ASIPP Pain States Questions Flashcards

1
Q
  1. Characteristics of diffuse idiopathic skeletal hyperostosis
    (DISH) include:
    A. Extensive degenerative disease
    B. Traumatic insult.
    C. Cystic in presentation.
    D. Osteophytosis without evidence of disk space narrowing
    or sclerosis.
    E. Posterior calcifi cation in four contiguous vertebrae
A
  1. Answer: D
    Source: Helms CA. Fundamentals of Skeletal Radiology.
    W.B. Saunders Co., 1995; p. 117.
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2
Q
447. Which of the following is the most sensitive to visceral
stimuli?
A. Serosal membranes
B. Solid visceral organs
C. Walls of hollow organs
D. Ligamentous structures
E. Mesentery
A
  1. Answer: A

Source: Day MR, Board Review 2004

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3
Q
448. Which of the following has been targeted as the cause of ischemic muscle pain?
A. Substance P
B. Potassium ion
C. Leukotrienes
D. Adenosine
E. Histamine
A
  1. Answer: D

Source: Day MR, Board Review 2004

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4
Q
449. The spinal pathway theorized to be involved in the
pathogenesis of central pain is:
A. Spinothalamic tract
B. Posterior spinocerebeller tract
C. Anterior corticospinal tract
D. Fasciculi propii
E. All of the above
A
  1. Answer: A

Source: Day MR, Board Review 2004

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5
Q
450. Seventy percent of cervical radiculopathies caused by disc impingement involve the following nerve root:
A. T1
B. C7
C. C6
D. C5
E. C4
A
  1. Answer: B
    Explanation:
    B. 70% of cervical radiculopathies involve C7.
    C. 20% of cervical radiculopathies involves C6.
    A, D & E. Only 10% of cervical radiculopathies involve the
    nerve roots other than C6, C7.
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6
Q
451.Based on burn depth classifi cation, which type/types
is/are painful?
A. 1st degree
B. 2nd degree
C. 3rd degree
D. 1st and 2nd degree
E. 1st, 2nd, and 3rd degree
A
  1. Answer: D
    Explanation:
    Ref: DeLoach and Stiff. Chapter 18. Burn Patient. In: Pain
    Management and Regional Anesthesia in Trauma. 1st
    Edition. Rosenberg, Grande, Berstein. W.B. Saunders,
    1999, page 302.
    Source: Day MR, Board Review 2003
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7
Q
452. What is the most common etiology of brain central pain?
A. Neoplasm
B. Arteriovenous malformation
C. Stroke
D. Multiple sclerosis
E. Syringobulbia
A
  1. Answer: C

Source: Day MR, Board Review 2004

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8
Q
453. A 40-year-old man develops depressed mood, anhedonia, initial and terminal insomnia, loss of appetite, signifi cant weight loss, and sexual dysfunction. The clinical features of the patient’s psychiatric illness suggest dysfunction of the
A. Frontal lobes
B. Pituitary
C. Hippocampus
D. Hypothalamus
E. Corpus Callosum
A
  1. Answer: D
    Explanation:
    D. Clinical studies of patients with major depressive
    disorders indicate that an intrinsic regulatory defect
    involving the hypothalamus underlies the disorder. It also
    involves the monoamine pathways.
    The hypothalamic modulation of neuroendocrine activity
    has been implicated, as have been the neurotransmitter
    systems of serotonin and norepinephrine, in major
    depression. The evidence suggests a major role for the
    heritability of such neurochemical disorders.
    A, B, C & E. The frontal lobes, the pituitary, the
    hippocampus, and the corpus callosum are related to the
    emotions, memory, and neural communications.
    However, they do not play a major role in the depressive
    disorders as does the hypothalamus.
    Source: Ebert 2004
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9
Q
  1. The best description of the relationship between pain and
    psychiatric disorders is which of the following?
    A. There are low rates of psychiatric illness in patients with
    chronicpain.
    B. Medically ill patients are much more likely to have psychiatric
    illness.
    C. Psychiatric illnesses preclude the possibility of clinically
    important medical illnesses(pain).
    D. There is no relationship between pain, medical and
    psychiatric disorders.
    E. All the patients with chronic pain will also suffer with
    somatization disorder
A
  1. Answer: B

Source: Cole EB, Board Review 2003

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10
Q
  1. Neurological level of a C6 nerve root involvement is
    identifi ed by the following:
    A. Weakness in the wrist extension, loss of sensation in the
    lateral arm, and biceps refl ex suppression
    B. Weakness of shoulder abduction, pain in the lateral
    forearm, and suppression of brachioradialis refl ex
    C. Weakness of wrist extension, pain in the lateral forearm,
    thumb, and index fi nger, and suppression of brachioradialis
    refl ex
    D. Weakness of wrist fl exion and fi nger extension, pain
    in the thumb and index fi nger, loss of sensation in
    the thumb and index fi nger, and triceps refl ex suppression
    E. Weakness of wrist extension, pain in the lateral arm,
    and brachioradialis refl ex suppression
A
  1. Answer: C
    Source: Hoppenfeld S. Orthopaedic Neurology. A
    Diagnostic Guide to Neurologic Levels. Philadelphia,
    LWW, 1997.
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11
Q
  1. A young man with ankylosing spondylitis complains of
    neck, occipital, and shoulder pain. He denies any history
    of recent trauma or febrile illness. The most likely cause
    of his pain is:
    A. Compression fracture of C2
    B. Cervical osteomyelitis
    C. Atlantoaxial subluxation
    D. Epidural hematoma
    E. Cervical disc herniation C4/5
A
  1. Answer: C
    Explanation:
    Patients with ankylosing spondylitis may have erosion of
    the odontoid or destruction of the transverse ligament,
    which may allow C1 subluxation on C2.
    Patients will complain of neck, occipital, and shoulder
    pain. The subluxation is usually mild in these patients.
    Plain radiographs and MRI should be obtained to confi rm
    the diagnosis.
    Treatment is symptomatic.
    Source: Kahn CH, DeSio JM. PreTest Self Assessment and
    Review. Pain Management. New York, McGraw-Hill, Inc.,
    1996.
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12
Q
457. Unilateral sacroiliac joint erosion or sclerosis would be
characteristic of:
A. Osteoporosis
B. Psoriasis
C. HNP L5-S1
D. Reiter’s syndrome
E. Piriformis syndrome
A
  1. Answer: D
    Source: Helms CA. Fundamentals of Skeletal Radiology.
    W.B. Saunders Co., 1995; p. 125.
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13
Q
458. Ramsay Hunt syndrome (herpes zoster oticus) occurs
when herpes zoster involves the:
A. Gasserian ganglion
B. Sphenopalatine ganglion
C. Ciliary ganglion
D. Geniculate ganglion
E. Trigeminal nerve
A
  1. Answer: D
    Explanation:
    Ramsay Hunt syndrome develops from a herpes zoster
    infection involving the geniculate ganglion.
    Zoster lesions of the external ear and oral mucosa on the
    ipsilateral side are usually observed.
    The syndrome can present as a deep, painful sensation primarily behind the ear between the pinna and mastoid
    process and radiating to the face, ear, neck, and occipital
    areas.
    Source: Raj (Pain Review, 2nd Ed., page 236)
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14
Q
  1. A 54-year old man complained of back pain after heaving
    lifting. Two weeks later, he had diffi culty walking on his
    heels, and increased pain in the lower back, buttock, and
    dorsum of the foot. Straight leg raising was positive at
    50°. Likely diagnosis is:
    A. L3 radiculopathy
    B. L4 radiculopathy
    C. L5 radiculopathy
    D. S1 radiculopathy
    E. L3/4 disc herniation
A
  1. Answer: C
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15
Q
460. Diagnosis of CRPS may be performed:
A. typical personality
B. recent surgery
C. exclusion of other likely diagnosis
D. psychological testing
E. drug intake profi le
A
  1. Answer: C

Source: Racz G. Board Review 2003

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16
Q
  1. A female patient presents with gluteal and leg pain. The pain is exacerbated when the patient lies down on the
    affected side or with crossed legs. Physical examination
    revealed local trochanteric tenderness with iliotibial
    band tightness and tenderness. The most likely diagnosis
    is:
    A. Piriformis syndrome
    B. Trochanteric bursitis
    C. Lumbar radiculopathy
    D. Sacroiliitis.
    E. Osteoarthritis of hip
A
  1. Answer: B
    Explanation:
    Trochanteric bursitis or gluteal fasciitis may be seen in
    approximately 25% of the patients with back pain
    predominantly in women.
    Etiology is typically unknown. However, one may fi nd leg
    length difference, abnormal gait, muscle tightness,
    osteoarthritis of the hip or spine, and occasional trauma.
    Signs and symptoms:
    Gluteal and leg pain, 64%
    Pain lying on affected side or with crossed legs, 50%
    Local trochanteric tenderness, frequently with iliotibial
    band tightness and tenderness
    Differential diagnosis of trochanteric bursitis includes
    osteoarthritis of hip, lumbar radiculopathy, and septic
    bursitis.
    Source: Cole & Herring. Low Back Pain Handbook
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17
Q
  1. A young female patient presents with buttock and leg
    pain. She also reported occasional low back pain and
    severe dyspareunia. Physical examination showed pain
    on resisted external rotation and abduction of hip. The
    likely diagnosis in this patient is:
    A. Severe osteoarthritis of hip
    B. Piriformis syndrome
    C. Lumbar disc herniation
    D. Trochanteric bursitis
    E. Sacroiliac joint arthritis
A
  1. Answer: B
    Explanation:
    B. The description above indicates piriformis syndrome:
    Piriformis muscle originates medially from the inner
    surface of the sacrum and exits the pelvis through the
    greater sciatic foramen and attaches to the greater
    trochanter of the femur.
    The innervation is from the fi rst and second sacral nerves
    (S1 and S2).
    Buttock and nerve pain or pseudosciatica resulting from
    compression or infl ammation of sciatic nerve as it courses
    under or through piriformis muscle in buttock is the
    mechanism.
    There is no particular group at risk.
    Minor trauma to piriformis may result in muscle
    contraction or infl ammation.
    Pseudosciatica or buttock and leg pain is the most
    common symptom.
    Low back pain is seen in 50% of the patients.
    Dyspareunia is seen in 23%.
    Piriformis muscle tenderness may be found transrectally
    or transgluteally.
    There is pain on resisted external rotation and abduction of hip.
    There is also pain on internal rotation of hip.
    The piriformis should be assessed above and below 90° of
    hip fl exion.
    Reproduction of symptoms in combination with forceful
    internal rotation of the fl exed thigh is referred to as
    Freiberg’s sign.
    If you add adduction, it is called Bonnet’s sign.
    The pace maneuver also assesses weakness and pain with
    resisted abduction and external rotation of the thigh. This
    is done with the patient in the seated position.
    Tenderness may present throughout the length of the
    piriformis
    Differential diagnosis includes lumbar radiculopathy and
    sacroiliitis.
    Source: Cole & Herring. Low Back Pain Handbook
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18
Q
  1. In a patient whose headaches are positional and are
    associated with diplopia, vertigo, tinnitus, nystagmus,
    hearing loss, photophobia, nausea, and vomiting the
    diagnosis is:
    A. Cervicogenic headache
    B. Intractable migraine with aura
    C. Episodic cluster headache
    D. Post-dural puncture headache
    E. Non-intractable migraine without aura
A
  1. Answer: D
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19
Q
464. The usual site of herniation of a cervical intervertebral
disk is:
A. Posterior
B. Lateral
C. Postero lateral
D. Anterior
E. Antero lateral
A
  1. Answer: C
    Explanation:
    The uncinate processes are bony protrusions located
    laterally from the C3 to C7 vertebrae. They prevent the
    disc form herniating laterally. The posterior longitudinal
    ligament is the thickest in the cervical region. It is 4 to 5
    time thicker than in the thoracic or lumbar region. The
    nucleus pulposus in the cervical disc is present at birth but
    by the age of 40 years it practically disappears. The adult
    disc is desiccated and ligamentous. It is mainly composed
    of fi brocartilage and hyaline cartilage. After the age of 40, a
    herniated cervical disc is never seen because there is no
    nucleus pulposus. The most common cervical herniated
    nucleus pulposus (HNP) occurs between the C6 to C7
    (50%) and followed by the C5 to C6 (30%)
    Source: Chopra P. 2004
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20
Q
  1. Which of the following statements is true?
    A. Pneumothorax is a common complication of thoracic
    epidural.
    B. Thoracic facet pathology can refer pain to the scapular
    region
    C. The intercostal nerve innervates only the scapular
    region
    D. Noncardiac chest pain is purely psychogenic
    E. There is no risk of pneumothorax with a simple trigger
    point injection
A
  1. Answer: B
    Explanation:
    Pneumothorax is a risk from rib blocks and trigger point
    injections. The thoracic facets refer to the scapular region,
    but the intercostal nerve can refer into the anterior chest.
    There are multiple causes of noncardiac chest pain.
    Source: Trescot AM, Board Review 2004
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21
Q
466. Lower esophageal pain can be relieved by blocking spinal nerve roots at which levels?
A. T2 - T3
B. T2- T5
C. T5- T8
D. T8 - T9
E. T8- T10
A
  1. Answer: C
    Explanation:
    Ref: Raj. Chapter 43. Thoracoabdominal Pain. In:
    Practical Management of Pain. 3rd Edition, Raj et al,
    Mosby, 2000, page 620
    Source: Day MR, Board Review 2003
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22
Q
467. Thoracic pain can come from all of the following
EXCEPT:
A. intercostal nerves
B. myofascial trigger points
C. thoracic or cervical facets
D. lung tissue
E. atlanto-axial joint
A
467. Answer: E
Explanation:
All of the above are causes of thoracic pain except Altantoaxial
Joint
Source: Trescot AM, Board Review 2004
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23
Q
468. What is the lifetime prevalence of radicular pain?
A. 0.2%
B. 2%
C. 10%
D. 20%
E. 80%
A
  1. Answer: B

Source: (Bonica, 3rd Ed., page 1528)

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24
Q
  1. The affective dimensions of the pain response include
    A. Increase in pain tolerance
    B. Disruption of appetitive and arousal drive states
    C. Memory loss
    D. Sharp, shooting pain
    E. Dermatomal sensory loss
A
  1. Answer: B
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25
Q
  1. A 65-year old man with a history of chronic back pain
    has been a patient for 5 years, receiving 3-4 months relief
    from epidural steroid injections before pain increases to
    the level where repeat injection is required. Following
    6 weeks after epidural, he presents to the clinic with the
    complaint of a recent increase in his pain. The pain is
    constant and is exacerbated by movement. NSAIDS,
    bedrest, and narcotics failed to help. There was no
    history of fever. The L4 and L5 vertebrae were tender to
    palpation. There was also paraspinal muscle spasm. No
    motor or sensory defi cits were present. The most likely
    diagnosis entertained in this patient:
    A. Vertebral osteomyelitis
    B. Spinal stenosis
    C. Herniated disc
    D. Paget’s disease
    E. Epidural abscess
A
  1. Answer: A
    Explanation:
    The symptoms described in the question are consistent
    with the diagnosis of vertebral osteomyelitis. Clinical
    features include persistent, localized pain with heat,
    swelling, tenderness, and erythema over the involved bone.
    Fever may be low-grade or absent. Diagnosis can be made
    by history, physical examination, radiographic studies of
    the spine, bone scan, blood cultures, erythrocyte
    sedimentation rate, complete blood count, needle
    aspiration of the intervertebral disc space, or biopsy of
    infected bone. Staphylococcus aureus is the most common
    causative organism, but gram-negative bacteria can also
    cause osteomyelitis (most common in a urinary tract
    infection) (Bonica, pp 393-394).
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26
Q

471.Which of the following statements best described
Conversion Disorder?
A. Involves one or more symptoms or defi cits affecting
voluntary motor or sensory function that suggest a
neurological or other general medical condition.
B. Psychological factors are not judged to be associated
with the symptom or defi cit because the initiation or
exacerbation of the symptom or defi cit follows confl
icts with healthcare professionals.
C. Patients intentionally produce or feign symptoms and
defi cits to call attention to themselves.
D. Symptoms or defi cit can after appropriate investigation
be fully explained by a culturally sanctioned behavior
or experience.
E. It generally develops in late life.

A
  1. Answer: A

Source: Cole EB, Board Review 2003

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27
Q
  1. Spondylolysis is defi ned as:
    A. Dysplasia of the L5/S1 facet joints
    B. Forward slippage of vertebral body
    C. Traumatic degeneration of posterior elements
    D. Isthmus defect without vertebral slippage
    E. Pathologic dissolution of the facet joint
A
472. Answer: D
Explanation:
Spondylolysis is a pars defect without vertebral body
slippage
Source: Boswell MV, Board Review 2005
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28
Q
  1. A 41-year-old man presents with spastic legs, bilateral
    extensor plantar refl exes, hyperrefl exia and loss of
    sensation (position sense and vibration) of the lower
    extremities. Choose correct diagnosis:
    A. Upper motor neuron disease
    B. Lower motor neuron disease
    C. Myelopathy
    D. Radiculopathy
    E. Broca’s aphasia
A
  1. Answer: C
    Explanation:
    A. Upper motor neuron (UMN) disease (above the level of
    the corticospinal synapses in the gray matter) is
    characterized by spastic paralysis, hyperrefl exia, and a
    positive Babinski refl ex (everything is up in UMN
    disease).
    B. Lower motor neuron (LMN) disease (below the level of
    synapse) is characterized by fl accid paralysis, signifi cant
    atrophy, fasciculations, hyporefl exia, and a fl exor (normal)
    Babinski refl ex (everything is down in LMN disease).
    C. Myelopathy causes severe sensory loss 0 posterior
    column sensation (position sense and vibration),
    spasticity, hyperrefl exia, and positive Babinski refl exes.
    D. A radiculopathy occurs with root compression from a
    protruded disk that causes sensory loss, weakness, and
    hyporefl exia in the distribution of the nerve root.
    E. Broca’s aphasia (left inferior frontal gyrus) is a
    nonfl uent expressive aphasia (Broca’s should remind you
    of broken speech); Wernicke’s aphasia (left posteriorsuperior
    temporal gyri) is a receptive aphasia because
    patients lack auditory comprehension (Wernicke’s should
    remind you of wordy speech that makes no sense).
    (Source: Seidel, 5/e, p 798.)
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29
Q
474. The superior hypogastric plexus is:
A. a collection of para sympathetic nerves
B. innervates the foregut
C. blocked to treat pelvic pain
D. may cause lumbar radiculopathy
E. performed under fl uoroscopy at L2
A
  1. Answer: C
    Explanation:
    The superior hypogastric plexus is a collection of
    sympathetic nerves that innervate the pelvis and is blocked
    to treat pelvic pain. They are not involved in lumbar
    radiculopathy.
    Source: Trescot AM, Board Review 2004
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30
Q
  1. The uncommon Sluder’s neuralgia characterized by severe
    pain in the face blow the eyebrows primarily involves the
    A. Gasserian ganglion
    B. Sphenopalatine ganglion
    C. Ciliary ganglion
    D. Geniculate ganglion
    E. Trigeminal nerve
A
  1. Answer: B
    Explanation:
    Sluder’s neuralgia, also known as sphenopalatine ganglion
    neuralgia, is an uncommon facial neuralgia characterized
    by severe pain in the face below the eyebrows.
    The pain is unilateral, constant, and boring.
    The cause of Sluder’s syndrome is thought to be
    involement of the sphenopalatine ganglion from an
    irritation such as sinusitis.
    Source: Raj, P
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31
Q
476. A patient with hallux valgus develops lateral displacement
of the extensor and fl exor hallucis longus tendons.
CHOOSE CORRECT DIAGNOSIS:
A. Hammer toe
B. March fracture
C. Genu valgum
D. Genu varum
E. Bunion
A
  1. Answer: E
    Explanation:
    (Seidel, 5/e, p 732.) Improper footwear results in lateral
    deviations of the great toe, extensor, and fl exor hallucis
    longus tendons (bunion formation). Hammer toe often
    affects the second toe. The metatarsophalangeal joint is
    dorsifl exed and the proximal interphalangeal joint
    displays plantar fl exion. A stress fracture of a metatarsal is
    called a march fracture. Stress fractures result in bone
    resorption followed by insuffi cient remodeling due to
    continued activity Stress fractures occur in the tibia as well
    as the metatarsal; examination typically reveals point
    tenderness and swelling. In genu varum (bowleg), the
    lateral femoral condyles are widely separated when the feet
    are placed together in the extended position. In genu
    recurvatum, the knee hyperextends, and in genu
    impressum, there is fl attening and bending of the knee to
    one side with displacement of the patella. Pes planus is a
    fl attened longitudinal arch of the foot, often called fl at
    foot.
    Morton’s neuroma causes pain in the forefoot that radiates
    to one or two toes with tenderness between the two
    metatarsals. The pain may be further aggravated by
    squeezing the metatarsals together.
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32
Q
477. Which of the following is innervated by the T1 nerve
root?
A. Thumb
B. Index finger
C. Lateral biceps
D. Medial arm
E. Middle finger
A
  1. Answer: D
    Explanation:
    The medial arm is innervated by the intercostals brachial
    nerve, and is comprised of fi bers from T1 and T2 roots.
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33
Q
  1. A 20-year-old college student develops left shoulder
    pain after jumping into a lake from a swinging rope. She
    presents holding her arm beside her body (adducted) and
    avoiding any shoulder movement. On examination, the
    rounded contour of the shoulder is lost and the head of
    the humerus is felt under the coracoid process. Which of
    the following is the most likely diagnosis?
    A. Inferior glenohumeral dislocation
    B. Rupture of the long head of the biceps
    C. Posterior glenohumeral dislocation
    D. Anterior glenohumeral dislocation
    E. Fracture of clavicle
A
  1. Answer: D
    Explanation:
    (Seidel, 5/e, p 720.) Glenohumeral dislocations may be
    anterior, posterior, or inferior depending on the position of the head of the humerus in relation to the glenoid. The
    most common dislocation is anterior (>90%)and is due to
    forceful abduction, external rotation, or extension. There
    is typically fl attening of the deltoid and loss of the greater
    tuberosity, causing a squared-off appearance of the
    shoulder. The patient is usually in severe pain and holds
    the arm in slight abduction and external rotation.
    Posterior dislocations are typically seen following a
    seizure. Possible complications of shoulder dislocation
    include damage to the axillary artery, axillary nerve
    (deltoid paralysis), and brachial plexus. First-time
    dislocation requires orthopedic management (surgery or
    therapeutic exercise), since 80% of patients will have a
    recurrence. Rupture of the long head of the biceps causes a bulge in the lower half of the arm and pain on elbow
    flexion.
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34
Q
479. A young, high school girl develops a painful vesicular rash around her left eye. This is followed by blurry vision that occurs only when both eyes are open. She is diagnosed with vericella zoster ophthalmicus. Which ocular motor nerve is most likely to be affected?
A. Superior division of the third.
B. Inferior division of the third.
C. Fourth (trochlear)
D. Sixth (abducens)
E. Long ciliary
A
  1. Answer: C
    Explanation:
    Varicella Zoster, or herpes zoster, spreads to the face along
    the trigeminal nerve. The fourth nerve is presumably
    involved because it shares its nerve sheath with the
    ophthalmic division of the trigeminal nerve. The third and
    sixth nerves may also be involved with varicella zoster, but
    this occurs much less frequently than involvement of the
    fourth nerve.
    Source: Anschel 2004
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35
Q
  1. 55 year old, former sailor states that he has pain on the
    right side of his face when he chews his food. It also
    starts when he shaves his beard. It is a sharp, electric like
    stabbing pain and not present all the time. The pain is
    mostly over his right cheek and jaw. The most likely cause
    of his pain is:
    A. Dental caries
    B. Atypical neuralgia
    C. Trigeminal Neuralgia
    D. Temporomandibular joint disorder
    E. Atypical facial pain
A
  1. Answer: C
    Explanation:
    Trigeminal neuralgia (Tic Douloureux) is pain restricted
    to the distribution of the trigeminal nerve.It can be
    present in any of the three divisions - frontal (V1),
    maxillary or the mandibular. The commonest to be
    affected are the maxillary (V2) and the mandibular (V3).
    The peak incidence is mostly between the ages of 50 years
    and 70 years. The pain is intermittent with pain free
    intervals. It is described as a sharp, electric, stabbing,
    shooting pain. The triggers are chewing, swallowing,
    talking and exposure to cold. Trigeminal neuralgia is
    mostly unilateral.
    Atypical neuralgias are almost always constant with very
    rare pain free intervals. This is an important
    distinguishing symptom with trigeminal neuralgia. The
    pain burning in character and not sharp. It is not triggered
    by non-noxious stimulus. It tends to affect young adults.
    Source: Chopra P, 2004
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36
Q
  1. A 43-year old male house painter reports shoulder pain
    of 2 weeks duration after a half a can of paint fell onto his
    right shoulder. He feels stiff and weak when attempting
    to elevate his right arm overhead. When attempting to
    elevate the shoulder, he does so with an overexaggerated
    right shoulder shrug up to 40° and suddenly fl ops down
    to his side. The most likely diagnosis is:
    A. Rotator cuff tear
    B. Cervical spondylosis
    C. Suprascapular neuropathy
    D. Brachial neuritis
    E. Bicipital tendonitis
A
  1. Answer: A
    Explanation:
    Rotator cuff disorders encompasses four stages with Stage
    I with edema and hemorrhage, Stage II with tendonitis,
    Stage III with partial thickness tear, and Stage IV with full
    thickness tear of the rotator cuff. With partial thickness
    tear, there is history of tendonitis and patient can begin abduction but experiences pain or a painful arc during the
    attempt. Active abduction becomes more comfortable
    afterinjection of a local anesthetic and this feature helps
    differentiate tendonitis or a partial tear from a complete
    tear of the rotator cuff. Since the patient with a large tear
    does not regain strength after the subacromial space is
    anesthetized.
    Full thickness tear of the rotator cuff occurs, as the fi nal
    stage of the degenerative process in which the provoked
    tendon succumbs to something as trivial as opening up a
    stuck window or more seriously after sustaining a fall on
    the shoulder or on an outstretched abducted arm. A
    complete tear may also occur after greater humeral
    tuberosity fracture scar or from shoulder dislocations.
    Differential diagnosis includes bursitis, cervical
    spondylosis, suprascapular neuropathy, and brachial
    neuritis, etc.
    Source: Saidoff DC, McDonough AL. Critical Pathways in
    Therapeutic Intervention. Extremities and Spine. St.
    Louis,Inc., 2002
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37
Q
  1. Following a radical mastectomy, the patient is found
    to have winging of the scapula when the fl exed arm is
    pressed against a fi xed object. This indicates injury to
    which of the following nerves?
    A. Axillary
    B. Long thoracic
    C. Lower subscapular
    D. Supraclavicular
    E. Thoracodorsal
A
  1. Answer: B
    Explanation:
    A. The axillary nerve, deep in the brachial portion of the
    axilla, innervates the deltoid muscle.
    B. The serratus anterior muscle (protractor and stabilizer
    of the scapula) is innervated by the long thoracic nerve (of
    Bell), which arises from roots C5 to C7 of the brachial
    plexus. During modifi ed radical mastectomy, this nerve is
    usually spared to maintain shoulder function. However, its
    location places it in jeopardy during the lymphatic
    resection.
    C. The lower subscapular nerve innervates the teres major
    muscle and a portion of the subscapularis muscle.
    D. The supraclavicular nerves are sensory branches of the
    cervical plexus.
    E. The thoracodorsal nerve, which arises from the
    posterior cord of the brachial plexus, innervates the
    latissimus dorsi.
    Source: Klein RM and McKenzie JC 2002.
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38
Q
  1. A middle-aged man presents with complaints of right
    elbow pain. He is an avid golf player. He does not play
    tennis. He tried high doses of Aspirin and Tylenol
    without any signifi cant relief. Physical examination
    showed resisted wrist extension with elbow extended and
    radial deviation, forced passive wrist fl exion and ulnar
    deviation, and forearm pronation with elbow extension
    reproduced the pain in the vicinity of lateral epicondyle.
    The appropriate diagnosis in this patient is:
    A. Radiohumeral joint infl ammation
    B. Radial tunnel syndrome
    C. Posterior interosseous nerve entrapment
    D. Lateral epicondylitis
    E. Medical epicondylitis
A
  1. Answer: D
    Explanation:
    A. Radial humeral joint infl ammation and swelling may
    occur from rheumatoid arthritis, gout, or infectious
    arthritis, especially in the last if there has been a history of
    injections to this area, such as repeated steroid injections
    for recalcitrant tennis elbow. Swelling, if present, will
    occur between the lateral epicondyle and the olecranon
    process below.
    B. Radial tunnel syndrome may occur concomitantly with
    lateral epicondylitis and is a common cause of treatment
    resistant cases. It should be considered suspect when
    tennis elbow fails to respond to conservative treatment including injections.
    C. Involvement of the deep radial nerve is also known as
    posterior interosseous nerve entrapment. This may be
    confi rmed by a tension-test. The symptoms of entrapment
    of posterior interosseous nerve are similar to the radial
    tunnel syndrome in which pain is over the proximal dorsal
    forearm, with maximal tenderness at the site of radial
    tunnel, that is 4 cm distal to the lateral epicondyle over the
    posterior interosseous nerve.
    D. Lateral epicondylitis, or tennis elbow, is the most
    common affl iction.
    E. Medical epicondylitis or pain elicited on resisted wrist
    fl exion and pronation, as well as extremes of the passive
    wrist extension with the forearm supination and elbow
    extension and ulnar deviation eliciting the pain at the
    medial epicondyle.
    Source: Saidoff DC, McDonough AL. Critical Pathways in
    Therapeutic Intervention. Extremities and Spine. St.
    Louis,Inc., 2002.
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39
Q
  1. An elderly woman presents with recent onset of swelling
    of the right arm, neck and face. Her right jugular vein is visibly engorged and her right brachial pulse is
    diminished. On the basis of these signs, her chest x-rays
    might show
    A. A left cervical rib
    B. A mass in the upper lobe of the right lung
    C. Aneurysm of the aortic arch
    D. Right pneumothorax
    E. Thoracic duct blockage in the posterior mediastinum
A
  1. Answer: B
    Explanation:
    (April, 3/e, p 265.) A Pancoast tumor in the apex of the
    right lung may compress the right brachiocephalic vein
    with resultant venous engorgement of the right arm and
    right side of the face and neck. In addition, there may be
    compression of the brachial artery, the sympathetic chain,
    and recurrent laryngeal nerve with attendant defi cits. An
    aneurysm of the aortic arch could reduce pulse pressures
    as the great vessels are occluded, but it could not explain
    the venous congestion.
    Source: Klein RM and McKenzie JC 2002.
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40
Q
  1. A woman presents with complaints of left shoulder
    and arm pain approximately 2 years after undergoing
    radiation therapy for breast cancer. Physical examination
    reveals lymphedema of the left axilla and pressure over
    the left supraclavicular area precipitating a sharp pain
    that radiates down her left arm. The likely diagnoses is:
    A. Thromboangiitis obliterans
    B. Refl ex sympathetic dystrophy
    C. Tumor metastasis
    D. Radiation-induced plexopathy
    E. Cervical radiculopathy
A
  1. Answer: D
    Explanation:
    Radiation-induced fi brosis of the connective tissue
    surrounding the brachial plexus can cause compression
    and ischemic neuropathy. Symptoms have developed 6
    months to 20 years after radiation therapy. The patient
    complains of deafferentation-type pain. It is characterized
    as progressively increasing, diffuse, and burning. Other
    symptoms and signs may include numbness, paresthesias,
    dysesthesias, and C5/6 motor weakness. There are
    signifi cant differences in symptoms in patients with
    metastatic plexopathy versus radiation plexopathy. Most
    patients with metastatic plexopathy develop sensory
    changes in C8/T1 distribution versus C5/6 in radiation
    plexopathy. Patients with metastatic plexopathy also have
    a much higher incidence of Horner’s syndrome,
    lymphedema, and swelling of the painful limb, and
    development of epidural deposits.
    Source: Bonica
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41
Q
  1. A 20-year-old woman presents complaining of proximal
    forearm pain exacerbated by extension of the wrist
    against resistance with the elbow extended, She denies
    trauma but is an avid racquetball player. Which of the
    following is the most likely diagnosis?
    A. Lateral epicondylar tendinitis
    B. Medial epicondylar tendinitis
    C. Olecranon bursitis
    D. Biceps tendinitis
    E. Long thoracic nerve early paralysis
A
  1. Answer: A
    Explanation:
    (Goldman, 21/e, pp 1559-1560.) Tennis elbow or lateral
    epicondylar tendinitis is most commonly characterized by
    tenderness of the common extensor muscles at their origin
    (the lateral epicondyle of the humerus). Passive fl exion of
    the fi ngers and wrist and having the patient extend the
    wrist against resistance causes pain. Golfer’s elbow or
    medial epicondylar tendinitis is a similar disorder of the
    common fl exor muscle group at its origin, the medial
    epicondyle of the humerus. Olecranon bursitis is an
    infl ammation of the bursa over the olecranon process
    caused by acute or chronic trauma (student’s elbow) or
    secondary to gout, rheumatoid arthritis, or infection.
    Clinically, there is swelling or pain on palpation of the
    posterior elbow. Paralysis of the serratus anterior muscle
    (innervated by the long thoracic nerve) causes the scapula
    to protrude posteriorly from the posterior thoracic wall
    when the patient is asked to push against a wall (winged
    scapula).
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42
Q
  1. A 50-year old woman with systemic lupus erythematosus
    complains of fever, headache, and vomiting associated
    with a depressed level of consciousness over the last 24 h.
    She recently had begun taking ibuprofen as treatment for
    diffuse joint pain. CSF examination revealed neutrophilia
    and normal glucose. The most likely diagnosis is:
    A. Bacterial meningitis
    B. Drug-induced meningitis
    C. Fungal meningitis
    D. Viral meningitis
    E. Encephalitis
A
  1. Answer: B
    Explanation:
    B. Drug-induced aseptic meningitis may be due to a
    hypersensitivity reaction to drugs such as ibuprofen,
    sulindac, tolmetin, trimethoprim-sulfamethoxazole,
    azathioprine, penicillin, isoniazid, phenazopyridine, and
    sulfonamides.
    Facial swelling, urticaria, pruritus, and conjunctivitis may
    also occur along with the fever, headache, vomiting, and
    depressed level of consciousness.
    Symptoms usually resolve rapidly after the causative drug
    is eliminated.
    CSF studies show predominance of neutrophils and low or
    normal glucose.
    Patients with lupus, Sjögren’s syndrome, or mixed
    connective tissue disease have the greatest risk of
    developing drug-induced meningitis.
    The incidence is higher in women.
    Source: Kahn CH, DeSio JM. PreTest Self Assessment and
    Review. Pain Management. New York, McGraw-Hill, Inc.,
    1996.
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43
Q
488. The relationship between social and biologic processes in
the causation of psychopathology has historically been
classifi ed by the following terms.
A. Classically conditioned
B. Organic and functional
C. Genetic and familial
D. Neuropathologic and sociopathologic
E. Psychoanalytic and dynamic
A
  1. Answer: B
    Explanation:
    The relationship between social and biologic processes has
    historically been regarded by psychiatry and medicine as
    organic and functional.
    Organic mental illnesses have included the dementias and
    the toxic psychoses.
    The functional mental illnesses have included the various depressive syndromes, the schizophrenias, and the
    neuroses.
    The Psychoanalytic (dynamic) approaches and an
    understanding of conditioning (learning) played
    important roles in the evolution and development of an
    integrated biobehavioral understanding of human
    behavior and human biology.
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44
Q
489. The most common painful symptom associated with
central pain is
A. Burning pain
B. Dysesthesias
C. Lancinating pain
D. Visceral pain
E. Muscle pain
A
  1. Answer: A
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45
Q
  1. A unilateral throbbing headache, associated with
    nausea, phonophobia, photophonia, without preceding
    symptoms, would meet the IHS criteria for what type of
    headache?
    A. Migraine with aura
    B. Migraine without aura
    C. Cluster headache
    D. Trigeminal neuralgia
    E. Tic doloureux
A
  1. Answer: B
    Explanation:
    A. Migraines with aura are associated with preceding
    symptoms.
    B. Migraine without aura has symptomatology as
    described.
    C. Cluster headaches are usually centered over the eye.
    D. Trigeminal neuralgia is usually a sharp, lancinating
    pain.
    E. Tic Douloureux is trigeminal neuralgia
    Source: Trescot AM, Board Review 2004
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46
Q
  1. A patient complains of morning stiffness and pain
    in multiple joints, including the joints of the hand.
    Subcutaneous nodules are present over the extensor
    surfaces, and diagnostic tests indicate abnormal amounts
    of HLA-DR4. The most likely diagnosis is:
    A. Osteoarthritis
    B. Rheumatoid arthritis
    C. Gout
    D. Degenerative arthritis
    E. Fibromyalgia Syndrome
A
  1. Answer: B
    Source: Raj P, Pain medicine - A comprehensive Review -
    Second Edition
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47
Q
492. The presence of what factor distinguishes CRPS II from
CRPS I?
A. Sudomotor changes
B. An identifi able nerve injury
C. Allodynia
D. Sympathetically maintained pain
E. Hyperalgesia
A
  1. Answer: B

Source: Day MR, Board Review 2004

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48
Q
  1. A 40-year-old male presents with anterior shoulder
    pain. Physical examination shows full range of motion
    with painful arc present on elevation and depression
    at approximately 50° on both the upswing and the
    downswing. There is no muscle wasting. There is no
    cuff wasting and the patient admits to a history of cuff
    impingement and suspected tear of his right shoulder of
    several years’ duration that was operated a year before.
    There is tenderness noted in the shoulder, shoulder
    abduction, and glenohumeral rotation are painful. The
    likely diagnosis is:
    A. Bicipital tendonitis
    B. Anterior shoulder instability
    C. The coracoid impingement syndrome
    D. Subdeltoid bursitis
    E. Glenohumeral joint arthritis
A
  1. Answer: A
    Explanation:
    The biceps, a long fusiform muscle that arises by two
    heads, has no direct connection with the humerus as it
    originates above the shoulder and inserts below the elbow
    joint.
    The long head of the biceps arises from the supraglenoid
    tubercle and arches obliquely over the top of the humeral
    head within the capsule of the shoulder joint.
    The biceps tendon is intraarticular but extrasynovial.
    The short head of the biceps arises within the
    coracobrachialis from the scapulas coracoid process and
    runs down the medial side of the long head of the biceps.
    The two belles join as a common distal tendon shortly the
    elbow joint as fl attened tendon, only to separate into two
    distal insertions.
    The most common cause (95% to 98%) of bicipital
    tendonitis actually results as a secondary involvement of
    the biceps after primary impingement or tearing of the
    rotator cuff.
    Proximal biceps tendonitis is evidenced by proximal
    anterior shoulder pain and possibly a painful arc during
    shoulder fl exion and extension while the biceps is tensed
    and by tenderness in the bicipital groove on palpation.
    Pain may radiate to the muscle belly or proximally, like pain from cuff impingement, radiate to the deltoid
    insertion.
    However, there is no radiation into the neck or distally
    beyond the biceps muscle belly.
    Pain is less intense during rest and worse with use.
    Nighttime exacerbation is common.
    Source: Saidoff DC, McDonough AL. Critical Pathways in
    Therapeutic Intervention.
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49
Q
494. Brachial plexopathy following breast cancer treatment is most often the result of
A. Radiation therapy
B. Axillary dissection
C. Lymphedema
D. Chemotherapy
E. Metastases
A
  1. Answer: A
    Explanation:
    Radiation therapy is more likely to cause brachial
    plexopathy in patients with breast cancer. In lung cancer,
    plexopathy is more often due to metastatic disease.
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50
Q
495. Which of the following is considered to be the least helpful treatment for spinal cord injury pain?
A. Amitryptiline
B. Opioids
C. Marjiuana
D. Massage
E. Acupuncture
A
495. Answer: A
Explanation:
(Shah, Central Pain States Lecture; Cardenas, Pain; Warms,
Clin J Pain)
Source: Shah RV, Board Review 2004
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51
Q
  1. A 42-year-old male presents with pain in the region of the
    deltoid that began when he started to build a fence in his
    back yard 6 weeks ago. Now his pain is sharp, followed by
    a dull aching and increases when he elevates and lowers
    his arm during activity. He demonstrates a midrange
    painful arc when he elevates his arm. His symptoms are
    provoked with resisted shoulder abduction. However, the
    same test is negative when pulling on his humerus along
    its long axis. What is your diagnosis?
    A. External impingement with subacromiodeltoid bursitis
    B. External impingement with supraspinatus tendonitis
    C. Internal impingement with infraspinatus tendonitis
    D. Internal impingement with supraspinatus tendonitis
    E. Internal impingement with subacromiodeltoid bursitis
A
  1. Answer: A

Source: Sizer Et Al - Pain Practice March & June 2003

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52
Q
  1. A 27-year-old female patient presents with glenohumeral
    instability. Her imaging, demonstrates a dent in the
    posterior humeral head. How would this dent be
    classifi ed?
    A. Bankhart Lesion
    B. Bennett’s lesion
    C. Gray’s Lesion
    D. Hill Sach’s lesion
    E. Callifi c Tendinitis
A
  1. Answer: D

Source: Sizer Et Al - Pain Practice March & June 2003

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53
Q
  1. A radiological defi nition of severe spinal stenosis is:
    A. Spinal canal
A
  1. Answer: A

Source: Day MR, Board Review 2004

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54
Q
499. The most commonly used descriptor for central pain is:
A. Lancinating
B. Achy
C. Steady
D. Crampy
E. Burning
A
  1. Answer: E

Source: Day MR, Board Review 2004

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55
Q
500. Weakness, atrophy, and fasciculation in the triceps and
wrist extensors would indicate stenosis at what spinal
level?
A. C5
B. C6
C. C7
D. C8
E. T1
A
  1. Answer: C

Source: Day MR, Board Review 2004

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56
Q
  1. A 47-year-old man fell on his outstretched right hand
    while rollerblading. Several days later, he develops right
    wrist pain that is constant and progressive. Pain is in the
    area of the anatomical snuffbox and is worse with wrist flexion, extension, and ulnar deviation. The anatomical
    snuffbox is tender to palpation but there is no swelling.
    Finkelstein test is negative. Which of the following is the
    most likely diagnosis?
    A. Cervical radiculopathy
    B. Scaphoid fracture
    C. Compartment syndrome
    D. de Quervain’s disease
    E. Boxer’s fracture
A
  1. Answer: B
    Explanation:
    A. Cervical (C6-C8) radiculopathy causes pain,
    numbness, and tingling from the neck to the hand.
    B. Scaphoid fractures occur as a result of a fall on an
    outstretched hand.
    These fractures heal poorly due to a poor blood supply in
    this area.
    Radiographs done early may be negative, but later
    radiographs may show evidence of healing (callus
    fracture).
    C. Compartment syndrome is a surgical emergency and is
    due to a tight cast or swelling causing compression of the
    blood vessels and nerves in the forearm.
    D. de Quervain’s disease or tenosynovitis of the tendon
    sheath of the extensor pollicis brevis and abductor pollicis
    longus causes swelling and tenderness of the anatomic
    snuffbox.
    This disorder is usually found in middle-aged women
    who perform repetitive activity.
    The Finkelstein test is positive (patient makes a fi st
    around his or her own thumb; pain is produced with
    adduction toward the ulnar side) in de Quervain’s disease.
    E. A boxer’s fracture causes fl attening or loss of the fi fth
    knuckle prominence due to displacement of the
    metacarpal toward the palm. It is usually the result of
    striking an object with a clenched fi st.
    Source: Seidel
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57
Q
  1. Which of the following statements concerning
    spontaneous spinal epidural abscess is correct?
    A. Interventional techniques present greater risk than
    surgery
    B. Most cases present with nonspecifi c symptoms
    C. Myelography is the most appropriate diagnostic test
    D. Skin structures are the usual source of infection
    E. Leukocytosis is usually present
A
  1. Answer: E
    Explanation:
    Leukocytosis is usually present. MRI with gadolinium is
    the most sensitive diagnostic test, although myelogram is
    usually abnormal. However, spinal puncture may increase
    the risk of spinal fl uid seeding of bacteria. Gram positive
    organisms are most commonly cultured.
    Source: Merritt’s Neurology. 10th ed
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58
Q
  1. A 36-year-old executive of a Wall Street fi nancial company
    presents with headaches for many years. The headaches
    are episodic. Usually on the left side, they may occur in
    the maxillary, frontal or temporal region. Each attack
    lasts for approximately 2 hours. He describes the pain like
    a knife being driven through the head. It often wakes him
    up in the morning. The headache attacks some several
    times a day. This may continue for a week at a time.
    When he has an attack he is restless and unable to fi nd a
    comfortable position. What is the diagnosis?
    A. Tension type headache
    B. Hypertensive headache
    C. Subdural hematoma
    D. Cluster headaches
    E. Intractable Migraine with Aura
A
  1. Answer: D
    Explanation:
    A. Tension type headaches are constricting
    B. Hypertensive headaches are associated with nausea,
    vomiting, seizures and confusion.
    - There is a sudden rate of increase of blood pressure.
    - The headache is sudden, severe and unrelenting.
    - Fundoscopic examination often reveals severe
    hypertensive vascular changes.
    C. Subdural hematomas are commonly secondary to a
    trauma or anticoagulation therapy.
    - There is tearing of the bridging veins.
    - The headaches are chronic, mild to moderate in severity.
    - Neurological changes are usually subtle.
    D. Cluster headaches are unilateral, temporal, frontal or
    temporal.
    Cluster headaches are 6 times more common in men.
    - The usually start between the 3rd and 4th decade of life.
    - These are short lasting attacks that come together over a
    period of time.
    - They may have several attacks in a day and this may
    continue for several weeks or months.
    The headaches are very severe and sharp, often associated
    with lacrimation and conjunctival injection.
    - In contrast to migraines, these patients tend to restless
    and pace up and down.
    Abortive management of an acute cluster headache
    includes: oxygen by face mask, ergotamine (nasal) or
    sumatriptan.
    - Preventive treatment is recommended because of the
    severity of the attacks. A short course of steroids, lithium
    verapamil and/or valproic acid can be used.
    E. Intractable migraine with aura is associated with one or
    more fully reversible symptoms.
    Source: Chopra P, 2004
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59
Q
  1. Buttock pain that is reproduced by internal rotation of
    the femur suggests pain arising from the:
    A. Hip joint
    B. Spinal nerve
    C. Piriformis muscle
    D. Obturator neuralgia
    E. Tensor fascia lata
A
  1. Answer: C
    Explanation:
    Pain reproduced by internal rotation of the femur suggests
    piriformis syndrome, because the piriformis muscle
    externally rotates the hip; stretch on the muscle may
    aggravate pain. External rotation induced pain suggests
    hip joint or sacroiliac joint dysfunction.
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60
Q
  1. A patient has been scheduled for a block to differentiate
    somatic versus visceral pain. Appropriate blocks include:
    A. Thoracic paravertebral block
    B. Thoracic epidural block with 2% lidocaine
    C. Splanchnic nerve block
    D. Intercostal nerve block – T4-T9
    E. Intercostal nerve block – T8-T10
A
  1. Answer: C
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61
Q
506. Which of the following describes the location of pain
relief following a percutaneous cordotomy performed
at T3?
A. Contralateral side at T6 and below
B. Contralateral side T3 and below
C. Ipsilateral side at T3 and below
D. Ipsilateral side atT6 and below
E. Bilaterally at T6 and below
A
  1. Answer: A
    Explanation:
    STT fi bers cross within several segmental levels. Clinical
    and experimental evidence indicate that the uppermost
    level of analgesia is several segments (perhaps as many as
    5) caudad to the level of the cordotomy.
    Source: Bonica’s Management of Pain, 2nd edition, page
    54.
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62
Q
  1. A middle aged woman in late 50’s presents with a one year history of weakness and diffi culty with walking, with
    no signifi cant pain. Exam fi ndings include weak, wasted
    muscles with spasticity, fasciculations, extensor plantar
    responses, and hyperrefl exia. Most likely diagnosis is:
    A. Dorsal spinal root disease
    B. Ventral spinal root disease
    C. Arcuate fasciculus damage
    D. Motor neuron disease
    E. Purkinje cell damage
A
  1. Answer: D
    Explanation:
    Motor neuron disease in the anterior horns of the spinal
    cord and damage to the corticospinal tracts or motor
    neurons contributing axons to the corticospinal tracts
    would account for these neurologic signs. Damage to the
    dorsal spinal root would be expected to produce sensory,
    rather than motor, defi cits and would produce arefl exia,
    rather than hyperrefl exia, at the level of the injury.
    Damage to the ventral spinal roots would produce
    weakness and wasting, but no spasticity or hyperrefl exia
    would develop.
    Purkinje cell damage would be expected to produce ataxia
    without substantial weakness. The accurate fasciculus
    connects elements of the cerebral cortex not involved in
    the regulation of strength or motor tone.
    Source: Anschel 2004
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63
Q
  1. A 45 year old lady with a long standing history for
    migraines with aura which has been well controlled with
    rizatriptan, states that she has been having a constant
    headache which has not responded to any of her usual
    medications. The headache started a month ago and has
    progressively increased during this time. Last week she
    slipped and fell twice. What is the next best step?
    A. Lumbar puncture for CSF
    B. Increase the dose of Rizatriptan
    C. MRI of the head
    D. Aspirin
    E. Intramuscular Demerol
A
  1. Answer: C
    Explanation:
    Any change in the character of headache must raise the
    suspicion of a new organic pathology. Conditions that are
    red fl ags in headaches are:
    New neurologic symptoms, papilledema or change in the
    level of consciousness.
    New onset of headache.
    A slow but crescendo increase in headache over weeks or
    months.
    Significant change in the character or pattern of a
    preexisting headache.
    Unexplained fever, neck rigidity.
    Increase in headache with exertion as in coughing, bowel
    movement or after sexual intercourse.
    The differential diagnosis of change in the character of a
    headache or a new onset headache maybe subarachnoid or
    subdural headache, brain tumor, meningitis, glaucoma,
    stroke, internal carotid artery dissection, sinusitis,
    idiopathic intracranial hypertension, hypertensive
    encephalopathy.
    A. Lumbar puncture is contraindicated in the presence of a
    raised intracranial pressure.
    C. An MRI of the head is one of the most sensitive tests
    that can be done to rule out intracranial pathology as in a
    space occupying lesion.
    Ref: Robbins
    Source: Chopra P, 2004
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64
Q
509. A 48-year-old man presents with spastic paralysis,
hyperrefl exia, and an extensor plantar refl ex. Choose
correct diagnosis:
A. Upper motor neuron disease
B. Lower motor neuron disease
C. Myelopathy
D. Radiculopathy
E. Broca’s aphasia
A
  1. Answer: A
    Explanation:
    A. Upper motor neuron (UMN) disease (above the level of
    the corticospinal synapses in the gray matter) is
    characterized by spastic paralysis, hyperrefl exia, and a
    positive Babinski refl ex (everything is up in UMN
    disease).
    B. Lower motor neuron (LMN) disease (below the level of
    synapse) is characterized by fl accid paralysis, signifi cant
    atrophy, fasciculations, hyporefl exia, and a fl exor (normal)
    Babinski refl ex (everything is down in LMN disease).
    C. Myelopathy causes severe sensory loss 0 posterior
    column sensation (position sense and vibration),
    spasticity, hyperrefl exia, and positive Babinski refl exes.
    D. A radiculopathy occurs with root compression from a
    protruded disk that causes sensory loss, weakness, and
    hyporefl exia in the distribution of the nerve root.
    E. Broca’s aphasia (left inferior frontal gyrus) is a
    nonfl uent expressive aphasia (Broca’s should remind you
    of broken speech); Wernicke’s aphasia (left posteriorsuperior
    temporal gyri) is a receptive aphasia because
    patients lack auditory comprehension (Wernicke’s should
    remind you of wordy speech that makes no sense).
    (Source: Seidel, 5/e, p 798.)
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65
Q
  1. The celiac plexus:
    A. can safely and reliably performed by an anterior approach.
    B. innervates the entire gastrointestinal tract
    C. commonly used to treat the pain of pancreatic cancer
    D. commonly used to treat pelvic pain
    E. may b
A
  1. Answer: C
    Explanation:
    The celiac plexus innervates the forgut, and can be approached from an anterior or posterior approach to
    treat pancreatic pain. Pelvic pain of a sympathetic origin
    may be treated with a superior hypogastric plexus
    injection
    Source: Trescot AM, Board Review 2004
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66
Q
  1. The treatment of epicondylitis includes the following:
    A. Absolute rest with no activity
    B. Ice massage for 20 minutes, three times a day in the
    acute stage and the use of heat during acute or subacute
    stages
    C. Weekly steroid injections
    D. Stretching regimen to gain length in the extensor supinator
    muscle mass
    E. Strengthening with gradual concentric, as well as eccentric
    exercises
A
  1. Answer: E
    Explanation:
    A. Selecting rest preferably will avoid stressful activity
    until the pain has subsided. However, pain free
    movements are encouraged. Excessive activity or early
    return to activity may direct excessive stress to healing
    scar tissue. Activities that involve strong, repetitive
    grasping, such as hammering or tennis playing, should be
    restricted until there is minimal pain on resisted isometric
    wrist extension and little or no pain when the tendon is
    passively stretched. In the acute stage, the total rest may be
    achieved by immobilization of the wrist, hand, and fi ngers
    in a resting splint. However, the splint may be removed
    several times a day, so that the patient can gently and
    slowly actively move the wrist into fl exion, the forearm
    into pronation, and the elbow into extension to maintain
    the muscle and tendon extensibility.
    B. Ice massage for 20 minutes is recommended. Elevation
    and compression are not necessary because appreciable
    swelling does not occur.
    C. Steroid injections are recommended if all other
    modalities of treatments fail. However, these are
    administered with the intent of providing pain relief only
    to allow progressional rehabilitation effort. Thus, some
    believe that healing may occur through rehabilitation but
    not from steroid injection. However, there is no evidence
    to prove or disprove this assumption.
    D & E. Strengthening and stretching regimen is
    recommended.
    Other treatment modalities include:
    - High-voltage galvanic stimulation
    - Gradual return to activity
    - Anti-infl ammatory medications
    - Local anti-infl ammatory treatment
    - Iontophoresis or phonophoresis with hydrocortisone
    cream and dy lidocaine or dexamethasone injection may
    also be helpful.
    Source: Saidoff DC, McDonough AL. Critical Pathways in
    Therapeutic Intervention. Extremities and Spine. St. Louis,
    Inc., 2002
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67
Q
512. Myofascial pain is an example of
A. A central pain state
B. Neuropathic pain
C. Psychogenic pain
D. Somatic pain
E. Visceral pain
A
  1. Answer: D
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68
Q
  1. A 52-year-old nurse has a history of low back pain for 2 months. She states the pain started after she lifted a heavy
    patient at work. It is a nagging pain that worsens with
    bed rest. She has tried nonsteroidal antiInfl ammatory
    agents without any relief and has continued to work. She
    has a past medical history signifi cant for breast cancer 8
    years ago and, except for a recent 10-lb weight loss, has
    been well since her lumpectomy. Her neurologic exam
    and straight-leg raising test are normal. The rest of her
    physical examination is unremarkable. Which of the
    following is the most likely diagnosis?
    A. Lumbosacral strain
    B. Metastatic breast cancer
    C. Disk herniation of L5-S1
    D. Spondylolysis
    E. Spondylolisthesis
A
  1. Answer: B
    Explanation:
    Lower back pain is a very common complaint. The
    differential diagnosis includes soft tissue problems
    (muscles and ligaments), disk problems (prolapse), facet
    problems (degenerative joint disease), spinal canal disease (spinal stenosis), and vertebral body diseases
    (osteoporosis causing a compression fracture, infection,
    metastatic disease, spondylolisthesis).
    A. A lumbosacral strain is an injury to a ligament or
    muscle; it may mimic disk disease, but the neurologic
    exam and straight-leg raising test generally remain
    normal.
    B. Even though radiologic studies are needed to make a
    defi nitive diagnosis, the leading diagnosis with her history
    of breast cancer and weight loss is metastatic disease to
    the lumbosacral area.
    Pain made worse by lying down or at night may be a sign
    of malignancy or infection.
    C. Patients with disk herniation at L5-S1 may present with
    S1 nerve root compression The patient is unable to stand
    on her toes and has an absent Achilles refl ex (S1).
    The straight-leg raising test is positive.
    D. Spondylolysis is a defect of a lumbar vertebra (lack of
    ossifi cation of the articular processes) and rarely causes
    symptoms.
    E. Spondylolisthesis occurs when the vertebra slips
    forward from its position and is generally a consequence
    of spondylolysis
    It is usually asymptomatic.
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69
Q
  1. Renal changes in the kidney in a patient with diabetes
    mellitus of 30 years duration may result in which of the
    following:
    A. Decreased permeability to plasma proteins
    B. Enhanced selectivity of the fi ltration barrier
    C. Hyperalbuminemia
    D. A generalized increase in osmotic pressure
    E. Compensatory secretion of aldosterone
A
  1. Answer: E
    Explanation:
    (Kumar, 6/e, pp 446, 570. McKenzie and Klein, p 341.
    Junqueira, 9/e, p 362.) In patients who have suffered from
    diabetes mellitus for many years there is compensatory
    release of aldosterone. The initial change is the thickening
    of the glomerular basement membrane. The separation of
    laminae rarae and densa is obliterated, which results in a
    loss of selectivity of the fi ltration barrier. This causes the
    loss of protein from the blood to the urine (proteinuria).
    The liver adjusts to the proteinuria by producing more
    proteins (e.g., albumin). After continued proteinuria, the
    liver is unable to produce suffi cient protein, which results
    in hypoalbuminemia. This leads to an overall decrease in
    osmotic pressure. The result is edema as fl uid leaves the
    vasculature to enter the tissues. The movement of fl uid
    from the vasculature to the tissues results in reduced
    plasma volume and decreased glomerular fi ltration rate
    (GFR). The overall effect is further edema because of
    compensatory release of aldosterone coupled with reduced
    GFR and the already existing edema. These renal changes
    are known as nephrotic syndrome. The foot processes are
    affected in many diseases, such as diabetes mellitus, that
    lead to nephrotic syndrome. Loss of anionic charge and
    fusion of the foot processes result in the obliteration of the
    fi ltration slits.
    Source: Klein RM and McKenzie JC 2002.
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70
Q
515. What percentage of spinal cord injury patients have
central pain?
A. 90%
C. 8-40%
D. 50-60%
E. 60-70%
A
  1. Answer: C
    Explanation:
    (Shah, Central Pain States Lecture)
    Source: Shah RV, Board Review 2004
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71
Q
516. A treatment of rib fracture pain may include:
A. intercostal nerve block
B. thoracic sympathetic block
C. trigger point injections
D. splanchnic nerve block
E. costochondral injection
A
  1. Answer: A
    Explanation:
    A. Intercostal and thoracic epidural blocks are used to treat
    rib fracture pain.
    B. Thoracic sympathetic blocks are usually effective for
    upper extremity pain.
    C. Trigger point injections are ineffective in managing
    pain due to fractured rib.
    D. Splanchnic nerve blocks are for abdominal pain.
    E. Costo-chondral injections are ineffective in managing
    pain due to fracture rib.
    Source: Trescot AM, Board Review 2004
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72
Q
  1. Spondylolisthesis, is a anterior offset of S1 on L5. Grade
    II spondylolisthesis would be best described as:
    A. 25% but less than 50% in length of the S1 end plate
    B. Less than 20% of the length of the S1 end plate.
    C. Parallel axial line in place.
    D. 50% to 75% in length of the S1 end plate.
    E. Greater than 75% in length of the S1 end plate
A
  1. Answer: A
    Source: Helms CA. Fundamentals of Skeletal Radiology.
    W.B. Saunders Co., 1995; p. 87.
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73
Q
  1. A 70-year old man complains of severe back pain in the region of L3/4, with gradual worsening of the back pain
    with radiation into the lower extremity up to the knee
    joint. This patient received interlaminar epidural steroid
    injection for spinal stenosis at L3/4. The most likely
    diagnosis in this patient is:
    A. Epidural abscess
    B. Anterior spinal artery syndrome
    C. Discitis
    D. Cauda equina syndrome
    E. Epidural hematoma
A
  1. Answer: A
    Explanation:
    A. Epidural abscess is an extremely rare complication
    following epidural steroid injections. However,
    symptoms from an epidural abscess may not become
    apparent for several days after injection has been
    administered. The symptoms of epidural abscess include
    severe back pain, sensory disturbances, and motor
    weakness.Infections occur in 1% to 2% of spinal injections
    and range from minor to severe conditions such as
    meningitis, epidural abscess, and osteomyelitis. One case
    of discitis following caudal epidural steroid injection also
    has been reported. Severe infections are rare and occur
    between 1 and 1,000 and 1 in 10,000 spinal injections.
    Poor sterile technique is the most common cause of
    infection. Staphylococcus aureus is the most common
    infectious organism and is contracted from skin
    structures. Epidural abscess presents with severe back
    pain, fever, and chills with a leukocytosis developing on
    the third or fourth day following the injection. Patients
    with diabetes or other immunocompromising conditions
    are more susceptible to infection. Epidural abscess
    requires emergent surgical drainage to avoid neural
    damage or other complications.
    B. Anterior spinal artery syndrome due to damage to the
    anterior spinal artery or the feeding artery, the artery of
    Adamkiewicz, leads to ischemia in the thoracolumbar
    region of the spinal cord. This syndrome is characterized
    predominantly by motor weakness or paralysis of the
    lower extremities.
    C. Discitis from epidural steroid injections is extremely
    uncommon. However, there has been a case report of this
    following a caudal epidural steroid injection. Usually,
    discitis from lumbar discography involves a gramnegative
    arrow, is self-limited, and resolves with early
    recognition and administration of appropriate antibiotics.
    Symptoms are related to back pain and leukocytosis. The
    most common organisms infecting the lumbar disc or
    staphylococcus aureus and staphylococcus epidermatitis. Discitis usually presents as an increase in spine pain 5 to
    14 days following discography. Acutely, no change in the
    patient’s neurological status should be evident. An
    elevated sedimentation rate will be seen within the fi rst
    week to 10 days. Magnetic resonance imaging is now
    considered the gold standard in the detection of discitis,
    which was found to be superior to bone scan with 92%
    sensitivity, 97% specifi city, and a 95% overall accuracy.
    D. Cauda equina syndrome may be seen with trauma,
    lumbar disc herniation, compression of tumors, or in
    ankylosing spondylitis. The only absolute surgical
    indication for lumbar disc herniation is the cauda equina
    syndrome. This syndrome is characterized by bilateral
    lower extremity weakness and pain, saddle anesthesia,
    urinary retention, and diminished rectal tone.
    E. Signifi cant epidural bleeding may cause the
    development of an epidural hematoma. Clinically
    signifi cant epidural hematomas are rare and have a
    reported incidence of less than 1 in 4,000 to 1 in 10,000
    lumbar epidural steroid injections. however, they may lead
    to irreversible neurologic compromise if not surgically
    decompressed within 24 hours. Retroperitoneal
    hematomas which may occur following spinal injections if
    the large vessels are inadvertently penetrated, usually are
    self-limited but may cause acute hypolemma or anemia.
    Epidural hematoma as an acute onset of symptomatology
    with rapidly progressing neurological dysfunction. An
    immediate physical examination followed by a CT or MRI
    scan is essential for patients thought to have an epidural
    hematoma, because early surgical intervention can limit or
    even prevent permanent neurological damage.
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74
Q
  1. An 18 year old girl presents with frequent headaches, each lasting for several days. She has to take time off from
    school. She describes them as throbbing, localized to the
    temporal region. They are associated with nausea and
    vomiting, sensitivity to sound and light. A recent MRI was
    normal. A diagnostic lumbar puncture done was normal.
    The most probable cause of her headaches is:
    A. Migraine without aura
    B. Post dural puncture headache
    C. Tension type headache
    D. Temporal arteritis
    E. Trigeminal Neuralgia
A
  1. Answer: A
    Explanation:
    According to the International Headache Society,
    headaches are classifi ed into primary and secondary
    headache disorders. The primary headache disorders
    consist of:
    1.Migraine with aura
    2.Migraine without aura
    3.Tension type headache - chronic and episodic
    4.Cluster headache - chronic and episodic
    Primary headaches such as migraine with or without aura,
    tension-type, and cluster headache constitute about 90%
    of all headaches
    Migraine as defi ned by the International Headache Society
    is – Idiopathic, recurring headache disorder manifesting in
    attacks lasting 4 to 72 hours.
    A. Diagnostic Criteria for Migraine With and Without
    Aura
    Migraine Without Aura
    i. At least fi ve attacks fulfi lling II-IV.
    ii. Headache attacks lasting 4-72 h (untreated or
    unsuccessfully treated).
    iii. Headache has at least two of the following
    characteristics:
    1.Unilateral location.
    2.Pulsating quality.
    3.Moderate or severe intensity (inhibits or prohibits daily
    activities).
    4.Aggravation by walking stairs or similar routine
    physical activity.
    iv. During headache at least one of the following:
    1.Nausea and/or vomiting.
    2.Photophobia and phonophobia.
    v. At least one of the following:
    1.History & physical and neurologic examinations do not
    suggest headaches secondary to organic or systemic
    metabolic disease).
    2.History and/or physical and/or neurologic examinations
    do suggest such disorder, but it is ruled out by appropriate
    investigations.
    3.Such disorder is present, but migraine attacks do not
    occur for the fi rst time in close temporal relation to the
    disorder.
    Migraine With Aura
    i. At least two attacks fulfi lling ii.
    ii. At least three of the following four characteristics:
    1.One or more fully reversible aura symptoms indicating
    focal cerebral cortical and/or brain stem dysfunction.
    2.At least one aura symptom develops gradually over more
    than four minutes or two or more symptoms occur in
    succession.
    3.No aura symptom lasts more than 60 minutes. If more
    than one aura symptom is present, accepted duration is
    proportionally increased.
    4.Headache follows aura with a free interval of less than 60 minutes. (It may also begin before or simultaneously with
    the aura).
    C. At least one of the following:
    1.History & physical and neurologic examinations do not
    suggest headaches secondary to organic or systemic
    metabolic disease.
    2.History and/or physical and/or neurologic examinations
    do suggest such disorder, but it is ruled out by appropriate
    investigations.
    Such disorder is present, but migraine attacks do not occur
    for the fi rst time in close temporal relation to the
    disorder.
    B. Post dural puncture headaches develop after a dural
    puncture such as a spinal tap. The pain is usually frontal
    and occipital. It becomes worse in the upright position and
    is relieved signifi cantly with lying supine. Some patients
    develop sixth cranial nerve palsy because of the long
    intracranial course of the sixth cranial nerve.
    C. The differentiation between tension-type headache
    (TTH) and migraine without aura more diffi cult. Very
    often both headaches coexist. Tension-type headaches are
    tightening or pressing in character. They are mild to
    moderate in intensity and are bilateral. Tension-type
    headache are seldom associated with nausea and in most
    patients Tension-type headaches are not greatly
    exacerbated by physical activity.
    D. Giant cell (temporal) arteritis affects the extracranial
    vessels of the head and arms. There is tenderness over the
    scalp. The temporal or occipital arteries are enlarged and
    tender. They may have visual symptoms including
    amaurosis fugax, diplopia and blindness. Most patients
    also have symptoms of intermittent claudication with
    chewing. A temporal artery biopsy is diagnostic.
    E. Trigeminal neuralgia presents with typical lancinating,
    sharp, electric like, stabbing pain.
    Ref: Drugs for Pain
    Source: Chopra P, 2004
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75
Q
  1. A 67-year old white male presents with back pain,
    stiffness located in thoracolumbar region with history
    of dysphagia. Radiographic evidence showed fl owing
    anterior calcifi cation, along four contiguous vertebrae.
    The remaining evaluation was normal. The most likely
    diagnosis is:
    A. Lumbar facet joint pain
    B. Lumbar disc herniation
    C. Diffuse idiopathic skeletal hyperostosis
    D. Osteoporotic fracture
    E. Spondylolisthesis
A
  1. Answer: C
    Explanation:
    Diffuse idiopathic skeletal hyperostosis, also called DISH,
    or Forester’s disease is probably a variant of osteoarthritis
    characterized by exuberant ossifi cation of spinal ligaments.
    Epidemiology
    - More common with increase in age
    - Observed in 10% of spine fi lms in elderly
    - It is twice as common in men as women
    - It is more common in Caucasians than African-
    Americans
    Etiology:
    - Unknown, not associated with B27; may be increased in
    diabetics
    Signs and Symptoms
    - Back stiffness in 80%
    - Back pain in 50% to 60%
    - Pain is typically thoracolumbar
    - Dysphagia as a result of large cervical osteophytes in
    approximately 20%
    Diagnosis
    - Flowing anterior calcifi cation along four contiguous
    vertebrae
    - Preservation of disc height
    - No sacroiliac involvement
    Treatment
    - Active exercise program to optimize range of motion
    - Non-steroidal anti-infl ammatory agents
    - Rarely surgical removal of osteophytes
    - Role of interventional techniques is not known
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76
Q
  1. Wallenberg’s syndrome is characterized by:
    A. hoarseness of voice
    B. contralateral facial sensory loss
    C. ipsilateral pain and temperature loss in the body
    D. ipsilateral lateral gaze palsy
    E. mydriasis
A
  1. Answer: A
    Explanation:
    (Shah, Pain States Lecture and Raj, Pain Mgmt Review)
    Wallenberg’s syndrome is lateral medullary syndrome,
    which is characterized by: Ipsilateral facial sensory loss
    Contralateral pain and temperature loss in body
    Ipsilateral cranial nerve defi cits
    –IX, X- loss of taste
    –IX, X- palatal weakness (dysphagia), vocal cord weakness
    (hoarseness), diminished gag
    Ipsilateral cerebellar signs
    –Inferior cerebellar peduncle: clumsiness and ataxia (may
    be confused with true weakness)
    Source: Shah RV, Board Review 2004
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77
Q
  1. All of the following are true regarding phantom limb pain
    EXCEPT:
    A. Described as burning, aching, or cramping.
    B. Incidence decreases with more proximal amputations.
    C. The etiology is not clearly defi ned.
    D. The usual course of phantom limb pain is to remain
    unchanged or to improve.
    E. Neuromas are found in 20% of patients
A
  1. Answer: B
    Explanation:
    Ref: Hord and Shannon. Chapter 16. Phantom Pain. In:
    Practical Management of Pain, 3rd Edition. Raj et al.
    Mosby, 2000, pages 213-218.
    Source: Day MR, Board Review 2003
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78
Q
  1. A previously healthy 36-year old woman presents with a complaint of generalized muscular pain with aching in the
    left buttock for 1 week, 4 weeks after left transforaminal
    epidural injection at L5. The pain travels down the back
    of her leg to the heel and lateral side of her foot to the
    small toe. She has also noted a progressive numbness
    in her legs and arms, which has worsened over the week.
    On examination, walking was very diffi cult and her legs
    buckled when she stood up. The most likely diagnosis is:
    A. Postherpetic neuralgia
    B. Brain tumor
    C. Hysterical reaction
    D. Guillain-Barré syndrome
    E. Epidural abscess
A
  1. Answer: D
    Explanation:
    The patient has symptoms consistent with Guillain-Barré
    acute infl ammatory demyelinating polyneuropathy. Pain is
    a common early symptom of the disease. The patient may
    complain of muscular or radicular pain or both, followed
    by sensorimotor dysfunction. The pain may be severe but usually resolves as the symptoms improve. Presentation
    of epidural abscess with back pain is 1-2 weeks after
    injections.
    Source: Kahn CH, DeSio JM. PreTest Self Assessment and
    Review. Pain Management. New York, McGraw-Hill, Inc.,
    1996.
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79
Q
  1. A patient with cholecystic pain will often present with
    pain from which somatic dermatome?
    A. T1-T3 due to the ascending nature of the afferent visceral
    tracts involved
    B. T3 only as it overlies the affected area
    C. T8 only as it overlies the affected area
    D. T6-T8 as it refl ects the referred component of the upper
    viscera
    E. T9-T11 as it refl ects the referred component of the upper
    viscera
A
  1. Answer: D

Source: Giordano J, Board Review 2003

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80
Q
  1. A 65 year old man presents with symptoms of pain in
    the cervical region. He also complains of radiation of his
    pain along the lateral part of his right forearm He has an
    MRI of the cervical region with evidence of a herniated
    disc between the fi fth and the sixth cervical vertebra. The
    nerve root that is most likely compressed is:
    A. Fourth cervical nerve root
    B. Fifth cervical nerve root
    C. Sixth cervical nerve root
    D. Seventh cervical nerve root
    E. Eight cervical nerve root
A
  1. Answer: C
    Explanation:
    Disc herniations in the cervical region are relatively less
    common than the lumbar region. In the cervical region the
    C5 and C6 and C7 intervertebral disc are most susceptible
    to herniation. The C6 and C7 intervertebral disk
    herniation is the most common cervical disk herniations.
    In the cervical region each spinal nerve emerges above the
    corresponding vertebra. An intervertebral disc protrusion
    between C5 and C6 will compress the sixth cervical spinal
    nerve. There are seven cervical vertebra and eight cervical
    spinal nerves. These patients characteristically present
    with pain in the lower part of the posterior cervical region,
    shoulder and in the dermatomal distribution of the
    affected nerve root.
    Source: Chopra P. 2004
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81
Q
526. A pituitary adenoma is likely to result in
A. Cushing’s syndrome
B. Defi ciency in T3 and T4
C. Diabetes insipidus
D. Osteoporosis
E. Stunted growth or dwarfi sm
A
  1. Answer: A
    Explanation:
    (Junqueira, 9/e, pp 380-383, 394, 402-405.) Pituitary
    adenomas are anterior pituitary specifi c. A corticotrophadenoma
    would cause increased levels of ACTH and
    stimulate excessive production of corticosteroids from the
    adrenal cortex (Cushing’s syndrome). LH and FSHproducing
    gonadotrophs occur but tend to result in
    hypogonadism. Somatotropic tumors produce GH and
    cause giantism. Prolactinomas are the most common form
    of pituitary adenoma resulting in infertility, galactorrhea
    (excessive production of milk), and amenorrhea. Diabetes
    insipidus is caused by absence of vasopressin [arginine
    vasopressin (AVP)], leading to excretion of a large
    quantity of dilute fl uid (hypotonic polyuria).
    Overproduction of parathyroid hormone (PTH) leads to
    osteoporotic changes, but PTH is not regulated by the
    anterior pituitary.
    Source: Klein RM and McKenzie JC 2002.
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82
Q
  1. A 28-year old female secretary complained for 6 months
    of paresthesias and aching in the right hand. The aching
    and numbness were most pronounced in the middle
    fi nger. The aching, tingling, and numbness made it
    diffi cult for her to sleep at night. She also noted that she
    was dropping things. The most likely diagnosis is:
    A. Refl ex sympathetic dystrophy
    B. Pancoast syndrome
    C. Ulnar neuropathy
    D. Carpal tunnel syndrome
    E. Radial nerve entrapment
A
  1. Answer: D
    Explanation:
    The patient’s symptoms are most consistent with carpal
    tunnel syndrome,which is due to entrapment of the
    median nerve at the wrist.
    Prolongation of distal motor latency may be seen on EMG.
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83
Q
528. The number one etiology of cord central pain is:
A. Neoplasm
B. Infl ammatory
C. Cord infarction
D. Arteriovenous malformation
E. Trauma
A
  1. Answer: E

Source: Day MR, Board Review 2004

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84
Q
529. The most common presenting symptom of rheumatoid
arthritis is:
A. Pain in the small joints of the hand
B. Neck pain
C. Knee pain
D. Low back pain
E. Shoulder pain
A
  1. Answer: B
    Explanation:
    Neck pain is the most common presenting symptom of
    rheumatoid arthritis (RA). Approximately 50% of the
    head’s rotation is at the atlanto-axial joint, the rest is at the
    sub axial cervical spine. The atlanto-axial joint complex is
    made up of three articulations.The axis articulates with
    the atlas at the two facet joints laterally and another joint
    posterior to the odontoid process. A bursa separates the
    transverse band of the cruciate ligament from the dens.
    Rheumatoid arthritis affects all three joints. The
    articulations formed by the uncinate processes also known
    as the joint of Luschka, are not true joints and do not have
    synovial membrane. Hence, they are not subject to the
    same changes as seen in RA.
    Rheumatoid arthritis is an infl ammatory polyarthritis that
    typically affects young to middle-aged women. They
    present with a joint pain and stiffness in the hands. They
    have a history for morning stiffness. Almost 80% of these
    patients have a positive rheumatoid factor.
    Source: Chopra P. 2004
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85
Q
  1. A young patient presents with a 6-month history of
    an aching right arm, which is exacerbated by carrying
    heavy objects or by raising his arms over his head. No
    neurologic defi cits were found. There was obliteration of
    the radial pulse with arm extension and abduction. The
    most likely diagnosis is:
    A. Herniated nucleus pulposus
    B. Brachial plexitis
    C. Pancoast’s tumor
    D. Thoracic outlet syndrome
    E. Neurofi broma of the brachial plexus
A
  1. Answer: D
    Explanation:
    Thoracic outlet syndrome may be due to a cervical rib,
    abnormal fi rst thoracic rib, hypertrophy of the scalenus
    anterior, abnormal insertion of the scalenus medius, bands
    in Sibson’s fascia, or costoclavicular abnormalities. There
    is usually involvement of the subclavian vessels and
    brachial plexus (most commonly C8-T1). The degree of
    vascular and neurologic dysfunction is variable. Patients
    may complain of radicular pain or a poorly localized, deep,
    aching pain under the arm. Cold weather, lifting heavy
    objects, working with arms over the head, and repetitive
    movement may worsen symptoms. Pain may occur for
    years before any neurologic symptoms or signs develop.
    Diagnosis is made by physical examination and radiologic
    studies of the neck and chest. Treatment is conservative if
    there is no signifi cant vascular or neurologic compromise.
    (Bonica).
    Source: Kahn CH, DeSio JM. PreTest Self Assessment and
    Review. Pain Management. New York, McGraw-Hill, Inc.,
    1996.
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86
Q
  1. Of those patients chronic neck pain due to whiplash,
    approximately what percentage would respond to a
    diagnostic intra-articular facet injections or medial
    branch blocks?
    A. 10%
    B. 20%
    C. 30%
    D. 90%
    E. 50%
A
  1. Answer: E
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87
Q
  1. A patient with a history of breast cancer 10 years ago was
    treated with a radical mastectomy and radiation therapy.
    Recently she developed dull, ipsilateral arm pain and
    associated swelling in the thoracic region. Your diagnosis
    is:
    A. Radiation plexopathy
    B. Re-occurrence of cancer
    C. Lymphoedema
    D. Tumor invasion in brachial plexus
    E. Lymphangiosarcoma
A
  1. Answer: E
    Explanation:
    Stewart-Treves Syndrome (lymphangiosarcoma) is a rare,
    aggressive and cutaneous angiosarcoma often associated
    with long standing lymphedema. The malignancy arises
    from the endothelial cells of the lymphatic system. Most
    cases arise from lymphedema induced by a radical
    mastectomy in breast cancer patients with an average onset
    of 5 - 15 years and an occurance rate of
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88
Q
533. The sitting position that places the lowest load on the L3
disc is with the back of the chair at
A. 90° without a lumbar support cushion
B. 90° with a lumbar support cushion
C. 110° without lumbar support
D. 100° with lumbar support
E. 100° without lumbar support
A
  1. Answer: D
    Explanation:
    Maximum load on the disc occurs when a person is sitting
    against a 90° back rest without lumbar support. There is
    slightly less load on the lumbar spine when one sits at 90°
    with lumbar support. There is even less load on the
    lumbar spine when the back of the chair is inclined to 110°
    without lumbar support. There is least pressure on the
    spine with the back of the chair at 100° with a lumbar
    support (Bonica).
    Source: Kahn CH, DeSio JM. PreTest Self Assessment and
    Review. Pain Management. New York, McGraw-Hill, Inc.,
    1996.
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89
Q
  1. A 26-year-old woman presents with the chief complaint of
    weakness that worsens throughout the day. She especially
    notices weakness and feeling tired when chewing food.
    The patient states that she feels strong on arising in the
    morning but the weakness develops over the course of
    the day. She also complains of her eyelids drooping and
    occasional diplopia. Neurologic examination reveals
    ptosis after 1 min of sustained upward gaze. Which of the
    following is the most likely diagnosis?
    A. Lambert-Eaton syndrome
    B. Botulism
    C. Myasthenia gravis
    D. Multiple sclerosis
    E. Friedreich’s ataxia
A
  1. Answer: C
    Explanation:
    A. Lambert-Eaton myasthenic syndrome (LEMS) is a
    progressive generalized weakness that improves with
    exercise and is associated with small cell carcinoma of the
    lung.
    Ocular bulbar muscles are spared, but patients often have
    autonomic dysfunction.
    B. Botulism causes rapid progressive paralysis of the
    bulbar (dilated pupils) and extraocular muscles and
    eventually causes skeletal and respiratory muscle
    weakness.
    The disorder is caused by ingestion of the exotoxin
    produced by Clostridium botulinum, which blocks
    acetylcholine release from nerve terminals.
    C. Myasthenia gravis is fatigable weakness that primarily
    affects the respiratory, bulbar, and ocular muscles.
    The etiology of the disorder is autoimmune, causing
    destruction of the acetylcholine receptors in the affected
    muscles.
    Thymic abnormalities often accompany the disorder, and
    the Tensilon test (injection of edrophonium, which is an
    acetylcholinesterase inhibitor) often results in
    improvement of symptoms.
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90
Q
  1. A 72-year old woman complains of a 3-year history of
    progressive lower back pain with aching and numbness
    radiating from the right buttock to the lateral aspect and
    dorsum of his right foot. Pain is increased with walking.
    She reported that leaning on a shopping cart and using
    it as support for ambulation was very helpful. The most
    likely diagnosis is:
    A. Herniated nucleus pulposus
    B. Lumbar plexopathy
    C. Spinal stenosis
    D. Arachnoiditis
    E. Severe spondylolisthesis
A
  1. Answer: C
    Explanation:
    The patient has lumbar spinal stenosis involving the L5
    and S1 nerve roots most prominently.
    Spinal stenosis is a slowly progressive disease and
    therefore allows for neural adaptation over time.
    Shopping cart syndrome is a hallmark of spinal stenosis.
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91
Q
  1. An obese woman presents with complaints of anterior
    knee pain after running. She reported a grinding
    sensation in her knee, with stiffness and pain in the
    morning hours that occur following the activity for
    sitting several hours each day. However, she reported
    feeling better after she started running or walking.
    She occasionally experiences a giving away sensation
    during descent, as if she cannot rely on the affl icted leg.
    Kneeling is extremely uncomfortable. There is no history
    of trauma to her knee or back. Family history shows
    osteoarthritis of both knees and hips in her mother and
    father. Physical and neurological examination is normal.
    She had no problems with the other knee except for some
    grinding sensation. The most likely diagnosis:
    A. Plica syndrome
    B. Fat pad infl ammation
    C. Patellofemoral osteoarthritis
    D. Retropatellar pain syndrome
    E. Chondromalacia of the patella
A
  1. Answer: E
    Explanation:
    A. Plica syndrome is synovial or embryologic remnants
    presenting as folds of tissue adjacent to the patella. They
    are a rare source of pain and dysfunction at the knee and
    may present a challenge to differentiating from
    chondromalacia. Synovial plica may prove symptomatic
    and manifest as knee stiffness following sitting with the
    knee bent for any length of time. Stiffness may be
    experienced when attempting to get up out of this
    position.The key, however, to differentiating from plica
    and chondromalacia derived pain is by historically
    determining when the patient experiences pain. Pain
    during activity is generally seen with patellar tracking of
    abnormalities such as chondromalacia or patellar
    instability, whereas pain after activity is typical of
    infl ammatory disorders such as synovial plica irritation.
    B. Fat pad infl ammation or fi brosis, is a relatively
    common problem contributing to inferior knee pain in
    patients’ who have had previous knee surgery or in those
    who play sports or engaging vocations that directly
    traumatize this area. Pain is located immediately adjacent
    to the patellar ligament and stems from the richly
    innervated fad pad. If fi brosis is extensive, as it may be
    following several knee surgeries or severe trauma to this
    site, the retropatellar tendon bursae, as well as the
    infrapatellar tendon will eventually scar down to the
    proximal tibia.
    C. Patellofemoral osteoarthritis represents the end
    sequelae of chondromalacia and presents with symptoms
    similar to chondromalacia. However, the articular surface
    involvement is more advanced with subchondral bone
    exposure and often has a poorer prognosis. Unlike
    chondromalacia, radiographs of patellofemoral
    osteoarthritis show narrowing of the joint space, sclerosis
    and spurring. These patellofemoral osteophytes typically
    form on the marginal areas of the femur and may be
    palpated during the physical examination and viewed on
    infrapatellar radiographs. These osteophytes may result in
    catching and popping sensations from synovial catching,
    entrapment, and irritation from these bone spurs.
    Patellofemoral arthritis may show a relatively short onset
    following traumatic injury or may have a more insidious
    onset in patients with long-standing patellofemoral
    complaints. The latter typically occurs in patients who
    endure abnormal forces to the knee, such as maybe
    incurred from rough sports or heavy work, over many
    years.
    D. Retropatellar pain, pre-parapatellar pain, and
    patellofemoral stress syndrome all describe an overuse
    injury characterized by peripatellar pain following acutely
    or slowly from repetitive knee fl exion-extension activities
    such as jumping, running or kicking. This type of patellar
    disorder differs from chondromalacia in that arthroscopy evaluation of the retropatellar surface does not reveal the
    typical fi brillated cartilage surfaces associated with
    chondromalacia or degenerative changes following an
    acute blow to the patella.
    E. Chondromalacia of the patella is commonly
    encountered in joggers and long-distance runners and has
    subsequently been called “runners knee.” Nevertheless, the
    increasing interest in sports among the general population,
    patellofemoral pain has been identifi ed as the primary
    complaint of knee pain. Adolescent females are often
    susceptible to developing chondromalacia as well as
    patellofemoral instability. Chondromalacia is literally a
    pathologic description that means softening of the
    articular cartilage located along the underside of the
    patella and is commonly the diagnosis given to patients
    with anterior knee pain. Chondromalacia is a degenerative
    process believed to result from excessive loading of
    articular cartilage lining the patellar facets. Articular
    cartilage is loaded by compressive forces that may be
    exceeded resulting in decreased diffusion of nutrients and
    eventual malacia of the involved facet. Classic physical
    symptoms of chondromalacia include retropatellar pain,
    recurrent effusion, retropatellar crepitation,
    patellofemoral grinding during the knee fl exion or
    extension, and tenderness upon palpation of the patellar
    facets.
    Source: Saidoff DC, McDonough AL. Critical Pathways in
    Therapeutic Intervention. Extremities and Spine,St.
    Louis,Inc., 2002
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92
Q
537. The incidence of fractured ribs found in closed thoracic
trauma is:
A. 10-20%
B. 20-30%
C. 30-40%
D. 40-50%
E. > 50%
A
  1. Answer: E
    Explanation:
    Ref: Sinatra and Ennevor. Chapter 19. Trauma Patient
    with Thoracic and Abdominal Injuries. In: Pain
    Management and Regional Anesthesia in Trauma.1st
    Edition. Rosenberg, Grande, Berstein. W.B. Saunders,
  2. page 312.
    Source: Day MR, Board Review 2003
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93
Q
  1. A 33-year-old graduate student complains of low back
    pain after carrying heavy suitcases on a recent vacation
    in Europe. Because of his pain, he went to a neurologist
    in London who recommended bed rest and nonsteroidal
    anti-infl ammatory agents. After 10 days, the back pain
    resolved, but the patient comes to see you because of new
    weakness of his right anterior tibialis. The rest of the
    physical examination is normal. Which of the following
    is the most likely diagnosis?
    A. Nerve root impingement
    B. Tibial stress fracture
    C. Anterior compartment syndrome
    D. Gastrocnemius muscle tear
    E. Popliteal cyst
A
  1. Answer: A
    Explanation:
    A. Lumbar disk herniation may occur after lifting heavy
    objects.
    A short period of rest (“unloading the spine”) and
    nonsteroidal anti-infl ammatory agents may help.
    If a patient develops signifi cant neurologic defi cit after the
    initial pain has resolved, the diagnosis is most likely nerve
    root impingement.
    B. Tibial stress fractures (shin splints) may occur due to
    weight-bearing exercises or training errors. These injuries
    cause anterior tibial pain after exercise but not weakness.
    C. Anterior compartment syndrome occurring after
    weight-bearing exercise may cause a neuropraxia of the peroneal nerve, leading to footdrop.
    D. A gastrocnemius muscle tear usually occurs suddenly
    after rapid dorsifl exion of the ankle and causes severe
    midcalf pain.
    In a few days, the calf characteristically develops a bluish
    discoloration.
    E. A popliteal cyst (Baker’s cyst) causes calf pain, swelling,
    and knee effusion. It is often a complication of rheumatoid
    arthritis and represents a diverticulum of the synovial sac
    that protrudes through the posterior joint capsule of the
    knee.
    (Source: Goldman, 21/e, p 2187.)
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94
Q
  1. All of the following are true regarding carpal tunnel
    syndrome except:
    A. Caused by compression of the median nerve by the
    transverse carpal ligament.
    B. History of wrist pain and paresthesias in the thumb,
    index fi nger, and long fi ngers.
    C. Physical examination may demonstrate atrophy of the
    hypothenar eminence.
    D. EMGs/NCTs may confi rm denervation of thenar musculature
    E. Treatment includes splints, steroid injections, and/or
    surgical release.
A
  1. Answer: C
    Explanation:
    Ref: Merkow. Chapter 16. Hand Disorders. In: Manual of
    Rheumatology and Outpatient Orthopedic Disorders, 2nd
    Edition. Beary; Little, Brown and Company, 1990, page 95-
    96.
    Source: Day MR, Board Review 2003
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95
Q
  1. Costochondritis is characterized by all of the following
    except:
    A. Can mimic intrathoracic and intrabdominal disease
    B. Local tenderness with palpation
    C. May produce radiating symptoms
    D. Presents as infl ammation of multiple costovertebral
    articulations
    E. Most often occurs in adults over 40 years of age
A
  1. Answer: D
    Explanation:
    Ref: Raj. Chapter 13. Miscellaneous Pain Syndromes. In:
    Pain Medicine: A Comprehensive Review, 2nd Edition,
    Raj, Mosby, 2003, page 121.
    Source: Day MR, Board Review 2003
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96
Q
541. Classic hemophilia A is associated with a defi ciency of
which factor?
A. V
B. VIII
C. IX
D. X
E. All of the above
A
  1. Answer: B
    Source: Raj P, Pain medicine - A comprehensive Review -
    Second Edition
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97
Q
  1. Which of the following analgesics are least effective with
    the treatment of chronic post-stroke pain?
    A. Morphine
    B. Mexilitene
    C. Carbamazepine
    D. Doxepin
    E. Propanolol
A
  1. Answer: A
    Explanation:
    (Raj, Practical Mgmt of Pain, 3rd Edition, page 262)
    Central post-stroke pain is diffi cult to manage. Opioids
    have not been successful in managing CPSP for at least
    100 years. Some authors recommend detoxifi cation. The
    mainstays for treatment include anti-dysrhythmics, anticonvulsants,
    and antidepressants.
    Carbamazepine, doxepin, propanolol, and Mexilitene have
    been demonstrated to have benefi t in CPSP
    Source: Shah RV, Board Review 2004
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98
Q
  1. A 66 year old woman presents with pain in the posterior
    cervical region for the last 1 year. It radiates to the right
    shoulder, lateral upper arm, and right index fi nger. She
    also complains in the medial part of the right scapula
    and anterior shoulder. On physical examination, she has
    numbness to the index and middle fi ngers of the right
    hand and weakness of the triceps muscle. The cause of
    her pain is most likely:
    A. Herniated nucleus pulposus of the C5 to C6 disk causing
    compression of the C5 nerve root
    B. Herniated nucleus pulposus of the C5 to C6 disk causing
    compression of the C6 nerve root
    C. Herniated nucleus pulposus of the C6 to C7 disk causing
    compression of the C7 nerve root
    D. Herniated nucleus pulposus of the C6 to C7 disk causing
    compression of the C6 nerve root
    E. Herniated nucleus pulposus of the C7 to T1 disk causing
    compression of the C8nerve root
A
  1. Answer: C
    Explanation:
    The pattern of pain helps identify the cervical disk causing
    the most problems. Herniated nucleus pulposus (HNP)
    are more common in the lumbar region.The cervical nerve
    roots exit above the vertebral body of the same segmentthe
    C7 nerve root exits between the C6 to C7 vertebra.
    Source: Chopra P. 2004
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99
Q
  1. Trigeminal neuralgia
    A. is also called tic doloureux
    B. is characterized by sudden, sharp, stabbing facial pain
    C. often has a specifi c “trigger zone”
    D. may be treated with surgery, medications, or injections.
    E. all of the above
A
  1. Answer: E
    Explanation:
    Trigeminal neuralgia is a devastating facial pain
    characterized by sudden facial pain, and may be treated
    with surgery, medications, or injections.
    Source: Trescot AM, Board Review 2004
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100
Q
545. A 22 year old healthy woman with a history of migraine headaches develops an intense frontal headache after eating ice cream at a party. The pain is sharp and intense. What is the most likely diagnosis?
A. Frontal sinusitis
B. Cold stimulus headache
C. Conversion headache
D. Chronic paroxysmal hemicrania
E. Intractable Migraine without Aura
A
  1. Answer: B
    Explanation:
    A. A frontal sinusitis is a persistent frontal headache and
    does not have an abrupt onset.
    B. Cold stimulus headache start with exposure of the head
    to very cold temperatures as in diving into cold water. An
    intense focused pain develops in the frontal region when a
    very cold food ingested. The pain lasts for a short duration
    of a few minutes. It maybe in the frontal or
    retropharyngeal region.
    C. Conversion headaches are associated with severe
    behavioral abnormalities.
    D. Chronic paroxysmal hemicrania is very similar to a
    cluster headache in the form that it is similar in intensity
    and location. The attacks are short and frequent. They
    respond well to indomethacin.
    E. Intractable migraine with aura is associated with one or
    more fully reversible symptoms.
    Source: Chopra P, 2004
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101
Q
  1. Which of the following is true about spinal stenosis
    A. Spinal stenosis can only be diagnosed if a patient has
    neurogenic claudication
    B. Spondylolysis of the pars interarticularis is the most
    common etiology of spinal stenosis
    C. Classically, patients develop pain after walking and
    must stop and stand, in order to obtain pain relief
    D. Patients typically have relief of symptoms when walking
    downhill
    E. Urinary dysfunction is common among patients with
    spinal stenosis
A
  1. Answer: E
    Explanation:
    A subset of patients with spinal stenosis have neurogenic
    claudication, but most patients present with aching low
    back and thigh pain. Degenerative arthritic changes of the
    L4-5 facet joints and spondylosis of the L4-5 disc are the
    most common etiologies of spinal stenosis.
    Spondylolisthesis is also associate with these changes.
    Classically, patients must sit or stoop forward in order to
    obtain pain relief. Patients with vascular claudication have
    to stop walking and just stand in order to get relief.
    Patients have an exacerbation of symptoms when walking
    downhill, due to relative spine extension.
    Patients with spinal stenosis frequently have urinary
    dysfunction, as evidenced by urodynamic abnormalities
    (Inui Y. Spine 2004; 29(8): 869-873)
    Source: Shah RV, Board Review 2004
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102
Q
  1. A 12-year old boy complains of neck and jaw pain. He
    underwent tonsillectomy 6 months ago. The pain is
    exacerbated by swallowing, talking, or turning his head.
    There was no evidence of infection. The most likely cause
    of his persistent pain is
    A. Riedel’s struma
    B. Eagle’s syndrome
    C. Ludwig’s angina
    D. Post traumatic stress disorder
    E. Infection of tonsillar bed
A
  1. Answer: B
    Explanation:
    Eagle’s syndrome, also known as stylohyoid syndrome,
    occurs after tonsillectomy, rarely. This is secondary to
    fi brosis developing around an elongated styloid process,
    impinging on the carotid sheath. It causes pain in the
    upper neck, jaw, face, ears, sternocleidomastoid, or
    temporal region. Pain may be exacerbated by swallowing,
    talking, or turning the head. Surgical removal of the
    styloid may be necessary
    Source: Kahn CH, DeSio JM. PreTest Self Assessment and
    Review. Pain Management. New York, McGraw-Hill, Inc.,
    1996.
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103
Q
548. Patients with sickle cell disease can experience episodic painful crises, which are characterized by
A. Hypothermia
B. Normoxemia
C. Acidosis
D. Dehydration
E. Cocaine addiction
A
  1. Answer: B
    Source: Raj P, Pain medicine - A comprehensive Review -
    Second Edition
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104
Q
549. What sign is classical for multiple sclerosis?
A. Hoffman’s sign
B. Homan’s sign
C. Lhermitte sign
D. Koenig’s sing
E. Brudzinski’s sign
A
  1. Answer: C

Source: Day MR, Board Review 2004

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105
Q
550. A 62-year-old woman complains of limb discomfort and trouble getting off the toilet. She is unable to climb stairs and has noticed a rash on her face about her eyes. On examination, she is found to have weakness about the hip and shoulder girdle. Not only does she have a purplishred discoloration of the skin about the eyes, but she also has erythematous discoloration over the fi nger joints and purplish nodules over the elbows and knees. The most
likely diagnosis is:
A. Systemic lupus erythematosus
B. Psoriasis
C. Myasthenia gravis
D. Dermatomyositis
E. Rheumatoid arthritis
A
  1. Answer: D
    Explanation:
    This woman presents with proximal muscle weakness and
    pain and a heliotrope rash about her eyes. The term
    heliotrope refers to the liliac color of the periorbital rash
    characteristic of dermatomyositis. This rash surrounds
    both eyes and may extend onto the malar eminences, the
    eyelids, the bridge of the nose, and the forehead. It is
    usually associated with an erythematous rash across the
    knuckles and at the base of the nails and may be associated
    with fl at-topped purplish nodules over the elbows and
    knees. Men with dermatomyositis are at higher than
    normal risk of having underlying malignancies. Psoriatic
    arthritis may be associated with reddish discoloration of
    the knuckles and muscle weakness, but the heliotrope rash
    would not be expected with this muscle weakness, but the
    heliotrope rash would not be expected with this disorder.
    The age of onset for a psoriatic myopathy is also atypical.
    Similarly, the patient’s rashes are not suggestive of lupus
    erythematosus, although a myopathy may occur with this
    connective tissue disease as well.
    Source: Anschel 2004
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106
Q
551.The most common organism identified in spinal
infections is
A. Staphylococcus aureus
B. Staphylococcus epidermidis
C. Mycobacterium tuberculosis
D. Pseudomonas aeruginosa
E. Escherichia coli
A
  1. Answer: A
    Explanation:
    Gram positive aerobic bacteria are most commonly
    isolated, and staph aureus is the most common organism.
    Source: Boswell MV, Board Review 2005
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107
Q
552. The most common source of spine infection is
A. Genitourinary
B. Dermatologic
C. Respiratory
D. Bowel
E. Dental
A
  1. Answer: A

Source: Boswell MV, Board Review 2005

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108
Q
553. Delayed onset of central pain after spinal cord injury is
most commonly due to
A. Infl ammation
B. Fibrosis
C. Infection
D. Syrinx
E. Tumor
A
  1. Answer: D

Source: Boswell MV, Board Review 2005

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109
Q
  1. A 52-year-old man presents with locked-in syndrome. On neurologic examination, the patient is quadriplegic with
    sensory loss and cranial nerve involvement. He is able to
    respond to questions using his eyes. Choose appropriate
    diagnosis:
    A. Basilar artery stroke
    B. Middle cerebral stroke
    C. Anterior cerebral stroke
    D. Transient ischemic attack
    E. Posterior cerebral stroke
A
  1. Answer: A
    Explanation:
    (Tierney, 42/e, pp 962-963.) Basilar artery stroke causes
    quadriplegia, sensory loss, and cranial nerve involvement;
    patients may present with coma or locked-in syndrome.
    Wallenberg syndrome or lateral medullary syndrome
    causes an ipsilateral weakness of the palate and vocal
    cords,ipsilateral ataxia, ipsilateral Horner syndrome, and
    ipsilateral loss of facial pain and temperature but
    contralateral loss of body pain and temperature sensation.
    There is no limb weakness in Wallenberg syndrome.
    Anterior cerebral stroke causes unilateral leg weakness and
    sensory loss. Posterior cerebral artery stroke causes an occipital stroke and a homonymous hemianopsia. Middle
    cerebral artery stroke causes hemiplegia or hemiparesis
    greater in the arm than the leg, aphasia, unilateral sensory
    loss, and eyes that deviate to the side of the hemispheric
    lesion. Patients with lacunar infarcts may present with
    different syndromes, such as dysarthria and mild
    hemiparesis (clumsy-hand dysarthria). Lacunar infarcts
    represent small artery occlusions; hypertension and
    diabetes are risk factors for these infarcts. Patients in a
    vegetative state from diffuse cortical damage have
    spontaneous eye opening and movement without evidence
    of awareness.
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110
Q
  1. Acute Herpes zoster (shingles) involving the anterior
    external ear canal, palate, tongue, and face is due to
    reactivation of virus in which of the following ganglia?
    A. Otic
    B. Geniculate
    C. Gasserian
    D. Sphenopalatine
    E. Pterygopalatine
A
  1. Answer: C
    Explanation:
    The virus involves the ganglion that forms the 5th nerve,
    the gasserian ganglion. Ramsay Hunt syndrome involves
    the ear, by reactivation in the geniculate ganglion, which
    appears to have sensory fi bers from the pinna and
    posterior external auditory canal.
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111
Q
556.The mechanism of injury of a C2 traumatic
spondylolisthesis is
A. Flexion
B. Flexion-rotation
C. Compression
D. Extension
E. Other
A
  1. Answer: D
    Explanation:
    This fracture is also known as a hangman’s fracture; the
    mechanism is hyperextension, such as might occur at the
    end of a short rope tied around ones neck, with the knot
    under the mandible.
    Source: Boswell MV, Board Review 2005
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112
Q
  1. A 41-year-old construction worker complains of the
    sudden onset of severe back pain after lifting some heavy
    equipment. He describes the pain as being in his right
    lower back and radiating down the posterior aspect of his
    right buttock to the knee area. He has no bladder or bowel
    dysfunction. The pain has improved with bed rest. On
    physical examination, the patient has tenderness in his
    lumbar area with palpation. The straight-leg maneuver
    with the right leg increases the back pain at 80°. The
    straight-leg maneuver with the left leg also causes thigh
    pain. Sensation, strength, and refl exes are normal. Which
    of the following is the most likely diagnosis?
    A. Nerve root compression
    B. Paravertebral abscess
    C. Lumbosacral strain
    D. Osteoporosis compression fracture
    E. Paget’s disease
A
  1. Answer: C
    Explanation:
    (Tierney, 42/e, pp 793-795.) Since the patient has no
    neurologic compromise, the most likely diagnosis is back
    strain. Strain is common in people in their forties. It is
    exacerbated by activity and improves with rest. A straightleg
    maneuver is positive for nerve root compression from
    disk herniation when pain is produced at less than 70° of
    elevation. Crossover pain (straight-leg maneuver of
    nonpainful leg worsens pain of involved leg) is also a
    strong indicator of nerve root compression, but only if
    pain is produced below the knee. Paravertebral abscess
    usually presents with fever and tenderness with percussion
    of the affected back area. Risk factors for osteoporosis
    include female gender, menopause, lack of activity, slim
    body habitus, older age, inadequate calcium intake,
    medications such as corticosteroids, and racial-ethnic
    background (Asian and northern European descent).
    Paget’s disease (osteitis deformans) is a slowly
    progressing disease of bone that may be asymptomatic or
    may cause bone pain, deformities (such as a large skull or
    leg bowing), hearing loss, and fractures. It begins in
    middle-aged men and is thought to be due to an inborn
    error of metabolism causing the formation of poorly
    organized bone.
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113
Q
558. The hallmark that distinguishes ankylosing spondylitis from other forms of arthritis is:
A. Synovitis
B. Enthesitis
C. Kyphosis
D. Amyloidosis
E. Osteoporosis
A
  1. Answer: B
    Explanation:
    Infl ammation at insertion of tendons, ligaments and fascia
    on bone is an important mechanism of the spinal bony
    changes
    Source: Boswell MV, Board Review 2005
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114
Q
559. A 61-year-old man presents with fl accid paralysis,
atrophy, fasciculaions, and hyperrefl exia. Choose correct
diagnosis:
A. Upper motor neuron disease
B. Lower motor neuron disease
C. Myelopathy
D. Radiculopathy
E. Broca’s aphasia
A
  1. Answer: B
    Explanation:
    (Seidel, 5/e, p 798.) Upper motor neuron (UMN) disease
    (above the level of the corticospinal synapses in the gray
    matter) is characterized by spastic paralysis, hyperrefl exia,
    and a positive Babinski refl ex (everything is up in UMN
    disease). Lower motor neuron (LMN) disease (below the
    level of synapse) is characterized by fl accid paralysis,
    signifi cant atrophy, fasciculations, hyporefl exia, and a
    fl exor (normal) Babinski refl ex (everything is down in
    LMN disease). A radiculopathy occurs with root
    compression from a protruded disk that causes sensory
    loss, weakness, and hyporefl exia in the distribution of the
    nerve root. Myelopathy causes severe sensory loss 0
    posterior column sensation (position sense and vibration),
    spasticity, hyperrefl exia, and positive Babinski refl exes.
    Broca’s aphasia (left inferior frontal gyrus) is a nonfl uent
    expressive aphasia (Broca’s should remind you of broken
    speech); Wernicke’s aphasia (left posterior-superior
    temporal gyri) is a receptive aphasia because patients lack
    auditory comprehension (Wernicke’s should remind you
    of wordy speech that makes no sense).
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115
Q
  1. A 30-year-old woman with a history of diabetes mellitus presents with a 3-week history of hand numbness that often awakens her from sleep. The symptoms resolve
    after she shakes her hands for a few minutes. On physical
    examination, there is no sensory or motor defi cit of her
    hands but there is a positive Tinel sign. Which of the
    following is the most likely diagnosis?
    A. Thoracic outlet syndrome
    B. Carpal tunnel syndrome
    C. Dupuytren’s contracture
    D. Mallet fi nger
    E. Ganglion
A
  1. Answer: B
    Explanation:
    (Seidel, 5/e, p 735.) Carpal tunnel syndrome (CTS) is the
    most likely diagnosis. It is due to median nerve
    compression by the transverse carpal ligament. Risk
    factors for this disorder include diabetes mellitus,
    pregnancy, hypothyroidism, rheumatoid arthritis,
    repetitive activity, and acromegaly. The Tinel sign
    (paresthesias or pain reproduced with percussion of the
    volar surface of the wrist) and Phalen sign (symptoms are
    reproduced by holding the wrist in passive fl exion for 1
    min)may be positive. Patients may complain of pain in the
    forearm, the thenar eminence, and the fi rst three digits.
    Thoracic outlet syndrome usually causes medial arm pain
    and paresthesia when using the arms. The presence of a
    cervical rib is a risk factor for this disorder. Dupuytren’s
    contracture is a fi brotic process of the palmar fascia that
    causes fi xed fl exion of the ring fi nger. Mallet fi nger is a
    fl exion deformity of the distal interphalangeal joint and is
    generally the result of traumatic rupture of the extensor
    tendon of the distal phalanx. A ganglion is a painless, fi rm
    cystic mass arising from any joint or tendon sheath. A
    trigger fi nger may be seen in patients with rheumatoid
    arthritis. It occurs when an enlarged fl exor tendon sheath
    passes through the pulleys of the digits, causing locking or
    catching.
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116
Q
561. A 20-year-old man presents with complaints of pain in the left hip and left proximal femur. The pain has been present for approximately 3 weeks and is increasing in severity. It is worse at night and is relieved by aspirin. There is no history of trauma or previous hip or leg problems. Which of the following is the most likely diagnosis?
A. Osteosarcoma
B. Paget’s disease
C. Osteoid osteoma
D. Chondrosarcoma
E. Muscle strain
A
  1. Answer: C
    Explanation:
    (Tierney, 42/e, p 835.)
    C. A history of pain that increases in severity, worsens at
    night, and is relieved by aspirin suggests the diagnosis of
    osteoid osteoma. This benign tumor is more common in
    males than females,and patients present between20 and 30
    years of age. The proximal femur is the most common site
    for this tumor. Other benign tumors of bone include giant
    cell tumor (osteoclastoma), osteochondroma,
    chondroblastoma, and osteoblastoma.
    A & D. The most common malignant tumors of bone
    include osteosarcoma (45%), chondrosarcoma (25%),
    Ewing’s sarcoma (15%), and malignant fi brous
    histiocytoma.
    Osteosarcomas commonly involve the distal femur.
    Chondrosarcomas are seen in older patients (40 to 50
    years old).
    Osteosarcomas may be seen later in life as a complication
    of Paget’s disease.
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117
Q
  1. Duchenne muscular dystrophy is a sex-linked disorder
    involving the gene responsible for the synthesis of
    A. Glucose-6-phosphatase
    B. Hexosaminidase B
    C. Myosin
    D. Dystrophin
    E. Actin
A
  1. Answer: D
    Explanation:
    Duchenne dystrophy has been incontrovertibly linked to
    the gene, located on the X chromosome, that makes
    dystrophin. The more profound the disturbance of this
    gene, the earlier the disease becomes symptomatic. The
    gene for dystrophin has single or multiple deletions in
    affected children. Women who are probable carriers of the
    defective gene can be checked for heterozygosity and given
    genetic counseling. Chorionic villus biopsy at 8 to 9 weeks
    can determine if a fetus that is at risk for the deletion
    actually carries it.
    Source: Anschel 2004
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118
Q
  1. The commonest cause of Trigeminal neuralgia symptoms is:
    A. Infected tooth
    B. Multiple sclerosis
    C. Temporomandibular joint disorder
    D. Compression by the superior cerebellar artery.
    E. Post Therpetic Neuralgia
A
  1. Answer: D
    Explanation:
    The most common cause of trigeminal neuralgia is
    mechanical compression of the trigeminal nerve as it
    leaves the pons and traverses the subarachnoid space
    towards Meckel’s cave. The cross compression is usually
    by the superior cerebellar artery and may occasionally be
    by the posterior inferior cerebellar artery, anterior inferior
    or the vertebral artery.
    The region of pain in the face corresponds with the region
    of compression of the trigeminal nerve by the artery.
    Compression of the rostral and anterior portion of the
    nerve by the superior cerebellar artery causes pain in the
    maxillary (V2) and mandibular divisions (V3). Pain in the
    frontal (V1) division is due to compression of the
    trigeminal nerve root in its caudal and posterior portions
    by the anterior inferior cerebellar artery.
    Multiple sclerosis is not a common cause of trigeminal neuralgia. Dental abscess, infection and
    temporomandibular joint dysfunction has not been
    proven to be a cause of trigeminal neuralgia.
    Source: Chopra P, 2004
119
Q
564. An 35-year-old man presents with a history of low back pain that awakens him from sleep. He also complains of morning stiffness and decreased mobility. The pain does not improve with activity. Schober test is positive. What is
the accurate diagnosis?
A. Refl ex sympathetic dystrophy
B. Ankylosing spondylitis
C. Reiter syndrome
D. Hypertrophic osteoarthropathy
E. Charcot joint
A
  1. Answer: B
    Explanation:
    Hypertrophic osteoarthropathy is nail clubbing
    accompanied by a symmetrical polyarthritis involving the
    large joints and occasionally the metacarpophalangeal
    joints. Hypertrophic osteoarthropathy may be seen
    secondary to malignancy, endocarditis, vasculitis, and
    other pulmonary and cardiac diseases. Ankylosing
    spondylitis (AS) is a chronic and progressive
    infl ammatory disease, seen mostly in men in their thirties,
    that most commonly affects the spinal, sacroiliac, and hip
    joints. It may go undiagnosed for many years, and bilateral
    hip pain due to sacroiliac involvement may be clinically
    undetectable. It is strongly associated with HLA-B27.
    Examination of the spine usually reveals limitation in
    movement; patients in advanced stages may have a
    characteristic bent-over posture. Patients with AS may
    present with an acute nongranulomatous uveitis and
    limited chest expansion due to involvement of the
    costovertebral joints. The Schober test is positive in AS
    (with the patient erect, marks are made 5 cm below and 10
    cm above the lumbosacral junction between the posterior
    superior iliac spines; the patient bends, marks are
    measured, and if the distance between the two marks
    increases by less than 4 cm there is spinal immobility). The
    pathogenesis of refl ex sympathetic dystrophy is unknown.
    The presentation may be seen after peripheral limb injury;
    early symptoms include pain in the limb and edema. This
    disorder may lead to contractures. Charcot joint is a
    complication of peripheral neuropathy seen in diabetic
    patients. Repetitive minor trauma to the foot causes
    deformities, which may lead to skin breakdown, erythema,
    edema, and callus formation.
    Source: Goldman
120
Q
  1. All of the following are true regarding diabetic peripheral neuropathy except:
    A. Is Symmetric
    B. Involves sensory nerves only
    C. Symptoms are gradually progressive
    D. The pain progresses in a proximal direction
    E. Treatment includes anti-epileptic drugs and sympathetic
    blocks
A
  1. Answer: B
    Explanation:
    Ref: Manning, Loar, Raj, Hord. Chapter 10. Neuropathic
    Pain. In: Pain Medicine: A Comprehensive Review, 2nd
    Edition, Raj, Mosby. 2003, page 78
    Source: Day MR, Board Review 2003
121
Q
566. Neuropathic pain is diagnosed by:
A. History
B. Physical exam
C. Laboratory testing
D. Neurodiagnostic testing
E. None of the above
A
  1. Answer: E
    Explanation:
    Neuropathic pain is a diagnosis of exclusion. There are no
    single diagnostic criteria.
    Source: Trescot AM, Board Review 2004 for Shah
122
Q
  1. A 23-year old female complains of pain when elevating
    her right shoulder and when carrying her briefcase in
    either hand to and from work. She also complains of
    slight grinding or crunching sensation when actively
    elevating her right shoulder. She admits that her left
    shoulder bothers her as well, though not as much as
    right shoulder. There is no history of injury. Physical
    examination shows no muscle wasting. There was
    pinpoint tenderness slightly inferior to the anterior
    border of the acromion while the shoulder is passively
    extended. She had a presence of painful resisted external
    rotation and abduction, as well as during passive internal
    rotation while the shoulder is elevated to 80°. The most
    likely diagnosis is:
    A. Impingement of supraspinatus tendon
    B. Rotator cuff syndrome
    C. Bicipital tendonitis
    D. Cervical spondylosis
    E. Acromioclavicular joint arthritis
A
  1. Answer: A
    Explanation:
    The term impingement syndrome was popularized by Charles Neer in 1972 as such. Neer Test for positive
    impingement sign was popularized by Neer and Walsh
    which reproduces pain in concomitant fascial grimace
    when the arm is forcefully fl exed forward by the examiner,
    jamming the greater tuberosity against the anteroinferior
    acromial surface.
    The injection of 10 mL of lidocaine in to the subacromial
    space, followed by pain relief, helps confi rm the diagnosis
    and rules out other causes of shoulder pain such as
    acromioclavicular joint sprain and adhesiocapsulitis
    which are not relieved by injection.
    Source: Saidoff DC, McDonough AL. Critical Pathways in
    Therapeutic Intervention. Extremities and Spine. St.
    Louis,Inc., 2002
123
Q
  1. A 14-year-old boy presents with a history of intermittent
    facial grimacing, twitching, and eye blinking since
    childhood. The movements are repetitive and often
    move from one part of the face to another. On physical
    examination, cranial nerve, sensory, and cerebellar
    examinations are normal. Motor examination reveals
    frequent and quick repetitive eye blinking, nasal
    twitching, and facial grimacing accompanied by an
    occasional snort or grunt. Which of the following is the
    most likely diagnosis?
    A. Tardive dyskinesia
    B. Tourette syndrome
    C. Asterixis
    D. Sydenham’s chorea
    E. Huntington’s chorea
A
  1. Answer: B
    Explanation:
    (Tierney, 42/e, pp 979-982.) Tourette syndrome is a
    disorder of repetitive progressive multiple tics involving
    the face, head, and shoulders and is often accompanied by
    vocal tics (i.e., grunts, snorts, involuntary swearing, or
    coprolalia). Huntington’s disease is an autosomal
    dominant disorder characterized by abrupt, involuntary,
    nonrepetitive, jerky movements (chorea) and dementia.
    Patients with tardive dyskinesia have developed
    purposeless movements, such as mouth smacking tongue
    protrusion, after use of a dopamine-blocking neuroleptic
    drug. Asterixis is seen in patients with hepatic
    encephalopathy (liver nap) renal failure and is
    characterized by frequent inability to sustain wrist
    extension (bye-bye gesture). Wilson’s disease
    (hepatolenticular degeneration) is an autosomal recessive
    disorder of copper metabolism characterized by
    choreoathetosis, ataxia, cirrhosis, and corneal deposits
    called Kayser-Fleischer rings. A low serum ceruloplasmin
    or a high urinary copper level is found in Wilson’s disease.
    Sydenham’s chorea is seen rheumatic fever.
124
Q
  1. Neuropathic pain is caused by:
    A. direct stimulation of mechanoreceptors
    B. pain receptors in the brain
    C. dysfuntion in the nervous tissue itself
    D. indirect stimulation of mechanoreceptors
    E. Thermoreceptors
A
  1. Answer: C
    Explanation:
    Neuropathic pain results from injury or disease of the
    nervous tissue itself. Although there can be central pain
    states, they are not due to actual “pain receptors” in the
    brain. Mechanical pain is considered nociceptive.
    Source: Trescot AM, Board Review 2004 for Shah
125
Q
570. The most common psychiatric disorder seen in patients
with chronic low back pain is
A. Generalized anxiety disorder
B. Somatization disorder
C. Personality disorder
D. Depression disorder
E. Factitious disorder
A
  1. Answer: D

Source: Boswell MV, Board Review 2005

126
Q
  1. A 42-year-old man presents with a crush injury to his
    left lower extremity. He complains of severe leg pain that
    seems out of proportion to his injury. He also complains
    of paresthesias of left lower extremity. Leg examination is
    signifi cant for pallor and coldness. The dorsalis pedis and
    posterior tibialis pulses are not palpable. Which of the
    following is the most likely diagnosis?
    A. Arterial insuffi ciency
    B. Pelvic fracture
    C. Aortic insuffi ciency
    D. Aortic dissection
    E. Compartment syndrome
A
  1. Answer: E
    Explanation:
    (Tintinalli, 5/e, pp 1838-1841.) The patient most likely has
    compartment syndrome from elevated pressure in a
    confi ned space compromising nerve, soft tissue, and
    muscle perfusion. Etiologies include burn injuries, crush
    injuries, and fractures. Compartment syndrome is often referred to as the disorder of Six P’s (Pain, Pallor,
    Paralysis, Paresthesias, Poikilothermia, and
    Pulselessness). Immediate fasciotomy and restoration of
    tissue perfusion is the treatment for compartment
    syndrome.
127
Q
572. Neuropathic pain may be:
A. peripheral
B. central
C. both peripheral and central
D. neither peripheral or central
E. none of the above
A
  1. Answer: C
    Explanation:
    Neuropathic pain can be both central and peripheral.
    Source: Trescot AM, Board Review 2004 for Shah
128
Q
573. The most common primary malignant spine tumor is
A. Myeloma
B. Osteosarcoma
C. Chondrosarcoma
D. Chordoma
E. Lymphoma
A
  1. Answer: A
    Explanation:
    The 1st, 2nd and 3rd most common primary malignant
    tumors of bone, in descending order, are multiple
    myeloma, osteosarcoma and chondrosarcoma. Chordoma
    is a malignant notochord remnant, and lymphoma is not a
    primary bone tumor.
    Source: Boswell MV, Board Review 2005
129
Q
574. The most common cause of thoracic radiculopathy is
A. Metastasis
B. Herniation
C. Infection
D. Diabetes
E. Scoliosis
A
  1. Answer: D

Source: Boswell MV, Board Review 2005

130
Q
575. Absolute central lumbar stenosis is defi ned as:
A. Less than 8mm diameter
B. Less than 10mmdiameter
C. Less than 12mm diameter
D. Less than 15mm diameter
E. Less than 2mm diameter
A
  1. Answer: B
    Explanation:
    The spinal canal is nearly round in shape; it is 12mm or
    more in the anteroposterior diameter. Relative stenosis is
    defi ned as midline sagittal diameter of
131
Q
576. Impingement of the L5 nerve root may cause loss of which
refl ex?
A. Plantar
B. Patellar
C. Cremasteric
D. Hamstring
E. Achilles
A
  1. Answer: D
    Explanation:
    Hamstring refl ex, also known as the posterior tibial refl ex
    Source: Boswell MV, Board Review 2005
132
Q
577. Herniation of the C4-5 disc may cause weakness of which of the following muscles?
A. Biceps brachii
B. Triceps brachii
C. Interosseus dorsales
D. Flexor digitorum
E. Extensor carpi radialis
A
  1. Answer: A
    Explanation:
    The C5 root is most commonly impinged. The best
    answer is biceps, but note that the biceps is innervated by
    C5 and C6. Pain radiates to the shoulder and anterior arm
    and radial forearm.
    Source: Boswell MV, Board Review 2005
133
Q
  1. During a burn debridement procedure, ketamine is
    utilized as an analgesic in a twelve-year-old child. A
    undesirable side effect of ketamine in the pediatric
    population include:
    A. Profound respiratory depression in standard analgesic
    doses
    B. Bradycardia and hypotension
    C. Dysphoria and dream terror
    D. Decrease of renal blood fl ow
    E. Improved compliance in drug-dependent patients
A
  1. Answer: C

Source: Hansen HC, Board Review 2005 for Shah

134
Q
  1. Physiologic risk from traumatic injury includes:
    A. Immobility, and increased risk of dermal breakdown
    B. Decreased respiratory effort and resultant atelectasis
    C. Increased risk of deep venous thrombosis
    D. Impaired gastric motility and splanchnic circulation
    E. Increased functional status
A
  1. Answer: D

Source: Hansen HC, Board Review 2005 for Shah

135
Q
  1. True statement about lateral epicondylitis are as follows:
    A. Peak incidence is fourth decade
    B. Associated with pain at the elbow, with radiation to the
    forearm and wrist.
    C. Decrease in grip strength and pain with extension of
    the elbow
    D. Progressive weakness and paresthesia inhibits supination
    and pronation
    E. Lateral epicondylitis is also called Golfer’s elbow
A
  1. Answer: D

Source: Hansen HC, Board Review 2005 for Shah

136
Q
  1. The etiology of carpal tunnel syndrome includes all of the following except:
    A. Paresthesias are noted in thumb, index fi nger, and long
    fi ngers, and is frequently associated with decreased
    grip strength.
    B. Is felt to be caused by compression at wrist by thickening
    transverse carpal ligament.
    C. An increase in volume or tunnel contents secondary to
    tenosynovitis.
    D. Alteration of the osseous margins of carpus
    E. Systemic disease
A
  1. Answer: A

Source: Hansen HC, Board Review 2005 for Shah

137
Q
  1. A middle aged, mildly obese woman presents complaining
    of bilateral medial right knee pain that occurs with
    prolonged standing. The pain does not occur with sitting
    or climbing stairs but seems to be worse with other
    activity and at the end of the day. The patient denies
    morning stiffness. Examination of the knees reveals no
    deformity, but there are small effusions. Some mild pain
    and crepitus are produced with palpation of the medial
    aspect of the knees. The most likely diagnosis is:
    A. Rheumatoid arthritis
    B. Gouty arthritis
    C. Chondromalacia patellae
    D. Osteoarthritis
    E. Psoriatic arthritis
A
  1. Answer: D
    Explanation:
    Osteoarthritis most often affects the weight-bearing joints
    and is associated with obesity or other forms of
    mechanical stress. It has no systemic manifestations. It is
    more common in women, and onset is usually after the
    age of 50.
    Pain often occurs on exertion and is relieved with rest,
    after which the joint may become stiff. Distal
    interphalangeal joints may be involved, with the
    production of Heberden nodes. Bouchard nodes are often
    found at the proximal interphalangeal joint. Crepitus (the
    sensation of bone rubbing against bone) is often felt on
    examination of the involved joint. Rheumatoid arthritis is
    a systemic disease of women under the age of 40. joint
    involvement is usually symmetric, involving the proximal
    interphalangeal and metacarpophalangeal joints. Ninetyfi
    ve percent of gouty arthritis occurs in men and often
    involves the great toe. Chondromalacia patellae or
    chondromalacia means softening of the cartilage. Patients
    present with anterior knee pain and tenderness over the
    undersurface of the patella. Pain is worse when sitting for
    long periods of time or when climbing stairs. Psoriatic
    arthritis is an asymmetric oligoarthritis that involves the
    knees, ankles, shoulders,or digits of the hands and feet and
    occurs in 50% of patients with psoriasis.
    Source: Tierney
138
Q
  1. Breakthrough pain, i.e., episodic exacerbations of pain
    above an established baseline level of pain is experienced
    by what percentage of patient with cancer?
    A. >90%
    B. 75-90%
    C. 50-74%
    D. 25-49%
    E.
A
583. Answer: A
Explanation:
(Raj, Pain Review, 2nd Ed., page 110)
Breakthrough pain is experienced by 93% of patients with
cancer
Source: Shah RV, Board Review 2005
139
Q
  1. Of the following, which is the correct defi nition?
    A. Allodynia -pain brought on by a non-painful stimulus
    B. Hyperpathia -burning, pins and needles sensation
    C. Paresthesia - extreme sensitivity to noxious stimulus
    D. Dysesthesia - sharp, shooting pains
    E. Hyperalgesia - pain brought on by a non-painful stimulus
A
  1. Answer: A
    Explanation:
    A. Allodynia is pain brought on by a non-painful stimulus.
    B. Hyperpathia is an abnormal response to a stimulus.
    C. Paresthesia is a burning or “pins and needles” sensation.
    D. Dysesthesia is an abnormal and disagreeable symptom.
    E. Hyperalgesia is an exaggerated pain caused by a
    normally painful stimulation.
    Source: Trescot AM, Board Review 2004 for Shah
140
Q
  1. Which of the following is true of trigeminal neuralgia?
    A. Like post-herpetic neuralgia, the V1 distribution is the
    most affected
    B. Like temporal arteritis, patients typically develop jaw
    claudication with chewing
    C. The pain is paroxysmal, shooting and electrical in nature
    and lasts 10 to 30 minutes at a stretch
    D. Pain typically lingers between episodes
    E. Facial muscles innervated by cranial nerve 7 may contract during episodes
A
  1. Answer: E
    Explanation:
    (Raj, Pain Review, 2nd Ed., pages 28-39)
    Trigeminal neuralgia represents painful ectopic or
    ephaptic fi ring of trigeminal neurons: the ‘kindling’
    phenomenon occurs when abnormal impulses in damaged
    trigeminal neurons are ‘driven’ into a sensory seizure
    activity by the afferent barrage from trigger zones. Several
    mechanisms have been proposed. The most common is an abnormal blood vessel, such as the superior cerebellar
    artery and anterior inferior cerebellar artery. Other
    mechanisms include demyelinating plaques that affect the
    caudalis nucleus or direct tumor infi ltration of the rootlets
    (acoustic neuromas,aneurysms, angiomas,cholesteatomas)
    A. Unlike PHN, V2 and V3 are the most commonly
    affected.
    B. Unlike temporal arteritis, the pain is not gradual and
    progressive with eating.
    C. Chewing rather induces paroxysmal, lancinating,
    electrical shocks that last from seconds to a few minutes
    (usually less than 2 minutes).
    D. Patients are usually pain free between episodes.
    E. Facial muscles may contract during episodes…
    voluntarily. Patients grimace the face in order to
    immobilize any trigger zones: tic doloreux.
    Note hemifacial spasm involves compression or ephaptic
    discharges of the facial nucleus which can lead to
    involuntary pain contractions of facial muscles on one
    side.
    This is unlike the ‘voluntary’ grimacing of facial muscles
    with trigeminal neuralgia.
    Source: Shah RV, Board Review 2005
141
Q
586. Which of the following most commonly is associated with central pain?
A. Stroke
B. Epilepsy
C. Brain tumor
D. Spinal cord injury
E. Parkinson’s disease
A
  1. Answer: D

Source: Boswell MV, Board Review 2005

142
Q
587.Central pain most likely requires injury to which of the
following pathways?
A. Posterior columns
B. Corticospinal fi bers
C. Spinothalamic tract
D. Reticulospinal fi bers
E. Mesencephalic system
A
  1. Answer: C

Source: Boswell MV, Board Review 2005

143
Q
588.The most common site of spinal cord lesions causing
central pain is
A. Brainstem
B. Cervical
C. Thoracic
D. Lumbar
E. Sacral
A
  1. Answer: B

Source: Boswell MV, Board Review 2005

144
Q
589.Infections of the spine most commonly involve which segments?
A. Cervical
B. Thoracic
C. Thoracolumbar
D. Lumbar
E. Sacral
A
589. Answer: D
Explanation:
Lumber spine is involved slightly more often than thoracic
spine.
Source: Boswell MV, Board Review 2005
145
Q
  1. Patient controlled anesthesia allows all of the following
    except:
    A. Patient controlled administration of analgesia by demand
    B. Decreased risk of normeperidine induced seizure activity
    with demerol administration
    C. Improved compliance with post-traumatic rehabilitation
    D. Improved compliance with JCAHO fi fth pathway recommendations
    E. Improved analgesia with reduced overall opioid administration
A
  1. Answer: B

Source: Hansen HC, Board Review 2005 for Shah

146
Q
591.The most common painful symptom associated with
spinal cord injury is
A. Burning
B. Dysesthesias
C. Lancinating
D. Muscle cramps
E. Visceral pain
A
  1. Answer: A

Source: Boswell MV, Board Review 2005

147
Q
592.The most common cause of mononeuropathy multiplex
is
A. Diabetes mellitus
B. Temporal arteritis
C. Sarcoidosis
D. Systemic lupus erythematosus
E. Periarteritis nodosa
A
  1. Answer: A
    Explanation:
    A. Diabetes mellitus is the most common cause of
    mononeuropathy multiplex. In this disorder, individual
    nerves are transiently disabled. The neuropathy usually
    develops over the course of minutes to days, and the
    recovery of function may require weeks to months.
    B. Various rheumatoid disease and sarcoidosis produce similar clinical pictures, but temporal arteritis does not
    typically lead to this type of neuropathy.
    A vascular lesion is believed to be the most common basis
    for this type of neuropathy. If the giant cell arteritis seen
    with temporal arteritis does cause a neuropathy, it is an
    optic neuropathy with resultant blindness.
    Unlike the peripheral nerve injuries that develop with
    mononeuropathy multiplex, this ischemic optic
    neuropathy of temporal arteritis produces irreversible
    injury to the affected cranial nerve.
    The patient who loses vision as part of temporal arteritis
    does not recover it.
148
Q
  1. Which of the following is not a barrier to effective pain
    control in the cancer population?
    A. Lack of validated instruments to assess the multidimensional
    aspects of pain in a cancer patient
    B. Under-reporting of pain by cancer patients
    C. Fear of civil or criminal penalties due concerns by practitioners
    of improperly prescribing analgesics
    D. Inadequate reimbursement by payers
    E. Inadequate assessment of pain and lack of knowledge of
    pain therapies by practitioners
A
  1. Answer: A
    Explanation:
    A. There are several validated instrument for assessing
    cancer pain:
    Multidimensional Scales:
    Memorial Pain Intensity Card- 100 mm VAS, pain relief
    scale, mood scale, and 8-point verbal rating scale. Its utility
    is its brevity
    McGill Pain Inventory
    Brief Pain Inventory
    Unidimensional Scales:
    VAS
    Numerical Rating Scale- 11
    B. Under-reporting by patients and families
    C. Fear of over-regulation by the government
    D. Inadequate reimbursement or requirements for
    excessive documentation by 3rd party payers
    E. Inadequate assessment by practitioners
    - Lack of knowledge regarding current pain treatment by
    practitioners
    Source: Shah RV, Board Review 2005
149
Q
594.The most prominent areas of degeneration with
Friedreich’s disease are in the
A. Cerebellar cortex
B. Inferior olivary nuclei
C. Anterior horns of the spinal cord
D. Spinocerebellar tracts
E. Spinothalamic tracts
A
  1. Answer: D
    Explanation:
    Degeneration occurs primarily in the spinal cord rather
    than the cerebellum or brainstem in patients with
    Friedreich’s disease. Both the dorsal and ventral
    spinocerebellar tracts are involved. The other spinal cord
    structures exhibiting degeneration include the posterior
    columns and the lateral corticospinal tracts.
    Source: Anschel 2004
150
Q
  1. Acute pain is never well tolerated, but in which of the
    following would you expect the patient to have the
    greatest tolerance?
    A. Early in the course of the cancer
    B. Late in the course of the cancer
    C. After a bone biopsy
    D. Mucositis following radiation therapy
    E. Abdominal distention and cramps following chemotherapy
A
  1. Answer: A
    Explanation:
    Patients may tolerate high levels of pain early in the course
    of the illness because of the expectation that anti-cancer
    therapy may relieve their symptoms.Late in the course
    they may have increase anxiety, apprehension, and fear. Diagnostic procedures tend to be frequent in these
    patients.
    Since patients may be wary of the results and since bone
    biopsies are frequently painful, this may not be well
    tolerated. Mucositis is diffi cult to treat and will be
    unpleasant. Abdominal distention and cramps, along with
    nausea following chemotherapy would also be poorly
    tolerated
    Source: Shah RV, Board Review 2005
151
Q
  1. A patient with inoperable pancreatic cancer has severe
    abdominal pain. A celiac plexus block failed to provide
    any relief. Over a period of one month, the patient has
    required higher and higher doses of fentanyl to150
    mcg/hour (two 75 mcg/hr patches). You decide to proceed
    with an intrathecal trial of morphine in anticipation of
    placing a permanent intrathecal pump. How much would
    you trial with?
    A. 15 milligrams
    B. 15 micrograms
    C. 30 milligrams
    D. 30 micrograms
    E. 500 micrograms
A
  1. Answer: E
    Explanation:
    Typically the conversion ratios for different routes are as
    follows:
    Oral to intravenous = 3:1
    Intravenous to epidural = 10:1
    Epidural to intrathecal = 10:1
    Also, although debatable, fentanyl to morphine the
    conversion ratio is 1:100.
    Thus, an appropriate trial would start with 0.5 mg or 500
    micrograms. The issue of management is controversial,
    since most patients with inoperable pancreatic cancer are
    not expected to live more than 4-6 months. Intrathecal
    pumps typically are cost-effective when the life expectancy
    is greater than 4-6 months. If less than that then consider a
    tunneled epidural catheter.
    Source: Shah RV, Board Review 2005
152
Q
597. Which of the following is NOT a disorder of the
microcirculation?
A. Raynaud’s disease
B. Acrocyanosis
C. Livedo Reticularis
D. Erythromelalgia
E. Thromboangiitis obliterans
A
  1. Answer: E
    Explanation:
    A. Raynaud’s disease is a disease of the microcirculation
    B. Acrocyanosis is a vasospastic disorder manifested by
    persistent coldness, intense cyanosis, edema, and
    hyperhidrosis
    C. Livedo Reticularis is manifested by marbled mottling
    of the skin with cold intolerance
    D. Erythromelalgia is the opposite of acrocyanosis and
    Raynaud’s disease: vasodilatation, redness, and burning
    pain
    E. Thromboangiitis obliterans is a non-atherosclerotic
    lesion of medium sized arteries and veins in the distal leg
    or arm.
    - Young cigarette smoking males are almost exclusively
    affected.
    - The pain is symmetric and bilateral.
    - Patients usually have a cold intolerance.
    -The most common symptoms are instep claudication
    and rest pain
    Source: Shah RV, Board Review 2005
153
Q
  1. A 17 -year-old football player with his foot planted is
    tackled from the side, causing a forced valgus bending
    of the knee. On physical examination, there is tenderness
    over the medial femoral condyle. McMurray test is
    negative for any palpable clicks. Which of the following is
    the most likely diagnosis?
    A. Tear of the lateral meniscus
    B. Rupture of the lateral collateral ligament
    C. Rupture of the medial collateral ligament
    D. Dislocation of the patella
    E. Subluxation of the patella
A
  1. Answer: C
    Explanation:
    (Seidel, 5/e, pp 737-738.) The lateral and medial collateral
    ligaments are on either side of the knee. Forced valgus bending of the knee may rupture the medial collateral
    ligament (MCL), also called the tibial collateral ligament.
    This is the most frequently injured ligament of the knee.
    Patients present with pain over the medial aspect of the
    knee. Injuries to the MCL may in turn tear the medial
    meniscus since the MCL is attached to the medial
    meniscus. Patients with medial mensical tears may
    complain of locking of the knee in fl exion with activity
    while walking. Injuries of the lateral (fi bular) collateral
    ligament cause tenderness over the lateral knee with
    palpation, but these injuries are not common. Dislocation
    or subluxation of the patella is due to a great force.
    Locking is common and the patella is usually displaced
    laterally.
    Subluxation reduces by itself, while dislocation requires
    reduction.
154
Q
  1. Which of the following is typical of neurogenic
    claudication associated with spinal stenosis?
    A. Spinal canal diameter of 12 mm
    B. Decreased pedal pulses
    C. Leg pain with standing
    D. Horner’s syndrome
    E. Brachial plexus compression
A
  1. Answer: C

Source: Boswell MV, Board Review 2005

155
Q
  1. A patient presents with serve pain during resisted
    shoulder abduction, along with minimal pain during
    resisted external rotation. The following tendopathies
    would be most likely responsible for the pain.
    A. Biceps Tendinitis
    B. Infraspinatus Tendinitis
    C. Subscapularis Tendinitis
    D. Supraspinatus Tendinitis
    E. Gleno Humeral Tendinitis
A
  1. Answer: D

Source: Sizer Et Al - Pain Practice March & June 2003

156
Q
  1. When taking the history of a new headache patient, which of the following would not raise your suspicion of a
    serious pathologic etiology?
    A. Headache that is always in one spot
    B. Relief of headache with sleep
    C. Double vision with lateral gaze
    D. Headache that worsens when lifting a heavy object
    E. The worst headache ever
A
  1. Answer: B
    Explanation:
    (Raj, Pain Review, 2nd Ed., page 25, Table 5-1)
    Several factors in a targeted headache history should raise
    concern:
    New headache of recent onset (‘the fi rst’)
    New headache of unusual severity
    Headache associated with systemic illness
    Headache that peaks rapidly
    Headache associated with exertion
    Focal headache
    Sudden change in a previously stable headache pattern
    Headache associated with a Valsalva maneuver
    Nocturnal headache
    In this case, a headache that is in one spot may be
    associated with malignancy or other intracranial
    pathology. Double vision with lateral gaze implies a
    neurological
    abnormality, such as increased intracranial pressure.
    Headache that worsens with heavy lifting implies
    increased pain with transient increases in ICP (Valsalva).
    The worst headache ever may signal a catastrophe such as
    an aneurysm rupture or meningitis. Relief of headache
    with sleep is often associated with a benign process.
    Source: Shah RV, Board Review 2005
157
Q
602. The structure that is most often associated with bursitis at
the shoulder is the
A. Acromioclavicular joint capsule
B. Glenohumeral joint capsule
C. Subacromial bursa
D. Subdeltoid bursa
E. None of the above
A
  1. Answer: C
    Explanation:
    C. Shoulder bursitis is often the result of calcium deposits
    associated with the subacromial bursa, which separates
    the acromion process from the underlying supraspinatus
    muscle, or within the suprajacent supraspinatus tendon.
    D. The subdeltoid bursa separates the deltoid muscle from
    the head of the humerus and the insertions of the rotator
    cuff muscles.
    Source: Klein RM and McKenzie JC 2002.
158
Q
  1. A 46-year old homemaker enters your offi ce holding
    her right upper extremity in a guarded posture with a
    complaint of an acute and worsening throbbing pain of 3
    days duration in the right shoulder that is unrelieved by
    rest. She provided the history that the mild pain started
    approximately 4 months ago. She had tenderness over the
    deltoid muscle and pain elicited when rolling over onto
    the right shoulder while sleeping. There was initially a
    loss of range of motion, as well as a catching and painful
    sensation whenever the right arm was elevated between
    75° to 100°. High doses of Aspirin helped her pain. There
    was no history of trauma. The x-ray taken of the shoulder
    is depicted below. The most likely diagnosis is:
    A. Dystrophic calcifi cation of the shoulder
    B. Massive calcifi cation of the shoulder
    C. Osteoarthritis of the humerus
    D. Bicipital tendonitis
    E. Calcifi c tendonitis
A
  1. Answer: E
    Explanation:
    Calcifi c tendonitis of the anterior cuff is a common
    disorder that demonstrates a cyclic nature of calcium
    deposition and eventual absorption as the tendons heal.
    Source: Saidoff DC, McDonough AL. Critical Pathways in
    Therapeutic Intervention. Extremities and Spine.St. Louis,
159
Q
604. Pain referred to the right side of the neck and extending laterally from the right clavicle to the tip of the right shoulder is most likely to involve the
A. Cervical cardiac accelerator nerves
B. Posterior vegal trunk
C. Right intercostal nerves
D. Right phrenic nerve
E. Right recurrent laryngeal nerve
A
  1. Answer: D
    Explanation:
    (April, 3/e, p 260.) The phrenic nerve, which arises from
    cervical nerves C3 through C5, mediates sensation from
    the diaphragmatic pleura and peritoneum, as well as from
    the pericardium; in addition, it carries motor fi bers to the
    diaphragm. Therefore, pain from the diaphragmatic pleura
    or peritoneum, as well as from the parietal pericardium,
    may be referred to dermatomes between C3 and C5,
    inclusive. These dermatomes correspond to the clavicular
    region and the anterior and lateral neck, as well as to the
    anterior, lateral, and posterior aspects of the shoulder.
    Source: Klein RM and McKenzie JC 2002.
160
Q
605. Waddell’s Signs are used to help identify
A. Depressive disorder
B. Non-physiologic signs
C. Munchausen’s syndrome
D. Factitious disorder
E. Somatoform disorder
A
  1. Answer: B

Source: Boswell MV, Board Review 2005

161
Q
606.The most common cause of spinal cord-related central
pain is
A. Trauma
B. Neoplasms
C. Vascular lesions
D. Surgical injury
E. Inflammatory lesions
A
  1. Answer: A

Source: Boswell MV, Board Review 2005

162
Q
607.Which of the following plays a limited role in the management of cancer pain?
A. Nalbuphine
B. Choline magnesium trisalicylate
C. Hydromorphone
D. Amitriptyline
E. Methylprednisolone
A
  1. Answer: A
    Explanation:
    The World Health Organization recommends a 3 step
    ladder for cancer pain management:
    Step 1: Non-opioid analgesics (Aspirin, NSAIDS,
    acetaminophen) +/-Adjuvants (medications used in pain
    management whose primary indication is for another
    disorder)
    Step 2: Weak opioids analgesics (Codeine, Hydrocodone,
    Oxycodone) +/-Non-opioid analgesics Adjuvants
    Step 3: ‘Strong’ opioids analgesics (Morphine,
    Hydromorphone, Oxycodone, Fentanyl patch) +/-
    A. Nalbuphine is a mixed opioids agonist and antagonist
    that has a limited role in cancer pain for two reasons:
    ceiling analgesic effect and possible induction of opioids
    withdrawal in opioids tolerant patients.
    B. Choline magnesium trisalicylate is a non-acetylated
    salicylate that has a minimal effect on platelet function and
    lower rates of GI upset compared to acetylated salicylates
    C. Hydromorphone is a strong opioid agonist.
    D. Amitriptyline is a tricyclic antidepressant and adjuvant
    analgesic that has effi cacy in several neuropathic pain
    syndromes.
    E. Methylprednisolone is an adjuvant that may improve
    mood and appetite, but also alleviate pain due to neural
    compression or bony infi ltration
    Source: Shah RV, Board Review 2005
163
Q
  1. After biopsy resection of a lymph node in her neck, a
    23-year-old woman notices instability of her shoulder.
    Neurologic examination reveals winging of the scapula
    on the side of the surgery. During surgery, she probably
    suffered damage to the
    A. Deltoid muscle
    B. Long thoracic nerve
    C. Serratus anterior muscle
    D. Suprascapular nerve
    E. Axillary nerve
A
  1. Answer: B
    Explanation:
    Winging of the scapula most often occurs with weakness
    of the serratus anterior muscle.
    This is innervated by the long thoracic nerve, whose
    course starts high enough and runs superfi cially enough to
    allow injury to the nerve with deep dissection into the root
    of the neck. The long thoracic nerve is derived from C5,
    C6, and C7.
    Winging is elicited by having the patient push against a
    wall with the hands at shoulder level. With this maneuver,
    the scapula with the weak serratus anterior will be pulled
    away from the back and vertical margin of the scapula will
    stick out from the back.
    Injuries to the long thoracic nerve are usually unilateral
    and are often due to trauma or surgical manipulation.
    Source: Anschel 2004
164
Q
  1. A 45-year-old swimmer presents with a sore right
    shoulder for nearl 12 months. He was taking nonsteroidal
    anti-infl ammatory agents throughout this period with
    minimal relief. Over the last several days, he has developed
    pain with elevation of his arm above the horizontal and
    has some loss of passive motion in external rotation and
    with abduction. The pain is relieved after you inject 2 mL
    of lidocaine into the subacromial space. Which of the
    following is the most likely diagnosis?
    A. Fracture of the surgical neck of the humerus
    B. Bicipital tendinitis due to snapping
    C. Cervical radiculopathy due to a herniated disk
    D. Calcifi c tendinitis
    E. Frozen shoulder due to a rotator cuff injury
A
  1. Answer: E
    Explanation:
    A. Fracture of the surgical head of the humerus is usually
    seen in the elderly after a fall.
    Swelling and ecchymosis are visible.
    B. Bicipital tendinitis may be seen with overuse and
    trauma, but pain is typically felt over the anterior aspect of
    the shoulder and palpation of the biceps tendon in the
    bicipital groove elicits tenderness.
    Pain produced on supination of the forearm against
    resistance (Yergason sign) confi rms bicipital tendinitis.
    Lidocaine injection into the synovial sheath of the long
    head of the biceps relieves pain.
    C. Cervical radiculopathy typically results in decreased
    sensation, strength, and refl exes all matching to one root
    level of the upper extremity.
    D. Calcifi c tendinitis is due to calcium deposits in the
    subacromial region and is especially common in the
    supraspinatus tendon near its insertion.
    E. Passive range of motion (ROM) tests are performed by
    the examiner, while active ROM tests are performed by the
    patient. Passive ROM tests need not be done if active ROM
    tests are performed adequately. The loss of passive range of
    motion indicates a stiffening shoulder (frozen shoulder or
    adhesive capsulitis).
    The most likely etiology in this patient would be
    impingement of the rotator cuff causing infl ammation,
    degeneration, and possibly a tear.
    The rotator cuff, which is formed by the SITS tendons of
    the Supraspinatus, Infraspinatus, Teres minor, and
    Subscapularis muscles, stabilizes the glenohumeral joint
    and prevents upward movement of the head of the
    humerus.
    Injuries may occur from overhead activities including
    freestyle and butterfl y-style swimming
    The drop arm sign may be positive in rotator cuff tear
    (abduct the arm to 180° and ask patient to bring it down
    slowly; at 90° the arm will drop quickly due to weakness).
    An injection of lidocaine often relieves the infl ammation
    inthe subacromial space in patients with rotator cuff
    tendinitis and alleviates the symptoms.
    Source: Goldman
165
Q
  1. Retrograde release of Substance-P contributes most to
    which of the following phenomena:
  2. Co-morbidity of pain and depression
  3. Reduction in local concentration of cytokine(s)
  4. Nociceptive pain
  5. Neurogenic infl ammation
A
  1. Answer: D (4 Only)

Source: Giordano J, Board Review 2003

166
Q
  1. Diabetic neuropathy:
  2. can cause diffuse, generalized, or symmetrical polyneuropathies
  3. can involve sensory, motor, or autonomic nerves
  4. can cause focal neuropathesies
  5. can involve cranial nerves
A
  1. Answer: E (All)
    Explanation:
    Diabetes can cause all of these
    Source: Trescot AM, Board Review 2004 for Shah
167
Q
  1. Which of the following statements best describes Factitious Disorders?
  2. There is no deliberate production or feigning of physical
    or psychological signs or symptoms
  3. External incentives for the behavior are clearly present
  4. It is the new term used to describe “malingering.”
  5. Motivation for the behavior is the desire to assume
    sick role
A
  1. Answer: D (4 Only)

Source: Cole EB, Board Review 2003

168
Q
  1. Which of the following statements are true about the
    evaluation of patients with chronic pain regarding their
    potential for suicide?
  2. It is safer to not directly confront patients about their
    suicidal ideation because doing so may suggest to
    them that suicide is a viable option.
  3. Co-existing depression increases the relative risk.
  4. Participation in an established religious denomination
    may increase the risk.
  5. Work is protective so that unemployment raises the
    risk.
A
  1. Answer: C (2 & 4)

Source: Cole EB, Board Review 2003

169
Q
  1. True statements regarding plexopathies include:
  2. Complaints of exquisite burning pain and intense allodynia
    in the distribution of the nerve plexus
  3. Treatment can include spinal cord or peripheral nerve
    stimulation
  4. Symptoms can occur days to weeks after the injury
  5. Frequently caused by tumor infi ltration and radiation
    injury in cancer patients.
A
  1. Answer: E (All)
    Explanation:
    Ref: 1) Cherry and Portenoy. Chapter 45. Cancer Pain:
    principles of Assessment and syndromes. In: Textbook of
    Pain, 4th Edition. Wall & Melzack, Churchill Livingston,
    1999, page 1042. Rauck. Chapter 6. Trauma. In: Pain
    Medicine: A Comprehensive Review, 2nd Edition, Raj,
    Mosby, 2003, page 36.
    Source: Day MR, Board Review 2003
170
Q
  1. Burn injury reveals each of the following in initial stages
    of assessment:
  2. Obvious traumatic exposure of burn injury
  3. Increase in metabolic activity
  4. Wound involvement refl ecting suspected underlying
    tissue destruction
  5. Potentially massive fl uid loss at the site of burn
A
  1. Answer: C (2 & 4)

Source: Hansen HC, Board Review 2005 for Shah

171
Q
  1. Which of the following is most correct about the
    distinction between delirium and dementia?
  2. Both are caused by underlying acute and generally
    reversible medical conditions.
  3. Dementia has less frequent and vivid hallucinations
    than delirium.
  4. Both produce signifi cant agitation and require the ongoing
    administration of antipsychotic medications.
  5. While dementia has no clear onset, delirium has a very
    specific onset.
A
  1. Answer: C (2 & 4)

Source: Cole EB, Board Review 2003

172
Q
  1. Electrical burns are characteristically:
  2. Determined by severity, voltage, amperage, and duration
    of electrical contact
  3. Resistance of current is an important determinant of
    the extent of contact wound
  4. Contact wound may be deceptively benign and not
    reveal signifi cant underlying tissue damage
  5. Requires both superfi cial and deep debridement
A
  1. Answer: A (1,2, & 3)

Source: Hansen HC, Board Review 2005 for Shah

173
Q
  1. Characteristics of entrapment syndromes include:
  2. Pain worse at night
  3. Unrelenting pain
  4. Local pain at the area of nerve entrapment
  5. Muscles distal to the entrapment are always painful
A
  1. Answer: B (1 & 3)
    Explanation:
    Ref: Sola, Chapter 24. Upper extremity pain. In: Textbook
    of Pain, 4th Edition Wall & Melzack, Churchill
    Livingston, 1999, page 571-572.
    Source: Day MR, Board Review 2003
174
Q
  1. Epidural catheters are considered a poor choice for
    control of burn pain involving the posterior thorax and
    lumbar region as a result of:
  2. Poor landmarks and diffi culty of access to proper
    placement of catheter
  3. Potential for wound infection and seeding the epidural
    space of contaminant
  4. Diffi culties with anchoring, and placement of catheter
    for prolonged infusion
  5. Increased local sensitivity to anesthetics
A
  1. Answer: A (1,2, & 3)

Source: Hansen HC, Board Review 2005 for Shah

175
Q
  1. True statements regarding Superior Mesenteric Artery
    Syndroms is/are:
  2. Recurrent, acute attacks of diffuse, colicky abdominal
    pain
  3. Tense and distended abdomen
  4. Can be treated with balloon angioplasty
  5. Does not usually require surgery.
A
  1. Answer: A (1, 2, & 3 )
    Explanation:
    Ref: Raj. Chapter 43. Thoracoabdominal Pain. In:
    Practical Management of Pain. 3rd Edition, Raj et al,
    Mosby, 2000, page 626.
    Source: Day MR, Board Review 2003
176
Q
  1. Neuropathic pain:
  2. can be caused by axonal degeneration
  3. can be sympathetically mediated
  4. can be caused by strokes
  5. can be caused by spinal cord injuries
A
  1. Answer: E (All)
    Explanation:
    All of the above are true statements
    Source: Trescot AM, Board Review 2004 for Shah
177
Q
622. Which of the following patients are at increased risk for
developing a spinal epidural abscess?
1. Immuno compromised
2. Alcoholic
3. Diabetic
4. Intravenous drug users
A
  1. Answer: E (All)
    Explanation:
    Spinal epidural abscesses must be quickly recognized and
    effectively treated due to its rapid course. S. Aureus is the
    most common organism. Mass effect or thrombotic
    ischemia is the typical mechanism of action. The above are
    risk factors for developing this condition.
    Source: Shah RV: 2003(Bonica, 3rd Ed., page 1014)
178
Q
  1. True statements in reference to spondylolysis and
    spondylolisthesis include:
  2. Incidence in school-aged children in 4%, increasing to
    6% by adulthood
  3. Pars defects have been found in 20% of asymptomatic
    adults
  4. Increased incidence of isthemic spondylosis is associated
    with certain sports including diving, gymnastics,
    wrestling, and weight lifting
  5. Degenerative spondylolisthesis is most common at
    L3/4 and more common in men
A
  1. Answer: B (1 & 3)
    Explanation:
  2. Incidence in school-aged children in 4%, increasing to
    6% by adulthood
  3. Pars defects have been found in approximately 7% of
    asymptomatic adults.
    - Pars defects are twice as common in young males but
    high grade slips are 4 times more common in the girls.
  4. Increased incidence of isthemic spondylosis is
    associated with certain sports including diving,
    gymnastics, wrestling, and weight lifting
  5. Degenerative spondylolisthesis is most common at L4/5
    and more common in women
    History:
    - Chronic, dull, aching, or cramping low back pain
    - Often located along the belt line
    - Exacerbated by rotation and/or hyperextension
    - Underlying history of chronic repetitive motions
    Physical examination
    - Pain with extension
    - Symptoms can be attenuated by having the patient stand
    on one leg and bend backward
    - Paraspinal muscle spasm
    - Tight hamstrings
    - Loss of lumbar lordosis
    Source: Cole & Herring. Low Back Pain Handbook.
179
Q
  1. Mittelschmerz syndrome is usually:
  2. Dull aching pain
  3. At mid-cycle
  4. Lasting from minutes to hours
  5. Felt in both lower quadrants
A
  1. Answer: A (1, 2, & 3)

Source: Nader and Candido – Pain Practice. June 2001

180
Q
  1. The activities exacerbating pain the most in an elderly
    patient with severe spinal stenosis include:
  2. Walking uphill
  3. Riding a bicycle
  4. Bending forward
  5. Walking downhill
A
  1. Answer: D (4 Only)
    Explanation:
    Pain from spinal stenosis is caused by narrowing of the
    spinal canal due to degenerative changes in the joints and
    discs. This often results in multidermatomal leg pain in
    one or both legs, buttocks, and low back. Movements that open the spinal canal, such as leaning forward (walking
    uphill, riding a bicycle), will often decrease the pain.
    Movements that decrease the size of the spinal canal, such
    as walking downhill, will increase the pain.
    Source: Kahn CH, DeSio JM. PreTest Self Assessment and
    Review. Pain Management. New York, McGraw-Hill, Inc.,
    1996.
181
Q
  1. True statements regarding glossopharyngeal neuralgia
    include:
  2. It is more common in adults than children
  3. Attacks can be associated with cardiac arrest
  4. It is most often described as aching and burning between
    attacks
  5. It is found to occur more frequently in patients with
    tic douloureux
A
  1. Answer: A (1, 2, & 3)
    Explanation:
  2. Glossopharyngeal neuralgia is characterized by
    paroxysms of lancinating pain in the tonsillar region, base
    of the tongue, ear and ipsilateral face, neck, or scalp.
    Patients are almost always older than 20.
  3. Other symptoms that may occur during attacks are
    cardiac arrhythmias (including arrest), hiccups, seizures,
    coughing, stridor, and excessive salivation.
  4. Attacks may last minutes or seconds and rarely occur at
    night. The etiology is unknown. Attacks can be triggered
    by swallowing or by touching the ear, face, or neck.
    Patients may complain of a constant burning or dull ache
    between attacks of lancinating pain.
  5. There is no association between the incidence of tic
    douloureux and glossopharyngeal neuralgia (Wall, p 713).
182
Q
  1. True statements about painful polyneuropathies caused
    by selective small fi bre loss include the following:
  2. Diabetes
  3. Amyloid neuropathy
  4. Hereditary sensory neuropathy
  5. Chronic renal failure
A
  1. Answer: A (1, 2, & 3)
    Explanation:
    Small myelinated and unmyelinated fi bre loss is found in
    diabetic neuropathy, Fabry’s disease, amyloid neuropathy,
    and hereditary sensory neuropathy.
    Patients with these disorders may complain of a burning,
    aching, lancinating pain.
    Chronic renal failure is associated with large myelinated
    fi bre loss, which is rarely painful.
183
Q
  1. A young man presents with morning back pain and
    stiffness and tenderess over the sacroiliac joints.
    The patient denies any previous history of eye or
    genitourinary problems. On physical examination, there
    is a diastolic rumbling murmur. The most likely diagnosis
    in this patient is:
  2. Rheumatoid arthritis
  3. Sjogren syndrome
  4. Reiter syndrome
  5. Ankylosing spondylitis
A
  1. Answer: D (4 Only)
    Explanation:
    (Tierney, 42/e, pp 825-826.) Ankylosing spondylitis
    (Marie-Strumpell arthritis) is a chronic and progressive,
    infl ammatory disease that most commonly affects the
    spinal, sacroiliac, and hip joints. All patients have
    symptomatic sacroiliitis. Other symptoms ml, include
    uveitis and aortitis.Men in the third decade of life are most
    frequently affected, and there is a strong association with
    HLA-B27 (900 in white patients. Patients with advanced
    disease present with a bent over posture. A positive
    Schober test indicates diminished anterior fl exion of the
    lumbar spine. Involvement of the costoveretebral joints
    limits chest expansion and eye involvement may cause an
    iritis. Patients with Reiter syndrome may present with a
    history of conjunctivitis, urethritis, arthritis, and
    enthesopathy (Achilles tendinitis). Aortitis in ankylosing spondylitis may cause aortic
    insuffi ciency. The AI manifests itself early in the course of
    the spinal disease and may lead to congestive heart failure.
184
Q
  1. Characteristic features of peripheral neuropathies
    include:
  2. Paresthesias and dysesthesias
  3. Sensory loss
  4. Loss or diminution of tendon refl exes
  5. Pain
A
  1. Answer: A (1, 2, & 3)
    Explanation:
    1, 2, 3. Peripheral neuropathies, regardless of their cause,
    have several characteristic signs and symptoms:
    paresthesias and dysesthesias, sensory loss, loss or
    diminution of tendon refl exes, and impaired motor
    function.
  2. Not all peripheral neuropathies are painful, and when
    pain is associated with a peripheral neuropathy, it usually
    is not a distinguishing feature of the neuropathy (Wall, pp
    991-995)
    Source: Kahn CH, DeSio JM. PreTest Self Assessment and
    Review. Pain Management. New York, McGraw-Hill, Inc.,
    1996.
185
Q
630. The following mechanical factors are related to an
impingement event at the shoulder
1. Acromion length
2. Acromion orientation
3. Os Acromiale
4. Acromian softness
A
  1. Answer: A (1, 2, & 3)

Source: Sizer et al - Pain Practice - March & June 2004

186
Q
  1. All of the following structures are essential to posterior
    glenohumeral joint stability
  2. Anterior angulation of the glenoid fossa
  3. Anterior-inferior glenohumeral ligament complex
  4. Integrity of the glenoid labrum
  5. Posterior glenohumeral capsule
A
  1. Answer: A (1, 2, & 3)

Source: Sizer Et Al - Pain Practice March & June 2003

187
Q
632. Identify all the items packaged under the Medicare
outpatient prospective payment system
1. recovery room
2. supplies
3. anesthesia
4. medical visits
A
  1. Answer: A (1, 2, & 3)
188
Q
  1. Cause(s) of continued low back pain in post lumbar laminectomy syndrome include:
  2. epidural fi brosis
  3. recurrent disc herniation
  4. spinal instability
  5. facet joint arthropathy
A
  1. Answer: E (All)
189
Q
634. The following conditions typically produces localized
symptoms
1. Subacromiodeltoid bursitis
2. Glenohumeral arthritis
3. Sternoclavicular synovitis
4. Acromioclavicular instability
A
  1. Answer: D (4 Only)

Source: Sizer Et Al - Pain Practice March & June 2003

190
Q
  1. The true statements regarding pain and spinal cord
    lesions are
  2. only incomplete spinal cord lesions can cause pain
  3. traumatic spinal cord lesions are the most common
    cause of central pain of spinal cord origin
  4. the development of central pain after a spinal cord lesion
    depends on cord level
  5. pain is usually produced in an area of somatosensory
    loss
A
  1. Answer: C (2 & 4)
    Explanation:
  2. Central pain of spinal cord origin most commonly
    occurs after traumatic spinal cord lesions.
  3. Spinal cord lesions of any cause commonly result in
    central pain.
  4. The pain usually occurs in an area of spinothalamic
    somatosensory loss. Central pain may also occur with
    lesions that fail to produce clinically detectable
    somatosensory loss.
  5. Both complete and incomplete lesions, regardless of
    cord level, can cause central pain.
    Source: Kahn and Desio
191
Q
636. Which of the following medications is/are FDA approved
for use in intrathecal pumps?
1. Hydromorphone
2. Baclofen
3. Clonidine
4. Morphine
A
  1. Answer: C (2 & 4)

Source: Day MR, Board Review 2004

192
Q
  1. A 55 year old woman comes into the ER with a sudden
    onset of “the worst headache of my life”. She has a history
    of migraines but this feels “different”. Diagnostic studies
    should include:
  2. CT scan
  3. CBC and sed rate
  4. Lumbar puncture
  5. EEG
A
  1. Answer: B (1 & 3)
    Explanation:
    For a possible subarachnoid bleed, a CT followed by an LP
    would be appropriate. CBC and sed rate might be appropriate for temporal arteritis, and EEG for epilepsy
    related migraines.
    Source: Trescot AM, Board Review 2004
193
Q

638.True statements regarding Eagle’s syndrome include
which of the following:
1. Pain occurs during mandibular movement or twisting
of the neck
2. Pain never occurs spontaneously with the mouth
closed
3. The pain is stabbing in nature
4. Trigger points are present

A
  1. Answer: A (1, 2, & 3)
    Explanation:
    Eagle’s syndrome, also known as stylohyoid syndrome, is
    caused by dystrophic calcifi cation of the stylohyoid
    ligament. Treatment consists of surgical excision of the
    stylohyoid ligament and the elongated styloid or cervical
    process, if present.
  2. Pain occurs during mandibular movement or with
    twisting of the neck.
  3. Pain is absent when the mouth is closed.
  4. The pain is stabbing, with radiation from the tonsil area
    to the temporomandibular joint and base of the tongue.
  5. There are no trigger points
    Source: Kahn CH, DeSio JM. PreTest Self Assessment and
    Review. Pain Management. New York, McGraw-Hill, Inc.,
    1996.
194
Q
639. The glenohumeral joint capsule is reinforced by the
tendons of all the following muscles
1. Infraspinatus
2. Subscapularis
3. Supraspinatus
4. Teres Major
A
  1. Answer: A (1, 2, & 3)

Source: Sizer Et Al - Pain Practice March & June 2003

195
Q
  1. During an occipital nerve block, suddenly, the patient
    complains of lightheadedness and states “I don’t feel
    good”. The differential diagnosis must include:
  2. subarachnoid injection
  3. vertebral artery injection
  4. anaphylactic reaction
  5. Raynaud’s phenomena
A
  1. Answer: A ( 1, 2, & 3)
    Explanation:
    1 & 2. Injections into the foramen magnum or the
    vertebral artery are very real and potential complications.
    3.Depending on the medications, anaphylactic reactions to
    the injectate (e.g. PABA allergies with multi-dose
    medications) may occur.
  2. Raynaud’s phenomena would not be related to the
    injection.
    Source: Trescot AM, Board Review 2004
196
Q
  1. Tension type headaches :
  2. are usually bilateral
  3. are not usually associated with nausea and vomiting
  4. may become chronic
  5. are described as sharp and stabbing
A
  1. Answer: A ( 1, 2, & 3)
    Explanation:
    Tension headaches are usually described as dull, bilateral
    headaches associated with photophobia and phonophobia
    but not nausea. They may become chronic, and they are
    often associated with analgesia rebound.
    Source: Trescot AM, Board Review 2004
197
Q
  1. The ligament systems is most responsible for stabilizing
    the acromioclavicular joint in the frontal plane (ie…in
    the cranial-caudal direction) is:
  2. Acromioclavicular ligaments
  3. Coracoacromial ligament
  4. Coracohumeral ligaments
  5. Coracoclavicular ligaments
A
  1. Answer: D (4 Only)

Source: Sizer Et Al - Pain Practice March & June 2003

198
Q
  1. Discontinuation of tramadol can result in
  2. seizures
  3. tardive dyskinesia
  4. ventricular tachycardia
  5. cholinergic activity
A
  1. Answer: D (4 Only)
199
Q

644.True statements with regards to lateral epicondylitis
(tennis elbow) include:
1. Peak incidence is the fourth decade of life.
2. Characterized by pain in the lateral aspect of the elbow.
3. Physical exam reveals point tenderness of the lateral
epicondyle.
4. Usually fails to respond to conservative treatment

A
  1. Answer: A (1, 2, & 3 )
    Explanation:
    Ref: Sisto. Chapter 21. Sports injuries. In: Manual of
    Rheumatology and Outpatient Orthopedic Disorders, 2nd Edition. Beary: Little, Brown and Company, 1990, page
    121-122.
    Source: Day MR, Board Review 2003
200
Q
  1. A patient presents with acute low back pain with radiation
    into lower extremity with weakness of extensor digitorum
    longus, and numbness on dorsum of the foot. Refl exes
    were normal. The most likely diagnosis is:
  2. L4/5 disc herniation
  3. L3/4 disc herniation
  4. L5 nerve root involvement
  5. S1 nerve root involvement
A
  1. Answer: B (1 & 3)
    Explanation:
    L4/5 disc herniation with L5 nerve root involvement
    causes weakness of extensor hallucis longus, with
    numbness on the lateral leg and dorsum of foot. However,
    L5 has no refl exes
    Source: Hoppenfeld S. Orthopaedic Neurology. A
    Diagnostic Guide to Neurologic Levels. Philadelphia,
    LWW, 1997.
201
Q
  1. A C4/5 disc herniation with neurological involvement
    of C5 will have the following features on physical
    examination:
  2. Loss of sensation on the lateral arm
  3. Refl ex suppression of biceps
  4. Weakness of shoulder abduction
  5. Weakness of wrist extension
A
  1. Answer: A (1, 2, & 3)
    Source: Hoppenfeld S. Orthopaedic Neurology. A
    Diagnostic Guide to Neurologic Levels. Philadelphia,
    LWW, 1997.
202
Q

647.True statements with regards to spondylolysis and
spondylolisthesis include the following:
1. Classifi cation includes dysplastic, isthemic, degenerative,
traumatic, pathological, and post surgical.
2. Isthemic is due to a lesion in pars interarticularis usually
present in the fi rst years of school with subtype
A and B
3. Degenerative are due to long-standing segmental instability
with remodeling of articular processes at the affected
level and degeneration of supporting structures
leading to loss of lumbosacral locking mechanisms
4. Pathological is due to localized or generalized bone
disease.

A
  1. Answer: E (All)

Source: Cole & Herring. Low Back Pain Handbook.

203
Q
  1. True statements about differences and similarities of
    Basilar migraine and classic migraine are as follows:
  2. Sex of the persons most often affected
  3. Resistance of the visual system to involvement
  4. Severity of symptoms
  5. Duration of the aura and the sequence of neurologic
    defi cits and headache
A
  1. Answer: D (4 Only)
    Explanation:
  2. As with classic migraine, with basilar migraine women
    are more susceptible than men.
  3. Disturbances of vision are common, the aura usually
    resolve within 10 to 30 min, and the headache invariably
    follows, rather than precedes, the neurologic defi cits.
  4. The visual change may evolve to complete blindness.
  5. The character and severity of neurologic defl ects
    associated with basilar migraine are distinct. Irritability
    may develop into frank psychosis. Rather than a mild
    hemiparesis, the patient may have a transient quadriplegia.
    Stupor, syncope, and even coma may appear and persist
    for hours.
    Source: Anschel 2004
204
Q
  1. A young female in her early 20’s presents with history of facial pain for one week on right side. She describes it as
    an intense shooting pain that comes and goes. Most likely
    underlying problem of this patient is:
  2. Tolosa-Hunt syndrome
  3. Migraine
  4. Anterior communicating artery aneurysm
  5. Multiple sclerosis
A
  1. Answer: D (4 Only)
    Explanation:
  2. The Tolosa-Hunt syndrome is a presumably
    infl ammatory disorder that produces ophthalmoplegia
    associated with headache and loss of sensation over the
    forehead.
    - Papillary function is usually spared, and the site of
    pathology is believed to be in the superior orbital fi ssure
    or the cavernous sinus.
    - It is usually not associated with trigeminal neuralgia.
  3. Migraine has typical pattern of headaches with or
    without aura.
  4. Anterior communicating artery aneurysm produces
    symptoms inconsistent with this description.
  5. Multiple sclerosis is often associated with trigeminal
    neuralgia, which is then termed symptomatic trigeminal
    neuralgia because it occurs ass a symptom of another
    illness. Other causes of symptomatic trigeminal neuralgia
    include basilar artery aneurysms, acoustic schwannomas,
    and posterior fossa meningiomas, all of which may cause
    injury to the fi fth cranial nerve by compression.
    Source: Anschel 2004
205
Q
  1. The scapulothoracic instability when exhibited during
    the eccentric and or concentric phases of upper extremity
    elevation is indicated with
  2. Scapular downward rotation
  3. Scapular tipping
  4. Scapular winging
  5. Scapular upward rotation
A
  1. Answer: A (1, 2, & 3)

Source: Sizer Et Al - Pain Practice March & June 2003

206
Q
  1. A 35-year-old man injured his thoracic spine in a motor
    vehicle accident 2 years ago. Initially he had a bilateral
    spastic paraparesis and urinary urgency, but this has
    improved. He still has pain and thermal sensation loss on
    part of his left body and proprioception loss in his right
    foot. There is still a paralysis of the right lower extremity
    as well. True Statements about his status include:
  2. This patient has Brown Sequard (hemisection) syndrome.
  3. In this patient, the pain and temperature abnormalities
    start at one or two segments below the lesion.
  4. The posterior column neurons decussate at the medulla.
  5. The lateral corticospinal tract decussates at the junction
    of the midbrain and the medulla
A
  1. Answer: A (1, 2, & 3)
    Explanation:
  2. Hemisection of the spinal cord results in a contralateral
    loss of the pain and thermal sensation due to
    spinothalamic damage, and ipsilateral loss of
    proprioception due to posterior column damage. There
    is also an ipsilateral motor paralysis due to destruction
    of the corticospinal and rubrospinaltracts as well as motor
    neurons.
    Complete transection of the spinal cord would cause a
    bilateral spastic paralysis, and there would be no conscious
    appreciation of any cutaneous or deep sensation in the
    area below the transection.
    Posterior column syndrome would result in a bilateral
    loss of proprioception below the lesion, with relative
    preservation of pain and temperature sensation.
    Syringomyelic syndrome results from a lesion of the
    central gray matter. Pain and temperature fi bers that cross
    at the anterior commissure are affected, which may result
    in bilateral loss of these sensations over several
    dermatomes. However, tactile sensation is spared. The
    most common cause of this type of syndrome is
    syringomyelia. Trauma, hemorrhage, or tumors are other
    possible etiologies. If the lesion becomes large enough,
    then other spinal cord systems affected as well.
    Tabetic syndrome results from damage to proprioceptive
    and other dorsal root fi bers. It is classically caused by
    syphilis. Symptoms include paresthesias, pain, and
    abnormalities of gait. Vibration sense is most affected.
  3. The spinothalamic system is responsible for pain and
    temperature sensation.It enters the spinal cord through
    the dorsal root ganglion. The second-order neurons then
    ascend one or two levels as they cross in the anterior gray
    commissure. Thus a lesion of the right spinothalamic tract
    at the T8 spinal cord level would result in a contralateral
    loss of pain and temperature on the left body beginning at
    approximately T9-10 dermatome.
  4. After the primary sensory fi ber enters the spinal cord,
    the ascending branch enters the dorsal columns and travels
    to the medulla. The fi bers from the legs and trunk level
    medially in the fasciculus gracilis, while those from the
    arm and neck travel laterally in the fasciculus cuneatus.
    These fi rst-order neurons synapse in the medulla, and then
    the second-order neurons decussate as the internal arcuate
    fi bers and ascend in the medial lemniscus. The secondorder
    fi bers synapse in the ventroposterolateral nucleus of
    the thalamus, which then synapses on the somatosensory
    cortex.
  5. The lateral corticospinal tract originates primarily in
    the precentral gyrus (primary motor cortex). These axons
    then travel in the posterior limb of the internal capsule,
    and then the middle section of the cerebral peduncle. They
    enter the basal pons and continue as the pyramids in the
    medulla. At the decussation of the pyramids, the lateral
    corticospinal tract crosses and then continues down the
    spinal cord.
    Source: Anschel 2004
207
Q
  1. Bone pain may be characterized by which of the following
    descriptions?
  2. It can originate from the cortex and marrow
  3. It is transmitted by A-delta and C fi bers
  4. It has the highest pain threshold of the deep somatic
    structures
  5. It primarily arises from cancellous bone
A
  1. Answer: C (2 & 4)
    Explanation:
  2. The cortex and marrow do not receive nociceptive
    fi bers.
  3. Bone is innervated by A-delta and C fi bers that form a
    plexus around the periosteum and invest the cancellous
    bone.
  4. Bone is said to have the lowest pain threshold of the
    deep somatic structures.
  5. Bone is innervated by A-delta and C fi bers that form a
    plexus around the periosteum and invest the cancellous
    bone.
    Source: Kahn and Desio
208
Q
653. Which of the following structures may be involved in
postmastectomy syndrome?
1. Chest
2. Shoulder
3. Axilla
4. Arm
A
  1. Answer: E (All)
    Explanation:
  2. Chest is involved in postmastectomy syndrome.
  3. Shoulder is involved in postmastectomy syndrome.
  4. Axilla is involved in postmastectomy syndrome.
  5. Arm is involved in postmastectomy syndrome.
    Pain following mastectomy can arise after lumpectomy or
    more extensive procedures. Axillary node dissection
    increases the risk.
    - Onset occurs from 2 weeks to 6 months and the
    incidence is 5 to 20%.
    - The most often cited cause is damage to the
    intercostobrachial nerve, which is a branch of the 2nd
    intercostal nerve, with frequent contribution from the 3rd intercostal nerve.
    - Postoperative complications such as infection increase
    the incidence.
    Source: Bonica’s Management of Pain, 3rd edition, page
    1216.
209
Q
  1. Which of the following can be associated with a neuropathic pain syndrome?
  2. Diabetes
  3. Mercury poisoning
  4. Causalgia
  5. Guillain-Barré syndrome
A
  1. Answer: E (All)
    Explanation:
    Certain alterations of neurologic structure and function
    may result in pain. Metabolic changes of diabetes or
    mercury poisoning may produce a painful peripheral
    neuropathy. Viral dA mange (herpes zoster, late
    poliomyelitis, and Guillain-Barré syndrome) may also
    produce painful states. Trauma to peripheral nerves can
    lead to neuropathic pain from neuromas, causalgia, or
    phantom pain
210
Q
  1. True statements about trigeminal neuralgia and atypical
    facial pain include the following:
  2. Lancinating and Paroxysmal
  3. Associated with anesthetic patches
  4. The gasserian ganglion block relieves pain
  5. Unilateral
A
  1. Answer: D (4 Only)
    Explanation:
  2. Patients with trigeminal neuralgia, complain of
    paroxysmal, lancinating pains.
    - However, patients with atypical facial pain usually
    complain of a constant, deep pain.
  3. Progressive loss of sensation in the distribution of the
    fi fth cranial nerve is seen with trigeminal neuralgia.
  4. Gasserian ganglion block is treatment for trigeminal
    neuralgia.
  5. Atypical facial pain is often bilateral, but it may be
    unilateral and fairly limited in its distribution.
    - The cheek, nose, or zygomatic regions are often affected
    by this idiopathic pain syndrome.
    Source: Anschel 2004
211
Q
  1. A 68-year-old man has had severe, constant burning, and
    aching in the right forehead and anterior scalp for six
    weeks after an episode of herpes zoster. True statements
    concerning this patient’s condition including:
  2. It is more common in elderly patients
  3. The neuralgia involves supraorbital branches of the
    ophthalmic division of the facial nerve
  4. Tricyclic antidepressants often provide effective pain
    relief
  5. Opioid analgesics or the fi rst-line treatment
A
  1. Answer: A (1, 2, & 3)
212
Q
  1. Which of the following may be evident in more severe
    cases of carpal tunnel syndrome?
  2. Numbness with hand in the fl exed position
  3. Increased conduction velocity across the wrist crease
  4. Fibrillation potentials in the abductor pollicis brevis
  5. Atrophy of the hypothenar muscles
A
  1. Answer: A (1,2, & 3)
    Explanation:
    Conduction velocity is decreased, and involvement of the
    hypothenar muscles does not occur (innervated by the
    ulnar nerve).
213
Q
  1. The coracohumeral ligament serves as a principle
    constraint to all of the following movements
  2. Glenohumeral external rotation
  3. Glenohumeral fl exion
  4. Glenohumeral inferior translation with the arm at the
    patient’s side
  5. Glenohumeral abduction
A
  1. Answer: A (1, 2, & 3)

Source: Sizer Et Al - Pain Practice March & June 2003

214
Q
  1. True statements regarding quality of life interference with
    CRPS include:
  2. Insomnia
  3. unable to work or keep sustained activity
  4. Depression
  5. Hypoglycemia
A
  1. Answer: A (1, 2, & 3)

Source: Racz G. Board Review 2003

215
Q
  1. All of the following structures serve as components of the rotator cuff interval
  2. Coracohumeral ligament
  3. Subscapularis tendon
  4. Superior glenohumeral ligament
  5. Infraspinatus tendon
A
  1. Answer: A (1, 2, & 3)

Source: Sizer Et Al - Pain Practice March & June 2003

216
Q
661. Which of the following is directly useful for assessing
pain levels in the chronic pain patient?
1. Visual analogue scale(s) (VAS)
2. Modifi ed McGill Pain Questionnaire
3. Physical examination
4. Beck’s Depression Inventory
A
  1. Answer: A (1, 2, & 3 )

Source: Giordano J, Board Review 2003

217
Q
  1. A patient presents with C7/T1 disc herniation. The expected findings are as follows:
  2. Weakness of fi nger fl exion
  3. Loss of sensation in lateral forearm and middle fi nger
  4. Loss of sensation in medial forearm, ring, and small
    fi nger
  5. Triceps refl ex suppression
A
  1. Answer: B (1 & 3)
    Source: Hoppenfeld S. Orthopaedic Neurology. A
    Diagnostic Guide to Neurologic Levels. Philadelphia,
    LWW, 1997.
218
Q
  1. A young ataxic woman with a family history of Friedreich’s
    disease develops polyuria and excessive thirst over the
    course of a few weeks. She notices that she becomes
    fatigued easily and has intermittent blurred vision. True
    statements about the condition
  2. The most likely explanation for her symptoms is Diabetes
    mellitus.
  3. The peripheral neuropathy that would be expected to
    be seen with this patient develops in part because of
    degeneration in Dorsal root ganglia.
  4. This patient’s condition has been consistently linked to
    a defect on Chromosome9.
  5. If this patient has children, at Juvenile period stage of
    life, they will be expected to become symptomatic if
    they inherited Friedreich’s ataxia.
A
  1. Answer: E (All)
    Explanation:
  2. More than 10% patients with Friedreich’s disease
    develop diabetes mellitus.
    - A more life-threatening complication of this
    degenerative disease is the disturbance of the cardiac
    conduction system that often develops.
    - Visual problems occur with the hyperglycemia
  3. The peripheral neuropathy that would be expected to be
    seen with this patient develops in part because of
    degeneration in Dorsal root ganglia.
  4. This patient’s condition has been consistently linked to a
    defect on Chromosome 9.
  5. If this patient has children, at Juvenile period stage of
    life, they will be expected to become symptomatic if they
    inherited Friedreich’s ataxia.
219
Q
  1. Endocrine and metabolic effects of burn injury include
    the following:
  2. Increased production of catecholamines
  3. Increased oxygen consumption and demand
  4. Decreased insulin levels
  5. Interleukin 2 depletion
A
  1. Answer: A (1, 2, & 3)

Source: Hansen HC, Board Review 2005 for Shah

220
Q
  1. Lumbosacral spondylosis is associated with which of the following?
  2. Facet arthritis
  3. Disc degeneration
  4. Ligamentous hypertrophy
  5. Vertebral ankylosis
A
  1. Answer: E (All)
    Explanation:
    Spondylosis may include all of these abnormalities
    Source: Boswell MV, Board Review 2005
221
Q
  1. Migraine headaches typically:
  2. affect males more than females
  3. can be diagnosed by MRI
  4. are always associated with auras
  5. affect as many as 40 million patients
A
  1. Answer: D (4 Only)
    Explanation:
    Migraine headaches primarily affect females, can not be
    diagnosed by MRI, and may not be associated with auras
    (“common migraine”)
    Source: Trescot AM, Board Review 2004
222
Q
  1. Diabetic peripheral neuropathy
  2. is one of the most common neuropathic pains
  3. affects the feet primarily
  4. is characterized by “die back”
  5. is sympathetically mediated
A
  1. Answer: E (All)
    Explanation:
  2. Diabetic peripheral neuropathy is the 2nd most
    common neuropathy in the US behind LBP.
  3. It primarily affects the feet and hands fi rst, and is not
    common as a primarily facial pain.
  4. It is commonly described as “die back” because of the
    progressive advance cephalad.
  5. Is sympathetically mediates.
    Source: Trescot AM, Board Review 2004 for Shah
223
Q
  1. In a patient with 5 lumbar vertebrae and without prior
    back surgery, which level(s) is/are most commonly
    affl icted with spondylolisthesis
  2. L4-5
  3. L2-3
  4. L5-S1
  5. T12-L1
A
  1. Answer: B (1 & 3)
    Explanation:
    L4-5 and L5-S1 are the most commonly involved levels in
    the general population. Multiple etiologies can cause this but ultimately there is incompetence of the posterior
    elements, ligaments, and disc.
    Source: Shah R: 2003(Bonica, 3rd Ed., page 1522)
224
Q
  1. When comparing hemophilia A to hemophilia B, which
    is true?
  2. Only hemophilia A occurs almost exclusively in males
  3. Hemophilia A is associated with low factor IX level
  4. Chronic hemophiliac arthropathy is only associated
    with A
  5. Desmopressin is useful in hemophilia A
A
  1. Answer: D (4 only)
    Explanation:
    Hemophilia A and B are X-linked (hence, affecting almost
    exclusively males), congenital bleeding disorders. Type A
    is associated with low factor VIII levels. Type B is
    associated with low or defi cient factor IX levels.
    Hemophiliacs can develop hemorrhages that develop
    hours or days after a trauma.Hemorrhage can occur in any
    organ, but commonly affl ict weight bearing joints, soft
    tissues, or muscles. Recurrent hemarthroses lead to
    chronic joint arthritis or ankylosis. This can occur in type
    A or B.
    Primary therapy consists of factor replacement.
    Desmopressin can be used in Hemophilia A. to boost
    factor VIII levels.
    Other pain therapy includes acetaminophen and opioids.
    Opioids should not be given subcutaneously or
    intramuscularly. Avoid NSAIDs due to their anti-platelet
    effects. Non-invasive strategies such as biofeedback and
    TENS should be explored.
    Source: Shah RV, Board Review 2005
225
Q
  1. Which of the following is not true about rheumatoid
    arthritis?
  2. Initial age of presentation is over 55
  3. First-line therapy involves the use of tumor necrosis
    factor-alpha inhibitors
  4. Elevated rheumatoid factor levels are required for
    diagnosis
  5. Rheumatoid arthritis is typically progressive and leads
    to worsening disability
A
  1. Answer: A (1,2, & 3)
    Explanation:
  2. Age of presentation varies from 30-50.
    - Most patients have a destructive, progressive, and
    disabling disease process.
  3. Treatment goals of RA include:
    - decrease infl ammation
    - joint preservation
    - preserve function
    - resolve the pathologic process
    Drug therapy includes:
    - First line: Salicylates and NSAIDs (reduce pain and
    swelling but do not interrupt the disease process)
    - Second-line: Immunosuppressive or
    immunomodulatory agents such as methotrexate,
    cyclophosphamide, azathioprine, and newer TNF-alpha
    inhibitors
    - Third-line: Surgery
  4. Diagnosis of RA requires 4 out of 7 of the following
    criteria (note that all are weighted equally):
    - Morning stiffness
    - 3 or more joints are affected
    - Hand joints are affected
    - Symmetric arthritis
    - Rheumatoid nodules
    - Serum rheumatoid factor
    - Radiographic changes
    4.In some cases RA may be intermittent and rarely, there is
    a remission.
    Source: Shah RV, Board Review 2005
226
Q
671. Which of the following are associated with multiple
sclerosis?
1. Trigeminal neuralgia
2. Peripheral neuropathy
3. Paroxysmal lancinating pain
4. Paresthesias with neck fl exion
A
  1. Answer: E (All)

Source: Boswell MV, Board Review 2005

227
Q
  1. Neuropathic pain treatment includes:
  2. antiepileptic drugs (AEDs)
  3. Opioids
  4. tricyclic antidepressants
  5. local anesthetics
A
  1. Answer: E (All)
    Explanation:
    All of the above are current treatments.
    Source: Trescot AM, Board Review 2004 for Shah
228
Q
  1. Which of the following would support the diagnosis of
    C5 nerve root compression?
  2. Pain in the neck, shoulder, and lateral aspect of the
    upper arm.
  3. Pain in the neck, shoulder, and dorsal aspect of the
    forearm.
  4. Weakness of the deltoid, supraspinatus, infraspinatus,
    biceps, and brachioradialis.
  5. Numbness of thumb and index fi nger.
A
  1. Answer: B (1 & 3)
    Explanation:
  2. C5 nerve root compression is associated with pain in
    the neck, shoulder, medial scapula, anterior chest, and
    lateral aspect of the upper arm.
  3. With C6 nerve root compression, pain is present in the
    neck, shoulder, medial scapula, anterior chest, lateral
    aspect of the upper arm, and also dorsal aspect of the
    forearm.
  4. With C5 nerve root compression, weakness of the
    deltoid, supraspinatus, infraspinatus, biceps, and
    brachioradials is observed with diminished biceps and
    brachioradials refl exes. With C6 nerve root compression,
    weakness of the biceps and extensor carpi radialis is
    frequently observed with diminished or absent biceps
    refl exes.
  5. With C5 nerve root compression, numbness may be
    observed in upper and lateral aspect of the shoulder. With
    C6 nerve root compression numbness, numbness is
    present in the thumb and index fi nger.
    Source: Shah RV: 2003
229
Q
  1. Renal effects of a burn injury include:
  2. Decreased renal plasma fl ow
  3. Decreased free water clearance, sodium retention
  4. Decreased GFR
  5. Decreased myoglobin
A
  1. Answer: A (1,2, & 3)

Source: Hansen HC, Board Review 2005 for Shah

230
Q
  1. The genitofemoral neuralgia:
  2. causes pain in the rectum
  3. causes pain in the testicles or vagina
  4. can be mistaken for appendicitis
  5. the nerve runs along the psoas muscle
A
  1. Answer: C (2 & 4)
    Explanation:
  2. The GFN nerve innervates the testicles and vagina, not
    the rectum.
  3. The GFN nerve innervates the testicles and vagina, not
    the rectum.
  4. The ilioinguinal nerve can be mistaken for
    appendicitis.
  5. The GFN nerve runs along the psoas muscle.
    Source: Trescot AM, Board Review 2004
231
Q

676.True statements regarding the cervical facet joint include:
1. Primarily innervated by C-type nociceptors.
2. Substance P has been isolated enhancing a nociception
at the joint
3. Chronic infl ammation at the joint may be contributory
of osteophytic production
4. The facet joint is a true synovial joint.

A
  1. Answer: E (All)
232
Q
  1. Which of the following is true regarding central nervous system pain?
  2. Spinal cord lesions are responsible for most central
    pain states.
  3. Wallenberg’s Syndrome is the most common vascular
    cause of central nervous system pain.
  4. Generally two types of central pain are noted: spontaneous
    pain and hyperesthesia
  5. The clinical features are similar whether the lesion is
    located in the spinal cord, brainstem, or brain.
A
  1. Answer: E (All)
    Explanation:
    Ref: Manning, Loar, Raj, Hord. Chapter 10. Neuropathic
    Pain. In: Pain Medicine: A Comprehensive Review, 2nd
    Edition, Raj, Mosby. 2003, page 77.
    Source: Day MR, Board Review 2003
233
Q
  1. The true statements regarding a spinal epidural abscess
    include:
  2. The most common symptom is back pain
  3. It commonly leads to radicular symptoms
  4. Symptoms may not occur for 1 to 2 weeks following a
    medical procedure
  5. Paraplegia can result
A
  1. Answer: E (All)
234
Q
  1. Which of the following is true regarding complex regional
    pain syndrome (CRPS)
  2. More common in males
  3. Most common cause is trauma secondary to accidental
    injury
  4. Triple phase bone scan alone is diagnostic of CRPS
  5. The mainstays of current therapeutic management are
    sympathetic block and physical therapy
A
  1. Answer: C (2 & 4)
    Explanation:
    Ref: Manning, Loar, Raj, Hord. Chapter 10. Neuropathic
    Pain. In: Pain Management: A Comprehensive Review, 3rd
    Edition, Raj, Mosby, 2003. page 82-86.
235
Q
  1. In the diabetic patient, painful neuropathy occurs
  2. Due to loss of A-delta fi ber function
  3. Due to increase in A-delta fi ber function
  4. Due to hyper sensitization of C-fi bers
  5. Due to loss of C-fi ber function
A
  1. Answer: B (1 & 3)

Source: Giordano J, Board Review 2003

236
Q
  1. A 56 year old. Female patient is referred to your clinic
    with a tentative previous diagnosis of polymyalgia
    rheumatica. What would represent a sensible approach
    to her evaluation for pain?
  2. Addressing Immunologic parameters through the administration
    of specifi c tests (eg.- ANA, SMA, RF)
  3. Use of physical examination to assess painful areas and
    articulation(s)
  4. Use of pain scale(s) and pain diagrams
  5. Use of interrogative questioning to evaluate her personal
    experience(s) of discomfort
A
  1. Answer: E (All)

Source: Giordano J, Board Review 2003

237
Q
  1. True statements about CRPS are as follows:
  2. CRPS Type II is like causalgia
  3. CRPS Type II is like hand shoulder syndrome
  4. CRPS Type I is like refl ex sympathetic dystrophy
  5. CRPS Type I is like neuralgia major and neuropraxia
A
  1. Answer: B (1 & 3)

Source: Racz G. Board Review 2003

238
Q
  1. Geniculate neuralgia is:
  2. Most often seen in middle aged patients
  3. Called the Ramsay Hunt syndrome when accompanied
    by ipsilateral facial paralysis
  4. less common than glossopharyngeal neuralgia
  5. Associated with ocular pain
A
  1. Answer: A (1, 2, & 3)
    Explanation:
    The geniculate ganglion is located in the roof of the
    temporal bone. The nervus intermedius, which is a branch
    of cranial nerve VII, has its cell bodies in the geniculate
    ganglion.
    It supplies sensory afferents to the tympanic membrane,
    external auditory canal,skin in the area between the ear
    andmastoid process, and some deep structures of the head
    and neck.
  2. Young to middle-aged adults are most commonly
    affected.
  3. Ramsay Hunt syndrome is geniculate neuralgia
    associated with the occurrence of a herpes zoster-type
    vesicular rash in the external ear and around the mastoid
    area, often accompanied by ipsilateral fascial paralysis.
  4. It is less common than glossopharyngeal neuralgia.
  5. Geniculate neuralgia is associated with ear pain and
    neck pain – but, not ocular pain
239
Q
  1. Post-operative analgesia for the lower extremity may be treated effectively by:
  2. Epidural analgesia at the T4-8 level
  3. Patient controlled analgesia utilizing morphine with
    the Basal and Bolus program
  4. Ilioinguinal nerve block
  5. Epidural analgesia at the L2-L4 level
A
  1. Answer: C (2 & 4)

Source: Hansen HC, Board Review 2005 for Shah

240
Q
  1. The conditions causing coccygodynia include:
  2. Levator syndrome
  3. Arachnoiditis
  4. Pilonidal cyst
  5. Fracture of the L3 vertebral body
A
  1. Answer: A (1, 2, & 3)
    Explanation:
    Primary causes of coccygeal pain include sprained
    ligaments, dislocation fracture, childbirth, osteoarthritis
    of the coccygeal joints, and subluxation of the coccyx.
    Metastases and external compression by a tumor mass
    represent 2% of cases.
    1, 2, 3. Referred pain may occur in patients with lumbar
    disc disease, cauda equina syndrome, arachnoiditis, spinal
    cord tumor, perirectal abscess or fi stula, pilonidal cyst,
    pelvic infl ammatory disease or tumor, vaginismus, levator
    syndrome, and psychoneurosis.
  2. Fracture of L3 vertebral body is an unlikely source of
    coccygodynia.
    Source: Kahn CH, DeSio JM. PreTest Self Assessment and
    Review. Pain Management. New York, McGraw-Hill, Inc.,
    1996.
241
Q
  1. The ganglion of Impar:
  2. is associated with low back pain
  3. is a collection of sympathetic nerves
  4. causes pain down the leg
  5. often needs a specially bent needle to reach it.
A
  1. Answer: C (2 & 4)
    Explanation:
    The ganglion of Impar is the termination of the lumber
    sympathetic chain. It is associated with pelvic and
    coccygeal pain but not leg pain, and needs often specially
    curved needles to reach the site.
    Source: Trescot AM, Board Review 2004
242
Q
  1. What types of pain predominate in cord central pain?
  2. Spontaneous steady pain
  3. Evoked pain
  4. Spontaneous neuralgic pain
  5. Musculoskeletal pain
A
  1. Answer: B (1 & 3)

Source: Day MR, Board Review 2004

243
Q
  1. Factor(s) capable of inducing visceral pain is/are:
  2. Abnormal distension and contraction of hollow visceral
    walls
  3. Rapid stretching of the capsule of a solid visceral
    organ
  4. Ischemia of visceral musculature
  5. Cutting normal viscera
A
  1. Answer: A ( 1, 2, & 3)

Source: Day MR, Board Review 2004

244
Q
  1. Which of the following are components in the criteria for
    establishing post-polio syndrome?
  2. acute febrile illness during a polio epidemic
  3. residual, asymmetric muscle atrophy, weakness, and
    arefl exia in at least one limb with normal sensation
  4. musculoskeletal complaints
  5. recovery or functional stability for 15 years following
    a polio illness
A
  1. Answer: E (All)
    Explanation:
    Acute polio starts with a non-specifi c viral syndrome,
    during which time the virus replicates in the nasopharynx
    and gut. A viremia develops and gives rise to sore throat,
    headache, nausea, vomiting, and abdominal pain lasting a
    few days. Patients may have signs that mimic meningitis.
    Only 1-2% of cases develop a partial or complete paralytic
    illness due to viral infection of the anterior horn cells. Up
    to 50% of the anterior horn cells infected with the virus
    undergo cell death, whereas the remainder are
    dysfunctional.
    Some patients recover, but may develop symptoms later.
    This condition is thought to be post-polio syndrome. The
    above criteria of post-polio syndrome were developed at
    the NIH and should be met before a patient is classifi ed as
    having post-polio syndrome.
    Source: Shah RV, Board Review 2004
245
Q
690. Where are the cell bodies of visceral afferent nerves
located?
1. Dorsal root ganglion of spinal nerves
2. Thoracic sympathetic ganglion
3. Ganglion of cranial nerves
4. Lumbar sympathetic ganglion
A
  1. Answer: B (1 & 3)

Source: Day MR, Board Review 2004

246
Q
  1. Glossopharyngeal neuralgia
  2. may be associated with bradycardia
  3. is associated with lancinating pain at the base of the
    tongue, posterior pharynx, and tongue
  4. microvascular decompression may be successful in
    some cases
  5. is an exclusively idiopathic neuropathic pain condition
A
  1. Answer: A (1,2, & 3)
    Explanation:
    (Shah, Pain Practice 2003; 3(3): 232-237)
    Glossopharyngeal neuralgia may be idiopathic or
    secondary to injury.It is associated with lancinating pain at
    the base of the tongue, tonsillar fossae, posterior pharynx,
    and ear. Microvascular decompression is the most
    successful surgical procedure for the idiopathic variety, as
    compared to other surgical techniques: neurectomy. Since the vagus nerve is intimately related to the
    glossopharyngeal nerve, this syndrome may be associated
    with bradycardia and hypotension. In fact, during
    radiofrequency procedures,bradycardia is a potential
    hazard
    Source: Shah RV, Board Review 2004
247
Q
  1. True statements regarding sickle cell disease include: 1. Valine is substituted for glutamic acid in the sixth acid
    of the beta chain of hemoglobin
  2. With proper treatment, patients with homozygous
    sickle cell disease have a normal life expectancy
  3. Homozygous patients have all HbS, with a variable
    amount of HbF (fetal globulin)
  4. Splenectomy and hematinics have been shown to be
    effective in prolonging life expectancy and decreasing
    frequency of crises in patients with severe sickle cell
    disease
A
  1. Answer: B (1 & 3)
    Explanation:
    Sickle cell disease is a chronic hemolytic anemia. It occurs
    primarily in the black population because of genetic
    transmission of a molecular lesion of hemoglobin.
    - 0.15% of black children are homozygous for this trait
    and manifest symptoms of sickle cell disease.
    - Diagnosis of the disease is made by history, physical
    examination, and blood electrophoresis.
  2. Valine is substituted for glutamic acid at the sixth
    position in the beta chain of hemoglobin.
    - The sickle hemoglobin is fragile and thereby less able to
    withstand the trauma of circulation, infection, and
    dehydration.
  3. Patients with sickle cell disease suffer from recurrent,
    painful vaso-occlusive attacks, which may result in
    progressive infarction of the liver, spleen, gallbladder, and
    lungs.
    - Complications associated with these crises lead to
    shorter life expectancy.
  4. Homozygotes have almost all HbS with a variable
    amount of HbF (fetal hemoglobin). They have no HbA.
    - Heterozygotes, patients with sickle cell trait, have more
    HbA than HbS, and as such will not experience hemolysis,
    painful crises, and thrombotic complications associated
    with sickle cell disease.
  5. Therapy consists of symptomatic treatment.
    Splenectomy and hematinics are not helpful.
248
Q
  1. A woman in her sixties complains of recent onset of
    unilateral temporal headaches. She has muscle and joint
    aches without neck stiffness. She also complains of loss
    of appetite, low-grade fever, and visual disturbances. The
    most likely diagnosis is:
  2. Migraine headaches
  3. Subarachnoid hemorrhage
  4. Venous thrombosis
  5. Giant cell arteritis
A
  1. Answer: D (4 Only)
    Explanation:
    The Diagnosis is Giant cell arteritis
    The prevalence of giant cell arteritis (temporal arteritis)
    increases after age 50 and occurs twice as often in women.
    Patients complain of temporal headache of a constant,
    boring quality, which may be relieved with aspirin.
    They may also have symmetric arthralgias and myalgias,
    general malaise, anorexia, low-grade fever, claudication of
    jaw muscles, and visual loss due to ischemia of the optic
    nerve and retina.
    Facial and temporal artery pulsations may be absent. Blindness and stroke have occurred. Patients with giant
    cell arteritis also have an increased ESR.
    The diagnosis is confi rmed by temporal artery biopsy.
    Treatment is with corticosteroids. In the presence of
    intolerable side effects, azathioprine has been used with
    some success. Patients should be on the lowest dose of
    medication that will suppress the ESR, which should be
    checked regularly. Rise in the ESR may indicate potential
    relapse.
    Source: Kahn CH, DeSio JM. PreTest Self Assessment and
    Review. Pain Management. New York, McGraw-Hill, Inc.,
    1996.
249
Q
  1. Which of the following is true about restless leg
    syndrome?
  2. The syndrome is rare and affl icts less than 0.5% of the
    population
  3. Uremia is strongly associated with this condition
  4. Leg movement is involuntary
  5. Patients often complain of a ‘creeping’ and ‘crawling’
    sensation in their legs
A
  1. Answer: C (2 & 4)
    Explanation:
  2. Restless legs syndrome affl icts 2-10% of the population.
  3. Uremia, hyper and hypothyroidism, and diabetes are
    associated with RLS.
    - Additionally, CHF is associated with it also known as
    Vesper’s curse (reduced cardiac compliance results in the
    engorgement of epidural veins)
  4. The motions are not involuntary, but rather the patient
    describes an irresistible urge to move the legs.
  5. Patients typically complain of unusual sensations in
    their legs that can be described as ‘creeping’, ‘crawling’,
    ‘tingling’, and ‘itching’.
    - The feeling is unlike that of the legs falling
    asleep…rather the pain is deep.
    Source: Shah RV, Board Review 2004
250
Q

695.True statements about painful polyneuropathies with
selective loss of large fi bres include the following:
1. Isoniazid neuropathy
2. Pellagra neuropathy
3. Hypothyroid neuropathy
4. Diabetic neuropathy

A
  1. Answer: A (1, 2, & 3)
    Explanation:
    1.Isoniazid neuropathy, pellagra neuropathy, and
    hypothyroid neuropathy are all painful polyneuropathies
    associated with the selective loss of neural fi bres of large
    diameter. Isoniazid may cause distal numbness and
    tingling followed by a deep ache or burning pain as the
    myelinated fi bres are selectively damaged. Lower
    extremity sensorimotor neuropathy and cutaneous
    hyperesthesia may also be present.
    2.Pellagra neuropathy is due to niacin defi ciency.
    Sensorimotor neuropathy of the lower extremities with
    painful feet, tender calf muscles, and cutaneous
    hyperesthesia occurs.
    3.Hypothyroid sensorimotor neuropathy is associated with
    painful feet and paresthesias of the hands.
    4.Diabetic neuropathy is associated with loss of small
    fi bres.
251
Q
  1. The true statement about the pain condition(s) with the nerve block(s) include the following:
  2. arm pain - thoracic sympathetic block
  3. abdominal pain - ilioinguinal block
  4. abdominal pain - splanchnic block
  5. fractured rib - thoracic sympathetic block
A
  1. Answer: A ( 1, 2, & 3)

Source: Trescot AM, Board Review 2004

252
Q
  1. Which of the following can cause spinal stenosis?
  2. Short pedicles
  3. Spondylosis
  4. Disc protrusion
  5. Ligamentous hypertrophy
A
  1. Answer: E (All)

Source: Day MR, Board Review 2004

253
Q

698.True statements regarding deafferentation pain
syndromes include that they:
1. Are rarely successfully treated with narcotic agents
2. May manifest as burning, crushing, or tearing pain
3. Typically produce pain that is constant and unremitting
4. Seldom respond to neurosurgical intervention

A
  1. Answer: E (All)
    Explanation:
  2. Narcotic analgesics characteristically do not afford much
    relief beyond their sedative and mood-altering effects.
  3. Patients experiencing deafferentation pain commonly
    complain of numbness, burning (causalgia, caustic pain),
    coldness, or, in severe cases, crushing, tearing, or ripping
    sensations.
  4. Their pain is usually constant, unremitting, and
    accompanied by prominent suffering.
  5. Further destruction of neural tissue via neurosurgical
    intervention rarely gives the patient lasting relief and may
    result in an even more widespread deafferentation pain
    state.
    Source: Kahn CH, DeSio JM. PreTest Self Assessment and
    Review. Pain Management. New York, McGraw-Hill, Inc.,
    1996.
254
Q
  1. The differential diagnosis for intermittent claudication includes:
  2. Lumbar spinal stenosis
  3. Thromboangiitis obliterans
  4. Atherosclerotic obliterans
  5. Osteoarthritis of the hip
A
  1. Answer: E (All)

Source: Day MR, Board Review 2004

255
Q
700. Noninvasive technique/s to measure macro circulatory
blood fl ow is/are:
1. Segmented pressure
2. Duplex scanning
3. Systolic toe pressures
4. Ankle-brachial indices
A
  1. Answer: E (All)

Source: Day MR, Board Review 2004

256
Q
  1. Thalamic pain syndrome
  2. was described by Dejerine and Roussy
  3. may follow a thalamic stroke
  4. a pain syndrome that develops on the hemiplegic side
  5. may be associated with hemiataxia and choreoathetoid
    movements
A
  1. Answer: E (All)
    Explanation:
    (Raj, 3rd Edition, Practical Mgmt of Pain)
    Dejerine Roussy described pain associated with a stroke,
    specifi cally ‘thalamic’ pain syndrome following a thalamic
    stroke. Their patients had mild hemiplegia, hemisensory
    losss, astereognosis, hemiataxia, choreoathetoid
    movements, and pain.
    Source: Shah RV, Board Review 2004
257
Q
  1. Drugs associated with rebound headaches include:
  2. Butalbutal
  3. Caffeine
  4. Triptans
  5. Opioids
A
702. Answer: E (All)
Explanation:
All of these medicines can cause analgesic rebound
headaches
Source: Trescot AM, Board Review 2004
258
Q

703.What are the true statements regarding carpal tunnel
syndrome?
1. In Phalen’s test or Tinel’s sign, the median nerve is
easily depolarized when mechanically stimulated by
direct tapping over the palmaris longus tendon over
the fl exor retinaculum.
2. Positive fi ndings are present in over 90% of all cases.
3. Intercarpal pressure is greatest at 90° wrist fl exion superimposed
on ulnar deviation.
4. Pronator syndrome presents with identical symptoms
as carpal tunnel syndrome with similar fi ndings on the
nerve conduction studies.

A
  1. Answer: B (1 & 3)
    Explanation:
    Carpal tunnel syndrome is one of the most common, best
    defi ned, and most carefully studied entrapment
    neuropathies.
    -It affects middle-aged females between 40 and 60 years of
    age, that is menopausal women, a characteristic suggestive
    of a hormonal aberration as a causative development of
    this disorder.
    -The most common cause of carpaltunnel syndrome is an idiopathic non-specifi c fl exor tenosynovitis that may
    simply arise from chronic repetitive occupational stress,
    both in males and females.
    - Carpal tunnel syndrome may occur acutely after lunate
    bone dislocation or from a Colles’ fracture and requires
    immediate medical attention as to prevent acute nerve
    ischemia.
    Carpal tunnel syndrome may be subdivided into one of
    the four categories.
    - An increase in volume or tunnel content secondary to
    non-specifi c tenosynovitis of the fl exor tendons within the
    carpal tunnel
    - Thickening or fi brosis of the transverse carpal ligament
    - Alteration of the osseous modus of the carpus caused by
    fractures, dislocations or arthritic joint changes
    - Tumor or systemic disease
    The median nerve has both sensory and motor branches.
    During median nerve compression at the carpal tunnel
    sensory, abnormalities usually occur fi rst only to progress
    to motor involvement as the pathology evolves.
    Clinical fi ndings are proportional to the degree of nerve
    damage, which in turn is related to the severity of
    compression and not to the duration of compression.
    The differential diagnosis includes C6 radiculopathy with
    refl ex changes and EMG studies showing denervation out
    of the median nerve territory and sensory loss of the 6th
    cervical dermatome.
  2. Carpal tunnel is diagnosed with positive Phalen’s test
    or Tinel’s sign where the median nerve is easily
    depolarized when mechanically stimulated by direct
    tapping over the palmaris longus tendon over the fl exor
    retinaculum.
  3. Positive fi ndings occur only in approximately 45% of
    all cases.
  4. Intercarpal pressure is greatest at 90° wrist fl exion
    superimposed on ulnar deviation.
  5. Pronator syndrome referring to compression of the
    median nerve by pronator muscle as it passes through the
    heads of that muscle and to a lesser extent,by fi brous
    bands near the origin of deep fl exor muscles known as the
    lacertus fi brosis and fl exor digitorum superfi cialis arcade,
    and even less commonly by the ligament of Struthers, an
    analomous structure found in about 1% of the population.
    - Pronator syndrome may also be expressed with
    expressed with median nerve paresthesias mimicking
    those of CTS, it differs in several aspects. Night pain,
    symptoms brought on by wrist movement, intrinsic
    weakness of opponents and abduction movements, as well
    as positive Phalen and Tinel wrist signs are not common
    to this condition.
    Source: Saidoff DC, McDonough AL. Critical Pathways in
    Therapeutic Intervention. Extremities and Spine. St.
    Louis,Inc., 2002
259
Q

704.True statements regarding spondylolysis and
spondylolisthesis include the following:
1. Spondylolysis defi nes anterior displacement of one
vertebra on another
2. Degenerative spondylolysis and spondylolisthesis occurs
due to long standing segmental instability with
remodeling of articular processes at affected level
3. MRI provides gold standard in evaluation of spondylosis
and spondylolisthesis
4. Bone scan with single-photon emission computed tomography (SPECT) is the gold standard

A
  1. Answer: C (2 & 4)
    Explanation:
  2. Spondylosis is fracture of the pars interarticularis.
  3. Spondylolisthesis is anterior displacement of one
    vertebrae on another.
  4. Plain fi lms and CT scan assist in the diagnosis.
    - MRI may provide additional soft tissue information -
    but not gold standard
  5. Bone scan with single-photon emission computed
    tomography is the gold standard.
    Source: Cole & Herring. Low Back Pain Handbook.
260
Q
  1. Which of the following rarely result in central pain?
  2. Arteriovenous malformations
  3. Craniocerebral injury
  4. Infarction
  5. Craniotomy
A
  1. Answer: C (2 & 4)

Source: Day MR, Board Review 2004

261
Q
  1. Second order neurons that receive input from the viscera are located in which Rexed laminae?
  2. X
  3. V
  4. I
  5. II
A
  1. Answer: A ( 1, 2, & 3)

Source: Day MR, Board Review 2004

262
Q
  1. In which of the following would you suspect a potentially
    serious cause of back pain?
  2. elderly female that sustains minor trauma
  3. age >50 years old
  4. new onset urinary frequency
  5. progressive neurologic defi cit in lower extremity
A
  1. Answer: E (All)
    Explanation:
    There are several red fl ags for potentially serious
    conditions causing acute low back pain. These include:
    Major trauma such as motor vehicle accident
    Minor trauma in an elderly or osteoporotic individual
    Age >50 and
263
Q
  1. The severity of electrical burns is determined by which
    of the following:
  2. Duration of electrical contact
  3. Resistance of current at contact points, entry and exit
  4. Voltage
  5. Adipose insulation capacity
A
  1. Answer: A (1,2, & 3)

Source: Hansen HC, Board Review 2005 for Shah

264
Q
  1. Nerves of the anterior abdominal wall are entrapped by:
  2. the rectus abdominus muscle
  3. the external oblique muscle
  4. scar tissue
  5. Pfannenstiel incisions
A
  1. Answer: E (All)
    Explanation:
    All of these can entrap abdominal nerves.
    Source: Trescot AM, Board Review 2004
265
Q
710. The pathophysiologic factors involved in neuropathic
pain include
1. well-defi ned inhibitory mechanisms
2. poorly defi ned central pathways
3. well-defi ned nociceptive mechanisms
4. well-defi ned neurologic damage
A
  1. Answer: C (2 & 4)
    Explanation:
    Neuropathic pain is typically not biologically useful,
    although the neurologic damage may be well defi ned. Its
    nociceptive mechanisms, central pathways, and inhibitory
    mechanisms are poorly defi ned. Pain is often appreciated
    in a region of sensory defi cit.
    Source: Kahn and Desio
266
Q
  1. Possible mechanisms for the production of neuropathic
    pain include
  2. malfunction of the “gate”
  3. generation of ectopic impulses by nerves
  4. “crosstalk” between large and small fi bers
  5. malfunction of central processing
A
  1. Answer: E (All)
    Explanation:
    There are four possible mechanisms for the production of
    pain in peripheral nerve lesions, as proposed by Wall:
  2. The “gate” might be closed to malfunction.
  3. The nerves might become mechanically sensitive and
    generate ectopic impulses.
  4. There might be “crosstalk” between large and small
    fi bers.
  5. There might be changes in the central processing.
    Source: Kahn and Desio
267
Q
  1. Cortisol is responsible for:
  2. Gluconeogenesis
  3. Direct activation of insulin production
  4. Indirect action of glycolytic hormones and catecholamine
    production
  5. Interleukin 1 release
A
  1. Answer: B (1 & 3)

Source: Hansen HC, Board Review 2005 for Shah

268
Q

713.The benefi ts of continuous epidural analgesia after
traumatic incident to the chest wall includes:
1. Early post-injury extubation
2. Improved ventilator weaning capacity
3. Improved respiratory therapy efforts
4. Decreased potential for nosocomial chest wall infection

A
  1. Answer: A (1,2, & 3)

Source: Hansen HC, Board Review 2005 for Shah

269
Q
  1. Which of the following distinguishes Raynaud’s disease
    from Raynaud’s phenomenon?
  2. Raynaud’s disease is a progressive disorder that leads to irreversible digital gangrene requiring amputation
  3. Both manifest symptomatology whereby the digits
    become white, blue, and then red-in this order
  4. Only Raynaud’s phenomenon responds to a sympathetic
    block
  5. Raynaud’s disease is a primary idiopathic disorder
    which can present bilaterally, whereas Raynaud’s
    phenomenon is typically secondary to an underlying
    disease process and unilateral
A
  1. Answer: C (2 & 4)
    Explanation:
    (Raj, Pain Review 2nd Ed., page 30)
    Raynaud’s disease is a relatively common clinical problem
    characterized by vasospasm of the microcirculation of the
    fi ngers and is not due to any other pathologic process.
    Raynaud’s phenomenon is usually secondary to an
    underlying disease process, but the symptomatology is
    similar. Raynaud’s phenomenon is typically unilateral and
    the disease is typically bilateral. Both processes are
    reversible when a sympathetic block is used or if patients
    avoid the triggering stimulus, e.g., keeping the hands
    warm. Although skin necrosis may develop, patients don’t
    typically develop digital gangrene. The color changes may be found in both conditions: white-vasospasm, bluecyanosis,
    red-reperfusion and vasodilatation.
    Source: Shah RV, Board Review 2005
270
Q
  1. Neuralgic pain differs from nociceptive pain in that it
    usually
  2. has a delayed onset after a causative event
  3. less responsive to opioid administration
  4. has a dysesthetic component to it
  5. can be treated by proximal surgical interruption
A
  1. Answer: A (1, 2, & 3 )
    Explanation:
    Neural (neurogenic) pain differs from nociceptive pain in
    several ways. Typically, its onset is delayed after a causative
    event and it is often causalgic or dysesthetic in nature.
    Neurogenic pain may respond to intravenous
    administration of barbiturate-like drugs but less response
    to opiates.
    It is usually temporarily relieved by proximal local
    anesthetic blockade but not permanently relieved by
    surgical interruption at the same site.
    Source: Kahn and Desio
271
Q
716. Which of the following are associated with migraine
improvement in females?
1. Menses
2. First trimester of pregnancy
3. Use of birth control pills
4. Menopause
A
  1. Answer: C (2 & 4)
    Explanation:
    1 & 3. Menses and birth control pills may trigger or
    worsen the intensity of headache.
    2 & 4. Menopause and the fi rst trimester of pregnancy are
    associated with headache improvement.
    Source: Shah RV, Board Review 2005
272
Q
717. Which of the following are common with Parkinson’s
Disease?
1. Pain
2. Rigidity
3. Tremors
4. Bradykinesias
A
  1. Answer: E (All)

Source: Boswell MV, Board Review 2005

273
Q
  1. Schizophrenic patients experiencing chronic painful
    conditions pose signifi cant challenges for pain
    practitioners because of which of the following?
  2. Their complaints about pain are delusional and diffi
    cult to assess.
  3. They are overrepresented in chronic pain management
    programs and require excessive amounts of time to
    satisfactorily treat.
  4. Current healthcare delivery models require that medical
    conditions be treated separately from ongoing serious
    mental disorders.
  5. They appear to complain less about pain than patients
    with other psychiatric disorders so often fail to receive
    adequate medical evaluations.
A
  1. Answer: D (4 Only)

Source: Cole EB, Board Review 2003

274
Q
  1. Which of the following signs may be associated with T1
    root compression
  2. Weakness of the intrinsic muscles of the hand
  3. Subjective numbness in the ulnar aspect of the forearm
  4. Pain in the neck, medial scapula, and anterior chest
  5. Horner’s syndrome
A
  1. Answer: E (All)
    Explanation:
    Typical fi ndings in T1 root (i.e., T1/2 disc) compression
    include pain in the neck, medial scapula,and anterior
    chest;subjective numbness in the ulnar aspect of the
    forearm; weakness of the intrinsic muscles of the hand;
    and normal deep tendon refl exes. Occasionally, Horner’s
    syndrome (miosis, anhidrosis, and ptosis) can be caused
    by compression of the sympathetic nerves (Wall, p 745)
    Source: Kahn CH, DeSio JM. PreTest Self Assessment and
    Review. Pain Management. New York, McGraw-Hill, Inc.,
    1996.
275
Q
  1. Diagnostic features of an epidural abscess include that it:
  2. Is most commonly caused by Staphylococcus epidermidis
  3. May present as severe back pain
  4. Will show normal myelographic fi ndings
  5. May present as local back tenderness
A
  1. Answer: C (2 & 4)
    Explanation:
  2. Staphylococcus aureus is the most common infecting
    organism.
    -Thus, antibiotic administration should include treatment
    for a staphylococcal infection if positive cultures are not
    available.
  3. Epidural abscess generally presents with severe back
    pain, local back tenderness, fever, and leukocytosis.
  4. An abnormal myelogram with obstruction to flow of contrast medium is a common fi nding.
  5. Epidural abscess generally presents with severe back
    pain, local back tenderness, fever, and leukocytosis.
276
Q
  1. True statements with regards to spinal stenosis causing
    low back and lower extremity pain include the following:
  2. Pathophysiology includes narrowing of the spinal canal
    with disc, osseous thickening of bone, facet joints,
    or spondylolisthesis
  3. Narrowing of the spinal canal with thickening of the
    ligamentum fl avum, association with DISH or Paget’s
    disease
  4. Venous congestion of the roots of the cauda equina
  5. Clinical defi nition of neurogenic claudication includes
    pain relieved by standing or walking
A
  1. Answer: A (1, 2, & 3)
    Explanation:
    Spinal stenosis: narrowing of the spinal canal.
    Neurogenic claudication: radiating pain or paresthesia into
    buttocks and lower extremities. Pain exacerbated by
    standing or walking
    Pain relieved by lumbar fl exion
    Radiologic evidence of spinal stenosis
    Central stenosis defi ned by sagittal diameter of less than
    11 mm
    Lateral recess stenosis-lateral to the central canal with a
    depth of less than 3 mm
    Pathophysiology: narrowing of the spinal canal
    Speculation of venous congestion of the roots of the cauda
    equina
    History: Slowly progressive increase in back and unilateral
    and bilateral legs.
    Symptoms are relieved by lumbar fl exion and/or sitting.
    Increase in symptoms walking downhill due to increased
    lumbar extension.
    Shopping cart syndrome
    Important to differentiate from peripheral vascular disease
    by the need to have sit or bend forward to relieve
    symptoms or the ability to tolerate cycling with neurogenic
    claudication.
    Physical Examination
    Diffi cult to stand upright and knees are bent slightly
    forward.
    Loss of lumbar lordosis
    Neurological examination may be normal but ankle jerks
    may be absent
    Straight leg raising is often normal. Look for
    abnormalities of peripheral vascular system
    Source: Low Back Pain Handbook.Cole & Herring. Low
    Back Pain Handbook
277
Q
  1. Which of the following regarding phantom limb pain are true?
  2. Pain increases with time after amputation.
  3. The incidence of phantom pain is less than 10%.
  4. Pain is more common with distal amputations
  5. Phantom pain is not infl uenced by age or gender
A
  1. Answer: D (4 Only)
    Explanation:
    Phantom limb pain is a term used to describe painful
    sensations that are perceived to originate in the amputated
    portion of the extremity. In addition, patients may have
    localized pain following the amputation that originates
    from the stump itself.
  2. Phantom limb pain has been reported to occur as early
    as 1 week after amputation. Generally, the incidence
    decreases with time. However, 60% of the amputees may
    experience pain 6 months after amputation. In the fi rst
    month following amputation, 85% to 97% of patients
    experience phantom limb pain. One year after amputation,
    approximately 60% of patients continue to have phantom
    limb pain. Even though, phantom limb pain may begin
    months to years after amputation, pain starting more than
    1 year following amputation occurs in less than 10% of the
    patients.
    2.The incidence of phantom limb pain is higher than 10%.
    Early literature reports the incidence of phantom limb
    pain in amputees to be less than 10%. However, it is now
    believed that this fi gure is artifi cially low because of the
    reluctance of patients to report phantom limb pain. Large
    studies have shown the incidence of phantom limb pain to
    be 72% to 85%.
  3. The incidence of phantom limb pain increases with
    more proximal amputations. For example, it was reported
    that phantom pain existed in 68% after hemipelvectomy,
    40% after hip disarticulation, 19% after above knee
    amputation, and 0% with below knee amputation.
  4. Phantom limb pain is not infl uenced by age or gender.
    There is no genetic predisposition toward phantom limb
    pain, and there is no evidence that learned behavior
    infl uences the incidence of it. Some studies suggest that it
    may be less prevalent in the diabetic population. Further, a
    predisposition to phantom limb pain has been shown in
    patients of lower socioeconomic class and in those with
    postoperative wound complications or frozen joints.
    Reference: Hord and Shannon. Chapter 16. Phantom Pain.
    In: Practical Management of Pain, 3rd Edition. Raj et al.
    Mosby, 2000, page 212-213.
278
Q
  1. Rheumatoid arthritis would include all of the following:
  2. Joint space narrowing
  3. Soft tissue edema and swelling.
  4. Symmetrical presentation.
  5. Osteomyelitis.
A
  1. Answer: A (1, 2, & 3)
    Source: Helms CA. Fundamentals of Skeletal Radiology.
    W.B. Saunders Co., 1995; p. 120.
279
Q
  1. The true statements regarding endometriosis are as
    follows:
  2. Is commonly felt in the hypogastric region
  3. May be resolved with NSAIDs
  4. May result from a direct action on nerve endings
  5. May mimic acute appendicitis
A
  1. Answer: E (All)
    Explanation:
    Endometriosis can cause pain and tenderness by direct
    action on nerve endings or by interfering with the
    function of involved or adjacent organs. The pain is
    characteristically worse a few days before menstruation
    rather than during the early period of fl ow. Hypogastric
    midcycle pain (mittelschmerz) in patients with
    endometriosis can be severe for a few hours to days and
    canmimic the pain of acute appendicitis.
280
Q
  1. Exteroceptive sensations include
  2. Temperature
  3. Vibration
  4. Touch
  5. distention
A
  1. Answer: B (1 & 3)
    Explanation:
    Exteroceptive sensations are those that arise from or
    originate in sense organs in the skin or mucous
    membranes and respond to external agents and changes in the environment. They may also be designated as
    superfi cial sensations.
    There are three major types: pain, temperature, and touch.
    Source: Kahn and Desio
281
Q
  1. The pathology of neuropathic pain may be:
  2. axonal degeneration
  3. central sensitization
  4. segmental demyelination
  5. none of the above
A
  1. Answer: B (1 & 3)
    Explanation:
    Neuropathies may be classifi ed as axonal, segmental, or
    mixed.
    Source: Trescot AM, Board Review 2004 for Shah
282
Q
  1. At the site of injury, or at the level of tissue destruction,
    pain providing infl ammatory processes is stimulated by:
  2. Endocrine mediated responses
  3. Catecholamine response
  4. Infl ammatory mediators, bradykinin, platelet-activating
    factor, prostaglandins
  5. Elaboration of insulin, increasing the insulin to glucagon
    ratio
A
  1. Answer: A (1,2, & 3)

Source: Hansen HC, Board Review 2005 for Shah

283
Q
  1. Dejerine and Roussy described which of the following
    abnormalities in their patients with central pain?
  2. Ataxia
  3. Asteriognosia
  4. Hemiplegia
  5. Paroxysmal pain
A
  1. Answer: E (All)

Source: Boswell MV, Board Review 2005

284
Q
  1. Treatment of pelvic pain may include:
  2. pudendal nerve blocks
  3. intercostal nerve block
  4. superior hypogastric block
  5. celiac plexus block
A
  1. Answer: B (1 & 3 )
    Explanation:
    Pudendal and superior hypogastric blocks treat pelvic
    pain. Intercostal blocks treat thoracic pain, and celiac
    plexus blocks treat upper abdominal pain.
    Source: Trescot AM, Board Review 2004
285
Q
  1. Which of the following are true about tension-type
    headache?
  2. They are always bilateral
  3. They typically occur from 11pm to 3 am
  4. There is a male predominance
  5. Patients typically have a band-like tightness around
    the scalp
A
  1. Answer: D (4 only)
    Explanation:
    (Raj, Pain Review, 2nd Ed., page 27)
    The typical patient profi le of tension-type headache:
    - Usually bilateral, but can be unilateral
    - Possible bandlike, non-pulsatile ache or tightness in the
    frontal, temporal, and occipital region
    - Often has neck etiology…hence the associated term
    cervicogenic headache
    - Evolves over a period of hours to days and lingers; hence
    unlike a migraine-which by defi nition is an intermittent
    headache-tension headaches tend to be present all the time
    until the exacerbating factors are removed. Exacerbating
    factors include physical and psychological stress. TMJ and cervical spine disorders can also trigger a headache
    - No aura
    - Sleep disturbance is usually present
    - Female predominance
    - No hereditary pattern
    Source: Shah RV, Board Review 2005
286
Q

731.Theories regarding the etiology of neuropathic pain
include:
1. Peripheral nerve injury resulting in neuromas
2. Glial scar formation secondary to CNS nerve injury
3. Spontaneous hyperactivity in the wide dynamic range
neuron after peripheral nerve injury
4. Sympathetic hyperdynamic state after an injury

A
  1. Answer: E (All)

Source: Trescot AM, Board Review 2004 for Shah

287
Q
  1. Which of the following neurologic abnormalities are
    commonly seen in patients with central pain?
  2. Loss of position sense
  3. Reduced light touch
  4. Diminished temperature sensation
  5. Complete numbness
A
  1. Answer: A (1, 2, & 3 )

Source: Boswell MV, Board Review 2005

288
Q
733. Several painful conditions have been described in patients
with AIDS. These include:
1. Guillain-Barré syndrome
2. Postherpetic neuralgia
3. Encephalopathy
4. Predominant sensory neuropathy
A
  1. Answer: E (All)
    Explanation:
    Neurologic disease can be either a direct result of HIV
    infection or a direct or indirect result of HIV
    immunosuppression. Early clinical manifestations of HIV
    encephalopathy include cognitive symptoms, behavioral
    changes, and motor symptoms. Late manifestations
    include frank dementia, seizures,and pyramidal tract signs.
    Painful syndromes in patients with AIDS that involve the
    peripheral nervous system include Guillain-Barré
    syndrome, postherpetic neuralgia, and a predominant
    sensory neuropathy (Raj)
289
Q
  1. Causes of scrotal pain include:
  2. Testicular cancer
  3. Epididymo-orchitis
  4. Testicular torsion
  5. Paraphimosis
A
  1. Answer: A (1, 2, & 3)
    Explanation:
    Scrotal pain or pain in the inguinal area is often associated
    with pathology of the testicle or epididymis. A careful
    history and physical examination should be performed to
    rule out acute conditions such as testicular torsion,
    infection of the epididymis or testicle, and fracture of a
    portion of the testicle after trauma. Testicular cancer is
    most common in men 20 to 40 years of age. Urinalysis
    will provide information regarding infl ammatory or
    infectious causes of pain. If examination of the testicle
    reveals that it is elevated in the scrotum close to the
    external inguinal ring, torsion exists and may be a surgical
    emergency. If a portion of the testicle has been fractured in
    a traumatic event, the painful necrotic portion of the
    testicle may requirer excision and anastomosis of the
    tunica albuginea to preserve function of the remaining
    portion of the testicle. Early testicular cancer is usually
    nonpainful, but it is frequently associated with
    epididymitis. After appropriate treatment of the
    infection/infl ammation, ultrasound and possibly a
    testicular biopsy should be performed to rule out testicular
    cancer. Paraphimosis is a condition in which the retracted
    foreskin forms a constricting band at the base of the
    glams. This may be associated with penile pain.
    Source: Kahn CH, DeSio JM. PreTest Self Assessment and
    Review.
290
Q
  1. True statements in postmastectomy pain syndrome are
    as follows:
  2. The intercostobrachial nerve is rarely affected.
  3. Pain may be exacerbated by arm movement
  4. The patient complaints of tight, constricting, burning
    pain in the mid back
  5. Painful areas often include the posterior arm and
    axilla
A
  1. Answer: C (2 & 4)
    Explanation:
  2. The intercostobrachial nerve is often affected.
  3. Pain may be exacerbated by arm movement.
    3.The patient with postmastectomy pain may complain of
    a tight, constricting, burning pain in the posterior arm,
    axilla, and anterior chest wall, with the pain being
    exacerbated by movement of the arm.
    - Patients may respond to a combination of therapies,
    including stellate ganglion blocks, thoracic epidural
    blocks, transcutaneous electrical nerve stimulation
    (TENS), anticonvulsants, and other medications used to
    treat neuropathic pain.
  4. Painful areas often include the posterior arm and axilla.
291
Q
  1. Cyclical pain:
  2. Usually indicates a gynecological etiology
  3. May be experienced during an exacerbation of a bowel
    process during menstruation
  4. May be associated with ovulation (Mittelschmerz)
  5. Is always of organic origin
A
  1. Answer: A (1, 2, & 3)

Source: Nader and Candido – Pain Practice. June 2001

292
Q
  1. An epidural abscess may be caused by:
  2. Staphylococcus aureus
  3. Pseudomonas species
  4. Gram-negative rods
  5. Streptococcal species
A
  1. Answer: E (All)
    Explanation:
    All the organisms listed have been known to cause
    epidural abscess.
    - Staphylococcus aureus is by far the most common.
293
Q
  1. The true statements regarding the occurrence of acute
    herpes zoster (AHZ) in cancer patients include:
  2. The location of the AHZ infection is not associated
    with the site of the cancer
  3. Patients with hematologic or lymphoproliferative cancer
    have an increased incidence of AHZ
  4. Patients receiving immunosuppressive therapies have
    lower incidence of AHZ
  5. AHZ occurs less frequently in nonirradiated areas than
    in irradiated areas
A
  1. Answer: C (2 & 4)
    Explanation:
  2. The location of the cancer is associated with the site of
    AHZ occurrence.
  3. AHZ occurs more frequently in patients with
    hematologic or lymphoproliferative cancers, and in those
    patients who receive immunosuppressive therapies.
  4. Patients with breast or lung cancer are more likely to
    develop thoracic AHZ, those with head and neck cancer
    tend to develop facial AHZ, and those with gynecologic or
    urologic tumors frequently develop lumbar or sacral
    AHZ.
  5. AHZ also occurs most often in areas that have been
    previously irradiated.
    Source: Kahn CH, DeSio JM. PreTest Self Assessment and
    Review. Pain Management. New York, McGraw-Hill, Inc.,
    1996.