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Flashcards in ASIPP Diagnosis and Therapy Questions Deck (603):
1

739. Proposed mechanisms of action for spinal cord
stimulation include all of the following except:
A. Segmental antidromic inhibition of A-beta afferents
B. Blocking of transmission in the spinothalamic tract
C. Supraspinal pain inhibition
D. Activation of central inhibition of sympathetic efferent
neurons
E. Antidromic activation of C nociceptive afferents

739. Answer: E
Explanation:
Reference:
Krames, Interventional Pain Management,Second Edition;
Chapter 53 Mechanisms of Action of Spinal Cord
Stimulation
A. Segmental activation of large A-beta fi bers within the
dorsal columns which antidromically inhibit reception of
small fi ber nociceptive information at the substantia
gelatinosa of the dorsal horn.
This was Melzack and Wall’s original hypothesis and is
consistent with a classic “gate control” theory of spinal
cord stimulation.
B. Segmental blockade of neurotransmission in the
spinothalamic tract.
This theory is supported by studies that show there is
inhibition of pain transmission locally within the cord
during spinal cord stimulation.
C. Spinal cord stimulation produces changes in
supraspinal neurons that either modulate supraspinal
pain transmission or trigger supraspinal descending
inhibition of the dorsal horn.
D. Activation of central inhibition of sympathetic efferent
neurons could affect pain processing. The consistent effect
of vasodilation supports a sympathetic inhibition effect of
spinal cord stimulation.
E. Release of putative neurotransmitters and/or
neuromodulators. This theory is based on the observation
that pain relief often outlasts the duration of stimulation
for minutes, hours and sometimes days.
Source: Schultz D, Board Review 2004

2

740. For brachial plexus avulsion pain, the long-term outcomes
of DREZ lesioning are approximately:
A. 60-65%
B. 10-15%
C. 1-2%
D. 40-50%
E. 15-25%

740. Answer: A
Explanation:
(Raj, Practical Mgmt of Pain, 3rd Ed., page 802)
Long term relief of brachial plexus avulsion pain with
DREZ lesioning is 60-65% at 3-7 years. Phantom and
stump pain success is about 50-60%. Spinal cord injury
pain is usually not responsive, except for end zone pain
(segmental) occurring just below the level of injury. 70-
75% of patients report successful relief with end zone pain.
Source: Schultz D, Board Review 2004

3

741. The anterior spinothalamic tract:
A. Is the primary target of a cordotomy
B. Primarily conveys proprioceptive afferent fi bers
C. Primarily conveys small fi ber afferents.
D. Conveys light touch.
E. Conveys temperature sensation

741. Answer: D
Source: Feler C, Board Review 2005

4

742. Which of the following carries the lowest risk of
complications?
A. Microvascular decompression
B. Subtemporal sensory rhizotomy
C. Selective trigeminal rhizotomy
D. Open trigeminal (nucleus caudalis) tractotomy
E. Stereotactic trigeminal tractotomy

742. Answer: A
Explanation:
(Raj, Pain Review 2nd Ed., page 311, Raj, Practical Pain
Mgmt, 3rd Ed. Page
798, Bonica 3rd ed. Page 2042-2043)
Microvascular decompression, initially developed by
Janetta, is a non-destructive and potentially curative
operation for trigeminal neuralgia. A pulsating aberrant
vessel loop, e.g., superior cerebellar artery (V3),
trigeminal vein (V2), or anterior inferior cerebellar artery
(V1), is felt to be the cause. An interposition felt of Tefl on
or polyvinyl sponge is placed between the vessel loop and
the trigeminal nerve. Recall, V1+V2+V3 --> TG -->
Trigeminal Nerve --> Brainstem. Although, complications
such as cerebellar or brainstem strokes, CSF leaks,
meningitis…complication rates are

5

743. Dextrose is added to lidocaine, during a spinal anesthetic.
Which position would most likely result in anesthesia of
the sacral dermatomes?
A. Prone
B. Side-lying
C. Jack Knife
D. Sitting upright
E. Trendelenburg

743. Answer: D
Explanation:
(Raj, Practical Management of Pain, 3rd Ed., page 632,
635)
Baricity of a local anesthetic is described as the density of a
local anesthetic solution divided by the density of CSF. The
density of CSF is 1.001 to 1.005 at 37°C. Local anesthetic
solutions are characterized relative to CSF as hyperbaric,
hypobaric, or isobaric. Understanding this density
relationship allows the anesthesiologist to take advantage
of the characteristics of the local anesthetic or the position
of the patient to direct local anesthetic toward the
dermatomes to be anesthetized. A hyperbaric solution has
a higher specifi c gravity than CSF, so that it moves to lowlying
parts of the subarachnoid.
Although prone may result in blockade of the sacral
dermatomes, the sitting position would do this most
effectively, by having the bulk of the local anesthetic dose
go towards the sacral nerve roots.
Source: Shah RV, Board Review 2005

6

744. The most widely practiced percutaneous technique for
relief of trigeminal neuralgia is:
A. Glycerol rhizolysis
B. Balloon-catheter decompression
C. Microvascular decompression
D. Radiofrequency thermocoagulation
E. Radiosurgery

744. Answer: D
Explanation:
(Raj, Pain Review 2nd Ed, page 311)
Radiofrequency thermocoagulation of the trigeminal
ganglion is the most widely practiced percutaneous
intervention. MVD and radiosurgery are not percutaneous
methods.
Source: Schultz D, Board Review 2004

7

745. What percentage of patients is affl icted by
glossopharyngeal neuralgia compared to trigeminal
neuralgia?
A. 0.1-0.5%
B. 1-2%
C. 10-15%
D. 30-40%
E. 10-20%

745. Answer: B
Explanation:
(Raj, Pain Review 2nd Ed., page 312)
Glossopharyngeal neuralgia affl icts 1-1.3% as many
individuals as trigeminal neuralgia. The lancinating,
paroxysmal qualities are similar but the pain is located at
the base of the tongue, throat, and deep in the ear. Triggers
include chewing and swallowing. GPN may rarely be
associated with syncope or bradycardia.
Source: Schultz D, Board Review 2004

8

746. Rotator cuff tear is diagnosed by:
A. Plain radiographs
B. MRI
C. MR arthrography
D. CT
E. Sonography

746. Answer: B
Explanation:
MRI provides the greatest imaging resolution and
complete evaluation in the setting of shoulder pain.
Although a rotator cuff tear may be diagnosed with
ultrasound or MR arthrography, diagnostic MRI remains
the best modality in MRI compatible patients
Source: Bieneman B, Board Review 2005

9

747. As a part of a psychological evaluation, a clinical interview
includes all of the following EXCEPT:
A. History
B. Financial and legal information
C. General medical status
D. Psychosocial information
E. Pain tolerance testing

747. Answer: E
Source: Janata JW, Board Review 2005

10

748. While performing a right lumbar sympathetic
radiofrequency lesioning, at L3, the patient complains
of pain in the right groin. What is the likely etiology of
this pain?
A. Lesioning of the ilioinguinal nerve
B. Psoas spasm
C. Lesioning of the iliohypogastric nerve
D. Lesioning of the genitofemoral nerve
E. Quadratus spasm

748. Answer: D
Source: Day MR, Board Review 2005

11

749. Which of the following is a true statement regarding a
thoracic sympathetic block?
A. Can only be performed with the patient in the prone
position.
B. Can be performed bilaterally at the same visit.
C. Pneumothorax is not a concern.
D. Blocks Kuntz’s fi bers
E. Not effective for treating thoracic visceral pain.

749. Answer: D
Source: Day MR, Board Review 2005

12

750. Which of the following factors infl uence the spread of
local anesthetic in the subarachnoid space the most?
A. baricity
B. barbotage
C. anesthetic dose
D. injection level
E. injection speed

750. Answer: A
Explanation:
(Raj, Practical Mgmt of Pain 3rd Ed., page 635)
Factors affecting the spread of local anesthetic include (1)
baricity of the local anesthetic, (2) position of the patient
after injection, (3) level of injection, (4) speed of injection,
(5)dose and volume of the local anesthetic used, and (6) a
technique known as barbotage. Of these, the two with the
greatest infl uence are the baricity of the local anesthetic
and the position of the patient.
Source: Shah RV, Board Review 2005

13

751. The somatoform condition with the lowest incidence is:
A. Factitious disorder
B. Hypochondriasis
C. Conversion disorder
D. Somatization disorder
E. Malingering

751. Answer: C
Source: Janata JW, Board Review 2005

14

752. The following is (are) true regarding Deep Brain
Stimulation (DBS):
A. Deep brain stimulation is an effective method for controlling
back pain.
B. It is FDA approved for painful conditions.
C. It is FDA approved for spasticity
D. It is FDA approved for some movement disorders
E. Two of the above

752. Answer: D
Source: Feler C, Board Review 2005

15

753. Which of the following is true?
A. “Radiculopathy” requires no neurologic defi cit
B. Any patient who has had prior lumbar spine surgery
who later presents with low back pain should be considered
to have FBSS.
C. A refl ex change alone is suffi cient to diagnose a
radiculopathy
D. Discogenic pain typically radiates into the affected dermatome
E. Two of the above

753. Answer: C
Source: Feler C, Board Review 2005

16

754. The following is not true:
A. MRI evidence of degenerative disc disease is necessary
for consideration of spinal instrumentation
B. A patient complaining of mechanical back pain who
has no evidence of instability is properly selected for
decompression of a nerve root without stabilization.
C. SCS is an FDA approved therapy for many indications
D. The L4 disc is usually the level of disease in a L5
radiculopathy
E. An absent ankle refl ex is indicative of a S1
radiculopathy

754. Answer: A
Source: Feler C, Board Review 2005

17

755. Subarachnoid hemorrhage is best diagnosed by what
test?
A. Enhanced CT
B. Unenhanced CT
C. Enhanced MRI
D. Unenhanced MRI
E. Skull radiographs

755. Answer: B
Explanation:
Noncontrast CT brain is the appropriate exam for any
acute neurologic abnormality
Source: Bieneman B, Board Review 2005

18

756. Which of the following opioids should be avoided in a
patient with renal disease?
A. Meperidine
B. Sufentanil
C. Morphine
D. Hydrocodone
E. Hydromorphone

756. Answer: A
Source: Day MR, Board Review 2005

19

757. Thalamic lesioning is usually used to treat:
A. Shooting, allodynic pain
B. Deafferentation pain
C. Burning, dysesthetic pain
D. Peripheral nociceptive pain
E. Radicular pain

757. Answer: A
Explanation:
(Raj, Pain Review 2nd Ed., page 309)
Thalamotomy is useful for intermittent, shooting,
hyperpathic or allodynic pain. Thalamotomy may not be
useful for burning, dysesthetic, central, or deafferentation
pain. Thalamotomy is not useful for peripheral nociceptive
pain. One of the most effective targets is the inferior
posteromedial thalamus.
Source: Schultz D, Board Review 2004

20

758. A conversion disorder is:
A. Intentionally produced or feigned
B. Limited to pain
C. Suggestive of a neurological or general medical condition
D. Explainable by the effects of a substance.
E. Unrelated to functional impairment

758. Answer: C
Source: Janata JW, Board Review 2005

21

759. Munchhausen syndrome is an type of:
A. Hypochondriacal presentation
B. Conversion disorder
C. Somatization disorder
D. Personality disorder
E. Factitious disorder

759. Answer: E
Source: Janata JW, Board Review 2005

22

760. Which of the following is true about the stellate
ganglion?
A. Everybody has one
B. It is located at C6
C. It is formed by the fusion of the inferior cervical and fi rst
thoracic ganglion.
D. It is bordered anteriorly by the vertebral artery.
E. Blockade of the ganglion reliably causes a sympathectomy
of the ipsilateral upper extremity.

760. Answer: C
Source: Day MR, Board Review 2005

23

761. Somatization disorder criteria include all of the following
EXCEPT:
A. A history of many physical complaints
B. Onset after age 30
C. Four pain symptoms
D. Two gastrointestinal symptoms
E. One sexual symptom

761. Answer: B
Source: Janata JW, Board Review 2005

24

762. The presence of pain behavior in chronic pain
presentations:
A. is an indication of psychopathology
B. is abnormal in chronic pain populations
C. indicates that pain is “all in the patient’s head”
D. indicates the absence of true pathophysiology
E. is a normal adaptation to an abnormal set of circumstances

762. Answer: E
Source: Janata JW, Board Review 2005

25

763. With respect to cortical stimulation:
A. It is FDA approved for the treatment of atypical facial
pain.
B. There is suffi cient evidence based medicine to recommend
the procedure for patients with Anesthesia Dolorosa
of the face.
C. The procedure is easy to do for leg pain
D. Complication rates for the procedure are reasonabable
E. B and D are true

763. Answer: D
Source: Feler C, Board Review 2005

26

764. In taking the pain history, what factors are critical to
assess?
A. Temporal features
B. Expectational values of the patient
C. Educational features of the patient
D. All of the above
E. None of the above

764. Answer: A
Explanation:
The pain history should include temporal, provocative,
alleviative, and causative (initiative) parameters/ factors of
a particular patent’s pain.
Expectational values and educational features of the
patient may contribute to pain intensity, duration,
expression,and amenability to treatment, but are not
constituents of the pain history.
Source: Giordano J, Board Review 2005

27

765. Of the following statements pertaining to post lumbar
puncture headaches, which is least accurate? Choose one:
A. Age, female gender, body mass index, and history of recurrent
headaches are major risk factors for PLPH.
B. 80% of the cases of PLPH occur within 48 hours of the
procedure.
C. 30 cc’s of CSF taken will not induce a headache by volume
loss and will be replaced within 90 minutes given
that CSF is produced at a rate of 1cc/3 minutes or approximately
500 cc’s a day.
D. 30 cc’s of CSF taken will likely induce a headache by
volume loss but will be replaced within 270 minutes
given that CSF is produced at a rate of 1cc/9 minutes or
approximately 150 cc’s a day.
E. Lying prone for 1 hour and drinking 24 ounces of water
after a LP has been shown to decrease the incidence of
PLPH.

765. Answer: D
Source: Goodwin J, Board Review 2005

28

766. Personality disorders are easily diagnosed by:
A. Careful history-taking
B. Clinical interview
C. Observing waiting room behavior
D. Utilizing the Symptom Checklist – 90
E. None of the above

766. Answer: C
Source: Janata J, Board Review 2006

29

767.The presence of pain behavior in chronic pain
presentations:
A. indicates that pain is “all in the patient’s head”
B. is a normal adaptation to an abnormal set of circumstances
C. is an indication of psychopathology
D. is abnormal in chronic pain populations
E. indicates the absence of true pathophysiology

767. Answer: C
Source: Janata J, Board Review 2006

30

768. Münchhausen syndrome is a type of:
A. Somatization disorder
B. Factitious disorder
C. Conversion disorder
D. Hypochondriacal presentation
E. Personality disorder

768. Answer: B
Source: Janata J, Board Review 2006

31

769. The somatoform condition with the lowest incidence is:
A. Malingering
B. Somatization disorder
C. Factitious disorder
D. Conversion disorder
E. Hypochondriasis

769. Answer: D
Source: Janata J, Board Review 2006

32

770. Diagnostic of which plexus nerve should be performed
for the testicular pain?
A. Splanchnic nerves
B. Lumbar sympathetic nerves
C. Hypogastric plexus
D. Genitofemoral nerve
E. Ganglion impar

770. Answer: A
Source: Day MR, Board Review 2005

33

771. Tietze’s syndrome is defi ned as unilateral costochondritis
of what rib level/s?
A. 1st and 2nd
B. 2nd and 3rd
C. 3rd and 4th
D. 2nd only
E. 3rd only

771. Answer: B
Source: Day MR, Board Review 2006

34

772. Which statement regarding occipital nerve stimulation
is true:
A. The electrode is placed transversely in the subcutaneous
tissue plane overlying C1-2.
B. The technique is contra-indicated in patients who have
undergone posterior cervical spine surgery.
C. Paresthesias are typically felt in the ipsilateral occiput
and down the ipsilateral arm
D. Bilateral occipital leads are contraindicated
E. A stimulation trial is not necessary prior to implant

772. Answer: A
Explanation:
With occipital nerve stimulation, the lead is placed
transversely in the subcutaneous tissue plane overlying
C1-2, Unilateral or bilateral leads can be placed depending
on the patients’ pain pattern. Paresthesias are typically felt
in the occiput and sometimes in the posterior neck and
shoulder but do not radiate down the arm.The technique
is extraspinal so it can be used in patients’ who have
undergone previous posterior cervical spine surgery. As
with all neurostimulation, a successful trial of stimulation
is a necessary prerequisite for implant.
Reference:
Heavner, Interventional Pain Management, Second
Edition; Chapter 57 Peripheral Nerve Stimulation:
Current Concepts
Source: Schultz D, Board Review 2004

35

773. Regarding meningitis, which of the following best
suggests meningeal irritation? Choose one:
A. Bilateral Horner’s syndrome
B. Inability to stay awake
C. A stiff neck coupled with Kernig’s and Brudzinski’s
signs
D. Inability to fall asleep because of headache-induced
nausea
E. Opisthotonus

773. Answer: C
Source: Goodwin J, Board Review 2005

36

774. Self-effi cacy is synonymous with:
A. Exclusive reliance on pain interventions
B. External locus of control
C. Internal locus of control
D. Social support
E. Euthymia

774. Answer: C
Source: Janata JW, Board Review 2005

37

775. Malingering involves production of false or exaggerated
symptoms that are:
A. Intentionally produced
B. Unconsciously motivated
C. Symptomatic of a psychotic process
D. Easily detectable on exam
E. Associated with family history of depression

775. Answer: A
Source: Janata JW, Board Review 2005

38

776. Exclusion criteria for group therapy include all of the
following EXCEPT:
A. Severe depression
B. Pain behavior
C. Signifi cant personality disorders
D. Capacity for violence
E. Signifi cant history of noncompliance

776. Answer: B
Source: Janata JW, Board Review 2005

39

777. After heat radiofrequency lesioning of the right
sphenopalatine ganglion, the patient complains of right
upper tooth numbness. What is the likely explanation?
A. The greater palatine nerve was lesioned as well
B. The lesser palatine nerve was lesioned as well
C. The Vidian nerve was lesioned as well
D. The maxillary nerve was lesioned as well
E. The mandibular nerve was lesioned as well

777. Answer: D
Source: Day MR, Board Review 2005

40

778. All of the following neurosurgical procedures for pain
relief have historically been used for the treatment of
psychiatric conditions except:
A. Cingulotomy
B. Anterior capsulotomy
C. Leucotomy
D. Hypothalamotomy
E. Subtemporal sensory rhizotomy

778. Answer: E
Explanation:
(Raj, Pain Review 2nd Ed., pages 309-311)
Cingulotomy, anterior capsulotomy (anterior limb of
internal capsule), leucotomy (pre-frontal lobotomy), and
hypothalamotomy have been used for intractable cancer
pain in multiple sites and for psychiatric disorders, such as
obsessive compulsive disorders. Hypothalamotomy, in
fact, may be benefi cial if there is a strong emotional
component to the pain. Subtemporal sensory rhizotomy
was the main operation performed for trigeminal
neuralgia before the 1950s’. Unfortunately, recurrence
rates ranged from 5-20% and there was a high incidence of
complications: anesthesia dolorosa, dyesthesias, keratitis.
Source: Schultz D, Board Review 2004

41

779. Which heating method is contraindicated in patients
with spinal cord stimulation?
A. Diathermy
B. Hydrotherapy
C. Heat Lamps
D. Paraffi n
E. Hot packs

779. Answer: A
Explanation:
Diathermy is contraindicated in patients with spinal cord
stimulation
Source: Shah RV, Board Review 2005

42

780. Proper patient positioning for a subarachnoid phenol
block is:
A. Painful side up with no tilt
B. Painful side down with no tilt
C. Painful side up with the patient tilted anteriorly 45°.
D. Painful side down with the patient tilted posteriorly 45°.
E. Painful side down with the patient tilted anteriorly 45°.

780. Answer: C
Source: Day MR, Board Review 2005

43

781. In which of the following types of patients would
you expect the best results following a surgical
sympathectomy?
A. Failure of response to sympathetic blocks
B. Raynaud’s syndrome
C. Diabetic peripheral neuropathy
D. Phantom limb pain
E. Spinal cord injury end zone pain

781. Answer: B
Explanation:
(Raj, Practical Management of Pain, page 803; Raj, Pain
Review 2nd Ed. Page 314).
All surgical sympathectomy should be prognosticated by a
series of sympathetic blocks which unequivocally give a
positive response. That being said, all of the above
disorders may have a sympathetically maintained
component. However, a painful vasospastic disorder such
asRaynaud’s or complex regional pain syndrome would do
the best. Central and chronic peripheral pain syndromes
are less predictable.
Source: Schultz D, Board Review 2004

44

782. What is true about Tuffi er’s line?
A. It represents a horizontal line connecting the superiormost
aspects of the palpable iliac crests
B. It can be identifi ed, by using the inferior poles of the
scapulae as landmarks
C. It can be helpful in performing cervical epidural anesthesia
D. It is an imaginary line connecting the C7 and L5 spinous
processes
E. It represents needle trajectory during the performance of
a spinal anesthetic

782. Answer: A
Explanation:
(Raj, Practical Mgmt of Pain, 3rd Ed., page 634)
Spinal anesthesia is usually instituted with a needle
inserted at an easily palpable interspace below L2.
Depending on the patient’s individual anatomical features,
the second, third, or fourth lumbar interspace may be
selected. After the most prominent point of the iliac crests
is located, an imaginary line is drawn between them
(Tuffi er’s line), which usually crosses the L4 spinous
process or the L4-L5 interspace.
Source: Shah RV, Board Review 2005

45

783. The following are necessary of successful spinal cord
stimulation implant except:
A. Paresthesia sensation that overlaps region of pain
B. Comfortable paresthesia
C. Pain relief at low amplitudes
D. Intact cognitive abilities of the patient recipient
E. Absence of stimulation in nonpainful targets

783. Answer: C
Explanation:
Reference:
Bedder, Interventional Pain Management, Second Edition;
Chapter 55 Implantation Techniques for Spinal Cord
Stimulation
Successful SCS implant requires a comfortable paresthesia
sensation that overlaps the area of pain. This should be
demonstrated in a trial of stimulation with the selected
device prior to a decision to implant. The patient should
have reasonably intact cognition because spinal cord
stimulation requires the patient to turn on and off the
device, keep track of the external programmer and be able
to manage a certain amount of technology. Many patients
with successfully implanted stimulators have paresthesia
sensation in areas outside the pain target region. This is
not necessarily a problem. Pain relief at low amplitudes is
desirable but not required since an RF system with an
external battery source can be used in these cases.
Source: Schultz D, Board Review 2004

46

784. A far left lateral disc bulge at the L4-5 level will likely
affect which nerve root?
A. The left L5 nerve root
B. The left L4 nerve root
C. The left L4 and L5 nerve roots
D. The bilateral L4 nerve roots
E. The bilateral L4 nerve roots

784. Answer: B
Source: Bieneman B, Board Review 2005

47

785. Which of the following regarding pontine spinothalamic
tractotomy is true?
A. A more caudal level of analgesia may be obtained compared
to a high cervical cordotomy
B. There is minimal risk of obstructive sleep apnea compared
to high cervical cordotomy
C. Pancoast tumor-related pain is not an indication
D. One theoretical advantage over mesencephalotomy is
that the neospinothalamic and paleospinothalamic
fi bers are in closer proximity
E. Oculomotor disturbances are common

785. Answer: D
Explanation:
(Raj, Pain Review 2nd Ed., pages 310; Bonica 3rd Ed.,
pages 2048-9 & 2052-4;
Raj, Practical Mgmt of Pain 3rd Ed., pg 795)
Pontine spinothalamic tractotomy produces a more rostral
level of analgesia compared to a high cervical cordotomy.
Hence, it was introduced for neck and shoulder pain. C1-2
cordotomy at was among the most useful procedures for
unilateral cancer pain below the C5 dermatome. Both
pontine spinothalamic tractotomy and high cervical
cordotomy carry a similar risk of paralyzing the automatic
phase of respiration and thus, causing sleep apnea. Neck
and shoulder pain due to cancer, e.g., Pancoast tumor, are
indications for pontine spinothalamic tractotomy. The
neospinothalamic (spatial and temporal aspects of painful
stimuli and more laterally located) and paleospinothalamic
(affective and motivational aspects of painful stimuli and
more medially located)are closer together at the pontine as
compared to the midbrain (mesencephalotomy) level.
Oculomotor complications are common at the midbrain
level due to the proximity of the oculomotor nucleus and
medial longitudinal fasciculus. However,
mesencephalectomy does not carry a risk of sleep apnea.
Source: Schultz D, Board Review 2004

48

786. For a patient presenting with a left facial droop and right
upper extremity paresis, the most likely site of the lesion
is:
A. Brainstem
B. Right parietal lobe
C. Origin of the left facial nerve and left motor cortex
D. Anterior bundle of the corpus collosum
E. Left frontal lobe

786. Answer: A
Source: Goodwin J, Board Review 2005

49

787. Splenic laceration is best diagnosed by which of the
following tests?
A. Ultrasound
B. Plain radiographs
C. CT
D. MR
E. Sulfur colloid scan

787. Answer: C
Explanation:
CT is the appropriate imaging modality in acute
abdominal emergencies and is preferred with IV contrast
for abdominal trauma
Source: Bieneman B, Board Review 2005

50

788. Which of the following statements about nystagmus are true? Choose one:
A. Attenuating nystagmus may be a medication side effect
B. Immediate-onset nystagmus usually implicates inner ear
pathology
C. Delayed-onset nystagmus is a common cerebellar disease
fi nding
D. Nystagmus generally precedes and therefore heralds a neuromuscular junction disorder such as myesthenia
gravis, so one should initiate a search for a small cell
carcinoma of the lung.
E. A, B and C are correct

788. Answer: A
Source: Goodwin J, Board Review 2005

51

789. Referred pain from pericarditis is felt where?
A. Left shoulder
B. Right shoulder
C. Left upper quadrant of the abdomen
D. Right upper quadrant of the abdomen
E. Mid epigastrium

789. Answer: A
Source: Day MR, Board Review 2006

52

790. The 2004 International Headache Society’s revised
criteria for chronic tension- type headache (TTH),
requires a frequency over time consistent with which
one of the following:
A. 15 or more days per month over a minimum of 3
months
B. No more than 6 headache-free days in a 3 month period
C. No fewer than 2 days involvement per week for a minimum
of 3 months
D. Between 1 and 14 days per month over a 3 month period
E. An average of 60 days per year for at least 60 months (5
years

790. Answer: A
Source: Goodwin J, Board Review 2005

53

791. Current Perception Threshold testing:
A. Can evaluate small nerve fi bers impossible to assess on
standard EMG/NCS’s
B. Is of minimal value in the blind because visual perception
of stimuli is key to accuracy
C. Is very expensive to perform and therefore not widely
available
D. Is of little value in assessing pain and temperature
thresholds because the nerve fi bers are too small
E. Is of greatest value where axonal versus demyelinating
neuropathies need clarifi cation

791. Answer: A
Source: Goodwin J, Board Review 2005

54

792. Regarding plexopathies, which of the following is true?
A. Both the H-refl ex and F-waves may be prolonged
B. The H-refl ex and F-waves are usually normal
C. Fibrillations in paraspinal muscles do not rule in a
plexopathy, but are suggestive of it
D. Current perception threshold testing is less expensive
and more sensitive than EMG
E. Loss of an F-wave is meaningless because the action
potential is impeded by a proximal lesion and therefore
cannot be assessed with accuracy

792. Answer: A
Source: Goodwin J, Board Review 2005

55

793. The initial imaging modality recommended for evaluation
of traumatic odontoid (dens) fracture is?
A. X-ray tomograms of the odontoid process
B. Plain radiographs with lateral and open mouth views
C. CT scan with axial and coronal recontructions
D. T1-weighted MRI sagittal and coronal views
E. Triple phase bone scan to identify fracture line

793. Answer: B
Source: Bieneman B, Board Review 2005

56

794. Nociception of the pancreas is mediated through which
splanchnic nerves?
A. T5-9
B. T10-11
C. T12
D. T8-11
E. T10-12

794. Answer: A
Explanation:
Reference: Raj and Patt. Chapter 11. Visceral Pain. In:
Pain Medicine: A Comprehensive review, 2nd Edition. Raj,
Mosby, 2003, page 101.
Source: Day MR, Board Review 2005

57

795. Which of the following does not characterize pelvic
congestion syndrome?
A. There is no identifi able pathologic condition
B. Pain is dull and achy
C. Complaints of suprapubic pain
D. May have psychosomatic features such as headaches and
urinary symptoms
E. Common in post-menopausal women

795. Answer: E
Explanation:
Reference: Raj and Pott. Chapter 11. Visceral Pain. In Pain
Medicine: AComprehensive Review, 2nd Edition, Raj,
Mosby, 2003, page 102
Source: Day MR, Board Review 2005

58

796. All of the following are complications of a celiac/
splanchnic block except:
A. Constipation
B. Hypotension
C. Paraplegia
D. Pneumothorax
E. Vascular injury

796. Answer: A
Explanation:
Reference: Raj and Patt. Chapter 11. Visceral Pain. In:
Pain Medicine: AComprehensive Review, 2nd Edition, Raj,
Mosby, 2003, page 105
Source: Day MR, Board Review 2005

59

797. True statements regarding Sacroiliac joint dysfunction
include all of the following except:
A. Pain radiating to hip, back, and thigh
B. Pain worsened by twisting movements
C. Straight leg raising may be positive
D. Pain worsened by sitting on the contralateral ischeal
tuberosity
E. May cause hamstring spasm

797. Answer: D
Explanation:
Reference: Raj. Chapter 43. Thoracoabdominal Pain. In:
Practical Management of Pain.
3rd Edition. Raj et al, Mosby, 2000. page 627.
Source: Day MR, Board Review 2005

60

798. When present, which of the following refl exes or signs
best localizes an upper motor lesion to a level above the
cervical spinal cord? Choose one:
A. Brisk jaw jerk
B. Babinski sign (upgoing toe)
C. Hoffman sign
D. Loss of the superfi cial abdominal refl exes
E. Clonus of one or both ankles

798. Answer: A
Source: Goodwin J, Board Review 2005

61

799. The most appropriate imaging modality for acute
headache is
A. Magnetic resonance imaging
B. Computed tomography
C. Magnetic resonance angiography
D. Intravenous angiography
E. Duplex scanning

799. Answer: B
Source: Bieneman B, Board Review 2005

62

800. What percentage of community-dwelling elderly suffer
from chronic pain?
A. 10-20%
B. 20-25%
C. 25-50%
D. 50-60%
E. > 60%

800. Answer: C
Source: Day MR, Board Review 2006

63

801. Classic features of a syrinx include:
A. Dissociated sensory loss
B. Long tract signs below the level of the lesion
C. Bowel or bladder dysfunction
D. All of the above
E. None of the above

801. Answer: D
Source: Wirght PD, Board Review 2004

64

802. Shoulder shrug tests which nerve?
A. Vagus
B. CN X
C. CN XII
D. Accessory Nerve
E. Phrenic Nerve

802. Answer: D
Source: Wirght PD, Board Review 2004

65

803. The corneal refl ex tests the trigeminal nerve and:
A. Vagus nerve
B. Spinal accessory nerve
C. Facial nerve
D. Oculomotor nerve
E. None of the above

803. Answer: C
Source: Wirght PD, Board Review 2004

66

804. The true statements about electromyography and nerve
conduction velocity:
A. Electromyographic changes occur within 24 h of neural
injury
B. Testing of neural conduction velocity is more sensitive
than electromyography in the early stages of neural
injury
C. Increased motor potential in muscle groups occurs with
neural injury
D. Increased neural conduction velocity occurs with neural
injury
E. Changes in neural conduction velocity take weeks to
become apparent after neural injury

804. Answer: B
Explanation:
Reference: Tollison, p 326.
If neural injury is suspected, electromyography and testing
of neural conduction velocity can provide information as
to the extent and location of injury.
With neural injury, a decrease in motor potential in
muscle groups and slowed conduction velocities occur.
Neural conduction velocities are decreased quickly after
neural injury.
Electromyographic changes may take weeks to occur.
Therefore, testing of neural conduction velocity is more
sensitive than electromyography in the early stages of
neural injury.
Source: Kahn and Desio

67

805. Spine myelography:
A. Contrast is instilled into the epidural space
B. Contrast is instilled into the subdural space
C. Contrast is instilled into the subarachnoid space
D. Myelography is not used for patients with MR contraindications
E. Myelography is preferable to MR for pregnant patients

805. Answer: C
Source: Bieneman B, Board Review 2005

68

806. In studying the interaction of psychological stress and
DNA repair, suppressed DNA repair was found in persons
with
A. Chronic stress more often than those with acute stress
B. Low distress over an extended period of time
C. A diagnosis of major depression
D. Increased anxiety and depression from bereavement
E. Recently diagnosed cancer

806. Answer: C
Explanation:
(Baum, pp 194-198.)
·In studying peripheral blood lymphocytes (PBLs) from
patients with a major depression,it was found that they
had poorer DNA repair (PBLs exposed to radiation
damage) than lymphocytes obtained from nondepressed
or low-distressed persons. When patients with a diagnosis
of major depression were divided into low and highdistress
subgroups, the PBLs from the high-distress
subgroup had poorer DNA repair than the PBLs from the
low-distress subgroup.
·While acute stress is immunosuppressive, chronic stress
over time is associated with adaptation and can even
enhance immunity.
·It is hypothesized that the impact of psychosocial stress
(distress) on DNA repair could increase cancer risk. While
the impact of psychosocial stress and DNA repair on the
initiation of cancer has not been demonstrated, stressinduced
suppression of the immune system, and
enhancement of the immune system, has been shown to
affect the growth and progression of neoplasms.
·The increased anxiety and depression from bereavement
does produce suppressed lymphocyte proliferative
response to mitogen stimulation 2 to 6 weeks after the
death of a spouse.
Source: Ebert 2004

69

807. A 67-year-old man with lung cancer presents with
metacarpophalangeal joint pain. On physical
examination, there is pain on moving his fi ngers and a
spongy sensation when palpating the proximal aspects of
the fi ngernails. CHOOSE ACCURATE DIAGNOSIS:
A. Refl ex sympathetic dystrophy
B. Ankylosing spondylitis
C. Reiter syndrome
D. Hypertrophic osteoarthropathy
E. Charcot joint

807. Answer: D
Explanation:
(Goldman, 21/e, p 1558.)
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.

70

808. Depletion of which neurotransmitter in the substania
nigra is associated with Parkinson’s disease?
A. Acetylcholine
B. Epinephrine
C. Calcitonin gene-related peptide
D. Dopamine
E. Substance P

808. Answer: D
Source: Day MR, Board Review 2006

71

809. A 42-year-old woman (5 ft, 3in., 170 lb) complains of
sudden onset of severe pain in the right upper abdomen
“under the ribs” accompanied by sweating, nausea, and a
feeling of imminent collapse. The pain lasts for about two
hours and then persists as a dull ache. When seen several
hours later, she has normal bowel sounds, is tender
throughout the abdomen, especially in the right upper
quadrant, and is faintly icteric. She has noticed her urine
is darker than usual but has not passed stool recently. She
recalls occasional episodes of “indigestion” referred to
the right upper abdomen and radiating to the shoulder.
This has occurred especially after eating fried foods or
after eating a meal following a long period of fasting.
She has no fever but is anxious and tachycardic.The
tests available are a blood count and blood chemistry
including liver enzymes, alkaline phosphatase, and
bilirubin. She has a WBC of 10,000. Her cellular hepatic
enzymes are: AST/SGOT = 52 (2-33) and ALT/SGPT = 70
(4 to 44), alkaline phosphatase = 300 (17 to 91), bilirubin
= 6.3 (0.2 to 1.0).The most probable diagnosis is
A. Hepatitis A
B. Intercostal neuritis
C. Carcinoma of the head of the pancreas
D. Gallstone obstructing common bile duct
E. Biliary cirrhosis

809. Answer: D
Explanation:
(Braunwald, 15/e, pp 255-259, 1785. Kumar, 6/e, pp 550-
552. Junqueira, 9/e, pp 318-319. Guyton, l0/e, pp 800-801.)
The most probable diagnosis is gallstones. The pattern
of elevated liver enzymes, alkaline phosphatase, and
bilirubin are consistent with obstructive jaundice (see
table below). The presence of pain (in the right upper
quadrant radiating to the shoulder) after eating a meal
consisting of fried foods makes gallstones the most
probable diagnosis. Similar pain often occurs in these
patients when they have not eaten for long periods of time
and then have a large meal. The pain is caused by the
obstruction of the cystic duct or common bile duct that
produces increased lumenal pressure within the bile
vessels, which cannot be compensated for by
cholecytokinin-induced contractions. The pain lasts for
about one to four hours as a steady, aching feeling.
Source: Klein RM and McKenzie JC 2002.

72

810. Which of the following words is defi ned as A chronic
preoccupation with obtaining the substance of choice
and misuse or overuse of the substance despite negative
consequences?
A. Tolerance
B. Physical dependence
C. Pseudo addiction
D. Psychological dependence
E. Addict

810. Answer: D
Source: Day MR, Board Review 2006

73

811. What is the most frequent initial site of metastatic tumor
spread to the spine?
A. Bone marrow
B. Vertebral pedicle
C. Nucleus pulposus
D. Epidural space
E. Posterior elements

811. Answer: A
Explanation:
Because of its high vascularity, bone marrow is involved
fi rst, with extension to pedicle and posterior elements.
Extension to epidural space may occur from vertebra or
through foramen.
Source: Bieneman B, Board Review 2005

74

812. Which of the following type A, or coronary-prone,
behavioral factors appears to be the best predictor of
coronary heart disease?
A. Hostility
B. Competitiveness
C. Time Urgency
D. Explosive speech
E. Hyperactivity

812. Answer: A
Explanation:
(Baum, pp 144-148.)
Among the psychosocial variables
considered to be risk factors for coronary heart disease, the type behavior pattern is most prominent. The type A
behavior pattern is most prominent. The type A behavior
pattern consists of extremes of competitiveness, a chronic
sense of time urgency, easily evoked hostility,
aggressiveness, explosive speech, and increased rate of
activity. More recent studies have shown that
aggressiveness and hostility (especially unexpressed
hostility) are the most consistent and important factors
Source: Ebert 2004

75

813. The most common cause of peripheral neuropathy is:
A. Idiopathic
B. Diabetes Mellitus
C. Nutritional Defi ciencies
D. ETOH
E. None of the above

813. Answer: B
Source: Wirght PD, Board Review 2004

76

814. In the clinical assessment of neuropathic pain, which
procedure(s) should be included in the diagnostic
workup?
A. EMG and/or NCV
B. Laboratory evaluations
C. Imaging studies
D. All of the above
E. None of the above

814. Answer: D
Source: Giordano J, Board Review 2003

77

815. The best defi nition for a vertebral disc bulge is which of
the following?
A. An intraverterbral disk herniation (Schmorl’s node)
B. Disruption of concentric fi bers of the annulus fi brosis
C. Generalized extension of disc material beyond the edge
of the vertebra involving 180°
D. Localized displacement (

815. Answer: C
Source: Bieneman B, Board Review 2005

78

816. A complete electrodiagnostic evaluation would include
all the following EXCEPT
A. Electromyography and late response studies
B. Peripheral nerve conduction studies of motor and sensory
nerves
C. Muscle biopsy
D. Somatosensory evoked potentials
E. Radiologic evaluation

816. Answer: C
Explanation:
Reference: Bonica, p 629.
The electromyogram (EMG), peripheral nerve conduction
studies (NCSs), late response studies, and somatosensory
evoked potentials (SEPs) help to characterize the nature
and location of the abnormality being studied.
Determination of the cause of the abnormality can occur
only after integration of the information obtained from
the physical examination, history, and electrodiagnostic
and radiologic studies.
Muscle biopsy is not a component of electrodiagnostic
evaluation.
Source: Kahn and Desio

79

817. A celiac-plexus block would not effectively treat pain
resulting from a malignancy involving the following
organs:
A. Ureter
B. Adrenal gland
C. Stomach
D. Pancreas
E. Gallbladder

817. Answer: A
Explanation:
The celiac-plexus innervates most of the abdominal
viscera, including the pancreas, liver, spleen, kidneys,
adrenal glands, biliary tract, omentum, and small and large
bowel.
The pelvic organs are supplied by the hypogastric
plexus.

80

818. Traditional psychotherapy emphasizes all of the following
EXCEPT:
A. Formation of defense mechanisms
B. Psychosexual development
C. The role of environmental reinforcement
D. The therapeutic process of transference
E. The relationship between conscious and unconscious
processes

818. Answer: C
Source: Janata JW, Board Review 2005

81

819. Positive reinforcement refers to:
A. A stimulus that increases the likelihood that a certain
behavior will be maintained or repeated
B. A consequence that decreases the likelihood that a certain
behavior will be maintained or repeated
C. A consequence that increases the likelihood that a certain behavior will be maintained or repeated
D. A stimulus that decreases the likelihood that a certain
behavior will be maintained or repeated
E. A consequence that does not infl uence the likelihood that
a certain behavior will be maintained or repeated

819. Answer: C
Source: Janata JW, Board Review 2005

82

820. Which of the following medications does not potentiate
opioid respiratory depression?
A. Dexmetetomidine
B. Methohexital
C. Etomidate
D. Diazepan
E. Propofol

820. Answer: A
Source: Day MR, Board Review 2005

83

821. Understanding the complex interaction of a patient’s pain
and mood is best accomplished by:
A. Integrating medical and psychological data from a variety
of sources
B. Performing a pain tolerance test in the laboratory
C. Having the patient complete the Michigan Pain States
Inventory (MPSI)
D. Asking offi ce staff to observe waiting room pain behavior
E. Obtaining family history of alcoholism

821. Answer: A
Source: Janata JW, Board Review 2005

84

822. Personality disorders can be readily assessed by:
A. Clinical interview
B. Careful history-taking
C. Utilizing the Symptom Checklist - 90
D. Observing waiting room behavior
E. MMPI or MCMI

822. Answer: E
Source: Janata JW, Board Review 2005

85

823. A “fake bad” profi le can be estimated by using the:
A. Medical Outcomes Survey (MOS)
B. Sickness Impact Profi le (SIP)
C. Minnesota Multiphasic Personality Inventory (MMPI)
D. Coping Strategies Questionnaire
E. Spielberger State-Trait Anxiety Inventory (STAI)

823. Answer: C
Source: Janata JW, Board Review 2005

86

824. Which of the following statements regarding the superior
hypogastric plexus block is not true?
A. It is most appropriate for pelvic pain of visceral origin
B. It is associated with few side effects
C. It must be performed with the assistance of fl uoroscopy
D. It is most appropriate for upper abdominal pain
E. It must be performed at L5

824. Answer: D
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition

87

825. A 30-year old patient presents with foot pain. She was
diagnosed with a calcaneal heel spur. Non-steroidal antiinfl
ammatory agents failed to provide her any signifi cant
relief. Appropriate treatment is:
A. Soft padding of the shoe
B. Local steroid injection
C. Strengthening exercises
D. Surgical excision of spur
E. Stretching exercises in combination with ultrasound

825. Answer: A
Explanation:
Goals of therapy include controlling the abnormal
biomechanics of the foot, decreasing the infl ammatory
condition, and improving the fl exibility. Various
modalities of treatments mentioned include the
following:
Non-steroidal anti-infl ammatory agent
Rest
Night splint
Padding
Physical therapy with stretching and strengthening
exercises
Physical therapy with ultrasound
Orthosis
Steroid injection
Surgical removal

88

826. Spinal Shock:
A. Occurs weeks to months after initial injury
B. Is frequently associated with autonomic dysfunction
C. Will usually result in full recovery of function
D. All of the above
E. None of the above

826. Answer: B
Source: Wirght PD, Board Review 2004

89

827. The Mutidimensional Pain Inventory (MPI):
A. Is a projective test
B. Assesses malingering
C. Yields depression and anxiety scores
D. Utilizes three profi le types - Dysfunctional, Interpersonally
Distressed and Adaptive Coper.
E. Contains 576 true-false questions

827. Answer: D
Source: Janata JW, Board Review 2005

90

828. Factitious disorder is motivated by:
A. Secondary gain
B. Assumption of the sick role
C. Financial reward
D. Evasion of responsibility
E. External incentive

828. Answer: B
Source: Janata JW, Board Review 2005

91

829. Which of the following is most appropriate for the initial
treatment of tension headache?
A. Acetaminophen
B. Amitriptyline
C. Gabapentin
D. Oxycodone
E. Tramadol

829. Answer: A

92

830. A thoracic epidural is placed at T10 after abdominal
surgery. A test dose is given and the patient becomes
numb above the incision for 2 hours. An epidural
catheter is inserted and an infusion is started. After 24
hours, she develops abdominal pain over 30 minutes.
Your next course of action is:
A. Notify surgeon
B. Give IV NSAIDs
C. Give IV morphine
D. Test the epidural
E. Apply TENS unit

830. Answer: D

93

831. A 41-year-old man was recently in a motor vehicle
accident (MVA) where he was the driver. He states he was
wearing his seat belt at the time of the accident. A day
after the accident, he developed neck pain that has now
continued for 10 days. He notices crunching on extension
and lateral bending of the neck. On physical examination,
the patient has no neurologic defi cits. His neck has no
areas of tenderness and there are no areas of spasm. He
has normal lateral bend, extension, and fl exion of the
neck. Which of the following is the most likely diagnosis?
A. Ankylosing spondylitis
B. Osteoarthritis
C. Reiter syndrome
D. Whiplash
E. Wry neck

831. Answer: D
Explanation:
(Tierney, 42/e, p 792.)
The most likely diagnosis in this patient is whiplash or
cervical musculoligamental sprain or strain. Whiplashassociated
disorders begin after a symptom-free period
following a hyperextension or hyperfl exion injury, usually in an MVA. It is vital to perform a complete neurologic
examination to exclude other causes of neck pain.
Ankylosing spondylitis is a chronic and progressive
infl ammatory disease that most commonly affects spinal,
sacroiliac, and hip joints.
Osteoarthritis most often affects the weight-bearing joints.
Reiter syndrome usually causes an arthritis of the hips, and
there is often a history of urethritis, conjunctivitis, and
foot involvement.

94

832. The appropriate initial treatment for mild mandibular
pain following oral surgery is
A. Nonsteroidal antiinfl ammatory drug
B. Mandibular nerve block
C. Acetaminophen
D. Oxycodone
E. Gabapentin

832. Answer: A

95

833. A 29-year old female with upper extremity complex
regional pain syndrome undergoes a stellate ganglion
block in your offi ce pain clinic. She is otherwise healthy
with normal body habitus and normal airway. She has
been NPO for 12 hours. 20cc of 0.25% bupivacaine is
injected incrementally over one minute with no other
medication administered. 5 minutes after injection
the patient complains of generalized weakness which
progresses to complete unresponsiveness, apnea and
hypotension over the ensuing several minutes. Eight
minutes after injection, the patient continues to be
completely unresponsive and apneic with a systolic blood
pressure of 50. ECG monitor shows sinus bradycardia.
The patient has no IV. Your fi rst action should be:
A. Start an IV
B. Use an ambu bag to ventilate the patient
C. Intubate the patient
D. Administer subcutaneous epinephrine
E. Begin CPR

833. Answer: B
Explanation:
In resuscitation scenarios, always remember the ABCs:
airway
breathing
circulation
Immediate control of the airway is the most important
and pressing concern in any arrest situation. This patient is
completely apneic therefore airway management takes
precedence over circulatory compromise. Since the patient
has a normal airway and has been NPO, there is no
immediate need to intubate if the airway can be
maintained easily with a mask and ambu bag. The patient
will likely regain the ability to ventilate on her own in a
relatively short period of time (1-2 hours).Intubation
in this patient would introduce a number of additional
concerns including the potential for airway damage, the
potential for bronchospasm, and issues related to timing
of extubation.
Intravenous access and epinephrine are circulation
interventions. Starting an intravenous line is important
but only after the airway is secure. Epinephrine is an
extremely potent sympathomimetic and should be used
very cautiously. It has the potential to cause severe
hypertension and tachycardia in a patient who is not in
full cardiac arrest (when the patient is in full cardiac arrest,
epinephrine is indicated per ACLS guidelines). This
patient is hypotensive and bradycardic secondary to
sympathetic blockade. Intravenous volume perhaps with
the edition of a milder vasopressor such as ephedrine is a
better choice than epinephrine.
Source: Schultz D, Board Review 2004

96

834. Tissues that are more echogenic on sonography:
A. Appear darker
B. Include cysts
C. Have more refl ective surfaces
D. Do not include fat
E. Include moving blood

834. Answer: C
Source: Bieneman B, Board Review 2005

97

835. Mixed Upper and Lower Motor Neuron fi ndings can be caused by:
A. Vit B12 defi ciency
B. Nitrous Oxide Exposure
C. Cervical Spinal Stenosis
D. All of the above
E. None of the above

835. Answer: D
Source: Wirght PD, Board Review 2004

98

836. A L4-5 left paracentral disc protrusion will likely affect
which nerve root?
A. The left L5 nerve root
B. The left L4 nerve root
C. The left L4 and L5 nerve roots
D. The bilateral L5 nerve roots
E. The bilateral L4 nerve roots

836. Answer: A
Source: Bieneman B, Board Review 2005

99

837. Which of the following is the most appropriate initial
examination to evaluate for disc herniation?
A. Enhanced MR
B. Unenhanced MR
C. Enhanced CT
D. Unenhanced CT
E. CT Myelogram

837. Answer: B
Source: Bieneman B, Board Review 2005

100

838. Aortic dissection is best diagnosed by what test?
A. Unenhanced CT
B. Ultrasound
C. Unenhanced and enhanced CT
D. MRI
E. Angiography

838. Answer: C
Explanation:
Aortic dissection is an acute abdominal emergency and
best imaged with CT due to the speed of examination and
ability to characterize the type of dissection without delay.
MRI and ultrasound may provide appropriate imaging of
an aortic dissection in the non acute setting. Angiography
is reserved for cases with clinical questions not answered
by the initial imaging modality and for cases where further
intervention is planned such as fenestration of a dissection
of placement of a stent graft for aortic aneurysm
Source: Bieneman B, Board Review 2005

101

839. Increased activity on bone scintigraphy may be from all except:
A. Healing fracture
B. Prostate metastases
C. Stress fracture
D. Interrupted sympathetic nerve supply
E. Old orthopedic hardware

839. Answer: E
Source: Bieneman B, Board Review 2005

102

840. Vertebral discitis and osteomyelitis are best imaged by
A. MRI
B. Bone scan
C. CT-myelogram
D. Plain radiographs
E. Duplex ultrasound

840. Answer: A
Source: Bieneman B, Board Review 2005

103

841. Bilateral cingulumotomy is a properly selected therapy in nociceptive back pain.
A. If the patient has no obsessive compulsive feature
B. In cancer patients who have no other option
C. In most benign pain patient
D. If the patient hass failed oral opiate analgesics and tricyclic
antidepressant
E. Two of the above

841. Answer: B
Source: Feler C, Board Review 2005

104

842. Tissues that appear denser on plain radiographs have:
A. More electron density
B. Less electron density
C. More neutron density
D. Less neutron density
E. None of the above

842. Answer: A
Source: Bieneman B, Board Review 2005

105

843. Which of the following statements about DREZ lesions
is correct?
A. DREZ is currently recommended in the treatment of
PHN
B. DREZ lesions typically produce sensory loss that improves
with time
C. The techniques used to create DREZ lesions include
ultrasonic aspiration
D. Results of DREZ lesioning are predictable in all neuropathic
pain state
E. All of the above

843. Answer: B
Source: Feler C, Board Review 2005

106

844. Houndsfield units on CT:
A. Are a measure of enhancement
B. Water=200 HU
C. Acute hemorrhage = -100 HU
D. Are a measure of density
E. Air=5 HU

844. Answer: D
Explanation:
(See lecture notes)
Source: Bieneman B, Board Review 2005

107

845. In the fi eld of electromyography:
A. The blink refl ex assesses the integrity of peripheral and
central circuitry involving CN5 and CN7
B. Presence of a blink refl ex is suggestive of frontal lobe
dementia
C. Repetitive stimulation is a technique unlikely to detect
pathology at the NMJ
D. Myopathies tend to be characterized by a reduced pattern
of recruitment
E. Neuropathies tend to be characterized by an early pattern of recruitment

845. Answer: A
Source: Goodwin J, Board Review 2005

108

846. The following statements regarding TENS are true
except:
A. It has been used very successfully in the treatment of
acute pain.
B. It works by stimulating A-beta fi bers which in turn close
the dorsal horn “gate” to nociceptive input.
C. TENS has been shown to increase blood fl ow in the
stimulated region
D. The effects of TENS occur only during the stimulation
period
E. Conventional TENS uses a nearly continuous high frequency
stimulation (60-100 Hz) and a relatively low
intensity current (10-30 milliamps)

846. Answer: D
Explanation:
Reference:
Bonica’s Management of Pain, Third Edition, Chapter 98,
Transcutaneous Electrical Nerve Stimulation
TENS works by stimulating A-beta fi bers which in turn
close the dorsal horn “gate” to nociceptive input. It has
been shown in many well-controlled studies to be highly
effective for acute pain. The results of TENS for chronic
pain have been less impressive although there is data to
suggest that TENS is helpful for well selected patients with
chronic pain. Conventional TENS uses a nearly
continuous high frequency stimulation (60-100 Hz) and a
relatively low intensity current (10-30 milliamps). The
effects of TENS have been shown to increase blood fl ow in
the stimulated area with pain relief sometimes outlasting
the period of stimulation by hours to days.
Source: Schultz D, Board Review 2004

109

847. Which of the following is most appropriate for a patient
with end-stage rectal cancer?
A. Lissauer tractotomy
B. Cingulotomy
C. Hypophysectomy
D. Commisural myelotomy
E. Percutaneous C1-2 cordotomy

847. Answer: D
Explanation:
(Raj 2nd Ed., page 313)
Midline or commissural myelotomy sections those
midline fi bers just dorsal to the central canal of the spinal
cord. The original intent was to lesion crossing
spinothalamic neurons, which would eliminate pain, but
preserve sensory function. However, pain relief extended
caudally, without demonstrable caudal analgesia. This lead
several investigators to postulate several alternate pain
pathways. A multisynaptic short tract afferent pathway or
an anterior tract located in between the posterior columns
were proposed. The latter mediate pelvic and epigastric
visceral pain. Nonetheless, myelotomy is indicated for
bilateral pelvic and perineal pain of malignant origin.
Unilateral percutaneous cordotomy is among the most
useful procedures for unilateral cancer pain below C5. It
targets the spinothalamic tract. Radiofrequency energy is
used. Electrical stimulation (sensory to obtain a feeling of
warmth or coolness on the contralateral side and motor to
obtain ipsilateral cervical muscles; ipsilateral contraction
of muscles below the neck implies the probe is in the
corticospinal tract) is used to identify the lesion target
Lissauer tractotomy is the goal of the dorsal root entry
zone (DREZ) procedure…but all dorsal horn lamina (I-V)
may be affected. The DREZ lesion is classically indicated
for central nervous system damage related pain: brachial
plexus avulsion, stump pain, spinal cord injury pain.
Hypophysectomy is recommended in the treatment of
metastatic prostate and breast cancer, irrespective of the
hormonal responsiveness of the tumors. The analgesic
mechanism is unknown, but limbic system or
psychological effects are unlikely to be the reasons for pain
relief.
Cingulotomy, anterior capsulotomy (anterior limb of
internal capsule), leucotomy (pre-frontal lobotomy), and
hypothalamotomy have been used for intractable cancer
pain in multiple sites and for psychiatric disorders, such as
obsessive compulsive disorders.
Source: Schultz D, Board Review 2004

110

848. Deep brain stimulation to treat primarily nociceptive
pain would most likely target the:
A. Periaqueductal grey
B. Ventroposterolateral or Ventroposteromedial thalamus
C. Caudalis subnucleus
D. Nucleus gracilis
E. Reticular formation

848. Answer: A
Explanation:
(Raj, Pain Review 2nd Ed., pages 311; Bonica 3rd Ed.,
pages 122, 130-2, & 153-4, ;
Raj, Practical Mgmt of Pain 3rd Ed., pg 795)
The periaqueductal and periventricular grey are located in
the midbrain. The PAG and PVG can be excited by
endogenous opioids or electrical stimulation to initiate
descending antinociception. The VPM and VPL located in
the thalamus are useful for deafferentation or neuropathic
pain. The caudalis subnucleus, also known as the
trigeminal spinal nucleus, is thought to be integral for a
variety of head pain syndromes. The reticular formation
may be responsible for some of the affective and
motivational responses to pain and the regulation of spinal
motor, respiratory, and autonomic functions: arousal and
escape. Pos-synaptic touch and proprioception fi bers (dorsal column) project to the dorsal column nuclei:
cuneatus and gracilis: lumbar and thoracic fi bers to the
gracilis and cervical to the cuneatus.
Source: Schultz D, Board Review 2004

111

849. All of the following are typically associated with the
technical aspects of epidural anesthesia, except:
A. Paramedian
B. Bromage grip
C. Hanging drop
D. Taylor approach
E. Sacral hiatus.

849. Answer: D
Explanation:
(Raj, Practical Mgmt of Pain, 3rd Ed, pages 641-6, 634)
A. Midline and paramedian approaches to the epidural
space have been described.
B. The Bromage grip is a useful technique for slow,
controlled advancement of an epidural needle towards the
ligamentum fl avum.
The needle is fi rmly gripped between the thumb and
index fi nger of the nondominant hand.
The dorsum of the wrist is placed against the patient’s
back.
The needle is advanced by extension of the wrist while
the dominant hand provides intermittent or constant
pressure on the plunger, depending on whether one uses
the loss-of-resistance technique to air or to saline solution,
respectively.
C. The negative pressure often found within the epidural
space is the basis for the hanging-drop technique.
This hanging-drop sign of Gutierrez is used to
identify the epidural space and is usually applied
for cervical epidural blockade in the seated patients.
A winged needle is usually used and is advanced with
both hands, as with the intermittent technique.
A drop of fl uid is placed at the end of the needle once
it is anchored in the interspinous ligament.
Because of the persistent subatmospheric pressure
within the epidural space, penetration of the ligamentum
fl avum and entrance of the epidural space cause the drop
to be sucked into the hub of the epidural needle.
Injection of air or fl uid without resistance confi rms
the position in the epidural space.
D. The Taylor is used to identify the subarachnoid space by
way of the L5 interspace, which is the largest interspace in
the vertebral column.
To enter this space, the operator introduces the spinal
needle through the skin wheal approximately 1cm medial
and 1cm inferior to the posterior superior iliac spine.
The spinal needle is directed medial and cephalad to
enter the subarachnoid space at the midline at the L5-S1
interspace.
E. Identifi cation of the sacral hiatus is important for
caudal epidural procedures.
The sacral hiatus is formed secondary to nonfusion of
the fi fth sacral vertebral arch.
The hiatus is covered by the sacrococcygeal membrane and
bordered by two cornua (large bony processes on each side
of the hiatus).
The sacral hiatus is most easily identifi ed with the
patient lying in the prone or lateral position.
Firm pressure is used to identify the coccyx with the
nondominant index fi nger.The fi rst pair of bony
protuberances in moving cephalad are the two cornua,
surrounding the sacral hiatus.
Source: Shah RV, Board Review 2005

112

850. Back pain developing after spine surgery is best imaged by
A. Unenhanced MR
B. Contrast Enhanced MR
C. Unenhanced CT
D. Enhanced CT
E. Myelography

850. Answer: B
Source: Bieneman B, Board Review 2005

113

851. What is the co-morbid condition of body dysmorphic
disorder?
A. Depression
B. Multiple recurrent somatic complaints without medical
findings
C. Delusion
D. “La belle indifference”
E. Fear of having a serious illness despite adequate medical evaluation

851. Answer: C
Explanation:
(A) Major depression is a comorbid condition of both
somatization disorder and hypochondriasis, but not a
major diagnostic feature.
(B) Somatization disorder is characterized by the
recurrence of multiple somatic complaints not accounted
for by medical fi ndings. It is a chronic condition with
female predominance.
(C) Delusion is the common feature of body dysmorphic
disorder.
(D) La belle indifference is an associated feature of
conversion disorder, where symptoms do not conform to
anatomic pathways. Delusional disorder may be a
comorbid condition in body dysmorphic disorder.
(E) Hypochondriasis is a chronic condition characterized
by a fear or belief that one has a serious illness despite
adequate medical evaluation. Its prevalence is 4% to 9% of
medical outpatients with equal incidence between men
and women.
Source: Laxmaiah Manchikanti, MD

114

852. The dorsal columns of the spinal cord primarily carry:
A. Pain sensation
B. Temperature sensation
C. Spinothalamic tracts
D. All of the above
E. None of the above

852. Answer: E
Source: Wirght PD, Board Review 2004

115

853. In a patient with midthoracic back pain who reports
tenderness to palpation over the T-6 vertebral body, the
most likely diagnosis is:
A. Thoracic disk herniation
B. Metastatic neoplasm
C. Facet osteoarthropathy
D. Rheumatoid arthritis
E. Epidural hematoma

853. Answer: B
Explanation:
Local spine tenderness elicited when palpating directly
over the vertebral body is highly suggestive of vertebral
body neoplasm or infection. Neoplastic conditions or
infectious-infl ammatory disorders (osteomyelitis) may
distend the periosteum, causing local tenderness. This
discrete local tenderness should be differentiated from
more diffuse muscle spasm seen with a herniated disk.
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

116

854. Which of the following sedative - hypnotic medications
should not be used in a patient with increased intracranial
pressure?
A. Thiopental
B. Etomidate
C. Ketamine
D. Propofol
E. Midazolam

854. Answer: C
Source: Day MR, Board Review 2006

117

855. A “fake bad” profile is provided in scoring the:
A. Spielberger State-Trait Anxiety Inventory (STAI)
B. Minnesota Multiphasic Personality Inventory (MMPI)
C. Coping Strategies Questionnaire
D. Medical Outcomes Survey (MOS)
E. Sickness Impact Profi le (SIP)

855. Answer: C
Source: Janata J, Board Review 2006

118

856. Which of the following is not defi ned as a disc
herniation?
A. Protrusion
B. Localized displacement of disc material beyond the confi
nes of the disc space
C. Bulge
D. Extrusion
E. Intravertebral end plate disruption secondary to disc
material

856. Answer: C
Explanation:
A disc bulge is not a herniation
Source: Bieneman B, Board Review 2005

119

857. Understanding the complex interaction of a patient’s
pain and mood is best accomplished by:
A. Obtaining family history of depression
B. Asking offi ce staff to observe waiting room pain behavior
C. Having the patient complete the Michigan Pain States
Inventory (MPSI)
D. Integrating medical and psychological data from a variety
of sources
E. Performing a pain tolerance test in the laboratory

857. Answer: E
Source: Janata J, Board Review 2006

120

858. Mesencephalic tractotomy is indicated in patients who
suffer from the pain of head and neck cancer.
A. If there is no preoperative neurologic defi cit
B. If the neck pain does not come higher than the C5 segment
C. If the patient has a preoperative myelopathy
D. If the pain involves the lower face
E. Two of the above

858. Answer: E
Source: Feler C, Board Review 2005

121

859. Which of the following drugs shows a good correlation between the blood level and the clinical effect?
A. Phenelzine
B. Trazodone
C. Fluoxetine
D. Paroxetine
E. Imipramine

859. Answer: E
Explanation:
Blood level can be obtained for all antidepressant drugs.
But not all of them have shown a correlation between the
therapeutic effect and the blood level.
Plasma level measurements of imipramine,
desmethylimipramine, and nortriptyline are unequivocally
clinically useful in certain situations. For imipramine, the
percentage of favorable responses correlates with plasma
levels in a linear manner between 200 and 250 ng/mL, but
some patients may respond at a lower level. At levels that
exceed 250 ng/mL, there is no improved favorable
response, and side effects increase.
Source: Laxmaiah Manchikanti, MD

122

860. Some physiological consequences of epidural blockade
may include:
A. increased peristalsis
B. interference with satiety
C. impaired respiratory function, by modifying respiratory
drive, reducing diaphragmatic contractility, permitting
increased airway hyperactivity, and impairing V/Q
mismatch
D. hypertension
E. degree of sympathetic blockade that correlates with the
degree of sensory blockade

860. Answer: A
Explanation:
(Raj, Practical Mgmt of Pain, 3rd Ed, pages 639-41)
A. The gastrointestinal tract is innervated by both the
sympathetic and parasympathetic systems.Visceral afferent
parasympathetic fi bers transmit sensations of satiety,
distention, and nausea (but not pain).
Parasympathetic efferent outfl ow increases tonic
contraction, sphincter tone, peristalsis, and secretions.
Pain is mediated via sympathetic afferents, whereas
sympathetic efferent fi bers inhibit peristalsis and gastric
secretions, constrict vasculature, and increase sphincter
tone.
Sympathetic denervation of the gastrointestinal tract
by neuroaxial blockade conceivably may lead to
generalized contraction of the bowel secondary to
unopposed parasympathetic efferent outfl ow.
The degree to which the bowel is affected after neural
blockade depends on the extent of the blockade.
C. It is conceivable that a high thoracic or cervical block
may impair respiratory function by affecting sensory
function (modifying respiratory drive), motor function (decreasing abdominal muscles, intercostal muscles, and
diaphragmatic strength), and sympathetic function
(unopposed cholinergic tone can lead to hyperreactive
airways).
Sympathetic block may diminish pulmonary blood fl ow
and ventilation-perfusion ( V/Q ) mismatch.
All of these changes have the potential to lead to airway
closure, atelectasis, decreased blood fl ow, and diminished
functional reserve capacity (FRC), causing (V/Q)
mismatch and hypoxemia.
Experimental evidence, however, does not support this
scheme.
D. The principal cardiovascular consequences of extensive
epidural blockade are hypotension and bradycardia.
E.The extent of sympathetic blockade, however, correlates
very poorly with the sensory level. The amount of
sympathetic denervation and sensory blockade might be
larger than the classically taught two levels.
It has been demonstrated that the sympathetic block
could extend six or more spinal segments above the level
of sensory blockade.
Source: Shah RV, Board Review 2005

123

861. What is the major diagnostic feature of somatization
disorder?
A. Depression
B. Multiple recurrent somatic complaints without medical
fi ndings
C. Delusion
D. “La belle indifference”
E. Fear of having a serious illness despite adequate medical evaluation

861. Answer: B
Explanation:
(A) Major depression is a comorbid condition of both
somatization disorder and hypochondriasis, but not a
major diagnostic feature.
(B) Somatization disorder is characterized by the
recurrence of multiple somatic complaints not accounted
for by medical fi ndings. It is a chronic condition with
female predominance.
(C) Delusion is not a common feature of either
somatization disorder or hypochondriasis.
(D) La belle indifference is an associated feature of
conversion disorder, where symptoms do not conform to
anatomic pathways. Delusional disorder may be a
comorbid condition in body dysmorphic disorder.
(E) Hypochondriasis is a chronic condition characterized
by a fear or belief that one has a serious illness despite
adequate medical evaluation. Its prevalence is 4% to 9% of
medical outpatients with equal incidence between men
and women.
Source: Laxmaiah Manchikanti, MD

124

862. Which one of the following drugs causes Grand mal
seizure as the most prominent side effect?
A. Venlafaxine (Effexor®)
B. Phenelzine (Nardil®)
C. Fluoxetine (Prozac®)
D. Amitriptyline (Elavil®)
E. Bupropion (Wellbutrin®)

862. Answer: E
Explanation:
Bupropion is associated with grand ,al seizures in
approximately 0.4% (4/1000) of patients treated at doses
up to 450 mg/day.This incidence of seizures may exceed
that of other marketed antidepressants by as much as 4-fold. This relative risk is only an approximate estimate
because of the lack of direct comparative studies. The
estimated seizures incidence for Bupropion increases
almost 10-fold between 450 and 600 mg/day, which is
twice the usually required daily dose (300 mg).
Source: Laxmaiah Manchikanti, MD

125

863. Electroconvulsive therapy is least likely to be successful in which of the following diseases?
A. Major depression
B. Acute schizophrenia
C. Acute manic episodes
D. Chronic schizophrenia
E. Obsessive-compulsive disorder

863. Answer: D
Explanation:
Catatonia, mania, major depression, and acute
schizophrenia are established indications of
electroconvulsive therapy (ECT). Other indications of
electroconvulsive therapy with less evidence of its
effectiveness include Parkinson disease, obsessivecompulsive
disorder, neuroleptic malignant syndrome,
and intractable epilepsy
Source: Laxmaiah Manchikanti, MD

126

864. The CAGE questionnaire is used in case of
A. Mental retardation
B. Bipolar disorder
C. Major depression
D. Opioid abuse
E. Alcohol abuse

864. Answer: D
Explanation:
Four clinical interview questions, the CAGE questions,
have proved useful in helping to make a diagnosis of
alcoholism. The questions focus on Cutting Down,
Annoyance by Criticism, Guilty Feeling, and Eye-Openers.
The acronym “CAGE” helps the physician recall the
questions:
“C”: Have you ever felt you should cut down on your
drinking?
“A”: Have people annoyed you by criticizing your
drinking?
“G”: Have you ever felt bad or guilty about your drinking?
“E:: Have you ever had a drink fi rst thing in the morning
to steady your nerves or to get rid of a hangover?
Source: Laxmaiah Manchikanti, MD

127

865. Cordotomy is most useful in treating patients with pain
complaints involving the extremities.
A. The open procedure is a lesion of the anterior cord.
B. The lesion is made in the anterior spinothalamic tract.
C. The lesion is made in the intermediolateral cell column
D. Results are optimal if the procedure is done bilaterally
E. The percutaneous procedure gives excellent relief of
pain to the C2 segment

865. Answer: A
Source: Feler C, Board Review 2005

128

866. The following is true regarding cordectomy operations:
A. An optimally selected patient has normal preoperative
neurologic function
B. It is most useful in pain of the upper extremities
C. It is a commonly performed procedure in patients who
have cancer pain
D. A patient with a preoperative transverse myelopathy is
well selected for the procedure
E. Two of the above

866. Answer: D
Source: Feler C, Board Review 2005

129

867. Which of the following statements about major
depression is TRUE?
A. Thirty percent of individuals with a single episode of
major depression develop bipolar disorder
B. The lifetime prevalence rates for adult men range from
3% to 9%.
C. Full recovery from major depression occurs in 25% of
patients by 6 months
D. Relapse after a single episode is about 50%.
E. The average age of onset of unipolar major depression is
50 years

867. Answer: D
Explanation:
A. Five to ten percent of individuals with a single episode
of major depression will eventually develop bipolar
disease.
B. The National Comorbidity Survey carried out a
structured psychiatric interview of a representative sample
of the general population and reported a lifetime rate of
major depression of 21.3% in women and 12.7% in men
producing a female-to-male ration of 1.0 to 1.7. A gender
difference was found beginning in early adolescence and
persisting through the mid-50s. Although this increased
tendency for depression in women refl ects a long-term
trend,over the short term, an increase has also been seen in
the rate of depression among young women. The highest
rate occurs in adult women aged more than 44 years
C. 50% of cases of major depression will have full
recovery by 6 months.
D. Major depression is a recurrent illness; the risk of
relapse after one episode is about 50%, whereas it is
greater than 80% after 3 episodes. The average lifetime
number is 4.
E. The average age of onset of unipolar depression is 29
years
Source: Laxmaiah Manchikanti, MD

130

868. The catheter location for continuous infusion for post-op pain relief for lower abdominal surgery should be
A. T2-8
B. T4-L1
C. T10 - L3
D. T12 - L3
E. L1 - L3

868. Answer: C
Source: Raj, Pain Review 2nd Edition

131

869. Four days after a left total hip arthroplasty, an obese a
62-year-old woman complains of severe back pain in the
region where the epidural was placed. Over the ensuing
48 hours, the back pain gradually worsens and a severe
aching pain that radiates down the left leg to the knee
develops. The most likely diagnosis is
A. Epidural abscess
B. Epidural hematoma
C. Anterior spinal artery syndrome
D. Arachnoiditis
E. Meralgia paresthetica

869. Answer: A
Explanation:
A.Epidural abscess is an exceedingly rare complication of
spinal and epidural anesthesia.
* Symptoms from an epidural abscess may not become
apparent until several days after placement of the block.
* The usual symptoms include severe back pain, sensory
disturbances, and motor weakness.
* Patients with epidural abscesses will complain of
radicular pain approximately 3 days after development of
the back pain.
B. In an epidural hematoma severe back pain is the key
feature.
C. Anterior spinal artery syndrome is characterized
predominantly by motor weakness or paralysis of the
lower extremities.
D. Arachnoiditis starts as a minimal cellular infl ammatory
response.
*It may follow trauma, surgery, tumors, infections,
hemorrhage orsome intrathecal compound administration
* Onset of symptoms varies from hours to months,
resulting in delay in diagnosis
* Symptoms include:
- Radicular pain
- Perineal sensory loss
- Lower extremity paresis or paralysis
* Diagnosis can be made by CT, MRI or myelography
E. Meralgia paresthetica is related to entrapment of the
lateral femoral cutaneous nerve as it courses below the
inguinal ligament and is associated with burning pain over
the lateral aspect of the thigh. It is not a complication of
epidural anesthesia.

132

870. A 49-year-old man presents with painful, recurring
episodes of swelling in his left great toe. He takes 25 mg
of hydrochlorothiazide daily for blood pressure control
but otherwise is in good health. On physical examination,
the patient is afebrile but his great toe is warm, swollen,
erythematous, and exquisitely tender to palpation. He has
several subcutaneous nodules in his pinna. The following
is the most likely diagnosis:
A. Calcium pyrophosphate dihydrate deposition disease
B. Calcium oxalate deposition disease
C. Monosodium urate deposition disease
D. Calcium phosphate deposition disease
E. Osteoarthritis of the great toe

870. Answer: C
Explanation:
(Tierney, 42/e, pp 786-790.)
Tophaceous gout is characterized by the fi nding in synovial
fl uid of monosodium urate crystals that are needle-shaped and strongly negative birefringent (bright yellow when
parallel to the axis). Gouty attacks may be precipitated by
trauma, medications that inhibit tubular secretion of uric
acid (aspirin, hydrochlorothiazide), surgery, stress,
alcohol, or a high-protein diet. The patient may have an
accumulation of tophi in and around the joints and
earlobe.
Radiographs may show “rat bite” erosions. Pseudogout is
due to calcium pyrophosphate dihydrate (CPPD)
deposition disease; the crystals here are rhomboid-shaped
and weakly positive birefringent (blue when parallel to the
axis). Calcium oxalate deposition disease is usually seen in
patients with end-stage renal disease; calcium phosphate
deposition disease causes calcifi c tendinitis or Milwaukee
shoulder.

133

871. Your patent is a 38-year-old male who plays in a weekend volleyball league on a regular basis. He has developed posterior shoulder pain that is aching in nature and increases with increased slamming of the ball over the net. You have noticed that his symptoms are provoked
with passive internal rotation and adduction of his arm
behind his back, followed by passive cervical sidebending
to the contralateral side. Which disorder do you suspect?
A. Acromioclavicular arthritis
B. Bennett’s lesion
C. Posterior glenohumeral labral tear
D. Suprascapular nerve entrapment
E. Adhesive Capsulitis

871. Answer: D
Source: Sizer Et Al - Pain Practice March & June 2003

134

872. When testing a patients extraocular muscle movements,
you detect that the right eye cannot adduct past the
midline. However, when you move a fi ngertip toward
the patient’s nose, convergence does occur. Which of the
following is the most likely diagnosis?
A. Paralysis of cranial nerve VI
B. Paralysis of cranial nerve III
C. Internuclear ophthalmoplegia
D. Retrobulbar optic neuritis
E. Paralysis of cranial nerve II

872. Answer: C
Explanation:
(Goldman, 21/e, p 2240.)
Internuclear ophthalmoplegia (INO) is caused by a lesion
in the medial longitudinal fasciculus (MLF) and may be
due to glioma in children, multiple sclerosis in young
adults, or vascular infarction in the geriatric age group.
INO commonly causes paresis of adduction of the
ipsilateral eye (patients cannot look medially), horizontal
nystagmus in the contralateral abducting eye, and vertical
nystagmus with upward gaze, but convergence is intact.

135

873. According to psychoanalytic theory, which of the
following statements about the development of the
superego is true?
A. It is present at birth
B. It begins to develop during the fi rst two years of life
C. It begins to develop during the fi fth or sixth year of life
D. It begins to develop during puberty
E. It begins to develop in late adolescence

873. Answer: C
Explanation:
(Kaplan, pp 206-223.)
Freud maintained that the
superego begins to develop around the age of 5 or 6 as part
of the resolution of the Oedipus complex.At the end of the
phallic stage of psychosexual development (which lasts
from around 211> to 6 years of age), children must
abandon the sexual and aggressive impulses that were
directed toward their parents to avoid the parents’ strong
disapproval. In abandoning these impulses, children
identify with their parents. Part of this identifi cation
involves the internalization of parental standards of
morality; this internalization marks the beginning of the
superego.
Source: Ebert 2004

136

874. At a follow-up visit one month after a 22-year-old male
was newly diagnosed with schizophrenia and started
on chlorpromazine, he has several complaints, listed
below. Which of the following cannot be attributed to
chlorpromazine?
A. Restless feeling
B. Sexual dysfunction
C. Urinary hesitancy
D. Vomiting
E. None of the above

874. Answer: D
Explanation:
Antipsychotic agents, particularly prochlorperazine, are
also useful as antiemetic agents, thought to be due to
dopamine blockade at the stomach and at the
chemoreceptor trigger zone of the medulla.
Source: Stern - 2004

137

875. Which of the following negative emotional states or
conditions most commonly precedes relapse in the
treatment of addictive behaviors?
A. Stress
B. Depression
C. Anxiety
D. Anger
E. Frustration

875. Answer: C
Explanation:
(Taylor, pp 108-114.)
Negative emotional states of
anxiety, depression, anger, frustration, and stress are
related to relapse in the treatment of addictive behaviors
involved in such disorders as alcoholism, smoking,
obesity, and drug addiction. Most patients (about 70%)
have negative affects preceding the relapse. The most
common negative affect or mood state is anxiety related to
the need for the addicting substance to relieve the anxiety.
This is followed by anger, frustration, and depression.
Furthermore, patients are at increased risk for relapse if
they smoke, drink, eat, and so on in an attempt to reduce
negative affect.
Source: Ebert 2004

138

876. A 40-year-old man is asked to be evaluated by the company
physician because he failed a mandatory random drug
screen. The history indicates a pattern of substance abuse.
The psycosocial factor most likely to be found in this
person is
A. Delusions of grandeur
B. Depression mood
C. Rationalization
D. Denial
E. Antisocial behavior

876. Answer: D
Explanation:
(Sierles, pp 295-296. Ebert pp 233-259.)
Even though there is no single personality type associated
with substance abuse, denial is the major psychosocial
factor in these persons. Denial can also complicate the
treatment, even though the substance abuser may admit to
the addiction. Substance abusers do frequently display
delusions of grandeur, are often in a depressed mood,
frequently display antisocial behavior, and often rationalize
their behavior or situation, but denying the seriousness of
their drinking or drug problem and its effect on their life
or loved ones is the most common psychosocial factor
seen. Denial is a form of self-deception that permeates
their psychological and social behavior.
A physician must be constantly aware of the infl uence of
denial on the patient’s self-reported history and the effect
of denial on prognosis.
Source: Ebert 2004

139

877. If resisted shoulder external rotation is the MOST
painful procedure during the shoulder basic functional
examination, which tendon insertion is most likely the
pain generator?
A. Supraspinatus
B. Infraspinatus
C. Subscapularis
D. Deltoid
E. Biceps

877. Answer: B
Source: Sizer Et Al - Pain Practice March & June 2003

140

878. What is the approximate scapulo-humeral movement
ratio produced between the glenohumeral joint and
scapulothoracic complex at 40° of arm elevation?
A. A ratio of 1 : 1
B. A ratio of 7 : 1
C. A ratio of 3 : 1
D. A ratio of 5 : 1
E. A ratio of 2 : 1

878. Answer: B
Source: Sizer Et Al - Pain Practice March & June 2003

141

879. A 40-year-old male with a diagnosis of moderate to severe
asthma is placed on zileuton. What is the mechanism of
action of zileuton?
A. Inhibition of cytokine production
B. Inhibition of leukotriene production
C. Inhibition of mediator release
D. Inhibition of muscarinic receptor action
E. Inhibition of calcium (Ca2+) channel activity

879. Answer: B

142

880. In a patient with spinal stenosis at L5/S1 levels with
history of low back and lower extremity pain, the likely
electrodiagnostic fi ndings are as follows:
A. Reduced amplitude of H-have response
B. Increased amplitude of the somatosensory evoked response
C. Normal F-wave response
D. Reduced conduction velocity of the genitofemoral
nerve
E. Fibrillation in tibialis anterior

880. Answer: A
Explanation:
Slowing of nerve conduction velocity occurs through the
region of neurologic impairment. Needle EMG may not
show evidence of membrane instability. Motor unit action
potentials may have increased amplitude and duration
because of collateral innervation, which occurs over time.
Somatosensory evoked potentials will be abnormal to
varying degrees in the dermatomes of the affected nerve
roots. Both F- and H-wave late responses will be
abnormal. Fibrillation or sharp waves in tibialis anterior
are seen with involvement of L4 nerve root.

143

881. You were performing a stellate ganglion block at C6. You withdrew the needle 0.2 cm after inserting the needle
to a depth of 1.4 cm. You were unable to inject due to
resistance and pain. The tip of the needle is most likely
located within the
A. Periosteum
B. Longus colli
C. Vertebral artery
D. Intervertebral disc
E. Subarachnoid space

881. Answer: B

144

882. Epidural use of which of the following opioids would
result in the greatest incidence of delayed respiratory
depression?
A. Sufentanyl
B. Fentanyl
C. Morphine sulfate
D. Hydromorphone
E. Meperidine

882. Answer: C
Explanation:
Water-soluble drugs such as morphine have a higher
potential for inducing delayed respiratory depression
through cephalad migration in the CNS.

145

883. A 36-year-old male has been experiencing intense pressure to be more productive at work. This has resulted
in his becoming extremely anxious, which makes it very
diffi cult for him to function effectively. He wishes to keep
his job. Physical examination and blood chemistries are
normal. He is given diazepam, which diminishes his
anxiety and allows him to concentrate on his work. What
is the mechanism of action of diazepam?
A. It directly opens the Cl¯ channel of the GABA receptor
B. It increases the frequency of the Cl¯ channel of the GABA
receptor
C. It prolongs the duration of opening of the Cl¯ channel of
the GABA receptor
D. It simulates k receptors
E. It simulates m receptors

883. Answer: B
Explanation:
Reference: Hardman, pp 365-367.
Benzodiazepines, such as diazepam, bind to the GABA
receptor/ion channel complex, enhancing GABA-induced
Cl¯ currents related to more frequent bursts of Cl¯
channel opening by GABA.
kappa and μ receptors are opioid receptors.
Source: Stern - 2004

146

884. An elderly patient presents with a complaint of pain in
the distribution of the trigeminal nerve. The patient has
no other medical problems except a history of congestive
heart failure for which he takes digoxin and thiazide.
In addition to his chief complaint, the patient over the
last 72 hours has complained of dysesthesia in the feet,
diffi culty with vision, and emesis on 3 or 4 occasions. The
most appropriate step at this time would be
A. Trigeminal nerve block with bupivacaine
B. Obtain neurologic workup for multiple sclerosis
C. Administration of fentanyl and ondansetron
D. Initiate therapy with carbamazepine
E. Obtain a digoxin level

884. Answer: E
Explanation:
The early signs of digitalis toxicity include loss of appetite
and nausea and vomiting. In some patients there may be
pain that is similar to trigeminal neuralgia. Pain or
discomfort in the feet and pain and discomfort in the
extremities may be a feature of digitalis toxicity. Transient
visual disturbances have been reported in patients with
digitalis toxicity.
Source: Hall and Chantigan.
Source: Hall and Chantigan

147

885. An elderly woman presents with persistent and prolonged
thoracic pain after a herpes zoster infection. Which of the
treatments below would be the LEAST effi cacious in the
treatment of her pain?
A. Topical capsaicin ointment
B. Oral clonidine
C. Topical lidocaine patch
D. Oral amitriptyline
E. Transcutaneous electrical nerve stimulation

885. Answer: B
Explanation:
Postherpetic neuralgia is defi ned as pain persisting
beyond the healing of the herpes zoster lesions.
The incidence of postherpetic neuralgia increases with
age and occurs in 20% to 50% of patients older than 50
years and greater than 50% in patients older than 80 years.
A, C, D, E. Treatment of established postherpetic neuralgia
has been shown to be resistant to interventions and thus
can be diffi cult. Proven therapies include tricyclic
antidepressants, antoconvulsants, topical local anesthetics,
topical capsaicin, and sympathetic blocks.
B. Oral clonidine, which is used to treat hypertension and
opioid withdrawl, has not been shown to be an effective
treatment for postherpetic neuralgia.

148

886. Complex regional pain syndrome type II (causalgia) is
differentiated from complex regional pain syndrome type
I (refl ex sympathetic dystrophy) by knowledge of its
A. Etiology
B. Rapidity of onset
C. Type of symptoms
D. Affected body region
E. Chronicity

886. Answer: A
Explanation:
Complex regional pain syndrome type I (refl ex
sympathetic dystrophy) is a clinical syndrome of
continuous burning pain usually occurring after an
injury or surgery. Patients present with variable
sensory, motor, autonomic, and trophic changes.
Complex regional pain syndrome type II (causalgia)
exhibits the same features of refl ex sympathetic dystrophy,
but the etiology is damage to a major nerve.

149

887. A patient presents with acute onset of pain which started when he was stepping off a curb located over hip and buttock area which is referred to groin and lower
extremity. Physical examination showed no leg length
discrepancy but pain over superior iliac spine. The most
likely diagnosis is:
A. Lumbar facet joint pain
B. Osteoarthritis of hip
C. Lumbar radiculopathy
D. SI joint pain
E. Trochanteric bursitis

887. Answer: D

150

888. In traditional psychoanalysts, transference is the process wherein:
A. Psychic energy, or libido, is transferred from the id to the
ego and superego
B. A patient invests the analyst with attitudes and feelings
derived from vital earlier associations
C. Certain psychological symptoms seemingly defer to
new symptoms that frequently are more accessible to
analysis
D. Early object choices are gradually decathected
E. Latent dream content is transformed into manifest content

888. Answer: B
Explanation:
(Kaplan, pp 885-888.)
In traditional psychoanalytic treatment, analysts purposely
reveal very little about themselves to their patients. That is
intended to help promote transference-to create an
ambiance that facilitates a patient’s ability to transfer his or
her past emotional attachments to the psychoanalyst. The
analyst becomes a substitute for the parental fi gure. In
positive transference, the patient becomes attached to the
analyst to obtain love and emotional satisfaction, where as
in negative transference the analyst is seen as an unfair,
unloving, and rejecting parental fi gure. Interpretations of
transference may help the patient see the positive or
negative feelings as a refl ection of previous of emotional
entanglements
Source: Ebert 2004

151

889. The therapeutic action of b-adrenergic receptor blockers
such as propranolol in angina pectoris is believed to be
primarily the result of
A. Reduced production of catecholamines
B. Dilation of the coronary vasculature
C. Decreased requirement for myocardial oxygen
D. Increased peripheral resistance
E. Increased sensitivity to catecholamines

889. Answer: C
Explanation:
Beta-adrenergic receptor blockers cause a slowing of heart
rate, lower blood pressure, and lessened cardiac
contractility without reducing cardiac output. There is also
a buffering action against adrenergic stimulation of the
cardiac autoregulatory mechanism. These hemodynamic
actions decrease the requirement of the heart for oxygen.
Source: Hardman, pp 855-856

152

890. True statements with worker’s compensation coverage are as follows:
A. State-mandated worker’s compensation programs also
cover all types of federal employees.
B. Diffi cult cases are automatically settled after 12 months.
C. Self-insured employers that do not subscribe to state
laws are foolproof from litigation
D. Self-insured employers that subscribe to state laws and
administer their own benefi ts are very rigid and do not
accommodate injured workers at light duty positions.
E. Inherent problems with worker’s compensation system
include poor understanding of the cause of pain, particularly
in the absence of defi nitive diagnostic tests
resulting in unsuccessful return to work and ineffective
case management, etc.

890. Answer: E
Source: Cole and Hearring to the evaluation of Permanent
Impairment, 2001.

153

891. A 39-year-old man presents with progressive weakness of his arms and legs. He noticed diffi culty in performing tasks such as buttoning up his shirt several months ago, and his symptoms have continued to worsen. On physical examination, cranial nerve and sensory findings are normal. Severe atrophy and fasciculations are seen in the legs, arms, and tongue. The patient has a spastic
muscle tone, hyperactive refl exes, and bilateral extensor
plantar refl exes. Which of the following is the most likely
diagnosis?
A. Werdnig-Hoffmann disease
B. Multiple sclerosis
C. Pott’s disease
D. Amyotrophic lateral sclerosis
E. Todd’s paralysis

891. Answer: D
Explanation:
(Tierney, 42/e, pp 990-991.)
Amyotrophic lateral sclerosis (ALS) is a degenerative
disease that is the result of lower (anterior horn cells) and
upper (corticospinal tracts) motor neuron loss. Patients
present with asymmetric muscle weakness, atrophy,
fasciculations, spasticity, hyperactive refl exes, and extensor
plantar refl exes. Patients may complain of dysphagia and
diffi culty holding the head up. Pott’s disease tuberculosis
of the thoracic vertebral bodies. Todd’s paralysis is a
transient paralysis following a seizure. Werdnig-Hoffmann disease is fl oppy baby disease; infants present
with fasciculations. Poliomyelitis is a 1m motor neuron
disease.

154

892. The following contrast in recommended in interventional
techniques
A. Hypaque
B. Renographin
C. Non-ionized water soluble contrast
D. Ionized water soluble contrast
E. Ionized non water soluble contrast

892. Answer: C
Source: Racz G. Board Review 2003

155

893. A 34-year-old man has been diagnosed with chronic
paranoid schizophrenia for 10 years. He is currently
in a psychiatric hospital and is not on psychotropic
medications. More than 50% of individuals with this
diagnosis and off medications would have abnormalities
in which of these tests?
A. Lactate infusion test
B. Dexamethasone suppression test
C. Eye pursuit test
D. Thyrotropic releasing hormone (TRH) stimulation test
E. Prolactin stimulation test

893. Answer: C
Explanation:
(Sierles, pp 185-187. Ebert, pp 268-270.)
· Many psychiatric disorders manifest evidence of brain
dysfunction.
· Evidence of brain dysfunction has been found in 50% or
more of patients with schizophrenia. For example, a
neurologic examination will demonstrate soft signs (e.g.,
grasp refl ex, rooting refl ex, motor impersistence) in 70%
of adult schizophrenics; 75% (whether ill or recovered)
will also demonstrate abnormalities in eye pursuit; 75%
will have moderate-to-severe bilateral impairment on
neuropsychological tests; and 50% will have nonspecifi c
abnormalities on the EEG. Also, 50% will have some
cortical atrophy and ventricular enlargement on imaging
tests.
· The lactate infusion test induces panic behavior in 80%
of patients with panic disorder, but not in patients with
schizophrenia.
Source: Ebert 2004

156

894. A 23-year-old woman complains of periodic, throbbing,
right-sided headaches accompanied by nausea and
vomiting. On physical examination during the time of
headache, the patient demonstrates a right oculomotor
nerve palsy. MRI is normal. Choose correct type of
headache:
A. Complicated migraine
B. Basilar migraine
C. Classic migraine
D. Common migraine
E. Temporal arteritis

894. Answer: A
Explanation:
(Tierney, 42/e, pp 947-949)
A. Complicated migraines may be preceded by aura and
are headaches accompanied by sensory or motor defi cits
or muscle palsies.
The patient described is having a specifi c kind of
complicated migraine called an ophthalmoplegic migraine.
A mnemonic for migraine is POUND (Pulsatile, lasts
One day, Unilateral, Nausea, and interferes with Daily
activities).
B. Basilar artery migraine is a variant of classic migraine
in which the aura consists of drop attacks, confusion,
blindness, and vertigo (all signs of basilar artery
ischemia).
C. Classic migraine is a unilateral headache that is
pulsatile and throbbing in nature and is preceded by a
prodromal aura consisting of scotomas (black spots),
scintillations (light fl ashes), or hemianopsia.
D. Common migraines lack a prodromal aura.
E. Patients with temporal arteritis are older (>50 years
old) and have headaches along with jaw claudication and
tenderness over the temporal artery.

157

895. A patient has had an implanted intrathecal infusion
pump for post-laminectomy syndrome for the past 3
years. He has had relatively good pain control with a
combination infusion of morphine, bupivacaine, and
baclofen. You are asked to evaluate him in the emergency
room for increasing low back pain associated with new
onset of right leg pain and right leg weakness. Physical
examination reveals positive right straight leg raising
with loss of right Achilles refl ex. Plain x-ray has identifi ed
the titanium catheter tip marker at the T8 level in the
ventral intrathecal space. The following statement is
false:
A. Most patients who are diagnosed with catheter tip granuloma
present with gradual loss of pain control associated
with gradual onset of lower extremity neurological
defi cits evolving over weeks and months.
B. When catheter tip granuloma is diagnosed, surgical
removal of the catheter and pump is the treatment of
choice.
C. MRI with and without gadolinium enhancement is the
imaging study of choice to assess catheter tip granuloma.
D. Baclofen when used alone in the pump for spasticity
management has not been implicated in catheter tip
granuloma.
E. Right lumbar radiculopathy is a much likelier diagnosis
than catheter tip granuloma in this patient

895. Answer: B
Explanation:
Reference:
Management of Intrathecal Catheter-Tip Infl ammatory
Masses: A Consensus Statement
Hassenbusch et. Al. Pain Medicine 2002
Infl ammatory mass formation at the tip of an implanted
intrathecal catheter is a rare but potentially devastating
complication of intrathecal drug infusion. Hassenbush et.
Al. reviewed published and unpublished case reports and
their own experiences to recommend methods to diagnose
and treat catheter-tip infl ammatory masses in the above
article.
After comprehensive review, the Hassenbush consensus
panel concluded that:
Fluctuations in patients’ subjective symptoms and
underlying pain levels are common after the implantation
of drug delivery systems, but the occurrence of new or
extraordinary complaints that require unexpected
analgesic dose changes should alert physicians to consider
a catheter-tip mass among other possibilities in the
differential diagnosis. Gradual, insidious neurological
deterioration weeks or months after the appearance of
subjective symptoms was the most common clinical
course for catheter tip granulomas before the onset of
myelopathy or cauda equina syndrome in cases reported to
date.
Physicians should have a low threshold for performing
an imaging study to confi rm or rule out the presence of a
catheter-tip mass in patients with suspicious symptoms or
physical fi ndings. Unless medically contraindicated, MRI
with and without intravenous gadolinium contrast
enhancement is the imaging procedure of choice. CT
myelogram is an acceptable alternative and is equally
sensitive and reliable. Catheter-tip masses are visualized
best on intravenous contrast-enhanced T2-weighted
images. The mass appears as an enhancing lesion having
the tip of the drug administration catheter embedded
within it.
Not all patients with catheter tip granuloma require
catheter and pump removal. When catheter tip granuloma
is diagnosed, optimal management should take into
account the patient’s clinical condition, the wishes of the
patient and the available options for chronic pain
management. Mildly symptomatic patients with small
masses that are diagnosed during investigation of
diminished analgesic effi cacy or other subjective
complaints have been managed safely and successfully
without open surgical decompression or removal of the
mass. These masses did not signifi cantly compress neural
structures, nor compromise neurological function, and
were treated with prompt discontinuation of intrathecal
drug administration. Shrinkage or disappearance of the
mass was documented on follow-up imaging studies after
an interval of 2-5 months. Consequently, catheter-tip
infl ammatory masses that are detected early in the clinical
course can be treated safely and effectively by maneuvers
directed at modifying rather than removing the drug
infusion system. If the decision is made to leave the
infusion system in place, the responsible physician
eventually must decide whether to continue intrathecal
therapy and whether to change the dose, concentration, or
the drug(s) being infused. Alternatives to complete
removal of the catheter and pump include ceasing or
changing drug infusion and:
1.Repositioning of the catheter at a different spinal level.
2.Placing a new catheter to replace the existing catheter.
3.Allowing the catheter and pump to remain dormant for
a period of time.
In contrast, patients presenting with paraplegia or
progressive myelopathy or with apparently fi xed
neurological defi cits of short duration may require
emergent operative intervention because of concern that
delayed treatment could foreclose the possibility of
neurological recovery. Surgical intervention to remove the
mass and/or de-compress the spinal canal has restored
neurological function or prevented further neurological
deterioration in several reported cases. The extent of
resection was limited in some cases owing to adhesions to
the spinal cord or nerve roots or because of the ventral
location of a mass beneath the thoracic spinal cord.
Because the masses were not neoplastic, in several cases the
postoperative residual mass gradually shrank or
disappeared over time.
Source: Schultz D, Board Review 2004

158

896. A 70-year old patient presents with a history of increasing
pain in the back, buttocks and leg. Pain in the leg worsens
with standing and walking. Pain is relieved on bending
forward. No neurological defi cits were identifi ed on
physical examination. Acetaminophen gives minimal
relief. Your next treatment would be administration of:
A. Opioids
B. Epidural steroid injections
C. Non-steroidal anti-infl ammatory drugs
D. Facet joint injections
E. Transcutaneous electrical stimulation

896. Answer: C
Explanation:
The pain noted by this patient may include
musculoskeletal pain associated with spondylosis, as well
as radicular pain or neurogenic claudication.The fi rst
approach should be noninvasive, and NSAIDs are
appropriate, because acetaminophen was minimally

159

897. A 60-year-old man was involved in a motor vehicle
accident and suffered multiple long bone fractures and a
severe injury to the pelvis. Two days following admission
to the hospital, he develops fever, tachypnea, and
tachycardia. The rest of his physical examination reveals
chest, neck, and conjunctival petechiae. Respiratory exam
reveals scattered crackles bilaterally but no wheezes.
Pulse oximetry reveals a hemoglobin saturation of 80%
on room air. Which of the following is the most likely
diagnosis?
A. Pneumothorax
B. Pneumonia
C. Exacerbation of chronic obstructive pulmonary disease
(COPD)
D. Anemia from traumatic blood loss
E. Fat embolism syndrome

897. Answer: E
Explanation:
(Goldman, 21/e, p 448.)
The signs and symptoms of fat embolism syndrome are
those of adult respiratory distress syndrome (ARDS) in
association with musculoskeletal trauma. It usually occurs
2 to 4 days after the injury. The predominant feature is
respiratory failure. Petechiae are found in 50 to 60% of
patients, generally on the anterior chest and neck, axillae,
and conjunctiva.Although fractures of the pelvis may
cause life-threatening blood loss and subsequent
hypovolemic shock, the patient will probably have other symptoms, such as oliguria, hypotension, pale conjunctiva,
clouded sensorium, and cool extremities.

160

898. Following cholecystectomy, a patient is receiving
bupivacaine by intrapleural infusion at 8mL/hr. The
patient is noted to have a Horner’s syndrome and
inadequate pain relief. The next step in managing this
patient is to :
A. Increase the rate of bupivacaine infusion
B. Remove and reinsert the catheter
C. Obtain neurology consultation
D. Obtain an MRI of the head
E. Perform a chest radiograph

898. Answer: B
Explanation:
Assuming that you wish to continue the postoperative
intrapleural infusion, the catheter should be removed and
replaced. A Horner’s syndrome is a recognized side effect
of interpleural infusions. Poor pain relief means that the
catheter not covering the area of the incision. The
Horner’s syndrome means that the infusion is not
intravascular

161

899. Patients with a strong sense of an external locus of
control of health will be more apt to respond to inpatient
treatment in the following way:
A. They delegate control of their health to their doctor or
signifi cant other
B. They can be relied on to follow treatment orders when
they are discharged for outpatient follow-up
C. They respond poorly and less comfortably to inpatient
care
D. They prefer to make as many decisions about their care
as possible
E. They prefer to maximize their own decision making
about their own health care

899. Answer: A
Explanation:
(Sierles, pp 103-104. Wedding, pp 378-390.)
A. Persons with a strong sense of an external locus of
health control delegate responsibility for their health to an
external force, such as fate, powerful others, chance, or
God.
B. As outpatients they cannot be relied on to take
responsibility for their own care.
C. They can be relied on to follow treatment orders in the
hospital, where they are in an authoritarian system.
D. They prefer to make as few decisions as possible about
their own health and prefer to accept the authority and
orders of their own physician, except if the authority is not
present to follow up on them.
E. Patients with a strong sense of internal control tend to
accept responsibility for and control their own health.
This information can be of help to physicians by allowing
them to establish follow-up procedures that will ensure
maximum compliance.
Source: Ebert 2004

162

900. Patients with low back pain have been found to have:
A. Normal levels of aerobic fi tness compared to normal
controls.
B. An inability to improve their aerobic capacity.
C. Protection against low back pain at work after a period
of aerobic training.
D. Spine problems that would prohibit most forms of aerobic
exercise.
E. Lumbar disc herniation in 90% of cases

900. Answer: C
Source: Malanga G, Board Review 2003

163

901. Patient notes the “worst headache ever” after exercise. Physical examination shows neck pain with movement. The next course of action is:
A. MRI of head
B. MRI of neck
C. CT of head
D. CT of neck
E. Cervical spine films

901. Answer: C
Explanation:
the patient needs a head CT to evaluate for possible
subarachnoid hemorrhage.The subsequent step would be
a spinal tap, assuming no mass lesion or shift.

164

902. A patient presents with acute low back and lower
extremity pain. Motor examination showed weakness
with foot inversion. There was sensory defi cit on the
medial aspect of the leg. The most likely diagnosis is:
A. L3/4 disc herniation with L4 nerve root involvement
B. L5 nerve root involvement with L4/5 disc herniation
C. S1 nerve root involvement with L5/S1 disc herniation
D. L3 nerve root involvement with L2/3 disc herniation
E. L4/5 disc herniation with S1 nerve root involvement

902. Answer: A
Explanation:
L4 nerve root involvement with L3/4 disc herniation
shows weakness of tibialis anterior demonstrated by
weakness of foot inversion. Refl exes are patellar and
sensation is on the medial leg.
Source: Hoppenfeld S. Orthopaedic Neurology. A
Diagnostic Guide to Neurologic Levels. Philadelphia,
LWW, 1997.

165

903. Which of the following is not an indication for
stretching?
A. Prolonged immobilization
B. Restricted mobilitiy
C. Connective tissue diseases
D. Structural damage due to trauma
E. Recent fracture

903. Answer: E
Explanation:
(Raj, Practical Mgmt of Pain, 3rd Ed., page 535-536)
Indications
Prolonged immobilization leading to adhesions and
contractures.
Restricted mobility.
Connective tissue or neuromuscular diseases.
Structural damage secondary to trauma.
Congenital or acquired bony deformities.
Contraindications
Restricted motion secondary to a bony block.
After a recent fracture.
Evidence of an acute infl ammatory or infective process,
either in or around a joint.
Patients in whom contractures are the chief means of
providing joint stability
Source: Shah RV, Board Review 2005

166

904. A 46-year-old woman has a l-month history of headache.
She has no past medical history of headache and no
family history of headache. She does not use illicit drugs,
drink alcohol, or smoke cigarettes. Physical examination
reveals alexia, agraphia, acalculia, right-left confusion,
and linger agnosia. An MRI of the brain with gadolinium
is most likely to show which of the following?
A. Frontal lobe lesion
B. Parietal lobe lesion
C. Temporal lobe lesion
D. Occipital lobe lesion
E. Cerebellar lesion

904. Answer: B
Explanation:
(Tierney, 42/e, p 969-971.)
MRI will most likely reveal a lesion of the parietal lobe.
Parietal lobe lesions may produce contralateral
hyperpathia and pain (thalamic syndrome) and
Gerstmann syndrome (alexia, agraphia, acalculia, right-left
confusion, and fi nger agnosia).
Occipital lobe lesions produce partial fi eld defects.
Temporal lobe lesions produce seizures, lip smacking,
olfactory or gustatory hallucinations, and behavioral
changes. Frontal lobe lesions lead to intellectual decline
and personality changes. The most common adult primary
tumors are gliomas.

167

905. A college student presents with complain of pain in
fi ngers with blanching and cyanosis of her fi ngertips in
cold weather and numbness. She has a 6-month history
of dysphagia and arthralgias. She does not smoke or
take any medications. On physical examination, the
skin of her hands appears to be taut and atrophic with a
fl exion deformity from the tight skin (sclerodactyly). The
following is the most likely diagnosis:
A. Rheumatoid arthritis
B. Progressive systemic sclerosis
C. Dermatomyositis
D. Ulcerative colitis
E. Sarcoidosis

905. Answer: B
Explanation:
(Tierney, 42/e, pp 813-814.)
The patient presents with symptoms suggestive of
scleoderma or progressive systemic sclerosis (PSS). This
disease, when diffuse, involves the skin, joints, lungs,
heart, and gastrointestinal system. Limited systemic
sclerosis (lSSc) was formerly known as the CREST
syndrome (Calcinosis cutis, Raynaud’s phenomenon,
Esophageal dysfunction, Sclerodactyly, and
Telangiectasia).
Raynaud’s phenomenon may be associated with tobacco
use, medication use (ß-adrenergic blockers), or diseases
such as systemic lupus erythematosus, rheumatoid
arthritis, carpal tunnel syndrome, or thromboangiitis
obliterans.
Dermatomyositis is a systemic disease characterized by a
violaceous rash of the eyelids and periorbital areas
(heliotrope) and fl at, violaceous papules over the knuckles
(Gottron sign). The rash seen in ulcerative colitis is
pyoderma gangrenosum. These painful ulcers are large and
irregular and drain purulent, hemorrhagic exudates.
Sarcoidosis is a systemic disease with skin
manifestations, bilateral hilar adenopathy, and pulmonary
disease. Patients with sarcoidosis may present with
erythema nodosum, which typically takes the form of
multiple fi rm, red, painful plaques that are bilateral and
most frequently distributed on the legs. Musculoskeletal
fi ndings in sarcoidosis include arthritis and tenosynovitis

168

906. What is transmitted in the tarsal tunnel?
A. Anterior tibial tendon
B. Posterior tibial nerve
C. Flexor hallucis longus tendon
D. Posterior tibial tendon
E. Flexor digitorum longus tendon

906. Answer: A
Explanation:
The tarsal tunnel is bounded by a fl exor retinaculum that
spans the medial malleolus and the calcaneus
The tibialis posterior, fl exor digitorum longus, and fl exor
hallucis longus tendons and the posterior tibial artery and
nerve pass through the tarsal tunnel
Source: Shah RV, Board Review 2004

169

907. A 30-year-old obese woman presents with a 2-month
history of a nonthrobbing headache that is constant and
dull in nature. The headache is worsened with bending
over or sneezing and on awakening in the morning. The
patient also complains of blurred vision and occasional
diplopia. Funduscopic examination reveals blurring of
the optic discs bilaterally and no other neurologic defi cit.
Which of the following is the most likely diagnosis?
A. Infratentorial brain tumor
B. Pseudo tumor cerebri
C. Supratentorial brain tumor
D. Pituitary adenoma
E. Metastatic brain tumor

907. Answer: B
Explanation:
(Tierney, 421e, p 974.)
Patients with pseudotumor cerebri (benign intracranial
hypertension) present with headache and papilledema.
They are often obese women in their childbearing years.
Other possible causes include hypervitaminosis A and the
use of oral contraceptives or antibiotics (tetracycline).
Lumbar puncture will reveal an elevated opening pressure.
Treatment includes weight reduction and repeated lumbar
punctures to reduce intracranial pressure. A complication
of pseudo tumor cerebri is blindness; patients with visual
changes may require emergency optic nerve sheath
decompression.Pituitary adenomas are benign tumors that
may cause a bitemporal hemianopsia and endocrine
disturbances, such as hyperprolactinemia (galactorrhea),
acromegaly or gigantism, and Cushing’s disease. A
ruptured berry aneurysm causes a subarachnoid
hemorrhage (SAH). Patients present with the acute onset
of severe headache, photophobia,and neck stiffness.Adults
commonly have supratentorial primary brain tumors
(astrocytoma including glioblastoma multiforme is the
most common), while children have infra tentorial
primary brain tumors (medulloblastoma is the most
common). Overall, metastatic brain tumors are more
common than primary brain tumors. The most common
metastatic brain tumors come from the Lung, Breast, Skin,
Kidney, or GI tract (mnemonic: Lots of Bad Stuff KillsGlia). The headache of tumor is often continuous;
exacerbated by coughing, sneezing, movement, or the
Valsalva maneuver; and worse in the morning.

170

908. A 24-year-old woman has a 2-year history of recurrent
right-sided headaches that are throbbing in nature and
are preceded by 30 min of scintillating scotomas and
fortifi cations. Choose correct type of headache:
A. Complicated migraine
B. Basilar migraine
C. Classic migraine
D. Common migraine
E. Temporal arteritis

908. Answer: C
Explanation:
(Tierney, 42/e, pp 947-949)
A.Complicated migraines may be preceded by aura and are
headaches accompanied by sensory or motor defi cits or
muscle palsies.
The patient described is having a specifi c kind of
complicated migraine called an ophthalmoplegic migraine.
A mnemonic for migraine is POUND (Pulsatile, lasts
One day, Unilateral, Nausea, and interferes with Daily
activities).
B. Basilar artery migraine is a variant of classic migraine
in which the aura consists of drop attacks, confusion,
blindness, and vertigo (all signs of basilar artery
ischemia).
C. Classic migraine is a unilateral headache that is
pulsatile and throbbing in nature and is preceded by a
prodromal aura consisting of scotomas (black spots),
scintillations (light fl ashes), or hemianopsia.
D. Common migraines lack a prodromal aura.
E. Patients with temporal arteritis are older (>50 years
old) and have headaches along with jaw claudication and
tenderness over the temporal artery.

171

909. A long-distance runner develops foot pain with exercise.
CHOOSE CORRECT DIAGNOSIS:
A. Hammer toe
B. March fracture
C. Genu valgum
D. Genu varum
E. Bunion

909. Answer: B
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.

172

910. The mechanism of cryotherapy’s affect on pain occurs
by:
A. Increasing metabolic rate of tissues.
B. Vasodilatation of blood vessels.
C. As a counter-irritant.
D. Improving contractility of muscle and ligament fi bers.
E. Increasing nerve conduction along pain pathways.

910. Answer: C
Source: Malanga G, Board Review 2003

173

911. An aphasia is most likely to be associated with a lesion
of
A. The hippocampus
B. The temporal lobe
C. The parietal lobe
D. The limbic system
E. The reticular activating system

911. Answer: B
Explanation:
(Guyton, pp 669-671.)
Aphasia is a language disorder in which a person is unable
to properly express or understand certain aspects of
written or spoken language. It is caused by lesions to the
language centers of the brain, which, for the majority of
persons, are located within the left hemisphere in the
portions of the temporal and frontal lobes known as
Wernicke’s and Broca’s areas, respectively. Language
disorders caused by memory loss, which could be the
result of a hippocampal lesion, are not classifi ed as
aphasias.

174

912. McKenzie exercises:
A. Would include repetitive extension even if radicular
symptoms are increased.
B. Stresses “centralization” of back pain symptoms.
C. Is most helpful in chronic nonorganic low back pain.
D. Is contra-indicated in acute disc herniations.
E. Would stress on fl exion exercises

912. Answer: B
Source: Malanga G, Board Review 2003

175

913. Parrafi n Wax is most helpful in which of the following
conditions:
A. Following an acute burn injury.
B. Joint pain of the hands from osteoarthritis.
C. Carpal tunnel syndrome.
D. An acute hand fracture.
E. Ankle Strain

913. Answer: B
Source: Malanga G, Board Review 2003

176

914. The most important role of the gamma motoneurons is
to
A. Stimulate skeletal muscle fi bers to contract
B. Maintain afferent activity during contraction of muscle
C. Generate activity in Ib afferent fi bers
D. Detect the length of resting skeletal muscle
E. Prevent muscles from producing too much force

914. Answer: B
Explanation:
(Berne, 3/e, pp 117-118.)
The gamma motoneurons innervate the intrafusal fi bers of
the muscle spindles. When a skeletal muscle contracts, the
intrafusal muscle fi ber becomes slack and the Ia afferents
stop fi ring. By stimulating the intrafusal muscle fi bers
during a contraction,the gamma motoneurons prevent the
intrafusal muscle fi bers from becoming slack and thus
maintain fi ring during the contraction

177

915. A 55-year-old woman walks by lifting one foot further off the ground than the other. Choose correct description of
gait:
A. Ataxic gait
B. Parkinsonian gait
C. Spastic hemiplegic gait
D. Steppage gait
E. Scissor gait

915. Answer: D
Explanation:
(Berne, 3/e, pp 117-118.)
The gamma motoneurons innervate the intrafusal fi bers of
the muscle spindles. When a skeletal muscle contracts, the
intrafusal muscle fi ber becomes slack and the Ia afferents
stop fi ring. By stimulating the intrafusal muscle fi bers
during a contraction,the gamma motoneurons prevent the
intrafusal muscle fi bers from becoming slack and thus
maintain fi ring during the contraction

178

916. A Middle aged woman presents with a one year history
of pain and morning stiffness accompanied by swelling
of her wrists and the proximal interphalangeal joints of
both hands. She also has knee pain and swelling of knee
joints. Physical examination reveals synovial tenderness
and swelling of her knees, wrists, and proximal
interphalangeal joints. She has subcutaneous nodules
in the extensor area of her right forearm.The right knee
has a positive bulge sign consistent with an effusion. The
most likely diagnosis is:
A. Osteoarthritis
B. Rheumatoid arthritis
C. Septic arthritis
D. Chondrocalcinosis
E. Scleroderma

916. Answer: B
Explanation:
(Tierney, 42/e, pp 829-831.)
C. A septic joint will usually produce systemic symptoms
such as fever.
A. Osteoarthritis produces a short period of morning
stiffness and often affects the distal interphalangeal joints.
D. Chondrocalcinosis is a radiologic fi nding (destructive
arthropathy) associated with pseudogout or CPPD
crystals.
B. The patient most likely has rheumatoid arthritis since
she meets four of the seven criteria as classifi ed by the
American College of Rheumatology:
Symmetric polyarthritis for over 3 months
Morning stiffness lasting more than 1 h
Rheumatoid nodules
Arthritis of more than three joint areas
Involvement of the joints of the hands and wrists;
patients may have swan-neck deformity
(hyperextension of the proximal interphalangeal joints
with compensatory fl exion of the distal joint),
boutonniere deformity (extension of the distal
interphalangeal joint), or ulnar deviation of the digits
A positive rheumatoid factor (RF)
Erosions or decalcifi cation on radiographs

179

917. All of the following psychiatric disorders are diagnosed
more often in women than in men. The most frequently
diagnosed disorder in women is
A. Depression
B. Obsessive-compulsive disorders
C. Anxiety disorders
D. Bulimia
E. Anorexia nervosa

917. Answer: A
Explanation:
(Fauci, pp 21-24.)
The most frequently diagnosed
psychological disorders in women are depression, anxiety
disorders, bulimia, and anorexia nervosa. Obsessivecompulsive
disorders are almost equally distributed
between adult men and women(prevalence about 2%), but
with a slightly higher prevalence among boys than girls.
Psychological disorders may have a higher prevalence in
women because men are more reluctant to consult a
physician for emotional problems. Another explanation is
that physicians may be more apt to diagnose vague mood
and anxiety complaints as psychological if there is no
obvious organic basis.
Source: Ebert 2004

180

918. A 31-year-old man complains of daily throbbing
headaches for the last 2 weeks. He has approximately eight
episodes per day, each lasting 20 min. The headaches are
localized to the left periorbital area and are accompanied
by tearing of the left eye, left ptosis, rhinorrhea, and left
facial redness. The patient remembers having a similar
problem 2 years ago that lasted for 3 weeks. He did not
seek medical help at that time. The patient feels that the
headaches are often precipitated by drinking a glass of
wine. Which of the following is the most likely diagnosis?
A. Migraine headache
B. Cluster headache
C. Tension headache
D. Trigeminal neuralgia
E. Sinusitis

918. Answer: B
Explanation:
(Tierney, 42/e, pp 948-949.)
Cluster headaches are often referred to as “suicide
headaches” because of the severity of the symptoms. These
recurring headaches are accompanied by facial fl ushing,
nasal stuffi ness, tearing, and a partial Horner syndrome
(there is no anhidrosis). They are more common in men
(the usual age is 20 to 50)than women and are exacerbated
by alcohol use.Migraine headaches do not have this timing
or duration. Tension headaches are bilateral,non throbbing, and symmetric. They are usually located in
the frontal or occipital areas of the skull and are thought to
be related to muscle contraction. They are often described
as being viselike. The headache of sinusitis is not abrupt in
onset or cessation, and patients often have tenderness with
percussion of the sinuses. Trigeminal neuralgia (tic
douloureux) is a paroxysmal severe facial pain over the
distribution of the trigeminal nerve. Women are affected
more than men, and patients are usually over the age of 40.
The pain of trigeminal neuralgia can be triggered by
simply touching the skin near the nostril.

181

919. For diagnostic lumbar sympathetic block commonest
sites include:
A. L1-L2
B. L2-L3
C. L3-L4
D. L4-L5
E. L5-S1

919. Answer: B
Source: Racz G. Board Review 2003

182

920. Migraine symptoms are most likely due to:
A. Vasoconstriction.
B. Epileptiform discharges.
C. Cerebral edema.
D. Decreased cerebral metabolism due to spreading cortical depression.
E. Vasodilatation

920. Answer: D
Explanation:
Studies of migraine have focused on vascular factors
indicating that vasoconstrictive drugs reduce the
amplitude of pulsation in the superfi cial temporal artery
but that this does not always reduce headache.It is believed
that extracranial vasodilatation is the cause of headache
and intracranial vasoconstriction is the cause of
neurological symptoms. Currently, the concept that
“spreading cortical depression,” which is a primary neural
(not vascular) event, is the major migraine mechanism.
This cortical depression leads to hypometabolic state and
hypoperfusion. The role of unstable serotonergic
neurotransmission in this cortical depression in migraine
is being explored. (Neurology 43 [suppl. 3], p. 51, 1993;
Journal of Neurophysiology 7, pp. 359-390, 1941;
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

183

921. A 35-year old man presented with constant low back pain
that radiated to the left or right upper buttock region
with occasional radiation to the thigh and calf posteriorly
with tingling sensation in the left heel. The symptoms
started approximately a year ago when he lifted a heavy
box which caused the gradual onset of low back pain at
the time with increasing intensity in a week. His motor
examination was grossly within normal limits. However,
he had a positive left straight leg raising at 50°. There was
decreased sensation to pin prick on the lateral side of the
foot on the left side. The following MRI shows:
A. L4/5 disc herniation
B. L5/S1 disc herniation
C. Large osteophyte pressing on L5 nerve root
D. Large osteophyte pressing on L4 nerve root
E. Facet joint arthritis causing spinal stenosis

921. Answer: B
Explanation:
Axial T2-weighted MRI scan at the lumbosacral level.
The arrow shows the degree of disc protrusion and the
effect that it is having on the pain sensitive anterior part of
the dural tube (D) and, to some extent, on the S1 nerve
roots (small white arrows). R = right side of patient. The
rectangle shows the approximate area shown in C.
Lateral T2 weighted MRI scan showing the lumbosacral
spine. S1 = fi rst sacral segment. The posterior disc
protrusion at the L5/S1 level is shown by the black arrow;
it can be seen compressing the anterior part of the dural
tube (D) (thecal sac). Note that the disc is becoming
‘black’ between L5 and S1 which indicates that it is
undergoing dehydration (desiccation) as a result of injury.
The L4/5 disc shows some early desiccation with
essentially normal disc hydration at the levels above.
A 200-micron thick histological section from a cadaver
with a similar but less extensive, disc protrusion; this is to
orientate the reader to the various anatomical structures.
The histological section is represented approximately by
the area within the rectangle on (D). R = right nerve roots
budding off from the dural tube (D) containing small nerve roots from the cauda equina (C). H = hyaline
cartilage on the zygapophysial joint facet surfaces. L =
ligamentum fl avum; N = spinal nerve; S = spinous process.
Open arrow head = intervertebral disc protrusion.
Source: Giles LGF. 50 Challenging Spinal Pain Syndrome
Cases. Edinburgh, Butterworth Heinemann, 2003.

184

922. Sumatriptan succinate is effective for the treatment of
acute migraine headaches by acting as
A. An antagonist at BETA1 – and BETA2 – adrenergic receptors
B. A selective antagonist at histamine (H1) receptors
C. An inhibitor of prostacyclin synthase
D. An agonist at nicotinic receptors
E. A selective agonist at 5-hydroxytryptamine 1D (5-HT1D)
receptors

922. Answer: E
Explanation:
Sumatriptan is closely related to serotonin (5-HT) in
structure, and it is believed that the drug is effective in the
treatment of acute migraine headaches by virtue of its
selective agonistic activity at 5-HT1D receptors. These
receptors, present on cerebral and meningeal arteries,
mediate vasoconstriction induced by 5-HT. In addition, 5-
HT1D receptors are found on presynaptic nerve terminals
and function to inhibit the release of neuropeptides and
other neurotransmitters.It has been suggested that the
pain of migraine headaches is caused by vasodilation of
intracranial blood vessels and stimulation of
trigeminovascular axons, which cause pain and release
vasoactive neuropeptides to produce neurogenic
infl ammation and edema. Sumatriptan acts to reduce
vasodilation and the release of neurotransmitters and,
therefore, reduces the pain that is associated with migraine
headaches. Oher antimigraine drugs (e.g.,ergotamine and
dihydroergotamine) also exhibit high affi nities for the 5-
HT1D-receptor site
Source: Katzung, pp 280-281.

185

923. What of the following is not an indication for a
glossopharyngeal nerve block?
A. Glossopharyngeal neuralgia
B. Atypical facial pain
C. Wisdom tooth extraction
D. Tonsillectomy
E. Pharyngeal cancer pain

923. Answer: C
Explanation:
(Raj Pain Review, 2nd Ed.,)
Primary (idiopathic) and secondary (oropharyngeal
cancer) glossopharyngeal neuralgia (cranial nerve 9) are
indications for the block of this nerve. Atypical facial pain
and tonsillectomy (pre-emptive analgesia) are also
indications. Maxillary nerve block is indicated for upper
teeth extraction and mandibular is indicated for lower
teeth extractions.
Source: Shah RV, Board Review 2003

186

924. Sphincter detrusor dyssynergia may respond to
transsacral stimulation at:
A. S1 nerve stimulation
B. S2 nerve stimulation
C. S3 nerve stimulation
D. S4 nerve stimulation
E. S5 nerve stimulation

924. Answer: C
Source: Racz G. Board Review 2003

187

925. A patient complains of worsening chronic headache,
despite treatment with aspirin, butalbital, caffeine and
ergotamine. MRI of the head was normal, but MRI of the
neck demonstrated spondylosis. Headache most likely is
due to:
A. Migraine
B. Drug rebound
C. Cervical spondylosis
D. Pseudo-tumor cerebri
E. Vasodilation due to ergotamine

925. Answer: B

188

926. A middle aged woman complains of abdominal pain that
began at age 8. Multiple medical and surgical evaluations
have been completely within normal limits. The patient
states that she has “always been sickly” and that her
mother “had the same problem.” There is no history of
childhood trauma or abuse. She has been unable to work
for the last 4 years. Which of the following psychological
diagnoses best describes her condition?
A. Somatization disorder
B. Conversion disorder
C. Hypochondriasis
D. Major depression
E. Generalized anxiety disorder

926. Answer: A
Explanation:
A. The patient has a somatization disorder (also called
hysteria or Briquet’s syndrome).
* Patients often present with a long history of physical
complaints before 30 years of age.
- Many have undergone comprehensive medical
evaluations and surgical interventions without diagnosis
of any signifi cant disease process.
- They also have impaired social development because of their perceived illness.
- Occupational development is also affected.
- Many do not work or work at jobs limited by their
perceived pain.
B. In conversion disorder, there is loss of a physical
function that is temporarily related to a psychosocial
stressor.
* Sexual dysfunction, pain, blindness, and paralysis have
been described as manifestations of the psychological
confl ict experienced by patients with conversion disorder.
C. Hypochondriasis is the excessive preoccupation with
disease and with one’s health. Hypochondriacs believe that
a disease process exists despite medical evaluation and
reassurance over long periods of time.
* Patients must pay obsessive attention to perceived pain
symptoms without signifi cant fear or depression.
- They complain to family and physicians and are not
reassured by normal medical examinations and test results.
D. Major depression is symptomatically different from
somatization disorder.
E. Generalized anxiety disorder is symptomatically
different from somatization disorder.

189

927. The daughter of a 65-year-old man describes her father as
having changed from an active, vivacious, caring person
to one who occasionally has trouble learning new facts,
has very little motivation to do any activity, and rarely
expresses feelings or emotions for his grandchildren
whom he has adored. The area of the brain most apt to be
involved in this type of behavior change is the
A. Hypothalamus
B. Reticular activating system
C. Heteromodal association areas
D. Limbic system
E. Unimodal association areas

927. Answer: D
Explanation:
(Carlson, pp 91-94.)
· The limbic system includes regions of the limbic cortex,
as well as a group of interconnected structures that
surround the core of the forebrain.
· The limbic system forms a circuit whose primary
function was formerly regarded as modulating motivation
and emotional responses.
· Studies have discribed that the hippocampal formation
and the limbic cortex that surround it are involved in
learning and memory, rather than emotional behavior.
However, the remaining sections of the limbic system are
responsible for emotions, feelings, moods, and motivation.
Thus, limbic system is the site primarily responsible for
his learning diffi culty, lack of motivation, and emotional
feelings.
Source: Ebert 2004

190

928. Which of the following is false with respect to tennis
elbow?
A. Forearm fl exors are typically involved
B. The involved muscles have tendinous attachments to the
lateral epicondyle of the humerus
C. The backhand stroke may be impaired
D. Corrective action includes loosening tight racquet
strings
E. Corrective action includes enlarging the racquet grip

928. Answer: A
Explanation:
(Shah, Musculoskeletal Examination Presentation)
The wrist extensors are involved, typically due to
overuse/infl ammation/degeneration at their insertion on
the lateral epicondyle of the humerus. Forearm fl exors are
involved in medial epicondylitis, ‘golfer’s’ elbow. The
above corrective actions are true
Source: Shah RV, Board Review 2004

191

929. A celiac plexus block is not indicated for:
A. Pancreatic cancer
B. Chronic pancreatitits
C. Sigmoid colon diverticulitis
D. Hepatic metastases
E. Chronic cholecystitis

929. Answer: C
Explanation:
(Raj, Pain Review 2nd ed.)
The classic indication for celiac plexus block and
neurolysis is pancreatic cancer. The liver and gallbladder
are also indicated. The sigmoid colon is innervated by the
lumbar sympathetic chain Sympathetic innervation to the
gut distal to the mid-transverse colon is supplied by the
lumbar sympathetics. Note that the celiac plexus contains
both parasympathetic and sympathetic fi bers. However,
preganglionic sympathetics coalesce to form the greater
splanchnic (T5-T9) and lesser splanchnic (T10-T11)
nerves. These do not synapse in the sympathetic chain but
synapse in the celiac, aortico-renal, and superior
mesenteric ganglia.
Source: Shah RV, Board Review 2003

192

930. The most common complication associated with a
supraclavicular brachial plexus block is
A. Blockade of the phrenic nerve
B. Intravascular injection into the vertebral artery
C. Spinal blockade
D. Blockade of the recurrent laryngeal nerve
E. Pneumothorax

930. Answer: E
Explanation:
The most common complication associated with a
supraclavicular brachial plexus block is pneumothorax.
Other potential complications include phrenic nerve
paralysis, Horner’s syndrome, nerve damage or neuritis, or
intravascular injection.

193

931. A 59-year-old female with mild CHF is treated with
furosemide. What is its primary mechanism of action?
A. Inhibition of sodium-potassium (Na+, K+) adenosine
triphosphatase (ATPase)
B. Inhibition of Na+, K+, choloride (Cl-) co-transporter
C. Inhibition of Na+, Cl- co-transporter
D. Inhibition of Cl- transporter
E. Inhibition of Ca2+ divalent cation (Ca2+) transporter

931. Answer: B
Explanation:
The primary action of furosemide is inhibition of the Na+,
K+,Cl- transporter in the thick ascending limb of the loop
of Henle
Source: Hardman, p 697

194

932. The most frequent work-related musculoskeletal disorder
found in the upper extremity is:
A. Carpal tunnel syndrome
B. Tendopathy of the extensor carpi radialis brevis
C. Posterior interosseus nerve entrapment
D. Shoulder external impingement
E. Cubital tunnel Syndrome

932. Answer: A
Source: Sizer et al - Pain Practice - March & June 2004

195

933. True statement concerning phantom limb pain is:
A. Trauma amputees have a higher incidence of phantom
limb pain than nontrauma amputees
B. The incidence of phantom limb pain increases with more
distal amputations
C. Nerve blocks are commonly used to treat phantom limb
pain
D. Most amputees do not experience phantom limb pain
E. Most phantom limb pain becomes more severe with
time

933. Answer: C
Explanation:
The incidence of phantom limb pain is estimated to be 0
- 88%. The incidence of phantom limb
pain does not differ between traumatic and nontraumatic
amputees.
The incidence of phantom pain increases with more
proximal amputation.
Although very diffi cult to treat, and there is no clinical
evidence nerve blocks are commonly used in an attempt to
treat phantom pain. These include trigger point injections,
peripheral and central nerve blocks, and sympathetic
blocks.

196

934. A 60-year-old man ambulates with his upper torso
stooped forward. His feet shuffl e and he has lost his arm
swing. Choose correct description of gait:
A. Ataxic gait
B. Parkinsonian gait
C. Spastic hemiplegic gait
D. Steppage gait
E. Scissor gait

934. Answer: B
Explanation:
(Seidel, Sle, pp 791-792.)
A. Ataxic gait is often characterized by clumsiness; when
steps are taken, the advancing foot is lifted high.The foot is
then brought down in a slapping or stamping manner.
B. Parkinsonian gait is noted for the forward stoop of the
head and shoulders, with arms slightly abducted and
forearms partially fl exed; there is decreased arm swing as
the feet shuffl e.
C. Spastic hemiplegic gait is the result of spasticity of the
involved limb. The limb is moved forward by abduction
and circumduction.
D. Steppage gait occurs with footdrop (paralysis of the
peroneal nerve); the affected foot is raised higher than
normal to prevent dragging of the toe. Bilateral footdrop
results in a gait resembling that of a high-stepping horse.
E. Spastic diplegia gait or scissor gait occurs with
extrapyramidal disorders. The patient uses short steps and
drags the foot; the legs are extended and stiff and cross on
each other.

197

935. Peripheral nerve stimulation for CRPS II:
A. peripheral nerve stimulation is more effective than spinal
cord stimulation
B. peripheral nerve stimulation and spinal cord stimulation
together is better than either alone
C. peripheral nerve stimulation should be used in mononeuropathy
D. psychological assessment should be done to rule out
contraindications
E. All of the above

935. Answer: E
Source: Racz G. Board Review 2003

198

936. Most common indication for gasserian ganglion block is
A. Glossopharyngeal neuralgia
B. Atypical facial pain
C. Trigeminal neuralgia
D. Migraine headache
E. Tension headache

936. Answer: C
Source: Raj, Pain Review 2nd Edition

199

937. Patrick’s test is a common physical exam technique to
elicit pain in which condition?
A. Sacro-iliac joint mechanical dysfunction and pain
B. Radicular pain due to lumbar spinal stenosis
C. Radicular pain due to a lumbar disc protrusion
D. Lumbar facet arthropathy
E. Lumbar discogenic pain

937. Answer: A
Explanation:
(Bonica, 3rd Ed., page 1587; Raj, Pain Review, 2nd Ed.,
page 139)
Source: Shah RV: 2003

200

938. A 22-year-old woman presents with the chief complaint
of diplopia for several weeks. She admits to occasional
vertigo and ataxia. Six months ago, she had urinary
incontinence for 1 month. Examination of the eyes
reveals nystagmus, and funduscopic exam reveals
swelling of the optic nerve (papillitis). The patient has
increased muscle tone of the lower extremities and is
hyperrefl exic. She has bilateral extensor plantar refl exes
and loss of position sense. Which of the following is the
most likely diagnosis?
A. Multiple sclerosis
B. Friedreich’s ataxia
C. Acute transverse myelitis
D. Brown-Sequard syndrome
E. Syringomyelia

938. Answer: A
Explanation:
A. The patient most likely has multiple sclerosis, a
demyelinating disease characterized by visual impairment,
an afferent pupillary defect (Marcus Gunn pupil),diplopia,
nystagmus, limb weakness, spasticity, hyperrefl exia,
extensor plantar refl exes, vertigo, ataxia, dysarthria,
scanning speech, emotional lability, and bladder
dysfunction.
Patients with optic neuritis are at risk for developing
blindness.
B. Friedreich’s ataxia is an autosomal recessive disease in
which young patients present with pes cavus foot
deformity, spasticity, arefl exia, ataxia, and cardiomyopathy.
C. Patients with acute transverse myelitis initially present
with back pain followed by weakness and loss of sensation
below the level of the pain.
Often, there may be bladder and bowel incontinence. Transverse myelitis may be seen after vaccination or
infections.
D. Brown-Sequard syndrome (cord hemisection) is
characterized by contralateral loss of pain and temperature
and ipsilateral spasticity, weakness, hyperreflexia, extensor
plantar reflex, and loss of proprioception (vibration and
position sense).
E. Patients with syringomyelia have bilateral paralysis,
muscle atrophy, and fasciculations along with pain and
temperature sensory loss in a shawl-like or capelike
distribution.
Source: Tierney, 42/e, pp 983-984.

201

939. A patient experienced a prolonged stay in one position
during a recent surgery and postoperative recovery that
resulted in compression of the common peroneal nerve
against the fi bular head. Which of the following motor
defi cits would be most likely to occur?
A. Loss of extension at the knee
B. Loss of plantar fl exion
C. Loss of fl exion at the knee
D. Loss of eversion
E. Loss of medial rotation of the tibia

939. Answer: D
Explanation:
Compression of the common peroneal nerve would affect
all muscles innervated by this nerve, including tibialis
anterior, peroneus longus, and extensor digitorum longus.
Loss of dorsifl exion and eversion is usually complete. The
extensors of the knee joint (quadriceps femoris) are
supplied by the femoral nerve, whereas the fl exors of the
knee joint (the hamstrings and gracilis) are supplied by the
tibial nerve and obturator nerve, respectively. The
gastrocnemius and soleus muscles are the principal plantar
flexors of the foot and are innervated by the tibial nerve.
The popliteus is the prime medial rotator of the tibia and
is also innervated by the tibial nerve.
Source: Klein RM and McKenzie JC 2002.

202

940. A patient presents to the emergency room 18 hours
after recovering from a spinal anesthetic, in which 5%
lidocaine was used. He complains of moderate to severe
pain in the lower back, buttocks, and posterior thighs.
The neurological and genito-urinary exams are normal. A
lumbar spine MR is normal. What is this patient suffering
with?
A. cauda equina syndrome
B. anterior spinal artery syndrome
C. transient radicular irritation
D. spontaneous intracranial hypotension
E. epidural hematoma

940. Answer: C
Explanation:
(Raj, Practical Mgmt of Pain, 3rd Ed., page 371; Stoelting,
Pharmacology and Physiology of Anesthetic Practice, 3rd
Ed., page 168-169)
A. Given the absence of any neurological or GU signs, one
would most likely suspect transient radicular irritation
and exclude cauda equina syndrome.
B. Anterior spinal artery syndrome often presents with
isolated leg weakness.
C. Hyperbaric lidocaine that is injected intrathecally can
present as severe low back, buttock, and groin pain,
secondary to transient neurological irritation. Treatment
is conservative.
D. Spontaneous intracranial hypotension presents with
headache and neurological symptoms.
E. The MRI would exclude a new epidural hematoma.
Source: Shah RV, Board Review 2004

203

941. Increased activity of the sympathetic nervous system
causes
A. Penile erection
B. Pupillary constriction
C. Accommodation for near vision
D. Bronchiolar dilation
E. Gallbladder emptying

941. Answer: D
Explanation:
(Rhoades, pp 118-120.)
Activation of the sympathetic nervous system produces relaxation of the smooth muscles surrounding the
bronchioles, leading to bronchiolar dilation. The
parasympathetic nerves are responsible for penile erection,
pupillary constriction, contraction of the ciliary muscle
during accommodation for near vision, and
gallbladder emptying. Sympathetic stimulation causes
ejaculation and pupillary dilation but does not affect the
activity of the ciliary muscle or the gallbladder.

204

942. A 51-year-old alcoholic presents to the emergency room
with horizontal nystagmus, ataxic gait, and confusion.
Which of the following is the most likely diagnosis?
A. Wernicke syndrome
B. Niacin deficiency
C. Korsakoff syndrome
D. Kliiver-Bucy syndrome
E. Delirium tremens

942. Answer: A
Explanation:
(Tierney, 42/e, p 985.)
The triad of nystagmus and paralysis of eye muscles,ataxia,
and confusion is associated with Wernicke syndrome.
Korsakoff syndrome consists of confabulation, confusion,
and recent memory loss.These disorders are often found in
thiamine (B1) defi cient malnourished alcoholics and are
secondary to lesions in the mamillary bodies. Niacin
defi ciency (pellagra or vitamin B3 defi ciency) causes the
triad of D’s (Dementia, Dermatitis, and Diarrhea). Kluver-
Bucy syndrome is due to lesions in the amygdala; patients
present with hypersexuality, compulsive attention to detail,
docile behavior, and an inability to recognize objects
visually (agnosia). Delirium tremens is seen 48 to 96 h
following abstinence from alcohol; patients present with
insomnia, confusion, tremors, delusions, visual
hallucinations, and hyperactivity of the autonomic
nervous system (i.e., sweating, tachycardia, fever,and
dilated pupils).

205

943. The condition in which the covering of the spinal
cord, along with enclosed neural tissue, forms a saclike
projection through a dorsal defect in the vertebral
column is termed
A. Rachischisis
B. Anencephaly
C. Meningocele
D. Meningomyelocele
E. Hydrocephaly

943. Answer: D
Explanation:
In the family of conditions known as spina bifi da,failure of
the dural portions of the developing vertebrae may expose
a portion of the spinal cord and its covering. This usually
occurs near the caudal end of the neural tube.If there is no
projection of the spinal cord or its covering through the
bony defect, the condition is generally hidden (spina bifi da
occulta). However, it is termed spina bifi da cystica when
spinal material traverses the defect.
A. Rachischisis is an extreme example of spina bifi da
cystica in which the neural folds underlying the vertebral
defect fail to fuse, leaving an exposed neural plate.
B.Anencephaly occurs when the cranial neural tube fails to
fuse, thus resulting in lack of formation of forebrain
structures and a portion of the enclosing cranium.
C. In a meningocele, this is a saclike projection formed
only by the meninges.
D. If the projection contains neural material, it is a
meningomyelocele.
E. Hydrocephaly results from blockage of the narrow
passageways between the ventricles or between the
ventricles and the subarachnoid space. Resultant swelling
of the ventricles compresses the brain against the cranial
vault and may cause serious mental defi cits.

206

944. The most appropriate drug for reversing myasthenic crisis in a patient who is experiencing diplopia, dysarthria, and difficulty swallowing is
A. Neostigmine
B. Pilocarpine
C. Pralidoxime
D. Succinylcholine
E. Tubocurarine

944. Answer: A

207

945. A supraclavicular brachial plexus block, blocks the
following section of the plexus:
A. Roots
B. Trunks
C. Divisions
D. Cords
E. Branches

945. Answer: B
Explanation:
The advantages of the supraclavicular block are fourfold.
The plexus is blocked where it is most compact, namely at
the level of the trunks.
A small volume of anesthetic is required and no part of the
plexus is spared as with axillary or interscalene block.
The block can be performed with the arm in any position.

208

946. A patient presents with right low back and hip pain
following a motor vehicle accident several weeks ago.
Pain is made substantially worse with internal rotation of
the right lower extremity. Hip fl exion and extension are
not painful. MRI demonstrates an L4/5 disc herniation.
The source of pain is most likely arises from which of the
following structures?
A. Disc
B. Facet joint
C. Hip joint
D. Sacroiliac joint
E. Piriformis muscle

946. Answer: E

209

947. A college student has a headache history of 3 months.
Headache is bilateral, constricting with nausea, but no
vomiting. Physical and neurological exams are normal.
The drug of choice is:
A. Acetaminophen
B. Oxycodone
C. Gabapentin
D. Amitriptyline
E. Sumatriptan

947. Answer: A
Explanation:
The patient most likely has tension headache.

210

948. A patient with rectal cancer with infi ltration develops a
new onset of low back pain. He is on oxycodone and antidepressant therapy. For treatment of low back pain, the
recommended addition is as follows:
A. Ibuprofen
B. Gabapentin
C. Mexiletine
D. Morphine
E. Transdermal Fentanyl

948. Answer: A

211

949. A 25-year-old woman is involved in a motor vehicle
accident. Among her injuries is a lumbar vertebral body
fracture. Which of the following most likely contributed
to this injury?
A. Flexion
B. Extension
C. Torsion
D. Spondylolisthesis
E. Subluxation

949. Answer: A
Explanation:
the person is upright. Fracture of a lumbar vertebral body
may be seen in vehicular accidents when the victim is
restrained during a high-speed impact by a seat belt
without a shoulder harness. The rapid and extreme
forward fl exion of the lumbar spine may produce a variety
of spinal injuries, ranging from fractures to dislocations.
Fractures suffered during falls in which the person is
upright, such as may occur when someone jumps off a
building, are usually compression fractures of the
vertebral body. Fracture of the vertebral body will usually
produce pain coincidental with the injury. Patients with
fractures of the vertebral body that occur without trauma
or with inconsequential trauma must be investigated for
malignant processes, such as metastatic carcinoma,
multiple myeloma, and unsuspected osteomyelitis.
Source: Anschel 2004

212

950. The carpal bone that is most likely to dislocate anteriorly
and cause a form of carpal tunnel syndrome is the
A. Capitate
B. Hamate
C. Lunate
D. Navicular
E. Scaphoid

950. Answer: C
Explanation:
A. The capitate is frequently fractured but does not tend to
dislocate into the carpal arch.
B. The hamate provides an anchor for the transverse carpal
ligament and is, therefore, located lateral to the carpal
tunnel.
C. The lunate bone tends to dislocate anteriorly into the
transverse carpal arch, thereby entrapping the tendons of
the extrinsic digital fl exors and compressing the median
nerve.
D, E. The navicular (scaphoid) bone has a tendency to
fracture but does not dislocate into the carpal tunnel.

213

951. A 35-year-old man has acute onset of low back pain, lower
extremity weakness, and bladder dysfunction. He had a
lumbar laminectomy two years ago. A myelogram shows
disc herniation L4-5. The most appropriate management
is
A. Bed rest
B. Administration of nonsteroidal anti-inflammatory agent
C. Epidural administration of a corticosteroid
D. Epidural administration of a local anesthetic
E. Surgical decompression

951. Answer: E

214

952. Clinical fi ndings due to S-1 radiculopathy include:
A. Absent ankle (Achilles) refl ex
B. Weakness of foot dorsifl exion
C. Neurogenic bladder
D. Positive unilateral Babinski sign
E. All of the above

952. Answer: A
Explanation:
With S-1 radiculopathy, there is reduction of ankle refl ex
due to gastrocnemius muscle weakness. Dorsifl exion of
foot is normal, as this involves the L-4 and L-5 roots.
Neurogenic bladder is seen with spinal cord or S-2, S-3,
and S-4 root involvement. Babinski sign is seen with
spinal cord, not spinal root lesions.
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

215

953. A herniated T-8 thoracic disk may cause which of these findings:
A. Paraparesis
B. Autonomic bladder
C. Bilateral Babinski signs
D. Absent abdominal refl exes
E. All of the above

953. Answer: E
Explanation:
A herniated T-8 thoracic disk may compress the thoracic
spinal cord, causing all the listed neurological
disturbances. It can also cause thoracic radiculopathy
resulting in bandlike sensory disturbance in the thoracic
or abdominal region. This latter pattern may simulate
shingles (herpes zoster without rash).
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

216

954. In Hirschsprung’s disease, neural crest cells fail to migrate to, or invade, the wall of the lower colon, resulting in a loss of peristalsis in that region and often fatal obstruction. Preganglionic neurons, which would innervate the absent intramural ganglia, originate in
A. The nucleus ambiguus
B. Cervical intermediolateral cell column
C. Sacral levels two to four of the spinal cord
D. The motor nucleus of the vagus nerve
E. The ventral horn at spinal levels T12, L1, L2

954. Answer: C
Explanation:
A. The nucleus ambiguus is the source of preganglionic
parasympathetic neurons that innervate the heart via the
vagus nerve and cardiac plexus.
B. Neurons arising in the cervical intermediolateral cell
column are sympathetic preganglionics.
C. Preganglionic parasympathetic neurons to the lower
colon arise from the spinal cord at sacral levels two to four
and reach the wall of the colon via pelvic splanchnic
nerves.
D. Preganglionic parasympathetic neurons arising from
the motor nucleus of the vagus innervate the upper GI
tract.
E. Neurons arising from the ventral horn are primary
somatic motor neurons to skeletal muscle.

217

955. A 32-year-old man was admitted for neurologic
evaluation of a gun-shot wound received fi ve days
previously A 9-mm bullet had passed through both the
medial and lateral heads of the gastrocnemius muscle.
The bullet had not struck bone or signifi cant arteries.
Neurologic examination revealed losses of dorsifl exion
and eversion of the left foot. The patient could not feel
pinprick or touch on the dorsum of the left foot or
anterolateral surface of the left leg. Which nerve was most
likely involved in the injury?
A. Sciatic nerve
B. Femoral nerve
C. Sural nerve
D. Common peroneal nerve
E. Tibial nerve

955. Answer: D
Explanation:
A. The sciatic nerve generally divides into the tibial and
common peroneal nerves superior to the popliteal fossa.
Damage to it might result in defi cits in both plantar
fl exion and dorsifl exion.
B. The femoral nerve innervates the quadriceps muscles of
the anterior thigh.
Damage to it would impair fl exion of the thigh at the
hip.
C. The common peroneal nerve innervates all muscles in
the anterior and lateral compartments of the leg.
The common peroneal nerve provides sensory
innervation to the dorsum of the foot and the
anterolateral surface of the legs via the superfi cial and
sural/lateral sural cutaneous nerves, respectively.
D. The common peroneal nerve is the lateral terminal branch of the sciatic nerve.
After arising near the apex of the popliteal fossa, it
descends on the popliteus muscle and winds superficially
around the fibular neck.
It is extremely vulnerable in this position and is the
most often injured nerve in the lower extremity.
E. The tibial nerve innervates plantar flexors of the
posterior compartment.

218

956. A tumor in the infratemporal fossa may gain entrance to the orbit through which of the following?
A. The optic foramen
B. The ethmoidal sinuses
C. The pterygoid canal
D. The inferior orbital fi ssure
E. The superior orbital fi ssure

956. Answer: D
Explanation:
A, E. The optic foramen and superior orbital fi ssure open
into the middle cranial fossa and transmit the optic nerve
and the oculomotor, trochlear, and abducens nerves,
respectively.
B. The ethmoidal sinuses are mucosa-lined cavities within
the ethmoid and adjacent bones. They drain into the nasal
cavity.
C. The pterygoid canal connects the middle cranial fossa
with the pterygopalatine fossa and transmits the vidian
nerve.
D. The infratemporal fossa communicates directly with
the orbit via the inferior orbital fi ssure and the
pterygopalatine fossa.
The fi ssure normally transmits branches of the
maxillary nerve and branches of the infraorbital
vessels.

219

957. Which statement regarding cervical nerve roots is true:
A. The C7 spinal nerve exits through the C7-T1 foramen
B. The C2 spinal nerve exits through the C1-2 neuroforamen.
C. Sensory innervation to the occiput is supplied primarily
by branches from C1
D. The greater occipital nerve originates from the ventral
root of C2
E. The C6 and C7 spinal nerves are most commonly involved in cervical radiculopathy

957. Answer: E
Explanation:
References:
2.Gray’s Anatomy, Thirteenth American Edition. Page
960.
3.The Anatomic Relation Among the Nerve Roots,
Intervertebral Foramina, and Intervertebral Discs of the
Cervical Spine
4.Tanaka, The Anatomic Relation Among the Nerve Roots,
Intervertebral Foramina, and Intervertebral Discs of the
Cervical Spine SPINE 2000;25:286-291
5.Mercer, The Ligaments and Anulus Fibrosus of Human
Adult Cervical Intervertebral Discs, SPINE 1999;24:619
There are 7 cervical spinal levels and 8 cervical spinal
nerves. The fi rst two cervical nerves (C1 and C2) exit the
spinal canal posterior to the atlanto-occipital and atlantoaxial
joints respectively. These two nerves do not exit via a
foramen. The fi rst cervical foramen is C2-3 which
transmits the C3 nerve. From C2-3 to C7-T1, the spinal
nerve exiting the foramen is named by the last number of
the level (i.e. C3 exits the C2-3 foramen, C4 exits the C3-4
foramen and C7 exits the C6-7 foramen). The C8 nerve
exits the C7-T1 foramen. Below T1, the numbering
convention reverses and the exiting nerve is named for the
fi rst number of the level (i.e. T2 exits the T2-3 foramen
and L4 exits the L4-5 foramen).
The greater occipital nerve is the medial branch of the
dorsal primary ramus of C2. It supplies most of the
sensory innervation to the occiput. The C1 spinal nerve is
primarily motor.
Degenerative changes of the intervertebral discs and nerve
root impingement in the intervertebral foramen occur
most commonly at the C5–C6 and C6–C7 levels. Kelsey et
al investigated the epidemiology of prolapsed cervical
discs in an attempt to provide descriptive statistics on this
disorder and to identify possible risk factors. Most
patients (75%) had prolapsed discs at either the C5–C6 or
C6–C7 level. Likewise, according to Murphey et al, the
frequency of cervical radiculopathy was 26% for C6, 61%
for C7, and 8% for C8. The incidence of nerve root
compression is high for C6 and C7.
Cadaveric dissection data from Tanaka et. Al. predicts a
higher incidence of radiculopathy for the C5, C6 and C7
nerve roots. The C5 nerve roots were found to exit over
the middle aspect of the intervertebral disc,whereas the C6
and C7 nerve roots were found to traverse the proximal
part of the disc. The C8 nerve roots had little overlap with
the C7–T1 disc in the intervertebral foramen. The C6 and
C7 rootlets passed two disc levels in the dural sac. Also, a
high incidence of the intradural connections between the
dorsal rootlets of C5, C6, and C7 segments was found.
Source: Schultz D, Board Review 2004

220

958. Pattern of limitation most frequently accompanying
subacromial impingement
A. Glenohumeral abduction limits
B. Glenohumeral adduction limits
C. Glenohumeral external rotation limits
D. Glenohumeral internal rotation limits
E. Glenohumeral external and abduction limits

958. Answer: D
Source: Sizer Et Al - Pain Practice March & June 2003

221

959. Intervertebral disks have a tendency to herniate into the
intervertebral foramen because the
A. Annulus fi brosus is attenuated in the posterolateral
regions
B. Interspinous ligament reinforces the disks anteriorly and
anterolaterally
C. Ligamentum fl avum reinforces the intervertebral disks
posteriorly
D. Lumbar intervertebral disks are thicker posteriorly than
anteriorly
E. Posterior longitudinal ligament is stronger and more
complete posteriorly than posterolaterally

959. Answer: E
Explanation:
(Moore, Anatomy, 4/e, pp 451-453.)
Intervertebral disks are strongly reinforced ventrally
and laterally by the anterior longitudinal ligaments. The
posterior longitudinal ligament, although it is denticulate
and attenuated laterally, reinforces the posterior aspect of
the intervertebral disk. Because the posterolateral region of the disk is supported least by ligamentous structures, a
nucleus pulposus that is herniated through the annulus
fibrosus of the intervertebral disk will take the line of least
resistance and move posterolaterally into the
intervertebral foramen.In so doing, the herniation is apt to
impinge on a spinal nerve of the next lower vertebral
level.
Source: Klein RM and McKenzie JC 2002.

222

960. A 75-year-old female in congestive heart failure (CHF)
is unable to climb a fl ight of stairs without experiencing shortness of breath. Digoxin is administered to improve
cardiac muscle contractility. Within two weeks, she has
marked improvement in her symptoms. What cellular
action of digoxin accounts for this?
A. Inhibition of cyclic adenosine 5’-monophosphate
(cAMP) synthesis
B. Inhibition of mitochondrial calcium (Ca2+) release
C. Inhibition of the sodium (Na+) pump
D. Inhibition of b-adrenergic stimulation
E. Inhibition of adenosine triphosphate (ATP) degradation

960. Answer: C

223

961. The DSM-IV classifi cation of psychiatric disorders
represent a major advance in psychopathology by
A. Detailing the treatments for various mental disorders
B. Predicting the outcome of less severe psychological
problems
C. Evaluating the effi cacy of various drug treatments
D. Assessing the potential etiology of abnormal behaviors
E. Defi ning by empirical criteria a wide variety of psychiatric
disorders

961. Answer: E
Explanation:
(Baum, pp 264-271.)
The DSM-IV is a multiaxial classifi cation and
categorization manual for a wide variety of psychological
disorders. One of its newer contributions is that each
individual is scored according to broad categories and axes
so that an individual may be classifi ed as having several
disorders rather than being forced into a single category or disorder.
The various categories of axes are Axis I: Primary psychiatric disorders (including physical
and sexual abuse, medication-induced disorders,
noncompliance)
Axis II: Personality disorders and mental retardation (can
also be used for maladaptive personality and defense
mechanisms)
Axis III: General medical conditions (general physical
health important to the total diagnostic picture)
Axis IV: Psychosocial and environmental problems
(family, personal, or situational problems that might affect
the diagnosis, treatment, or program)
Axis V: Global assessment of functioning (a scale of the
level of functioning at the time of evaluation and at other
time periods)
Source: Ebert 2004

224

962. Which of the following conditions mimics thalamic pain
syndrome?
A. Wallenberg’s syndrome
B. Syringomyelia
C. Lateral medullary syndrome
D. Parietal cortical lesion
E. Lumbar Radioculopathy

962. Answer: B
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition

225

963. Acute Herpes zoster infection (shingles) of 3 week’s
duration is most appropriately treated by which of the
following?
A. Topical lidocaine patch
B. Peripheral nerve blockade
C. Topical capsaicin cream
D. Spinal cord stimulation
E. Intrathecal steroids

963. Answer: B
Explanation:
Lidocaine patches should only be used on intact skin.
Similarly, capsaicin should not be used on broken skin.
Peripheral nerve blockade, such as intercostal blocks, is
the best choice of the options provided. SCS and
intrathecal steroids may be appropriate for postherpetic
neuralgia.

226

964. Among combat veterans, the greatest risk for
posttraumatic stress disorder is among those who
A. Were violent prior to service
B. Have a prior history of depression
C. Have coexisting sociopathy
D. Participated in violence towards noncombatants
E. Have a history of substance abuse

964. Answer: D
Explanation:
(Sierles, pp 264-266. Ebert, pp 341-350.)
Posttraumatic stress disorder (PTSD) is a cluster of
symptoms that can occur in a person after exposure to a
severely stressful event (e.g., rape, combat, natural
disaster). There are three categories of symptoms:
reexperiencing the event (e.g., nightmares, daydreams,
obsessions, fl ashbacks), withdrawal (e.g., avoiding movies
about war and rape and feeling detached from others who
have not experienced the event), and hyperarousal (e.g.,
insomnia, irritability, hypervigilance, severe anxiety). Most
patients with PTSD recover, especially those with good
premorbid functioning and support. The greatest risk for
PTSD among combat veterans is among those who killed
noncombatants, participated in atrocities, or were
wounded. Another factor associated with increased risk for
PTSD is violence or behavioral problems, sociopathy, or
psychiatric disorders prior to the trauma. Substance
abuse, including alcoholism, is also relevant. It is estimated
thats many as 480,000 American veterans of the war in
Vietnam have PTSD.
Source: Ebert 2004

227

965. In general, modalities such as heat, electrical stimulation
and ultrasound:
A. Should be used until the patient is cured of their pain.
B. Are the best method to treat patients with chronic pain.
C. When combined with injections are the only thing necessary
to treat the majority of pain conditions.
D. Should be used to facilitate an active exercise program
for a short course.
E. Should never be used following interventional techniques

965. Answer: D
Source: Malanga G, Board Review 2003

228

966. A 36-year-old man presents with left hand weakness and atrophy of the first dorsal interosseous muscle. This may indicate damage to spinal roots
A. C5 and C6
B. C6 and C7
C. C7 and C8
D. C8 and T1
E. T1 and T2

966. Answer: D
Explanation:
The fi rst dorsal interosseous muscle is innervated by the
ulnar nerve. The fi bers of the ulnar nerve reaching this
muscle originate a the C8 and T1 roots. If the ulnar nerve
itself is the neural element injured, it is usually because of
damage at the elbow, where the ulnar nerve runs
superfi cially in the groove over the ulnar condyle. All the
interosseous muscles of the hand are supplied by the ulnar
nerve: complete transection of that nerve will produce
interosseous wasting and impaired fi nger adduction and
abduction. Although the lumbrical muscles are situated
alongside the interosseous muscles of the hand, only two
lumbricals – those on the ulnar metacarpals – are
innervated by the ulnar nerve. The other two lumbricals
are innervated by the median nerve. All four lumbricals
insert on the extensor sheaths of the fi ngers and
participate in extension of the digits.
Source: Anschel 2004

229

967. A 49-year-old woman is brought to the emergency room
after suddenly losing consciousness. Her husband states
that the patient was in good health until 2 h ago, when
she suddenly complained of a severe headache. After
one episode of vomiting, the patient lost consciousness.
The husband states that there were no seizure-like
movements and no incontinence. The patient did not
take any medications, smoke, drink, or use illicit drugs.
On physical examination, the patient has a regular heart
rate of l00/min, respiratory rate of 16/min, and blood
pressure of 120/80 mmHg, and is afebrile. Heart and
lung examinations are normal. On neurologic exam, the
patient responds only to painful stimuli and her deep
tendon refl exes are bilaterally equal. She has bilateral
fl exor plantar responses. She has neck stiffness and
attempts to resist forward fl exion. Which of the following
is the most likely diagnosis?
A. Carotid artery thrombosis
B. Embolic infarction of the brain
C. Frontal lobe hemorrhage
D. Subarachnoid hemorrhage
E. Complicated migraine

967. Answer: D
Explanation:
(Tierney, 42/e, pp 961-967.)
There are three types of stroke: subarachnoid hemorrhage,
cerebral infarction, and intracerebral hemorrhage. This
patient presented after complaining of a severe headache.
She has neck stiffness and no focal defi cit on neurologic
exam. The loss of consciousness requires bihemispheral
dysfunction, and this along with the abrupt history is
most consistent with a subarachnoid hemorrhage (SAH).
Common causes of SAH include ruptured aneurysm (i.e.,
berry) and arteriovenous malformation (AVM).
Intracerebral hemorrhage (ICH) rarely produces coma
(must be signifi cantly large to do so), and patients do not
complain of headache (does not involve the meninges).
Patients with ICH have focal defi cits that appear abruptly
slowly progress over hours. An embolic stroke can involve
any carotid artery but must be bilateral to cause loss of
consciousness. Patients have a history of atrial fi brillation
or cardiac problems.

230

968. During a C7 stellate ganglion block, 2 cc of bupivacaine
with epinephrine were injected. The patient developed
myoclonic activity and lost consciousness. The injection
most likely was into the
A. Subdural space
B. Vertebral artery
C. Epidural vein
D. Subarachnoid space
E. Internal jugular vein

968. Answer: B

231

969. A 62-year-old man walks with his feet widely spaced;
steps occur with each foot lifted abruptly and too high
and brought down in a stamping manner. Choose correct
description of gait:
A. Ataxic gait
B. Parkinsonian gait
C. Spastic hemiplegic gait
D. Steppage gait
E. Scissor gait

969. Answer: A
Explanation:
(Seidel, Sle, pp 791-792.)
A. Ataxic gait is often characterized by clumsiness; when
steps are taken, the advancing foot is lifted high.
The foot is then brought down in a slapping or stamping
manner. Spastic hemiplegic gait is the result of spasticity
of the involved limb. The limb is moved forward by
abduction and circumduction.
B. Parkinsonian gait is noted for the forward stoop of the head and shoulders, with arms slightly abducted and
forearms partially fl exed; there is decreased arm swing as
the feet shuffl e.
Steppage gait occurs with footdrop (paralysis of the
peroneal nerve); the affected foot is raised higher than
normal to prevent dragging of the toe.
Bilateral footdrop results in a gait resembling that of a
high-stepping horse.
C. Spastic diplegia gait or scissor gait occurs with
extrapyramidal disorders.
The patient uses short steps and drags the foot; the legs
are extended and stiff and cross on each other.

232

970. A 35-year-old woman with Complex Regional Pain
Syndrome I of the right upper extremity, develops miosis,
ptosis and enophthalmos after undergoing a stellate
ganglion block. She does not notice a signifi cant pain
relief. No signifi cant rise in skin temperature changes was
recorded to the right upper extremity. What is the most
likely cause?
A. Inadequate concentration of the local anesthetic
B. Intravascular injection
C. Subarachnoid block
D. Anomalous Kuntz nerves
E. Brachial plexus block

970. Answer: D
Explanation:
The sympathetic supply to the upper extremity is
through the grey rami communicantes of C7, C8 and T1
with occasional contributions from C5 and C6.
This innervation is through the stellate ganglion. Blocking
the Stellate ganglion would effectively cause a sympathetic
denervation of the upper extremity.
In some cases the upper extremity maybe supplied by the
T2 and T3 grey rami communicantes. These fi bers do not
pass through the stellate ganglion.
These are Kuntz’s fi bers and have been implicated in
inadequate relief of sympathetically maintained pain
despite a good stellate ganglion block.
These fi bers can be blocked by a posterior approach.
Successful block of the sympathetic fi bers to the head is
indicated by the appearance of Horner’s syndrome.
Successful block of the sympathetic block of the upper
extremity is indicated by a rise in skin temperature,
engorgement of veins on the back of the hand, loss of skin
conductance response and a negative sweat test.
Source: Chopra P. 2004

233

971. A 35-year-old woman falls 12 ft off a ladder and fractures her c-spine, causing damage at the C4 level. She is initially a flaccid quadriplegic with arefl exia. This arefl exia and flaccidity usually evolve into hyperrefl exia and spasticity within
A. 2 to 4 months
B. 1 to 2 months
C. 3 days to 3 weeks
D. 1 to 3 h
E. 5 to 25 min

971. Answer: C
Explanation:
Spinal shock is a transient phenomenon that occurs with
damage to fi bers from upper motor neurons.The spasticity
that usually develops within a few days of the spinal cord
injury is presumed to represent exaggeration of the normal
stretch refl exes in the limbs disconnected from upper
motor neuron control. The evolution from spinal shock to
spasticity is much more typical of spinal cord injuries than
it is of cerebrocortical injuries, but even with
cerebrocortical injuries there is usually an interval of hors
to days during which limbs that eventually become
hyperrefl exic and spastic are hyprorefl exic and fl accid.
Source: Anschel 2004

234

972. A 29-year old female with upper extremity complex
regional pain syndrome undergoes a stellate ganglion
block in your offi ce pain clinic. She is otherwise healthy
with normal body habitus and normal airway. She has
been NPO for 12 hours. 20cc of 0.25% bupivacaine is
injected incrementally over one minute with no other
medication administered. 5 minutes after injection
the patient complains of generalized weakness which
progresses to complete unresponsiveness, apnea and
hypotension over the ensuing several minutes.The
following is the most likely diagnosis:
A. Overdose of bupivacaine
B. Total spinal anesthesia
C. Spinal cord infarction
D. Anaphylactic shock
E. Vertebral artery injection

972. Answer: B
Explanation:
Reference:
Gilbert, Complications and Controversies in Regional
Anesthesia, in ASA Refresher Course, Chapter 6, Volume
3, ASA 2003
Neural Blockade, Cousins and Bridenbaugh, Second
Edition, Chapter 22 Complications of Local Anesthetic
Neural Blockade, pp. 695-718.
Total spinal anesthesia refers to the condition in which an
overdose of intrathecal local anesthetic is administered,
resulting in blockade of the entire intraspinal neuraxis.
Patients with total spinal will manifest a complete and
total, albeit temporary, paralysis. Manifestations include:
Blockade of C3, C4 and C5 nerve roots (C3, 4 and 5
keep the diaphragm alive) as well as all thoracic spinal
nerves resulting in diaphragm and chest wall paralysis
with apnea.
Blockade of sympathetic fi bers with hypotension
secondary to vasodilation and bradycardia.
Complete muscle paralysis with loss of all voluntary
movement including speech an eye opening.
Unless hypotension is severe, the patient may remain
awake and aware but completely unable to respond. Total
spinal is the most likely diagnosis here because of the
signifi cant risk of dural root sleeve injection with stellate
ganglion block and the delayed and gradual onset of the
event, taking several minutes to develop.
The other choices can be eliminated as follows:
Overdose of bupivacaine:
20 cc of 0.25% bupivacaine contains 50 mg of
bupivacaine (one can easily calculate the mg/ml from the
milliliters and percent of any local anesthetic. Simply
multiply the percent (0.25) by 10. This will give the
number of mg per milliliter (2.5). Multiply this number
by the volume of 20ml to arrive at 50 mg).
The following are recommended maximum single doses
for common local anesthetics:
lidocaine: 300 mg without epinephrine, 500 mg with
epinephrine
bupivacaine: 175 mg to 225 mg
Although there are case reports of cardiac toxicity with
direct intravascular injection of as little as 50 mg of
bupivacaine, direct intravascular injection would have
resulted in immediate, not delayed effects. Soft tissue
infi ltration overdose of bupivacaine would require a dose
in the range of 175 mg.
Spinal cord infarction would be exceedingly unlikely
from an injection of plain local anesthetic and the time
course would be quicker.
Vertebral artery injection would cause immediate
seizures.
Anaphylactic shock is a possibility but unlikely with the
use of an amide local anesthetic.
Source: Schultz D, Board Review 2004

235

973. A 36-year old felt a sharp pain in the neck, radiating to the dorsal aspect of the forearm when he was lifting a large
box. He started experiencing numbness of the thumb
and index fi nger, with decreased ability to perform biceps
fl exion. On examination, a diminished biceps refl ex was
found. What is the most likely cause of the patient’s
problems?
A. Fractured C5 vertebra
B. C5/6 disc protrusion
C. Facet syndrome at C5/6
D. Compression of the C5 nerve root by an osteophyte
E. C4/5 disc protrusion

973. Answer: B
Explanation:
The patient has evidence of C6 root compression, most
likely due to C5/6 disc protrusion. Pain in the neck,
shoulder, medial scapula, anterior chest, lateral aspect of
the upper arm, and dorsal aspect of the forearm associated
with biceps and extensor carpi radialis weakness is
frequently present.The patient may complain of numbness
of the thumb and index fi nger. The biceps refl ex may be
diminished or absent (Wall, p 715)
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.

236

974. A type I diabetic patient has been treated with relaxation
techniques daily for one month. This treatment is likely
to affect the management of her diabetes by
A. Increased levels of plasma cortisol
B. Increased sensitivity to insulin
C. Increased glucose-stimulated secretion of insulin
D. Signifi cant improvement in glucose tolerance
E. No signifi cant change in requirements for exogenous
insulin

974. Answer: D
Explanation:
(Taylor, pp 530-531.)
· The use of relaxation techniques to reduce stress has
proven very effective.
· Studies of diabetic patients who practiced progressive
muscle relaxation showed signifi cant improvement in
glucose tolerance following relaxation training.
· Plasma cortisol levels were also reduced in patients
trained in relaxation.
· Relaxation, however, did not affect insulin sensitivity or
glucose-stimulated secretion of insulin.
· Stress reduction techniques, such as relaxation, are
effective in reducing requirements for exogenous insulin
and in the management of both insulin-dependent and
non-insulin-dependent diabetes.
Source: Ebert 2004

237

975. A 31-year-old female has been treated with fl uoxetine for
two months with no improvement in her depression. You
decide to switch antidepressant therapy to phenelzine and
instruct her to wait one week after stopping fl uoxetine to
start taking the new pills. She begins therapy immediately
with phenyline without discontinuing fl uoxetine. Two
days later, she is brought to the ED with unstable vital signs, muscle rigidity, myoclonus, and hyperthermia.
What caused these fi ndings?
A. Increased serotonin (5-HT) in synapses
B. Increased norepinephrine in synapses
C. Increased acetylcholine in synapses
D. Increased dopamine in synapses
E. decreased norepinephrine in synapses

975. Answer: A
Explanation:
Reference: Hardman, p 444.
This patient has the serotonin syndrome.
Serotonin is already present in increased amounts in
synapses because of blockade of its reuptake by the SSRIs.
The amount of serotonin that is present further increased
when breakdown by MAO is inhibited.
The serotonin syndrome can be life threatening.
Source: Stern - 2004

238

976. A 40-year old construction worker presents with pain
over the dorsal aspect of the forearm and inability to
fully extend the arm at the elbow. Physical examination
reveals diminished sensation over the dorsal aspect of
the index and middle fi ngers as well as an absent triceps
refl ex. The most likely diagnosis:
A. C5
B. C6
C. C7
D. C8
E. T1

976. Answer: C
Explanation:
Pain in the posterior aspect of the arm is likely due to a C7
root lesions, whereas medial anterior or lateral arm pain
may be due to C6 or C7 nerve root lesions. A C7 nerve
root lesion will also produce symptoms (pain and
paresthesias) in the index and middle fi ngers as well as a
diminished or absent triceps refl ex. Absence of a
brachioradialis refl ex is an indication of a C6 nerve root
lesion (Raj, pp 272-273).
Source: Kahn CH, DeSio JM. PreTest Self Assessment and
Review. Pain Management. New York, McGraw-Hill, Inc.,
1996.

239

977. If nystagmus is a prominent symptom of a cerebellar
lesion, the lesion is within
A. The dentate nucleus
B. The fl occulonodular lobe
C. The lateral cerebellum
D. The cerebrocerebellar cortex
E. The superior cerebellar peduncle

977. Answer: B
Explanation:
(Guyton, p 655.)
The fl occulonodular lobe is known as the
archeocerebellum because it is, phylogenetically, the oldest
portion of the cerebellum. It is connected to the vestibular
nuclei and participates in the control of eye movements.
Lesions to the fl occulonodular lobe will cause nystagmus.
Lesions to the other regions of the cortex, the deep nuclei
of the spinocerebellar tracts, cause a variety of
abnormalities in motor coordination referred to as ataxia.

240

978. A patient presents with onset of upper extremity pain.
The physical examination revealed weakness of elbow
extension and loss of sensation of the middle fi nger. The
correct diagnosis in this patient is:
A. C4 nerve root involvement
B. C5 nerve root involvement
C. C6 nerve root involvement
D. C7 nerve root involvement
E. C8 nerve root involvement

978. Answer: D
Explanation:
The C7 (radial nerve) supplies the triceps, which is the
primary elbow extensor while the triceps, wrist fl exors,
and fi nger extensors are partially innervated by the C8,
they are predominantly C7 muscles.
C7 supplies sensation to the middle fi nger. Since the
middle fi nger sensation is also occasionally supplied by C6
and C8, there is no conclusive way to test the C7 sensation.
Source: Hoppenfeld S. Orthopaedic Neurology. A
Diagnostic Guide to Neurologic Levels. Philadelphia,
LWW, 1997

241

979. Finger fl exion best tests for what nerve root?
A. C5
B. C6
C. C7
D. All of the above
E. None of the above

979. Answer: E
Source: Wirght PD, Board Review 2004

242

980. A 22-year old woman goes on a date. Following dinner,
her date tries to be affectionate. She becomes anxious and
develops weakness with inability to walk. Previous history
includes sexual abuse at age of 16, with hospitalization
and psychotherapy. She has improved with treatment
and diazepam. The most likely diagnosis is
A. Conversion reaction
B. Somatoform disorder
C. Psychoaffective disorder
D. Fictitious disorder
E. Malingering

980. Answer: A

243

981. Intrathecal baclofen is indicated for:
A. peripheral neuropathy
B. spasticity from cerebral palsy
C. post-laminectomy syndrome
D. spasticity from fi bromyalgia
E. central thalamic pain

981. Answer: B
Explanation:
Intrathecal baclofen is indicated for spasticity from
cerebral palsy, multiple sclerosis, spinal cord injury, and
hypoxic brain trauma. Peripheral neuropathy, central thalamic pain, and post laminectomy syndrome are not
primarily spasticity issues. Although severe cases of
fibromyalgia have apparently responded to intrathecal
baclofen, it is not a primary treatment.
Source: Trescot AM, Board Review 2004

244

982. Intrathecal clonidine may be indicated for all conditions,
EXCEPT:
A. Neuropathic pain
B. Failed laminectomy syndrome
C. Complex regional pain syndrome
D. Cancer pain
E. Lumbar disc herniation

982. Answer: E
Explanation:
All of these conditions may respond to intrathecal
clonidine except for Lumbar disc herniation
Source: Trescot AM, Board Review 2004

245

983. When using intrathecal opioids, speed of onset of
analgesia is:
A. Directly related to lipid solubility
B. Inversely related to lipid solubility
C. Indirectly related to lipid solubility
D. Unrelated to lipid solubility
E. Speed and duration are directly related to lipid solubility

983. Answer: A
Explanation:
The more lipid soluble the opioid, the faster the onset of
analgesia. The duration of action is inversely related to the
lipid solubility.
Source: Trescot AM, Board Review 2004

246

984. Which of the following is the most appropriate
pharmacologic therapy for trigeminal neuralgia
A. Buprenorphine
B. Carbamazepine
C. Chlorpromazine
D. Pentazocine
E. Phenelzine

984. Answer: B
Source: American Board of Anesthesilogy, In-trainnig
examination

247

985. Which represents an important diagnostic”red fl ag” in
the patient with headache?
A. Abrupt onset with progressively increasing severity
B. Distinct temporal pulse
C. Retro-orbital pain with lacrimation lasting 5-10 minutes
D. Pain worse with extension
E. Normal bladder function

985. Answer: A
Source: Giordano J, Board Review 2003

248

986. Early medical treatment of CRPS includes:
A. Anti-infl ammatories
B. Steroids
C. Antidepressants
D. Anti-seizure medications
E. Any of the above

986. Answer: E
Source: Racz G. Board Review 2003

249

987. The following is characteristic of trigeminal neuralgia:
A. Usually due to multiple sclerosis
B. Episodes may be aborted by certain antiepileptic or antispasticity
medications.
C. Sensory loss is detected on the face.
D. Weak masseter muscle function.
E. Bursts of pain last 30-60 min.

987. Answer: B
Explanation:
Trigeminal neuralgia develops due to demyelination of the
trigeminal nerve (sensory portion). This could be due to
MS plaque, neoplasm in the cerebello-pontine angle, or
vascular lesion compressing the trigeminal nerve. In most
cases of trigeminal neuralgia, no etiology is found and
neurological examination is normal. Bursts of “electrical
shock” pain usually last less than 30 sec and are confi nedto
one division of the trigeminal nerve (mandibular is most
common). Prior to diagnosis being established, dental
origin for pain is considered, and many patients undergo
unnecessary tooth extractions. Treatment includes
carbamazepine, phenytoin, or baclofen. Surgical rhizotomy
may be needed if medical therapy is not effective. There is
a theory that the pain is due to compression of the
trigeminal nerve by abnormal blood vessels, and if this is
the case, microvascular decompression would be
warranted.
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

250

988. Parsonage Turner syndrome is:
A. Also known as idiopathic brachial plexitis
B. Can be bilateral in 20% of patients
C. Associated with a 90% recovery rate within 3 years
D. All of the above
E. None of the above

988. Answer: D
Source: Wirght PD, Board Review 2004

251

989. If a patient has thunderclap headache and CT scan shows
blood in the left sylvian fi ssure, the next diagnostic study
would be:
A. EEG
B. MRI
C. LP
D. Left carotid angiogram
E. Four-vessel cerebral angiogram

989. Answer: E
Explanation:
The term thunderclap headache implies the headache is
sudden and severe. This pattern should alert the physician
to the possibility of SAH. Although LP with CSF exam is
the most defi nitive diagnostic study for SAH, CT was done and showed fi ndings characteristic of ruptured middle
cerebral artery aneurysm. Since 20% of aneurysms are
multiple, a four-vessel angiogram is needed to study the
entire cerebral circulation; whereas a left carotid
angiogram would likely show the causal aneurysm only
and not screen for the possibility of multiple aneurysms.
(Lancet 2, pp. 1247-1248, 1986; postgraduate Medicine 86,
pp. 93-100, 1989).
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

252

990. In patients with neoplastic conus medullaris compression,
clinical features usually include:
A. Symmetrical paraplegia with analgesia at wrist level
B. Normal ankle jerks
C. Bladder dysfunction
D. Plantar fl exor signs
E. All of the above

990. Answer: A
Explanation:
With conus medullaries lesion, the lowest portion of the
spinal cord would be involved; therefore there would be
leg weakness with upper motor neuron sings (plantar
extensor sings) with early autonomic signs and loss of
ankle refl exes.
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

253

991. These drugs are effective in acute migraine management:
A. Isometheptene, dichloralphenazone.
B. Ergotamine
C. Caffeine
D. Imitrex
E. All of the above.

991. Answer: E
Explanation:
All listed agents are effective in treating migraine.
Isometheptene in combination with acetaminophen and
dichloralphenazone (Midrin) as well as caffeine are
effective, possibly due to vasoconstrictive effect, despite
the debate as to whether vascular factors are primary or
secondary. These medications also affect serotonin
receptors. Ergotamine is most effective when used
parenterally and is less orally. Caffeine may enhance the
effect of ergotamine is most effective and is a serotonin
receptor agonist.
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

254

992.The following is characteristic of “cluster-type” headache:
A. Pupillary dilatation.
B. Relieved by sleep.
C. Long duration of pain episodes.
D. Prominent automatic discharge during headache.
E. Diplopia during attack.

992. Answer: D
Explanation:
In cluster, patients awaken with severe short-lived
headache. This is associated with autonomic dysfunction
and Horner syndrome. The presence of headache with
diplopia should suggest ruptured carotid aneurysm with
oculomotor nerve dysfunction (ptosis, pupillary dilation,
and extraocular muscle dysfunction). (Neurologic Clinics
of North America 75, pp. 579-591, 1991;
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

255

993. Medications utilized for migraine prophylaxis are:
A. Dihydroergotamine
B. Indomethacin
C. Acetazolamide
D. Calcium channel blockers
E. Sumatriptan

993. Answer: D
Explanation:
Migraine treatment may be abortive or prophylactic.
Drugs that affect the serotonergic brainstem raphe systemergot
alkaloids, cyproheptadine, methysergide, calcium
channel blockers, beta-blockers are effective I prophylaxis
of migraine; whereas other drugs are effective in aborting
an acute attack.
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

256

994. Effective treatment strategies for “status migrainous”
include:
A. Adequate fl uid replacement.
B. DHE and Reglan.
C. Imitrex.
D. Phenothiazines.
E. All of the above

994. Answer: E
Explanation:
As a result of vomiting, dehydration may be a signifi cant
problem. This should be corrected, and pain is frequently
relieved by rehydration only. Subcutaneous Imitrex is
effective,but injection may need to be repeated due to pain
recurrence.Parenterally administered Phenothiazines may
be effective but may cause postural hypotension.
Dihydroergotamine (DHE) and antiemetic
(metoclopramide) Reglan are usually effective in
refractory migraine. (New England Journal of Medicine
329, pp. 1476-1482, 1993; Ref. 2, pp. 101-103).
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

257

995. A 30-year-old man develops “the fi rst and worst headache
of his life” after 5 min of weight lifting. The headache is
throbbing in quality. It causes him to stop lifting. The
headache disappears in 10 min. When he goes to the
emergency department (ED), he is asymptomatic and
the exam is entirely normal. What is the most likely
diagnosis?
A. Subarachnoid hemorrhage.
B. Bacterial meningitis.
C. Benign exertional headache.
D. Intracranial hypertension.
E. Hypertensive encephalopathy.

995. Answer: C
Explanation:
Sudden “thunderclap” headache suggests subarachnoid
hemorrhage (SAH). Because the headache lasts only 10
min and then resolves, this suggests effort migraine,
especially since the patient has no meningeal sings. It
would be unlikely for pain of SAH to resolve rapidly. Lack
of fever excludes meningitis; normal blood pressure
excludes hypertensive encephalopathy; lack of papilledema
excludes intracranial hypertension. (Lancet 2, pp. 1247-
1248, 1998).
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

258

996. A patient with lumbar disk disease requires lumbar epidural injection of a corticosteroid for control of low
back pain. Which of the following statements concerning
this treatment is true?
A. Maximum effect occurs one hour after injection
B. Maximum effect occurs when drug concentration peaks
in cerebrospinal fl uid
C. Maximum effect occurs during the acute phase of the
disease
D. The benefi cial effect results primarily from sympathetic
neurolysis
E. It is contraindicated the patient has had prior surgical
procedures on the lumbar disks

996. Answer: C
Source: American Board of Anesthesilogy, In-trainnig
examination

259

997. An 18-year-old gymnast heard a popping sound in her
left knee while practicing for the Olympic Games. Her
knee immediately became swollen and painful. On
physical examination, it is obvious that the left knee has
an effusion. The anterior drawer test and Lachman test
are positive. McMurray test is negative. Which of the
following is the most likely diagnosis?
A. Anterior crudate ligament tear
B. Posterior crudate ligament tear
C. Torn medial meniscus
D. Torn lateral meniscus
E. Popliteal cyst

997. Answer: A
Explanation:
(Seidel, 5/e, pp 737-738.)
The anterior and posterior cruciate ligaments are
intraarticular ligaments and contribute to the stability of
the knee. The most likely diagnosis in this gymnast is tear
of the anterior cruciate ligament (ACL). Both the Lachman
test (the patient is placed in the supine position with the
knee fl exed at 15° while the examiner stabilizes the distal
thigh with one hand and grasps the patient’s leg distal to
the tibiofemoral joint with the other hand; the test is
positive if the examiner is able to move the tibia
anteriorly) and the anterior drawer test (the foot is
immobilized while the hip and knee are fl exed, then the
tibia is moved anterior relative to the femur; a positive test
occurs with forward displacement of the tibia of more
than 0.5 cm) are positive in this kind of injury. The
Lachman test is more sensitive than the drawer test.
Aspirated joint fl uid is usually bloody in ACL injuries. An
MRI is helpful in diagnosing this injury. A posterior
cruciate ligament (PCL) tear would have a positive
posterior drawer test whereby posterior displacement of
the tibia is elicited on physical examination. A tom medial
meniscus often causes the patient to complain of knee
catching, locking, and clicking. The McMurray test (with
the patient supine, fl ex the knee and hold the foot in one
hand; rotate the leg and slowly extend the knee while palpating the posteromedial margins of the joint for a
palpable click as the femur passes over the tom meniscus)
is positive for a tom medial meniscus. A tom lateral
meniscus is tested by palpating the posterolateral margin
of the knee joint with the leg in full internal rotation as the
knee is extended. Medial meniscus tears are more common than lateral meniscus tears and are usually due to twisting injuries. Unlike the immediate swelling seen with tears of vascular structures such as the ACL, the relatively
avascular meniscus (cartilage) causes more gradual
swelling.

260

998. If the recurrent laryngeal nerve were transected bilaterally,
the vocal cords would
A. Be paralyzed in the open position
B. Be paralyzed in the closed position
C. Be paralyzed in the intermediate position
D. Not be affected unless the superior laryngeal nerve were
also injured
E. Appear exactly the same as if an intubating dose of succinylcholine were given

998. Answer: B
Explanation:
The recurrent laryngeal nerve innervates all the muscles
of the larynx except the cricothyroid muscle, which tenses
the vocal cords and is innervated by the external branch of
the superior laryngeal nerve.
Bilateral transections of the recurrent laryngeal nerve
would produce tense (because the superior laryngeal nerve
remains intact) closed (because the muscle that opens the
cords have been denervated) vocal cords. What is actually
seen are fl accid closed cords.
The cricothyroid muscle is evidently unable to tense the
vocal cords without resistance from the other muscle in
the larynx.

261

999. A patient who presents with an intention tremor, “pastpointing,” and a “drunken” gait might be expected to have a lesion involving the
A. Cerebellum
B. Medulla
C. Cortical motor strip
D. Basal ganglia
E. Eighth cranial nerve

999. Answer: A
Explanation:
(Guyton, pp 655-656.)
Ataxia, dysmetria, and an intention tremor all are classic
fi ndings in a patient with a lesion involving the
cerebellum. Affected persons also exhibit
adiadochokinesia, which is a loss of ability to accomplish a
swift succession of oscillatory movements, such as
external and internal rotation of the foot. These symptoms
all result from destruction of the normal feedback
mechanisms that are coordinated in the cerebellum

262

1000. Which of the following types of interventional
procedures is associated with the greatest serum
concentration of lidocaine?
A. Intercostal
B. Caudal
C. Epidural
D. Brachial plexus
E. Femoral nerve block

1000. Answer: A
Explanation:
The site of injection of the local anesthetic is one of the
most important factors infl uencing systemic local
anesthetic absorption and toxicity.
The degree of absorption from the site of injection
depends on the blood supply to that site. Areas
that have the greatest blood supply have the greatest
systemic absorption.
The greatest plasma concentration of local anesthetic
occurs after an intercostal block, followed by caudal,
epidural, brachial plexus, and femoral nerve block.

263

1001. True statements regarding treatment of pain in multiple
organ/system trauma include all of the following except:
A. May require more than one modality of analgesia
B. Head injury is an absolute contraindication to epidural
placement
C. An advantage of regional block techniques over IV PCA
is improved blood fl ow in the area of the block.
D. An interpleural catheter is a viable alternative for thoracic
trauma, when an epidural is contraindicated.
E. In a multitrauma patient needing an epidural catheter,
treatment of the pain secondary to a thoracic injury
takes precedent over other injuries.

1001. Answer: B
Explanation:
Ref: Rowels. Chapter 6. Trauma. In: Pain Medicine: A
Comprehensive Review, 2nd Edition. Raj, Mosby, 2003,
page 39-40.
Source: Day MR, Board Review 2003

264

1002. Spurling’s maneuver is a technique that
A. is used to evaluate pain emanating from the cervical
facet joint
B. involves having the patient actively extend and rotate
their neck
C. would help in evaluating a patient that gives a history of
arm pain that gets better when the arm is allowed rest
on top the head
D. evaluates the same problem as a Hoffman’s maneuver
E. if positive, one would be inclined to order a bone scan

1002. Answer: B (pg227)
Explanation:
The plain fi lm radiograph depicted above shows a grade I
spondylolisthesis of L5 on S1 with pars defect. A bone spicule
projecting into the L5/S1 intervertebral foramen was present
on the right side. The L5/S1 intervertebral disc was very then
and there were anterior osteophytes adjacent to on the L5 and
S1 bodies.
Clinically, grade I spondylolisthesis of L5 on S1 may be causing
entrapment of L5 nerve root with probable L5/S1 disc bulge and
protrusion. However, to rule out further abnormalities with disc
herniation, patient should undergo either a CT scan or MRI.
Source: Giles LGF. 50 Challenging Spinal Pain Syndrome Cases.
Edinburgh, Butterworth
Heinemann, 2003.

265

1003. The block that could be performed to confi rm the results of the differential epidural block in evaluation of pelvic pain would be
A. Splanchnic block
B. Lumbar sympathetic block
C. Hypogastric plexus block
D. Celiac plexus block
E. Sciatic nerve block

1003. Answer: B
A. Axial T2-weighted MRI scan at the lumbosacral level. The
arrow shows the degree of disc protrusion and the effect that it is
having on the pain sensitive anterior part of the dural tube (D)
and, to some extent, on the S1 nerve roots (small white arrows).
R = right side of patient. The rectangle shows the approximate
area shown in C.
B. Lateral T2 weighted MRI scan showing the lumbosacral
spine. S1 = fi rst sacral segment. The posterior disc protrusion
at the L5/S1 level is shown by the black arrow; it can be seen
compressing the anterior part of the dural tube (D) (thecal sac).
Note that the disc is becoming ‘black’ between L5 and S1 which
indicates that it is undergoing dehydration (desiccation) as a
result of injury. The L4/5 disc shows some early desiccation with
essentially normal disc hydration at the levels above.
C. A 200-micron thick histological section from a cadaver with a
similar but less extensive, disc protrusion; this is to orientate the reader to the various anatomical structures. The histological section is represented approximately by the area within the rectangle
on (D). R = right nerve roots budding off from the dural tube (D) containing small nerve roots from the cauda equina (C). H =
hyaline cartilage on the zygapophysial joint facet surfaces. L = ligamentum fl avum; N = spinal nerve; S = spinous process. Open
arrow head = intervertebral disc protrusion.
Source: Giles LGF. 50 Challenging Spinal Pain Syndrome Cases. Edinburgh, Butterworth
Heinemann, 2003.

266

1004. Although a patient was instructed not to use alcohol
because of a medication he was taking, he did not listen
to advice and decided to have a drink of alcohol. Within
minutes, he developed fl ushing, a throbbing headache,
nausea and vomiting. Which of the following medications
was he taking?
A. Naltrexone
B. Diazepam
C. Disulfi ram
D. Phenobarbital
E. Tranylcypromine

1004. Answer: A (pg 228)
This is a CT scan at the L4/5 disc level. There is a fairly large right-sided soft disc prolapse at L4/5 that is impinging upon the right
L5 root as it buds off from the theca.
Source: Giles LGF. 50 Challenging Spinal Pain Syndrome Cases. Edinburgh, Butterworth
Heinemann, 2003.

267

1005. A dilated pupil in an alert patient would suggest:
A. Adie’s pupil
B. CN II palsy
C. Uncal herniation
D. All of the above
E. None of the above

1005. Answer: B
The MRI in Figure A (pg 228)shows an axial T1 weighted MRI scan showing the right lateral protrusion of the L4/5 disc impinging upon
the right L5 nerve root. The fi gure B shows a parasagittal T1 weighted MRI scan indicating L4/5 disc protrusion.
In the examination, only one view may be provided. Most likely it is an axial MRI view.

268

1006. Single-fi ber electromyographic (EMG) recordings are
helpful in assessing
A. Sensory nerve fi bers affected by ABC syndrome
B. Jitter that occurs in some myopathies
C. Postherpetic neuralgia
D. Trigeminal neuralgia
E. All of the above

1006. Answer: B
Source: Raj P, Pain medicine - A comprehensive Review -Second Edition

269

1007. Spinal cord stimulation has been demonstrated to be
somewhat effective in which of the following disease
states?
A. Spasmodic torticollis
B. Mixed-migraine headaches
C. Temporal arteritis
D. Cluster headaches
E. Cervical disc herniation

1007. Answer: A
Source: Raj P, Pain Medicine - A Comprehensive Review Second Edition

270

1008. A wrist drop would suggest a problem with which
peripheral nerve?
A. Ulnar
B. Median
C. Radial
D. All of the above
E. None of the above

1008. Answer: C
Source: Wirght PD, Board Review 2004

271

1009. Each of the following is a potential complication of
lumbar sympathetic blocks EXCEPT
A. Puncture of the renal pelvis
B. Intravascular injection
C. Seizure
D. S1 nerve block
E. Accidental Subarachnoid injection

1009. Answer: D
Explanation:
Potential complications from lumbar sympathetic block
include subarachnoid injection, puncture of a major
vessel or renal pelvis, neuralgia, somatic nerve damage,
perforation of a disk, infection, ejaculatory failure, and
chronic back pain.
Blockade of nerves arising from the lumbar plexus is
possible, but given the anatomic location of the sacral
plexus, blockade of an S1 nerve would be extremely
unlikely if not impossible.

272

1010. Which of the following agents is useful in the treatment
of malignant hyperthermia?
A. Baclofen
B. Diazepam
C. Cyclobenzaprine
D. Dantrolene
E. Halothane

1010. Answer: D
Explanation:
Reference: Hardman, p 188.
Malignant hyperthermia (hyperpyrexia), a syndrome that
is associated with the use of a general anesthetic
(e.g.,halothane) in conjunction with a skeletal muscle
relaxant, is characterized by tachycardia, hyperventilation,
arrhythmias, fever, muscular fasciculation, and rigidity. It
is caused by a sudden increase in the availability of calcium
(Ca) ions in the myoplasma of muscle.
Dantrolene, which interferes with release Ca ions from the
sarcoplasmic reticulum, is indicated in treatment of the
disorder. The fi rst three agents are centrally acting skeletal
muscle relaxants that are not useful in the treatment of
malignant hyperthermia.
Source: Stern - 2004

273

1011.The most common surgical option for trigeminal
neuralgia is:
A. Stereotactic radiosurgery
B. Gangliolysis
C. Microvascular decompression of the trigeminal nerve
D. Peripheral neurectomy
E. Intracranial Trigeminal Neurectony

1011. Answer: C
Explanation:
The artery causing compression over the trigeminal nerve
as it leaves the Pons is repositioned. If it’s a vein, it is
coagulated. This surgery has an 85% success rate over 5
years. The surgical approach is by a suboccipital
craniectomy.
Stereotactic radiosurgery is performed using a gamma
knife or a linear accelerator. A radiosurgical lesion is
placed in the trigeminal root. The short term results are
good.
Gangliolysis is performed by positioning a percutaneous
needle through the foramen ovale and into the rootlets
behind the gasserian ganglion. The lesion is made either by
radiofrequency destruction of the posterior roots,
infl ation of a balloon in the Meckel’s cave or injection of
glycerol into the cistern of the trigeminal ganglion. This
procedure is indicated in debilitated patients who cannot
tolerate major surgical procedures.
Peripheral neurectomy is performed by repeat avulsions of
the peripheral branches of the trigeminal nerve. This is
sometime performed if patients fail treatment with
Gangliolysis.
Bonica - Source: Chopra P, 2004

274

1012. Which of the following appears to have the best outcomes
in terms of preventing low back injury at the worksite
A. Back School
B. Ergonomic adaptations according to NIOSH
C. Pre-employment physical examination
D. Prophylactic back belts
E. Pre-employment X-ray screening

1012. Answer: B
Source: Sizer et al - Pain Practice - March & June 2004

275

1013. Mesencephalotomy is a
A. Procedure done in the midmenstrual cycle
B. Lesion in the middle of the cerebral hemispheres
C. Stereotactic lesion not often used today
D. Special procedure with limited pain treatment
E. None of the above

1013. Answer: C
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition

276

1014. Complications of neurolytic lumbar sympathetic blocks
with phenol:
A. genito-femoral nerve neuralgia
B. lateral femoral cutaneous nerve injury
C. paralysis of lower extremity
D. renal pelvis and ureter destruction
E. all of the above

1014. Answer: E
Source: Racz G. Board Review 2003

277

1015. The most common complication of a celiac plexus block
is
A. Hypotension
B. Subarachnoid injection
C. Seizure
D. Retroperitoneal hematoma
E. Constipation

1015. Answer: A
Explanation:
The sympathectomy produced by a celiac plexus block
causes hypotension by decreasing pre-load to the heart.
Subarachnoid injection is the most serious complication
of celiac plexus block.
Seizure is possible with an intravascular injection.
Retroperitoneal hematoma is also possible but extremely
rare.
Celiac plexus block frequently relieves constipation by
interrupting the sympathetic fi bers and leaving the
parasympathetic fi bers unopposed.
Source: Hall and Chantigan.

278

1016. A 31-year-old female is treated with an antipsychotic
agent because of a recent history of spontaneously
removing her clothing in public places and claiming that
she hears voices telling her to do so. Her blood pressure
is normally 130/70 mmHg. Since being treated with a
drug, she has had several bouts of syncope. Orthostatic
hypotension was noted on physical examination. Which
drug most likely caused this?
A. Haloperidol
B. Olanzapine
C. Fluphenazine
D. Chlorpromazine
E. Sertindole

1016. Answer: D
Explanation:
Reference: Katzung, p 482.
Although many antipsychotic agents can cause orthostatic
hypotension, chlorpromazine is the most likely choice of
the agents above for causing this adverse effect.
Source: Stern - 2004

279

1017. Phalen’s test involves
A. Tapping on the volar wrist with a refl ex hammer to see if
paresthesias could be elicited.
B. using the tips of an unwound paper clip to evaluate areas
of suspected sensory loss
C. Actively fl exing the wrist for 30-60 seconds to see if pain
is reproduced
D. putting both hands in a prayer position for 30-60 seconds
E. having the patient bring the thumb perpendicular to the
palm against resistance

1017. Answer: C
Explanation:
All of the above are physical exam maneuvers to evaluate
the median nerve compression in carpal tunnel syndrome.
Tinel’s involves tapping at the proximal wrist and eliciting
paresthesias into the index and middle fi ngers including
the thumb
2-point discrimination can be easily performed with a
paper clip.
Phalen’s involves wrist fl exion to increase carpal tunnel
pressure
The ‘prayer’ maneuver involves wrist extension, aka,
reverse Phalen’s
Resisted thumb abduction is a way to test the abductor
pollicis brevis reliably and involvement may mean that the
median nerve is severely compressed
Source: Shah RV, Board Review 2004

280

1018. The H reflex is commonly recorded from which
muscle(s):
A. Gastrocnemius
B. Biceps brachii
C. Temporalis
D. Soleus
E. All of the above

1018. Answer: D
Source: Wirght PD, Board Review 2004

281

1019. When evaluating peripheral neuropathy, the most
informative nerve to test during nerve conduction studies
would be:
A. Median nerve
B. Sural nerve
C. Ulnar nerve
D. Plantar tibial nerve
E. Axillary nerve

1019. Answer: D
Source: Wirght PD, Board Review 2004

282

1020. Spinal cord stimulation in treatment of CRPS:
A. inhibits sympathetic outfl ow
B. should be preceded by psychological assessment
C. should be fi rst tested by trial stimulation
D. double electrodes need to be close to the “sweet spot”
E. All of the above

1020. Answer: E
Source: Racz G. Board Review 2003

283

1021. Muscle contractions from poorly treated CRPS:
A. can be surgically corrected by muscle lengthening
B. should be manually stretched by a strong physical therapist
C. Botox injections are ineffective
D. Acupuncture, but only on Yang points are completely
curative
E. None of the above

1021. Answer: E
Source: Racz G. Board Review 2003

284

1022. CRPS diagnostic absolute “gold standard”:
A. Bone scan
B. 3-phase bone scan
C. osteoporosis
D. overactive sympathetic nervous system
E. none of the above

1022. Answer: E
Source: Racz G. Board Review 2003

285

1023. A patient presents with an acute onset of pain in the
upper extremity. His physical examination showed
weakness of wrist extension. The sensory examination
showed hypoesthesia in the lateral forearm. What is the
most likely involvement of disc herniation and nerve root
in this patient?
A. C6/7 disc herniation with C7 nerve root involvement
B. C7/T1 disc herniation with C8 nerve root involvement
C. T1/T2 disc herniation with T1 nerve root involvement
D. C4/5 disc herniation with C5 nerve root involvement
E. C5/6 disc herniation with C6 nerve root involvement

1023. Answer: E
Explanation:
Wrist extensors are supplied by C6 and partially by C7.
The biceps has both C5 and C6 innervation. Under the
radial extensors, extensor carpi radialis, longus and brevis,
is supplied by radial nerve C6 in contrast to ulnar
extensors supplied by extensor carpi ulnaris and C7
innervation.
C6 supplies sensation to the lateral forearm, the thumb,the
index fi nger, and one half of the middle fi nger. To
remember the C6 sensory distribution more easily, form
the number 6 with your thumb, index, and middle fi ngers
by pinching your thumb and index fi nger together while
extending your middle fi nger.
Source: Hoppenfeld S. Orthopaedic Neurology. A
Diagnostic Guide to Neurologic Levels. Philadelphia,
LWW, 1997.

286

1024. Intermittent Horner syndrome may be seen in this
headache disorder:
A. Migraine with aura.
B. Migraine without aura.
C. Temporal arteritis.
D. Benign intracranial hypertension.
E. Cluster

1024. Answer: E
Explanation:
Intermittent Horner syndrome is most likely to occur with
cluster, due to distention of the internal carotid artery
wall as the sympathetic fi bers travel within the carotid
artery.Horner syndrome is partial, with ptosis and miosis
but no anhidrosis.Other autonomic signs are present
(perspiration, tachycardia, bradycardia, lacrimation),
which suggests autonomic instability. (Medical Clinics of
North America 75, pp. 579-591, 1986).
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

287

1025. Spasticity can be caused by sectioning
A. The corticospinal fi bers
B. The vestibulospinal fi bers
C. The afferent fi bers
D. The corticoreticular fi bers
E. The reticulospinal fi bers

1025. Answer: D
Explanation:
(Guyton, pp 639-640.)
Spasticity results from over activity of the alpha
motoneurons innervating the skeletal musculature. Under
normal circumstances, these alpha motoneurons are
tonically stimulated by reticulospinal and vestibulospinal
fi bers originating in the brainstem. These brainstem fi bers
are normally inhibited by fi bers originating in the cortex.
Cutting the cortical fi bers releases the brainstem fi bers
from inhibition and results in spasticity Cutting the fi bers
from the reticular formation, vestibular nuclei, or the Ia
afferents will reduce the spasticity.

288

1026. A patient presents with pain and paresthesia in the
left leg. The distribution of the pain-running down the
medial aspect of the leg and the medial side of the foot
and including the great toe-is suggestive of a herniated
intervertebral disk. The most likely location of herniation
is:
A. L3-L 4 intervertebral disk
B. L4-L5 intervertebral disk
C. L5-S1 intervertebral disk
D. S1-S2 intervertebral disk
E. Insuffi cient data to determine

1026. Answer: A
Explanation:
(April, 3/e, pp 133, 140.)
The deep incisure in the inferior border of the pedicle
ensures that the spinal nerve associated with that vertebra
will exit through the intervertebral foramen well above
the intervertebral disk so that it will not be affected by
a herniation at that level. However, a posterolateral
herniation (the usual direction) will impinge on the next
lower nerve as it courses toward its associated
intervertebral foramen. In this case, pain was distributed
along the medial side of the leg and foot as far as the
great toe-the distribution of the saphenous branch of
the femoral nerve (L4). Herniation of the third lumbar
intervertebral disk between vertebral bodies L3-L4 would
affect nerve L4.
Source: Klein RM and McKenzie JC 2002.

289

1027. A middle aged man is administered morphine via
patient-controlled analgesia (PCA) pump after a left total
hip arthroplasty. The pump is programmed to deliver a
maximum dose of 2 mg every 15 minutes (lockout time)
as needed for patient comfort. The total maximum dose
that can be delivered in 4 hours is 30 mg. On the fi rst day
the patient receives 15 doses every 4 hours by pressing the
delivery button every 15 to 18 minutes. How should his
pain control be further managed?
A. Discontinue the PCA pump and administer intramuscular
morphine
B. Increase the lockout time from 15 to 25 minutes
C. Change the analgesic from morphine to fentanyl
D. Increase the dose to 3mg every 15 minutes as needed up
to a total maximum dose of 40 mg every 4 hours
E. Make no changes

1027. Answer: D
Explanation:
Frequent dosing by a patient receiving postoperative
analgesia through a PCA pump suggests the need to
increase the magnitude of the dose.
A patient also should be given a suffi cient loading dose
of narcotic before initiative therapy with a
PCA pump.

290

1028. This fi ndings is characteristic of temporal arteritis:
A. Throbbing headache.
B. Markedly elevated ESR.
C. Tender temporomandibular joint.
D. Active arthritis.
E. Pulsatile, nontender temporal artery

1028. Answer: B
Explanation:
Headache is more commonly aching than throbbing. Jaw
pain may occur with chewing, but TMJ tenderness is not
usually present. The patient complains of joint pain and
stiffness (polymyalgia rheumatica), but no active arthritis
is found. The temporal artery is nonpulsative and
frequently tender. ESR is usually markedly elevated.
(American Journal of Medicine 67, pp. 839-845, 1972;
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

291

1029. Sustained clonus at the ankle is most consistent with:
A. Peripheral neuropathy
B. Polyradiculopathy
C. Myelopathy
D. Anterior horn cell disease
E. None of the above

1029. Answer: C
Source: Wirght PD, Board Review 2004

292

1030. Which of the following lie in the carpal tunnel?
A. Transverse carpal ligament
B. Radial artery
C. Flexor carpi radialis
D. Flexor pollicis longus
E. Palmar branch of median nerve

1030. Answer: D
Explanation:
The transverse (palmar) carpal ligament bounds the carpal
tunnel, at its volar surface. This ligament is attached to the
tubercle of the scaphoid and trapezium on the radial side
and the hamate on the ulnar side. This canal transmits the
median nerve, but not its palmar branch. Additionally, the
canal transmits the fl exor digitorum superfi cialis x4,
fl exor digitorum profundus x4, and fl exor policis longus.
The radial artery and the FCR do not pass through the
tunnel
Source: Shah RV, Board Review 2004

293

1031. Facet joint degeneration (osteoarthropathy) results
from:
A. Mechanical load and stress resulting from disk space
narrowing
B. Lumbar stenosis
C. Spine instability
D. Paget disease
E. All of the above

1031. Answer: A
Explanation:
Not all patients with back pain due to arthritic etiology
have a herniated disk. There may be arthritic changes
which occur in the superior and inferior articular facets
that result in back pain.
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

294

1032. If the patient has low back and hip pain and the pain can be exacerbated by external hip rotation, the most likely
source of the pain is:
A. L-4 radiculopathy
B. Sacro-iliac joint
C. Hip joint pathology
D. Lateral femoral cutaneous neuropathy
E. None of the above

1032. Answer: C
Explanation:
If back pain is exacerbated by stretch signs (straight-leg
raising test), consider nerve root compression. If it is
exacerbated by tenderness over the sacral-iliac joint,
consider local bursitis. If pain is exacerbated by external
rotation of the hip, consider hip pathology. Also, consider
visceral pathology (kidney, stomach, pancreas, aorta,
colon) as the cause of back pain.
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

295

1033. Which represents a diagnostic “red fl ag” when assessing
the patient with spine pain and/or sciatica?
A. Periodic”on-off” periods of episodic pain
B. Pain extending completely to the foot
C. Progressive neurologic signs and defi cits
D. All of the above
E. None of the above

1033. Answer: C
Source: Giordano J, Board Review 2003

296

1034. Erb’s Palsy results in:
A. Hypoesthesia in the C5 dermatome
B. Paralysis of scapular muscles
C. Hypoesthesia in the C6 dermatome
D. All of the above
E. None of the above

1034. Answer: D
Source: Wirght PD, Board Review 2004

297

1035. A 31-year-old man develops left ankle pain after stepping
off a curb. He treated the injury with ice overnight but the
next day cannot walk due to the pain. On examination of
the ankle, you notice that it is swollen and ecchymotic.
The anterior and lateral aspects of the ankle are tender to
palpation. Inversion of the ankle is painful. Which of the
following is the most likely diagnosis?
A. Ankle sprain
B. Rupture of the Achilles tendon
C. Metatarsal stress fracture
D. Plantar fasciitis
E. Tarsal tunnel syndrome

1035. Answer: A
Explanation:
(Tierney, 42/e, pp 801-802.)
Ligament injuries of the ankle are common and may occur
in sports requiring jumping and running. These injuries
occur when the foot twists as it lands on the ground and
can even be a consequence of walking on uneven ground.
The medial ligament is typically injured with eversion and
the lateral ligament (the ligament most commonly affected
by injuries) with inversion. The lateral ligament is
composed of three parts: the anterior talofi bular ligament,
the calcaneofi bular ligament, and the posterior talofi bular
ligament. The injured ligament is tender to palpation,
ecchymotic, and swollen. Metatarsal stress fractures
(march fractures) occur after long periods of running or
walking; pain is typically in the middle of the forefoot.
Rupture of the Achilles tendon may occur with running
and jumping. It causes a palpable defect, swelling, and
tenderness over the tendon. The Thompson test is positive
(patient lies with knee fl exed to 90° and the examiner
squeezes the calf muscle; if the Achilles tendon is ruptured,
the foot will not move, but if the tendon is intact, the foot
will plantarfl ex). Plantar fasciitis causes pain over the
medial aspect of the plantar fascia. It usually starts slowly
and is of long duration. The windlass test is positive (pain
increases with ankle and great toe dorsifl exion). Tarsal
tunnel syndrome occurs with entrapment of the posterior
tibial nerve. The patient complains of burning and
numbness that extends from the sole of the foot and toes
to the medial malleolus.

298

1036. Which of the following is true regarding anxiety
disorders and their relationship to pain?
A. Panic attacks are initiated by fear of movement (kinesiophobia).
B. Agoraphobia is frequently experienced by patients with
pain for > 6 months.
C. Patients in pain are often depressed than they are anxious
and worried.
D. 80% of Vietnam vets with PTSD report pain.
E. Chronic pain patient rarely suffer with anxiety.

1036. Answer: D
Source: Cole EB, Board Review 2003

299

1037. What is the neurotransmitter involved in migraine ?
A. Dopamine
B. Acetylcholine
C. Serotonin
D. GABA
E. Norepinephrine

1037. Answer: C
Explanation:
It is believed that there is unstable serotonin
neurotransmission in migraine, with increased raphe
neuronal fi ring rates. During acute migraine attack,
platelet serotonin levels fall and urinary serotonin
increases. Serotonin transmission abnormalities in the
gastrointestinal system explain prominent GI symptoms,
and affective-mood disturbances are also due to unstable
CNS serotonin changes. Drugs that treat migraine affect
serotonin receptors.
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

300

1038. Prophylactic medications for migraine are all EXCEPT:
A. Amitriptline
B. Topiramate
C. Verapamil
D. Isometheptene mucate
E. Atenolol

1038. Answer: D
Explanation:
Drugs used for preventive treatment of migraines are
tricyclic antidepressants, beta blockers, anticonvulsants
and calcium channel blockers. Some of the other drugs
used are SSRI (class of antidepressants, NSAIDS, MAO
(Monoamine oxidase) inhibitors.. Amitriptyline is a
tricyclic antidepressant. Topiramate is an anticonvulsant.
Verapamil is a calcium channel blocker. Atenolol is a beta
blocker. Isometheptene mucate is used for abortive therapy
and has no role in prophylactic therapy.
Source: Chopra P, 2004

301

1039. Which of the following is true with regards to phantom
limb sensation?
A. It is strongest in above elbow amputations
B. More frequent in the non-dominant limb in double
amputees
C. Described as an unpleasant, burning sensation
D. Requires aggressive treatment with medication and interventional
therapy
E. It is weakest in above knee amputations

1039. Answer: A
Explanation:
Ref: Hord and Shannon. Chapter 16. Phantom Pain. In:
Practical Management Of Pain, 3rd Edition. Raj et al,
Mosby, 2000, page 212-213
Source: Day MR, Board Review 2003

302

1040. A patient involved in a work related injury
approximately 2 weeks ago complains of intractable low
back and bilateral lower extremity pain. On examination,
the patient presents with non-physiological signs, which
included superfi cial tenderness and positive axial loading.
These fi ndings indicate:
A. Somatization disorder
B. Malingering
C. Conversion disorder
D. Disc herniation
E. Fibromyalgia

1040. Answer: B
Explanation:
Non-physiological signs described by Waddell include
superfi cial tenderness, axial loading, positive distraction,
and simulation.
Overreaction has been removed, thus, 2 positive signs
indicate non-physiological behavior which may also be
described as malingering.
Somatization disorder is different from malingering or
conversion disorder.
Non-physiological signs do not confi rm disc herniation or
fibromyalgia

303

1041. A young woman has a diagnosis of irritable bowel
syndrome. She has a constitutional predisposition to
respond physiologically to a situation in a particular
way, has inadequate homeostatic restraints, and develops
symptoms when exposed to activating situations. This
etiological sequence in a psychophysiologic disorder
follows the
A. Specifi c-attitudes theory
B. Diathesis-stress model
C. Weak organ/system theory
D. Individual response stereotypes
E. Specifi c-response pattern model

1041. Answer: B
Explanation:
(Baum, pp 211-220.)
· Psychophysiologic disorders were formerly referred to as
psychosomatic illnesses. They are characterized by
physical symptoms from organs of the body that have
become dysfunctional through an interaction between psychological, biologic (including genetic), and
sociocultural factors.
· The most common psychophysiologic disorders are
hypertension, bronchial asthma, dysmenorrhea, headache,
neurodermatitis, peptic ulcer, irritable bowel syndrome,
rheumatic arthritis, and ulcerative colitis. Diabetes, along
with many other diseases, has a strong psychological
component, but is not considered to be a
psychophysiologic disorder.
Source: Ebert 2004

304

1042. Which of the following approaches provides the most
consistent blockade of the brachial plexus?
A. Interscalene
B. Supraclavicular
C. Infraclavicular
D. Axillary
E. Suprascapular

1042. Answer: B
Explanation:
(Raj, Pain Medicine Review, pages 236-238)
A. The interscalene targets the roots and may miss C8 and
even, C7.
B. The upper, middle, and lower trunks of the brachial
plexus are predictably pass over the fi rst rib, between the
insertion of the anterior and middle scalene muscles onthe
fi rst rib. This is the most compact area of the brachial
plexus and hence, the supraclavicular approach is the most
effi cient way to block the brachial plexus.
C. The infraclavicular approach may block the plexus at
the level of the musculocutaneous and axillary nerves high
in the axilla: anesthesia is obtained from the shoulder to
the hand. However, since the block is at the level of the
formation of the musculocutaneous and axillary,
typically inferior and lateral to the coracoid process,
more cephalad and proximal neural branches may be
missed.
Since the brachial plexus is less compact at this level and
since a neural stimulator is required, less consistent
blockade may occur.
D. The axillary approach is indicated for surgery of the
forearm and hand.
It primarily targets the radial, median, and ulnar nerves,
but not the axilla nor musculocutaneous nerves.
It does not reliably provide analgesia for procedures
above the elbow.
E. The suprascapular nerve block relieves afferent pain
from the shoulder joint and causes motor blockade of the
supra- and infraspinatus muscles.
There is no suprscapular approach for brachial plexus
blocks.
Source: Shah RV, Board Review 2003

305

1043. Compression of the L4 nerve root will result in all of the following findings except:
A. Pain in the low back, anterior thigh, and sometimes medial aspect of the lower leg.
B. Numbness in top medial aspect of the lower leg
C. Weakness in the quadriceps and sometimes tibialis anterior
D. Diminished ankle jerk refl ex
E. Positive straight leg raise

1043. Answer: D
Explanation:
Ref: Chapter 37. Nerve Root Disorders and Arachnoiditis.
In: Textbook of Pain, 4th Edition, Wall and Melzack,Churchill Livingston, 1999, page 857.
Source: Day MR, Board Review 2003

306

1044. A patient with tennis elbow has been refractory to
conservative drug therapy. As a next step, you would like
to splint the elbow. Your instructions for splinting are as
follows:
A. EF 90° WE 15°
B. EF 50° WF 20°
C. EF 70° WF 25°
D. EF 10° WE 30°
E. EF 60° WE 30°

1044. Answer: A

307

1045. Extensive cord infarction caused by foraminal injection would most likely result from injection of particulate steroid directly into which of the following arteries:
A. Posterior radicular artery
B. Anterior radicular artery
C. Anterior segmental medullary artery
D. Anterior spinal artery
E. Posterior spinal artery

1045. Answer: C
Explanation:
Reference: Gray’s Anatomy, Thirteenth American Edition.
Pages 964-971.
Data from cases of extensive cord infarction after
transforaminal injection of particulate steroid suggest that
large portions of the cervical spinal cord can be infarcted
by intra-arterial injection of particulate steroid into the
anterior segmental medullary artery. The anterior
segmental medullary arteries course through various
neural foramina to connect to the anterior spinal artery
which in turn delivers blood to the cord parenchyma.
Injection of particulate steroid into this artery can disrupt
spinal cord blood fl ow by occluding end-arterioles with
microcrystal particles. These particles may exceed 20
microns in diameter and, with intravascular coalescence
and/or precipitation, much larger particles may be formed.
The anterior and posterior radicular arteries supply blood
to the anterior and posterior spinal nerve roots at every
spinal level bilaterally. These arteries do not supply blood
to large portions of the spinal cord parenchyma.
The anterior and posterior spinal arteries are deep within
the central spinal canal and are not directly accessible by
intraforaminal injection.
Source: Schultz D, Board Review 2004

308

1046. A person with which of the following mental disorders
is most apt to seek medical help?
A. Major depressive disorder
B. Bipolar depressive disorder
C. Dysthymic disorder
D. Anxiety disorder
E. Obsessive-compulsive disorder

1046. Answer: D
Explanation:
(Fauci, pp 2486-2490.)
Anxiety symptoms are very common in both medically ill
patients and those otherwise well. Five to 20% of
inpatients have anxiety symptoms and 5 to 20% of general
medical outpatients suffer from anxiety states. Patients
with anxiety disorders are more likely to seek help from
general physicians and to use emergency room services
than are patients with other types of mental disorders.
Furthermore, it has been documented that over the past 15
years, antianxiety medications have been the most
frequently prescribed medication in the U.S. Also, primary
physicians write over 80% of these prescriptions. In terms
of other mental disorders, over 5% of the U.S. population
suffers from mood disorders-including major depressive,
bipolar, and dysthymic-yet they are less apt to seek medical
help. Panic disorders occur in 1 to 2% of the population
and 29% of these persons seek help from emergency room
services. Obsessive-compulsive disorder usually begins in
adolescence or young adulthood, but is not often
recognized by general physicians. Help may not be sought
because of the private nature of the disorder

309

1047. Patients who have somatization disorder are diagnosed
on the basis of their
A. Having unexplained symptoms that persist after treatment
B. Experiencing symptoms in multiple organ systems
C. Having a history of past and present illnesses that have
not responded to self-treatment
D. Having a specifi c number of medically unexplained
symptoms
E. Demonstrating positive test results for several chronic
illnesses at the same time

1047. Answer: D
Explanation:
(Sierles, pp 266-269. Ebert, pp 366-377.)
Between 0.5 and 3% of the population experience many
vague and fl uctuating symptoms in multiple organsystems
over time. They are explored with medical tests and
treated, but are never cured. The unexplained symptoms
can start in childhood, are usually diagnosed by 25 years of
age, and can continue many years undiagnosed. The
Diagnostic and Statistical Manual of
Mental Disorders, 4/e (DSM-IV) lists many relevant
symptoms from multiple organ and psychological systems.
A diagnosis of somatization disorder (SD) can be made if
a patient experiences the following medically unexplained
symptoms: 4 pain symptoms, 2 gastrointestinal symptoms,
1 sexual symptom, 1 psychoneurologic symptom, and/or if
the physical complaints and social or occupational
impairments are in excess of the expected. This “lumping”
of so many related and unrelated symptoms into one
disorder has resulted in some disagreement among
clinicians who argue that it is label-oriented and does not
contribute to an understanding of causality or treatment.
Nevertheless, it is a serious disorder that should receive
more recognition and research.
The symptoms have to concern the patient enough to take
prescribed medication, to change behavior (e.g., to miss
work), or to consult a physician. Episodes of symptoms,
sometimes intense, typically last 6 to 9 months, with less
intense, but continuing symptoms for 9 to 12 months.
Generally, SD is a lifelong condition, and patients with SD
consider themselves to be sick. Eighty-six percent report
that their symptoms are so disabling that their work is
limited. Seventy-fi ve percent are not employed full-time,
as compared with 33% of patients with other psychiatric
diagnosis. When compared with the general population,
they are more likely to visit doctors, be hospitalized, and
receive unnecessary surgery. Eighty to 90% report past
depression, 27% have hysterectomies for non-cancerrelated
causes, 17 to 25% have irritable bowel syndrome,
and 12% experience chronic pain.
SD patients are also at increased risk for panic disorder,
phobias, general anxiety disorder, obsessive-compulsive
disorder, and alcoholism; 47% have coexisting personality
disorders (avoidant, paranoid, and histrionic). Female-tomale
ratios between 2: 1 and 20: 1 have been reported.
There is often an inability to identify and articulate their
emotions, they have diffi culty habituating to stimuli, and
they receive positive reinforcement from medical
attention.No treatment cures SD,but patients can be
taught about SD and taught a relaxation procedure.
Patients should establish regular doctor visits (versus
responding to symptoms). Physicians should direct I
conversation to the patients personal life and a healthy
lifestyle, while deemphasizing symptoms and praising
tolerance for symptoms.
Source: Ebert 2004

310

1048. A 55-year old male presents himself with sudden pain
and loss of function of the right shoulder fi ve days ago.
Symptoms started after intense activity. The patient was
holding the shoulder away from the body in 30° to 40°
adduction. The pain was presented anteriorly. There
was no history of recent injury. Aspirin helped his pain
temporarily. X-were normal. The most likely diagnosis
is:
A. Subacromial bursitis
B. Subcoracoid bursitis
C. Calcifi c tendonitis
D. Acromioclavicular joint arthritis
E. Branchial neuritis

1048. Answer: A
Explanation:
Subacromial bursitis may occur as a primary disorder after
a blow to the shoulder, but if, it most frequently occurs
secondary to degenerative lesions of the rotator cuff and is
part of the continuum of the many rotator cuff disorders.
It may be viewed as a separate yet related pathologic
condition to calcifi c tendonitis. Most of the body’s bursae
exists in or around the shoulder complex, and they are
listed up to 12. The most commonly present bursae
locations include the subacromial and subdeltoid.
The subdeltoid and subacromial bursae are really one but
are separately named according to their adjacent anatomic
structures.
Bursitis will have a swift onset of extremely severe
shoulder pain with dramatic tenderness localized to the
insertion of the deltoid at the upper middle third of the
anterolateral proximal arm. This is in contrast to more
diffuse involvement found with impingement of the
supraspinatus or biceps tendon or pain found adjacent to
the coracoid process at the medial aspect of the shoulder
in subcoracoid bursitis.
The patient maintains the shoulder in an adducted
position,which keeps the painful lesion away from the
acromial undersurface. Elevation is hindered, abduction
more so than forward fl exion, and a painful arc between
50° and 130° is present whether the movement is active or
passive.
On palpation, the physician will fi nd exquisite local
tenderness over the subacromial bursae, which may feel
thickened as compared to the contralateral shoulder.
Tenderness may also extend as far down as the bicipital
groove. Tests for supraspinatus tendonitis and
impingement will be positive in this condition.
Source: Saidoff DC, McDonough AL. Critical Pathways in
Therapeutic Intervention. Extremities and Spine. St.
Louis,Inc., 2002

311

1049. Decreased sensation from the nipple line inferiorly
would most likely suggest a lesion at:
A. T1
B. T2
C. T3
D. T4
E. T5

1049. Answer: D
Source: Wirght PD, Board Review 2004

312

1050. Examination of a patient’s visual fi elds reveals complete
blindness in the left eye. Ophthalmoscopic examination
is normal. Which of the following lesions is most likely
causing this abnormality?
A. A lesion between the optic chiasm and the lateral geniculate
body
B. A lesion between the retina and the optic chiasm
C. A lesion between the lateral geniculate body and the
visual cortex
D. A lesion at the medial longitudinal fasciculus
E. A lesion of one occipital lobe

1050. Answer: B
Explanation:
(Seidel, 5/e, p 311.)
When defects are detected in only one eye, the lesion must
be anterior to the optic chiasm.
Lesions at the optic chiasm produce a bitemporal
hemianopsia because this is where the nasal retinal fi bers
decussate. The medial longitudinal fasciculus (MLF) is
involved with extraocular muscle contraction; a lesion to
the MLF bilaterally will not allow either eye to look
medially. Lesions between the geniculate body and the
visual conex produce a contralateral upper homonymous
quadrantanopsia. A lesion in the visual cortex (occipital
lobe) produces similar defects in each eye. Bilateral lesions of the occipital lobes result in complete loss of vision, but
pupillary refl exes (fi bers end in the midbrain) and
extraocular muscle movements remain intact.

313

1051. A 60-year old woman presents with a sharp, electric
shock like, intermittent pain on the left side of her face.
It is mostly over the cheek and her jaw. She has pain free
intervals between attacks. She is unable to put on any
makeup because the slightest touch of a brush sets of her
pain. All of the following would be an appropriate initial
medication EXCEPT:
A. Baclofen
B. Carbamazepine
C. Lamotrigine
D. Carisoprodol
E. Lidocaine 5% patch

1051. Answer: D
Explanation:
The treatment of trigeminal neuralgia fi rst
pharmacological and if this fails then surgical options are
explored. Pharmacological management consists of
carbamazepine, phenytoin, gabapentin, lamotrigine,
baclofen.Carbamazepine is the initial drug of choice and is
generally started as a single dose of 100mg daily. It is then
increased every 2 or 3 days by 100mg until good relief is
obtained. A common dose is at least 200mg per day.The
common side effects of carbamazepine are
agranulocytosis, dizziness and sedation. Carisoprodol
is a muscle relaxant and has no role in the management of
trigeminal neuralgia.
The pathology of trigeminal neuralgia is usually at the
ganglion and no benefi t is obtained using local anesthetics.
Source: Chopra P, 2004

314

1052. Diplopia following lumbar puncture with a 25-gauge,
3½-inch needle is the result of
A. Stretching the abducens nerve
B. Pressure on the optic nerve
C. Distortion of the oculomotor nucleus from collapse of
the wall of the third ventricle
D. The severity of the accompanying headache
E. Compensatory cerebral swelling

1052. Answer: A
Source: American Board of Anesthesilogy, In-trainnig
examination

315

1053. The following is characteristic of migraine with aura:
A. Fortifi cation spectra.
B. Headache preceding motor weakness.
C. Headache preceding aphasia.
D. Amaurosis fugax and scintillating scotoma.
E. Headache precipitated by emotional stress.

1053. Answer: A
Explanation:
Fortifi cation spectra are the most characteristic visual
disturbance of migraine. These consist of C-shaped
serrated zig-zag arcs followed by scotoma (area of
blindness). Visual disturbance recedes before headache
develops. When headache precedes neurological
disturbance, consider nonmigraine disorders. Amaurosis
fugax is visual loss in one eye only and suggests severe
carotid stenosis. Emotional stress may precipitate
migraine. Migraine usually develops not at peak stress but
during a period of relaxation (“let-down”). This is
contrasted with tension headache, which correlates directly
with severity of emotional stress. (Archives of Neurology
36, p. 784, 1979;
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

316

1054. Clinical features of carpal tunnel syndrome (CTS)
include:
A. Pain in the forearm
B. Positive Phalen sign
C. Weakness of thumb fl exion
D. Normal triceps refl ex
E. All of the above

1054. Answer: E
Explanation:
CTS may simulate C-7 cervical radiculopathy. In cervical
radiculopathy, there would be neck pain and reduced
triceps refl ex. In CTS, pain is usually in the wrist and
thumb but may extend to the forearm.
In CTS, Tinel sign (tapping over the demyelinated median
nerve at the wrist) and Phalen sign (forced wrist fl exion
causing sensory symptoms in median nerve distribution)
are positive.
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

317

1055. The following are characteristic of migraine without
aura:
A. Bilateral location of pain
B. Thunderclap quality to pain onset.
C. Shock or jolt quality of pain
D. Photopsia and microscopia are present.
E. Headache is associated with nasal congestion, lacrimation,
and Horner syndrome

1055. Answer: C
Explanation:
Head shocks or jolts are quite characteristic of migraine.
Pain begins as unilateral headache but later becomes
bilateral. Thunderclap pattern or sudden increase to
maximal pain severity suggests subarachnoid hemorrhage.
Visual phenomena suggest migraine with aura, and
autonomic features suggest cluster.
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

318

1056.The spinal cord region responsible for refl exogenic
penile erection is the:
A. Parasympathetic center at S-2 to S-4
B. Sympathetic center at S-2 to S-4
C. Sympathetic center at T-10 to L-2
D. Somatic motor fi bers at S-2 to S-4
E. Hypothalamus

1056. Answer: A
Explanation:
Penile erection as well as bladder (micturition) and
rectum (defecation) emptying are controlled by
parasympathetic (PS) outfl ow through S-2 to S-4 (pelvic
nerves). Acetylcholine is the primary postganglionic PS
neurotransmitter. Sympathetic fi bers originating at T-10
through L-2 play a central role in seminal emission and
ejaculation and are involved in retention of urine and
feces.
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

319

1057. Sexual dysfunction occurs in these condition
A. Depressive illness
B. Diabetes mellitus
C. Multiple sclerosis
D. Lumbar sympathectomy
E. All of the above

1057. Answer: E
Explanation:
Sexual dysfunction occurs in all these conditions.
Depression as well as medications used to treat depression
should be considered as causal factors. MS causes spinal
cord dysfunction and depression, and both conditions lead
to sexual dysfunction. Diabetes may cause autonomic
neuropathy with sexual dysfunction.
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

320

1058.In patients with cauda equina compression, clinical
features usually include:
A. Asymmetric leg weakness
B. Absent ankle and knee refl exes
C. Bladder dysfunction
D. All of the above
E. None of the above

1058. Answer: D
Explanation:
With cauda equina compression, multiple nerve roots are
involved. Findings are asymmetrical and autonomic
dysfunction occurs late, since the spinal cord is not
compressed. (Ref. 1, p. 449; Ref 2, pp. 593–594)
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

321

1059. The following cranial structures are pain sensitive:
A. Venous sinuses.
B. Meningeal arteries.
C. Head and neck muscles.
D. Large cranial arteries.
E. All of the above.

1059. Answer: E
Explanation:
Pain-sensitive structures include:
Proximal portion of large extra-and intracranial arteries.
Large veins and venous sinuses.
Meninges.
Upper cervical nerve roots.
Cranial nerves V, IX, and X.
Brain parenchyma is pain-insensitive, as are ventricles and
choroid plexus. Electrode stimulation of the
periaqueductal gray (PAG) region and somatosensory
thalamus may cause headache. The descending analgesic
system includes the mid-brain PAG, medial medullary
raphe nucleus, reticular formation, and dorsal horn
neurons of the spinal cord.
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

322

1060. The term spinal shock refers to:
A. Depression of spinal refl ex activity below the level of
injury
B. Blood loss and hypovolemia following systemic injury
C. Loss of motor function following spinal injury
D. Loss of bladder function following spinal injury
E. All of the above

1060. Answer: A
Explanation:
Immediately following spinal cord injury, there is
electrical-chemical change which enhances inhibitory
neurotransmission such that all refl exes are absent. Later,
refl exes become hyperrefl exive.
In adults, spine or brain traumatic injuries do not cause
blood loss. With traumatic spinal cord injury, autonomic
function occurs immediately, and these patients require
catheterization.
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

323

1061. Choose the accurate statement about Visual Analogue
Scale.
A. A Visual Analogue Scale consists of a list of adjectives
describing different levels of pain intensity.
B. A Visual AnalogueScale consists of a line, usually 10 cm
long, whose ends are labeled as the extremes of pain (no
pain to pain as bad as it could be).
C. A Visual Analogue Scale involves asking patients to rate
their pain from 0 to 10 on an 11 point scale.
D. A Visual Analogue Scale employs pain intensity measure
which is determined by photographs or line drawings
that illustrate facial expressions of persons.
E. A Visual Analogue Scale consists of pain intensity which
describes from faint to very intense.

1061. Answer: B
Explanation:
A. A verbal rating scale consists of a list of adjectives
describing different levels of pain intensity. An adequate
VRS of pain intensity should include adjectives that refl ect
the extremes of this dimension from no pain to extremely
intense pain and suffi cient additional adjectives to capture
the graduations of pain intensity that may be experienced.
B. A Visual Analogue Pain Scale consist of a line, usually
10 cm long, whose ends are labeled as the extremes of pain
(e.g., “no pain” to “pain as bad as it could be”). A VAS may
have specifi c points along the line that are labeled with
intensity-denoting adjectives or numbers. Such a scale is
called a graphic rating scale. Patients are asked to indicate
which point along the line best represents their pain
intensity. The distance from the no pain end to the mark
made by the patient is that patient’s pain intensity score.
C. A numeric rating scale involves asking patients to rate
their pain from 0 to 10 (11 point scale), from 0 to 20 (21
point scale), or from 0 to 100 (101 point scale), with the
understanding that the 0 represents 1 end of the pain
intensity continuum with no pain while 10, 20, or 100
represents the other extreme of pain intensity. Verbal
rating scales do not require paper and pencil. The patient
is simply asked to verbally state his or her pain intensity on
a 0 to 10 or one of the other scales. Nonetheless, a number
of paper and pencil numeric rating scales exist. The
validity of numeric pain rating scales has been well
documented. They demonstrate positive and signifi cant
correlations with other measures of pain intensity.
D. Picture or face scales employ photographs or line
drawings that illustrate facial expressions of persons
experiencing different levels of pain severity. The patients
are asked to indicate which one of the illustrations best
represents their pain experience. Each face has a number
representing the rank order of pain illustrated, and the
number associated with the picture chosen by the patient
represents that individual’s pain intensity score.
E. Descriptor Differential Scale of pain intensity consists
of a list of adjectives describing different levels of pain
intensity. Patients are asked to rate the intensity of their
pain as being more or less than each word on the list. If
their experienced pain is greater than that described by the word, they place a check mark on the right of the word in
proportion to how much greater their pain is. The DDS-1
has many strengths because it is a multiple-item measure,
it is possible to assess the internal consistency of the scale,
and this consistency appears to be very high.
Descriptor Differential Scale of pain intensity DDS-1
consists of the words faint, moderate, barely strong,
intense, weak, strong, very mild, extremely intense, very
weak, slightly intense, very intense, and mild.

324

1062. Which of the following statements concerning postspinal headache is true?
A. Cerebrospinal fl uid leucocytosis occurs
B. Intravenous caffeine therapy is more effective than epidural
blood patch
C. The incidence decreases with age
D. The incidence is higher in males than in females of all
ages
E. The incidence is the same after single or multiple dural
punctures

1062. Answer: C
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

325

1063. The pathophysiological mechanism which initiate disk
herniation include:
A. Radial tear of annulus fi brosis
B. Prolapse of disk
C. Extrusion of disk
D. Biochemical changes within disk
E. All of the above

1063. Answer: A
Explanation:
Trauma-induced radial tears in the annulus appear to
initiate disk herniation. These may be imaged with highresolution
spinal MRI. With normal aging, disk
desiccation may occur without disk herniation.
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD

326

1064. Which of the following is true with respect to carpal
tunnel syndrome?
A. Patients develop nocturnal pain and burning in their
radial three fi ngers and wrist
B. Phalen’s test is not often used in clinical practice
C. Reverse Phalen’s test, unlike the Phalen’s test, alleviates
pressure from the wrist
D. Hypesthesia is present in the 5th digit
E. Hypothenar muscle atrophy may be present

1064. Answer: A
Explanation:
(See musculoskeletal examination presentation by Shah)
Patients develop hypesthesia of the radial 3 ½ digits.
Phalen’s and Reverse Phalen’s tests are median nerve
compression tests that are used in clinical practice.
Patients develop nocturnal pain and have to shake their
hands for relief. Thenar muscle atrophy may be present.
Source: Shah RV, Board Review 2004

327

1065. Which of the following nerves is most likely to be
injured by fracture of the shaft of the humerus?
A. Axillary
B. Median
C. Musculocutaneous
D. Radial
E. Ulnar

1065. Answer: B
Source: American Board of Anesthesilogy, In-trainnig
examination

328

1066. A 39-year-old female patient presents with a 4-month
history of sharp right lateral elbos pain after she suffered
a fall to the outstreached hand at work. She complains
of an intense sharp pain with use of right elbow on work
activities. Upon examining the patient, you fi nd she had
a (+) lateral pivot shift test. There was no evidence of
fracture. The likely diagnosis is:
A. Tendopathy of the extensor carpi radialis brevis
B. Lateral ulanr collateral ligament instability
C. Humeroradial joint degeneration
D. Posterior interosseus nerve entrapment
E. Laterl Epicondylitis

1066. Answer: B
Source: Sizer et al - Pain Practice - March & June 2004

329

1067. Bupivacaine is more likely than lidocaine to cause
refractory cardiac arrest because bupivacaine
A. Has a lower rate of plasma clearance
B. Has a secondary blocking effect on cardiac beta1-adrenergic
receptors
C. Dissociates more slowly from sodium channels in cardiac
muscle
D. Inhibits spontaneous space 4 decolorization in pacemaker
cells
E. Preferentially blocks calcium channels in Purkinje fi bers

1067. Answer: C
Source: American Board of Anesthesilogy, In-trainnig
examination

330

1068. In normal tissue, which property of drugs has the
greatest effect on the speed on onset of a local anesthetic?
A. Amide structure
B. Degree of protein binding
C. Intrinsic vasoconstrictor activity
D. pKa
E. Potency

1068. Answer: D
Source: American Board of Anesthesilogy, In-trainnig
examination

331

1069. The plasma concentration of equal doses of a local
anesthetic is highest when the site of administration is
A. Axillary brachial plexus
B. Caudal
C. Intercostal
D. Lumbar epidural
E. Subcutaneous

1069. Answer: C
Source: American Board of Anesthesilogy, In-trainnig
examination

332

1070.Which of the following statements concerning
interscalene brachial plexus block is true?
A. The three trunks of the plexus are in the same fascial
plane as the internal jugular vein
B. Distal spread of anesthetic past the humeral head is accelerated
by adduction of the arm
C. Anesthetic solution can spread up the fascial sheaths to
involve the stellate ganglion
D. Ipsilateral diaphragmatic paralysis results from epidural
spread
E. Rich vascularity in the sheaths promotes rapid vascular
uptake of anesthetic

1070. Answer: C
Source: American Board of Anesthesilogy, In-trainnig
examination

333

1071. Neurolytic block is most appropriate for
A. Abdominal pain secondary to hepatic carcinoma
B. Abdominal pain secondary to pancreatitis
C. Persistent chest wall pain secondary to intercostal neuralgia
following a thoracotomy for trauma.
D. Reflex sympathetic dystrophy of the upper extremity
with an excellent but transient response to a series of
stellate ganglion blocks with local anesthetic
E. A diabetic patient scheduled for surgical sympathectomy
to relieve unilateral lower extremity pain secondary to
severe peripheral vascular disease.

1071. Answer: A
Source: American Board of Anesthesiology, In-trainnig examination

334

1072. To evaluate warm temperature sensation, the stimulus should be in which of the following temperature ranges?
A. 25 to 29°C
B. 30 to 35°C
C. 36 to 39°C
D. 40 to 45°C
E. 46 to 50°C

1072. Answer: D
Explanation:
To test warm temperature sensation, a glass or metal tube
containing hot water with a temperature in the range of 40
to 45°C (104 to 113°F) should be used.
Temperatures higher than 45°C are perceived as painful.
Source: Raj P

335

1073. Injection of local anesthetic into the interspace between the 3rd and 4th toes may provide relief of which
condition
A. Morton’s neuroma
B. Metarsalgia
C. Plantar Fasciitis
D. Painful heel spur
E. Tarsal Tunnel Sundrome

1073. Answer: A
Explanation:
( Raj, {Practical Mgmt of Pain, 3rd Ed., page 355-6, 371)
A. Morton’s neuroma is the most common form of
interdigital neuritis. It typically occurs between the third
and fourth toes and rarely between the second and third
toes. Pain can be produced between the metatarsal heads,
which differentiates this condition from metatarsalgia, in
which pain is elicited with pressure against the plantar foot
under the metatarsal heads.
B. Pain along the plantar surface of the metatarsal heads
causes weight-bearing discomfort with each step and can
be replicated with manual compression. About 80% of the
weight is borne by the fi rst metatarsal head, but in
pronation, weight is shifted over the second and third toes
and painful repetitive trauma can accumulate. Pain is
typically increased in combined pronation and eversion,
and this gait
C. Plantar fasciitis is commonly found in those who must
stand on hard fl oors for long periods of time and is an
infl ammation of tendon and fascia and as they insert into
the calcaneal periosteum.Bone growth in the direction of
pull is frequently found as a calcaneal spur. The examiner
can elicit pain with plantar compression over the anterior
calcaneus, but pain may radiate along the plantar fascia.
D. Painful heel syndrome is often diagnosed in morbidly
overweight people or those who stand or walk
excessively.Degeneration of the normal heel compression
allows injury to weight-bearing surfaces of the calcaneus.
Frequently, symptoms are increased in the morning or
after a prolonged rest. Examination fi ndings are similar to
those in plantar fasciitis, but pain tends to be posterior and
localized to the plantar calcaneus.
E. The posterior tibial nerve is derived from L4 through
S3 roots and may be compressed in the tarsal tunnel.Nerve
conduction studies show prolongation of the distal motor
and sensory latency of the tibial nerve.There may be EMG
changes in the appropriate foot muscles. This syndrome is
relatively uncommon.
Source: Shah RV, Board Review 2004

336

1074. A 19-year-old female whose roommate is being treated
for depression decides that she is also depressed and
secretly takes her roommate’s pills “ as directed on the
bottle” for several days. One night, she makes herself a
snack of chicken liver pate and bleu cheese, accompanied
by a glass of red wine. She soon develops headache,
nausea, and palpitations. She goes to the ED, where her
blood pressure is found to be 200/110mmHg. What
antidepressant did she take?
A. Sertraline
B. Phenelzine
C. Nortriptyline
D. Trazodone
E. Fluoxetine

1074. Answer: B
Explanation:Reference: Hardman, p 444.
This patient ate tyramine-rich foods while taking an
MAOIand went into hypertensive crisis.
Tyramine causes release of stored catecholamines from
presynaptic terminals, which can cause hypertension,
headache, tachycardia, cardiac arrhymias, nausea, and
stroke.
In patients who do not take MAOIs,tyramine is inactivated
in the gut by MAO, and patients taking MAOIs must be
warned about the dangers of eating tyramine-rich foods.
Source: Stern - 2004

337

1075. Which of the following is the most important
disadvantage of interscalene brachial plexus block
compared with other approaches?
A. Frequent sparing of the musculocutaneous nerve
B. High incidence of pneumothorax
C. Not suitable for operations on the shoulder
D. Large volumes of local anesthetics required
E. Frequent sparing of the ulnar nerve

1075. Answer: E
Explanation:
The major disadvantage of the interscalene block for
hand and forearm surgery is that blockade of the inferior
trunk (C8-T1) is often incomplete.
Supplementation of the ulnar nerve is often required.
The risk of pneumothorax is quite low, but blockade of
the ipsilateral phrenic nerve occurs in up to 100% of
blocks. This can cause respiratory compromise in patients
with signifi cant lung disease.

338

1076. The immune system is not an autonomous system, it can be altered by
A. Relaxation
B. Stress
C. Suppressed emotions
D. Conditioning
E. Diet

1076. Answer: D
Explanation:
(Baum, pp 169-173.)
· Ader and Cohen discovered that the immune system
could be conditioned by neutral taste stimuli. Follow-up
studies reconfi rmed that immune system responses can be
conditioned to neutral stimuli in both animals and
humans.
· Immunologists previously had assumed that the immune
system was autonomous. Newer studies in this area have
demonstrated that many immune components can be
altered by behavioral factors such as stress, depression,
isolation, relaxation, and bereavement.
· All of the options listed in the question have some effect
on the immune system, but the ability to modify the
immune system by conditioning is most important.
Source: Ebert 2004

339

1077. The following statement is false regarding local
anesthetic toxicity:
A. Hyperventilation of a patient with a suspected overdose
of local anesthetic will make seizures less likely.
B. Lidocaine overdose causes seizures before cardiac depression.
C. Toxic dose for direct intravascular injection of lidocaine
is 300mg without epinephrine and 500mg when epinephrine
is added.
D. Intravenous benzodiazepines are recommended to treat
local anesthetic-induced seizures
E. Cardiac arrest from bupivacaine overdose is exceedingly
diffi cult to treat and prolonged resuscitation with large
doses of epinephrine may be required.

1077. Answer: C
Explanation:
References:
Neural Blockade, Cousins and Bridenbaugh, Second
Edition, Chapter 22 Complications of Local Anesthetic
Neural Blockade, pp. 695-718.
Waldman, Interventional Pain Management, Second
Edition; Chapter 16 Local Anesthetics in Clinical Practice,
pp. 214-218
Elevation of pCO2 and acidosis tend to increase the toxic
effects of local anesthetics by the following mechanisms:
Elevated pCO2 causes cerebral vasodilation, delivering
more local anesthetic to the brain
Decrease in intracellular pH will convert more local
anesthetic from the inactive base form to the cationic form
which is active on the nerve membranes.
Hypercarbia and acidosis decrease protein binding of
local anesthetics increasing the portion of free drug
available
Conversely, decreases in pCO2 and elevations in pH tend
to elevate the seizure threshold for local anesthetics by the
same mechanisms.
Lidocaine will almost invariable cause CNS effects prior to
causing cardiac toxicity. First the patient may complain of
dizziness, tinnitus and diffi culty focusing eyes. Increasing
toxicity causes muscle twitching and tremors involving
the face and distal extremities which progresses to grand
mal seizures. Cardiac arrythmias occur late and only with
massive overdose. The maximum dose for lidocaine soft
tissue infi ltration is 300mg without epinephrine and
500mg when epinephrine is added. This does not imply
that 300mg can be given directly IV as a bolus dose. The
toxic dose for direct intravenous injection of any local
anesthetic is much lower than the toxic dose for tissue
infi ltration. For instance, the tissue infi ltration maximum
dose for bupivacaine is approximately 200mg whereas
doses as small as 50mg have caused cardiac toxicity when
administered directly IV.
Bupivacaine has a much higher potential to cause lifethreatening
cardiac arrhythmias than lidocaine. Whereas
lidocaine is a fast-in/fast-out calcium channel blocker that
reaches steady state block in one to two heartbeats. In
contrast, bupivacaine is a fast-in/slow-out blocker
manifesting a blocking action that increases with
successive beats and with faster rates creating the potential
for malignant re-entrant cardiac arrhythmias.
Resuscitation from bupivacaine cardiac toxicity is diffi cult
and may require prolonged efforts with high doses of
epinephrine. There is no specifi c antidote or reversal agent
for bupivacaine overdose.
Benzodiazepenes increase the seizure threshold in the
brain and are the treatment of choice for local anesthetic
induced seizures.
Source: Schultz D, Board Review 2004

340

1078. The central anticholinergic syndrome is LEAST likely to occur after administration of
A. Atropine
B. Chlorpromazine
C. Diphenhydramine
D. Glycopyrrolate
E. Scopolamine

1078. Answer: D
Source: American Board of Anesthesilogy, In-trainnig
examination

341

1079. A 32-year-old previously healthy man is brought to the
emergency room after having a seizure. He has no family
history of seizure and denies alcohol use, illicit drug
use, or trauma. A family member states that recently
the patient has been complaining of a headache and has
been acting bizarre, which is a change in his personality.
Physical examination reveals a temperature of 100.9°F.
Blood pressure and heart rate are normal. During
examination, the patient has a partial complex seizure.
CT scan of the head reveals hemorrhagic necrosis of the
temporal lobes. Which of the following is the most likely
diagnosis?
A. Lyme disease
B. Cysticercosis
C. Progressive multifocal leukoencephalopathy
D. Herpes encephalitis
E. Rabies

1079. Answer: D
Explanation:
(Tierney, 42/e, p 1305.)
A. Lyme disease can produce an encephalitis or
demyelination that mimics multiple sclerosis, but
infection follows a tick bite. Waterhouse-Friderichsen
syndrome is hemorrhagic infarction of the adrenal glands
due to fulminant menigococcemia.
B. Cysticercosis is characterized by multiple brain cysts
produced by the larval form of the pork tapeworm (Taenia
solium).
C. Progressive multifocal leukoencephalopathy (PML) is
a human papovavirus (JC virus) seen in patients with
AIDS.
Patients present with dementia, visual fi eld defects,
weakness, and spasticity.
D. Patients with herpes simplex encephalitis present with
a subacute course consisting of personality changes, fever,
headaches, and seizures.
Temporal lobes are primarily affected, and the disease is
fatal without treatment.
E. Rabies causes personality changes, headache, dysphagia
to even water (hydrophobia), and pharyngeal muscle
spasm that makes patients appear to be frothing at the
mouth.

342

1080. The Triceps Refl ex best tests for what nerve root?
A. C5
B. C6
C. C7
D. C8
E. None of the above

1080. Answer: C
Source: Wright PD, Board Review 2004

343

1081. A young adult reports that he has not been able to sleep
for over two days and has been having strange reactions.
These reactions are most apt to be caused by
A. Feelings of excessive tiredness
B. Increased levels of blood cortisol
C. Physiologic stress in response to sleep deprivation
D. Perceptual distortions
E. The effects of the rebound phenomenon

1081. Answer: D
Explanation:
(Carlson, pp 259-267.)
· The human research on sleep has demonstrated that after
a few days of sleep deprivation people report perceptual
distortions or, in a few cases, even hallucinations. These
studies have documented statements such as “the fl oor
seems wavy” or “steam seems to be rising from the fl oor,”
indicating that sleep deprivation affects cerebral
functioning.
· Sleepiness can occur even without any activity and sleep
deprivation does not appear to interfere with the ability to
perform physical exercise. Likewise, there is no evidence of
a physiologic stress response to sleep deprivation,
indicated by little change in blood levels of cortisol and
epinephrine.Sleep does appear to be necessary for the
brain to function normally.
· After a period of sleep deprivation a rebound
phenomenon does occur. The individual will sleep longer
and spend a much greater time in REM sleep, but will not
regain the number of sleepless hours lost.
Source: Ebert 2004

344

1082. All of the following are true regarding uncontrolled
post-operative pain except:
A. Decreased chest wall and diaphragmatic excursion
B. Increased myocardial oxygen consumption
C. Increased cardiac work
D. Decreased risk of thromboembolic complications
E. Decreased gastrointestinal motility

1082. Answer: D
Explanation:
Ref: Crews. Chapter 14. Acute Pain Syndromes. In:
Practical Management of Pain, 3rd Edition. Raj et al,
Mosby, 2000, page 171.
Source: Day MR, Board Review 2003

345

1083. The preferred treatment of status epilepticus is
intravenous administration of
A. Chlorpromazine
B. Diazepam
C. Succinylcholine
D. Tranylcypromine
E. Ethosuximide

1083. Answer: B
Explanation:
Reference: Hardman, p 484.
Intravenously administered diazepam is the drug of choice
for treatment of status epilepticus.
Diazepam increases the apparent affi nity of the inhibitory
neurotransmitter GABA for binding sites on brain cell
membranes. The effects of diazepam are short-lasting.
Continuing therapy is usually with phenytoin.
Other drugs suggested for use in status epilepticus are
lorazepam and lidocaine.
Chlorpromazine is an antipsychotic.
Succinylcholine is a neuromuscular blocking agent.
Tranylcypromine is an antidepressant.
Ethosuximide is used in petit mal epilepsy.
Source: Stern - 2004

346

1084. In which of the following would you consider performing
a spinal nerve denervation?
A. Lumbar facet arthropathy
B. Failed back surgery syndrome
C. Severe spasticity and limb pain due to multiple sclerosis
D. Intercostal neuralgia
E. Sciatic nerve transaction

1084. Answer: C
Explanation:
(Raj, Practical Mgmt of Pain 3rd Ed. Page 802, Raj, Pain
Medicine Review, 2nd
Ed., page 314)
This is not a benign procedure. Make sure you understand
the difference between this procedure, dorsal rhizotomy,
and dorsal ganglionectomy. In this procedure, one is
targeting a mixed nerve. Spinal nerve more accurately
more describes the entity referred to as a selective nerve
root. The term, ‘selective nerve root’ should not be used
since it lacks anatomic precision. Nonetheless, it may still
be used in the exam.
Hence, lesioning the spinal nerve can cause motor and
sensory dysfunction. It should be used to treat pain related
to spasticity due to central nervous system damage. It
should be avoided in non-cancer conditions. Sciatic nerve
transaction may lead to deafferentation pain and central
sensitization. Denervation of those spinal nerves supplying
the sciatic nerve may worsen this pain condition.
Additionally, sciatic nerve transaction will not cause
spasticity.
Source: Schultz D, Board Review 2004

347

1085. A 30-year-old secretary who is a single mother with two preschool children has frequent symptoms of anxiety,
tension, headaches, and insomnia. Which of the following
behavioral interventions could be the most effective in
relieving her symptoms?
A. Progressive muscle relaxation
B. Psychoanalytic psychotherapy
C. Hypnosis
D. Selective biofeedback
E. Interpersonal psychotherapy

1085. Answer: A
Explanation:
(Baum, pp 297-301.)
· Progressive muscle relaxation, or a reasonable variation,
can serve as a powerful therapeutic technique for treating
generalized anxiety, insomnia, headaches, neck tension,and
mild forms of agitated depression. It has also effectively
been used to reduce pain.
· Relaxation therapy is based on the premise and
observation that muscle tension is a physiologic response
to anxiety and stress. There is a signifi cant reduction in
experienced anxiety if tense muscles can be relaxed.Muscle
relaxation also can change the physiologic activation
process.
· Other effective methods of relaxation include systematic
deep breathing, transcendental meditation, and yoga.
Source: Ebert 2004

348

1086. Which of the following is among the most useful
procedures for the relief of unilateral cancer pain below
the C5 dermatome?
A. Midline myelotomy
B. Lissauer tractotomy
C. Percutaneous C1-2 radiofrequency unilateral cordotomy
D. Post central gyrectomy
E. Bilateral high cervical cordotomy performed at the same
time

1086. Answer: C
Explanation:
(Raj, Pain Review, 2nd Ed., page 313)
Lissauer tractotomy is the goal of the dorsal root entry
zone (DREZ) procedure…but all dorsal horn lamina (I-V)
may be affected. The DREZ lesion is classically indicated
for central nervous system damage related pain: brachial
plexus avulsion, stump pain, spinal cord injury pain.
Midline or commissural myelotomy sections those
midline fi bers just dorsal to the central canal of the spinal
cord. The original intent was to lesion crossing
spinothalamic neurons, which would eliminate pain, but
preserve sensory function. However, pain relief extended
caudally, without demonstrable caudal analgesia. This lead
several investigators to postulate several alternate pain
pathways. A multisynaptic short tract afferent pathway or
an anterior tract located in between the posterior columns
were proposed. The latter mediate pelvic and epigastric
visceral pain. Nonetheless, myelotomy is indicated for
bilateral pelvic and perineal pain of malignant origin.
Post-central gyrectomy is not a primary neurosurgical
procedure for pain relief and is used for central pain
syndromes: thalamic or phantom pain. The post-central
gyrus is the principal cortical area for the integration of
sensory information.
Bilateral high cervical cordotomy may be responsible for
Ondine’s curse (sleep induced apnea) and is
contraindicated unless performed in a staged fashion.
Unilateral percutaneous cordotomy is among the most
useful procedures for unilateral cancer pain below C5. It
targets the spinothalamic tract. Radiofrequency energy is
used. Electrical stimulation (sensory to obtain a feeling of
warmth or coolness on the contralateral side and motor to obtain ipsilateral cervical muscles; ipsilateral contraction
of muscles below the neck implies the probe is in the
corticospinal tract) is used to identify the lesion target
Source: Schultz D, Board Review 2004

349

1087. Which of the following would not alter one’s decision to proceed with occipital neurectomy?
A. Xrays showing spondylotic changes at C2 and C3
B. History of brain tumor removal
C. Positive response of occipital nerve blocks
D. An MRI showing cerebellar descent into the spinal canal
and a syrinx
E. New onset posterior headache that is aggravated by
coughing and is associated with vomiting

1087. Answer: A
Explanation:
(Raj, Pain Medicine Review, 3rd Ed., 313, Raj, Practical
Mgmt of Pain, page 800)
Poorly worded question. Nonetheless, expect a lot of
questions to be worded poorly. Spondylotic changes are
common as we age. This fi nding would support an upper
cervicogenic etiology for occipital pain. The other choices
would change your management strategy, specifi cally the
presence of an Arnold-Chiari Malformation, posterior
fossa tumors, or foramen magnum lesion.
Source: Schultz D, Board Review 2004

350

1088. Proper patient positioning for a subarachnoid alcohol
block is:
A. Painful side up with the patient tilted posteriorly 45°.
B. Painful side down with the patient tilted posteriorly 45°.
C. Painful side up with the patient tilted anteriorly 45°.
D. Painful side down with the patient tilted anteriorly 45°.
E. Painful side up with no tilt.

1088. Answer: C
Source: Day MR, Board Review 2005

351

1089. The acupuncture point located between the fi rst and
second metatarsal bones in the web is called
A. Lieh Chuch
B. Ho Ku
C. Chih Tse
D. Chien chen
E. None of the above

1089. Answer: B
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition

352

1090. An example of secondary gain is:
A. Pain behavior
B. Anxiety
C. Unconscious motivation
D. Projection
E. Work avoidance

1090. Answer: E
Source: Janata JW, Board Review 2005

353

1091.Bilateral, compared to unilateral, surgical lumbar
sympathectomies pose the unique risk:
A. erectile dysfunction in men
B. ejaculatory dysfunction in men
C. genitofemoral neuralgia
D. spinal cord infarction
E. damage to the kidney or ureter

1091. Answer: B
Explanation:
(Raj, Practical Mgmt of Pain, 3rd Ed., page 803)
Bilateral lumbar sympathectomies pose an undue risk of
ejaculatory dysfunction. Lesions of S2, S3, and S4
parasympathetics may cause erectile dysfunction.
Genitofemoral neuralgia may be a complication of lumbar
sympathectomy either unilaterally or bilaterally. A leftsided
lumbar sympathectomy may inadvertently injury
branches of the aorta (including the artery of
Adamkiwiecz). Damage to the kidney or ureter can occur
on either side
Source: Schultz D, Board Review 2004

354

1092. You diagnosed a patient with torn epidural catheter of 1.2 cm. Your choice of treatment is:
A. Do Nothing
B. MRI
C. Monthly Neurological Exam
D. Surgical Exploration
E. Antibiotics

1092. Answer: A

355

1093. In assessing the characteristic pain patient, the clinician
must appreciate that they are often:
A. Emotionally debilitated and of low intellectual measure
B. Severely agitated and aggressive
C. Disabled, depressed and dependent
D. All of the above
E. None of the above

1093. Answer: C
Source: Giordano J, Board Review 2003

356

1094. Which of the following is the best indication for the
intraventricular infusion of morphine?
A. Migraine Headaches
B. Meningitis
C. Failed back surgery syndrome
D. Oropharyngeal carcinoma
E. Diabetic peripheral neuropathy

1094. Answer: D
Explanation:
(Raj, Pain Review 2nd Ed. Page 310, Raj, Practical Mgmt
of Pain 3rd Ed., pg. 795)
The main indications for intraventricular infusion of
opioids are (1) head and neck cancers and (2) failure of
relief with intraspinal opioids in a patient with limited life
expectancy,

357

1095. Appropriate workup for classic migraine includes:
A. Cranial MRI
B. Head CT
C. Fundoscopic examination
D. All of the above
E. None of the above

1095. Answer: C
Source: Wirght PD, Board Review 2004

358

1096. Maxillary nerve block is indicated for the diagnosis,
treatment, or management of all of the following except:
A. Temporo-mandibular joint problems
B. Atypical facial pain
C. Surgical anesthesia for removal of the upper incisors
D. Trigeminal neuralgia
E. Infiltrating tumor of the maxillary sinus

1096. Answer: A
Explanation:
(Raj, Pain Review, 2nd Ed., page 226)
The temporo-mandibular joint is innervated by the
auriculotemporal nerve a branch of V3. All the others are
indications for a maxillary nerve block
Source: Shah RV, Board Review 2003

359

1097. A 49-year-old woman walks by moving her right leg
forward by abduction and circumduction. Choose correct
description of gait:
A. Ataxic gait
B. Parkinsonian gait
C. Spastic hemiplegic gait
D. Steppage gait
E. Scissor gait

1097. Answer: C
Explanation:
A. Ataxic gait is often characterized by clumsiness; when
steps are taken, the advancing foot is lifted high.The foot is
then brought down in a slapping or stamping manner.
B. Parkinsonian gait is noted for the forward stoop of the
head and shoulders, with arms slightly abducted and
forearms partially fl exed; there is decreased arm swing as
the feet shuffle.
C. Spastic hemiplegic gait is the result of spasticity of the
involved limb. The limb is moved forward by abduction
and circumduction.
D. Steppage gait occurs with footdrop (paralysis of the
peroneal nerve); the affected foot is raised higher than
normal to prevent dragging of the toe. Bilateral footdrop
results in a gait resembling that of a high-stepping horse.
E. Spastic diplegia gait or scissor gait occurs with
extrapyramidal disorders. The patient uses short steps and
drags the foot; the legs are extended and stiff and cross on
each other.
Source: Seidel, Sle, pp 791-792.

360

1098. A patient loses consciousness in your pain clinic after
a procedure. Ventricular fi brillation is apparent on
the cardiac monitor. The patient’s airway is being well
managed. An IV line is in place. A defi brillator is at the
bedside. A precordial thump has been administered and
chest compressions are ongoing. The most appropriate
next intervention is:
A. Intravenous vasopressin
B. Intravenous epinephrine
C. Intravenous lidocaine
D. Intravenous amiodarone
E. Stop chest compressions and cardiovert with 200 joules

1098. Answer: E
Explanation:
Reference:
ACLS Provider Manual, 2000 Edition, American Heart
Association
Here is a pneumonic for cardiac resuscitation of
ventricular fi brillation from the ACLS manual:
Please Shock-Shock-Shock, EVerybody Shock, And Let’s
Make Patients Better
Source: Schultz D, Board Review 2004

361

1099. All of the following are contra-indications to ultrasound except:
A. An epiphyseal injury of a young athlete’s elbow.
B. An acute muscle tear.
C. A diabetic with peripheral neuropathy with a painful
great toe.
D. A contracture of a hip joint.
E. A pregnant female with an abdominal strain.

1099. Answer: D
Source: Malanga G, Board Review 2003

362

1100. A 44-year-old man presents with facial asymmetry. On
physical examination, touching the cornea of either eye
with a cotton swab results in blinking of only the left eye.
The patient states that he feels the cotton swab touch
in both eyes. Which of the following is the most likely
diagnosis?
A. Left trigeminal palsy
B. Right trigeminal palsy
C. Right facial nerve palsy
D. Left facial nerve palsy
E. Left oculomotor nerve palsy

1100. Answer: C
Explanation:
(Seidel, 51e, p 785.)
The corneal refl ex is normal when touching the cornea
(trigeminal nerve provides sensation) causes bilateral eye
closure (facial nerve provides motor).
This refl ex will not occur on the side of a facial nerve
paralysis.

363

1101. Pars Interarticularis defects are effectively diagnosed
by:
A. Ultrasound
B. CT
C. Plain radiographs
D. Upper GI series
E. MR

1101. Answer: B
Explanation:
Although plain fi lms may reveal pars defects, CT is the
imaging modality which best confi rms and characterizes
the abnormality
Source: Bieneman B, Board Review 2005

364

1102. A 45-year old, slim, heavy smoker, presents with low back pain that radiates into right buttock and to the leg slightly below
the knee. The pain started somewhat suddenly for this episode but he suffered with chronic pain on and off for 20 years.
Most recently, the pain was associated after driving continuously for 8 hours in a pickup truck. The physical examination
was grossly normal except for tenderness in the lumbar spine and exacerbation of pain with hyperextension. Patient
brought plain x-ray picture fi lms with him and refuses to undergo any further investigations. Based on the plain x-ray
films shown below (pg.180), your radiologic diagnosis is as follows:
A. Grade I spondylolisthesis and spondylolysis of L5 on S1
B. Grade I spondylolisthesis of L5 on S1 with bilateral pars defects
C. Grade II spondylolysis of L5 on S1
D. Grade III spondylolisthesis of L5 on S1 with bilateral pars defects
E. Extensive facet joint arthritis with spinal stenosis

1102. Answer: E
Explanation:
(Tierney, 42/e, pp 797-798.)
The patient most likely has carpal tunnel syndrome (CTS),
which is compression of the median nerve by the
transverse volar ligament of the wrist. Patients complain
of pain and paresthesias of the ‘hand and weakness and
atrophy of the thenar muscles. The Tinel sign (tapping the
median nerve at the wrist) and Phalen sign (forced wrist
fl exion) intensify the symptoms. Risk factors for CTS
include pregnancy, diabetes mellitus, hypothyroidism,
rheumatoid arthritis, amyloid infi ltration as seen in
patients with multiple myeloma, acromegaly, and
repetitive trauma. Ulnar nerve paralysis causes a claw hand
deformity Radial nerve palsy causes wristdrop. Erb-
Duchenne palsy (C5-C6) causes weakness of the shoulder
and elbow and results in the waiter’s tip position (arm
dangles at the side with palm in a backward position with
fi ngers fl exed). Klumpke-Dejerine palsy (C8-Tl) is a triad
of claw hand deformity, absent triceps refl ex, and Horner
syndrome. Patients with cervical radiculopathy (C6 or C7
root) complain of neck pain that radiates to the arm
(radicular pain), dermatomal sensory loss, and decreased
refl exes.

365

1103. A 35-year old man presented with constant low back pain that radiated to the left or right upper buttock region with
occasional radiation to the thigh and calf posteriorly with tingling sensation in the left heel. The symptoms started
approximately a year ago when he lifted a heavy box which caused the gradual onset of low back pain at the time with
increasing intensity in a week. His motor examination was grossly within normal limits. However, he had a positive left
straight leg raising at 50°. There was decreased sensation to pin prick on the lateral side of the foot on the left side. The
following MRI shows (pg.180):
A. L4/5 disc herniation
B. L5/S1 disc herniation
C. Large osteophyte pressing on L5 nerve root
D. Large osteophyte pressing on L4 nerve root
E. Facet joint arthritis causing spinal stenosis

1103. Answer: B
Source: Giordano J, Board Review 2003

366

1104. A 38-year old man presented with low back pain of 3 months’ duration which started following a lifting incident. Pain was present in the low back with radiation into lower extremity associated with signifi cant stiffness. He failed to respond to non-steroidal anti-infl ammatory medication, an aggressive exercise program, intramuscular and oral corticosteroids. Patient was referred to you for a transforaminal epidural steroid injection. You will perform the transforaminal epidural steroid injection in this patient at the following level (pg181):
A. Right L5 transforaminal epidural steroid injection
B. Left L5 transforaminal epidural steroid injection
C. Right L4 transforaminal epidural steroid injection
D. Left L4 transforaminal epidural steroid injection
E. Left S1 transforaminal epidural steroid injection

1104. Answer: A
Source: Wirght PD, Board Review 2004

367

1105. A 44-year old white male presents with a history of spontaneous onset of low back pain with radiation into lower extremity
associated with numbness, tingling, and a positive straight leg raising test at 60°. A surgeon recommended discectomy, however,
the patient refused and wanted to try conservative management with interventional techniques. Non-steroidals, oral and
intramuscular steroids, and physical therapy failed to provide him any signifi cant relief. Your diagnosis in this patient based on
the following MRI (pg 181)is:
A. Right L3/4 disc herniation with pressure on L4 nerve root
B. Right L4/5 disc herniation with pressure on L5 nerve root
C. Right L5/S1 disc herniation with pressure on L5 nerve root
D. Left L3/4 disc herniation with pressure on L4 nerve root
E. Left L4/5 disc herniation with pressure on L5 nerve root

1105. Answer: E
Explanation:
(Raj, Pain Medicine Review, 2nd Ed., page 236-238)
An interscalene block is performed with the patient supine
and their head rotated away from the operator. The C6
level is palpated by identifying the cricoid cartilage. The
non-dominant hand’s index fi nger is used to gently palpate
the posterior border of the sternocleidomastoid muscle.
The fi nger is moved further posteriorly to identify the
groove between the anterior and middle scalenii. The
patient may be asked to deep breathly to accentuate this
groove. The ext. jugular vein may run across this location.
A 22g needle is advanced medial, posterior, and slightly
caudad (perpendicular to skin). Paresthesias should be
elicited in the shoulder, or hand is obtained. 40-50 cc of
local may be instilled incrementally.
The block is performed at the level of the cervical roots
and is most likely to miss the C8 spinal nerve. Thus, one
may get incomplete analgesia of the ulnar aspect of the
hand. All the others are covered by the C5, C6 areas
primarily.
Source: Shah RV, Board Review 2003

368

1106.Ganglion impar neurolytic block after successful
diagnostic block for rectal pain may be performed by
using:
1. 25 ml of 50% alcohol
2. 10 ml of absolute alcohol
3. 4 ml of 25% phenol in glycerol
4. 4 ml of 6% phenol

1106. Answer: D (4 Only)
Source: Racz G. Board Review 2003

369

1107. Anterior Spinal Artery Syndrome usually results in:
1. Unilateral impairment of position sense
2. Normal motor function below the lesion
3. Brain stem stroke
4. Bilateral impairment of pain and temperature

1107. Answer: D (4 Only)
Source: Wirght PD, Board Review 2004

370

1108.During EMG testing, abnormal electrical activity
includes the following:
1. Fibrillation potentials
2. Fasciculation potentials
3. Myokymic discharges
4. Miniature endplate potentials

1108. Answer: A ( 1, 2, & 3)
Source: Wirght PD, Board Review 2004

371

1109. A 42 year-old man develops excruciating pain extending
from his buttocks to the dorsum of his foot. Which
of the following would confi rm the presence of a disc
protrusion?
1. The Lasegue’s sign
2. Thomas test
3. Milgram Test
4. Fabere Test

1109. Answer: B (1 & 3)
Explanation:
(Raj, Practical Mgmt of Pain, 3rd Ed., page 350 and 358)
1. Straight Leg Raising Test: Lasègue’s Sign: This
maneuver can test for sciatic irritation (pain radiating to
the ankle of the tested leg),but sciatic nerve irritation must
be differentiated from hamstring tightness (pain
descending the posterior thigh only). The patient lies
supine, with the examiner stabilizing the heel in one palm
and helping to maintain knee extension with the other.
Elevation is performed to 70 to 90 degrees at the hip, and
radiating pain to the ankle confi rms the test.
2. Thomas Test.The Thomas test evaluates fl exion
contracture of the hip. The patient lies supine with the
pelvis level, allowing a T to form between the vertebral
spine and the pelvic brim. The hip is passively fl exed with
the examiner’s other hand beneath the small of the back,
feeling the point where the lumbar curve is lost. The thigh
is then placed against the abdominal wall. The other leg is
fl exed in similar fashion and allowed to descend to the
examination table. If compensation is attempted by
arching
3. MILGRAM TEST: The patient lies supine and attempts
to hold the heels about 2 inches off the table for 30
seconds.
Intrathecal pressure is elevated, and if a mass lesion or
herniated disk is present, the patient lowers the affected
side to the table.
4. Fabere (Flexion-Abduction-External Rotation [-
Extension]) Test: This maneuver tests for sacroiliac or hip
pathology. The patient is supine with the knee and hip
fl exed and the heel on the opposite knee, allowing the
femur to lower to the examination table. This position
results in hip abduction and external rotation. Groin pain suggests hip pathology, and sacroiliac pain suggests a
problem with this joint
Source: Shah RV, Board Review 2004

372

1110. A positive Froment’s sign indicates
1. Weakness of the adductor pollicis
2. Weakness of the flexor pollicis brevis
3. Weakness of the first dorsal interosseous
4. Weakness of the hypothenar muscles

1110. Answer: A (1,2, & 3)
Explanation:
Froment’s sign is a sign of ulnar nerve palsy. It refl ects a
reduction in the ability to pinch between the thumb and
adjacent digits. Specifi cally, a patient cannot pinch a piece
of paper between the ulnar side of the thumb and radial
side of the index fi nger. The patient compensates by using
median nerve muscles: FPL, FDS, Index FD. Muscles in
choices A,B,C are involved
Although the hypothenar muscles are affected by the ulnar
nerve palsy, they are not part of Froment’s sign
Source: Shah RV, Board Review 2004

373

1111. Which of the following are late responses?
1. H-refl ex
2. A-wave
3. F-wave
4. M-wave

1111. Answer: A ( 1, 2, & 3)
Source: Wirght PD, Board Review 2004

374

1112. Which statements are false regarding spinal injection
and bleeding complications:
1. Aspirin and other NSAIDS, in and of themselves, do
not signifi cantly increase the risk of epidural hematoma
and need not be discontinued prior to spinal injection.
2. Spinal injection may be safely performed on a patient
who has been off Coumadin for 4 days and has an INR
of 1.4
3. Cox 2 inhibitors such as Celebrex and Vioxx do not inhibit
platelets and do not affect coagulation.
4. Bleeding time predicts hemostatic compromise in patients
taking anti-platelet drugs.

1112. Answer: D (4 Only)
Explanation:
Reference:
Horlocker, et. Al.
Regional Anesthesia in the Anticoagulated Patient:
Defi ning the Risks (The Second ASRA Consensus
Conference on Neuraxial Anesthesia and Anticoagulation)
At the 1998 Consensus Conference on Neuraxial
Anesthesia and Anticoagulation, it was concluded that
NSAIDs, in and of themselves, did not appear to present
signifi cant risk to patients for developing spinal-epidural
hematomas. There is no recommendation to discontinue
aspirin or other NSAIDS prior to spinal injection in the
ASRA guidelines.
Normal clotting requires 40% or greater clotting factor
activity. An INR value of 1.5 indicates approximately 40%
activity of clotting factors and essentially normal ability to
clot. This value has been derived from studies correlating
hemostasis with clotting factor activity levels. INR below
1.5 is considered safe for spinal injection.
Cyclooxygenase (COX) exists in 2 forms. COX-1
regulates constitutive mechanisms, while COX-2 mediates
pain and infl ammation. NSAIDs inhibit platelet COX 1
and COX 2 and prevent the synthesis of thromboxane A2.
NSAIDS inhibit platelet function. Celecoxib (Celebrex)
and Rofecoxib (Vioxx) are anti-infl ammatory agents that
primarily inhibit COX-2,an inducible enzyme which is not
expressed in platelets. Therefore COX 2 inhibitors do not
cause platelet dysfunction. Platelets from patients who
have been taking COX 2 inhibitors have normal platelet
adherence to subendothelium and normal primary
hemostatic plug formation. After single and multidosing
regimens, there have not been fi ndings of signifi cant
disruption of platelet aggregation, nor is there a history of
undesirable bleeding events.
It has been suggested that the Ivy bleeding time is the most
reliable predictor of abnormal bleeding in patients
receiving antiplatelet drugs. However, there is no evidence
to suggest that a bleeding time can predict hemostatic
compromise and this test is not recommended to
determine safety of spinal injection in the setting of
platelet inhibition.
Source: Schultz D, Board Review 2004

375

1113. In assessing a possible C8 radiculopathy, the following
muscle(s) would be benefi cial:
1. Triceps
2. Flexor carpi ulnaris
3. Abductor policis brevis
4. Trapezius

1113. Answer: A ( 1, 2, & 3)
Source: Wirght PD, Board Review 2004

376

1114. Complication of C6 transverse process stellate ganglion
block include:
1. Seizure from injection into vertebral artery
2. Total spinal with subarachnoid injection
3. Spinal cord trauma
4. Nerve injury

1114. Answer: E (All)
Source: Racz G. Board Review 2003

377

1115. In the rehabilitation of a chronic low back pain patient,
which of the following has been scientifi cally validated as
effective treatment?
1. A long course of hot packs, ultrasound and electrical
stimulation.
2. Manipulation and other manual treatments.
3. Daily traction combined with cryotherapy.
4. An active exercise program.

1115. Answer: D (4 Only)
Source: Malanga G, Board Review 2003

378

1116. A 70 year old woman with spinal stenosis and lumbar
radiculopathy is hospitalized for TIA episodes. She is
placed on intravenous low molecular weight heparin
(LMWH) because she is at high risk for stroke. You are
asked by the neurologist to perform a lumbar epidural
injection prior to hospital discharge to treat her
radiculopathy. The patient stops heparin and clotting
returns to normal as measured by pre-procedure aPTT.
You then perform an atraumatic L3-4 epidural steroid
injection. She is re-heparinized 2 hours after injection.
24 hours later she begins complaining of increased back
pain and increasing numbness and weakness in her lower
extremities. You are concerned about spinal hematoma.
The following statement(s) are true:
1. Epidural hematoma is unlikely because 24 hours have
passed since injection.
2. Surgical decompression of spinal hematoma has good
outcome if performed within 24 hours of onset of
symptoms.
3. Severe back pain is the most common presenting complaint
of patients with epidural hematoma.
4. The best test to order fi rst is an emergency MRI scan of
the spine.

1116. Answer: D (4 Only)
Explanation:
Reference:
Horlocker, et. Al.
Regional Anesthesia in the Anticoagulated Patient:
Defi ning the Risks (The Second ASRA Consensus
Conference on Neuraxial Anesthesia and Anticoagulation)
Spinal hematoma, defi ned as symptomatic bleeding within
the spinal neuraxis, is a rare and potentially catastrophic
complication of spinal or epidural anesthesia. The actual
incidence of neurologic dysfunction resulting from
hemorrhagic complications associated with central neural
block is unknown. In an extensive review of the literature,
Tryba identifi ed 13 cases of spinal hematoma following
850,000 epidural anesthetics and 7 cases among 650,000
spinal techniques. Based on these observations, the
calculated incidence is approximated to be less than 1 in
150,000 epidurals and less than 1 in 220,000 spinal
anesthetics. Hemorrhage into the spinal canal most
commonly occurs in the epidural space, most likely
because of the prominent epidural venous plexus.
Between 1993 and 1998, there were 45 cases of spinal
hematoma associated with LMWH, 40 of which involved a
neuraxial anesthetic.Severe radicular back pain was not the
presenting symptom; most patients complained of new
onset numbness, weakness, or bowel and bladder
dysfunction. Neurologic compromise presented as
progression of sensory or motor block (68% of patients)
or bowel/bladder dysfunction. Approximately half of
patients reported neurological defi cits 12 hours or more
following spinal procedure. Median time interval between
initiation of LMWH therapy and neurologic dysfunction
was 3 days, while median time to onset of symptoms and
laminectomy was over 24 hours. Only 38% of patients had
partial or good neurological recovery and spinal cord
ischemia tended to be reversible in patients who
underwent laminectomy within 8 hours of onset of
neurological dysfunction. Early diagnosis by MRI scanning
is therefore of paramount importance.
Source: Schultz D, Board Review 2004

379

1117. True entrapment of the ulnar nerve at as described
by Guyon at Guyon’s canal could lead which of the
following?
1. Loss of sensation on the dorsum of the 5th digit
2. Wrist pain that radiates to the forearm
3. Paralysis of the hypothenar
4. A positive Froment’s sign

1117. Answer: C (2 & 4)
Explanation:
(Dawson, Entrapment Neuropathies,
The American Academy of Physical Medicine and
Rehabilitation--
http://www.aapmr.org/education/archive/emg0102e.htm.)
Okay, a Trick Question. Entrapment at the proximal aspect
of Guyon’s canal before the deep motor branch sends a
hypothenar motor branch could cause weakness of the
hypothenar and intrinsics. However, even, then
hypothenars are often mildly involved and can be
overlooked. Froment’s sign occurs with ulnar palsies as
described earlier
Source: Shah RV, Board Review 2004

380

1118. Sleep Studies (polysomnography) involve measurements
of following parameters:
1. O2 saturation
2. Heart Rate
3. Eye movements
4. Respiratory movement

1118. Answer: E (All)
Source: Wirght PD, Board Review 2004

381

1119. Which of the following statements is most accurate
concerning our current understanding of medication
overuse headache (MOH), formerly referred to as
analgesic rebound headache syndrome? Pick one of the
following:
1. Medication overuse headache is likely to occur over
time when short acting pain relieving medications or
compounds are, on average, used more frequently than
two days a week to relieve headache.
2. Long acting preparations of opioid analgesics do not
generally result in MOH even when used daily over
years in the control of headache or other pain.
3. Prophylaxis of headache will fail in the face of excessive
(too frequent) use of short acting abortive medication
over time no matter the type, dose or combination of
prophylactic medication used.
4. The majority of those who overuse short acting ‘over the
counter’ and / or controlled substances for the management
of headaches tend to have addictive personalities

1119. Answer: A
Source: Goodwin J, Board Review 2005

382

1120. Mechanism of action of TENS pain relief is thought to
be:
1. Stimulates corticospinal system
2. Stimulates reticulospinal system
3. Inhibits large A fi ber activity
4. Inhibits C fiber activity

1120. Answer: D (4 Only)
Explanation:
TENS is thought to involve the gate control theory;
activation of large fi bers presumably inhibits C fi ber
activity.

383

1121. Spinal stenosis rehabilitation includes the following:
1. A lumbar fl exion program
2. Modifi ed abdominal strengthening
3. Bicycling
4. Downhill walking

1121. Answer: A (1, 2, & 3)
Explanation:
Therapeutic exercises are benefi cial and should include a
lumbar fl exion program, modifi ed abdominal
strengthening, trunk and lower extremity fl exibility,
bicycling, and uphill treadmill walking.

384

1122. A 33 year-old female pricks her index fi nger and
progressively develops pain involving her upper limb.
Which of the following is required for a diagnosis of
complex regional pain syndrome?
1. diffuse pain in the upper limb
2. pain that becomes worse with light touch or exposure
to cold
3. swelling of the hand
4. tremor of the hand

1122. Answer: A (1,2, & 3)
Explanation:
(Shah, et. al. Recurrence and spread of CRPS, accepted to
American Journal of Orthopedics)
Complex regional pain syndrome (CRPS) describes a
constellation of sensory, motor, autonomic, and trophic
disturbances, with spontaneous pain and hyperalgesia
being the most persistent signs (Birklein). The term,
‘CRPS’, was introduced by a consensus group in 1996, to
describe a variety of painful conditions that follow injury
(Stanton-Hicks). They are characterized by spontaneous
pain or hyperalgesia, a distal regional predominance,
variable progression over time, impairment of motor
function, and a magnitude and duration exceeding the
expected clinical course of the inciting event; temperature,
skin color, edematous, and sudomotor abnormality are or
have been present (Stanton-Hicks 1998). The two subtypes
include all the foregoing features but either exclude
(CRPS I) or include (CRPS II) a peripheral nerve injury
(Stanton-Hicks).
Motor dysfunction is not required for diagnosis, but is
often present in most patients with CRPS
Source: Shah RV, Board Review 2004

385

1123. Which of the following are included in a complete
electrodiagnostic evaluation?
1. Electromyography and late response studies
2. Peripheral nerve conduction studies of motor and sensory
nerves
3. Somatosensory evoked potentials
4. Muscle biopsy

1123. Answer: A (1, 2 & 3)
Explanation:
Reference: Bonica, p 629.
The electromyogram (EMG), peripheral nerve conduction
studies (NCSs), late response studies, and somatosensory
evoked potentials (SEPs) help to characterize the nature
and location of the abnormality being studied.
Determination of the cause of the abnormality can occur
only after integration of the information obtained fromthe
physical examination, history, and electrodiagnostic and
radiologic studies.
Muscle biopsy is not a component of electrodiagnostic
evaluation.
Source: Kahn and Desio

386

1124. Operant interventions are specifi c and targeted. These are all of the below:
1. Patient sets goals and has a predefi ned award for attainment
of goal.
2. Goals are increasingly more diffi cult in an attempt to
maximize function.
3. Medical staff and family members are asked to acknowledge
adaptive behaviors by the patient.
4. Medical staff and family members are instructed to support
the patient’s pain behavior

1124. Answer: A (1, 2, & 3)
Source: Raj, Pain Review 2nd Edition

387

1125. A patient presents with an acute onset of upper extremity
pain. On examination, there was decrease in sensation in
the lateral arm. The patient may be suffering with the
following condition(s):
1. C5/6 disc herniation
2. C4/5 disc herniation
3. C6 radiculopathy
4. C5 radiculopathy

1125. Answer: C (2 & 4)
Explanation:
The C5 neurological level supplies sensation to the lateral
arm, from the summit of the shoulder to the elbow. The
purest patch of axillary nerve sensation lies over the lateral
portion of the deltoid muscle. This localized sensory area
within the C5 dermatome is useful for indicating specifi c
trauma to the axillary nerve, as well as general trauma to
the C5 nerve root.
Source: Hoppenfeld S. Orthopaedic Neurology. A
Diagnostic Guide to Neurologic Levels.
Philadelphia,LWW, 1997.

388

1126. The most common cause of acquired fl atfoot in the adult
population is one of the following:
1. Tarsal tunnel syndrome
2. Posterior tibialis dysfunction
3. Plantar fasciitis
4. Spring ligament failure

1126. Answer: B (1 & 3)
Source: Sizer et al - Pain Practice - March & June 2004

389

1127. Coccygodynia has been reported to be treated with:
1. cryoneurolysis of S5
2. radiofrequency thermocoagulation of S5
3. sacral nerve root stimulation – transsacral
4. retrograde dual electrode placement to S3

1127. Answer: E (All)
Source: Racz G. Board Review 2003

390

1128. Which of the following treatments is relevant to
managing cervical whiplash pain?
1. Prolonged immobilization of the neck
2. Non-steroidal anti-infl ammatory drugs
3. Benzodiazepines
4. Cervical medial branch radiofrequency neurotomy

1128. Answer: C (2 & 4)
Explanation:
Short-term immobilization of the neck maybe appropriate
to provide relief. However, prolonged immobilization
leads to weakening of the cervical spine musculature. Nonsteroidal
anti-infl ammatory medications provide analgesia
and reduce infl ammation may be benefi cial in the shortterm.
Benzodiazepines are not analgesics despite their
purported effi cacy in reducing muscle spasm. Rather,
biofeedback and psychological counseling may be more
appropriate. Other less addicting and sedating ‘muscle
relaxants’ maybe more appropriate, e.g., baclofen or
tizanidine. Cervical medial branch neurotomy in those
selected with placebo controlled diagnostic blocks may benefi t patients with whiplash.
Source: Shah RV: 2003 (Bonica, 3rd Ed., page 1010)

391

1129. Which of the following percutaneous procedures
compares favorably to re-operation in the management
of failed back surgery syndrome?
1. Spinal cord stimulation
2. Peripheral nerve stimulation
3. Radiofrequency denervation of the lumbar facet joints
4. Translaminar epidural steroid injections

1129. Answer: B (1 & 3)
Explanation:
The term failed back surgery syndrome refers to persistent
or recurrent chronic pain after one or more surgical
procedures on the lumbosacral spine. Management is
mired in controversy.
However, radiofrequency denervation of the lumbar facets
compares favorably to re-operation in long-term followup.
Spinal cord stimulation also compares favorably to reoperation.
Although SCS is best described for radicular
pain, it may also be useful for axial pain. Peripheral nerve
stimulators are usually reserved for patients with a well
defi ned single peripheral nerve injury and complex
regional pain syndrome. Placement must be proximal to
the injured nerve. In radiculopathy, this would require
placement in a retrograde approach parallel to the
descending root, i.e., in the lateral recess and out towards
the foramen. This technique, although described, is not
widely practiced. Translaminar epidural steroids have been
mired in controversy in patients without previous back
operations. Only a few studies have demonstrated short
term benefi t in failed back surgery syndrome and they too,
probably won’t escape the attack of the evidence-based
axe.
Source: Shah RV: 2003(Bonica, 3rd Ed., pages 1544-1547)

392

1130. Single fi ber EMG is most useful in evaluating:
1. Carpal tunnel syndrome
2. Multiple sclerosis
3. Charcot Marie Tooth Disease
4. Myasthenia gravis

1130. Answer: D (4 Only)
Source: Wirght PD, Board Review 2004

393

1131. Which of the following is true about cerebrospinal
fl uid?
1. CSF is reabsorbed by the choroidal plexi in the ventricles
2. CSF passes from the lateral to the 3rd ventricle via the
foramen of Lushcka
3. CSF is formed by arachnoid villi
4. The total volume of CSF is 150 ml., of which 25-30 cc are
in the spinal subarachnoid space

1131. Answer: D (4 only)
Explanation:
(Raj, Practical Management of Pain, 3rd Ed., page 632)
Cerebrospinal fl uid (CSF) is a clear, colorless ultrafi ltrate
of blood formed by the choroid plexuses in the ventricles
of the brain. CSF passes through the interventricular
foramen of Monro into the third ventricle, then through
the cerebral aqueduct to the fourth ventricle. It exits the
fourth ventricle by way of the lateral and median foramina
of Luschka and Magendie to reach the subarachnoid space.
CSF is then absorbed by arachnoid villi that project from
the subarachnoid space. The total volume of CSF is about
150ml, with about 25 to 35ml contained within the spinal
subarachnoid space.
Source: Shah RV, Board Review 2005

394

1132. The major strength of the McGill Pain Questionnaire
(MPQ) is that it is organized as a list of words, which
are rated on a common intensity scale. It is possible to
compare diagnosis and treatment with various pain
syndromes by calculating the score obtained by the
patients’ responses. All of the following are part of the
evaluation
1. The number of words chosen
2. The total score based on each subclass intensity scale
3. Rating of the common intensity scale
4. Rating of the patient’s depression scale

1132. Answer: A (1,2, & 3)
Source: Raj, Pain Review 2nd Edition

395

1133. The McGill Pain Questionnaire is designed to measure
which of the following components of pain?
1. Societal
2. Sensory
3. Quantitative
4. Evaluative

1133. Answer: C (2 & 4)
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition

396

1134. Which of the following symptoms are the earliest
indication of lithium intoxication?
1. Impaired consciousness
2. Myoclonus
3. Seizures
4. Coarse tremor

1134. Answer: E
Explanation:
The early signs and symptoms of lithium toxicity include
coarse tremor, dysarthria, and ataxia; the later signs and
symptoms include impaired consciousness, muscular
fasciculations, myoclonus, seizures, and coma. The higher
the lithium levels (and the longer they have been elevated),
the worse the symptoms of lithium toxicity.
Source: Laxmaiah Manchikanti, MD

397

1135. Factitious disorder is differentiated from malingering
by which of the following characteristics?
1. The production of physical signs is under voluntary
control
2. The presence of a serious organic disorder as a comorbid
factor
3. The primary motivation of the patient is to assume the
sick role.
4. The absence of secondary gain

1135. Answer: D
Explanation:
1.In factitious disorder, the patient intentionally produces
physical or psychological signs or symptoms that are
under voluntary control and are not explained by any
other underlying physical or mental disorder.
2.There is no serious organic disorder.
3.The primary motivation of the behavior is to assume the
sick role. In factitious disorder however, there is no
secondary gain such as economic benefi t or avoidance of
legal responsibilities. In malingering, the patient has an
obvious recognizable secondary gain in producing their
signs and symptoms such as avoiding work or
prosecution, or obtaining fi nancial gain.
4.Absence of secondary gain is the main feature that
differentiates factitious disorder from malingering.
Source: Laxmaiah Manchikanti, MD

398

1136. The following statements are true regarding
contraindications and side effects for TENS:
1. TENS should not be used in patients with cardiac pacemakers
2. TENS should not be used in the vicinity of peripheral
arteries
3. TENS should not be used in the anterolateral neck
4. TENS should not be used for more than one hour at a
time

1136. Answer: B (1 & 3)
Explanation:
Reference:
Bonica’s Management of Pain, Third Edition, Chapter 98,
Transcutaneous Electrical Nerve Stimulation
1. TENS should probably be avoided in patients with
cardiac pacemakers because of the risk of electrical
interference with pacemaker function.
2..TENS can be used in the vicinity of other arteries.
3. TENS electrodes should not be placed over the
anterolateral neck because the carotid sinus may be
stimulated causing bradycardia, hypotension and syncope.
4. It is safe to use TENS for many hours.
The most common side effect is skin irritation at the site
of the patches.
Source: Schultz D, Board Review 2004

399

1137. Pain originating from which of the following viscera can
be treated with a celiac plexus block?
1. Pancreas
2. Gall bladder
3. Ascending colon
4. Sigmoid colcon

1137. Answer: A (1, 2 & 3)
Source: Day MR, Board Review 2005

400

1138. Which of the following are true about deep brain
stimulation?
1. Good results are obtained with Dejerine-Roussy syndrome
2. Short term pain relief exceeds 60%
3. Periaqueductal gray mediated anti-nociception does not
depend on non-opioid analgesic systems
4. Poor results are obtained with complete spinal cord
injury pain

1138. Answer: C (2 & 4)
Explanation:
(Raj, Pain Review 2nd Ed., page 311, Bonica 3rd Ed., pages
130-2)
Poor results are obtained with central thalamic and complete spinal cord injury pain. Peri-aqueductal grey
mediated analgesia depends on both opioids and nonopioid
systems. Short-term pain relief is 61-80%, but long
term relief drops to 50-63%.
Source: Schultz D, Board Review 2004

401

1139. Regarding temporomandibular Disorders (TMD), which
of the following statements have empirical support?
1. The male to female ratio of symptomatic TMD is 1:2
2. MRI is the imaging study of choice because effusion into
a temporomandibular synovial joint (TMJ) correlates
well with pain, and because disc displacement and soft
tissues are well visualized.
3. The most common source of pain from TMD is myofascial.
4. The most common source of pain is degeneration
or displacement of the TMJ’s disc brought about by
malocclusion, bruxism and/or severe and chronic jaw
clenching.

1139. Answer: A
Source: Goodwin J, Board Review 2005

402

1140. Effects of spinal cord stimulation on circulation
include:
1. Increase in capillary density within stimulated region
2. Increase in red cell volume within microcirculation at
stimulation target
3. Increase in number of capillaries perfused within stimulated
region
4. Decrease in diastolic blood pressure

1140. Answer: A ( 1, 2, & 3)
Explanation:
Spinal cord stimulation causes vasodilation in the
stimulated region. This effect is the result of
microvascular changes occurring at the capillary level
most likely as a result of central inhibition of sympathetic
neurons. Spinal cord stimulation does not cause
macrocirculatory changes and blood pressure and pulse
remain unchanged.
Reference:
Krames, Interventional Pain Management, Second Edition;
Chapter 53 Mechanisms of Action of Spinal Cord
Stimulation
Source: Schultz D, Board Review 2004

403

1141. Where a nerve root is permanently injured, on physical
examination one might observe:
1. fi brillations in muscles served by that root
2. increased refl exes involving that root
3. numbness in at least two adjacent dermatomes due to
overlapping innervation
4. fasciculations and atrophy of the muscles innervated
by that root

1141. Answer: D
Source: Goodwin J, Board Review 2005

404

1142. Which of the following central nervous system changes
occurs with age?
1. Reduced Sympathetic function
2. Low-frequency hearing loss
3. Increased muscle tone
4. Decrease in primitive refl exes

1142. Answer: B
Source: Day MR, Board Review 2006

405

1143. Which of the following is or are true regarding
Pseudotumor Cerebri (PTC) a.k.a. Benign Intracranial
Hypertension (BIH)? Choose only one:
1. It is strongly associated with obesity at all ages.
2. It is probably, in part, due to overproduction of CSF
rather than poor drainage of CSF
3. It can occur without evidence of papilledema
4. It is usually self-limited with only transient headaches
that are commonly mistaken for the presence of a supratentorial
tumor, ruled out by MRI hence the designations
‘pseudotumor’ and ‘benign’.

1143. Answer: A
Source: Goodwin J, Board Review 2005

406

1144. Which of the statements concerning cluster headache are
currently felt to be true? Choose one:
1. The pain is always unilateral but can occur on one side
or the other in any given individual over time
2. Unlike migraine, cluster headaches do not induce nausea
3. The only abnormal physical sign seen between attacks is an ipsilateral partial Horner’s syndrome (a minor
degree of ptosis and myosis).
4. The stabbing pain of cluster headaches occurs most
commonly in the area innervated by the 3rd branch
(V3) of the trigeminal nerve

1144. Answer: B
Source: Goodwin J, Board Review 2005

407

1145. The visual analog scale is characterized by all of the
following
1. It is a progression of the numeric pain scale
2. It uses a 10-cm line with 0 on one side and 10 on other
3. The patient is asked to place a mark along the line to
denote the level of pain
4. It is a multidimensional pain scale

1145. Answer: A (1,2, & 3)
Source: Raj, Pain Review 2nd Edition

408

1146. A 70 year old woman with spinal stenosis and lumbar
radiculopathy is hospitalized for TIA episodes. She is
placed on intravenous low molecular weight heparin
(LMWH) because she is at high risk for stroke. You
are asked by the neurologist to perform a lumbar
epidural injection prior to hospital discharge to treat
her radiculopathy. Which of the following statements
regarding heparin and spinal injection are true?
1. LMWH should be stopped for a minimum of 24 hours
prior to spinal injection
2. Low dose, subcutaneous heparin (5000 units every 12
hours) creates minimal increased risk for spinal hematoma
with spinal injection
3. There is a higher incidence of spinal hematoma associated
with LMWH than with unfractionated (standard)
heparin
4. An epidural catheter may be safely removed in a fully
heparinized patient

1146. Answer: A ( 1, 2, & 3)
Explanation:
Reference:
Horlocker, et. Al.
Regional Anesthesia in the Anticoagulated Patient:
Defi ning the Risks (The Second ASRA Consensus
Conference on Neuraxial Anesthesia and Anticoagulation)
When heparin is administered in the setting of spinal
injection, there is increased risk for spinal bleeding in
certain situations. The concurrent use of medications such
as oral anticoagulants antiplatelet medications that affect
other components of the clotting mechanism may increase
the risk of bleeding complications for patients receiving
standard heparin. Guidelines for spinal injection in the
patient receiving standard, unfractionated heparin were
established over 2 decades ago and are well outlined in the
ASRA article listed above.
Placement of a needle into the spinal canal and
withdrawing a catheter from the spinal canal are both possible causes for epidural hematoma in the heparinized
patient and recommendations for performing either spinal
injection or catheter removal are similar. The following
table illustrates the relative risk of spinal injection in
various scenarios involving heparin:
During SC heparin (mini-dose) prophylaxis, there is no
contraindication to the use of neuraxial techniques. The
risk of neuraxial bleeding may be reduced by delay of the
heparin injection until after the block and may be
increased in debilitated patients after prolonged therapy.
Because heparin-induced thrombocytopenia may occur
during heparin administration, patients receiving
subcutaneous heparin for greater than 4 days should have
a platelet count assessed prior to neuraxial block and prior
to catheter removal.
With unfractionated heparin, administration should be
delayed for 1 hour after needle or catheter placement. In
patients receiving heparin pre-procedure, spinal injection
and/or catheter removal shouldbe performed after heparin
cessation only after clotting status has returned to normal
as determined by activated partial thromboplastin time
(aPTT). Typically spinal injection should be delayed for at
least 4 hours after the last heparin dose and indwelling
neuraxial catheters should be removed 2 to 4 hours after
the last heparin dose. Re-heparinization after spinal
intervention should be delayed for 1 hour or longer.
The biochemical and pharmacologic properties of LMWH
differ from those of unfractionated heparin and patients
receiving LMWH heparin are considered to be higher risk
for spinal hematoma. During the fi rst 5 years of LMWH
use in the United States, some 60 epidural hematomas
were reported, prompting a “black box” warning label by
the FDA.The most relevant differences with LMWH are
its’ pro-longed half-life, its’ irreversibility with protamine
and the lack of monitoring of the anticoagulant response
with standard lab testing. Prolonged LMWH therapy may
be associated with an accumulation of anti-Xa activity and
fi brinolysis.
Patients on preoperative lower dose LMWH for
thromboprophylaxis can be assumed to have altered
coagulation. In these patients, needle placement should
occur at least 10 to 12 hours after the last LMWH dose.
Patients receiving higher doses of LMWH for
anticoagulation, such as enoxaparin 1 mg/kg every 12
hours, enoxaparin 1.5 mg/kg daily, dalteparin 120 U/kg
every 12 hours, dalteparin 200 U/kg daily, or tinzaparin
175 U/kg daily will require delays of at least 24 hours to
assure normal hemostasis at the time of needle insertion.
Source: Schultz D, Board Review 2004

409

1147. A patient undergoes a left stellate ganglion block without
fl uoroscopic guidance. One week later the patient develops
intermittent fever and increasingly severe posterior neck
pain. The following statements are true:
1. The patient should be treated with a 10 day course of
oral antibiotics.
2. Discitis is more likely after a left-sided vs. a right sided
stellate block.
3. Symptoms are most likely unrelated to the stellate ganglion
block.
4. The most appropriate immediate work up includes ESR,
C-reactive protein and cervical MRI scan.

1147. Answer: C (2 & 4)
Explanation:
Reference:
Pyogenic cervical epidural abscess and discitis following
stellate ganglion block
Vadodaria B.S., Bridgens J. and Richmond M.
Anaesthesia 2001 56:9 (871-873)
Disc space infection (commonly called discitis) is a rare but potentially catastrophic complication of injection into
the spinal region. Any time a needle enters an
intervertebral disc there is a potential for this
complication. Epidural abscess and/or vertebral body
osteomyelitis are common consequences of untreated disc
space infection. Symptoms may include increasingly severe
neck pain worse with movement, fevers and general
malaise. Rapid diagnosis and aggressive treatment are of
vital importance to prevent severe neurological
consequences and life-threatening infection. The most
important early diagnostic maneuvers include laboratory
analysis with ESR and C-reactive protein and emergent
MRI scan. ESR is a somewhat nonspecifi c test and Creactive
protein is more specifi c and sensitive for discitis.
The MRI may be relatively normal early on in the course
of discitis and repeat MRI scans may be used to reevaluate
and track progression or regression of disc space
infection.
MRI is also important to rule out epidural abscess which
may require surgical intervention. Irradication of disc
space infection in the relatively avascular disc is diffi cult
and treatment typically includes intravenous antibiotics
for a period of many weeks.
Discitis is most commonly associated with discography
but can occur after stellate ganglion block since the needle
is in close proximity to the disc and disc penetration can
occur. In the cervical region, the esophagus is a left-sided
structure and any needle traversing the esophagus and
entering a cervical disc has the potential to cause disc
space infection. For this reason, cervical discography
is always
performed from the right side. Left-sided stellate ganglion
block therefore has an inherently higher risk of discitis.
Source: Schultz D, Board Review 2004

410

1148. A 50-year old typist complains of numbness of 6 weeks
in duration in her entire right hand that is relieved by
placing her hand under cold running water. Numbness
and tingling are prominent to the index fi nger when
driving her car or typing. She had entered menopause
fi ve years previously. She is also a non-insulin dependent
diabetic for approximately 10 years. There was no
evidence of diabetic neuropathy. The true statements
regarding this patient’s condition include:
1. She suffers with carpal tunnel syndrome
2. Nerve conduction studies showed a prolong residual
latency and normal conduction velocity in the forearm
3. Treatment includes non-steroidal anti-infl ammatory
agents, a cock-up volar splint with wrist is loose-packed
position (10° to 30° dorsifl exion) to be worn during day
and night and tendon-gliding exercises.
4. Her diagnosis is C6 radiculopathy caused by cervical
spondylosis.

1148. Answer: A (1,2, & 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 carpal tunnel 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 motorbranches.
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.
* Other diagnosis include:
- 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.
- Other conditions include anterior interosseous
syndrome.
- 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. However, positive fi ndings occur only in
approximately 45% of all cases.
Source: Saidoff DC, McDonough AL. Critical Pathways in
Therapeutic Intervention. Extremities and Spine.
St. Louis,Inc., 2002

411

1149. Regarding Nerve Conduction Studies:
1. Slowing of conduction velocity most often implies demyelination
2. Diminished amplitude of the action potential implies
axonal damage
3. Prolonged distal latencies are seen in entrapment neuropathies
4. Needle electrodes are used only in morbidly obese individuals
due to attenuation of the AP signal secondary
to adipose tissue transduction blockade

1149. Answer: A
Source: Goodwin J, Board Review 2006

412

1150. With audio amplifi cation, a ‘dive bomber’ sound is
characteristic of which phenomenon?
1. A post synaptic, decremental response-generating condition
such as myesthenia gravis
2. Myokymia
3. Pronged but attenuating fi brillation potentials
4. Myotonia

1150. Answer: D
Source: Goodwin J, Board Review 2006

413

1151. Which of the following statements is true?
1. In compression neuropathies, sensory nerve conduction
tests are more sensitive than motor.
2. Plexopathies usually involve diminished SNAP’s
3. In radiculopathies, SNAP’s are usually undiminished
4. The absence of paraspinal muscle fi brillations rules out
radiculopathy

1151. Answer: A
Source: Goodwin J, Board Review 2006

414

1152. Which of the following are common fi ndings on MRI
with an epidural abscess?
1. Discitis
2. Dural enhancement
3. Vertebral osteomyelitis
4. Epidural fl uid collection

1152. Answer: E (All)
Source: Bieneman B, Board Review 2005

415

1153. Which of the following are true regarding multiple
myeloma?
1. Most common primary bone tumor
2. Bone scan is normal in majority of cases
3. MRI more sensitive than plain radiographs
4. Long bones more often involved than axial skeleton

1153. Answer: A (1,2, & 3)
Source: Bieneman B, Board Review 2005

416

1154. Which of the following is or are true with respect to post
lumbar puncture headaches (PLPH?
1. Sprotte or Whitacre needles increase the risk of PLPH as
compared to Quincke needles because they cut rather
than spread apart the longitudinal fi bers of the dura
mater.
2. While strict bed rest, IV caffeine and IV theophyline
may help reduce or stop a PLPH, the quickest and most
effective method is a blood patch.
3. Lying prone for 3 hours after a lumbar puncture reduces
the incidence of PLPH by 30-50%.
4. Cranial nerve 6 is the most likely cranial nerve to be
affected by low CSF levels because it is the longest one
exposed to low CSF levels and can be stretched over the petrous ridge of the temporal bone when the CSF
levels fall.

1154. Answer: C
Source: Goodwin J, Board Review 2005

417

1155. Which of the following hepatic metabolic pathways
dcrease with age?
1. Conjugation
2. Microsomal hydroxylation
3. Oxidation
4. Demethylation

1155. Answer: D
Source: Day MR, Board Review 2006

418

1156. A 38-year-old white male with chronic low back pain
and history of alcoholism, on total of 200 mg of morphine
per day, was admitted to the emergency room because he
was found by his neighbors to be acting agitated and
confused. ER physician notifi es you of his admission.
Which of the following identifi es delirium tremens in
differential diagnosis of this patient’s condition?
1. Clear sensorium
2. Prominent tremor
3. Auditory hallucination
4. Dilated pupils with slow reaction to light

1156. Answer: B
Explanation:
1.There is diffi culty sustaining attention, disorganized
thinking, and perceptual disturbances.
2.Acute alcoholic hallucinosis may start without a drop in
blood alcohol concentration, and without delirium,
tremor, or autonomic hyperactivity
3.Hallucinations are usually auditory and paranoid and
may last more than 10 days.
4.In delirium tremens, the patient is confused, with
prominent tremor and psychomotor activity, disturbed
vital signs, autonomic dysfunction with dilated pupils, and
a slow reaction to light. Hallucinations are usually of the
visual type
Source: Laxmaiah Manchikanti, MD

419

1157. A massage technique that applies gentle taps or blows
would be classifi ed as a
1. stroking
2. petrissage
3. friction vibration
4. percussion

1157. Answer: D (4 only)
Explanation:
(Raj, Practical Mgmt of Pain 3rd Ed., page 538-539)
Massage
Massage is the scientifi c application of force by the hands
to soft tissue, usually the skin, fascia, muscles, tendons, and
ligaments, to produce a therapeutic effect. Several types
exist
Stroking or Effl eurage
Kneading and Pétrissage
Friction Massage
Percussion, Tapotement, or Clapping
Stroking and Vibration
Source: Shah RV, Board Review 2005

420

1158. The criteria for diagnosing hypochondriasis include all
of the following:
1. Preoccupation with the fear of having a serious disease
2. Persistent preoccupation despite medical reassurance
3. The preoccupation has a duration of 6 months or more
4. The preoccupation is delusional

1158. Answer: A ( 1, 2, & 3)
Source: Janata JW, Board Review 2005

421

1159. Psychophysiologic assessment might include:
1. Malingering indices
2. Depression scales
3. The MMPI
4. Biofeedback assessment

1159. Answer: D (4 only)
Source: Janata JW, Board Review 2005

422

1160. Complex pain presentations are generally optimally
treated using:
1. A single medical specialist
2. Biofeedback
3. Polypharmacy
4. Interdisciplinary treatment

1160. Answer: D (4 only)
Source: Janata JW, Board Review 2005

423

1161. The Beck Depression Inventory may slightly overestimate
depression in pain populations because it includes:
1. Family history of depression
2. A malingering scale
3. An interpersonal distress index
4. Somatic symptoms

1161. Answer: D (4 only)
Source: Janata JW, Board Review 2005

424

1162. Which of the following describes a method of heat
transfer
1. Conduction
2. Convection
3. Conversion
4. Radiation

1162. Answer: E
Explanation:
(Raj, Practical Mgmt of Pain, 3rd Ed., page 530)
Conduction is the transfer of thermal energy between two
bodies in direct contact.
Convection uses movement of a transfer medium such as
air or water to convey the change in temperature.
Conversion is the transformation of energy in one form,
such as sound, into another, such as heat.
Radiation is the thermal energy given off by any object
whose surface temperature is above absolute zero.
Source: Shah RV, Board Review 2005

425

1163. A pain psychologist might use the Millon Behavioral
Health Inventory to assess:
1. Basic coping style
2. Psychogenic attitudes
3. Psychosomatic correlates
4. Personality Disorders

1163. Answer: A ( 1, 2, & 3)
Source: Janata JW, Board Review 2005

426

1164. The visceral afferent fi bers of the heart are transmitted
through what nerves
1. Vagus
2. Middle and inferior cervical ganglia
3. Thoracic cardiac nerves
4. Thoracic ganglia 3-6

1164. Answer: A (1, 2, and 3)
Explanation:
Reference: Raj. Chapter 43. Thoracoabdominal Pain. In:
Practical Management of Pain.3rd Edition. Raj et al,
Mosby, 2000. page 618
Source: Day MR, Board Review 2005

427

1165. On T2-weighted images of the lumbar spine
1. Intervertebral disc height is usually greatest at L4/5
2. Disc signal intensity is greatest at its central aspect
3. The nuclear cleft is normal in most cases
4. The conus usually ends at or above L1

1165. Answer: A (1,2, & 3)
Explanation:
The conus usually ends at or above L2. (reference:
Renfrew; Atlas Spine Imaging, Saunders, 2003, page 1)
Source: Bieneman B, Board Review 2005

428

1166. Conus Medullaris Syndrome differs from Cauda Equina
Syndrome in that the former:
1. is less likely to be painful, but if present, is a relatively
mild perineum and thigh pain
2. results in earlier and more severe sphincter dysfunction
3. generally presents with symmetrical and bilateral sensory
defi cits
4. generally presents with radicular pain

1166. Answer: A
Source: Goodwin J, Board Review 2005

429

1167. Subacute combined degeneration due to vitamin B12
defi ciency typically produces which of the following
spinal cord changes on imaging?
1. Atrophy of the cord on CT scan
2. MRI T2-weighted hyperintensity of dorsal columns
3. Hyperintensity of ventral cord on T2-weighted MRI
4. Mild cord enlargement with abnormal signal in dorsal
cord

1167. Answer: C (2 & 4)
Source: Bieneman B, Board Review 2005

430

1168. Acute infl ammatory demyelinating polyradiculipathy
(Guillain-Barre Syndrome) is characterized by which of
the following?
1. Diffuse enhancement of cauda equina and conus medularis
2. Atrophy frequently present in images of anterior cord
3. Best seen on MRI scan
4. Readily visualized on CT scans

1168. Answer: B (1 & 3)
Explanation:
The most common cause of acute paralysis in the western
world, also known as ascending paralysis. An
infl ammatory demyelinating disease involving peripheral
nerves, nerve roots and cranial nerves. Believed to occur
most commonly after viral illness, campylobacter infection
or with autoimmune responses, such as with vaccination
Source: Bieneman B, Board Review 2005

431

1169. Regarding demyelinating diseases of the spinal cord
1. Cord edema and atrophy are common in the acute setting
2. T1 weighted sequence with contrast is best for diagnosing
MS
3. All actively demyelinating lesions enhance
4. ADEM and MS may have an identical appearance

1169. Answer: D (4 Only)
Source: Bieneman B, Board Review 2005

432

1170. Which items are safe for MRI?
1. Internal orthopedic hardware
2. Intrauterine device
3. Epilepsy depth electrodes
4. Drug infusion pumps

1170. Answer: E (All)
Explanation:
It is alwatys important o refer to an up-to-date reference of
MRI compatible devices before imaging patients, however,
these devices are usually safe.
Source: Bieneman B, Board Review 2005

433

1171. Spray and stretch is a therapeutic cold technique that
uses
1. Ice massage
2. Cold water immersion
3. Cold Packs
4. Ethyl chloride

1171. Answer: D (4 only)
Explanation:
(Raj, Practical Mgmt of Pain, 3rd Ed., page 532-533)
Vapocoolant Spray
Topical anesthetics like ethyl chloride and fl uori-methane
are used in the technique of spray-and-stretch to treat the
many myofascial and musculoskeletal pain syndromes
typically characterized by the presence of trigger points.
The trigger point and its referral zone are sprayed in
unidirectional parallel sweeps while the muscle is
maintained at a passive stretch.
Source: Shah RV, Board Review 2005

434

1172. With regards to NCS’s:
1. Slowing of conduction velocity most often implies demyelination.
2. Diminished amplitude of the action potential implies
axonal damage
3. Prolonged distal latencies are seen in entrapment neuropathies
4. Needle electrodes are used only in morbidly obese individuals
due to attenuation of the AP signal secondary
to adipose tissue transduction blockade

1172. Answer: A
Source: Goodwin J, Board Review 2005

435

1173. Relative and absolute contraindications to MRI include:
1. hemodynamic instability
2. implanted pacemaker or defi brillator
3. signifi cant claustrophobia
4. Severe contrast reaction

1173. Answer: A (1,2, & 3)
Explanation:
1. Patients who are hemodynamically unstable should not
be placed in an MRI, as there is limited access to the
patient.
2. Implanted pacemaker or defi brillator is a
contraindication for MRI.
3. Claustrophobia is a relative contraindication and
pacemakers are an absolute contraindication.
4. Contrast reaction is not a contraindication to MRI.
It is a contraindication to contrast administration.
Source: Bieneman B, Board Review 2005

436

1174. Which of the following modalities does not use ionizing
radiation:
1. MRI
2. CT scan
3. Ultrasound
4. Radiography

1174. Answer: B (1 & 3)
Explanation:
(See lecture notes)
Source: Bieneman B, Board Review 2005

437

1175. MR signal:
1. Is based on electron spins
2. Fluid is hypointense on T1
3. Water is hyperintense on T2
4. The nucleus pulposus is dark on T2

1175. Answer: A (1,2, & 3)
Source: Bieneman B, Board Review 2005

438

1176. Immediately following complete transection of the
spinal cord, deep tendon refl exes and muscle tone below
the level of the lesion are most likely to:
1. Increase
2. Fluctuate according to the presence or absence of dysautonomia
3. Remain unchanged
4. Decrease

1176. Answer: B
Source: Goodwin J, Board Review 2005

439

1177. On axial MRI images of the lumbar spine
1. Ventral rami of L5 nerves lie on the ventral sacrum
2. Nucleus pulposus demonstrates T2 prolongation compared
to the annulus
3. The disc constitutes the anterior border of the intervertebral
foramen
4. The superior articular process lies anterior to the inferior
process

1177. Answer: E (All)
Explanation:
All of the above (reference: Renfrew; Atlas Spine Imaging,
Saunders, 2003, page 5)
Source: Bieneman B, Board Review 2005

440

1178. FDA approved indications for spinal cord stimulation
include
1. Angina
2. Peripheral vascular disease
3. Chronic pelvic pain
4. Neuropathic leg pain associated with multiple lumbar
spine surgeries

1178. Answer: D (4 Only)
Explanation:
There is literature support for spinal cord stimulation to
treat angina, peripheral vascular disease and chronic pelvic
pain but none of these indications are FDA approved at
present.
Source: Schultz D, Board Review 2004

441

1179. Which of the following reduce the rate of post-dural
puncture headache, actually or theoretically?
1. using a Whitacre needle instead of a Quincke-Babcock
2. using a 25 gauge needle instead of a 24 gauge
3. advancing a Quincke-Babcock needle parallel to the
dura instead of perpendicular
4. using a 6 inch needle instead of a 4 inch needle

1179. Answer: A (1,2, & 3)
Explanation:
(Raj, Practical Management of Pain, 3rd Ed., page 633)
Needle length, as well as needle tip shape, may affect the
length of time you have to wait before recognizing thatyou
are subarachnoid, i.e., it takes longer for CSF to drip out of
a longer, as compared to shorter needle.Spinal needles vary
with regard to length, inside and outside diameters, as
well as the shape of their tip. The latter affects the size and
shape of the hole made in the dura as well as the speedwith which CSF appears in the hub after dural puncture. The
incidence of postdural puncture headache appears to be
directly related to the size of needle used and the
orientation of the needle in performing spinal anesthesia.
A spinal needle oriented parallel to the dura separates the
fi bers rather than cutting them, as a perpendicularly
oriented needle does, and produces a smaller defect in the
dura.
All spinal needles come with a removable stylet, which
must be close-fi tting to prevent coring of the skin and the
resultant obstruction of the needle and contamination of
spinal space with epidermal tissue and skin bacteria.
Several spinal needle types and sizes are commercially
available, although only two different needle tip points are
available. The tip points can have either a beveled cutting
point or a noncutting, rounded pencil point.
The commonly used spinal needle with a cutting point is
the Quincke-Babcock, which has a short bevel with cutting
edges and a rounded heel. The cutting-point spinal needles
appear to be associated with a high incidence of postspinal
headache even when smaller needles are used. Spinal
needles with a noncutting, rounded, pencil tip seem to
cause less trauma to the dura mater and appear to be
associated with a lower incidence of postspinal headache
when larger-caliber needles are used.
The Greene, Sprotte, Whitacre, and Huber needles have a
noncutting, rounded, pencil tip. The Sprotte and Whitacre
needles have completely rounded non-cutting bevels with
solid tips, and the opening on their side approximately 2
mm proximal to the tip. These are currently the most
widely used needles for spinal anesthesia as a result of their
association with a reduced incidence of postdural
puncture headache.
Note: the Greene, Sprotte, Whitacre, and Huber needles do
not have to be advanced parallel to the dura, since they are
‘pencil point’ needles.
Source: Shah RV, Board Review 2005

442

1180. Indications for spinal imaging in pediatric patients with
back pain include
1. Neurologic fi ndings
2. Decreased function
3. Chronic pain
4. Fever

1180. Answer: E (All)
Source: Bieneman B, Board Review 2005

443

1181. Which of the following statements is true regarding
peripheral nerve stimulation:
1. Positive response to TENS is a reliable predictor for
positive response to peripheral nerve stimulation
2. Pain relieving effects are caused by local anesthetic-like
blockade of neural conduction within the peripheral
nerve.
3. Pain due to nerve root injury often responds well to
PNS
4. The best indication is pain in the distribution of a single
traumatized peripheral nerve

1181. Answer: D (4 Only)
Explanation:
Reference:
Heavner, Interventional Pain Management, Second
Edition; Chapter 57 Peripheral Nerve Stimulation:
Current Concepts
The pain relieving effects of PNS are similar to those of
SCS and are thought to be mediated by stimulation of Abeta
fi bers within the peripheral nerve with subsequent
activation of local inhibitory circuits within the dorsal
horn. Peripheral nerve stimulation is best used to treat
pain caused by trauma to a single peripheral nerve
although two peripheral nerves within the same region can
successfully be treated with a single stimulation system (2 leads and 1 pulse generator or receiver). Pain due to nerve
root injury or to spinal mechanisms usually does not
respond to PNS. Patients who have a positive response to
TENS may be somewhat more likely to respond to PNS
although TENS response is not a reliable predictor of PNS
effect and a negative response to TENS does not mean that
PNS should not be tried.
Source: Schultz D, Board Review 2004

444

1182. AIDS-induced vacuolar myelopathy, involving the
posterior columns of the spinal cord, results in the loss of
which sensory modalities?
1. Pain and temperature sensation contralateral to and
below the side of the lesion
2. Proprioception and vibratory sensation of the lower and
upper extremities
3. Inability to detect a full bladder
4. Two point discrimination

1182. Answer: C
Source: Goodwin J, Board Review 2005

445

1183. Which of the following about hypophysectomy is true?
1. Stereotactic instillation of phenol is the most commonly
described method
2. Gamma knife stereotactic radiotherapy of the hypothalamus
is administered percutaneously
3. The analgesic mechanism is thought to be due to interruption
of limbic pathways
4. One of the best described indications is diffuse pain due
to bone metastases from breast or prostate carcinoma

1183. Answer: D (4 Only)
Explanation:
(Raj, Pain Review 2nd Ed., page 309)
Percutaneous stereotactic instillation of alcohol is the best
described technique. Other percutaneous methods for
hypophysectomy include the use of radiofrequency
thermocoagulation, cryotherapy, or radioactive seeds.
Gamma knife radiotherapy is a noninvasive method for
creating hypophyseal lesions. The analgesic mechanism is
unknown, but limbic system or psychological effects are
unlikely to be the reasons for pain relief. Hypophysectomy
is recommended in the treatment of metastatic prostate
and breast cancer, irrespective of the hormonal
responsiveness of the tumors.
Source: Schultz D, Board Review 2004

446

1184. What are the main types of cervical spine pathology
found in rheumatoid arthritis?
1. Cranial settling
2. Atlanto-axial subluxation
3. Erosion or fusion of the facet joints
4. Multilevel subluxations

1184. Answer: E (All)
Explanation:
(reference Renfrew page 354)
Source: Bieneman B, Board Review 2005

447

1185. For the following non-organic signs, which method of
assessment is a reasonable?
1. Numbness around torso: use 128Hz tuning fork to see if
vibration is felt above the line
2. Astasia-abasia: refer to ENT to rule out a problem with
the inner ear before jumping to conclusions
3. Paralysis of one leg: use Hoover’s maneuver to check for
reciprocal extension
4. Loss of consciousness: squeeze nipples really hard to see
if the patient ‘wakes up’

1185. Answer: B
Source: Goodwin J, Board Review 2005

448

1186. Which of the following is not a deep heating method?
1. Ultrasound
2. Phonopheresis
3. Diathermy
4. Hot packs

1186. Answer: D (4 only)
Explanation:
(Raj. Practical Mgmt of Pain, 3rd Edition, page 530-532)
Superficial Deep
Hot Packs Ultrasound
Paraffin Diathermy
Heat Lamps Phonophoresis
Hydrotherapy
Fluidotherapy
Source: Shah RV, Board Review 2005

449

1187. Pain behaviors can include all of the following:
1. Reduced activity level
2. Verbal behavior
3. Nonverbal behavior
4. Pain beliefs

1187. Answer: A ( 1, 2, & 3)
Source: Janata JW, Board Review 2005

450

1188. Which items are not safe for MRI?
1. Chest ports for chemotherapy
2. Oxygen tanks
3. All types of cerebral aneurysm clips
4. Metal in the eye

1188. Answer: C (2 & 4)
Explanation:
It is always best to refer to an up-to-date reference of MRI
compatible devices before imaging patients, however,
foreign body metal and metallic objects unrelated to
patients are not safe. Current cerebral aneurysm clips are
MRI compatible, however, older clips may not be- again
check the operative notes to determine if a clip is non ferromagnetic
Source: Bieneman B, Board Review 2005

451

1189. A patient presents with an acute onset of upper extremity
pain with numbness in the little fi nger. Physical
examination showed weakness with fi nger fl exors. Most
likely, diagnosis in this patient is:
1. C5 nerve root involvement
2. C6 nerve root involvement
3. C7 nerve root involvement
4. C8 nerve root involvement

1189. Answer: D (4 Only)
Explanation:
Flexor digitorum superfi cialis is supplied by a median
nerve, C8. Similarly, fl exor digitorum profundus are also
supplied by medial and ulnar nerves, C8. Lumbricals are
supplied by median and ulnar nerve, C8 and T1.The fl exor
digitorum profundus, which fl exes the distal
interphalangeal joint, and the lumbricals,which fl ex the
metacarpal phalangeal joint, usually receive innervation
from the ulnar nerve on the ulnar side of the hand and
from the median nerve on the radial side. If there is any
injury to the C8 nerve root, the entire fl exor digitorum
profundus becomes weak, with secondary weakness in all
fi nger fl exors. If, however, there is a peripheral injury to
the ulnar nerve, weakness will exist only in the ring and
little fi ngers. The fl exor digitorum superfi cialis, which
fl exes the proximal interphalangeal joint, has only median
nerve innervation, and is affected by root injury to C8 and
peripheral nerve injuries to the median nerve.
C8 supplies sensation to the ring and little fi ngers of the
hand and the distal half of the forearm. The ulnar side of
the little fi nger is the purest area for sensation of the ulnar
nerve, which is predominantly C8, and is most effi cient
location for testing.
Source: Hoppenfeld S. Orthopaedic Neurology. A
Diagnostic Guide to Neurologic Levels. Philadelphia,
LWW, 1997.

452

1190. Subdural blockade is typically characterized by:
1. immediate onset of sensory and motor block
2. motor paralysis and sensory preservation
3. upper motor neuron signs
4. occurrence following the injection of a small volume of
local anesthetic

1190. Answer: D (4 only)
Explanation:
(Raj, Practical Mgmt of Pain, 3rd Edition, page 648)
The subdural space is a potential space between dura and
arachnoid mater. Injection of drugs into this space can
cause extensive and erratic spread. The onset of a block
after a subdural injection characteristically is slower (5 to
10 minutes) than after an intrathecal block (3 to 5
minutes) but signifi cantly faster than an epidural injection
(10 to 20 minutes). Moreover, a profound patchy sensory
block with mild motor block may develop.
Diagnosis can often be made by subsequent injection of a
radiopaque dye in case an epidural catheter was threaded
into the subdural space. A small volume of dye (e.g., 5 ml)
shows an extensive spread of a very thin fi lm of the dye that is confined within the subdural space. The incidence of
subdural injections is between 0.3% and 1%.
Motor paralysis and sensory preservation is typically due
to anterior spinal artery syndrome, whereas motor
preservation and sensory loss is associated with subdural
blockade.
Source: Shah RV, Board Review 2005

453

1191. Loss of resistance to air or saline describes a method to
access the epidural space. What are the characteristics of
the ligamentous structure that offers ‘resistance’?
1. A ligament that is weaker than the supraspinous ligament
2. A ligament that is composed of 20% elastin
3. A ligament that spans from the anterior surface of the
caudad lamina to the posterior surface of the cephalad
lamina
4. A ligament that is referred to as the yellow ligament

1191. Answer: D (4 only)
Explanation:
(Raj, Practical Management of Pain, 3rd Ed., page 638)
The ligamentum fl avum, which consists of more than 80%
elastin, is the toughest of the three ligaments. It usually is
easy to identify by its increased resistance to advancement
of the epidural needle and ability to inject air or saline
solution. It spans from the anterior surface of the cephalad
lamina of an adjacent pair of vertebrae to the posterior
aspect of the lower lamina. The ligamenta fl ava arise
embryonically from two separate laminae. They fuse to a
variable degree in the midline. Sometimes the fusion is
incomplete, which may unintentionally lead to a dural
puncture. The right and left halves meet at an angle of less
than 90 degrees. The lateral edges wrap anteriorly around
the facet joints.
Source: Shah RV, Board Review 2005

454

1192. Which of the following are true regarding segmentation
abnormalities of the spine?
1. Vertebral column abnormalities due to congenital malformations
2. Classic fi nding is scoliosis with deformed vertebral
bodies
3. Posterior element defects best seen on axial CT views
4. Most common form is an indeterminate (transitional)
vertebra

1192. Answer: E (All)
Source: Bieneman B, Board Review 2005

455

1193. Which of the following is true regarding neurolytic
blocks?
1. Target is the ventral root
2. Lumbar subarachnoid neurolysis is performed at the
vertebral level corresponding to the level of desired
blockage.
3. Lower potential for motor defi cits using the epidural
approach
4. Less predictable spread of the neurolytic agent with an
epidural approach

1193. Answer: D (4 only)
Source: Day MR, Board Review 2005

456

1194.Regarding polysomnography (PSG), which of the
following is true?
1. This is a good test to order prior to seeing a sleep specialist
given the information it can generate
2. It is a poor choice of testing if the patient has trouble
sleeping because the data will be invalid unless he or she
gets at least 4 hours of sleep.
3. The strength of the test is that two night’s testing results
are averaged for accuracy
4. With a history of restless legs syndrome, periodic leg
movements of sleep will likely show up

1194. Answer: D
Source: Goodwin J, Board Review 2005

457

1195. Regarding headaches associated with tumors, which of
the following are consistent with clinical experience?
1. Slow growing tumors and those that compress the brain
from outside are more likely to present with seizures
than with headache.
2. Infratentorial tumors are more likely to present with
headache than supratentorial tumors.
3. 90% of childhood tumors will cause headache at some
point while the corresponding number in adults is
60%.
4. Supratentorial tumors tend to refer pain anteriorly to
the frontotemporal region

1195. Answer: E
Source: Goodwin J, Board Review 2005

458

1196. Which of the following actions (or lack thereof) could
lead to severe complications, put the patient into a
persistent vegetative state or prove fatal in the case of
certain intracranial infections?
1. Failure to consider subdural empyema in the face of
classic signs and symptoms, failing in the meantime to
get the necessary neurosurgical consultation.
2. Delaying the L.P and / or wide spectrum antibiotics
when imaging studies are delayed or unavailable having
been requested to rule in or out a supratentorial mass
that could, if present, lead to uncal herniation via CSF
withdrawal by lumbar puncture.
3. Failure to use IV acyclovir at the same time as other
antibiotics since Herpes simplex is the only directly treatable life threatening viral infection of the brain parenchyma,
the diagnosis of which may take some time.
4. Failing to check for Brudzinski and Kernig signs when
doing the neurologic evaluation following a quick and
incomplete history.

1196. Answer: E
Source: Goodwin J, Board Review 2005

459

1197. Cervical traction would be useful in which of the
following conditions
1. Arnold-chiari malformation
2. cervical myelopathy
3. rheumatoid arthritis
4. cervical disc herniation

1197. Answer: D (4 only)
Explanation:
(Raj, Practical Mgmt of Pain, 3rd Ed., page 540)
TRACTION
In the therapy of traction, the soft tissues of the body
(cervical or lumbar spine) are stretched by a pulling
(traction) force. This force can be applied either manually
or mechanically. Factors that determine the amount of
separation (and thus pain reduction) include the position
of the spine, the angle of pull, and the amount of force
applied.Traction, when applied properly, may prevent
adhesion formation, subdue painful muscle spasm, relieve
pain, maintain anatomic alignment, and prevent or correct
a deformity.
Contraindications to the use of these techniques include
acute trauma, infl ammation, hypermobility, increasing
pain, and any spinal condition in which movement is to be
avoided.
Source: Shah RV, Board Review 2005

460

1198. The following are advantages of a surgically implanted
“paddle” lead over a percutaneous wire lead:
1. Positional stimulation is less common
2. There is less risk of lead migration
3. There is dorsal shielding with less stimulation of dorsal
structures
4. The lead is easier to implant

1198. Answer: A ( 1, 2, & 3)
Explanation:
Reference:
Bedder, Interventional Pain Management, Second Edition;
Chapter 55 Implantation Techniques for Spinal Cord
Stimulation
Surgical paddle leads over the following advantages:
· Broader surface area with less risk of migration
· Dorsal shielding with less uncomfortable stimulation of
dorsal spinal structures
· Less positional stimulation
· Increased effi ciency and less power requirement
The leads are more diffi cult to implant because they
require a laminotomy to insert into the spinal canal.
Source: Schultz D, Board Review 2004

461

1199. Indications for a trial of spinal cord stimulation
include:
1. Complex regional pain syndrome of bilateral extremities
2. Refractory angina
3. Post-laminectomy syndrome with neuropathic back
and leg pain
4. Severe intractable ibromyalgia

1199. Answer: A ( 1, 2, & 3)
Explanation:
Krames, Interventional Pain Management, Second Edition;
Chapter 54 Spinal Cord Stimulation: Patient Selection
Spinal cord stimulation is effective for neuropathic pain. It
is most likely to be effective for single or bilateral
extremity neuropathic pain but has a reasonable chance
for success in cases of intractable neuropathic back and leg pain. It is not indicated for axial somatic, nociceptive pain except in the case of intractable angina where it has proven
to be effi cacious.
Source: Schultz D, Board Review 2004

462

1200. Regarding Evoked Potentials in general, which of the
following is true?
1. The BSAEP’s anatomic pathway is the middle ear, 8th
cranial nerve, brainstem and auditory cortex
2. The P300 waveform latency in CP’s can be delayed by
autism, Schizophrenia and dementia
3. The most commonly used peripheral nerve in SSEP testing
is the posterior tibial
4. The most important peak of electrical activity in VEP’s
is the P120 with a maximum latency of 100 msec

1200. Answer: A
Source: Goodwin J, Board Review 2005

463

1201. Which of the following factors are capable of inducing
pain in visceral structures?
1. Abnormal distention and contraction of hollow visceral
structures
2. Rapid stretching of the capsule of solid visceral organs
3. Ischemia of visceral musculature
4. Traction or compression of ligaments, vessels, or mesentery

1201. Answer: E (ALL)
Explanation:
Reference: Raj and Patt. Chapter 11. Visceral Pain. In:
Pain Medicine: A
Comprehensive Review, 2nd Edition, Raj, Mosby, 2003,
page 95
Source: Day MR, Board Review 2005

464

1202. The MMPI is a psychological test that assesses:
1. Pain tolerance
2. Beliefs and attitudes about pain
3. Psychotic process
4. Personality

1202. Answer: D (4 only)
Source: Janata JW, Board Review 2005

465

1203. Which of the following is/are true regarding intravenous
Propofol?
1. Decreased mean arterial pressure
2. Decreased heart rate
3. Increased venodilation
4. Increased systemic vascular resistance

1203. Answer: B (1 & 3)
Source: Day MR, Board Review 2005

466

1204.Potential complications with aggressive percutaneous
thermal lesioning of the trigeminal ganglion include the
following:
1. corneal keratitis
2. weakness of ocular abduction
3. diffi culty chewing
4. palsy of the 4th cranial nerve

1204. Answer: E (All)
Explanation:
(Raj, Pain Review 2nd Ed., page 311)
Aggressive heat lesions may provide better pain relief, but
also increase the risk of complete hemifacial anesthesia
and motor weakness of ipsilateral masticatory muscles
(pterygoids, temporalis, masseter). Cranial nerves in the
cavernous sinus (III, IV, VI) may also become injured due
to excessive heating and cause weakness of some or all
ocular movements.
1. It may cause corneal keratitis.
2. It may cause weakness of muscles of ocular abduction.
3. It may cause motor weakness of masticatory muscles
including masseter, temporalis and pterygoids
4. It may cause paralysis of oculomotor (III), trochlear
(IV), and trigeminal nerve (VI) by injury in cavernous
sinus.
Source: Shah RV, Board Review 2005

467

1205. The defi nition of pyogenic spondylitis includes which of
the following structural fi ndings?
1. Discitis
2. Osteomyelitis
3. Endplate erosions
4. Epidural

1205. Answer: A (1,2, & 3)
Source: Bieneman B, Board Review 2005

468

1206. Which of the following is/are a component/s of a
Horners Syndrome?
1. Mydriasis
2. Ptosis
3. Facial anhidrosis
4. Enophthalmos

1206. Answer: C (2 & 4)
Source: Day MR, Board Review 2005

469

1207. Which of the following is most likely to cause respiratory
compromise?
1. Unilateral percutaneous C1-2 cordotomy in a patient
with a contralateral pneumonia
2. Ipsilateral C1-2 cordotomy and contralateral C5-6
cordotomy
3. Bilateral C1-2 percutaneous cordotomy
4. Stereotactic mesencephalectomy with ipsilateral diaphragmatic
paralysis

1207. Answer: B (1 & 3)
Explanation:
(Raj, Pain Review 2nd Ed. Page 313, Raj Practical Mgmt of
Pain 3rd Ed., page 801)
In patients with diaphragmatic paralysis, pneumonectomy,
pneumonia, extensive pulmonary carcinoma, contralateral
high cervical cordotomies or mesencephelectomies can
reduce ventilatory drive and cause respiratory demise.
Bilateral high cervical cordotomies can lead to sleepinduced
apnea (Ondine’s curse). A staged high cervical
cordotomy or a combination of a high and low cervical
cordotomy can avoid this problem. Others have assessed
the absence of the 2-3 fold rise in minute volume to CO2
as a marker for the development of sleep induced apnea.
Source: Schultz D, Board Review 2004

470

1208. Regarding NMJ disease:
1. Lambert-Eaton Myesthenic Syndrome (LEMS) is a presynaptic
condition
2. Myesthenia gravis (MG) is a post synaptic phenomenon
3. MG results in a decremental response to repetitive
stimulation
4. LEMS results in an incremental response to repetitive
stimulation

1208. Answer: E
Source: Goodwin J, Board Review 2005

471

1209. Congenital spinal stenosis
1. May result in neurogenic claudication
2. Is known as” short pedicle” syndrome
3. Results in decreased anterioposterior canal narrowing
4. Often is associated with acquired (degenerative) spinal
stenosis

1209. Answer: E (All)
Source: Bieneman B, Board Review 2005

472

1210. Assumptions underlying cognitive-behavioral therapy
include:
1. Cognitions interact with emotions, sensations and
behavior
2. Individuals must be active participants in treatment
3. The interaction between an individual and the environment
is reciprocal
4. Behavior is infl uenced by expectations of outcomes and consequences

1210. Answer: E (All)
Source: Janata JW, Board Review 2005

473

1211. Which of the following are resistive exercises?
1. Isometric
2. Active assisted
3. Isokinetic
4. Proprioceptive neuromuscular facilitation

1211. Answer: B (1 & 3)
Explanation:
(Raj, Practical Mgmt of Pain, 3rd Ed., page 536-538)
All of the above are forms of therapeutic exercise.
Therapeutic exercise may be broken down into Range of
Motion, Resistive, Endurance Activities, Desensitization,
Breathing Exercises, Relaxation, Coordination Training,
and Proprioceptive Neuromuscular Facilitation. The goals
of therapeutic exercise include:
Strengthening the muscles.
Improving fl exibility of muscles and tendons.
Increasing endurance.
Reinstating the normal pattern of motion to the affected
muscles and to the body in general.
1. Isometric Resistive Exercise
Isometric exercise is a static form of motion performed
by contraction against an immovable object.
2. Active Assisted Range-of-Motion Exercises
Active assisted movement is movement through a ROM
by means of a muscular contraction supplemented by an
external force either manually or mechanically
3. Isokinetic Resistive Exercise
Isokinetic exercise is a form of dynamic motion in
which the velocity of muscle shortening or lengthening
and thus the velocity of the body part is controlled by a
rate-limiting device
4. Proprioceptive Neuromuscular Facilitation
In general, proprioceptive neuromuscular facilitation
(PNF) is used to promote or hasten the response
of the neuromuscular mechanism of the proprioceptors.
It employs total patterns of movement, specifi c patterns of
facilitation, and techniques for expediting motor learning
Source: Shah RV, Board Review 2005

474

1212. Secondary gain can include:
1. Financial compensation
2. Responsibility avoidance
3. Reinforcement from family
4. Reinforcement from friends

1212. Answer: E (All)
Source: Janata JW, Board Review 2005

475

1213. Transcutaneous electrical stimulation:
1. Is based on the gate control theory of pain
2. Mechanistically activates large diameter afferent fi bers,
in order to suppress afferent small fi ber input into the
spinal cord
3. High intensity, low frequency stimulation is thought to
work via a naloxone reversible mechanism
4. Low frequency, high pulse duration cause strong muscle
contractions

1213. Answer: E (All)
Explanation:
(Raj, Practical Mgmt of Pain, 3rd Ed., pages 534-535)
1.The gate control theory explains the mechanisms of pain
relief associated with TENS treatment for many
conditions.
2. Simply stated, this theory proposed the existence of a
gating mechanism in the dorsal horns of the spinal cord,
where there is an interaction between the small-diameter,
unmyelinated C fi bers, which mediate the transmission of
pain, and the larger-diameter, myelinated A fi bers, which
mediate sensation of light touch and pressure.
3. High-intensity, low-frequency stimulation (frequently
referred to as “acupuncture-like TENS”) also appears to
offer pain relief, the effects of which can be reversed with
naloxone, an opiate antagonis
4. Central to the discussion of the rationale of TENS
therapy are its various stimulation parameters. Lowfrequency
and high-pulse [width] energy cause strong,
rhythmic muscle contractions.
Source: Shah RV, Board Review 2005

476

1214.There is increased risk of depression in chronic pain
secondary to all of the following :
1. The aversive nature of pain
2. Sense of loss of control
3. Disrupted sleep patterns
4. Disability income

1214. Answer: A ( 1, 2, & 3)
Source: Janata JW, Board Review 2005

477

1215. Chronic pain syndrome includes all of the following:
1. Disrupted activity levels
2. Minor to moderate pathophysiology
3. Excessive reliance on medications
4. Minor to moderate pain complaining

1215. Answer: A ( 1, 2, & 3)
Source: Janata JW, Board Review 2005

478

1216. Interventional pain management techniques used to
treat pelvic pain include:
1. Splanchnic Nerve Block
2. Hypogastric Plexus Block
3. Celiac Plexus Block
4. Ganglion Impar Block

1216. Answer: C (2 and 4)
Explanation:
Reference: Raj, Chapter 17. Visceral Pain. In: Practical
Management of Pain. 3rd Edition. Raj et al, Mosby, 2000,
page 236.
Source: Day MR, Board Review 2005

479

1217. Which of the following statements are true regarding
atypical facial pain?
1. The pain is constant, non-paroxysmal and poorly localized,
even if generally unilateral.
2. It is usually resistant to uni-modal approaches to care
whether medical, surgical or behavioral.
3. Patients appear less distressed than one might expect
from the descriptors of pain which include ‘crushing’
or ‘ripping’
4. Depression is believed to be the underlying cause

1217. Answer: A
Source: Goodwin J, Board Review 2005

480

1218. Contact thermography
1. Is more reliable than infrared thermography
2. It best performed at normal room temperatures
3. Can picture the entire body
4. Is less expensive than infrared thermography

1218. Answer: D (4 Only)
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition

481

1219. Spinal cord stimulation is most effective in:
1. Brachial plexopathy
2. Phantom limb pain
3. Post herpetic neuralgia
4. Acute lumbar radiculopathy

1219. Answer: A (1,2, & 3)

482

1220. During which of the following upper extremity motions
is scapular posterior tilting most prevalent?
1. Abduction elevation
2. Extension elevation
3. Internal rotation
4. Flexion elevation

1220. Answer: D (4 Only)
Source: Sizer Et Al - Pain Practice March & June 2003

483

1221. A 42-year-old female patient presents with an 12 month
history of elbow pain on the lateral aspect, resulting from
repetitive strain at work. Symptoms were worse at night.
Physical examination revealed mild provocation with
resisted dorsal extension, but signifi cant provocation
with resisted forearm supination.
1. Tendopathy of the extensor carpi radialis brevis
2. Tendopathy of the fl exor carpi ulnaris
3. Humeroradial joint chondropathy
4. Posterior interosseus nerve entrapement

1221. Answer: D (4 Only)
Source: Sizer et al - Pain Practice - March & June 2004

484

1222. Twenty years ago, a patient was informed by her dentist
that she was allergic to local anesthetics. True statements
include:
1. The local anesthetic solution most likely contained
methylparaben
2. The antigenic local anesthetic was most likely an amide
3. Skin testing is unreliable in confi rming the diagnosis
4. Enzyme-linked immunosorbent assay (ELISA) will confi
rm the diagnosis

1222. Answer: D (4 Only)
Source: American Board of Anesthesilogy, In-trainnig
examination

485

1223. Landmarks for stellate ganglion block include the
1. Cricoid cartilage
2. Mastoid process
3. Transverse process of C6
4. Hyoid bone

1223. Answer: D (4 Only)
Source: American Board of Anesthesilogy, In-trainnig
examination

486

1224. What are the advantages of performing a stellate
ganglion block at C7 compared to C6?
1. Easier to identify anatomic landmarks by palpation
2. Increased risk of recurrent laryngeal nerve palsy
3. Decreased risk of pneumothorax
4. Reduced volume of local anesthetic is needed

1224. Answer: D (4 Only)
Explanation:
(Raj, Pain Review 2nd Ed.)
Since the stellate ganglion is located at C7-T1, a C7
approach requires less volume. The risk of recurrent
laryngeal nerve palsy is less at C7. There is an increased
risk of pneumothorax due to the dome of the lung. The
landmarks at C6 are easier to identify by palpation. The C6
transverse process is easier to identify than C7; the C6
transverse process, specifi cally the tubercle, is known as
Chassaignac’s tubercle. There is an increased risk of
pneumothorax at C7 as is the case for a supraclavicular
approach to the brachial plexus.
Source: Shah RV, Board Review 2003

487

1225. Each of the following items describes pain in the
abdominal viscera:
1. Pain is transmitted via the vagus nerve
2. The nerve fi bers are type C versus A-delta
3. Pain is in a dermatomal distribution
4. Pain is characterized by a dull aching or burning sensation

1225. Answer: C (2 & 4)
Explanation:
1, 2. Virtually all pain arising in the thoracic or abdominal
viscera is transmitted via the sympathetic nervous system
in unmyelinated type C fi bers.
3. Visceral pain is caused by any stimulus that excites
nociceptive nerve endings in diffuse areas.
Distention of a hollow viscus causes a greater sensation
of pain than does the highly localized damage produced by
transecting the gut.
4. Visceral pain is dull, aching, burning, and non-specifi c.
Source: Hall and Chantigan

488

1226. Which of the following blocks can be performed by both
intra-oral and extra-oral approach?
1. Sphenopalatine ganglion block
2. Glossopharyngeal nerve block
3. Infra-orbital nerve block
4. Greater palatine nerve block

1226. Answer: A (1, 2, & 3 )
Explanation:
(Raj, Pain Medicine Review 2nd Ed., ) The sphenopalatine
ganglion and greater palatine nerve block can be
performed intra-orally through the greater palatine
foramen (on the hard palate). The greater palatine nerve
block, however, can only be performed intra-orally. A
glossopharyngeal nerve block can be performed extra- or
intra-orally. The infra-orbital nerve block can be
performed extra-orally or intra-orally
Source: Shah RV, Board Review 2003

489

1227. A patient with history of chronic low back pain of several
years starts complaining of lower extremity pain with
radiation into lateral foot. Examination showed loss of
refl ex of Achilles tendon with reduced sensation on the
lateral foot with weakness on foot eversion. The true
statements with reference to EMG fi ndings with lumbar
spine evaluation are as follows:
1. S1 nerve root involvement shows fi brillation or sharp
waves in peroneus longus and brevis
2. L4 nerve root involvement shows fi brillation or sharp
waves in tibialis anterior
3. L5 nerve root involvement shows fi brillation or sharp
waves in extensor hallucis longus
4. S1 nerve root involvement shows fi brillation or sharp
waves in extensor hallucis longus

1227. Answer: A (1, 2, & 3)
Source: Hoppenfeld S. Orthopaedic Neurology. A
Diagnostic Guide to Neurologic Levels. Philadelphia,
LWW, 1997.

490

1228. Which of the following is correct about the Global
Assessment of Function (GAF) indicated on Axis V?
1. GAF scores, like VAS scores, are reported as whole numbers
between 0 and 10.
2. Lower GAF scores correlate with lower levels of daily
functioning for patients.
3. GAF scores are objectively determined through the
Mental Status Examination.
4. GAF scores involved severity of symptoms and level of
functioning

1228. Answer: C (2 & 4)
Source: Cole EB, Board Review 2003

491

1229. The Sternocleidomastoid (SCM) muscle can cause:
1. Headaches
2. Hearing loss
3. Vertigo
4. Nystagmus

1229. Answer: A (1, 2, & 3 )
Explanation:
SCM pathology can cause headaches, vertigo, ear pain,
hearing loss, but not nystagmus.
Travel J, Simmons D. The Trigger Point Manual
Source: Trescot AM, Board Review 2003

492

1230. The following are the methods of achieving hypnotic
pain control
1. Alter the perception of pain
2. Substitute the painful sensation with a different or less
painful sensation
3. Move the pain to another area of the body
4. Distortion of time

1230. Answer: E (All)
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition

493

1231.Which of the following statements is (are) true
concerning thermogrpahy?
1. It is useful in localizing trigger points in myofascial pain
syndrome
2. It uses infrared radiation from the body for diagnostic
purposes
3. It is useful for revealing dysfunction in microcirculation
4. It is usually associated with abnormal laboratory studies

1231. Answer: C (2 & 4)
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition

494

1232. Which of the following is (are) the most common
causative organism(s) implicated in the genesis of pelvic
infl ammatory disease?
1. Neisseria gonorrhoeae
2. Staphylococcus epidermitis
3. Chlamydia trachomatis
4. Herpes simplex virus

1232. Answer: B (1 & 3)
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition

495

1233. Potential complications associated with an ophthalmic
nerve block include:
1. Orbital Perforation
2. Bradycardia
3. Ptosis
4. Miosis

1233. Answer: A (1, 2, & 3 )
Explanation:
(Raj, Pain Review 2nd Ed.,)
The opthalmic nerve block or the retrobulbar block is
indicated for intraocular surgery and rarely, refractory eye
pain.
The goal of the technique is to block the ophthalmic
branch of V1, the oculomotor nerve, abducens nerve, and
trochlear nerve. The ciliary ganglion (located in the
intracone area) will also be blocked.
If this latter parasympathetic output is blocked, then one
will see papillary dilatation (mydriasis) and not
contraction (miosis).
Cardiac arrhythmias have been reported with this block
including the oculo-bradycardic refl ex. Globe perforation
is possible with needle entry. Lid ptosis occurs since the
oculomotor nerve supplies the superior levator palpebra.
Recall that the sympathetics supply the superior tarsal muscle (elevates the eyelid) and may be
spared…nonetheless, the block of the oculomotor will
cause ptosis
Source: Shah RV, Board Review 2003

496

1234. Which of the following is true about performing a
‘carpal tunnel’ injection?
1. It is indicated for analgesia of the 5th digit
2. The target nerve lies medial to the palmaris longus
tendon
3. The injection is superfi cial to the fl exor retinaculum
4. The target nerve lies medial the fl exor carpi radialis
tendon

1234. Answer: D (4 Only)
Explanation:
(Raj, Pain Review 2nd Ed.)
The median nerve is the target in carpal tunnel injections
and is the compressed nerve in carpal tunnel syndrome.
However, the nerve (with the hands in supinated anatomic
position) is located LATERAL to the palmaris longus and
MEDIAL to the fl exor carpi radialis. It is not indicated for
analgesia of the 5th digit. The median nerve that traverses
the carpal tunnel provides sensory innervation to the
radial 3 ½ digits on the palmar side, but distally on the
radial side. The palmar branch of the median nerve does
not go through the carpal tunnel and innervates the radial
palm. The roof of the carpal tunnel is formed by the fl exor
retinaculum; hence the injection should be deep and not
superfi cial to this structure.
Source: Shah RV, Board Review 2003

497

1235. Thermography can be used for the following purposes
:
1. Documents the locations of myofascial trigger points
2. Evaluate sympathetic blockade after stellate ganglion
block
3. Support the diagnosis of refl ex sympathetic dystrophy
4. Prove the presence of psyschogenic pain syndromes

1235. Answer: A (1, 2, & 3)
Explanation:
In clinical practice, thermography is useful only as a
means to measure skin temperature over a wide body area.
1. Thermography can also document locations of
myofascial trigger points.
2. It has also been used to evaluate the degree of
sympathetic blockade after stellate ganglion, lumbar
sympathetic, or epidural blocks.
3. It has been used to diagnose refl ex sympathetic
dystrophy, entrapment neuropsthies, spinal nerve root
irritation, vascular disease, joint disease, and fractures.
4. Psychogenic pain syndrome is not proven by
thermography.
Source: Ramamurthy

498

1236.Which of the following electrodiagnostic studies is
typically used to assess radicular pain involving the spine
and related extremities?
1. Selective tissue conductance tests
2. Nerve conduction velocity studies
3. Somatosensory evoked potentials
4. Needle EMG recordings

1236. Answer: C (2 & 4)
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition

499

1237. If you use the inion as a point of reference and march
anteriorly, you will encounter several nerves innervating
the cranium. Which of the following sequences would be
correct?
1. Greater occipital nerve, Least occipital nerve, Lesser occipital
nerve, Greater auricular nerve
2. Lesser occipital nerve, Greater occipital nerve, Least occipital
nerve, Auriculotemporal nerve
3. Least occipital nerve, Lesser occipital nerve, Greater
auricular nerve, Auriculotemporal nerve
4. Greater occipital nerve, Least Occipital Nerve, Auricolotemporal,
Greater auricular nerve

1237. Answer: B (1 & 3)
Explanation:
(Raj, Pain Review 2nd Ed.)
The correct order is greater occipital nerve (C2), least
occipital nerve (C3), lesser occipital (C2-3), greater
auricular nerve (C2-3), auriculotemporal (V3),
supraorbital (V1), and supratrochlear(V1).
Source: Shah RV, Board Review 2003

500

1238. The true statements with regards to EMG fi ndings with
cervical nerve root involvement.
1. With C7 nerve root irritation, fi brillation or sharp waves
are detected in triceps
2. With C8 involvement, fi brillation or sharp waves are
detected in intrinsic hand muscles
3. With C6 involvement, fi brillation or sharp waves are
detected in biceps
4. With C5 involvement, fi brillation or sharp waves are
detected in biceps and triceps

1238. Answer: A (1, 2, & 3)
Explanation:
1, 2, 3. With C7 nerve root irritation, fi brillation or sharp
waves are detected in triceps. With C8 involvement,
fi brillation or sharp waves are detected in intrinsic hand
muscles. With C6 involvement, fi brillation or sharp
waves are detected in biceps
4. With C5 involvement, fi brillation or sharp waves are
detected in deltoid and biceps.
Source: Hoppenfeld S. Orthopaedic Neurology. A
Diagnostic Guide to Neurologic Levels. Philadelphia,
LWW, 1997.

501

1239. An ulnar nerve injury would most likely produce:
1. Numbness of part of the 4th and all of the 5th digit of
the hand
2. Claw hand deformity
3. Weakened fl exion of the wrist
4. Numbness of thumb

1239. Answer: A ( 1, 2, & 3)
Source: Wirght PD, Board Review 2004

502

1240. Which of the following may cause referred pain to the
inguinal/thigh region?
1. femur fracture
2. osteonecrosis of the femoral head
3. inguinal hernia
4. Dermatomyositis

1240. Answer: E (All)
Explanation:
(Raj, Practical Mgmt of Pain 3rd Ed., Box 24-3)
COMMON SOURCES OF INGUINAL OR THIGH PAIN
FRACTURE TO FEMUR
Traumatic
Pathological
Stress
MUSCLE
Strain
Fever-related myalgias
Dermatomyositis
Polymyositis
VASCULAR
Sickle cell crisis
Iliofemoral venous thrombosis
Avascular necrosis of femoral head
REFERRED
Inguinal or femoral hernia
Inguinal or femoral lymphadenitis
Degenerative arthritis of the hip joint (severe)
Source: Shah RV, Board Review 2004

503

1241. The treatment of trochanteric bursitis or gluteal fasciitis
includes the following:
1. Non-steroidal anti-infl ammatory drugs
2. Physical therapy and exercise program
3. Local corticosteroid injection
4. Correction of mechanical abnormality

1241. Answer: E (All)
Source: Cole & Herring. Low Back Pain Handbook.

504

1242. Regarding Axis I of the DSM-IV-TR Multiaxial diagnostic
methodology, which of the following is correct?
1. Use Axis I for reporting all signifi cant personality disorders.
2. Medical disorders should be reported on Axis I, but the
principal psychiatric diagnosis should be listed fi rst.
3. When no Axis I disorder is present, note the Global Assessment
of Function (GAF) as “>100.”
4. The principal diagnosis or reason for the visit will be assumed
on Axis I unless the Axis II diagnosis is followed
by a qualifying phrase (“reason for visit”).

1242. Answer: D (4 Only)
Source: Cole EB, Board Review 2003

505

1243. Each of the following is associated with an increased
incidence of headache after spinal anesthesia:
1. Young age
2. Female gender
3. Pregnancy
4. Large needle size

1243. Answer: E (All)
Explanation:
Other factors that affect the incidence of spinal headache
include the number of dural punctures and the position of
the needle bevel.
The incidence of spinal headache increases as the number of dural punctures increases.
The incidence of headache has been shown to be less when
the dural fi bers are split longitudinally rather than when
they are cut while the needle is held in a transverse
direction.
The timing of ambulation relative to dural puncture has
not been shown to affect the incidence of postspinal
headache.

506

1244. A 42-year-old male patient presents with anterior knee
pain. Pain started at work. Physical examination showed
positive resisted knee extension. The conditions included
in differential diagnosis include the following:
1. Meniscal anterior horn lesion
2. Prepatellar bursitis
3. Patellofemoral joint pathology
4. Infrapatellar bursitis

1244. Answer: B (1 & 3)
Source: Sizer et al - Pain Practice - March & June 2004

507

1245. Which is true of a superior hypogastric plexus?
1. When blocking the SHP, the needle ideally should be
anterior to the L5-S1 disc
2. It is composed of parasympathetic and sympathetic
fi bers
3. It is indicated for pelvic malignancy and chronic interstitial
cystitis
4. It receives branches of the sacral nerves

1245. Answer: B (1 & 3)
Explanation:
(Raj, Pain Review, 2nd Ed., page 267-269)
The SHP block is indicated for chronic pains in the pelvis.
It is composed of sympathetic fi bers, unlike the inferior
hypogastric plexus. The IHP receives parasympathetic
branches of the sacral nerve: nervi erigentes. The ideal
placement should have the needle anterior to the L5-S1
disc, with dye spread inferiorly along the sacral
promontory. Needle entry is initially at L4-5, but this
procedure can be done transdiscally through L5-S1.
Source: Shah RV, Board Review 2003

508

1246.Which of the following complications may be attributable to unrelieved constipation?
1. Chronic abdominal Pain
2. Headache
3. Back Pain
4. Lower extremity weakness

1246. Answer: A (1, 2, & 3)
Source: Reddy Etal. Pain Practice: Dec 2001, march 2002

509

1247. Somatization Disorder is best characterized by which of
the following statements?
1. It generally develops in early life.
2. Pain is rarely described by these patients.
3. Physical complaints are in excess of what would be expected
based upon the history, physical examinations
and laboratory studies.
4. Symptoms are intentionally produced or feigned.

1247. Answer: B (1 & 3)
Source: Cole EB, Board Review 2003

510

1248. Sacral nerve root stimulation for rectal pain is achieved
by:
1. bilateral stim-cath to S2 nerves
2. bilateral stim-cath to S3 nerves
3. bilateral S5 nerves with stim-cath
4. bilateral S4 nerves with stim-cath

1248. Answer: D (4 Only)
Source: Racz G. Board Review 2003

511

1249. With seizures following lidocaine injection,
hyperventilation with 100% O2 is recommonded. The
rationale for this therapy is to
1. Decrease delivery of lidocaine to the brain
2. Prevent hypoxia
3. Hyperpolarize the nerve membranes
4. Convert of lidocaine to the protonated (ionized) form

1249. Answer: A (1, 2, & 3)
Explanation:
1. Hyperventilation causes cerebral vasoconstriction and
decreased delivery of local anesthetic to the brain.
2. Administration of 100% O2, during a seizure helps to
prevent hypoxia in a patient who otherwise might not be
breathing.
3. Hyperventilation includes hypokalemia and respiratory
alkalosis, both of which result in hyperpolarization of
nerve membranes and elevation of the seizure threshold.
4. Hyperventilation also raises the patient’s pH
(respiratory alkalosis) and converts lidocaine into the
nonionized (nonprotonated) from, which crosses the
membrane easily. This has no beneficial effect.

512

1250. The multiaxial distinction among Axis I, II and III
disorders implies theimportance given to which of the
following statements?
1. Mental disorders are related to physical or biological
factors, or that general medical conditions are related to
behavioral or psychosocial factors.
2. General medical conditions are rarely the direct etiological
causes for the development or worsening of
mental symptoms.
3. Enhanced communication among healthcare providers
of different specialties is essential for the care of
patients with pain.
4. Axis I disorders are not psychological reactions to an
Axis III general medical conditions.

1250. Answer: B (1 & 3)
Source: Cole EB, Board Review 2003

513

1251.The incidence of postdural puncture headache is
increased in which of the following situations?
1. Pregnancy
2. Young age
3. Use of large-bore spinal needle
4. Use of paramedian instead of midline approach

1251. Answer: A (1, 2, & 3)
Explanation:
1, 2. Patients who are at increased risk of headache after
dural puncture include parturients and young patients.
3. Use of large-bore needles and glucose-containing local
anesthetics also can raise the risk of spinal headache.
Spinal headaches result from leakage of CSF through the
dural sheath.
The headache is typically frontal or occipital in location
and is worsened by sitting or standing up.
4. There is some evidence that the incidence of spinal
headache is less after a dural puncture made through the
paramedian approach.
Source: Hall and Chantigan

514

1252. A patient with constant supraorbital pain comes into
your offi ce. Possible etiologies include:
1. Frontal sinusitis
2. SCM pathology
3. Supraorbital neuralgia
4. Spinal accessory neuralgia

1252. Answer: E (All)
Explanation:
Frontal sinusitis, SCM spasms, and supraorbital neuralgia
all can cause supraorbital pain. The spinal accessory nerve
innervates the SCM and therefore could cause SCM
pathology.
Source: Trescot AM, Board Review 2003

515

1253. Which of the following are advantages of intravenous
PCA over conventional IM therapy?
1. Decreased work load for health care personnel
2. Avoids excess drowsiness
3. Rapid pain relief
4. Equipment cost

1253. Answer: A (1, 2, & 3 )
Explanation:
Ref: Rosenberg, Porter, Lupatkin. Chapter 11. Patientcontrolled
Analgesia. In: Pain Management and Regional
Anesthesia in Trauma. Rosenberg, Grande, Bernstein. W.B.
Saunders, 2000, page 165.
Source: Day MR, Board Review 2003

516

1254. Treating patients with painful conditions and underlying
Personality Disorders is made complicated because of
which of the following?
1. The more bizarre patients appear to be the more likely
they are to be assaultive.
2. There are no objective means to confirm compliance
with treatment provided.
3. Insurance companies rarely provide defined benefits for
“dual diagnosed” patients.
4. Borderline personality disorders are prone to exaggerated
complaints, inappropriate attachments and impulsivity
making their care very difficult.

1254. Answer: D (4 Only)
Source: Cole EB, Board Review 2003

517

1255. Constipation can be lead to?
1. Nausea
2. Increased Pain
3. Delirium
4. Hypercalcemia

1255. Answer: A (1, 2, & 3)
Source: Reddy Etal. Pain Practice: Dec 2001, march 2002

518

1256. A patient on tramadol (Ultram) and sertraline (Zoloft)
develops confusion. Your diagnosis is:
1. Drug abuse
2. Drug withdrawal
3. Cardiac side effects
4. Serotonin syndrome

1256. Answer: D (4 Only)
Explanation:
Serotonin syndrome is a toxic hyperserotonergic state that
develops soon after initiation or dosage increments of the
offending agent. Patients may differ in their susceptibility
to the development of serotonin syndrome. The (+)
enantiomer of tramadol inhibits serotonin uptake.
Tramadol is metabolized to an active metabolite, M1, by
the CYP2D6 enzyme. If this metabolite has less
serotonergic activity than tramadol, inhibition of CYP2D6 by sertraline may cause increased levels of serotonin in the
synaptic cleft.

519

1257.True statement/s regarding peripheral nerve blocks
is/are:
1. Frequently used as a component of multimodal analgesia
2. Interrupts the transmission component of the nociceptive
process
3. Provide more selective anesthesia and analgesia than
central neural blockade techniques, i.e. subarachinoid
or epidural neural blockade
4. Femoral nerve block (3-in-1 block) is effective for anesthesia
and analgesia of the lower leg.

1257. Answer: A (1, 2, & 3 )
Explanation:
Ref: Crews. Chapter 14. Acute Pain Syndromes. In:
Practical Management of Pain. 3rd Edition, Raj et al,
Mosby, 2000, page 177.
Source: Day MR, Board Review 2003

520

1258. The anatomic features contributing to the development
of carpal tunnel syndrome, include:
1. Abnormalities of the hamate hook
2. Capitate exostosis
3. Size and proximal insertion of the lumbricle muscles
4. Extensor digitorum communis tendon hypertrophy

1258. Answer: A (1, 2, & 3)
Source: Sizer et al - Pain Practice - March & June 2004

521

1259. A young woman in her forties has a 20-year history of
Crohn’s disease, presents with the acute onset of right
ankle and left knee pain. She recalls a worsening of her
gastrointestinal symptoms a few days before the joint
symptoms developed. Radiographs of the knee and ankle
demonstrate soft tissue swelling and small effusions but
no bone destruction. The true statements include:
1. The patient is HLA- B27 positive
2. The patient is experiencing the most common extraintestinal
manifestation of infl ammatory bowel disease
3. Controlling the intestinal symptoms will eliminate the
knee and ankle arthritis
4. The patient will go on to develop bone erosion and destruction
of the knee and ankle

1259. Answer: B (1 & 3)
Explanation:
(Tierney, 42/e, pp 825-829)
· HLA-B27 diseases are easy to remember with the
mnemonic PAIR (Psoriasis, Ankylosing spondylitis,
Infl ammatory bowel disease, and Reiter syndrome). These
are called the seronegative spodylarthropathies. Reiter
syndrome preceded by a bacterial infection (Yersinia,
Salmonella, or gonococcus) has a high association with a
positive HLA-B27. Ankylosing spondylitis has a 90%
association with HLA-B27; overall, Reiter syndrome and
infl ammatory bowel disease (IBD) have an 80% HLA-B27
association.
Patients with IBD (Crohn’s disease and ulcerative colitis)
may dev op a nonerosive oligoarthritis of the large
peripheral joints that is usually eliminated after
controlling the gastrointestinal symptoms. Arthritis is the
second most common extraintestinal manifestation in
patients the IBD (anemia is the most common
extraintestinal manifestation). NSAIDs must be used with
caution in patients with IBD.

522

1260. After a cervical plexus block, it is noted that the patient
is unable to elevate the shoulder. Following nerves were
blocked during the cervical plexus block
1. Thoracodorsal
2. Anterior cervical
3. Supraclavicular
4. Accessory

1260. Answer: C (2 & 4)
Explanation:
Blockade of the accessory nerve (CN XI) is useful for
trapezius muscle block as an adjunct to interscalene nerve
blocks of the brachial plexus for surgery on the shoulder.
The accessory nerve traverses the posterior triangle of
the neck in a very superfi cial location. It emerges from the
body of the sternocleidomastoid muscle at the junction of
the superior and middle third of the posterior border of
the muscle and therefore is frequently unintentionally
blocked when a superfi cial cervical plexus block is
performed.
Source: Kahn and Desio

523

1261. Which of the following statements about cachexia in the
cancer patient is NOT true?
1. Cachexia in cancer patients may be managed by increasing
caloric intake.
2. Cachexia is found in a majority of cancer patients and
is a major contributing factor of death in 50% of these
patients.
3. The main cause of cathexia in the cancer patient is depression
leading to food aversion and apathy.
4. Corticosteroids may stimulate the appetite and decrease
nausea in these patients.

1261. Answer: B (1 & 3)
Source: Reddy Etal. Pain Practice: Dec 2001, march 2002

524

1262. The initial treatment for leg pain associated with sickle cell crisis should include:
1. NSAIDs
2. Opioids
3. Hydration
4. Hydroxyurea

1262. Answer: A (1,2, & 3)
Explanation:
Hydroxyurea stimulates fetal hemoglobin synthesis and
will not provide acute relief of pain.

525

1263. Post lumbar puncture headaches
1. Usually occur immediately following dural puncture
2. Are relieved 8 to 12 hours after an epidural blood patch
is performed
3. Occur more frequently in nonpregnant compared with
pregnant patients
4. Can be associated with neurologic defi cits

1263. Answer: D (4 Only)
Explanation:
Postspinal headaches are characterized by frontal or
occipital pain, which worsens with sitting and improves
with reclining.
The etiology of postspinal headaches is unclear;
however, they are believed to be caused by a
reduction in CSF pressure and resulting tension on
meningeal vessels and nerves (which result
from leakage of CSF through the needle hole in the dura
mater).
1. Usually occurs 24-48 hrs after lumbar puncture.
2. Conservative therapy for a postspinal headache include
bed rest, analgesics, and oral and intravenous hydration.
If conservative therapy is not successful after 24 to 48
hours, it is recommended that an epidural
“blood patch” with 10 to 20 mL of the patient’s blood be
performed. An epidural “blood patch” provides prompt
relief of the postspinal headache.
3. Factors associated with an increased incidence of
postspinal headaches include pregnancy, size and type of
needle used to perform the block, age of the patient, the
number of dural punctures.
4. Postspinal headaches may be associated with neurologic
symptoms such as diplopia, tinnitus, and reduced hearing
acuity.
Source: Hall and Chantigan

526

1264. Dyspnea, a common symptom in patients with advanced cancer may be caused by:
1. Pleurl effusion
2. Psychological distress
3. Pneumonia
4. Intracranial metastases

1264. Answer: A (1, 2, & 3)
Source: Reddy Etal. Pain Practice: Dec 2001, march 2002

527

1265. Which of the following is/are signs and symptoms of a
myelopathy?
1. Positive Babinski
2. Positive Hoffman’s sign
3. Clonus
4. Hyporefl exia

1265. Answer: A (1, 2, & 3 )
Explanation:
Ref: Simon. Chapter 15. Physical Examination. In: Pain
Medicine: A Comprehensive Review, 2nd Edition. Raj,
Mosby, 2003, page 132.
Source: Day MR, Board Review 2003

528

1266. Appropriate indications for intrathecal opioids include:
1. Post laminectomy syndrome
2. CRPS
3. Cancer pain
4. Spasticity from spinal cord injury

1266. Answer: A ( 1, 2, & 3)
Explanation:
Post laminectomy syndrome pain and cancer pain are well
recognized indications for intrathecal opioids. CRPS is
considered an indication if the trial gives good relief.
Although MSO4 intrathecally may decrease some of the
spasticity, intrathecal baclofen is probably more
appropriate
Source: Trescot AM, Board Review 2004

529

1267. The true statements regarding management of low back
pain secondary to spondylosis or spondylolisthesis are as
follows:
1. Physical therapy initially using slight fl exion bias with
neutral spine position
2. Flexibility training program to improve hamstrings
3. Strength training to help to maintain segmental spinal
mechanics
4. Spine extension program

1267. Answer: A (1, 2, & 3)
Explanation:
Recommended management is as follows:
1.Bracing based on isthemic spondylosis in adolescent
2.Medication
3.Physical therapy
A.Education
B.Modalities to control pain and muscle spasm
i.fl exibility training program
Initially use slight fl exion bias with neutral spine position
because this position decreases stress on the posterior
elements and may help to decrease pain, particularly
hamstrings
4.Strength training
A.Initially use a slight fl exion bias with neutral spine
positron because this position decreases stress on the
posterior elements and may help to decrease pain
B.Helps to maintain
i.segmental spinal mechanics and lower extremity kinetic
chain strength balance
5.Home program
6.Fluoroscopically guided epidural or transforaminal
injections for associated discogenic or radicular
symptoms
7.Facet joint injections if indicated
8.Surgery

530

1268. In terminal abdominal cancer pain, celiac plexus
neurolytic block is:
1. An accepted procedure
2. Performed with 50 percent alcohol 25 ml bilaterally
3. Performed with absolute alcohol 12 ml transaortic
route
4. Its effectiveness has been shown to be 100%

1268. Answer: A (1, 2, & 3)
Explanation:
1. Neurolytic celiac plexus block is an accepted procedure
in terminal carcinoma of abdomen.
2. Neurolytic celiac plexus block is performed with 50
percent alcohol 25 ml bilaterally.
3. Neurolytic celiac plexus block is performed with
absolute alcohol 12 ml transaortic route.
4. Effectiveness has been reported to be as high as 90% in
some studies.
Source: Racz G. Board Review 2003

531

1269. Potential complication(s) of a stellate ganglion block
include
1. Recurrent laryngeal nerve paralysis
2. Subarachnoid block
3. Brachial plexus block
4. Pneumothorax

1269. Answer: E (All)

532

1270. Sacral nerve root stimulation for coccygodynia is
achieved by:
1. bilateral stim-cath to S2 nerves
2. bilateral S4 nerves with stim-cath
3. bilateral S5 nerves with stim-cath
4. bilateral stim-cath to S3 nerves

1270. Answer: D (4 Only)
Source: Racz G. Board Review 2003

533

1271. Spinal cord stimulation has been demonstrated to
produce which of the following changes?
1. Temperature increase
2. Peripheral vasodilation
3. Increased peripheral blood fl ow
4. Blockade of noxious pain sensations

1271. Answer: A (1,2, & 3)
Explanation:
SCS does not block afferent small fi ber, high threshold,
nocieptive input.
Ref: Bonica’s Management of Pain, 3rd edition, page 1860.

534

1272. The true statements regarding conversion disorder are:
1. An alteration in physical functioning occurs as a consequence
of psychological conflict.
2. Limb paralysis and blindness can be symptoms of conversion
disorder.
3. Sexual dysfunction is a common conversion symptoms
encountered clinically.
4. The patient is conscious of the connection between the
physical dysfunction and the psychological stress at the
time it occurs.

1272. Answer: A (1, 2, & 3 )
Explanation:
* Conversion disorder is the loss or alteration of physical
functioning that is temporarily associated with
psychosocial stressor. The patient is not conscious of
intentionally producing the physical symptom in response
to the psychic stressor.
* Paralysis and blindness are often described as classic
symptoms of conversion disorder.
* Sexual dysfunction is common.
* Pain is the least common conversion symptom
encountered clinically. Patient may not be able to connect.

535

1273. Rehabilitation exercises recommended for lumbar
spondylolysis and spondylolisthesis include the
following:
1. Stretches to reduce impairments of trunk mobility, hip
fl exors, hamstrings, quadriceps, and calves
2. Modalities including ultrasound and electrical stimulation
have been shown to improve symptoms and are
generally of great value
3. Improving back and abdominal strength can help decrease the discomfort associated with the lumbar spine
instability
4. Exercises to improve back and abdominal strength can
be very painful and increase lumbar spine instability

1273. Answer: B (1 & 3)

536

1274. Which of the following is (are) true of osteochondritis
(Scheuermann’s Disease)?
1. Abnormality at junction of vertebral body and disc
2. Irregularity of ossifi cation and endochondral growth
3. Thoracic spine involvement in teenagers
4. Anterior wedging and kyphosis

1274. Answer: E (All)
Source: Boswell MV, Board Review 2004

537

1275. MRI fi ndings in carpal tunnel syndrome include
1. Increased diameter of median nerve proximal to entrapment
2. Flattening of nerve deep in carpal tunnel
3. Increased signal on T2 images
4. Decreased signal on STIR images

1275. Answer: A (1,2, & 3)
Source: Bieneman B, Board Review 2005

538

1276. Which of the following are included in the diagnosis of
Major Depressive Episode?
1. Diminished interest or pleasure in activities
2. Negative symptoms such as affective fl attening
3. Weight loss or weight gain when not dieting
4. Catatonic or disorganized behavior

1276. Answer: B (1 & 3)
Explanation:
Flat affect and disorganized behavior are criteria for
schizophrenia
Source: Boswell MV, Board Review 2004

539

1277. The true statements concerning neurolytic nerve blocks
include.
1. There is little difference in the effi cacy between alcohol
and phenol
2. Destruction of peripheral nerves can be followed by
a denervation hypersensitivity that is worse than the
original pain
3. Neurolytic blocks should be reserved for patients with
short life expectancies
4. Neurolytic blockade with phenol is permanent

1277. Answer: A (1, 2, & 3)
Explanation:
Alcohol and phenol are similar in their ability to cause
nonselective damage to neural tissues.
Neural tissue will regenerate; therefore, neurolytic blocks
are never “permanent” and neurolysis can lead to a
denervation hypersensitivity, which can be extremely
painful.
Source: Hall and Chantigan.

540

1278. A nerve is undergoing Wallerian degeneration, but has preservation of the epineurium. This nerve injury could
be classified as:
1. Seddon’s axonotmesis
2. Sunderland class 1
3. Sunderland class 4
4. Sunderland class 5

1278. Answer: B (1 & 3)
Explanation:
Wallerian degeneration occurs following axonal loss
hence, Sunderland class 1 (conduction block) is false.
Sunderlan class 5 implies complete nerve transection,
which is false.
Other truisms would be Sunderland class 2,3,4—the
epineurium is intact in all of these. Seddon’s axonotmesis
would be true, because Wallerian degeneration would
occur and the epineurium, endoneurium, and
perineurium are intact.
Source: Shah RV, Board Review 2004

541

1279. Advantages of intrathecal opioids include:
1. Absence of sympathetic blockade
2. Absence of hypotension
3. Avoidance of cardiovascular effects
4. Lack of tolerance

1279. Answer: A (1, 2, & 3)
Explanation:
Intrathecal opioids do not cause sympathetic blockade,
hypotension, or cardiovascular effects. Intrathecal opioids
do develop tolerance.
Source: Trescot AM, Board Review 2004

542

1280. Opioids that are commonly used intrathecally include:
1. Morphine
2. Fentanyl
3. Hydromorphone
4. Tramadol

1280. Answer: A ( 1, 2, & 3)
Explanation:
Tramadol is not commonly used in intrathecal pumps.
Source: Trescot AM, Board Review 2004

543

1281. Which of the following agents is/are useful in treating
cancer-related fatigue?
1. Megestrol acetate
2. Corticosteroids
3. Antidepresssants
4. Methylphenidate

1281. Answer: E (All)
Source: Reddy Etal. Pain Practice: Dec 2001, march 2002

544

1282. Cauda equina tumors may present with.
1. Acute persistent rectal pain
2. Lower extremity weakness
3. Patchy sensory loss
4. Sphincter disturbances

1282. Answer: E (All)
Source: Nader and Candido – Pain Practice. June 2001

545

1283. A 36-year old white male presents to your clinic
with complaints of neck and upper extremity pain. on
examination, shoulder abduction was relatively weak
compared to the normal side. There was also weakness
of elbow fl exion. An MRI of the neck will likely confi rm
the presence of a disc protrusion at _____ level and
involvement of ______ nerve root.
1. Disc protrusion at C4/5
2. Disc protrusion at C5/6
3. Neurological level C5
4. Neurological level C6

1283. Answer: B (1 & 3)
Explanation:
The deltoid and the biceps are the two most easily tested
muscles with C5 innervation. The deltoid is almost a pure
C5 muscle; the biceps is innervated by both C5 and C6,
and evaluation of its C5 innervation may be slightly
burred by this overlap.
The deltoid is by axillary nerve or C5. It is a 3-part
muscle. The anterior deltoid fl exors, the middle deltoid
abducts, and the posterior deltoid extends the shoulder; of
the three motions, the deltoid acts most powerfully on
abduction. Since the deltoid does not work alone in any
motion, it may be diffi cult to isolate it for evaluation.
Therefore, note its relative strength in abduction, its
strongest plane of motion.
Primary shoulder abductors:
1. Deltoid (middle portion)
C5, C6 axillary nerve
2. Supraspinatus
C5, C6 suprascapular nerve
Secondary shoulder abductors:
1. Deltoid (anterior and posterior portions)
2. Serratus (anterior)
Biceps
C5, C6, musculoskeletal nerve. The biceps is a fl exor of the
shoulder and elbow and supinator of the forearm. To
determine the neurologic integrity of C5, biceps should be
tested only for elbow fl exion. Since the brachialis muscle,
the other main fl exor of the elbow, is also innervated by
C5, testing fl exion of the elbow should give a reasonable
indication of C5 integrity.
Source: Hoppenfeld S. Orthopaedic Neurology. A
Diagnostic Guide to Neurologic Levels. Philadelphia,
LWW, 1997

546

1284. Which of the following management strategies are
recommended for a patient with Idiopathic Adhesive
Capsulitis
1. Arthroscopic release
2. Hydraulic distention of the glenohumeral joint
3. Intra-articular injection
4. Stretching and resistive ROM exercises

1284. Answer: A (1, 2, & 3)
Source: Sizer Et Al - Pain Practice March & June 2003

547

1285. Cancer patients undergoing radiotherapy:
1. May have multiple pains in addition to the cancer-related
pain
2. Could have pain caused by the radiotherapy itself
3. May develop myelopathy of the spinal cord
4. May develop acute infl ammation of the nerves or plexuses

1285. Answer: E (All)
Source: Nader and Candido – Pain Practice. June 2001

548

1286. Which of the following drug class(es) have NO EFFECT
on acute neuropathic pain?
1. Opioids
2. Tricyclic antidepressants
3. Antiepileptics
4. Benzodiazepines

1286. Answer: D (4 Only)
Source: Reddy Etal. Pain Practice: Dec 2001, march 2002

549

1287. Which of the following can be used to perform the
sweating test, a special test of the function of the
autonomic nervous system?
1. Cobalt blue papers
2. Iodine in oil and starch powder
3. Ferric chloride and tannic acid
4. Pilocarpine hydrochloride

1287. Answer: E (All)
Explanation:
Observation and physical examination of the patient
provide substantial information about the function of the
autonomic nervous system.
Evaluation of endocrine status, body temperature, vital
signs, skin and mucous membranes, perspiration, hair and
nail growth, salivation, lacrimation, and extremities, as
well as documentation of autonomic refl exes involving the
cranial nerves should be performed prior to special tests of
autonomic function.
1. Several tests exist to supplement the information
obtained on examination of the patient.
The sweating test will reveal areas of autonomic
dysfunction.
Cobalt blue papers will turn pink when exposed to
moisture and will remain blue in areas of anhidrosis.
2. Iodine in oil will turn bluish black in the presence of
starch and moisture.
3. Ferric chloride turns black in the presence of tannic acid
and moisture.
4. Sweating can be elicited by application of external heat,
ingestion of hot fl uids and aspirin, emotional stimuli,
intellectual strain, painful cutaneous sensation, or
subcutaneous injection of 5 mg of pilocarpine
hydrochloride.
Other tests of autonomic function include assessment of the pilomotor response, vasomotor response, refl ex
erythema, histamine fl are, skin temperature, skin
resistance, capillary microscopy, and plethysmography.
Source: Raj, P

550

1288. An elderly patient undergoes a lumber sympathetic
block to improve blood fl ow after frostbite. Findings that
suggest a successful lumbar sympathetic block include
the following:
1. Inability to dorsifl ex foot
2. Blushing in the toes
3. Numbness from the knee to the toes
4. Temperature increase in the legs

1288. Answer: C (2 & 4)
Explanation:
1, 3. Numbness in the leg and inability to move it suggest
an accidental subarachnoid or epidural injection, a rare
but possible complication of this block.
2, 4. The completeness of a lumber sympathetic block can
be ascertained by skin temperature measurements and
increases in blood fl ow. The latter can be determined by a
number of techniques, including laser Doppler fl owmeter,
occlusion skin plethysmography, transcutaneous oxygen
electrodes, and mass spectrometry.

551

1289. Which of the following statements about fatigue in the
cancer patient is NOT true?
1. Fatigue refers to a subjective sense of decreased vitality
in physical or mental functioning.
2. Symptoms of fatigue may be alleviated by dexamethasone.
3. Some selective serotonin-reputake inhibitors (SSRIs)
have been shown to be useful in treating fatigue.
4. Correcting underlying problems such as depression,
anxiety, or sleep disturbances is rarely useful in treating
fatigue

1289. Answer: D (4 Only)
Source: Reddy Etal. Pain Practice: Dec 2001, march 2002

552

1290. An elderly man has had many years of deteriorating
kidney function due to diabetes. Dialysis was begun
because of electrolyte abnormalities, approximately
ten years ago. True statements about his pain problems
include:
1. The most common neurologic complication of chronic
renal failure is Seizures and Delirium.
2. The most common neurologic complication of chronic
renal failure is Peripheral neuropathy.
3. His symptoms of restless legs syndrome may be controlled
with either Haloperidol or Nifedipine
4. The most reliable treatment for the peripheral neuropathy
of chronic renal failure is Renal transplant.

1290. Answer: C (2 & 4)
Explanation:
1, 2. The type of peripheral neuropathy most commonly
developing with chronic renal failure is a symmetric, distal
mixed sensorimotor neuropathy. The legs are generally
affected fi rst and most severely. Men are more commonly
affected than women. Most of the peripheral neuropathies
in patients with chronic renal failure involve axonal
degeneration.
3. The restless legs syndrome (Ekbom syndrome) is
characterized by a feeling of discomfort in the legs that is
relieved by movement.The sensation is felt deep within the
limb, and is variably describes as pulling, stretching, or
cramping. Restless legs syndrome occurs primarily at
night, shortly after the patient lies down. It differs from
akathisia, which is a restlessness that occurs during the
daytime. It may be associated with peripheral neuropathy
and anemia and is seen in patients with chronic renal
disease, diabetes mellitus, and many other medical
conditions. Exercise before going to bed may alleviate
much of the discomfort. Agents that may be effective in
alleviating symptoms include Clonazepam, gabapentin, Ldopa,
and opiates. Neuroleptics, calcium channel blockers,
and caffeine may worsen symptoms.
4. The neuropathy usually improves with dialysis or
transplant.
B vitamins are generally replaced when patients receive
dialysis. Thiamine is water-soluble and so is easily lost
during dialysis, but even replacing thiamine is not nearly
as effective in retarding or reversing the neuropathy of
chronic renal failure as is renal transplantation. There are
presumed to be neurotoxins in the blood of patients with
uremia that are not removed by routine dialysis
Source: Anschel 2004

553

1291.The presence of positive sharp waves during needle
electromyography of a patient who describes debilitating
pain and weakness of the limb while being tested is
signifi cant because
1. This waveform is only found in patients with muscular
dystrophy and never in pain syndrome
2. This type of activity is an objective sign of denervation
or reinnervation
3. This pattern is an integral component of Waddell’s signs
of nonorganic pain behavior
4. This pattern cannot be created fi ctitiously, even during
reduced voluntary motor effort

1291. Answer: C (2 & 4)
Source: Raj P, Pain medicine - A comprehensive Review -
Second Edition

554

1292. Indications for prophylactic treatment in migraine are:
1. Upcoming job interview
2. Five migraine attacks a month
3. Tension type headache
4. Headaches associated with nausea

1292. Answer: C (2 & 4)
Explanation:
When deciding on the treatment of migraine, one must
take into consideration the frequency and severity of the
headaches. Prophylactic therapy is recommended if the
headaches are more than 3 in a month, or are
incapacitating requiring the patient to be hospitalized or
miss work or the response to abortive medications is not
satisfactory. A fi ne balance must be maintained between
overmedicating and limiting acute attacks. It is not
worthwhile to take prophylactic medication to prevent an
occasional migraine once in two months. The aim of
prophylactic therapy is to reduce the frequency and
severity of the headaches by at least 50%. The best therapy
for acute attacks is to use an abortive as in an upcoming
job interview. Prophylactic therapy is not effective in
tension type headaches. Migraines with prolonged aura
can lead to permanent neurologic sequelae, in such cases
prophylactic therapy maybe indicated.
Ref: Raj, Robbins
Source: Chopra P, 2004

555

1293. Thrombosed external hemorrhoid pain:
1. Has an abrupt onset
2. Is of an aching or burning quality
3. Is a localized anal pain
4. Is associated with a tender, almond shaped mass extruding outside the canal

1293. Answer: E (All)
Source: Nader and Candido – Pain Practice. June 2001

556

1294. The true statements regarding the N-methyl-D-aspartate
(NMDA) receptor include the following
1. Glutamate and aspartate act at the NMDA receptor
2. NMDA may be involved in injury-induced wind-up
3. Wind-up is prevented by NMDA antagonists
4. Ketamine is an NMDA receptor agonist

1294. Answer: A (1, 2, & 3 )
Explanation:
NMDA receptors are involved in the activation of
nociceptive neurons.
The action of excitatory amino acids such as glutamateand
aspartate at the NMDA receptor in the dorsal horn is
enhanced by the neuropeptides substance P, calcitonin
gene-related peptide (CGRP), and dynorphins.
The corelease of excitatory amino acids and neuropeptides
strengthens the synaptic connections in the dorsal horn
andmay increase the development of dorsal-horn
hyperxcitability (cord wind-up).
There is an expansion of the receptive fi elds of the wide
dynamic range (WDR) neurons.
Wind-up is prevented by NMDA receptor antagonists.
Both Mk-801 and ketamine are NMDA receptor
antagonists.
Source: Kahn and Desio

557

1295. Trauma to the spinal accessory nerve would be expected
to cause:
1. spasm of the trapezius muscle
2. winged scapula
3. torticollis
4. hoarsenes

1295. Answer: B (1 & 3)
Explanation:
1. The spinal accessory nerve innervates the trapezius
muscle, and trauma will cause spasm of trapezius and
torticollis.
2. Trauma of spinal accessory nerve cause torticollis – not
winged scapula.
- It is caused by pathology of long thoracic nerve.
3. Trauma to spinal accessory nerve causes torticollis.
4. Hoarseness might come from the recurrent laryngeal
nerve, but, not spinal accessory nerve.
Source: Trescot AM, Board Review 2003

558

1296. During an intravenous lidocaine test, all the following
monitors are recommended
1. Electrocardiography
2. Blood pressure
3. Pulse oximetry
4. Skin temperature

1296. Answer: A (1, 2, & 3)
Explanation:
Intravenous lidocaine can be used to determine the
effi cacy of treatment with oral antiarrhythmics such
as mexiletine or tocainide. It may be used as a treatment
itself if weekly infusions provide longer relief after each
treatment.
Some studies suggest that intravenous lidocaine may
have predictive value as to the effi cacy of anticonvulsants
such as phenytoin or carbamazepine.
1, 2, 3. Because of the possibility of systemic toxicity and
seizures, patients should be monitored by
electrocardiography, blood pressure, and pulse oximetry.
4. Skin temperature monitoring is not necessary.
Source: Ramamurthy

559

1297.A young female presents with a severe left-sided
throbbing headache associated with nausea, vomiting,
and photophobia. She has tried taking ibuprofen without
relief. On further questioning, she relates that she has
been having similar headaches three to four months:
1. Appropriate therapy for this patient’s present headache
includes Ergotamine tartrate.
2. Appropriate therapy for the present headache includes
Amitriptyline hydrochloride
3. Appropriate long-term management includes a prescription
for daily use of Amitriptyline hydrochloride.
4. Appropriate long-term management includes prescription
for daily use of Sumatriptan and metoclopramide.

1297. Answer: B (1 & 3)
Explanation:
1. This patient has migraine without aura. Of the agents
listed, only Ergotamine tartrate is generally considered of
use to abort a headache.
2. Verapamil and amitriptyline hydrochloride may be used
as prophylactic (preventive) therapy.
3. Several medications are effective as prophylactic agents
in the treatment of migraine. These include amitriptyline
hydrochloride, propranalol, verapamil, and valproate.
Most experts recommend initiating prophylactic therapy
only when headaches occur at least one to two times per
month.
4. Metoclopramide hydrochloride, sumatriptan, and
Ergotamine tartrate are appropriately used to treat an
acute attack of migraine, and should not be prescribed on
a daily basis. Daily use of these medications can establish a
rebound syndrome that results in a daily headache. Oral
contraceptives may be associated with either an increase or
decrease in the frequency of migraines, but are not
generally used as a treatment for migraine. Some experts
recommend not prescribing OCPs for patients with
migraine for fear of increasing the risk of a stroke,
although OCPs are probably safe to use in most patients
with common migraine.

560

1298. True statements regarding temporal arteritis include the
following:
1. A swollen, tender scalp artery is present
2. An elevated erythrocyte sedimentation rate (ESR)
3. Typical histologic features on biopsy
4. Polymyalgia rheumatica is frequently present

1298. Answer: E (All)
Explanation:
Diagnostic criteria for temporal arteritis (giant cell
arteritis) include the presence of typical histopathologic
features on temporal artery biopsy, a swollen and tender
scalp artery, elevated ESR, and the disappearance of the
headache with 48 h of steroid therapy.
The headache is usually temporal, of variable severity,
having a constant, boring quality, and is temporarily
relieved by analgesics such as aspirin.
Polymyalgia rheumatica as well as general malaise,
anorexia, or mild fever frequently accompanies this
systemic disease

561

1299. The benefi cial effects of epidural administration of
steroids have been attributed to of the following:
1. Inhibit phospholipase A2
2. Improve microcirculation around the nerve root
3. Block conduction of nociceptive C nerve fi bers
4. NMDA antagonist

1299. Answer: A (1, 2, & 3)
Explanation:
Administration of epidural steroids by interlaminar or
transforaminal approach is one of the commonest
approaches to treating spinal pain and radicular pain.
Steroids decrease infl ammation by inhibiting
phospholipase A2, thus inhibiting the formation of
arachidonic acid, prostaglandins and leukotrienes.
Steroids reduce infl ammatory edema around the infl amed
nerve root and improve microcirculation. They block the
conduction of nociceptive c fi bers. By restricting the
formation of prostaglandins they may decrease
sensitization of the dorsal-horn neurons.
Source: Chopra P, 2004

562

1300. True statements about complications from neurolytic
hypogastric plexus block are as follows:
1. intravascular injection
2. paralysis of lower extremity
3. injury to ureter
4. nerve injury

1300. Answer: E (All)
Source: Racz G. Board Review 2003

563

1301.Benefi ts of continuous epidural analgesia for chest
trauma includes:
1. Shorter ICU stay
2. Improved post-injury rehabilitation
3. Avoidance of endotracheal intubation
4. Earlier post-injury extubation

1301. Answer: E (All)
Explanation:
Ref: Crews. Chapter 14, Sente Pain Syndromes. In:
Practical Management of Pain, 3rd Edition. Raj et al,
Mosby, 2000, page 185.
Source: Day MR, Board Review 2003

564

1302. A patient presents with lateral epicondylitis. Pain is
noted on physical examination with which of following
maneuvers during the examination:
1. Resisted fl exion
2. Resisted extension
3. Resisted supination
4. Extension of the wrist with a fi st

1302. Answer: C (2 & 4)
Explanation:
Lateral epicondylitis, or tennis elbow, commonly involves
the origin of extensor-supinator muscle mass in the:
Extensor carpi radialis brevis
Extensor digitorum communis
Extensor carpi radialis longus
Extensor carpi ulnaris
Supinator
The extensor carpi radialis is most commonly involved.
Probably the position of wrist fl exion, elbow extension,
and forearm pronation stretch the tendon over the
prominence of the radial head.The most common cause of
lateral epicondylitis is cumulative trauma.
Provocative testing involves elbow in extension. Further,
in lateral tennis elbow, pain is reproduced when one asks
the patient to make a fi st and extend the wrist. Sudden,
severe pain is elicited at the lateral epicondyle when the
examiner forcefully extends the patient’s wrist.
Source: Saidoff DC, McDonough AL. Critical Pathways in
Therapeutic Intervention. Extremities and Spine,St. Louis,
Inc., 2002.

565

1303.True statements of adverse reaction of celiac plexus block
include the following:
1. Urinary retention
2. Hypotension
3. Sexual dysfunction
4. Diarrhea

1303. Answer: C (2 & 4)

566

1304. All of the following clavicular movements are involved in
upper extremity elevation less than 150°
1. Backward Spin
2. Elevation
3. Retraction
4. Protraction

1304. Answer: A (1, 2, & 3)
Source: Sizer Et Al - Pain Practice March & June 2003

567

1305. A patient has intractable cancer pain with a neuropathic
component. Ketamine is being considered as an adjuvant
analgesic agent. Which of the following are correct
regarding ketamine?:
1. Sympathomimetic effects
2. Noncompetitive NMDA antagonist
3. Contraindicated with increased ICP
4. May reduce the requirements for opioids

1305. Answer: E (All)

568

1306.The following maneuvers decrease carpal tunnel
pressure
1. Forearm neutral position
2. Intermittent low tension hand exercise
3. Slight wrist palmar fl exion with ulnar deviation
4. Full wrist dorsal extension (cock-up-position)

1306. Answer: A (1, 2, & 3)
Source: Sizer et al - Pain Practice - March & June 2004

569

1307. A 55-year old slender white female complains of back
pain that started a week ago. This started when she
lifted a box with both hands. There was no signifi cant
radiation, however, it was exacerbated with any further
activity including with lifting. She became menopausal
approximately 2 years ago, she smoked, she does not
exercise. The only medications she had used were
diazepam on a long term basis. The true statements
relating to the diagnosis and management of her
condition are as follows:
1. This patient suffered thoracic vertebral compression
fracture secondary to osteoporosis.
2. This patient suffered disc herniation
3. Treatment includes a rigid thoracolumbar hyperextension
orthosis, which provides external support and alleviates
fl exion forces on the affected vertebral segments
4. Manage with fl exion exercises

1307. Answer: B (1 & 3)
Source: Saidoff DC, McDonough AL. Critical Pathways in
Therapeutic Intervention. Extremities and Spine,St.
Louis,Inc., 2002

570

1308. Central pain arising from brain injury has been shown
to result from which of the following structures?
1. Brainstem
2. Cerebral cortex
3. Thalamus
4. Subcortical white matter

1308. Answer: E (All)
Explanation:
Modern imaging studies have demonstrated that lesions in
all regions of the brain can cause central pain. Bonica’s
Management of Pain, 3rd ed, page 441.

571

1309. Pulsed radiofrequency lesioning settings may be:
1. 46 degrees Celsius and 20 volts
2. 56 degrees Celsius and 100 volts
3. 80 degrees Celsius and 40 volts
4. 42 degrees Celsius and 40 volts

1309. Answer: D (4 Only)
Source: Racz G. Board Review 2003

572

1310. FDA approved intrathecal medications include:
1. Morphine
2. Clonidine
3. Baclofen
4. Ziconitide

1310. Answer: B (1 & 3)
Explanation:
Morphine and baclofen are FDA approved for intrathecal
use. Clonidine is approved for epidural but not intrathecal
use. Ziconitide is still awaiting fi nal approval.
Source: Trescot AM, Board Review 2004

573

1311. As a part of a psychological evaluation, a clinical
interview includes:
1. Pain distribution and pattern
2. Financial and legal information
3. General medical status
4. Psychosocial history

1311. Answer: A
Source: Janata J, Board Review 2006

574

1312. An interlaminar epidural steroid injection is an
appropriate treatment choice for a patient with:
1. A C6 disc herniation and severe cervical canal stenosis
2. Back and leg pain due to spinal metastases
3. Facet arthropathy producing severe back pain
4. An L5 disc herniation without neurological fi ndings

1312. Answer: D (4 Only)

575

1313. Which of the following are Waddell’s signs?
1. Evoked back pain with deep palpation of the lumber
paraspinals
2. Evoked back pain with en-bloc trunk rotation, i.e., moving
the shoulders and hips in unison
3. Refuses to be examined
4. Superfi cial tenderness

1313. Answer: C (2 & 4)
Explanation:
Waddell’s signs were developed to suggest a possible
non-organic etiology of back pain as opposed to suggesting malingering. These tests and the clinician’s
clinical impression may suggest a slower than expected
recovery.
The Waddell’s signs include (SONDSup, mnemonic):
Simulation
Load the spine with the weight of your hand on top of
the patients head to reproduce low back pain
Simulation of twisting the trunk when rotating the
shoulders and hips in unison to reproduce the back pain
Non-anatomic distribution of pain
Aberrant pain drawing give away’ weakness, i.e.,
inconsistent effort during ange of motion
Distraction
Sitting knee extension to test sciatic tension while
distracting the patient with a knee, foot, or peripheral
pedal pulse examination
If negative, then the supine straight leg maneuver
should be negative
Superfi cial or subcutaneous tenderness, not deep muscle
tenderness
1. Evoked back pain with deep palpation of the lumber
paraspinals is not a Waddell’s sign
2. Evoked back pain with en-bloc trunk rotation, i.e.,
moving the shoulders and hips in unison is a Waddell’s
sign
3. Refusal to examination is not a Waddell’s sign
4. Superfi cial tenderness is a Waddell’s sign
Source: Shah RV: 2003 (Bonica, 3rd Ed., page 1523)

576

1314. The criteria for diagnosing hypochondriasis include
1. Pseudoneurological presentation
2. Persistent preoccupation despite medical reassurance
3. The preoccupation is delusional
4. The preoccupation has a duration of six months or
more

1314. Answer: C
Source: Janata J, Board Review 2006

577

1315. The Cremasteric Reflex best tests for what nerve root?
1. L1
2. L2
3. L3
4. L4

1315. Answer: A ( 1, 2, & 3)
Source: Wirght PD, Board Review 2004

578

1316.The treatment of piriformis syndrome includes the
following:
1. Non-steroidal anti-infl ammatory drugs
2. Piriformis stretch exercise program
3. Piriformis injection with local anesthetic and steroids
4. Surgical section of piriformis muscle

1316. Answer: A (1, 2, & 3)
Explanation:
Surgical section of piriformis muscle is performed on
extremely rare occasions.

579

1317. Strengthening exercises:
1. Are helpful in patients with chronic low back pain.
2. Should be stopped if a patient complains of increase
muscle soreness.
3. Can result not only in improvement in strength but also
reduction of pain.
4. Provides the best results when performed one time per
week at low loads.

1317. Answer: B (1 & 3)
Source: Malanga G, Board Review 2003

580

1318. A 36-year old male presented with severe low back and
left lower extremity pain. He reported the pain to start
following a work related injury. Examination showed a
positive straight leg raising on the right at 60°, and an
absent left Achilles tendon refl ex. He was treated with
physical therapy, improved, and returned to work after 6
weeks. He had no pain at rest or numbness in the lower
extremities one year after onset. He was able to perform
all activities of daily living with only some back pain with
heavy activity. His MRI showed left posterolateral disc
herniation at L5/S1.
1. His diagnosis is lumbar strain.
2. His diagnosis is lumbar disc herniation with
radiculopathy.
3. His impairment rating is 20% impairment of the whole
person.
4. His impairment is 5% of the whole person.

1318. Answer: C (2 & 4)

581

1319. True statements about early changes on EMG/NCV after
L5 disc herniation include :
1. Positive sharp waves are fi rst noticeable in paraspinal
muscles within 7-10 days after loss of axon function
2. By 14-18 days, positive sharp waves can appear in limb
muscles, becoming evident throughout the involved
myotome
3. By 18-21 days, all muscles in the involved myotome
have abnormalities, including positive sharp waves and
fi brillation potentials
4. Smaller amplitude positive sharp waves (100-150 MV)
are indicative of acute injury

1319. Answer: A (1,2, & 3)

582

1320. All of the following muscles are adductors while the arm
is positioned at the patient’s side
1. Latissimus dorsi
2. Pectoralis major
3. Teres Major
4. Subscapularis

1320. Answer: A (1, 2, & 3)
Source: Sizer Et Al - Pain Practice March & June 2003

583

1321. Which of the following tests are used to evaluate the
meniscal injuries?
1. McMurray’s Test
2. Patellar Grind Test
3. Apley’s Compression Test
4. Lachman’s Maneuver

1321. Answer: B (1 & 3)
Explanation:
(Raj, Practical Mgmt of Pain, 3rd Ed.)
Special Tests
1. McMurray Test
This maneuver was developed to assess for posterior
meniscal tears and provides an excellent clinical
evaluation. The patient lies prone. The examiner fl exes the
symptomatic knee and rotates the tibia on the femur in
external and internal rotation. Valgus stress is added with
the leg in external rotation, and the knee is then slowly
extended. An audible or palpable click suggests a meniscal
tear.
2. Patellar Femoral Grinding Test
Chondromalacia patellae is a common problem in
degenerative knees, and there are common complaints of
increasing pain on arising from a chair or climbing stairs.
Exacerbation of symptoms can be elicited by compressing
the patella into the femoral groove. With the knee
extended, pressure is placed over the patella, which is
guided along the groove. Crepitance should also be
palpated with fl exion and extension of the knee while the
examiner’s hand is over the patella.
3. Apley’s Compression or Grinding Test:
A confi rmatory test for meniscal tears can be accomplished
by compressing the meniscus. The patient lies prone and
the affected knee is fl exed to 90 degrees. The examiner
applies downward pressure against the heel as he or she
rotates the tibia against the femur. Pain suggests a
meniscal tear and correlates medially or laterally with the
location of injury.
4. Drawer Signs
These tests were designed to examine injury or disruption
of the cruciate ligaments. The patient may be sitting or
lying prone with the knee fl exed at 90 degrees and the foot
fi xed in place (the examiner may sit on the foot). The tibia
is then drawn toward the examiner; if the tibia slides
beneath the femur, it is a positive anterior drawer sign and
identifi es a torn anterior cruciate ligament (ACL). If
sliding occurs beneath the femur when the tibia is pushed
away from the examiner, it is a positive posterior drawer
sign and identifi es a torn posterior cruciate ligament
(PCL).
Source: Shah RV, Board Review 2004

584

1322. The mechanism of action of low frequency acupuncture
pain relief is explained by which of the following?
1. Hypothalamic stimulation
2. Reticulospinal suppression
3. Activation of A fi ber pathways
4. Release of endogenous enkephalins

1322. Answer: D (4 Only)

585

1323. Complications of a single epidural steroid injection
may include
1. Cushing’s syndrome
2. Elevated blood glucose
3. Hypothalamic-pituitary-adrenal axis suppression
4. Arachnoiditis

1323. Answer: A (1, 2, & 3)

586

1324. The following trunk muscle groups have been identifi ed
as targets in a restorative spine stabilization program,
1. Diaphragm
2. Multifi dus
3. Transverse abdominus
4. Rectus abdominus

1324. Answer: A (1, 2, & 3)
Source: Sizer et al - Pain Practice - March & June 2004

587

1325. Anterior interosseous nerve syndrome would spare
which of the following muscles?
1. Flexor pollicis longus
2. Pronator quadratus
3. Index fl exor digitorum profundis
4. Pronator teres

1325. Answer: D (4 Only)
Explanation:
The anterior interosseous nerve usually innervates the
FPL, index and long fi nger FDPs, and PQ. It does not
mediate superfi cial sensation. Patients may present with
loss of fl exion of the distal phalanxes of the thumb and
index fi nger. They lose their pinching ability.
Source: Shah RV, Board Review 2004

588

1326. Which of the following can cause ulnar nerve palsy
1. Cubitus valgus deformity
2. Subluxation of the ulnar nerve onto or past the medial
humeral epicondyle
3. Occupational hazard, as a worker supports themselves
on their elbows
4. An aponeurotic band that extends from the medial
epicondyle of the humerus and attaches to the medial
border of the olecranon.

1326. Answer: E (All)
Explanation:
All can cause ulnar nerve palsy. Choice 4 is responsible for
cubital tunnel syndrome.
Source: Shah RV, Board Review 2004

589

1327. Resisted wrist dorsal extension can provoke symptoms
associated with following lateral elbow affl ictions
1. Humeroradial joint chondropathy
2. Posterior interosseus nerve entrapment
3. Tendopathy of the extensor carpi radialis brevis
4. Tendopathy of the fl exor carpi ulnans

1327. Answer: A (1, 2, & 3)
Source: Sizer et al - Pain Practice - March & June 2004

590

1328. True statements about hypogastric plexus are:
1. located in front of promontory crossing L5-S1
2. anterior just Left side of aorta
3. communicates with celiac ganglion
4. contains B-C and sympathetic fi bers

1328. Answer: E (All)
Source: Racz G. Board Review 2003

591

1329. The management of spinal stenosis includes the
following:
1. Medication with non-steroidal anti-infl ammatory
drugs and calcitonin
2. Flexibility training with slight fl exion bias in neutral
spine position as it improves the stenosis
3. Epidural injections are indicated in patients without
improvement with aggressive conservative care or increased
symptoms
4. Surgery is indicated for intolerable pain with deterioration
in functional status or progressive neurological
defi cit or cauda equina symptoms

1329. Answer: E (All)

592

1330. Shoulder impingement should be suspected in a patient
1. that demonstrates a positive drop arm test
2. that demonstrates a ‘Popeye’ deformity
3. if the Yergason’s test is positive
4. has pain with abduction

1330. Answer: D (4 Only)
Explanation:
(Raj, Practical Mgmt of Pain 3rd Ed., page 347-9)
1. A drop arm test is consistent with a complete rotator
cuff tear. A complete rotator cuff tear does not allow the
arm to remain abducted, but partial tears can also be
assessed by this test. The patient abducts the arm to 90
degrees and is asked to lower it slowly after the examiner
taps the extended forearm. Complete tears in the
supraspinatus tendon cause the arm to fall immediately to
the side, and partial tears prevent full strength or range.
2. A ‘popeye’ deformity signifi es a tear of the long head of
the biceps tendon
Impingement is most pronounced with forward fl exion
and thumbs down or abduction.Mechanical entrapmentof
the rotator cuff occurs at the space between the humeral
head and coracoacromial arch narrows.
3. The Yergason Test for Biceps Tendon Stability—while,
the patient is sitting or standing, the examined elbow is
fl exed at the waist and a fi st is made with the hand. The
examiner has one hand on the patient’s elbow and the
other on the distal forearm. The patient resists shoulder
external rotation (examiner pulls outward on distal
forearm) and pulls downward at the elbow. If the long
biceps tendon pops out of its groove, pain arises near the
anterior lateral
humeral head.
4. Shoulder impingement produces pain with abduction.
Source: Shah RV, Board Review 2004

593

1331. Positive Waddell’s signs are indicative of:
1. The effects of psychosocial factors
2. A poor response to surgical intervention
3. Need for a comprehensive evaluation of pain
4. Lack of response to treatment

1331. Answer: A (1, 2, & 3)
Explanation:
The 4 fi ndings include superfi cial, nonanatomic tenderness; a positive simulation response; a discrepancy
between results of examination of the same body part
in two different positions; and non-physiologic regional
disturbances of sensation, pain or weakness.
1. Positive Waddell’s signs greatly increase the likelihood
that psychosocial factors are playing a major role in the
patient’s complaints.
2. Patients with two or more positive test results may not
respond favorably to surgery.
3. Positive Waddell’s signs are indicative of the need for a
comprehensive evaluation.
4. Patients with positive Waddell’s signs may not respond
well.

594

1332. Which is true?
1. Axial loading of the neck may be helpful in the evaluation
of chronic low back pain
2. The Adson test is used to evaluate thoracic outlet syndrome
3. Resistance to passive neck fl exion with the hands behind
the head, so that the chin cannot touch the chest is a
sign that is used to evaluate meningeal irritation
4. Increased neck pain with side bending is pathognomic
for cervical facet pain

1332. Answer: A (1,2, & 3)
Explanation:
(Raj, Practical Mgmt of Pain, 3rd Ed., page 357, 358)
1. Axial loading of the neck is used in evaluating Waddell’s
signs (simulation testing). Waddell’s tests were developed
to evaluate functional overlay in low back paincomplaints.
Each of the following fi ndings is considered positive if
present; a total of three positive fi ndings is considered
signifi cant, strongly suggesting positive non-physiologic
signs.
2. The Adson test is used for subclavian artery
compression. The patient’s radial pulse is continually taken
at the wrist while the arm is abducted, extended, and
externally rotated.The patient then takes a deep breath and
turns the chin toward the tested arm. The examiner
palpates a drop in pulse pressure or loss of pulse,
suggesting compression of the artery.
3. Kernig test. The patient lies supine with hands behind
the head and is asked to fl ex the chin to the chest wall.
Nerve root, meningeal, or dural infl ammation results in a
shooting pain in the spinal canal or legs.
Tenderness: poorly localized and does not follow
dermatomal or documented referral patterns.
Light touch over the low back causing widespread
discomfort or deep touch spreading through the thoracic
spine or to the sacrum or hips.
Simulation testing: should not be uncomfortable or
cause discomfort in distant sites. Axial loading of the skull
causing lumbar pain or shoulder rotation causing lumbar
pain.
Distraction testing: inconsistent fi ndings with the same
test performed in formal fashion and when
attention is distracted. Sitting straight leg raising
without discomfort compared with lying straight
leg raising causing radiating pain from buttock to foot.
Regional disturbance: nonanatomical findings on sensory and motor testing. Give-way motor
testing (total release of motor activity without warning)
or unexplained weakness. Glove and
stocking dysesthesias rather than expected dermatomal
pattern.
Overreaction: inappropriate facial or verbal expressions,
withdrawal of limbs from touch, or posture
contortions. Flopping on the fl oor with twisting of the
spine, limiting hypersensitivity to joint examination, and
cries of pain or fear on superfi cial examination.
4. Cervical facet joint pain is diagnosed with a certain
degree of certainty, utilizing controlled diagnostic blocks -
but not by physical examination.
Source: Shah RV, Board Review 2004

595

1333. Which of the following observations, after nerve injury,
is correctly paired with the appropriate nerve?
1. Inability to fl ex the forearm --- radial nerve
2. Numbness in the index fi nger---median nerve
3. Inability to extend the forearm---musculocutaneous
nerve
4. Numbness in the little fi nger---ulnar nerve

1333. Answer: C (2 & 4)
Explanation:
To check the setup of a brachial plexus block, one can
perform the four P’s (push, pull, pinch, pinch). Have the
patient push or extend the forearm (triceps muscle is
innervated by the radial nerve), pull or fl ex the forearm
(biceps muscle is innervated by the musculocutaneous
nerve), pinch the index or second fi nger (median nerve),
pinch the little fi nger (ulnar nerve).
Source: Hall and Chantigan

596

1334. The Quebec Task Force on Whiplash Associated
Disorders recommends CT or MR imaging in which
subset of patients?
1. Grade II (neck pain + musculoskeletal injury)
2. Grade IV (neck pain + bony injury)
3. Grade I (neck pain)
4. Grade III (neck pain + neurological injury)

1334. Answer: C (2 & 4)
Explanation:
The Quebec Task Force on Whiplash Associated
Disorders graded the severity of whiplash, as follows:
Grade I (neck pain)
Grade II (neck pain + musculoskeletal injury)
Grade III (neck pain + neurological injury)
Grade IV (neck pain + bony injury)
1, 3. They recommended plain radiographic imaging in
grades II, III, IV
2, 4. They recommended CT or MRI in grades III, IV
Source: Shah RV: 2003 (Bonica, 3rd Ed., page 1010)

597

1335. A patient presents with pain in the upper extremity
following injury to the forearm. Examination showed
weakness in the ring and little fi ngers with numbness in
the little fi nger. The most likely diagnosis is:
1. C7/T1 disc herniation
2. T1/T2 disc herniation
3. Median nerve injury
4. Ulnar nerve injury

1335. Answer: D (4 Only)
Explanation:
A peripheral nerve injury to the ulnar nerve causes
weakness only in the ring and little fi ngers. However, a
central lesion or disc herniation will cause weakness in all
fi ngers. The fl exor digitorum superfi cialis, which fl exes
the proximal interphalangeal joint, has only median nerve
innervation, and is affected by root injury to C8 and
peripheral injuries to the median nerve, but not peripheral
injury to ulnar nerve
Source: Hoppenfeld S. Orthopaedic Neurology. A
Diagnostic Guide to Neurologic Levels. Philadelphia,
LWW, 1997

598

1336. Treatment for back, hip, and thigh pain in a patient
with spondylolisthesis at L5/S1 includes which of the
following?
1. Pelvic tilt for trunk stabilization
2. Flexibility training program with extension bias
3. Strength training with fl exion bias
4. Start exercises immediately in brace with pain

1336. Answer: B (1 & 3)

599

1337. What is true about carpal tunnel syndrome?
1. Patients may complain about numbness in the thumb
2. Pain may be present in the forearm, shoulder, and elbow
3. Hypesthesia is often present in the volar surface of the middle finger
4. Hypothenar muscle atrophy may be present

1337. Answer: A (1, 2, & 3 )
Explanation:
CTS has variable clinical presentations, but patients often
complain of numbness of the index fi nger, thumb, andring
fi ngers. Pain may extend from the wrist, hand, forearm,
elbow, and shoulder. Sensory testing may reveal loss of 2
point discrimination in the thumb, index, and middle
fi ngers. Hypothenar muscles are in the distribution of the
ulnar nerve, whereas the thenar muscles are in the median
nerve distribution
Source: Shah RV, Board Review 2004

600

1338. All of the following statements are true regarding the
subacromiodeltoid bursa
1. It is often the 1° source of pain with traumatic rotator
cuff tears in patients younger than 40 years.
2. It is the most densely innervated structure in the glenhumeral
region
3. It may be involved in the neurological regulation of
shoulder movements
4. It’s size and compartmental confi gurations are predictable
and consistent across patients.

1338. Answer: A (1, 2, & 3)
Source: Sizer Et Al - Pain Practice March & June 2003

601

1339. Which of the following would support the diagnosis of
an S1 nerve root lesion?
1. Absent ankle jerk
2. Weakness in toe walking
3. Atrophy of the gastrocnemius
4. Knee pain

1339. Answer: A (1, 2, & 3)
Explanation:
S1 nerve root injury may be associated with weakness of
plantar fl exion, occasional cramping in the calf, and absent
ankle jerk. Atrophy of the gastrocnemius, soleus, and
hamstrings may occur. Sagging of the gluteal fold and loss
of gluteal muscle tone also suggest S1 involvement.
Radicular pain in the knee is suggestive of L3 injury.
Source: Wall, p

602

1340. Tadpole lesions
1. Refers to the nerve swelling proximal to the area of the
entrapped nerve
2. Refers to delamination of myelin and resultant accumulation
in the internodes
3. Refers to appearance of ovoids, as the distal segment of
the axon breaks down following axonal injury
4. Are early harbingers of the process of demyelination
and remyelination that occur with conduction block

1340. Answer: C (2 & 4)
Explanation:
Tadpole lesions occur as a consequence of myelin
delamination and accumulation into the paranodal
bulbous aspects of the internode. They are early signs of
demyelination and remyelination, which occur as a
consequence of chronic entrapment and ischemia. The
myelin is of irregular thickness in the entire region of the
entrapment: thinner near the area of entrapment and
thicker away from the middle. These are polarized, such
that it looks as if a tadpole is swimming away from the
region of the entrapment.
During Wallerian degeneration, the axons in the distal
segment breakdown and begin to look like ovoids. Nerve
swelling proximal to the entrapped nerve can be visibly
seen during surgery and it represents fi brosis, increased
connective tissue, and endoneurial swelling
Source: Shah RV, Board Review 2004

603

1341. Proper stretching exercises includes:
1. Performing each stretch as quickly as possibly with multiple
repetitions.
2. Holding each stretch for at least 30 seconds.
3. Avoiding placing any tension on the muscle.
4. Stretching after a proper warm-up period to allow for a
better stretch.

1341. Answer: C (2 & 4)
Source: Malanga G, Board Review 2003