Peripheral Nerve and Pain Management Flashcards
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
A. Femoral nerve, abdominal level
For what condition did the World Health Organization (WHO) treatment ladder originally describe the escalating use of pain medications?
A. Complex regional pain syndrome
B. Cancer pain
C. Trigeminal neuralgia
D. Postherpetic neuralgia
E. Intercostal neuralgia
B. Cancer pain
What is the most likely vessel to make pathological contact with the glossopharyngeal nerve causing glossopharyngeal neuralgia?
A. Posterior choroidal artery
B. Superior cerebellar artery
C. Posterior cerebral artery
D. Posterior inferior cerebellar artery
E. Basilar artery
D. Posterior inferior cerebellar artery
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. Nerve transposition
B. Nerve transfer
C. Neurorrhaphy
D. Neuroplasty
E. Internal neurolysis
E. Internal neurolysis
What characteristic of the pain associated with Type 2 trigeminal neuralgia differentiates it from Type 1 trigeminal neuralgia?
A. Pain that is constant
B. Pain that is associated with lacrimation and rhinorrhea
C. Pain that is of psychogenic origin
D. Pain that is bilateral
E. Pain that radiates to the occipital region
A. Pain that is constant
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. Deep peroneal nerve
B. Saphenous nerve
C. Tibial nerve
D. Superficial peroneal nerve
E. Sural nerve
C. Tibial nerve
You are performing a supraclavicular brachial plexus exploration. Which of the following incisions would be most
appropriate?
A. Figure 1
B. Figure 4
C. Figure 2
D. Figure 5
E. Figure 3
E. Figure 3
Injury to the axillary nerve will result in a deficit in which of the following movements?
A. Depression of the scapula
B. External rotation of the shoulder
C. Elevation of the scapula
D. Internal rotation of the shoulder
E. Abduction of the shoulder from 60 - 120”
E. Abduction of the shoulder from 60 - 120”
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. Lumbar sympathetic block
C. Plain radiographs at the site of the fracture
D. Electrodiagnostic studies of the lower extremities
E. Neuropsychological testing
D. Electrodiagnostic studies of the lower extremities
The tumor represented in this photomicrograph most frequently occurs in association with what condition?
A. Tuberous sclerosis
B. Turcot syndrome
C. Sturge-Weber syndrome
D. Neurofibromatosis-2
E. Von Hippel-Lindau syndrome
D. Neurofibromatosis-2
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 Baclofen overdose
b Clonidine withdrawal
c Opioid withdrawal
d Ziconotide withdrawal
e Bupivicaine overdose
C. Opioid withdrawal
What is the nerve that is compressed in tarsal tunnel syndrome?
A. Deep peroneal nerve
B. Saphenous nerve
C. Sural nerve
D. Superficial peroneal nerve
E. Tibial nerve
E. Tibial nerve
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. Postganglionic injury of C7
C. Preganglionic injury of C7
D. Postganglionic injury of C8
E. Postganglionic injury of T1
A. Preganglionic injury of T1
‘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. Excise the lesion and nerve and perform a graft repair of the nerve
C. Biopsy the lesion for frozen and permanent sections and close
D. Leave the tumor and fascicles alone and close
E. Divide the fascicles and remove the lesion
E. Divide the fascicles and remove the lesion
For medically refractory postherpetic neuralgia of the trigeminal nerve, which of the following therapeutic interventions is most likely to alleviate
pain?
A. Caudalis dorsal root entry zone procedure
B. Microvascular decompression of the trigeminal root
C. Stereotactic radiosurgery of the trigeminal root
D. Percutaneous radiofrequency lesion of the gasserian ganglion
E. Percutaneous glycerol rhizolysis of the gasserian ganglion
A. Caudalis dorsal root entry zone procedure
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 5
B. Figure 2
C. Figure 4
D. Figure 1
E. Figure 3
D. Figure 1
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 cause severe respiratory depression.
B. Buprenorphine can cause seizures.
C. Buprenorphine can block the analgesic effects of opioids.
D. Buprenorphine can impair rates of bone fusion.
E. Buprenorphine can block the effects of inhalational anesthetics.
C. Buprenorphine can block the analgesic effects of opioids.
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. Adductor pollicis
B. Abductor poliicis brevis
C. Extensor digitorum communis
D. Flexor carpi ulnaris
E. First dorsal interosseous
C. Extensor digitorum communis
Which of the following neuropathic pain medications works as a GABA-b receptor agonist?
A Amitriptyline
B Baclofen
C Gabapentin
D Ketamine
E Clonidine
B Baclofen
Pathology at the level of which structure is most likely to cause isolated, unilateral weakness of ankle dorsiflexion and inversion?
A. L4 nerve root
B. Tibial nerve
C. s1 nerve root
D. L5 nerve root
E. Peroneal nerve
D. L5 nerve root
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. Sciatic nerve
B. Common peroneal nerve
C. Tibial nerve
D. Popliteal artery
E. Popliteal vein
C. Tibial nerve
What condition is present when reducing a drug effect results in a withdrawal syndrome?
A. Habituation
B. Tolerance
C. Use disorder
D. Addiction
E. Dependence
E. Dependence
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 pollicis longus and flexor digitorum profundus 1
B. Opponens pollicis and abductor pollicis brevis
C. Flexor digitorum superficialis and flexor digitorum profundus
D. Pronator teres and pronator quadratus
E. First lumbrical and second lumbrical
A. Flexor pollicis longus and flexor digitorum profundus 1
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. Oral lithium
D. Lying in bed in a dark, quiet room
E. Intravenous fosphenytoin
A. Subcutaneous sumatriptan
C. Oral lithium
YYou 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. Froment sign
B. wartenberg sign
C. Lhermitte sign
D. Phalen sign
E. Tinel sign
E. Tinel sign
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. Radiofrequency facet denervation
D. spinal cord stimulator trial
E. Lumbar interbody fusion
D. Spinal cord stimulator trial
Pain circuits within the substantia gelatinosa receive descending, inhibitory, serotonergic and adrenergic inputs from which brain structure?
A. Red nucleus
B. Cuneate nucleus
C. Locus ceruleus
D. Superior olivary nucleus
E. Interlaminar thalamic nucleus
C. Locus ceruleus
Which of the following diagrams most accurately depicts the typical course of the accessory nerve along the posterior
triangle:
A. Figure 4
B. Figure 2
C. Figure 1
D. Figure5
E. Figure 3
E. Figure 3
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. Piriformis muscles
B. Sciatic nerves
C. sacrospinous ligaments
D. Pudendal nerves
E. Obturator nerves
B. Sciatic nerves
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. Head CT
B. Plain X-rays of the pump system
C. Assessment by the Addiction Medicine service
D. Assessment by the Gastroenterology service
E. Blood and urine cultures
B. Plain X-rays of the pump system
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. Electromyography
B.Intraoperative MRI
C. Frozen section
D. High-resolution ultrasound
E. Nerve action potential recordings
E. Nerve action potential recording
In doing a nerve transfer procedure to recover elbow flexion, which of the following two nerves are coapted?
A. Ulnar and radial
B. spinal accessory and suprascapular
C. Radial and musculocutaneous
D. Radial and median
E. Ulnar and musculocutaneous
E. Ulnar and musculocutaneous
What is the first clinically important branch given off by the upper trunk of the brachial plexus?
A. Axillary nerve
B. Musculocutaneous nerve
C. Phrenic nerve
D. Dorsal scapular nerve
E. Suprascapular nerve
E. Suprascapular nerve
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. Color Scale for Pain
B. wong-Baker FACES Pain Scale
C. Verbal Descriptor Scale (VDS)
D. Numerical Rating Scale (NRS)
E. visual Analog Scale (VAS)
E. visual Analog Scale (VAS)
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. Symptomatic trigeminal neuralgia
B. Anesthesia dolorosa
C. Trigeminal neuropathic pain
D. Type 2 trigeminal neuralgia
E. Trigeminal deafferentation pain
Anesthesia dolorosa
Which of the following muscles is innervated by the median nerve?
A. supinator
B. Adductor pollicis
C. Lumbrical IV
D. Flexor carpi radialis
E. Flexor digitorum profundus IV
D. Flexor carpi radialis
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
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. wallerian degeneration
B. Denervational change
C. Dpemyelination
D. Exocytosis
E. Axon sprouting
A. wallerian degeneration
Examination of which of the following movements is most helpful in distinguishing an L4 radiculopathy from a femoral neuropathy?
A. Knee extension
B. Hip flexion
C. Knee flexion
D. Ankle plantar flexion
E. Thigh adduction
B. Hip flexion
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
The trigeminal cistern is an important structure in percutaneous trigeminal procedures. Where is the trigeminal cistern located in relation to the
gasserian ganglion?
A. Inferolateral
B. Inferomedial
C. superolateral
D. Anterior
E. Posterior
E. Posterior
YYou 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. small fiber neuropathy
C. HIV neuropathy
D. sarcoidosis
E. vasculitis
A. Amyloidosis
Injury to the suprascapular nerve results in which of the following neurological deficits?
A. Weakness of shoulder circumduction, numbness of posterior shoulder
B. Weakness of shoulder abduction, weakness of external shoulder rotation
C. Weakness of scapular rotation, weakness of scapular elevation
D. Weakness of external shoulder rotation, numbness of lateral shoulder
E. Weakness of internal shoulder rotation, numbness of anterior shoulder
B. Weakness of shoulder abduction, weakness of external shoulder rotation
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. Anterior tibialis
B. semimembranosus
C. short head of the biceps
D. Gluteus medius
E. Gastrocnemius
D. Gluteus medius
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. Embolic stroke
B. surgical trauma
C. Positioning nerve injury
D. Brachial plexus stretch injury
E. Residual muscle relaxation
C. Positioning nerve injury
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. Evaluation of the plexus through the operative site, with identification and tagging of any disrupted elements.
B. No intervention or evaluation is indicated intraoperatively
C. Intraoperative nerve action potential recordings (NAPs) across the injured segments.
D. Wide and total exploration of the plexus when vascular repair is completed.
E. Evaluation of the plexus at the operative site after vascular repair is complete, with repair of any disrupted elements.
A. Evaluation of the plexus through the operative site, with identification and tagging of any disrupted elements.
YYou 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. Brachial plexus MRI
B. Lower extremity DVT ultrasound
C. Thoracic outlet MRV
D. Chest X-ray
E. EMG/NCS
D. Chest X-ray
A grade of 4- on the Medical Research Council Muscle Grading Scale signifies which of the following?
A. Active movement against gravity with slight resistance
B. No muscle contraction
C. Active movement against gravity
D. Active movement with gravity eliminated
E. Normal strength
A. Active movement against gravity with slight resistance
What type of pain related to spinal metastases is most responsive to radiation?
A. Radicular pain
B. Mechanical pain
C. Neuropathic pain
D. Nocturnal pain
E. Nocturnal pain
Which of the following analgesics works by binding to voltage gated sodium channels in nerve cells, thus preventing depolarization?
A. Ibuprofen
B. capsaicin
C. Bupivacaine
D. Fentanyl
E. Ziconotide
C. Bupivacaine
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 2
B. Figure 1
C. Figure 5
D. Figure 3
E. Figure 4
A. Figure 2
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 adductor pollicis muscle.
B. Test ulnar sensation on the dorsal surface of the hand.
C. Test the strength of the abductor digiti minimi muscle.
D. Test ulnar sensation on the 4t and 5™ digits.
E. Test the strength of the first dorsal interosseous muscle.
B. Test ulnar sensation on the dorsal surface of the hand.
You are performing a percutaneous radiofrequency lesioning procedure in a patient with V3 distribution trigeminal neuraigia. 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 medial
B. superior and posterior
C. Inferior and lateral
D. Inferior and anterior
E. superior and lateral
C. Inferior and lateral
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. Ulnar nerve injury at an elbow level
C. Thoracic outlet syndrome
D. Raeder’s paratrigeminal neuralgia
E. Pancoast Tumor
E. Pancoast Tumor
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. selective nerve root block
D. sacroiliac joint injection
E. Provocative discography
C. selective nerve root block
YYou 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. wartenberg sign
B. Froment sign
C. Lhermitte sign
D. Pnalen sign
E. Tinel sign
D. Pnalen sign
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. Median nerve at the elbow
B. Uinar nerve at the mid forearm
C. Radial nerve at the elbow
D. Radial nerve at the distal forearm
E. Posterior interosseous nerve
E. Posterior interosseous nerve
Which of the following neuropathic pain medications works by binding to voltage-gated calcium channels in neurons?
A. Amitriptyline
B. Clonidine
C. Ketamine
D. Gabapentin
E. Baclofen
D. Gabapentin
YYou 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. Intemnal neurolysis
B. Neuroplasty
C. Nerve transposition
D. Neurorrhaphy
E. Nerve transfer
B. Neuroplasty
YYou 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. Biceps and brachioradialis
B. Biceps and pectoralis major
C. Long and lateral heads of the triceps
D. Biceps and lateral head of triceps
E. Deltoid and biceps
C. Long and lateral heads of the triceps
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. Biopsy the lesion for frozen and permanent sections and close
B. perform direct nerve stimulation to identify a safe zone to incise
C. Perform en bloc excision of the tumor, nerve, and surrounding muscle
D. Excise the lesion and perform a graft repair of the nerve
E. Perform an internal debulking of lesion
B. perform direct nerve stimulation to identify a safe zone to incise
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. C5 to upper trunk graft repair
B. Accessory to suprascapular nerve transfer
C. Ulnar to musculocutaneous
(Oberlin) nerve transfer
D. Observation
E. C5 nerve rootlet reimplantation
B. Accessory to suprascapular nerve transfer
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 2
B. Figure 5
C. Figure 3
D. Figure 4
E. Figure 1
B. Figure 5
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. Intraneural ganglion cyst
B. Tibial nerve hematoma
C. Baker cyst
D. Tibulofibular joint dislocation
E. Peroneal nerve schwannoma
A. Intraneural ganglion cyst
Anterior interosseous neuropathy causes weakness in the flexor pollicis longus, flexor digitorum profundus 1 and which muscle?
A. Opponens pollicis
B. Pronator teres
C. Pronator quadratus
D. Abductor pollicis brevis
E. First dorsal interosseous
C. Pronator quadratus
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. High cervical spinal cord stimulation
B. caudalis dorsal root entry zone procedure
C. Spinal infusion pump
D. Motor cortex stimulation
E. Occipital nerve decompression
E. Occipital nerve decompression
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 spindie-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. En bloc excision with negative margins
B. Fractionated radiation therapy
C. Nerve-sparing excision
D. Observation with surveillance imaging
E. Limb amputation
A. En bloc excision with negative margins
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. Paresthesia
B. Mechanical hyperalgesia
C. Hyperpathia
D. Tinel sign
E. Allodynia
E. Allodynia
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. Malingering
B. Opioid-induced hyperalgesia
C. Opioid addiction
D. Opioid dependence
E. Conversion disorder
B. Opioid-induced hyperalgesia
A 8-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 nerve exploration and possible repair.
B. Nerve exploration and possible repair at 1 year if no recovery.
C. Nerve exploration and possible repair at 3 months if no recovery.
D. Emergent electrodiagnostic studies.
E. Nerve exploration and possible repair at 1 month if no recovery.
C. Nerve exploration and possible repair at 3 months if no recovery.
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. Thoracic outlet syndrome
B. cervical disc herniation
C. spinal accessory nerve injury
D. Parsonage-Turner syndrome
E. Long thoracic nerve injur
C. spinal accessory nerve injury
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. Nucleus caudalis DREZ ablation
B. Microvascular decompression of the trigeminal nerve
C. Removal of the styloid process
D. Intradural section of the nervus intermedius
E. Intradural rhizotomy of the 9th and upper 1/3 of the 10th cranial nerves
D. Intradural section of the nervus intermedius
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. Immunosuppressed status
C. catheter allergy
D. High drug concentration
E. Contaminated pump refills
D. High drug concentration
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. Adductor pollicis
B. Dorsal interosseous
C. Flexor digitorum profundus
D. Flexor pollicis longus
E. Abductor pollicis brevis
A. Adductor pollicis
Which characteristic best distinguishes malignant from benign nerve sheath tumors?
A. cystic changes within the tumor
B. Extralesional T2 hyperintensity around the tumor
C. Intensity of contrast enhancement in the tumor
D. Location of the tumor
E. Central T2 hypointensity (“target sign”) within the tumor
B. Extralesional T2 hyperintensity around the tumor
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. Zoster oticus
B. Facial nerve schwannoma
C. Bell palsy
D. Vestibular schwannoma
E. Facial nerve hemangioma
A. Zoster oticus
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. Mechanical hyperalgesia
B. Paresthesia
C. Tinel sign
D. Allodynia
E. Hyperpathia
B. Paresthesia
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. Posterior cord graft repair
B. Nerve transfer
C. Observation for an additional 3 months
D. Axillary nerve neurolysis
E. Upper trunk graft repair
B. Nerve transfer
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. 1
B. 5
C. 4
D. 3
E. 2
A. 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
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. CT of the pelvis.
B. MRI of the leg.
C. EMGI/NCS of the leg.
D. Angiogram of the leg.
E. Fasting blood sugar level.
E. Fasting blood sugar level.
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. Dorsal root entry zone procedure
B. spinal cord stimulation trial
C. Oral buprenorphine trial
D. percutaneous cordotomy
E. Intrathecal morphine trial
E. Intrathecal morphine trial
‘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. Inguinal ligament
B. Obturator hiatus
C. Adductor canal
D. Pelvic brim
E. Inferior patellar tendon
C. Adductor canal
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. Paresthesia
D. Tinel sign
E. Mechanical hyperalgesia
A. Hyperpathia
What is a contraindication for bilateral percutaneous cordotomy in the treatment of chronic refractory pain?
A. Severe pulmonary dysfunction
B. Pain associated with tumor compression of a peripheral nerve
C. Presence of mild dementia
D. Unilateral upper extremity pain
E. Life expectancy of < 6 months
A. Severe pulmonary dysfunction
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. cervical spine flexion-extension x-rays
B. ChestCT
C. Bone scan
D. Scoliosis survey
E. Thermogram
B. ChestCT
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 5
C. Figure 1
D. Figure 2
E. Figure 3
D. Figure 2
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. Trigeminal neuropathic pain
B. Type 1 trigeminal neuralgia
C. symptomatic trigeminal neuraigia
D. Anesthesia dolorosa
E. Trigeminal deafferentation pain
E. Trigeminal deafferentation pain
‘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.. T11
B. T9
C. L5
D. L2
E. C1
B. T9
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. Guillain-Barre syndrome
B. Lambert-Eaton syndrome
C. Dermatomyositis
polymyositis
D. Myasthenia gravis
Myasthenia gravis
‘Which of the major nerves arising from the brachial plexus has the worst prognosis for return of motor function following injury?
A. Axillary
B. Radial
C. Ulnar
D. Median
E. Musculocutaneous
C. Ulnar
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. Intrathecal opiate trial
B. Cervical sympathectomy
C. Occipital nerve stimulator trial
D. Sphenopalatine ganglion ablation
E. Caudalis dorsal root entry zone procedure
C. Occipital nerve stimulator trial
Which of the following structures represents a potential site of ulnar nerve entrapment?
A. Osborne’s ligament
B. Bicipital aponeurosis
C. struther’s ligament
D. Pronator teres muscle
E. supinator muscle
A. Osborne’s ligament
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 en bloc excision of the tumor, nerve, and surrounding muscle
B. Perform a radical subtotal excision of the lesion
C. Biopsy the lesion for frozen and permanent sections and close
D. Excise the lesion and perform a graft repair of the nerve
E. Perform nerve action potential recordings
C. Biopsy the lesion for frozen and permanent sections and close
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. Superficial closure and nerve repair at 9 months
B. Superficial closure and nerve repair at 1 month
C. Superficial closure and nerve repair at 3 months
D. Acute electrodiagnostic studies
E. Acute wound exploration and nerve repair
E. Acute wound exploration and nerve repair
For which aspect of pain is the dorsal anterior cingulate cortex (JACC) responsible?
A. Affective
B. Neurogenic
C. psychosomatic
D. somatosensory
E. Nociceptive
A. Affective
Which cannabinoid is thought to be most effective at treating pain?
A. Tetrahydrocannabinol (THC)
B. cannabicyclol (CBL)
C. Cannabidiol (CBD)
D. Anandamide (AEA)
E. cannabinol (CBN)
C. Cannabidiol (CBD)
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 1
B. Figure 5
C. Figure 3
D. Figure 4
E. Figure 2
B. Figure 5
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. Epidural steroid injection
C. Cervical traction
D. CT myelogram
E. EMG/NCS
E. EMG/NCS
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. Neurogenic thoracic outlet syndrome
C. Central cervical stenosis
D. Pancoast tumor
E. Carpal tunnel syndrome
B. Neurogenic thoracic outlet syndrome
