Pain Flashcards
An injured worker with complex regional pain syndrome (CRPS), type 1, asks his physician to prescribe methadone instead of morphine because of ongoing pain. The physician orders blood work and an electrocardiogram (EKG) first. What finding would be a strong contraindication to prescribing methadone for this patient?
(a) Hyperkalemia
(b) Hypermagnesemia
(c) QT interval prolongation
(d) Premature atrial complexes
Answer: (c)
Commentary: A prolonged QT interval and serious arrhythmia (torsades de pointes) have been reported during treatment with methadone. Patients with cardiac hypertrophy, concomitant diuretic use, hypokalemia or hypomagnesemia are at higher risk for development of prolonged QT interval because methadone inhibits cardiac potassium channels. Premature atrial complexes without other cardiac abnormalities that would predispose the patient to QT interval prolongation would not be considered an absolute contraindication.
2013
Which pharmacologic and non-pharmacologic treatment combination is the most appropriate initial program in a patient with fibromyalgia?
(a) Duloxetine (Cymbalta) plus aerobic exercise
(b) Amitriptyline (Elavil) plus high intensity strength training
(c) Diazepam (Valium) plus trigger point injections
(d) Fentanyl (Duragesic) plus cognitive behavioral therapy
Answer: (a)
Commentary: Pharmacologic treatments used for fibromyalgia include tricyclic antidepressants (e.g., amitriptyline), serotonin-norepinephrine reuptake inhibitors (SNRIs, e.g., duloxetine, venlafaxine), and some anticonvulsants such as pregabalin. Opiates (e.g., fentanyl) and benzodiazepines (e.g., diazepam) are generally not recommended.
Non-pharmacologic therapies include cognitive behavioral therapy, aerobic exercise (low impact), and complementary therapies. To reduce the pain associated with exercise, it is recommended to “start low, go slow,” with gradual progression in exercise intensity. Patients with fibromyalgia would not likely comply with a high intensity strength training program.
2013
Which treatment is shown consistently to improve pain in patients with acute low back pain?
(a) Superficial heat
(b) Traction
(c) Transcutaneous electrical nerve stimulation (TENS)
(d) Ultrasonography
Answer: (a)
Commentary: Superficial heat is the only modality listed that has consistently decreased pain in
acute low back pain, which is pain that has been present for less than 4 weeks.
2010
25-year-old man presents to clinic with an insidious onset of low back pain over the past 6
months. He denies any trauma, but is quite active running and biking. He does not report any leg
symptoms. His pain is worse in the morning, but improves with activity and with anti-inflammatory medication. What additional information would be most helpful in making the diagnosis?
(a) Blood work revealing elevated erythrocyte sedimentation rate (ESR)
(b) Magnetic resonance imaging revealing degenerative disc disease
(c) Plain radiograph revealing sacroiliitis
(d) Physical examination revealing an absent Achilles deep tendon reflex (DTR)
Answer: (c)
Commentary: This patient presents with a clinical history consistent with ankylosing spondylitis
(AS).This spondyloarthropathy is more common in men in their late teenage years to early
twenties. It generally presents with morning stiffness in the low back and/or buttocks. Criteria for
diagnosis (modified New York classification) include the presence of sacroiliitis on x-ray and 1
of the following: history of inflammatory back, decreased range of motion of spine, and limited
chest expansion.
2010
The third occipital nerve innervates which structure?
(a) C2-3 zygapophysial joint
(b) C2-3 intervertebral disc
(c) C3-4 zygapophysial joint
(d) C3-4 intervertebral disc
Answer:(a)
Commentary: The third occipital nerve(TON) innervates the C2-3 zygapophysial joint. The C3-4
zyagpophysial joint is innervated by the C3 and C4 medial branches. Innervation to the cervical
discs involves the sinuvertebral nerve, vertebral nerve and sympathetic trunk.
2012
Which statement is TRUE when comparing a functional restoration program to active individual
therapy for chronic low back pain?
(a) Flexibility is increased to a greater extent with active individual therapy program.
(b) Pain intensity is reduced to a greater extent with active individual therapy.
(c) Functional restoration programs have a greater effect on flexibility and pain than do
active individual therapy programs.
(d) Functional restoration programs produce greater improvements in endurance than do
active individual therapy programs.
Answer: D
Commentary:Functional restoration programs produce a greater improvement in endurance, but
no differences are noted between functional restoration programs and active individual therapy
programs.
2009
Which nerve does NOT innervate the outer annulus of the lumbar intervertebral disc?
(a) sinuvertebral nerve
(b) lumbar medial branches of dorsal rami
(c) grey rami communicantes
(d) lumbar ventral rami
(b)
The lumbar medial branches of the dorsal rami supply the facet joints as well as the deep paraspinals, such as the rotators and multifidi. The sinuvertebral nerve, also termed the recurrent meningeal nerve is the primary source of nerve supply to the lumbar intervertebral disc. It is derived from portions of the ventral rami and grey rami communicantes (sympathetic input). Accordingly, the referral pattern seen with intrinsic disc pain is vague and diffuse.
2008
Which route of epidural steroid administration is most likely to deliver steroid to the junction of the posterior disc and anterior dura?
(a) Transforaminal
(b) Caudal with catheter
(c) Interlaminar
(d) Caudal
(a)
The subpedicular transforaminal route of epidural steroid delivery places the needle at the anterior portion of the intervertebral foramen. The retroneural route of delivery purposefully terminates needle placement at the posterior edge of the intervertebral foramen to avoid injuring radicular vasculature. The caudal and interlaminar approaches are of limited utility in delivering steroid anteriorly due to raphe within the epidural space.
2008
A 47-year-old woman develops complex regional pain syndrome (CRPS) type I following a fall
at work which resulted in a distal radius fracture. Although no established gold-standard
Page 31 of 33
treatment for CRPS currently exists, which option has been studied in multiple, large-scale
randomized trials?
(a) Bisphosphonates
(b) Gabapentin
(c) Stellate/lumbar sympathetic blocks
(d) Calcitonin
Answer: (a)
Commentary: While all of the listed options have been used for the treatment of CRPS, only
bisphosphonates have been investigated in multiple, large-scale randomized trials. Clear benefits
have not been reported with gabapentin or stellate/lumbar sympathetic blocks. Available evidence
does not support the use of calcitonin.
2011
A firefighter who is now 5 days postsurgery for a rotator cuff and labral tear is in significant pain,
but is concerned about opioid use for pain control. He is concerned about becoming “addicted to
the pain killers.” In educating the patient about opioids and the issues of addiction, dependence
and tolerance, which statement is correct?
(a) While all 3 terms have subtle differences, they are essentially identical in meaning and
can be used interchangeably.
(b) Since he is a firefighter, he should avoid use of any opioids at all times since he is subject
to toxicology screening.
(c) Addiction is predictable and avoidable, and since he already concerned about it, he is
unlikely to have problems with addiction.
(d) Addiction is characterized by behavioral issues, whereas dependence and tolerance are
characterized by physiologic adaptation.
Answer: (d)
Commentary: Physical dependence, tolerance, and addiction are discrete and different phenomena
that are often confused. Addiction is characterized by behaviors that include one or more of thefollowing: impaired control over drug use, compulsive use, continued use despite harm, andcraving. Addiction is not a predictable drug effect, but represents an idiosyncratic adversereaction in biologically and psychosocially vulnerable individuals. Physical dependence is a state
of adaptation characterized by specific withdrawal symptoms that can be produced by abrupt
cessation, rapid dose reduction, and/or administration of an antagonist. Tolerance is a state ofadaptation that results in a decreased effect of a drug over time.
2011
Which statement describes the chronic-pain concept of “central sensitization”?
(a) The evoked response of A-delta fibers to subsequent input is amplified.
(b) The influx of sodium is fundamental to electrical signaling and subsequent generation of action potentials and excitatory postsynaptic potentials.
(c) A complex set of activation-dependent post-translational changes occurs at the dorsal horn, brainstem, and higher cerebral sites.
(d) The so-called “inflammatory soup,” rich in algesic substances, causes a lowering of threshold for activation and subsequent evoked pain.
(c) Central sensitization is a complex set of activation dependent post-translational changes occurring at the dorsal horn, brainstem, and higher cerebral sites that sensitizes the central nervous system to further perception of pain. Wind-up is an amplified evoked response to repeated afferent inputs at the level of the dorsal horn
2007
When using local steroid injections in patients with tendinopathies
(a) injection into the tendon substance is optimal.
(b) minimum interval between injections is 2 weeks.
(c) select the finest needle that will reach the area.
(d) early postinjection local anesthesia is a complication
(c) It is advisable to select the finest needle that will reach the area. The injection should be peritendinous with avoidance of the tendon to prevent rupture. The minimum interval between injections should be at least 6 weeks. Early postinjection local anesthesia is not a complication of steroids, but it will occur if local anesthetic is mixed with the steroid.
2007
Which term describes a maladaptive pattern of drug use marked by increasing doses to achieve a similar pain relieving effect and a withdrawal syndrome?
(a) Dependence
(b) Addiction
(c) Craving
(d) Tolerance
(a) Dependence is a maladaptive pattern of drug use marked by tolerance and a drug-class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood levels of drug, or administration of an antagonist. Tolerance is a state of adaptation in which exposure to a drug induces changes that result in diminution of 1 or more of the drug’s effects over time. Addiction is a chronic biopsychosocial disease characterized by impaired control over drug use, compulsive use, continued use despite harm, and craving.
2007
Which statement is TRUE regarding post-stroke central pain?
(a) Damage to the thalamus plays a central role in the pathogenesis of central pain.
(b) Amitriptyline is the drug of first choice to treat central pain.
(c) 80% of stroke patients with central pain develop the pain within a month of their stroke.
(d) The pain usually resolves spontaneously and does not require medication.
(b) The onset of central pain following a stroke occurs more than 1 month after the stroke in 40% to 60% of all patients. The pathogenesis of central pain is still largely a matter of conjecture and hypothesis. It is generally believed that damage to the spinothalamicocortical sensory pathways plays a significant role in the pathogenesis, but central pain can occur with lesions in any part of the brain. Treatment options are limited and at present amitriptyline is the drug of first choice, other drugs, including antidepressants, anticonvulsants, antiarrhythmics, and opioids may provide relief for some patients who do not respond to amitriptyline.
2007
If the L3 and L4 medial branches of the dorsal rami are ablated, the patient will experience blocked afferents from the
(a) L5-S1 facet joint.
(b) L4-5 facet joint.
(c) L3-4 facet joint.
(d) L2-3 facet joint.
(b) The medial branches of the dorsal rami supply innervation to the facet joints and the deep paraspinals, namely the segmental multifidi and rotators. The sacral multifidi are innervated by the sacral (rather than the lumbar) dorsal rami. Each lumbar medial branch innervates the facet joint at and below its derivation. The L4-5 facet joint is innervated by the L3 and L4 medial branches, derived from the L3 and L4 nerve roots.
2007
