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