pain on the dorsum of the foot. What is this phenomenon called?
a. Tinel sign
b. Paresthesia
c. Hyperpathia
d. Allodynia
e. Mechanical hyperalgesia
d. Allodynia
A 48 year old woman presents with a one week history of progressive facial paresis, severe right ear pain, vertigo, imbalance and hearing loss. Her past medical history is unremarkable. She has right beating nystagmus. Based on the MRI scan (figures) what is your diagnosis:
a. Vestibular schwannoma
b. Facial nerve hemangioma
c. Facial nerve schwannoma
d. Zoster oticus
e. Bell palsy
d. Zoster oticus
A 40-year-old female undergoes biopsy of an enlarged posterior cervical lymph node. In the immediate post-operative period, she is noted to have severe aching shoulder pain and loss of shoulder abduction above horizontal. What is the most likely diagnosis?
a. Long thoracic nerve injury
b. Spinal accessory nerve injury
c. Parsonage-Turner syndrome
d. Cervical disc herniation
e. Thoracic outlet syndrome
b. Spinal accessory nerve injury
Which of the following diagrams most accurately depicts the typical course of the accessory nerve along the posterior triangle:
a. Figure 1
b. Figure 4
c. Figure 2
d. Figure 5
e. Figure 3
e. Figure 3
A 60 year old man presents with 3 months of worsening diffuse severe unremitting left upper extremity pain, parasthesias, and hand weakness. Exam shows 4/5 weakness of hand muscles including abductor pollicus brevis and all intrinsics, scattered sensory loss on the ulnar side of the forearm, normal deep tendon reflexes and no evidence of myelopathy. MRI of the cervical spine shows mild degenerative changes throughout the neck. What imaging study would assist in the diagnosis?
a. Thermogram
b. Bone scan
c. Scoliosis survey
d. Chest CT
e. Cervical spine flexion-extension x-rays
d. Chest CT
You have diagnosed your patient with a nerve entrapment and have decided to decompress the entrapped nerve. Which of the following procedures would be most appropriate for the majority of nerve entrapments?
a. Nerve transfer
b. Neurorrhaphy
c. Internal neurolysis
d. Neuroplasty
e. Nerve transposition
d. Neuroplasty
You are seeing a patient who developed new lower extremity symptoms after a surgical procedure. It is now 1 month post-procedure. You are considering a sciatic nerve injury vs. an idiopathic lumbosacral plexopathy as the most likely diagnoses. EMG abnormalities in which muscle would suggest the latter diagnosis?
a. Short head of the biceps
b. Gastrocnemius
c. Anterior tibialis
d. Gluteus medius
e. Semimembranosus
d. Gluteus medius
When a peripheral nerve is severed, the axon segments distal to the site of injury disappear over time, leading to the gradual loss of nerve conduction distal to the injury. What is this process called?
a. Demyelination
b. Wallerian degeneration
c. Denervational change
d. Axon sprouting
e. Exocytosis
b. Wallerian degeneration
You are seeing an adult patient who underwent left groin cannulation three weeks ago for cerebral angiography. They developed weakness and numbness of the left leg immediately afterwards. On your examination, they have weakness of left hip flexion and knee extension, and anteromedial leg numbness going down to the ankle. Electrodiagnostic studies reveal absent motor and sensory potentials in the femoral nerve, and EMG sampling of the lumbar paraspinal muscles is normal. Where is the most likely site of injury?
a. Femoral nerve, inguinal ligament level
b. Femoral nerve, abdominal level
c. Saphenous nerve
d. Femoral nerve, thigh level
e. L4 nerve root
b. Femoral nerve, abdominal level
You are seeing a patient with neuropathic lower extremity pain. On examination, repetitive pinprick provokes increasingly severe burning pain on the dorsum of the foot. This phenomenon is called:
a. Hyperpathia
b. Allodynia
c. Tinel sign
d. Paresthesia
e. Mechanical hyperalgesia
a. Hyperpathia
You are operating on a patient with a nerve sheath tumor that you suspect is a benign schwannoma of the ulnar nerve. After initial exposure and dissection of the lesion, you discover that the tumor is securely attached to the nerve by a pair of fascicles as marked with asterisks in Figure 1. What is the most appropriate maneuver at this point?
a. Perform an internal debulking of the lesion
b. Divide the fascicles and remove the lesion
c. Biopsy the lesion for frozen and permanent sections and close
d. Excise the lesion and nerve and perform a graft repair of the nerve
e. Leave the tumor and fascicles alone and close
b. Divide the fascicles and remove the lesion
Which cannabinoid is thought to be most effective at treating pain?
a. Tetrahydrocannabinol (THC)
b. Cannabicyclol (CBL)
c. Anandamide (AEA)
d. Cannabidiol (CBD)
e. Cannabinol (CBN)
d. Cannabidiol (CBD)
You are treating a patient with chronic, medically-refractory low back pain. You decide to proceed with a trial of spinal cord stimulation. What would be the most appropriate spinal level for electrode placement to achieve the best stimulation coverage of the patient’s painful area?
a. L2
b. C1
c. L5
d. T9
e. T11
d. T9
You are performing radiosurgery on a patient with left medically-refractory, lancinating ear and throat pain triggered by eating and drinking. Which figure shows the most optimal location of the radiation target?
a. Figure 4
b. Figure 1
c. Figure 3
d. Figure 2
e. Figure 5
d. Figure 2
Pain circuits within the substantia gelatinosa receive descending, inhibitory, serotonergic and adrenergic inputs from which brain structure?
a. Red nucleus
b. Locus ceruleus
c. Interlaminar thalamic nucleus
d. Superior olivary nucleus
e. Cuneate nucleus
b. Locus ceruleus
Which characteristic best distinguishes malignant from benign nerve sheath tumors?
a. Location of the tumor
b. Cystic changes within the tumor
c. Intensity of contrast enhancement in the tumor
d. Extralesional T2 hyperintensity around the tumor
e. Central T2 hypointensity (“target sign”) within the tumor
d. Extralesional T2 hyperintensity around the tumor
A 45-year-old male patient presents with right foot pain. What is the structure indicated in the MRI at the level of the popliteal fossa (Figure)?
a. Popliteal artery
b. Popliteal vein
c. Common peroneal nerve
d. Sciatic nerve
e. Tibial nerve
e. Tibial nerve
What is one of the best ways to ascertain that ulnar nerve compression is distal (at the wrist) and not proximal (at the elbow)?
a. Test the strength of the first dorsal interosseous muscle.
b. Test the strength of the abductor digiti minimi muscle.
c. Test ulnar sensation on the dorsal surface of the hand.
d. Test the strength of the adductor pollicis muscle.
e. Test ulnar sensation on the 4th and 5th digits.
c. Test ulnar sensation on the dorsal surface of the hand.
The McGill Pain Questionnaire Short Form (MPQ-SF) is a standardized pain assessment tool used for both clinical assessment and research. Which pain scoring system is a component of this assessment tool?
a. Wong-Baker FACES Pain Scale
b. Verbal Descriptor Scale (VDS)
c. Color Scale for Pain
d. Visual Analog Scale (VAS)
e. Numerical Rating Scale (NRS)
d. Visual Analog Scale (VAS)
You are seeing a semi-professional baseball pitcher who has weakness of right shoulder external rotation and abduction. There is muscle atrophy as indicated by the arrows in the figure. You recommend a nerve decompression. Which of the following incisions would be the most appropriate for this patient?
a. Figure 2
b. Figure 1
c. Figure 3
d. Figure 4
e. Figure 5
e. Figure 5
You are operating on a patient with a sciatic nerve sheath tumor who presents with pain and no significant neurologic defecit, and have performed the initial exposure of the lesion. You have incised the epineurium, but are unable to identify a distinct plane between tumor and nerve. What is the most appropriate maneuver at this point?
a. Perform nerve action potential recordings
b. Biopsy the lesion for frozen and permanent sections and close
c. Perform a radical subtotal excision of the lesion
d. Excise the lesion and perform a graft repair of the nerve
e. Perform en bloc excision of the tumor, nerve, and surrounding muscle
b. Biopsy the lesion for frozen and permanent sections and close
A 25 year-old man presents with a flail, anesthetic arm after an industrial accident with closed injury to the brachial plexus. After 6 months, he has recovered shoulder, elbow, and wrist movement, but the hand remains flail. Examination shows the presence of ptosis and miosis ipsilateral to the injured arm. Electrodiagnostic studies show normal sensory nerve action potentials of the ulnar nerve. Where is the most likely injury?
a. Preganglionic injury of T1
b. Preganglionic injury of C7
c. Postganglionic injury of C7
d. Postganglionic injury of C8
e. Postganglionic injury of T1
a. Preganglionic injury of T1
You are revising an intrathecal catheter in a chronic pain patient who developed myelopathy after several years of
benefit from a spinal infusion pump. You note the mass shown in the figure at the end of the catheter tip. Which of the following factors predisposes to the formation of these lesions?
a. Catheter fracture
b. High drug concentration
c. Contaminated pump refills
d. Catheter allergy
e. Immunosuppressed status
b. High drug concentration
You are seeing an adult patient with a history of a painless left ankle mass, as indicated by the dotted outline and asterisk. Imaging is suggestive of a peripheral nerve sheath tumor. Within which nerve distribution do you suspect the nerve is located:
a. Saphenous nerve
b. Sural nerve
c. Tibial nerve
d. Deep peroneal nerve
e. Superficial peroneal nerve
c. Tibial nerve
You are performing a percutaneous radiofrequency lesioning procedure in a patient with V3 distribution trigeminal neuralgia. After placing the electrode into the Gasserian ganglion and performing the test stimulation, the patient reports tingling in the V2 distribution. You wish to reposition the electrode to achieve V3 stimulation instead. In which direction will you move the electrode?
a. Inferior and anterior
b. Superior and posterior
c. Inferior and lateral
d. Inferior and medial
e. Superior and lateral
c. Inferior and lateral
For what condition did the World Health Organization (WHO) treatment ladder originally describe the escalating use of pain medications?
a. Trigeminal neuralgia
b. Postherpetic neuralgia
c. Cancer pain
d. Complex regional pain syndrome
e. Intercostal neuralgia
c. Cancer pain
A 30 year old woman presents with right arm weakness that has progressed over a period of two months. MRI shows an enlarging mass associated within the median nerve (see figure). Biopsy demonstrates diffuse spindle-shaped cells with palisading hyperchromatic nuclei, frequent mitotic figures, necrosis, and loss of S-100 immunoreactivity. What is the best next step in management of this lesion?
a. Limb amputation
b. En bloc excision with negative margins
c. Nerve-sparing excision
d. Observation with surveillance imaging
e. Fractionated radiation therapy
b. En bloc excision with negative margins
You are referred a patient who developed severe leg pain, redness, and swelling after undergoing an open reduction and internal fixation of a tibial fracture. What diagnostic test would be most useful in distinguishing complex regional pain syndrome type 1 from type 2?
a. Three phase bone scan of the whole body
b. Electrodiagnostic studies of the lower extremities
c. Neuropsychological testing
d. Lumbar sympathetic block
e. Plain radiographs at the site of the fracture
b. Electrodiagnostic studies of the lower extremities
A 30 year old laborer presents with worsening burning arm pain radiating to fourth and fifth digits with objective hand weakness, thenar and hypothenar wasting. These symptoms are exacerbated by extending his arm and turning the head towards the affected side. What is the most likely diagnosis?
a. C7/T1 herniated disk
b. Carpal tunnel syndrome
c. Pancoast tumor
d. Neurogenic thoracic outlet syndrome
e. Central cervical stenosis
d. Neurogenic thoracic outlet syndrome
You are seeing an adult male patient who sustained a left-sided brachial plexus injury 3 months ago. On examination he has weakness in the upper trunk muscles, and absent sensation in the C5 and C6 dermatomes. Electrodiagnostic studies reveal absent motor conduction in the musculocutaneous and axillary nerves. Sensory nerve action potentials in the axillary and musculocutaneous nerves are normal. What would be the most appropriate subsequent management step?
a. Upper trunk graft repair
b. Axillary nerve neurolysis
c. Nerve transfer
d. Posterior cord graft repair
e. Observation for an additional 3 months
c. Nerve transfer
Injury to the axillary nerve will result in a deficit in which of the following movements?
a. Depression of the scapula
b. Elevation of the scapula
c. External rotation of the shoulder
d. Internal rotation of the shoulder
e. Abduction of the shoulder from 60 - 120”
e. Abduction of the shoulder from 60 - 120”
What characteristic of the pain associated with Type 2 trigeminal neuralgia differentiates it from Type 1 trigeminal neuralgia?
a. Pain that is bilateral
b. Pain that is of psychogenic origin
c. Pain that is associated with lacrimation and rhinorrhea
d. Pain that radiates to the occipital region
e. Pain that is constant
e. Pain that is constant
You have performed a nerve biopsy on a patient with a suspected peripheral neuropathy. Congo Red staining reveals abnormal deposits in the tissue (Figure). What is the most likely diagnosis?
a. Amyloidosis
b. Sarcoidosis
c. Vasculitis
d. HIV neuropathy
e. Small fiber neuropathy
a. Amyloidosis
A patient presents with chronic neuropathic leg pain two years following an L4-S1 laminectomy for spinal stenosis. A current lumbar spine MRI shows no stenosis or nerve root impingement. Flexion and extension x-rays show no evidence of instability. What is the most appropriate treatment at this time for his pain?
a. Sacroiliac joint injection
b. Provocative lumbar discography
c. Spinal cord stimulator trial
d. Radiofrequency facet denervation
e. Lumbar interbody fusion
c. Spinal cord stimulator trial
A 43-year-old woman has been experiencing lancinating pain in the right occipital area for 8 months. She can trigger her pain by pushing on the back of her right scalp. Results of magnetic resonance imaging of the brain and spine are negative, and her neurologist has made the diagnosis of occipital neuralgia. The patient has exhausted numerous drug trials, but obtained 2 hours of pain relief with a right occipital nerve block. Which of the following would be the most appropriate treatment option for this patient?
a. Caudalis dorsal root entry zone procedure
b. Occipital nerve decompression
c. Spinal infusion pump
d. High cervical spinal cord stimulation
e. Motor cortex stimulation
b. Occipital nerve decompression
You are considering performing a multilevel lumbar spinal fusion in a patient taking buprenorphine for opiate addiction. Which clinical effect of buprenorphine will most likely complicate the management of this patient?
a. Buprenorphine can block the analgesic effects of opioids.
b. Buprenorphine can impair rates of bone fusion.
c. Buprenorphine can cause seizures.
d. Buprenorphine can cause severe respiratory depression.
e. Buprenorphine can block the effects of inhalational anesthetics.
a. Buprenorphine can block the analgesic effects of opioids.
You are seeing a patient with new onset foot drop and dorsal foot numbness and pain. You obtain the following MRI. What is the most likely diagnosis?
a. Tibulofibular joint dislocation
b. Baker cyst
c. Intraneural ganglion cyst
d. Tibial nerve hematoma
e. Peroneal nerve schwannoma
c. Intraneural ganglion cyst
Which of the following structures represents a potential site of ulnar nerve entrapment?
a. Bicipital aponeurosis
b. Supinator muscle
c. Pronator teres muscle
d. Osborne’s ligament
e. Struther’s ligament
d. Osborne’s ligament
You are seeing a patient with multiple stab wounds to the upper extremity. The patient has isolated deficits in finger extension and ulnar wrist extension. What is the most likely level of injury?
a. Ulnar nerve at the mid forearm
b. Radial nerve at the elbow
c. Posterior interosseous nerve
d. Median nerve at the elbow
e. Radial nerve at the distal forearm
c. Posterior interosseous nerve
The trigeminal cistern is an important structure in percutaneous trigeminal procedures. Where is the trigeminal cistern located in relation to the gasserian ganglion?
a. Superolateral
b. Inferolateral
c. Anterior
d. Inferomedial
e. Posterior
e. Posterior
You are examining your patient with suspected carpal tunnel syndrome and you ask that they aggressively flex their affected wrist. This maneuver reproduces their carpal tunnel symptoms. What is this response called?
a. Phalen sign
b. Lhermitte sign
c. Tinel sign
d. Wartenberg sign
e. Froment sign
a. Phalen sign
You performed an uneventful supraclavicular brachial plexus exploration to remove an upper trunk schwannoma. Postoperatively, the patient has a new complaint of dyspnea on exertion. On examination, her vitals are normal at rest. On exertion she has shortness of breath without tachycardia. She has full strength and sensation within an upper trunk distribution. What would be the most appropriate initial diagnostic test to evaluate the etiology of her symptoms?
a. Thoracic outlet MRV
b. Brachial plexus MRI
c. OEMG/NCS
d. Chest X-ray
e. Lower extremity DVT ultrasound
d. Chest X-ray
Exploration of a peripheral nerve lesion reveals a traumatic neuroma-in-continuity. Which of the following intraoperative diagnostic modalities would be most useful in deciding whether to proceed with excision of the neuroma and perform a graft repair?
a. Intraoperative MRI
b. Frozen section
c. Electromyography
d. High-resolution ultrasound
e. Nerve action potential recordings
e. Nerve action potential recordings
What condition is present when reducing a drug effect results in a withdrawal syndrome?
a. Habituation
b. Dependence
c. Use disorder
d. Addiction
e. Tolerance
b. Dependence
A 20-year-old man was thrown from his motorcycle, sustaining severe injury to his right shoulder, including fractures of the clavicle and scapula. He had no right radial pulse, and an infraclavicular and supraclavicular mass was noted. He was not moving his right arm. Angiography revealed a tear of the second segment of the axillary artery and the patient underwent emergent surgical exploration and vascular repair. What neurosurgical procedure should be performed in a concurrent fashion?
a. No intervention or evaluation is indicated intraoperatively
b. Wide and total exploration of the plexus when vascular repair is completed.
c. Evaluation of the plexus through the operative site, with identification and tagging of any disrupted elements.
d. Evaluation of the plexus at the operative site after vascular repair is complete, with repair of any disrupted elements.
e. Intraoperative nerve action potential recordings (NAPs) across the injured segments.
c. Evaluation of the plexus through the operative site, with identification and tagging of any disrupted elements.
Which of the following analgesics works by binding to voltage gated sodium channels in nerve cells, thus preventing depolarization?
a. Fentanyl
b. Bupivacaine
c. Capsaicin
d. Ibuprofen
e. Ziconotide
b. Bupivacaine
You are considering a surgical procedure to treat your patient with medically refractory pelvic cancer pain. A lesion at which of the following locations would be most likely to effectively treat this pain syndrome?
a. 4
b. 3
c. 5
d. 1
e. 2
d. 1
You are seeing a patient with neuropathic upper extremity pain. She reports a spontaneous, pins-and-needles and crawling sensation in the skin of the affected area. This symptom is called:
a. Allodynia
b. Paresthesia
c. Tinel sign
d. Hyperpathia
e. Mechanical hyperalgesia
b. Paresthesia
A 50-year-old female patient presents with pelvic and leg pain. What are the paired structures indicated by the white arrows in the axial (Figure 1) and coronal (Figure 2) pelvic MRI?
a. Pudendal nerves
b. Obturator nerves
c. Sciatic nerves
d. Sacrospinous ligaments
e. Piriformis muscles
c. Sciatic nerves
For which aspect of pain is the dorsal anterior cingulate cortex (dACC) responsible?
a. Affective
b. Somatosensory
c. Psychosomatic
d. Nociceptive
e. Neurogenic
a. Affective
You are seeing a patient with left leg pain and foraminal stenosis at four lumbar levels on the left side. You are considering decompressive surgery, but want to identify the symptomatic level(s) prior to operating. Which procedure would be best suited to identify the nerve root(s) responsible for the pain?
a. Facet joint injection
b. Interlaminar epidural steroid injection
c. Sacroiliac joint injection
d. Provocative discography
e. Selective nerve root block
e. Selective nerve root block
The tumor represented in this photomicrograph most frequently occurs in association with what condition?
a. Neurofibromatosis-2
b. Von Hippel-Lindau syndrome
c. Tuberous sclerosis
d. Turcot syndrome
e. Sturge-Weber syndrome
a. Neurofibromatosis-2
You are performing a supraclavicular brachial plexus exploration. Which of the following incisions would be most appropriate?
a. Figure 1
b. Figure 2
c. Figure 5
d. Figure 3
e. Figure 4
d. Figure 3
An obese 65-year-old man presents with 1 week of progressive weakness, aching pain, and mild sensory loss in his right quadriceps. He has no back, groin, or radicular pain, nor history of recent trauma or anticoagulant use. Pulses are normal, as is lumbosacral MRI. What is the most effective initial test to assess this condition?
a. Fasting blood sugar level.
b. EMG/NCS of the leg.
c. OCT of the pelvis.
d. OMRI of the leg.
e. Angiogram of the leg.
a. Fasting blood sugar level.
What is the nerve that is compressed in tarsal tunnel syndrome?
a. Tibial nerve
b. Superficial peroneal nerve
c. Saphenous nerve
d. Sural nerve
e. Deep peroneal nerve
a. Tibial nerve
For medically refractory postherpetic neuralgia of the trigeminal nerve, which of the following therapeutic interventions is most likely to alleviate pain?
a. Stereotactic radiosurgery of the trigeminal root
b. Percutaneous glycerol rhizolysis of the gasserian ganglion
c. Caudalis dorsal root entry zone procedure
d. Percutaneous radiofrequency lesion of the gasserian ganglion
e. Microvascular decompression of the trigeminal root
c. Caudalis dorsal root entry zone procedure
Examination of which of the following movements is most helpful in distinguishing an L4 radiculopathy from a femoral neuropathy?
a. Ankle plantar flexion
b. Hip flexion
c. Knee extension
d. Knee flexion
e. Thigh adduction
b. Hip flexion
A patient with chronic, medically-refractory migraine headaches has debilitating pain despite exhaustion of numerous preventative and abortive pharmacologic treatments. Which of the following would be the most appropriate intervention?
a. Sphenopalatine ganglion ablation
b. Cervical sympathectomy
c. Intrathecal opiate trial
d. Caudalis dorsal root entry zone procedure
e. Occipital nerve stimulator trial
e. Occipital nerve stimulator trial
What is the BEST pain procedure for treating pelvic and/or rectal pain due to ovarian carcinoma?
a. Punctate midline myelotomy
b. Dorsal root entry zone procedure
c. Spinal cord stimulation
d. Sacral rhizotomy
e. Sacral root stimulation
a. Punctate midline myelotomy
Which of the following neuropathic pain medications works by binding to voltage-gated calcium channels in neurons?
a. Baclofen
b. Amitriptyline
c. Clonidine
d. Ketamine
e. Gabapentin
e. Gabapentin
What type of pain related to spinal metastases is most responsive to radiation?
a. Mechanical pain
b. Radicular pain
c. Neuropathic pain
d. Nocturnal pain
d. Nocturnal pain
In doing a nerve transfer procedure to recover elbow flexion, which of the following two nerves are coapted?
a. Spinal accessory and suprascapular
b. Radial and median
c. Ulnar and musculocutaneous
d. Ulnar and radial
e. Radial and musculocutaneous
c. Ulnar and musculocutaneous
What is the first clinically important branch given off by the upper trunk of the brachial plexus?
a. Musculocutaneous nerve
b. Phrenic nerve
c. Axillary nerve
d. Dorsal scapular nerve
e. Suprascapular nerve
e. Suprascapular nerve
You have been treating a patient with low back pain with opiates for many years. His doses have been gradually increasing. Spinal imaging has shown no significant changes. More recently he reports that his pain has become progressively more severe, and increasing doses of opiates are associated with increased pain. What is this phenomenon called?
a. Opioid addiction
b. Malingering
c. Opioid-induced hyperalgesia
d. Conversion disorder
e. Opioid dependence
c. Opioid-induced hyperalgesia
A 45-year-old woman is referred with complaints of debilitating paroxysmal, lancinating pain involving the deep aspect of the left ear canal. Her neurological examination is normal. A CT scan of the brain and skull base along with an MRI of the brain are both normal. She has failed medical management of her condition. Which of the following represents the BEST surgical treatment option?
a. Microvascular decompression of the trigeminal nerve
b. Nucleus caudalis DREZ ablation
c. Intradural section of the nervus intermedius
d. Intradural rhizotomy of the 9th and upper 1/3 of the 10th cranial nerves
e. Removal of the styloid process
c. Intradural section of the nervus intermedius
A 45-year-old woman with colon cancer presents with severe bilateral pain in her abdomen and pelvis due to multiple metastases. Although her pain has been responsive to oral narcotics, escalating doses have given her unacceptable sedating side effects. Which of the following interventions would be MOST appropriate in this setting?
a. Spinal cord stimulation trial
b. Percutaneous cordotomy
c. Dorsal root entry zone procedure
d. Intrathecal morphine trial
e. Oral buprenorphine trial
d. Intrathecal morphine trial
Which of the following muscles is innervated by the median nerve?
a. Lumbrical IV
b. Adductor pollicis
c. Flexor digitorum profundus IV
d. Supinator
e. Flexor carpi radialis
e. Flexor carpi radialis
You are performing surgery on a patient with a suspected nerve entrapment, and discover that the nerve is severely narrowed (>50%) along the point of entrapment. What is the most appropriate treatment for this condition?
a. Internal neurolysis
b. Neuroplasty
c. Nerve transfer
d. Neurorrhaphy
e. Nerve transposition
a. Internal neurolysis
Anterior interosseous neuropathy causes weakness in the flexor pollicis longus, flexor digitorum profundus 1 and which muscle?
a. First dorsal interosseous
b. Pronator teres
c. Abductor pollicis brevis
d. Pronator quadratus
e. Opponens pollicis
d. Pronator quadratus
You are performing a radial to axillary nerve transfer for a patient who sustained a C5 nerve root avulsion injury 3 months previously. You have decided to utilize a posterior approach for this nerve transfer. What two muscles are separated to access the donor nerve?
a. Deltoid and biceps
b. Biceps and lateral head of triceps
c. Biceps and brachioradialis
d. Long and lateral heads of the triceps
e. Biceps and pectoralis major
d. Long and lateral heads of the triceps
A 65 year old man is seen for continued left medial hand pain after a failed submuscular ulnar nerve transposition procedure two months ago. Upon re-evaluation, new left ptosis and miosis is observed. What is the most likely diagnosis?
a. Parsonage-Turner syndrome of the medial cord
b. Raeder’s paratrigeminal neuralgia
c. Thoracic outlet syndrome
d. Ulnar nerve injury at an elbow level
e. Pancoast Tumor
e. Pancoast Tumor
An 18-year-old patient has sustained a gunshot wound through the mid thigh. At arrival to the emergency department, he is found to have intact pedal pulses but is unable to move his foot. The dorsum and sole of his foot have markedly decreased sensation. He can weakly flex his knee, although this is limited by pain. What is the most appropriate management of this suspected nerve injury?
a. Emergent electrodiagnostic studies.
b. Nerve exploration and possible repair at 1 month if no recovery.
c. Nerve exploration and possible repair at 1 year if no recovery.
d. Emergent nerve exploration and possible repair.
e. Nerve exploration and possible repair at 3 months if no recovery.
e. Nerve exploration and possible repair at 3 months if no recovery.
What is the most likely vessel to make pathological contact with the glossopharyngeal nerve causing glossopharyngeal neuralgia?
a. Basilar artery
b. Posterior cerebral artery
c. Posterior inferior cerebellar artery
d. Posterior choroidal artery
e. Superior cerebellar artery
c. Posterior inferior cerebellar artery
A grade of 4- on the Medical Research Council Muscle Grading Scale signifies which of the following?
a. Active movement with gravity eliminated
b. Active movement against gravity with slight resistance
c. Normal strength
d. Active movement against gravity
e. No muscle contraction
b. Active movement against gravity with slight resistance
A 76-year-old female has a history of lancinating pain just below her right eye. You performed stereotactic radiosurgery on her 1 year ago, giving her excellent pain relief for 9 months. She now returns to you complaining of constant burning pain and diminished sensation where her lancinating pain used to be. What is this patient’s most likely diagnosis at follow-up?
a. Symptomatic trigeminal neuralgia
b. Trigeminal deafferentation pain
c. Anesthesia dolorosa
d. Type 1 trigeminal neuralgia
e. Trigeminal neuropathic pain
b. Trigeminal deafferentation pain
During an examination you ask your patient to squeeze their thumbs and fingers together tightly. During this maneuver you note an abnormality in the left hand seen in the figure. Weakness in which muscle is responsible for this finding?
a. Abductor pollicis brevis
b. Adductor pollicis
c. Dorsal interosseous
d. Flexor digitorum profundus
e. Flexor pollicis longus
b. Adductor pollicis
Pathology at the level of which structure is most likely to cause isolated, unilateral weakness of ankle dorsiflexion and inversion?
a. S1 nerve root
b. Peroneal nerve
c. L5 nerve root
d. L4 nerve root
e. Tibial nerve
c. L5 nerve root
A patient presents 3 months after a motor vehicle accident with the following isolated injury to the right C5 nerve root. What would be the most appropriate treatment?
a. Ulnar to musculocutaneous (Oberlin) nerve transfer
b. C5 to upper trunk graft repair
c. C5 nerve rootlet reimplantation
d. Accessory to suprascapular nerve transfer
e. Observation
d. Accessory to suprascapular nerve transfer
You are consulted to perform a sural nerve biopsy to evaluate a peripheral neuropathy. What would be the most appropriate incision for this patient?
a. Figure 4
b. Figure 3
c. Figure 1
d. Figure 2
e. Figure 5
d. Figure 2
A patient with a history of left trigeminal neuralgia has undergone a percutaneous radiofrequency rhizotomy, which gave her 2 years of pain relief. This was followed by stereotactic radiosurgery of the trigeminal nerve root, resulting in absence of her lancinating pain. She now has new left facial pain that is constant and aching. On examination, her left face is anesthetic to light touch and pinprick. What is her diagnosis?
a. Type 2 trigeminal neuralgia
b. Trigeminal deafferentation pain
c. Symptomatic trigeminal neuralgia
d. Anesthesia dolorosa
e. Trigeminal neuropathic pain
d. Anesthesia dolorosa
A 16 year old female presents with a sharp laceration to the posterior thigh. Examination shows complete lack of foot dorsiflexion and eversion, consistent with peroneal nerve injury. Imaging studies show no vascular compromise. What is the most appropriate initial management?
a. Acute electrodiagnostic studies
b. Superficial closure and nerve repair at 3 months
c. Superficial closure and nerve repair at 1 month
d. Superficial closure and nerve repair at 9 months
e. Acute wound exploration and nerve repair
e. Acute wound exploration and nerve repair
Injury to the suprascapular nerve results in which of the following neurological deficits?
a. Weakness of external shoulder rotation, numbness of lateral shoulder
b. Weakness of shoulder abduction, weakness of external shoulder rotation
c. Weakness of internal shoulder rotation, numbness of anterior shoulder
d. Weakness of scapular rotation, weakness of scapular elevation
e. Weakness of shoulder circumduction, numbness of posterior shoulder
b. Weakness of shoulder abduction, weakness of external shoulder rotation
You are seeing a patient complaining of problems in her hand. You suspect that the patient has anterior interosseous neuropathy. In what pair of muscles would you expect to find weakness?
a. Flexor digitorum superficialis and flexor digitorum profundus
b. Flexor pollicis longus and flexor digitorum profundus 1
c. Opponens pollicis and abductor pollicis brevis
d. Pronator teres and pronator quadratus
e. First lumbrical and second lumbrical
b. Flexor pollicis longus and flexor digitorum profundus 1
A 25-year old female presents with new onset weakness and vision difficulties which worsen as the day progresses. Nerve conduction and EMG testing shows improvement after the administration of edrophonium. What is the diagnosis?
a. Lambert-Eaton syndrome
b. Dermatomyositis
c. Guillain-Barre syndrome
d. Polymyositis
e. Myasthenia gravis
e. Myasthenia gravis
A 38 year old male experiences severe acute right arm pain and then develops severe deltoid weakness and mild biceps and triceps weakness. After 6 weeks, he seeks consultation. Axial MRI imaging at C4-5 and C5-6 are shown. What is the next most appropriate step in management?
a. ACDF C4-5 and C5-6
b. EMG/NCS
c. Cervical traction
d. CT myelogram
e. Epidural steroid injection
b. EMG/NCS
Which of the major nerves arising from the brachial plexus has the worst prognosis for return of motor function following injury?
a. Axillary
b. Musculocutaneous
c. Ulnar
d. Radial
e. Median
c. Ulnar
You are examining your patient with a nerve injury and, when tapping along the course of the nerve at the site of injury, provoke an electrical sensation that radiates into the distribution of that nerve. What is this response called?
a. Tinel sign
b. Phalen sign
c. Lhermitte sign
d. Wartenberg sign
e. Froment sign
a. Tinel sign
You are examining a patient who recently sustained multiple missile injuries to the upper extremity following an IED explosion. You suspect a brachial plexus injury. Motor testing of which of the following muscles would be most helpful in distinguishing a medial cord from a lower trunk injury?
a. Flexor carpi ulnaris
b. Adductor pollicis
c. First dorsal interosseous
d. Extensor digitorum communis
e. Abductor pollicis brevis
d. Extensor digitorum communis
A patient sustains an accessory nerve injury during a lymph node biopsy. The biopsy incision is indicated by the dotted line in the images. Which of the following incisions permits the most effective exposure for assessment and possible repair of this nerve?
a. Figure 2
b. Figure 4
c. Figure 5
d. Figure 1
e. Figure 3
d. Figure 1
Which of the following analgesics works by binding to spinal cord vanilloid (TRVP1) receptors, thus causing prolonged depolarization and defunctionalization of the pain pathways?
a. Fentanyl
b. Bupivacaine
c. Capsaicin
d. Ibuprofen
e. Ziconotide
c. Capsaicin
The right obturator nerve is inadvertently sectioned sharply during a gynecologic procedure. What is the best management of this injury?
a. Delayed repair with graft
b. Immediate repair with graft.
c. Delayed tension-free end-to-end anastomosis.
d. No repair, physical therapy.
e. Immediate tension-free end-to-end anastomosis.
e. Immediate tension-free end-to-end anastomosis.
You are seeing an adult patient who is complaining of pain along the left medial knee and electrical shocks that shoot down the anteromedial left leg to the ankle. You suspect a nerve entrapment. Where is the most likely site of entrapment?
a. Adductor canal
b. Inguinal ligament
c. Inferior patellar tendon
d. Pelvic brim
e. Obturator hiatus
a. Adductor canal
Which of the following neuropathic pain medications works as a GABA-b receptor agonist?
a. Clonidine
b. Ketamine
c. Baclofen
d. Amitriptyline
e. Gabapentin
c. Baclofen
