Chapter 3. Pain Pathophysiology Flashcards

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

(B)
A. Central pain affects people with strokes,
spinal cord injuries, and multiple sclerosis.
It can also occur after neurosurgical procedures
on the brain and spine. The mechanism
is thought to be because of disruption
of spinothalamocortical transmission.
B. Pain may occur with syringomyelia, and it
may precede any other sign of the disease
by many years.
C. The pathophysiology of SCI has yet to be
completely elucidated, but both spinal and
supraspinal pathways may be involved.
D. Partial or total interruption of afferent
fibers results in the degeneration of presynaptic
terminals and an alteration in function
and structure. Denervated synaptic sites
may be reinnervated by other axons and
previously ineffective synapses may become
active (unmasking). Excitation spreads to
neighboring areas and supersensitivity
occurs, producing an abnormal firing pattern
that may depend on stimulation or
may occur spontaneously. This sequence of
events explains many of the symptoms of
central pain, including dysesthesia (abnormal
firing pattern), spontaneous shooting
pain (paroxysmal burst discharges),
evoked pain from nonpainful stimuli, diffusion
of the evoked abnormal sensation,
and the long-term failure of neurosurgical
treatment.

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17
Q
  1. A 35-year-old female with chronic low-back
    pain comes to see you in your office for the
    first time. You immediately notice her unusual
    affect and behavior. Which of the following
    statements is true?
    (A) Patients with somatization disorder,
    hypochondriasis, factitious physical disorders,
    and malingering may have pain
    complaints as part of their illness
    (B) Malingerers, by definition, are not consciously
    aware of their motivation
    (C) Other psychiatric disorders, such as
    depression, anxiety, and panic attacks,
    may strongly influence chronic pain
    without directly causing it; posttraumatic
    stress disorders do not usually impact a
    pain complaint
    (D) One of the main differences between
    pain associated with malingering and
    pain associated with anxiety is that in
    malingering, complaints or symptoms
    go beyond what should be expected
    from a specific disease process
    (E) None of the above
A
  1. (A)
    A. Common psychiatric conditions that often
    feature pain as part of the illness are somatization
    disorder, hypochondriasis, factitious
    physical disorders, and malingering.
    B. One of the ways to distinguish between
    these condition is whether there is conscious
    awareness (or lack of awareness) of
    both motivation and symptom production.
    Malingerers have a conscious awareness
    and motivation for a pain complaint.
    C. Other psychiatric disorders may strongly
    influence chronic pain without directly
    causing it—depression, anxiety, panic, and
    posttraumatic stress disorders.
    D. Chronic pain complaints often reflect or are
    influenced by psychiatric factors. Physicians
    commonly encounter “illness-affirming
    behaviors” in which patient complaints or
    symptoms go beyond what should be
    expected from a specific disease process.
    This is true of both anxiety and malingering.
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18
Q
  1. Apatient is referred to you by a dentist friend.
    This patient is having pain in and around her
    mouth on one side. Which of the following
    statements is true?
    (A) Primary burning mouth syndrome is a
    chronic, idiopathic intraoral pain condition
    that is not accompanied by clinical
    lesions; some consider it a painful
    neuropathy
    (B) Increasing evidence suggests that very
    few cases of trigeminal neuralgia that
    are classified as idiopathic are caused by
    compression of the trigeminal nerve by
    an aberrant loop of artery or vein
    (C) About 40% of patients with multiple
    sclerosis develop trigeminal neuralgia
    (D) Trigeminal neuralgia can occasionally be
    present over the occiput
    (E) All of the above
A
  1. (A)
    A. Primary burning mouth syndrome is a
    chronic, idiopathic intraoral pain condition
    that is not accompanied by clinical lesions
    but some consider it a painful neuropathy.
    The symptoms are often described as continuous,
    spontaneous, and often intense
    burning sensation in the mouth or tongue.
    B. Increasing evidence suggests that 80% to
    90% of cases that are technically still classified
    as idiopathic are caused by compression
    of the trigeminal nerve close to its exit from
    the brainstem by an aberrant loop of artery
    or vein.
    C. Less than 10% of patients will have symptomatic
    disease associated with an identifiable
    cause other than a vascularcompressive
    lesion—usually a benign tumor or cyst—or
    multiple sclerosis. About 1% to 5% of
    patients with multiple sclerosis develop
    trigeminal neuralgia.
    D. Trigeminal neuralgia, by definition, has to
    be in the distribution of the trigeminal
    nerve (not the distribution occipital nerve).
    Trigeminal neuralgia is defined as paroxysmal
    attacks of pain lasting from a fraction of
    a second to 2 minutes that affect one ormore
    divisions of the trigeminal nerve. Diagnostic
    criteria for classic trigeminal neuralgia:
    • Pain has at least one of these characteristics:
    intense, sharp, superficial, or stabbing precipitated
    from trigger areas or by trigger factors.
    • Attacks are similar in individual patients.
    • No neurological deficit is clinically evident.
    • Not attributed to another disorder.
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19
Q
  1. A patient is referred to you with facial pain.
    Which of the following statements is true?
    (A) The pain of glossopharyngeal neuralgia
    is very similar to that of trigeminal neuralgia
    but affects anterior two-thirds of
    the tongue, tonsils, and pharynx
    (B) Giant cell arteritis is a vasculitic condition
    that can lead to visual loss but has
    never been reported in a case of stroke
    (C) Cervical carotid artery dissection most
    commonly presents with neck, head, or
    facial pain
    (D) Pure facial pain is rarely associated with
    sinusitis alone
    (E) None of the above
A
  1. (C)
    A. The pain of glossopharyngeal neuralgia is
    very similar to that of trigeminal neuralgia
    but affects posterior-third of the tongue,
    tonsils, and pharynx.
    B. Giant cell arteritis is a common systemic
    vasculitis in the elderly. It is commonly
    associated with visual loss and strokes, so it
    must be diagnosed and treated aggressively.
    Temporal artery biopsy is the gold standard
    in the diagnosis of giant cell arteritis.
    Steroids are a common mode of treatment.
    C. Cervical carotid artery dissection most
    commonly present with head, facial, or
    neck pain. Other commonly seen symptoms
    include Horner syndrome, pulsatile
    tinnitus, and cranial nerve palsy.
    D. Pure facial pain is most often caused by
    sinusitis and the chewing apparatus, but
    also a multitude of other causes.
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20
Q
  1. A 47-year-old woman comes into the ER complaining
    of a vague sense of nausea and heart
    palpitations. She has a history of chronic refractory
    angina. Which of the following statements
    regarding chest pain is false?
    (A) In acute coronary syndrome men are
    more likely to present with chest pain,
    left arm pain, or diaphoresis and
    women may present with nausea
    (B) To consider the diagnosis of cardiac syndrome
    X, this patient would have to
    have an abnormal coronary arteriography
    (C) Controlled studies suggest that in
    patients with chronic refractory angina,
    spinal cord stimulation (SCS) provides
    symptomatic relief that is equivalent to
    that provided by surgical or endovascular
    reperfusion procedures, but with a
    lower rate of complications and
    rehospitalization
    (D) The mechanism of action of spinal cord
    stimulation in treating angina is not yet
    completely defined
    (E) None of the above
A
  1. (B)
    A. There are gender differences in the presentation
    of acute coronary syndrome. Men
    are more likely to present with chest pain,
    left arm pain, or diaphoresis. Nausea is
    more common in women.
    B. Cardiac syndrome X is angina-like chest
    pain in the presence of a normal coronary
    arteriography. Although symptoms in
    cardiac syndrome X are often noncardiac,
    a sizable proportion of patients have
    angina pectoris due to transient myocardial
    ischemia.
    C. Despite sophisticated medical and surgical
    procedures, including percutaneous endovascular
    methods, a large number of
    patients suffer from chronic refractory
    angina pectoris. Improvement of pain relief
    in this category of patients requires the use
    of adjuvant therapies, of which spinal cord
    stimulation (SCS) seems to be the most
    promising. Controlled studies suggest that
    in patients with chronic refractory angina,
    SCS provides symptomatic relief that is
    equivalent to that provided by surgical or
    endovascular reperfusion procedures, but
    with a lower rate of complications and
    rehospitalization. Similarly, SCS proved
    cost effective compared to medical as well
    as surgical or endovascular approaches in a
    comparable group of patients.
    D. Using SCS for the treatment of angina is
    still met with reluctance by the medical
    community. Reasons for this disinclination
    may be related to incomplete understanding
    of the action mechanism of SCS.
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21
Q
111. Which of the following statements regarding
knee pain is true?
(A) Children and adolescents who present
with knee pain are likely to have one of
three common conditions: patellar subluxation,
tibial apophysitis, or pseudogout
(B) A patient with a history of diabetes who
presents with acute onset of pain and
swelling of the joint with no antecedent
trauma is likely to have a patellofemoral
pain syndrome
(C) In pseudogout calcium pyrophosphate
crystals are the causative agents
(D) You would not expect to see cystic
changes on radiography of a knee with
suspected osteoarthritis
(E) All of the above
A
  1. (C)
    A. Children and adolescents who present
    with knee pain are likely to have one of
    three common conditions: patellar subluxation,
    tibial apophysitis, or patellar tendonitis.
    Additional diagnoses to consider
    in children include slipped capital femoral
    epiphysis and septic arthritis. Pseudogout
    is more likely present in older adults.
    B. Infection of the knee joint may occur in
    patients of any age but is more common in
    those whose immune system has been
    weakened by cancer, diabetes mellitus,
    alcoholism, acquired immunodeficiency
    syndrome, or corticosteroid therapy. The
    patient with septic arthritis reports abrupt onset of pain and swelling of the knee with
    no antecedent trauma.
    C. Acute inflammation, pain, and swelling
    in the absence of trauma suggest the possibility
    of a crystal-induced inflammatory
    arthropathy such as gout or pseudogout.
    Gout commonly affects the knee. In this
    arthropathy, sodium urate crystals precipitate
    in the knee joint and cause an intense
    inflammatory response. In pseudogout, calcium
    pyrophosphate crystals are the
    causative agents. On physical examination,
    the knee joint is erythematous, warm, tender,
    and swollen. Even minimal range of
    motion is exquisitely painful.
    D. Osteoarthritis of the knee joint is a common
    problem after 60 years of age. The patient
    presents with knee pain that is aggravated
    by weight-bearing activities and relieved by
    rest. The patient has no systemic symptoms
    but usually awakens with morning stiffness
    that dissipates somewhat with activity. In
    addition to chronic joint stiffness and pain,
    the patient may report episodes of acute
    synovitis. Findings on physical examination
    include decreased range of motion, crepitus,
    a mild joint effusion, and palpable
    osteophytic changes at the knee joint.
    Radiographs show joint-space narrowing,
    subchondral bony sclerosis, cystic changes,
    and hypertrophic osteophyte formation.
22
Q
  1. Apatient comes into your clinic complaining of
    right foot pain. Which of the following would
    be a correct diagnosis?
    (A) The most commonly seen neuropathy in
    diabetes, because the symptoms are unilateral
    (B) Plantar fasciitis, because the patient
    develops the symptoms after prolonged
    activity
    (C) Morton neuroma, because it is located
    on the heel
    (D) Tarsal tunnel syndrome, compression of
    the posterior tibial nerve as it passes by
    the medial malleolus
    (E) None of the above
A
  1. (D)
    A. Distal symmetric polyneuropathy is the
    most common neuropathy in diabetes
    (which would affect both legs symmetrically).
    There are other neuropathic entities
    that occur in diabetes, such as mononeuropathy,
    which could affect one foot.
    B. The plantar fascia is frequently a site of
    chronic pain. Patients typically complain
    of pain that starts with the first step on
    arising in the morning or after prolonged
    sitting. Pain onset is usually insidious but
    also may commence after a traumatic
    injury. Diagnosis is made by eliciting pain
    with palpation in the region of origin of the
    plantar fascia. Pain may be worsened by
    passive dorsiflexion of the foot.
    C. The interdigital spaces of the foot are sites
    for the occurrence of painful neuromas, a
    condition termed Morton neuroma. The
    second and third common digital branches
    of the medial plantar nerve are the most
    frequent sites for development of interdigital
    neuromas.
    D. The tarsal tunnel is formed by the medial
    malleolus and a fibrous ligament, the flexor
    retinaculum. The posterior tibial nerve
    passes through the tunnel and can be compressed
    by any condition that reduces the
    space of the tunnel. The medial plantar, lateral
    plantar, and calcaneal branches of the
    posterior tibial nerve innervate the base of
    the foot.
23
Q
  1. A35-year-old woman comes to your clinic complaining
    of pelvic pain. Which of the following
    is important to consider during her evaluation?
    (A) Endometriosis is the most common
    cause of pelvic pain in women
    (B) Endometriosis most likely does not have
    an inflammatory component
    (C) Endometriosis has been shown to be
    primarily dependent on blood levels of
    the hormone progesterone
    (D) An inflammatory process would be supported
    by findings of a decrease of
    interleukin 8 in testing of peritoneal
    fluid
    (E) All of the above
A
  1. (A)
    A. Endometriosis is the commonest cause of
    chronic pelvic pain in women. It is characterized
    by the presence of uterine endometrial
    tissue outside the uterus, most commonly
    in the pelvic cavity. The disorder mainly
    affects women of reproductive age.
    B. Endometriosis has been described as a
    pelvic inflammatory process with altered
    function of immune cells and increased
    number of activated macrophages in the
    peritoneal environment that secrete various
    local products, such as growth factors and
    cytokines.
    C. Endometriosis is estrogen-dependent, and
    traditional treatments have aimed to
    decrease production of estrogens such as
    estradiol. However, the exact mechanism
    by which estrogens promote endometriosis
    is unclear and suppression of estrogens
    has variable effects.
    D. Endometriotic lesions themselves secrete
    proinflammatory cytokines such as interleukin
    8 (IL-8), which recruit macrophages
    and T cells to the peritoneum and mediate
    inflammatory responses.
24
Q
  1. An 85-year-old man comes to your clinic having
    recovered from “a bad pneumonia” recently.
    He now complains of chest pain. Which of the
    following statements is false?
    (A) While the parietal pleura does not contain
    any nociceptive innervation, the
    visceral pleura does
    (B) Viral infection is the most common
    cause of pleurisy
    (C) A description of pain with coughing
    would be consistent with pleurisy
    (D) Pulmonary embolism is a possible cause
    of these symptoms
    (E) None of the above
A
  1. (A)
    A. The visceral pleura do not contain any
    nociceptors or pain receptors. The parietal
    pleura is innervated by somatic nerves that sense pain when the parietal pleura is
    inflamed. Inflammation that occurs at the
    periphery of the lung parenchyma can
    extend into the pleural space and involve
    the parietal pleura, thereby activating the
    somatic pain receptors and causing pleuritic
    pain.
    B. Viral infection is one of the most common
    causes of pleurisy. Viruses that have been
    linked as causative agents include influenza,
    parainfluenza, coxsackieviruses, respiratory
    syncytial virus, mumps, cytomegalovirus,
    adenovirus, and Epstein-Barr virus. Additionally,
    pleurisy may be the first manifestation
    of some less common disorders.
    C. Pleuritic pain typically is localized to the
    area that is inflamed or along predictable
    referred pain pathways. Patients’ descriptions
    of the pain are consistent in most
    cases of pleurisy. The classic feature is that
    forceful breathing movement, such as taking
    a deep breath, talking, coughing, or
    sneezing, exacerbates the pain.
    D. The differential diagnosis of chest pain in this
    patient should include myocardial infarction,
    endocarditis, pulmonary embolism,
    pneumonia, and pneumothorax. Pulmonary
    embolism can cause pleurisy
25
Q
  1. Which of the following statements regarding
    repetitive strain injuries is true?
    (A) Repetitive strain injury does not include
    the specific disorder cubital tunnel syndrome
    (B) Repetitive strain injury is a controversial
    diagnosis partially because there are few
    studies showing an association between
    physical risk factors and injury
    (C) Psychosocial factors are more clearly
    correlated than physical risk factors in
    repetitive strain injury
    (D) The “unifying hypothesis” of repetitive
    strain injury states that most often these
    diseases can be demonstrated to be due
    to focal injury
    (E) All of the above
A
  1. (B)
    A. Repetitive strain injury includes specific
    disorders such as CTS, cubital tunnel syndrome,
    Guyon canal syndrome, lateral
    epicondylitis, and tendonitis of the wrist
    or hand.
    B. Ample evidence exists for the association
    between physical risk factors such as
    repetitive movements, poor posture, and
    inadequate strength and the occurrence of
    repetitive strain injury.
    C. The effects of work-related and psychosocial
    factors are not as clear as those of physical
    factors, although high workload, stress,
    and physical or psychological demands,
    low job security, and little support from colleagues
    might be important.
    D. Several hypotheses for the pathophysiology
    of repetitive strain injury exist, but none
    has been strongly supported by scientific
    evidence. Despite initial distal presentation,
    this disorder seems to be a diffuse
    neuromuscular illness. Mechanical (elastic
    deformation of connective tissue due to
    increased pressure within muscles) and
    physiological (electrochemical and metabolic
    imbalances) reactions might cause
    damage to muscle tissue and lead to complaints
    of strain. Continuous contraction of
    muscles from long-term static load with
    insufficient breaks could result in reduced
    local blood circulation and muscle fatigue.
    Consequently, pain sensors in the muscles
    could become hypersensitive, leading to a
    pain response at low levels of stimulation.
    Other hypotheses suggest frequent cocontractions
    in muscles or changes in proprioception
    as the source of injury. There is no
    unifying hypothesis.
26
Q
  1. A 56-year-old woman comes into your clinic
    complaining of chest pain on the left. She has a
    history of breast cancer with mastectomy and
    radiation treatment. She may still have
    chemotherapy. Which of the following statements
    is true?
    (A) As treatments for breast cancer have
    advanced in the past decade, the incidence
    of this type of pain has plummeted
    (B) The incidence of peripheral neuropathy
    would be higher with cisplatin than
    with paclitaxel
    (C) With chemotherapy, there is a higher incidence
    of motor than sensory neuropathy
    (D) Axillary dissection poses risks to the
    intercostobrachial nerve and the medial
    cutaneous nerve of the arm
    (E) All of the above
A
  1. (D)
    A. Chronic pain following surgical procedures
    for breast cancer was once thought to
    be rare. The results of recent studies, however,
    suggest that the incidence of chronic
    pain following breast cancer surgery may
    be more than 50%. Although most surgical
    advances are less invasive and have fewer
    complications, the rapid pace of change in
    treatment complicates outcome research.
    B. Peripheral neuropathy, often painful, is
    common after paclitaxel, a second-line therapy
    for metastatic disease, and also occurs
    with other chemotherapeutic agents. The
    incidence of peripheral neuropathy is lower
    with platinum compounds like cisplatin.
    C. Sensory neuropathies are more common in
    chemotherapy than motor neuropathies.
    D. Axillary dissection poses risks to the intercostobrachial
    nerve, from stretch during
    retraction as well as from frank transection.
    Many patients will be left with an
    area of numbness on the upper inner arm,
    signifying damage to the intercostobrachial
    nerve, but only a minority of these
    will be painful. Other nerves at risk for
    damage from axillary dissection include
    the medial cutaneous nerve of the arm, which contains fibers from C8 and T1 and
    arises from the medial cord of the brachial
    plexus. It can be harmed during section of
    the tributaries of the axillary vein, leaving
    patients with sensory loss on the lower
    medial skin of the upper arm. Pain accompanied
    by sensory loss in one of these areas
    provides the basis for a diagnosis of injury
    to these specific nerves.
27
Q
  1. A52-year-old obese male with a 5-year history
    of diabetes is complaining of foot pain. Which
    of the following statements is false?
    (A) If this patient has “large-fiber” nerve
    dysfunction, it may include weakness
    (B) Blood sugar abnormalities have been
    shown to correlate with degree of nerve
    dysfunction
    (C) Neuropathy has been described in the
    context of diabetes and blood sugar
    levels less than the criteria for diabetes
    mellitus as defined by the American
    Diabetes Association have not been
    shown to correlate with neuropathy
    (D) Small fiber neuropathy can have autonomic
    features
    (E) None of the above
A
  1. (C)
    A. Peripheral nerves are composed of largeand
    small-diameter nerve fibers. Symptoms
    associated with large-diameter nerve fiber
    dysfunction include weakness, numbness,
    tingling, and loss of balance, while those
    associated with small-diameter nerve
    fiber damage include pain, anesthesia to
    pin and temperature sensation, and autonomic
    dysfunction (eg, changes in local
    vasoregulation).
    B. Diabetes duration and blood sugar control
    correlate with the development of neuropathy.
    C. Neuropathy with a predilection for smalldiameter
    nerve fibers can appear with
    impaired glucose tolerance, a prediabetic
    state that does not meet the criteria for diabetes
    mellitus as defined by the American
    Diabetes Association. Although this neuropathy
    is usually milder than the neuropathy
    seen in frank diabetes mellitus,
    impaired glucose tolerance has been associated
    with severe painful polyneuropathy
    without another known etiology.
    D. As these painful symptoms often result
    from small-diameter nerve fiber dysfunction,
    patients may have accompanying
    abnormalities of autonomic function in the
    feet (eg, decreased sweating, dry skin, and
    impaired vasomotor control).
28
Q
  1. An 85-year-old woman comes into your clinic
    with chronic pain over her left breast for more
    than 1 year. The symptoms began after she
    broke out in a rash in the same distribution.
    Which of the following statements is true?
    (A) Zoster reactivation is always accompanied
    by a rash
    (B) Zoster reactivation may occur two to
    three times for a healthy individual
    (C) Post herpetic neuralgia (PHN) is pain
    that persists for more than 120 days
    (D) The incidence of PHN is expected to
    remain stable in the future
    (E) All of the above
A
  1. (C)
    A. Reactivation of the varicella-zoster virus
    can cause dermatomal pain without a rash
    in a process termed “zoster sine herpete.”
    This cannot be made on the basis of clinical
    presentation alone and would require
    evidence of concurrent viral reactivation.
    B. Zoster reactivation typically occurs once for
    an individual. Atypical manifestations that
    occur in immunocompromised patients
    include prolonged course, recurrent lesions,
    and involvement of multiple dermatomes.
    Diagnostic laboratory tests are recommended
    when herpes simplex must be ruled out
    (eg, recurrent rash or sacral lesions) and for
    patients with atypical lesions.
    C. Until recently, these definitions have been
    arbitrary, but the results of recent research
    now provide support for the validity of
    distinguishing between three phases of
    pain in affected and adjacent dermatomes:
    (1) herpes zoster acute pain (also termed
    acute herpetic neuralgia), defined as pain
    that occurs within 30 days after rash onset;
    (2) subacute herpetic neuralgia, defined as
    pain that persists beyond the acute phase
    but that resolves before the diagnosis of
    PHN can be made; and (3) PHN, defined
    as pain that persists 120 days or more after
    rash onset.
    D. It can also be predicted that the number of
    adults developing herpes zoster in the
    United States may increase as a consequence
    of reduced opportunities for subclinical
    immune boosting resulting from
    near-universal varicella vaccination of children.
    Recent data showing an increase in
    herpes zoster in the United States are consistent
    with this prediction. An increase in
    the incidence of herpes zoster could be offset
    by zoster vaccination, but the extent to
    which widespread herpes zoster vaccination
    will occur is presently unknown.
29
Q
  1. Apatient comes into your clinic without a referral.
    He has a long history of chronic pain. He
    reports having some implantable device but he
    is unsure what it is. On examination, you find a
    surgical scar over the left lower quadrant of his
    abdomen. Over the past several weeks he has
    been developing worsening lower extremity
    pain. Your examination reveals spasticity. Which
    of the following is important to consider?
    (A) If the patient is getting intrathecal morphine,
    the rate of infusion would not
    have any impact on his complaint
    (B) If this patient has an intrathecal pump,
    only intrathecal morphine has been
    shown to result in granuloma formation
    (C) A microscopic investigation of an
    intrathecal morphine related granuloma
    would reveal necrotic tissue without
    immune cells
    (D) Morphine is a hydrophilic molecule
    (E) All of the above
A
  1. (D) This patient has evidence of having an
    intrathecal pump with granuloma formation.
    A. There is a strong relationship between higher
    doses of intrathecal morphine and granuloma
    formation. The notion that high-dose
    morphine is causative is not universally
    accepted. Some authors have suggested that
    long-term administration of opiates may
    lead to localized fibrosis and the formation
    of a granulomatous mass surrounding the
    catheter tip.
    B. There have been cases of granuloma formation
    reported involving the intrathecal infusion
    of baclofen. These lesions did not
    appear to cause any compression of the
    spinal cord or neurological deficits, resolved
    when the catheter tip was replaced, and
    could represent a different disease process.
    C. Microscopic pathology of intrathecal morphine
    related granulomas often reveals
    necrotic tissue surrounded by macrophages,
    plasma cells, eosinophils, or lymphocytes.
    Nearby vessels may be surrounded by
    mononuclear inflammatory cells consisting
    predominantly of plasma cells. Gross pathologic
    examination of catheter tip granulomas
    related to intrathecal morphine infusions
    often demonstrates the mass conforming to
    the distal portion of the catheter.
    D. Because of its (morphine) hydrophilic structure,
    it has a prolonged duration of action
    and due to the drug’s high localization; its
    analgesic effect is maximized at a lower
    dose. This results in a lower incidence of
    systemic side effects, reduces drug dependence,
    and does not significantly influence
    motor, sensory, or sympathetic reflexes.
30
Q
  1. The patient from question 119, relates that over
    the past decade he has had three back surgeries.
    This is why he thinks that the intrathecal
    pump was implanted. He reports that the first
    back surgery helped him for 6 months but the
    symptoms returned. The subsequent back surgeries
    only made his symptoms worse. Which
    of the following statements regarding this
    patient’s condition is true?
    (A) In failed back surgery syndrome (FBSS),
    the most common structural cause of
    symptoms has been shown to be foraminal
    stenosis
    (B) In FBSS, pure psychogenic pain is somewhat
    common
    (C) In the context of chronic pain, an
    improvement of 30% is usually considered
    satisfactory
    (D) Failed back surgery syndrome, for the
    most part, implies a specific anatomical
    derangement
    (E) None of the above
A
  1. (C)
    A. In the three studies that looked at the causes
    of FBSS, the most common structural
    causes of FBSS are foraminal stenosis (25%-
    29%), painful disc (20%-22%), pseudarthrosis
    (14%), neuropathic pain (10%), recurrent
    disc herniation (7%-12%), iatrogenic instability
    (5%), facet pain (3%), and sacroiliac
    joint (SIJ) pain (2%), among some others.
    B. Most patients with refractory low-back pain
    have symptoms of at least one major psychiatric
    disorder, most commonly depression,
    substance abuse disorder or anxiety
    disorder. Pure psychogenic pain (pain disorder,
    psychological type) is rare in patients
    with FBSS. All patients have some pain
    behavior, which may be appropriate or
    inappropriate.
    C. In patients with chronic pain, an improvement
    in visual analog scale (VAS) score of
    1.8 U, equivalent to a change in pain of
    about 30%, may be considered a satisfactory
    result.
    D. FBSS is a nonspecific term that implies that
    the final outcome of surgery did not meet
    the expectations of both the patient and the
    surgeon that were established before
    surgery.
31
Q
121. Which of the following statements is false
regarding pain and pregnancy?
(A) One of the common causes of pain in
early pregnancy includes stretch and
hematoma formation in the round
ligaments
(B) Radicular symptoms usually suggest a
herniated disc
(C) Pregnancy is not an absolute contraindication
to radiography
(D) Migraine headaches rarely begin during
pregnancy
(E) All of the above
A
  1. (B)
    A. True, this process usually begins at 16 to
    20 weeks. In early pregnancy it is important
    to exclude unruptured ectopic pregnancy
    and ovarian torsion.
    B. Radicular symptoms are common during
    pregnancy; there is a low incidence of herniated
    disc associated with these complaints.
    C. Limited plain radiographs that are considered
    vital may be okay to perform during
    pregnancy according to some studies.
    D. It is true that if a new onset migraine
    occurs during pregnancy, one should
    investigate a secondary cause (including
    consideration for an MRI).
32
Q
  1. A 10-year-old boy with a diagnosis of sickle cell
    disease comes into your clinic. Which of the following
    statements is true regarding his condition?
    (A) A vasoocclusive crisis commonly
    involves the back, legs, and eyes
    (B) Acute pain in patients with sickle cell
    disease is caused by ischemic tissue
    injury resulting from the occlusion of
    macrovascular beds by sickled erythrocytes
    during an acute crisis
    (C) When a vasoocclusive crisis lasts longer
    than 7 days, it is important to search for
    other causes of bone pain
    (D) Patients with homozygous sickle cell and
    sickle cell–β-thalassemia have a lower
    frequency of vasoocclusive pain crises
    than patients with hemoglobin sickle cell
    and sickle cell–β-thalassemia genotype
    (E) None of the above
A
  1. (C)
    A. A vasoocclusive crisis most commonly
    involves the back, legs, knees, arms, chest,
    and abdomen. The pain generally affects
    two or more sites. Bone pain tends to be
    bilateral and symmetric. Recurrent crises in
    an individual patient usually have the same
    distribution.
    B. Acute pain in patients with sickle cell
    disease is caused by ischemic tissue injury
    resulting from the occlusion of microvascular
    beds by sickled erythrocytes during
    an acute crisis. Acute bone pain from
    microvascular occlusion is a common reason
    for emergency department (ED) visits
    and hospitalizations in patients with sickle
    cell disease. Obstruction of blood flow
    results in regional hypoxemia and acidosis,
    creating a recurrent pattern of further
    sickling, tissue injury, and pain. The severe
    pain is believed to be caused by increased
    intramedullary pressure, especially within
    the juxta-articular areas of long bones, secondary to an acute inflammatory
    response to vascular necrosis of the bone
    marrow by sickled erythrocytes. The pain
    may also occur because of involvement of
    the periosteum or periarticular soft tissue
    of the joints.
    C. When a vasoocclusive crisis lasts longer than
    7 days, it is important to search for other
    causes of bone pain, such as osteomyelitis,
    avascular necrosis, and compression deformities.
    When a recurrent bone crisis lasts for
    weeks, an exchange transfusion may be
    required to abort the cycle.
    D. Patients with homozygous sickle cell and
    sickle cell–β-thalassemia have a higher frequency
    of vasoocclusive pain crises than
    patients with hemoglobin sickle cell and
    sickle cell–β-thalassemia genotype.
33
Q
  1. You enter a clinic’s examination room to do a
    new evaluation on a patient. You find the patient
    leaning back on the chair in a deep sleep. Upon
    waking the patient up, you immediately notice
    an inappropriate affect and decreased movement
    of the right arm and leg. Which of the
    following statements is false?
    (A) Sleep disturbance, which can occur in
    the context of depression, can cause
    chronic pain
    (B) The diagnostic criteria of substance abuse
    includes recurrent substance use in situations
    where it is physically hazardous
    (C) The diagnostic criteria of substance
    dependence includes recurrent substance
    use in situations where it is physically
    hazardous
    (D) Conversion disorder is voluntary
    (E) None of the above
A
  1. (B)
    A. Depression produces well documented
    disturbances to sleep architecture including
    reduced slow-wave sleep and early
    onset rapid-eye-movement (REM) sleep.
    Sleep disturbance has been well documented
    in fibromyalgia.
    B. This is one of the Diagnostic and Statistical
    Manual of Mental Disorders (Fourth Edition)
    (DSM-IV) diagnostic criteria of substance
    abuse.
    C. This is not included as one of the DSM IV
    diagnostic criteria for substance dependence.
    D. Conversion disorder is an alteration in
    voluntary motor or sensory function that
    suggests a neurologic or general medical
    condition.
34
Q
  1. A patient comes into your clinic several years
    after sustaining a SCI. He complains of pain in
    multiple areas of his body. Which of the following
    statements is true regarding this patient’s
    pain?
    (A) Chronic pain is a major complication of
    SCI with approximately two-thirds of all
    SCI patients experiencing some type of
    chronic pain and up to one-third complaining
    that their pain is severe
    (B) Central pain is the only cause of pain in
    patients with SCI
    (C) Cervical spine injuries have the highest
    incidence of central pain of all the spinal
    cord injuries
    (D) Central pain that occurs at the level of
    the SCI is because of nerve root damage
    (E) All of the above
A
  1. (A)
    A. Chronic pain is a major complication of
    SCI with approximately two-thirds of all
    SCI patients experiencing some type of
    chronic pain, and up to one-third complaining
    of that their pain is severe. The
    prevalence of pain after SCI often increases
    with time after injury.
    B. In addition to central pain, there are multiple
    types of pain that develop after SCI
    including musculoskeletal, visceral, and
    peripheral neuropathic pain.
    C. Central pain has been reported with injury
    to all levels of the spinal cord. There is conflicting
    evidence in the literature as to the
    level of injury that results in greatest frequency
    or severity of central pain, whether
    incomplete spinal cord lesions may result
    in a higher incidence of central pain or
    whether there is a link between type of
    injury and the development of central pain.
    D. Central neuropathic pain after SCI has
    been categorized based on the location of
    the complaint as either at the level of the
    injury or below the level of the injury.
    Although it may be difficult to distinguish
    the two clinically (and both may be present
    in the same patient), central pain that
    occurs at the level of injury is because of
    segmental spinal cord damage, and not
    because of nerve root damage.
35
Q
  1. The patient from the previous question used to
    be an anatomy and physiology teacher at a
    local college and is asking about some details
    about the mechanism of central pain in spinal
    cord injury (SCI). Which of the following explanations
    would you not give him?
    (A) Prolonged high intensity noxious stimulation
    activates the N-methyl-Daspartate
    (NMDA) receptors which
    induces a cascade that may result in
    central sensitization
    (B) Abnormal sodium channel expression
    may be involved
    (C) Thalamic neurons thought to be
    involved in the generation of pain
    undergo changes after SCI
    (D) Thalamic neurons in SCI are relay
    stations for pain signals but not pain
    generators
    (E) All of the above
A
  1. (D)
    A. Physiologic changes occur to the nociceptive
    neurons in the dorsal horn following
    SCI including an increase in abnormal
    spontaneous and evoked discharges from
    dorsal horn cell. Noxious stimulation
    causes primary afferent C-fibers to release
    excitatory amino acid neurotransmitters in
    the dorsal horn. Prolonged high intensity
    noxious stimulation activates the NMDA
    receptors which induces a cascade that
    may result in central sensitization.
    B. On a molecular level, abnormal sodium
    channel expression within the dorsal horn
    (laminae L1-L4) bilaterally has been implicated
    as a major contributor to hyperexcitability.
    These pain relay neurons tend to
    show increase activity with noxious and
    nonnoxious stimuli thus serving as a pain
    amplifier.
    C. Thalamic neurons appear to undergo
    changes after SCI in both human and animal
    models. In the animal model, enhanced
    neuronal excitability in the VPL has been
    demonstrated directly and as well as indirectly;
    enhanced regional blood flow has been found in the rate VPL after SCI suggesting
    increased neuronal activity.
    D. Much like the neurons in the dorsal horn,
    the thalamic neurons after SCI show
    increased activity with noxious and nonnoxious
    stimuli. VPL neurons are spontaneously
    hyperexcitable following SCI
    without receiving input from the spinal
    cord neurons suggesting that the thalamus
    may act as a pain-signal generator in central
    pain accompanying SCI.
36
Q
  1. Chronic pancreatitis is the progressive and permanent
    destruction of the pancreas resulting in
    exocrine and endocrine insufficiency and, often,
    chronic disabling pain. Which of the following
    statements about chronic pancreatitis is incorrect?
    (A) Excessive alcohol use plays a significant
    role in up to 70% of adults with chronic
    pancreatitis, whereas genetic and structural
    defects predominate in children
    (B) The pain with chronic pancreatitis is
    commonly described as midepigastric
    postprandial pain that radiates to the
    back and that can sometimes be relieved
    by sitting upright or leaning forward
    (C) Autoimmune pancreatitis accounts for
    up to 5% of cases
    (D) Because of its uniform presentation
    most cases of chronic pancreatitis are
    diagnosed
    (E) None of the above
A
  1. (D)
    A. Excessive alcohol use plays a significant
    role in up to 70% of adults with chronic
    pancreatitis. Genetic and structural defects
    predominate in children.
    B. Patients may have recurrent episodes of
    acute pancreatitis, which can progress to
    chronic abdominal pain. The pain is commonly
    described as midepigastric postprandial
    pain that radiates to the back and that
    can sometimes be relieved by sitting upright
    or leaning forward. In some patients there is
    a spontaneous remission of pain by organ
    failure (pancreatic burnout theory). Patients
    may also present with steatorrhea, malabsorption,
    vitamin deficiency (A, D, E, K, and
    B12), diabetes, or weight loss. Approximately
    10% to 20% of patients may have exocrine
    insufficiency without abdominal pain.
    C. Autoimmune pancreatitis accounts for 5%
    to 6% of chronic pancreatitis and is characterized
    by autoimmune inflammation,
    lymphocytic infiltration, fibrosis, and pancreatic
    dysfunction.
    D. Because of its varied presentation and
    clinical similarity to acute pancreatitis,
    many cases of chronic pancreatitis are not
    diagnosed
37
Q
  1. The definition of pain that is endorsed by the
    International Association for the Study of Pain
    is “Pain is an unpleasant sensory and emotional
    experience associated with actual or
    potential tissue damage, or described in terms of
    such damage.” There are a host of physiologic
    mechanisms by which injuries lead to nociceptive
    responses and ultimately to pain. That
    being said, not all nociceptive signals are
    perceived as pain and not every pain sensation
    originates from nociception. Which of the
    following statements regarding pain is false?
    (A) Mainly two types of pain receptors are
    activated by nociceptive input. These
    include low-threshold nociceptors that
    are connected to fast pain-conducting A-δ
    fibers, and high-threshold nociceptors
    that conduct impulses in slow (unmyelinated)
    C fibers
    (B) Many neurotransmitters (ie, glutamate
    and substance P) are able to modulate
    postsynaptic responses with further
    transmission to supraspinal sites (thalamus,
    anterior cingulated cortex, insular
    cortex, and somatosensory cortex) via
    ascending pathways
    (C) Prolonged or strong activity of dorsal
    horn neurons caused by repeated or sustained
    noxious stimulation may subsequently
    lead to increased neuronal
    responsiveness or central sensitization
    (D) Windup refers to a mechanism present
    in the peripheral nervous system in
    which repetitive noxious stimulation
    results in a slow temporal summation
    that is experienced in humans as
    increased pain
    (E) Substance P is an important nociceptive
    neurotransmitter. It lowers the threshold
    of synaptic excitability, resulting in the
    unmasking of normally silent interspinal
    synapses and the sensitization of
    second-order spinal neurons
A
  1. (D)
    A. Mainly two types of pain receptors are
    activated by nociceptive input. These
    include low-threshold nociceptors that are
    connected to fast conducting A-δ pain
    fibers, and high-threshold nociceptors that
    conduct impulses in slow (unmyelinated)
    C fibers. Within the dorsal horn of the
    spinal cord, these pain fibers synapse with
    spinal neurons via synaptic transmission.
    B. Many neurotransmitters (ie, glutamate
    and substance P) are able to modulate the
    postsynaptic responses with further transmission
    to supraspinal sites (thalamus,
    anterior cingulated cortex, insular cortex,
    and somatosensory cortex) via the ascending
    pathways.
    C. The simplest form of plasticity in nervous
    systems is that repeated noxious stimulation
    may lead to habituation (decreased response)
    or sensitization (increased response).
    Prolonged or strong activity of dorsal horn
    neurons caused by repeated or sustained
    noxious stimulation may subsequently lead
    to increased neuronal responsiveness or central
    sensitization. Neuroplasticity and subsequent
    CNS sensitization include altered
    function of chemical, electrophysiological,
    and pharmacological systems. These
    changes cause exaggerated perception of
    painful stimuli (hyperalgesia), a perception
    of innocuous stimuli as painful (allodynia),
    and may be involved in the generation of
    referred pain and hyperalgesia across multiple
    spinal segments. While the exact mechanism
    by which the spinal cord becomes
    sensitized or in “hyperexcitable” state currently
    remains somewhat unknown, some
    contributing factors have been proposed.
    D. Windup refers to a central spinal mechanism
    in which repetitive noxious stimulation
    results in a slow temporal summation
    that is experienced in humans as increased
    pain. In 1965, animal experiments showed
    for the first time that repetitive C fiber
    stimulation could result in a progressive
    increase of electrical discharges from the
    second-order neuron in the spinal cord.
    This mechanism of pain amplification in
    the spinal cord is related to temporal summation
    of second pain or windup. Second
    pain, which is more dull and strongly related
    to chronic pain states, is transmitted
    through unmyelinated C fibers to dorsal
    horn nociceptive neurons. During the C
    fibers transmitted stimuli, NMDA receptors of second-order neurons become activated.
    It is well-known that NMDA activation
    induces calcium entry into the dorsal horn
    neurons. Calcium entry into sensory neurons
    in the dorsal horn induces activation
    of nitric oxide (NO) synthase, leading to
    the synthesis of NO. NO can affect the
    nociceptor terminals and enhance the
    release of sensory neuropeptides (in particular,
    substance P) from presynaptic neurons,
    therefore contributing to the development of
    hyperalgesia and maintenance of central
    sensitization.
    E. Substance P is an important nociceptive
    neurotransmitter. It lowers the threshold of
    synaptic excitability, resulting in the
    unmasking of normally silent interspinal
    synapses and the sensitization of secondorder
    spinal neurons. Furthermore, substance
    P can extend for long distances in the
    spinal cord and sensitize dorsal horn neurons
    at a distance from the initial input
    locus. This results in an expansion of receptive
    fields and the activation of wide dynamic
    neurons by nonnociceptive afferent
    impulses.
38
Q
  1. The presence of several pain inhibitory and
    facilitatory centers in the brainstem is well recognized.
    Which of the following regarding
    these systems is incorrect?
    (A) The dorsolateral funiculus is involved in
    a pathway for descending pain inhibitory
    systems
    (B) One function of the descending inhibitory
    pathway is to expand the excitation of
    the dorsal horn neurons
    (C) The activity in descending pathways is
    not constant but can be modulated, for
    example, by the level of vigilance or
    attention and by stress
    (D) Certain cognitive styles and personality
    traits have been associated with amplification
    of pain and its extension in the
    absence of tissue damage. These include
    somatization, catastrophizing, and
    hypervigilance
    (E) All of the above
A

(B)
A. The presence of several pain inhibitory
and facilitatory centers in the brainstem is
well recognized. The dorsolateral funiculus
appears to be a preferred pathway for
descending pain inhibitory systems.
B. One function of the descending inhibitory
pathway is to ‘focus’ the excitation of the
dorsal horn neurons. The effect is to generate
a more urgent, localized, and rapid
pain signal by suppressing surrounding
neuronal activity.
C. Facilitatory pathways leading from the
brainstem have also been identified. There is
now behavioral evidence that forebrain centers
are capable of exerting powerful clinically
significant influences on various nuclei
of the brainstem, including the nuclei identified
as the origin of the descending facilitatory
pathway. The activity in descending
pathways is not constant but can be modulated,
for example, by the level of vigilance
or attention and by stress. This has been
referred to as cognitive emotional sensitization.
Forebrain products such as cognitions,
emotions, attention, and motivation have
influence on the clinical pain experience.
D. Certain cognitive styles and personality
traits have been associated with the amplification
of pain and its extension in the
absence of tissue damage. These include
somatization, catastrophizing, and hypervigilance.
Thus, via descending pathways
behavioral and cognitive therapies might
also effect synaptic transmission in the
spinal cord and thereby have the capacity
to prevent or reverse long-term changes of
synaptic strength in pain pathways.

39
Q
  1. Which of the following statements is incorrect
    regarding the mechanisms of neuropathic pain?
    (A) Injured and neighboring noninjured
    sensory neurons can develop a change
    in their excitability sufficient to generate
    pacemaker-like potentials, which evoke
    ectopic action potential discharges, a
    sensory inflow independent of any
    peripheral stimulus
    (B) Central sensitization represents a state
    of heightened sensitivity of dorsal horn
    neurons such that their threshold of activation
    is reduced, and their responsiveness
    to synaptic inputs is augmented
    (C) After peripheral nerve injury C fiber
    input may arise spontaneously and
    drive central sensitization
    (D) The negative symptoms of neuropathic
    pain, such as allodynia, essentially
    reflect loss of sensation owing to
    axon/neuron loss
    (E) All of the above
A
  1. (D)
    A. Injured and neighboring noninjured sensory
    neurons can develop a change in
    their excitability sufficient to generate
    pacemaker-like potentials, which evoke
    ectopic action potential discharges, a sensory
    inflow independent of any peripheral
    stimulus. These changes may manifest at
    the site of the injury, at the neuroma, and
    in the DRG. Ectopic input is most prominent
    in A fibers but also occurs to a more
    limited extent in cells with unmyelinated
    axons (ie, C fibers).
    B. Central sensitization represents a state of
    heightened sensitivity of dorsal horn neurons
    such that their threshold of activation
    is reduced, and their responsiveness to
    synaptic inputs is augmented. There are two
    forms of central sensitization; an activitydependent
    form that is rapidly induced
    within seconds by afferent activity in nociceptors
    and which produces changes in
    synaptic efficacy that last for tens of minutes
    as a result of the phosphorylation and
    altered trafficking of voltage- and ligandgated
    ion channel receptors, and a transcription-
    dependent form that takes some
    hours to be induced but outlast the initiating
    stimulus for prolonged periods.
    C. After peripheral nerve injury C fiber input
    may arise spontaneously and drive central
    sensitization.
    D. Peripheral neuropathic pain, that clinical
    pain syndrome associated with lesions to
    the peripheral nervous system, is characterized
    by positive and negative symptoms.
    Positive symptoms include spontaneous
    pain, paresthesia, and dysesthesia, as well
    as a pain evoked by normally innocuous
    stimuli (allodynia) and an exaggerated or
    prolonged pain to noxious stimuli (hyperalgesia/
    hyperpathia). The negative symptoms
    essentially reflect loss of sensation
    due to axon/neuron loss; the positive
    symptoms reflect abnormal excitability of
    the nervous system.
40
Q
  1. Which of the following statements about prolonged
    opiate use is false?
    (A) A patient who maintains the same dose
    of opiate over a prolonged period of time
    is not at risk for developing tolerance
    (B) Patients who receive long-term opiate
    therapy may be at risk of developing a
    paradoxical opioid induced pain
    (C) Pharmacologic induction of pain may
    occur through activation of the rostral
    ventromedial medulla
    (D) There is evidence that over the long
    term, opiates suppress pain by upregulation
    of spinal dynorphin, and
    enhanced, evoked release of excitatory
    transmitters from primary afferents
    (E) None of the above
A
  1. (D)
    A. It is well recognized that the prolonged
    use of opioids is associated with a requirement
    for ever-increasing doses in order to
    maintain pain relief at an acceptable and
    consistent level. This phenomenon is
    termed analgesic tolerance. All patients on
    opiates are at risk to develop tolerance.
    B. Tolerance may also be related to a state of
    hyperalgesia that results from exposure to
    the opioid itself. Patients who receive longterm
    opioid therapy sometimes develop
    unexpected, abnormal pain. Similar paradoxical
    opioid-induced pain has been confirmed
    in a number of animal studies, even
    during the period of continuous opioid
    delivery. This has been termed opiateinduced
    hyperalgesia (OIH).
    C. A number of recent studies have demonstrated
    that such pain may be secondary to
    neuroplastic changes that occur in the
    brain and spinal cord. One such change
    may be the activation of descending pain
    facilitation mechanisms arising from the
    rostral ventromedial medulla (RVM).
    D. Opioids elicit systems-level adaptations
    resulting in pain due to descending facilitation,
    upregulation of spinal dynorphin,
    and enhanced, evoked release of excitatory
    transmitters from primary afferents. These
    adaptive changes in response to sustained
    exposure to opioids indicate the need for
    the evaluation of the clinical consequences
    of long-term opioid administration.
41
Q
  1. An anatomy/physiology professor sees you in
    clinic. You believe he meets criteria for CRPS.
    He has several questions about the autonomic
    nervous system. Which of the following would
    you highlight to him as a significant difference
    between the peripheral pathways of the autonomic
    and somatic motor nervous system?
    (A) Unlike the somatic motor system which
    has its motor neurons in the CNS, the
    motor neurons of the autonomic nervous
    system (ANS) are located in the
    periphery
    (B) The peripheral efferent pathways of the
    somatic motor nervous system has two
    components: a primary presynaptic or
    preganglionic neuron, and a secondary
    postsynaptic or postganglionic neuron
    (C) The cell bodies of somatic motor nerves
    forms aggregates in the periphery called
    ganglia
    (D) There are no significant differences
    (E) All of the above
A
  1. (A)
    A. Unlike the somatic motor system which has
    its motor neurons in the CNS, the motor
    neurons of the ANS are located in the
    periphery.
    B. The peripheral efferent pathways of both
    the sympathetic and parasympathetic
    nervous system have two components: a
    primary presynaptic or preganglionic neuron,
    and a secondary postsynaptic or postganglionic
    neuron.
    C. The cell bodies of the autonomic postganglionic
    neurons are arranged in aggregates
    known as ganglia, wherein the synapses
    between pre- and postganglionic neurons
    take place. The transmission of signal from
    the CNS synapses at an autonomic ganglia
    in the periphery prior to reaching the target
    organ.
    D. There are multiple differences between the
    two systems. Some of the important points
    are highlighted above.
42
Q
  1. The professor from question 131 has several
    more questions about the autonomic nervous
    system. You would make all of the following
    statements about the sympathetic and parasympathetic
    divisions of the autonomic nervous
    system, EXCEPT
    (A) the parasympathetic preganglionic fibers
    travel from the CNS to synapse in ganglia
    located close to their target organs
    (B) while sympathetic nerve fibers are distributed
    throughout the body, parasympathetic
    fibers generally only innervate
    visceral organs
    (C) the preganglionic sympathetic neurons
    have their cell bodies in the gray matter
    of the brainstem and their fibers travel
    with the oculomotor, facial, glossopharyngeal,
    and vagus nerves
    (D) the efferent portion of the sympathetic
    division of the ANS includes preganglionic
    neurons, the two paravertebral
    (lateral) sympathetic chains, prevertebral
    and terminal ganglia, and postganglionic
    neurons
    (E) none of the above
A
  1. (C)
    A. The parasympathetic preganglionic fibers
    travel from the CNS to synapse in ganglia
    located close to their target organs. In most
    areas, parasympathetic innervation tends
    to be more precise than sympathetic innervation.
    B. Sympathetic fibers are generally distributed
    throughout the body. Parasympathetic
    fibers are generally only innervating the visceral
    organs.
    C. The preganglionic parasympathetic neurons
    have their cell bodies in the gray matter
    of the brainstem and their fibers travel
    with the oculomotor, facial, glossopharyngeal,
    and vagus nerves. The preganglionic
    fibers from the oculomotor, facial, and
    glossopharyngeal nerves synapse in the
    ciliary, sphenopalatine, otic, and submaxillary
    ganglia, all of which are located in
    the head. From these ganglia, the postganglionic
    fibers travel to the target organs
    (eg, the lacrimal and salivary glands).
    D. The efferent portion of the sympathetic division
    of the ANS consists of preganglionic neurons, the two paravertebral (lateral) sympathetic
    chains, prevertebral and terminal
    ganglia, and postganglionic neurons.
43
Q
133. A patient with a history of cancer comes to
your clinic complaining of neck, shoulder, and
arm pain. Which of the following is an important
consideration?
(A) Most tumors that affect the brachial
plexus are from skin cancer
(B) The most common presenting complaint
of a tumor affecting the brachial plexus
is pain
(C) Radiation induced plexopathy has not
been shown to be dependent on dose of
radiation
(D) Clinically, it is nearly impossible to distinguish
between neoplastic and radiation
plexopathy
(E) All of the above
A
  1. (B)
    A. Most tumors involving the brachial plexus
    originate from the lung or breast and as a
    result often invade the lower plexus, particularly
    the inferior trunk and medial cord.
    B. Pain was the most common presenting
    symptom (75%) in a large study of neoplastic
    brachial plexopathy and usually
    was located in the shoulder and axilla.
    Radicular pain was often distributed along
    the medial aspect of the arm and forearm
    into the fourth and fifth fingers. Motor and
    reflex findings commonly (75%) were in
    the lower plexus distribution (especially
    C8-T1). Most remaining patients had signs
    of more widespread (C5-T1) plexus
    involvement.
    C. Radiotherapy can produce plexus injury by
    both direct toxic effects on axons and on the
    vasa nervorum, with secondary microinfarction
    of nerve. Neurotoxicity is doserelated
    for greater than 1000 cGy, pathologic
    changes can be observed in Schwann cells,
    endoneurial fibroblasts, and vascular and
    perineural cells. Administration of 3500 Gy
    has produced injury to anterior and posterior
    nerve roots in rodents.
44
Q
  1. A patient with a history of multiple sclerosis
    comes into your office for an initial consult.
    She is wheelchair bound and has an intrathecal
    pump. She skipped the last appointment with
    her previous pain physician because she “did
    not like his bed-side manner.” She cannot recall
    exactly, but it probably has been 3 months since
    she saw a pain physician. Which of the following
    is an important consideration?
    (A) A withdrawal syndrome from intrathecal
    baclofen (ITB) may include respiratory
    depression and hypotonia
    (B) ITB is a calcium channel blocker that
    acts primarily at the dorsal root ganglion
    (DRG)
    (C) Withdrawal syndromes from ITB can be
    fatal
    (D) Symptoms of ITB overdose include pruritus
    and hyperthermia
    (E) All of the above
A
  1. (C)
    A. Overdose of baclofen causes side-effects
    that range from drowsiness, nausea,
    headache, muscle weakness, and lightheadedness
    to somnolence, respiratory
    depression, seizures, rostral progression of
    hypotonia, and loss of consciousness progressing
    to coma. There are a range of
    symptoms with withdrawal as well; pruritus
    without rash, diaphoresis, hyperthermia,
    hypotension, neurological changes,
    including agitation or confusion, sudden
    generalized increase in muscle tone, spasticity,
    and muscle rigidity. With severe withdrawal,
    rhabdomyolysis and multiple organ
    failure can occur.
    B. Baclofen is a γ-aminobutyric acid (GABA)
    analogue that has inhibitory effects on
    spinal cord reflexes and brain. The precise
    mechanism of action of baclofen as a muscle
    relaxant and antispasticity agent is not
    fully understood. Baclofen inhibits both
    monosynaptic and polysynaptic reflexes at
    the spinal cord level, possibly by decreasing
    excitatory neurotransmitter release
    from primary afferent terminals, although
    actions at supraspinal sites may also contribute
    to its clinical effects. Baclofen also
    causes enhancement of vagal tone and
    inhibition of mesolimbic and nigrostriatal
    dopamine neurons (directly or via inhibiting
    substance P).
    C. ITB withdrawal syndrome has been fatal
    in some cases. Differential diagnoses
    include malignant hyperthermia, neuroleptic-
    malignant syndrome, autonomic
    dysreflexia, sepsis, and meningitis.
    D. Refer to explanation A.
45
Q
  1. A hearing impaired patient with severe learning
    disabilities comes to your office accompanied
    by his mother. The day prior to seeing
    you, the patient had a translaminar lumbar
    epidural steroid injection for low-back pain at
    a “major medical center” and the physician
    performing the procedure said it was a perfect
    injection. The patient is not able to communicate
    proficiently at his baseline. The mother
    reports that since the injection was done, the
    patient appears more comfortable lying down
    than standing. He is groggy and keeps his eyes
    closed for most of your interaction, but he has
    been up most of the night. The patient has a
    low-grade fever and mild tachycardia. His neck
    is somewhat stiff but he is otherwise uncooperative.
    Which of the following is the most
    appropriate next step of management?
    (A) Place an IV line to prepare the patient
    for a blood patch
    (B) Explain to the mother that the patient
    should exhaust conservative therapy for
    48 to 72 hours prior to considering a
    blood patch
    (C) Send the patient to the ER for immediate
    performance of a lumbar puncture
    (D) Schedule the patient for an MRI of the
    lumbar spine
    (E) Initiate high-dose narcotic therapy
A
  1. (C)
    A. Although a post–lumbar puncture headache
    is a possibility, other processes including a
    CNS infection must be excluded.
    B. In general, prior to treating a post–lumbar
    puncture headache, conservative management
    should be trialed for at least 48 hours.
    C. The most appropriate step.
    D. MRI of the lumbar spine does not have a
    role at this stage.
    E. High-dose narcotic therapy does not have
    a role at this stage.
46
Q
  1. A physician is performing a cervical transforaminal
    epidural steroid injection at the C4-5
    level. After the needle is placed in what the practitioner
    believes is an appropriate position, he
    removes the stylet and gets return of pulsating
    red blood. This would be most concerning if
    (A) the needle is in the anterior neuroforamen
    (B) the needle is in the posterior neuroforamen
    (C) no need for concern, as the practitioner
    is only planning on injecting triamcinolone
    (D) the patient is feeling new radicular pain
    symptoms that are severe in the C5 dermatome
    (E) the patient has a significant history of
    vasovagal responses
A
  1. (A)
    A. Cervical transforaminal epidural steroid
    injections are controversial for several reasons.
    One of the major concerns is the potential
    involvement of the vertebral artery,
    which lies in the anterior neuroforamen.
    B. See explanation A.
    C. Injecting triamcinolone, which is a particulate
    steroid, could be problematic, especially
    if the steroid were to enter the vertebral
    artery circulation.
    D. Patients experiencing radicular symptoms
    in the course of a transforaminal procedure
    may suggest involvement of a nerve root.
    E. If the patient has a history of vasovagal
    responses, appropriate planning should
    be made to manage these symptoms
    should they occur during the procedure.
47
Q
137. Which of the following statements is true
regarding phantom limb pain and stump pain?
(A) Mastectomy has been documented to
lead to phantom sensation in the breast
in well more than 90% of cases
(B) Phantom sensations are almost always
more vivid in the distal extremity
(C) All amputees that have neuromata have
stump pain
(D) Phantom limb sensations usually
change with time; the distal part of the
limb usually disappears first
(E) None of the above
A
  1. (B)
    A. Mastectomy has been reported to lead to
    phantom sensation in 22% to 64% of
    women who have had the operation.
    B. Phantom sensations are present in the
    majority of amputees; the sensation is
    almost always more vivid in the distal
    extremity. The vast majority of these
    patients do not have phantom limb pain.
    C. Stump pain is perceived to be present in
    the existing body part in the region of
    amputation; it is often associated with palpable
    neuromata at the amputation site—
    however, all amputees have neuromata
    and not all amputees have stump pain.
    D. Phantom limb sensations “telescope” with
    time—the proximal part of the limb disappears
    first.
48
Q
  1. A 35-year-old ex-football player enters your
    office complaining of shoulder pain. Which of
    the following statements is true of his condition?
    (A) A complaint along the deltoid has been
    shown to correlate with rotator cuff
    pathology
    (B) A history of a thyroid disorder could
    suggest dysfunction of the acromioclavicular
    joint
    (C) Acromioclavicular joint pathology usually
    presents with diffuse shoulder pain
    (D) If the pain began before the age of 30,
    this would most fit the clinical picture of
    a rotator cuff tear
    (E) All of the above
A
  1. (A)
    A. The location of the pain can be helpful for
    diagnosis. Anterior-superior pain often can
    be localized to the acromioclavicular joint,
    whereas lateral deltoid pain is often correlated
    with rotator cuff pathology. Neck
    pain and radiating symptoms should be
    explored because cervical pathology can
    mimic shoulder pain. Typically, pain that
    radiates past the elbow to the hand is not
    related to shoulder pathology. However, it
    is not uncommon to have pain that radiates
    into the neck because the trapezius muscle
    often spasms in patients with underlying
    chronic shoulder pathology. The presence
    of both is more likely to be related to cervical
    pathology. Dull, achy night pain is often
    associated with rotator cuff tears or severe
    glenohumeral osteoarthritis
    B. The patient’s medical history, including
    joint problems, can help to narrow the differential
    diagnosis. Autoimmune diseases
    and inflammatory arthritis can affect the
    shoulder, resulting in erosions and wear in
    the glenohumeral joint, whereas diabetes
    and thyroid disorders can be associated
    with adhesive capsulitis.
    C. Acromioclavicular joint pathology is usually
    well localized. A history of an injury to
    the joint (shoulder separation), heavy
    weight lifting, tenderness to palpation at
    the acromioclavicular joint, pain with crossbody
    adduction testing, extreme internal
    rotation, and forward flexion are consistent
    with the diagnosis. Radiographs may be
    difficult to interpret because most patients
    have acromioclavicular osteoarthritis by
    the age of 40 to 50 years. A distal clavicle
    lysis or an elevated distal clavicle supports
    the diagnosis, whereas the absence of tenderness
    to palpation at the acromioclavicular
    joint is inconsistent with the diagnosis.
    D. Rotator cuff disorders that affect the function
    of the rotator cuff include a partial or
    complete tear, tendinitis or tendinosis, and
    calcific tendinitis. Initially, it is more important
    to differentiate this group of disorders
    from the other groups than it is to identify
    the specific diagnosis. Typically, the patients
    are older than 40 years and complain of pain
    in the lateral aspect of the arm with radiation
    no farther than the elbow. Weakness, a
    painful arc of motion, night pain, and a positive
    impingement sign are components of
    the history and physical examination that
    are consistent with this diagnosis. Findings
    that are inconsistent with this diagnosis
    include being younger than 30 years, having
    no weakness, and presenting no impingement
    signs. Positive radiographs can be
    helpful to diagnose calcific tendinitis, acromial
    spur, humeral head cysts, or superior
    migration of the humeral head, but are typically
    normal.
49
Q
  1. You suspect nerve root impingement in the
    lumbar spine. Which of the following physical
    findings would support this diagnosis?
    (1) You suspect L2 nerve root involvement
    and the patient has weakness of hip
    flexion and sensory loss on the lateral
    aspect of the calf
    (2) You suspect L4 nerve root involvement
    and the patient has weakness of leg
    extension and loss of patellar reflex
    (3) You suspect L5 nerve root involvement
    and the patient cannot dorsiflex his big
    toe and has a loss of the Achilles reflex
    (4) You suspect S1 nerve root involvement
    and the patient has loss of sensation
    over the bottom of the foot. Achilles
    reflex is normal
A
  1. (C)
  2. L2 nerve: weakness of hip flexion (iliopsoas)
    and sensory loss on anterior groin
    and thigh. No deep tendon reflex.
  3. L4 nerve: weakness of leg extension
    (quadriceps), ankle dorsiflexion (tibialis anterior); sensory loss medial calf/foot; loss
    of patellar reflex.
  4. L5 nerve: weakness of dorsiflexion of big
    toe (EHL) sensory loss lateral aspect of calf
    and dorsum of foot. No deep tendon reflex.
  5. S1 nerve: weakness of toe walking (gastrocnemius);
    sensory loss on dorsum of foot, loss
    of Achilles reflex. This is correct because the
    reflex does not have to be decreased/lost to
    suspect this nerve root’s involvement. The
    sensory abnormality is enough.
50
Q
  1. Which of the following structures that play a
    role in the neurobiology of addiction are properly
    linked?
    (1) Nucleus locus ceruleus—arousal, attention,
    and anxiety
    (2) Anterior cingulate cortex—functional
    part of limbic system
    (3) Amygdala—mediates drug craving
    (4) Nucleus accumbens—one of the brain’s
    reward centers
A
  1. (E) Addiction is a disease of the CNS. All substances
    of abuse activate essentially the same
    neuroanatomic structures. All of the structures
    listed above are properly linked.