Chapter 5. Diagnosis of Pain States Flashcards
1
Q
- A59-year-old female comes to your office complaining
of moderately severe low back pain
and right buttock pain which is exacerbated
with prolonged sitting. On physical examination
there is sciatic notch tenderness and the
pain is exacerbated with flexion, adduction,
and internal rotation of the right hip. Which of
the following is the most likely diagnosis?
(A) L5-S1 facet syndrome
(B) Piriformis syndrome
(C) Sacroiliac (SI) joint syndrome
(D) Sciatica
(E) L3 radiculopathy
A
- (B) The piriformis syndrome was originally
described by six common characteristics
(1) trauma; (2) pain in the muscle with sciatica
and difficulty in walking; (3) worsening with
squatting or lifting; (4) a sausage-like mass
within the muscle; (5) positive Lasègue sign;
and (6) gluteal atrophy. The female to male
ratio is 6 to 1.
There are many approaches to evaluate
piriformis syndrome. One method is in the sitting
position which involves the examiner
stretching the piriformis muscle by passively
moving the hip into internal rotation reproducing
buttock pain which is relieved by the
examiner passively moving the hip into external
rotation. The patient then actively rotates
the hip against the resistance which reproduces
buttock pain. Furthermore, there is generally
point tenderness on palpation of the
belly of the piriformis muscle. There tends to
be prolongation of the H-reflex with flexion,
adduction, and internal rotation.
2
Q
- A77-year-old female comes to your office complaining
of 6 months of severe right buttock
pain radiating into the right lower leg. The pain
is also present at night and not uncommonly
interferes with sleep. The pain is severe with
sitting or lying on her back or right side, however,
quickly dissipates with normal erect posture.
Which of the following is the most likely
diagnosis?
(A) Snapping bottom
(B) Sciatica
(C) Radiculopathy
(D) Piriformis syndrome
(E) Weaver’s bottom
A
- (E) In classic weaver’s bottom (ischiogluteal
bursitis)—the patients invariably get pain sitting
which goes away upon standing or lying
on their contralateral side. However, the pain
promptly returns upon resuming a seated position.
Typically, the patient can consistently
point to the spot where it hurts with their finger
and state “it hurts right here.” On physical
examination, tenderness is evoked with palpation
over the ischiogluteal bursa.
3
Q
- A 53-year-old male comes to your office complaining
of foot pain (predominantly in the
heel—but also with diffuse plantar symptoms)
which also occurs at night and can be exacerbated
by prolonged standing or walking. It is
associated with weakness of the phalanges
(impairing the pushing off phase of walking) as
well as sensory loss and paresthesia. After a
complete history and physical examination are
completed, which of the following is the next
most appropriate step?
(A) Magnetic resonance imaging (MRI) of
the ankle
(B) MRI of the lumbar spine
(C) Initiate anti-inflammatory medications
(D) Trial of arch support
(E) Electrodiagnostic testing
A
- (E) Imaging studies are most appropriate with
bony point tenderness or when the differential
diagnosis is likely calcaneal stress, fracture
Paget disease, tumors, calcaneal apophysitis
(Sever disease in adolescents), or calcaneal
stress fracture. The most appropriate diagnostic
evaluation for suspected tarsal tunnel syndrome
is electrodiagnostic evaluation.
4
Q
- A 53-year-old male comes to your office complaining
of foot pain (predominantly in the
heel—but also with diffuse plantar symptoms)
which also occurs at night and can be exacerbated
by prolonged standing or walking. It is
associated with weakness of the phalanges
(impairing the pushing off phase of walking) as
well as sensory loss and paresthesia. Which of
the following is the most likely diagnosis?
(A) Morton neuroma
(B) Peripheral neuropathies
(C) Medial plantar nerve entrapment
(D) Tarsal tunnel syndrome
(E) March fracture
A
- (D) The tarsal tunnel located behind and inferior
to the medial malleolus. It is bounded on
the lateral aspect by the tibia and medially by
the flexor retinaculum (laciniate ligament). Its
contents include the tibial nerve, posterior tibial
tendons, flexor digitorum longus tendon, flexor
hallucis longus tendon, tibial artery, and tibial
vein. Within the tarsal tunnel or immediately
distal to it, the tibial nerve divides into the
medial and lateral plantar nerves. The calcaneal
branch originates variably above or below the
flexor retinaculum to supply the heel and calcaneal
skin. The tarsal tunnel syndrome most
commonly arises from trauma (eg, fractures,
ankle dislocations) and is characterized by foot
pain and paresthesia, as well as potentially by
sensory loss and Tinel sign at the ankle. The
pain may be similar to carpal tunnel syndrome
in that it often occurs at night. Furthermore, it
may be exacerbated by prolonged standing or
walking. Amarch fracture is a stress fracture of
the metatarsal bone. The second and third
metatarsals are the most common sites. Patients
complain of increased intensity of pain with
activity or exercise. The pain is localized to the
site of the fracture.
5
Q
- A47-year-old female comes to your office complaining
of an aching forearm with discomfort
and numbness in the thumb and index finger,
and weakness in the hand. Apositive Tinel sign
is present in the forearm. Which of the following
is the most likely diagnosis?
(A) Anterior interosseous nerve syndrome
(B) Posterior interosseous nerve syndrome
(C) Ulnar nerve entrapment
(D) Pronator syndrome
(E) Radial nerve entrapment
A
- (D) Pronator syndrome may result from compression
of the median nerve proximal to the
branching of the anterior interosseous nerve.
Patients with pronator syndrome generally
complain of an aching discomfort of the forearm,
numbness in the thumb and index finger, and weakness in the hand. On physical examination
there may be tenderness over the proximal
part of the pronator teres muscle that is
exacerbated by pronation of the forearm
against resistance. Resisted pronation may also
result in paresthesia in the distribution of the
median nerve. A positive Tinel sign is often
present at the proximal edge of the pronator
muscle. If the entrapment is under the bicipital
aponeurosis this may result in weakness of the
pronator muscle and depending on the degree
of compression, weakness of other muscles (eg,
long flexor muscles of the fingers and thumb,
abductor pollicis brevis)
6
Q
257. Complex regional pain syndrome type II (CRPS II) differs from CRPS I because in CRPS II there is (A) allodynia (B) movement disorder (C) sudomotor and vasomotor changes (D) evidence of major nerve damage (E) severe swelling
A
- (D) CRPS I and CRPS II are clinically indistinguishable.
The only difference is that in CRPS II
there is evidence of major nerve damage.
7
Q
258. Which of the following range is the temperature most appropriate to use as a stimulus when evaluating warm temperature sensation? (A) 25°C to 30°C (B) 30°C to 35°C (C) 35°C to 40°C (D) 40°C to 45°C (E) 45°C to 50°C
A
- (D) The temperature range to test warm temperature
sensation is 40°C to 45°C—usually
done via a glass or metal tube with hot (40°C-
45°C) water. Temperatures higher than 45°C
are generally perceived as painful.
8
Q
259. Which of the following range is the temperature most appropriate to use as a stimulus when evaluating cold temperature sensation? (A) −5°C to 0°C (B) 0°C to 5°C (C) 5°C to 10°C (D) 10°C to 15°C (E) 15°C to 20°C
A
- (C) The temperature range to test cold temperature
sensation is 5°C to 10°C—which may be
done with a thermophore. Temperatures lower
than 5°C are generally perceived as painful.
9
Q
260. Which of the following may potentially facilitate or perpetuate myofascial trigger points in some patients? (A) Low creatine kinase (B) Low aldolase (C) Low cholesterol (D) Low vitamin D (E) Low vitamin B12 or folate
A
- (E) Low levels of vitamin B12 and/or folate may
be associated with increased trigger points in
many patients who suffer from myofascial pain
syndrome. Multiple coexisting systemic conditions
may also be associated with myofascial
pain syndrome and should be investigated
in patients with severe painful myofascial trigger
points.
10
Q
- A 39-year-old male with persistent coughing
attributed to upper respiratory infection (URI)
comes to your office complaining of moderate
anterior chest wall pain—it is only on the left
side—predominantly over the second and third
costal cartilages. Bulbous swellings and point
tenderness are present at these sites. Which of
the following is the most appropriate diagnosis
for this patient?
(A) Intercostal neuralgia
(B) Tietze syndrome
(C) Acute myocardial infarction
(D) Pneumonia
(E) Pleurisy
A
- (B) Tietze syndrome (costochondritis) should
only be diagnosed after other diagnoses are
ruled out. It is most frequently unilateral
involving the second and third costal cartilages
and is characterized by mild to moderately
severe anterior chest wall pain. The pain is typically
localized in the region of the costal cartilages
but may occasionally radiate to the arm
and shoulder. Tietze syndrome occurs more
commonly under the age of 40 years. On
physical examination, tenderness to palpation
as well as bulbous swelling over the costochondral
junctions may be found.
11
Q
- A 66-year-old woman who did not have a history
of trauma comes to your office complaining
of acute, severe, constant medial right knee
pain for 6 weeks. MRI imaging demonstrated
extensive narrow edema of the medial femoral
condyle with significant soft tissue edema
around the superficial and deep compartment
of the medial collateral ligament (MCL) but
without MCL disruption. Which of the following
is the most likely diagnosis?
(A) Stress fracture
(B) MCL tear
(C) Medial meniscal tear
(D) Spontaneous osteonecrosis of the
knee (SONK)
(E) Medical femoral condyle contusion
A
- (D) Spontaneous osteonecrosis of the knee
(SONK) is an entity whose precise pathogenesis
remains unclear. The pain may be present at
rest and is generally well-localized without
trauma or associated incited event. It is classically
defined as unilateral and spontaneous
with predilection for the medial femoral
condyle. It occurs typically in the elderly population
(> age 60) and is three times more
common in women than men. Initial radiographs
tend to be normal.
12
Q
- A 49-year-old male comes to your office after
climbing several mountain passes in the
Pyrenees on a bicycle with thigh complaints.
He relates to you that he developed a painful
sensation on the lateral aspect of his right thigh,
which lasted for about a week. This was followed
by numbness and paresthesia in the
same location. Physical examination revealed
sensory loss in the same location. Which of the
following is the most likely diagnosis?
(A) Tensor fascia lata syndrome
(B) Meralgia paresthetica
(C) Iliotibial band syndrome
(D) Greater trochanteric bursitis
(E) Lumbar radiculopathy
A
- (B) Meralgia paresthetica is a painful mononeuropathy
of the lateral femoral cutaneous nerve
(LFCN). Although it may be idiopathic in
nature it is commonly caused by focal entrapment
of the LFCN as it passes through the
inguinal ligament. Although there have been
numerous reported associated conditions,
some of these include weight change (eg, obesity,
pregnancy), possibly external compression
(eg, seat belts, tight clothing), perioperative
factors/trauma, retroperitoneal tumors, and
strenuous walking/cycling (the iliopsoas muscle
and tensor fascia lata are heavily involved in
walking and/or cycling movement).
13
Q
- A43-year-old male runner comes to your office
complaining of a dull ache in the anterior
aspect of the lower legs bilaterally which occurs
about 10 minutes into his running routine each
time he runs and dissipates with rest. The
patient states that he needs to stop running
because of this ache and also notes dysesthesia
in the first web space of both feet. Which of
the following is the most likely diagnosis?
(A) Shin splints
(B) Stress fractures
(C) Chronic osteomyelitis
(D) Periostitis
(E) Chronic exertional anterior compartment
syndrome of the lower leg
A
- (E) Chronic exertional compartment syndrome
of the anterior tibial compartment may occur in
runners, soccer players, and racers and may
present with a fullness in the anterior compartment,
exacerbation of pain on passive dorsiflexion
of the great toe, weakness of the
extensor hallucis longus muscle, and decreased
sensation in the first web space. Symptoms are
usually bilateral 75% to 95% of the time
14
Q
- A32-year-old construction worker felt a sharp
pain in his back radiating down to the heel of
his right foot after lifting a large, metal girder.
Two days later he noticed numbness in the sole
of his right foot and fifth toe. Physical examination
is notable for a decreased ability to walk
on his toes, a positive straight leg raising test on
the right, and a markedly diminished ankle
jerk reflex. Which of the following is the most
likely diagnosis?
(A) L4-5 herniated disc
(B) Discogenic low back pain
(C) L5-S1 herniated disc
(D) Spinal stenosis
(E) Piriformis syndrome
A
- (C) Symptoms from an L5-S1 herniated disc
are typically experienced in the distribution of
the S1 nerve root. These symptoms may
include pain or sensory changes in the calf, lateral
border of the foot, heel, sole, and sometimes
fourth and fifth toes. On physical
examination, the patient may have diminished
strength in the gastrocnemius, soleus, and the
peroneus longus and brevis muscles. An L4-5
herniated disc most frequently results in L5 symptoms, which include diminished sensation
in the lateral leg, dorsum of the foot, and
the first two toes. Spinal stenosis is narrowing
of the spinal canal that occurs with aging.
Patients may present with decreased strength
and loss of sensation, but with central stenosis
it is usually nondermatomal. Piriformis syndrome
is an uncommon cause of buttock pain
and/or sciatica that is caused by sciatic nerve
compression by the piriformis muscle. Although
sciatica is often present, pain from piriformis
syndrome is nonadicular, and hence straight
leg raising tests should not be positive.
Discogenic pain is pain that results from internal
disc disruption. The neurologic examination
should be nonfocal when pain results
solely from internal disc derangement.
15
Q
- An 80-year-old man presents with a 2-year
history of low back pain radiating down from
both legs to his ankles. He also notes numbness
in his left foot and slight weakness. The pain is
increased with walking and relieved within
seconds of cessation of activity. Leaning forward
eases his pain and lying supine relieves it.
Which of the following is the most likely
diagnosis?
(A) Herniated nucleus pulposus
(B) Facet arthropathy
(C) Muscle spasm
(D) Arachnoiditis
(E) Spinal stenosis
A
- (E) As we age, our spinal canal starts to narrow.
This narrowing is a result of many different
processes including disc bulging from a progressive
loss of disc height and elasticity,
hypertrophy of the facet joints and ligamentum
flavum and osteophyte formation.
Technically, the term “spinal stenosis” can refer
to central canal stenosis, lateral recess stenosis,
or foraminal stenosis. The typical presentation
of someone with spinal stenosis is an elderly
person with low back and leg pain brought on
by walking, especially on stairs or hills.
Frequently, the pain is bilateral. In contrast to
vascular claudication, patients with neurogenic
or pseudoclaudication often find that the cessation
of walking brings immediate pain relief.
Like spinal stenosis, facet arthropathy is more
common in the elderly, but the pain does not
typically radiate into the lower leg and is usually
not associated with loss of sensation.
16
Q
- A 31-year-old woman presents to your office
with marked pain and swelling in her ankle
6 weeks after an open reduction internal fixation
with casting. On examination, the ankle is
warm and erythematous. Lightly touching the
ankle with a cotton swab evokes severe, lancinating
pain. You suspect CRPS I. Which of the
following tests will confirm your diagnosis?
(A) Lumbar sympathetic block
(B) Phentolamine infusion test
(C) Triple phase isotope bone scan
(D) Erythrocyte sedimentation rate
(E) None of the above
A
- (E) In the early 1990s, a panel of experts
reached a consensus that the terms “reflex sympathetic
dystrophy” and “causalgia” had lost
their utility as clinical diagnoses and suggested
a new nomenclature be adopted. The new
terms designated for these conditions are “CRPS
types I and II”. According to the new diagnostic
criteria, CRPS need not be maintained by
sympathetic mechanisms. A three-phase isotope
bone scan is often positive in CRPS, but a
normal bone scan does not exclude the diagnosis.
Erythrocyte sedimentation rate is a nonspecific
test that is positive in many painful conditions
including infection, inflammatory arthritides
and inflammatory myopathies. As a syndrome,
CRPS is diagnosed by history and physical
examination. For CRPS I, the diagnostic criteria
include (1) an initiating noxious event; (2) spontaneous
pain and/or allodynia occur outside
the territory of a single peripheral nerve, and
are disproportionate to the inciting event; (3)
there is or has been evidence of edema, cutaneous
perfusion abnormalities, or abnormal
sudomotor activity, in the region of pain since
the inciting event; and (4) the diagnosis is
excluded by the existence of any condition that
would otherwise account for the degree of pain
and dysfunction.
17
Q
- A 46-year-old man complains of worsening
back and new onset leg pain and paresthesia
10 weeks after an L4-S1 posterior spinal fusion.
One week after the surgery, the patient
reported 85% pain relief. Which radiologic test
would be most appropriate for detecting the
cause of failed back surgery syndrome (FBSS)
in this patient?
(A) Computed tomographic (CT) scan with
contrast
(B) Myelography
(C) Epidural mapping via the injection of
contrast under fluoroscopy through a
catheter inserted through the caudal
canal
(D) T2-weighted MRI with contrast
(E) Further radiologic study is not indicated
at this point
A
- (D) The type and timing of pain after spine surgery
provide important clues as to the possible
diagnosis. For example, no change in a patient’s
pain pattern after surgery may indicate that
either the wrong surgery was done or the procedure
was technically unsuccessful. In this
case, the patient experienced initial pain relief,
which was followed by worsening back pain
and new-onset leg pain several weeks later.
Possible causes of this scenario include epidural
fibrosis, arachnoiditis, discitis, battered root
syndrome with perineural scarring, or an early
recurrent disc herniation. Pseudoarthrosis,
juxtafusional discogenic pain, and lumbar instability
can also be causes of FBSS, but in these
cases the recurrence of pain typically occurs
much later. For detecting disc pathology, MRI is
more sensitive than CT or myelography. It is
also more sensitive than CT for identifying contrast
enhancement. For the possible etiologies
that fit this patient’s pain history (ie, arachnoiditis,
epidural fibrosis, and discitis), contrast
enhancement with gadolinium will greatly
enhance the sensitivity of MRI. Epidural mapping
via the injection of radiopaque contrast
under fluoroscopy through a catheter inserted
through the caudal canal is sometimes used to
determine the location of epidural scar tissue in
FBSS patients, often as a precursor to epidural
lysis of adhesions (ie, Racz procedure) or
epiduroscopy. However, this procedure provides
very little additional information. In the patient with implanted hardware, foreign ferromagnetic
metal objects give rise to local distortion
of the magnetic field, which can greatly
degrade MRI results. When implants are made
of non-superparamagnetic materials like titanium,
MRI distortion is less but the anatomy
may still be obscured. Since this patient did not
have hardware implanted, this should not deter
the use of MRI. Generally, T2-weighted images
are more sensitive for detecting pathology,
whereas T1-weighted images are better for discerning
anatomy. The use of MRI to follow a
stable, pathologic condition of the lumbar spine
is controversial. The use of MRI to evaluate a
patient with chronic low back pain who has
recently undergone spine surgery and presents
with new symptoms is justified
18
Q
269. Which of the following is false regarding discogenic low back pain? (A) Sitting bent forward subjects the intervertebral disc to a greater amount of pressure than lying down, standing or sitting with one’s back straight (B) It is often diagnosed by using provocative discography (C) Because of their caudad position in the spine, the lower lumbar discs are most prone to degenerative disc disease (DDD) (D) Studies have shown a genetic predisposition to DDD (E) Intradiscal steroids are an effective means for treating DDD
A
- (E) Sitting bent forward subjects the lumbar
intervertebral discs to greater stress than standing,
sitting with one’s back straight, or lying
down. This helps explain why patients with
discogenic low back pain often present with
sitting intolerance. Although controversial,
discography, with or without CT scanning, is
still commonly used to diagnose discogenic
pain. Patients at high risk for false-positive
discography include those with psychopathology
and previous back surgery. The lower
lumbar discs are more likely to develop degenerative
changes, and hence become pain generators,
than more cephalad discs because of
the increased load they bear. Recent studies
have shown a genetic predisposition for both
degenerative disc disease and sciatica. Several
prospective studies have been conducted evaluating
intradiscal steroids in patients with
discogenic low back pain, and none have found
them to be efficacious.
19
Q
- Which of the following statements concerning
central pain is true?
(A) Spinal cord injury is the leading cause of
central pain in the United States
(B) Lesions involving spinothalamocortical
pathways are necessary and sufficient to
cause central pain
(C) Central pain is a common sequelae
following neurosurgic procedures
(D) Motor cortex stimulation is an effective
means to treat central pain
(E) The most typical presentation of central
pain is a spontaneous, burning sensation
on the entire body contralateral to
the lesion site
A
- (D) Owing to its high incidence, stroke is the
leading cause of central pain in the industrialized
world. The chance of developing central
pain following spinal cord injury is higher than
after stroke (30%-50% vs 8%), but the overall
number of stroke patients with central pain is
higher. Syringomyelia is the disorder with the
highest incidence of central pain (60%-80%).
According to neurosurgical studies conducted
by V. Cassinari and C.A. Pagni in the 1960s,
injury to spinothalamocortical pathways is necessary
but not sufficient to cause central pain.
The reason why some patients develop central
pain but others with identical injuries do not is
unknown. Central pain may occur after neurosurgical
procedures and intracranial bleeds,
but these are unusual occurrences. There are
now several prospective studies showing
motor cortex stimulation to be an effective
treatment for central pain. There is no typical
presentation for central pain. While spontaneous
pain is almost universal, allodynia also
affects a majority of central pain patients. The
time lag between the injury and onset of pain,
and the location of central pain are extremely
variable.
20
Q
- Which of the following is not commonly used
to diagnose the level of nerve root involvement
in radicular pain?
(A) MRI
(B) CT scan
(C) Selective nerve root block
(D) Electromyography (EMG)/nerve
conduction studies (NCS)
(E) Epidural injections with local anesthetic
and steroids
A
- (E) MRI is usually the first test used to evaluate
new-onset radicular pain. CT scan is less sensitive
than MRI for detecting disc pathology, but
is used in patients with pacemakers, spinal
hardware (owing to the poor resolution of MRI
in patients with ferromagnetic metal objects)
and when MRI is not available. Selective nerve
blocks are sometimes used to diagnose nerve
root pathology prior to surgery, but there is little
evidence as to whether or not this improves
outcomes. Although the terms are sometimes
used interchangeably, selective nerve blocks are
not the same as transforaminal epidural injections.
Since transforaminal epidural injections
typically result in injectate spread to contiguous
spinal levels, they cannot be considered diagnostic.
In addition to providing information
about the site of nerve root lesions, EMG/NCS
can help determine whether or not the lesion is
axonal or demyelinating; whether it is focal,
multifocal or diffuse; and the age, severity, and
prognosis of the lesion. QST is a subjective test
used to evaluate large and small fiber neuronal
dysfunction. It may be helpful in clarifying
mechanisms of pain, diagnoses, and guiding
treatment. It is not used to diagnose nerve root
pathology.
21
Q
272. Which of the following conditions is not generally associated with a painful neuropathy? (A) Chronic renal failure (B) Celiac disease (C) AIDS (D) Fabry disease (E) Amyloidosis
A
- (A) Chronic renal failure is associated with
large, myelinated fiber loss that is rarely
painful. Celiac disease is a chronic inflammatory
enteropathy resulting from sensitivity to
gluten. Neurologic complications are estimated to occur in approximately 10% of patients with
peripheral neuropathy and ataxia being the
most common. The neuropathy is usually sensory,
although infrequently motor weakness
may develop. There is some evidence that the
neurologic symptoms associated with celiac
disease may be ameliorated by a gluten-free
diet. Peripheral neuropathies are reported to
affect up to 35% of AIDS patients, being more
common in later stages of the disease. The most
common neuropathy in AIDS patients is a
distal sensory polyneuropathy caused by the
human immunodeficiency virus (HIV). Other
causes of neuropathy in AIDS patients include
toxic neuropathies from medications, co-infection
with cytomegalovirus (CMV) and other organisms,
and vitamin B12 deficiency. Fabry disease
is an X-linked, lysosomal storage disease that
involves the accumulation of galactosylglucosylceramide
because of deficiency of α-galactosidase
A. It usually presents in adulthood; if
symptoms occur in childhood they usually take
the form of a painful neuropathy. Amyloidosis
may result in a painful peripheral or autonomic
neuropathy secondary to deposition of amyloid
in nervous tissue. In one study, 35% of
patients with amyloidosis were found to have
peripheral neuropathy.
22
Q
- Apreviously healthy 31-year-old woman presents
to her internist with generalized muscle
pain, most prominent in her right thigh. The pain
travels down the back of her leg to the bottom
of her foot. She also notes progressive numbness
and weakness in her arms and legs.
Walking is difficult and a loss of fine motor
control makes routine tasks like eating a challenge.
A review of her medical record reveals
an URI 3 weeks earlier. Which of the following
is the most likely diagnosis?
(A) Multiple sclerosis
(B) Guillain-Barré syndrome
(C) Chronic fatigue syndrome
(D) Acute lumbar and cervical
radiculopathies
(E) Diabetic neuropathy
A
- (B) The patient’s symptoms are most consistent
with Guillain-Barré (GB) acute inflammatory
demyelinating polyneuropathy. Patients
with GB syndrome generally present with diffuse
muscular or radicular pain followed by
sensorimotor dysfunction. Most, but not all
(72%) patients with GB syndrome experience
pain during the course of their illness. GB syndrome
affects 1 to 1.5 people per 100,000 and
shows no age or gender preference. About 60%
to 70% of cases are preceded by an URI or gastrointestinal
(GI) illness 1 to 3 weeks before
symptoms begin. Cerebrospinal fluid (CSF)
analysis reveals normal pressures, increased
protein and no cells. The pathology of GB syndrome
is demyelination, with most patients fully
recovering. Multiple sclerosis is a demyelinating
disease that typically presents in early adult
life. The most common presenting symptom
of multiple sclerosis is ocular complaints,
which affects most patients at some time during
the course of their illness. Spinal cord lesions
can produce a myriad of sensorimotor problems
including weakness, spasticity, hyperreflexia,
bladder dysfunction, sensory loss, and
diminished temperature sensation and proprioception.
Central dysesthetic pain affects
approximately 20% of multiple sclerosis
patients. The diagnosis of multiple sclerosis is
usually supported by MRI, with or without
CSF analysis. Although muscle pain and weakness
may be present in chronic fatigue syndrome
(CFS), the hallmark of this disorder is
disabling physical and mental fatigue present
for more than 6 months. There is no firm data
causally linking viral infection to CFS despite
frequent reported associations. The most
common presentation of acute radiculopathy is
pain or sensory changes in a lower extremity.
The most common form of diabetic neuropathy
is distal, symmetrical polyneuropathy. It is predominantly
a sensory disturbance, occurring
in a stocking-glove distribution. Because the
feet are innervated by the longest nerves in the
body, they are usually the first part of the body
to be affected. Other types of neuropathy that
may be present in diabetics include lower
extremity proximal motor neuropathy, truncal
neuropathy, cranial mononeuropathy, and autonomic
neuropathy. The cause of diabetic neuropathy
is most likely related to metabolic and
ischemic nerve injury
23
Q
- Which of the following statements is true
regarding SI joint pain?
(A) The SI joint is a diarthrodial synovial
joint designed primarily for stability
(B) Patrick’s and Gaenslen’s tests are definitive
diagnostic tests for SI joint pain
(C) CT scanning is the most sensitive means
for diagnosing SI joint pain
(D) Lifting heavy objects is the one of the
most common causes of SI joint injury
(E) When diagnostic blocks fail, surgery can
usually provide long-term pain relief
A
- (A) The SI joints are large, paired, diarthrodial
synovial joints whose primary functions are
stability and dissipating truncal loads. The
joints are also involved in limiting x-axis rotation
and in women, parturition. There are literally
dozens of provocative tests that have
been advocated as screening tools for SI joint
pain, but several studies have shown that these
tests lack both specificity and high sensitivity.
On a similar note, CT scanning may show SI
joint pathology in over 30% of asymptomatic
control patients, and be negative in over 40% of
patients with SI pain. The most reliable method
for diagnosing SI joint pain is through diagnostic
local anesthetic blocks. The mechanism
of SI joint injury has been described as a combination
of axial loading and sudden rotation.
Common causes of SI joint pain include motor vehicle accidents, falls, athletic injuries, spondyloarthropathies,
and pregnancy. SI joint injections
with corticosteroids have been shown in
some but not all studies to provide short-term
pain relief. SI joint pain is usually not amenable
to surgical correction.
24
Q
275. Which of the following statements regarding headaches is false? (A) The International Headache Society’s diagnostic criteria for cervicogenic headaches includes unilaterality of symptoms and relief of pain by diagnostic anesthetic blocks (B) Migraine with aura is more common than migraine without aura (C) In chronic tension-type headache, the average headache frequency is equal to or greater than 15 days per month (D) Cluster headaches are more prevalent in men than in women (E) Tricyclic antidepressants are a mainstay of treatment for both migraine and tension-type headaches
A
- (B) In population-based studies, migraine without
aura is about twice as frequent as migraine
with aura. Major criteria for the diagnosis of
cervicogenic headache include signs and symptoms
of neck involvement such as the precipitation
of head pain by neck movement or
external pressure over the upper cervical or
occipital region, restricted range of motion in
the neck, unilaterality of head pain with or
without shoulder or arm pain, and confirmatory
evidence by diagnostic anesthetic blocks.
Chronic tension-type headache differs from
episodic tension-type headache in that the
average headache frequency is equal to or
greater than 15 days per month or 180 days
per year. A shift from peripheral to central
mechanisms is believed to play a role in the
evolution of episodic to chronic tension-type
headache. Cluster headaches typically present
as a series of intense unilateral headaches
occurring over a period of 2 weeks to 3 months.
They are associated with unilateral autonomic
features such as nasal congestion, rhinorrhea,
miosis, or lacrimation. The attacks are usually
brief, lasting between 15 and 180 minutes, and
occur in the orbital, supraorbital and/or temporal
regions. Unlike migraine headaches,
tension-type headaches, temporal arteritis, and
cervicogenic headaches, cluster headaches are
more frequent in men, with an average male to
female ratio of 5 to 1. Tricyclic antidepressants
have been shown in numerous clinical trials to
be effective in the prevention of both migraine
and tension-type headaches.
25
Q
- Which of the following statements regarding
postamputation pain is correct?
(A) Vascular conditions are the leading
cause of both lower and upper
extremity amputations
(B) There is no relationship between
persistent stump pain and phantom
limb pain in amputees
(C) The intensity of pain and the length of
the phantom increases with time
(D) Phantom breast pain is a common cause
of postmastectomy pain
(E) Phantom pain was first described in the
American Civil War
A
- (D) Phantom breast pain occurs in roughly 20%
of mastectomy patients, and phantom sensations
in close to half. Originally thought to be
rare, phantom limb pain is now recognized to
occur in between 60% and 80% of limb
amputees. Phantom limb pain must be distinguished
from phantom sensations, which occur
in over 90% of patients. Vascular conditions
account for over 80% of limb amputations in
the United States. However, trauma is responsible
for approximately 75% of upper extremity
amputations. Most researchers have found
a statistically significant association between
phantom limb pain and persistent stump pain.
Although earlier studies found a correlation
between preamputation pain and phantom
limb pain, more recent studies have not confirmed
this relationship. It is widely held that
phantom pain diminishes with time and eventually
fades away. Though described, phantom
pain associated with congenital absence of a
limb is rare. Phantom pain is generally worse in
the distal part of a limb. Most phantoms shrink
with time, with the most distal aspect of a limb
being the last to disappear. This is known as
“telescoping,” and occurs in approximately
half of all limb amputees. Archaeological
records demonstrate that purposeful amputations
have been practiced since Neolithic times.
The concept of “phantom pain” has been recognized
for hundreds, if not thousands, of
years. In the 16th century, the French military
surgeon Ambrose Paré outlined clear distinctions
between phantom limb pain, phantom
sensation, and stump pain. The term “phantom
pain” was coined by Weir Mitchell in the
American Civil War. A few years earlier,
Mitchell used the word “causalgia” to describe
the characteristic autonomic changes found in
the extremities of soldiers who suffered major
nerve damage.
26
Q
- Which of the following statements regarding
the assessment of pain in pediatric patients is
true?
(A) Palmar sweating and reduced transcutaneous
oxygen concentrations are indicative
of pain
(B) In a hospitalized 2-year-old child, crying
and increased vitals signs are likely to
indicate chronic pain
(C) The FACES scale and Charleston Pain
Pictures provide accurate assessments
of pain in preschool children
(D) The COMFORT scale and facial action
coding system (FACS) are pain instruments
used in young children that are
based predominantly on facial actions
(E) Visual analogue and numerical rating
scales are inappropriate pain indices for
most adolescents
A
- (A) Palmar sweating and reduced transcutaneous
oxygen concentration are indicative of,
though not specific for, acute pain. In a young
child, crying and increased vital signs (eg. heart
rate, respiratory rate, and blood pressure) are
associated with distress, which includes but is
not limited to pain. Other factors that may
cause these signs include separation anxiety,
hunger, and fear. Unlike acute pain, chronic
pain is usually not associated with elevated
vital signs. The FACES scale and Charleston
Pain Pictures are designed to provide assessments
of pain in school aged, not preschool
children. The FACS and COMFORT scale are
used to assess pain in infants and young children.
The FACS is a comprehensive coding system based on a wide range of facial actions.
The COMFORT scale is an eight-item scale
designed to measure distress (including pain)
that includes alertness, calmness, respiratory
response, physical movement, blood pressure,
muscle tone, and facial tension. Pain scales
used in adults such as verbal pain scores,
numerical rating scales, and visual analogue
scales provide accurate assessments of pain in
most adolescents.
27
Q
- Which of the following statements is not correct
regarding herpes varicella zoster?
(A) The most common presentation of acute
herpes zoster (AHZ) is pain and a vesicular
rash in the midthoracic dermatomes
(B) The polymerase chain reaction (PCR) is
the most common means to diagnose
AHZ
(C) The incidence of both AHZ and postherpetic
neuralgia increases with age
(D) There is no generally accepted time
period from the onset of AHZ to when a
diagnosis of postherpetic neuralgia is
made
(E) AHZ involving the lumbosacral
dermatomes may be misdiagnosed as a
herniated disc
A
- (B) The most common way to diagnose AHZ is
clinically. In a small percentage of patients,
AHZ may occur without a rash, a condition
known as “zoster sine herpete” (zoster without
rash). The PCR is often used to aid in the diagnosis
of this condition. In descending order,
the most common sites for AHZ are the
midthoracic dermatomes, the ophthalmic division
of the trigeminal nerve, and the cervical
region. The incidence of both AHZ and postherpetic
neuralgia increases with age. Other
risk factors for AHZ include HIV infection and
transplant surgery, which is likely because of
the resultant immunosuppression. There is no
standard time period after which persistent
pain from AHZ is diagnoses as postherpetic
neuralgia. Postherpetic neuralgia has been variably
defined as the persistence of sensory
symptoms 1 month, 6 weeks, 2 months, 3 months,
and 6 months after herpes zoster. AHZ affects
the lumbosacral dermatomes in between 5%
and 15% of patients. Lumbosacral AHZ may be
misdiagnosed as a herniated disc
28
Q
- Which of the following statements regarding
electrophysiologic testing is true?
(A) Nerve conduction velocities are more
likely to decrease in conditions such as
alcoholic and diabetic neuropathy that
are characterized by Wallerian degeneration
than in demyelinating neuropathies
such as Guillain-Barré
(B) EMG can provide information about the
type, extent and timing of injuries to
motor units and individual muscle
fibers
(C) The H reflex can aid in the evaluation of
brachial plexus injuries
(D) The F response is used to diagnose pure
sensory neuropathies
(E) EMG can readily identify processes
causing muscle denervation (neuropathies),
but is incapable of identifying
myopathies
A
- (B) EMG provides a wealth of information
about the integrity, function, and innervation of
motor units and (using special techniques) individual
muscle fibers. Serial EMG examinations
permit monitoring of recovery or disease progression.
A normal EMG indicates the absence
of motor unit involvement. In neuropathies
characterized by Wallerian degeneration, nerve
conduction velocities range from low normal to
mildly slow. In contrast, demyelinating neuropathies
of the acute and chronic inflammatory
types produce segmental demyelination,
which markedly slows conduction velocities.
The H wave is the electrical representation of the
tendon reflex circuit. In adults, it is only obtainable
in the lower reflexes. It is most prominent
during stimulation of the tibial nerve, being
particularly helpful in the diagnosis of S1
radiculopathy and predominantly sensory
polyneuropathies. The F wave is a late response
that is evoked by supramaximal stimulation of
a motor nerve. It occurs when a small percentage
of the stimulated motor neurons “rebound.”
The initial response to stimulation of a motor
nerve is the M wave. Unlike H waves, F waves
are not true reflexes.
29
Q
- Which of the following statements is true about
quantitative sensory testing (QST)?
(A) QST can be used to pinpoint which
nerve is injured and where along its
path the lesion lies
(B) Thermal sensation is used to measure
the integrity of large, myelinated nerve
fibers
(C) A beta function can be evaluated using
either a tuning fork or von Frey hair
(D) QST can be used to evaluate the function
of all different types of nerve fibers
(E) An advantage of QST is that it can accurately
assess function in uncooperative
or incapacitated patients
A
- (C) Large, myelinated nerves are more vulnerable
to injury than small neurons. The function
of large, myelinated A-β function can be
measured using both vibratory thresholds and
von Frey filaments. QST is used to evaluate the
function of individual nerve fibers. It is not
useful in determining which nerve is injured
and where along its path the injury lies. Both
cold and hot thermal sensations are used to
measure the function of small myelinated (A-δ)
and unmyelinated C fibers. QST cannot be
used to assess B (preganglionic autonomic) and
A-γ (muscle spindle efferent) function. Adownside
of QST is that its accuracy is dependent on
the cooperation and reliability of the patient.
30
Q
- A 38-year-old construction worker presents to
you with complaints of right lower extremity
pain for the last 8 months. Pain radiates from
the lower back to the outer aspect of the right
leg and goes down to the dorsum of the right
foot. The patient reports a problem with walking
and on examination reveals an antalgic gait
and inability to do heel-walking on right,
though toe-walking is not affected. Strength is
5/5 in all muscle groups except dorsi-flexion of
the right ankle which is 4/5 and strength testing
for extensor hallucis longus reveals 4/5
strength. Deep tendon reflexes are 2+ at both
knees and both ankles. Sensory testing reveals
mildly reduced sensation to light touch and
pinprick on the dorsum of the right foot when
compared to the left foot. This patient most
likely has
(A) right piriformis syndrome
(B) right L4 radiculopathy
(C) right L5 radiculopathy
(D) right S1 radiculopathy
(E) facet arthritis
A
- (C) Lumbar radiculopathy most often results
from disc herniation. Depending on the level of
herniated discs radiculopathy may affect specific
nerve roots. Disc herniation at L4-5 and
L5-S1 is most likely caused by mobility of the
segment. A herniated disc may compromise
the nerve root at the same level if displaced
laterally in the recess or in the foramen (L4-5
disc affecting L4 nerve root), or it may effect the
traversing nerve root to the level below (L4-5
disc affecting L5 nerve root). L5 radiculopathy
results in pain, sensory, and motor changes in
L5 dermatomal distribution. Pain is usually
described as shooting or occasionally aching
and burning sensation on the outside of leg
radiating to the dorsum of foot. Sensory testing
may also reveal a decrease in light-touch and
pinprick sensation in the same distribution.
L5 radiculopathy also may result in weakness
in the extensor hallucis longus and thus heel
walking. Deep tendon reflexes may be spared
in the lower extremity.
31
Q
- A46-year-old female with past medical history
of depression, anxiety, irritable bowl syndrome,
and asthma is referred to you for evaluation of
her lower back pain. History reveals onset of
generalized pain that started after she was
involved in a car accident 4 years ago. Physical
examination reveals nonfocal neurologic
examination. Musculoskeletal examination
reveals multiple areas of hypersensitivity. The
patient reports marked pain with moderate
digital pressure at base of skull, her neck, front
of her chest, her elbows as well as her lower
back, and bilateral lower extremities. The
patients MRI scan of the lumbar spine reveals
preserved disc height, no facet arthritis and
minimal disc bulge at L4-5 without any spinal
or foraminal stenosis. This patient most
likely has
(A) fibromyalgia syndrome
(B) discogenic pain
(C) myofascial pain disorder
(D) somatoform disorder
(E) opioid hyperalgesia
A
- (A) Fibromyalgia syndrome is a common pain
condition, estimated to occur in 2.4% of the
general population. The syndrome is characterized
by widespread musculoskeletal pain,
sleep disturbance, psychologic distress, and
comorbidity with other pain syndromes [eg,
irritable bowel syndrome (IBS), interstitial cystitis,
and the female urethral syndrome], which
have considerable impact on the everyday life
of patients. Fibromyalgia syndrome occurs predominantly
in women and demonstrates familial
aggregation. Since 1990, the diagnosis of
fibromyalgia syndrome has been based on criteria
of the American College of Rheumatology
(ACR). A key dimension of the ACR criteria is
the concept of tender points, 18 specific points
on the body surface at which digital palpation
elicits pain (11/18 “positive” tender points fulfills
an fibromyalgia criteria).
It is not uncommon for patients to have
other pain pathologies in addition to fibromyalgia.
However a complete clinical picture should
be viewed before consideration of treatment
options especially if it involves interventional
procedures. Patient describes above most likely
has fibromyalgia as evidenced by the presence
of tender points. A negative physical examination
except for tender points and hypersensitivity
argues against other listed options.
32
Q
- A25-year-old, healthy female volleyball player
has developed severe pain in right hand. This
pain started while playing volleyball and after
a reported wrist sprain. One month after the
initial injury and despite conservative care with
nonsteroidal anti-inflammatory drugs (NSAIDs),
muscle relaxants, and hand splint to avoid any
movement related pain, the patient complains
of even worse burning pain. Pain is worse with
light touch, even blowing air or rubbing of
clothes trigger unbearable pain. The patient
also reports her right hand to be cold and often
wet because of localized sweating. On examination
the patient has a markedly swollen, redappearing
hand. Patient is unable to make a
fist with her fingers and measurement of temperature
reveals a 7°C lower temperature compared
to opposite extremity. Which of the
following is the most likely diagnosis?
(A) CRPS I (RSD)
(B) CRPS II (causalgia)
(C) Peripheral vascular disease
(D) Deep venous thrombosis of upper
extremity
(E) Median neuralgia
A
- (A) Following is the diagnostic criteria for
CRPS I: - The presence of an initiating noxious event
or a cause of immobilization. - Continuing pain, allodynia, or hyperalgesia
with which the pain is disproportionate
to any inciting event. - Evidence at some time of edema, changes
in skin blood flow, or abnormal sudomotor
activity in the region of the pain. - This diagnosis is excluded by the existence
of condition that otherwise would account
for the degree of pain and dysfunction.
The patient in the question meets all the
criteria for diagnosis of CRPS I (RSD). CRPS II
(causalgia) by definition has a known injury to
a major nerve. Vascular etiology though possible
after trauma, is unlikely to give symptoms
of allodynia as well as sudomotor changes.
Median neuralgia would result in a similar
clinical pain picture but only hand discomfort
would be expected to be confined only to the
distribution of median nerve.
