Chapter 1. Anatomy Flashcards Preview

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Flashcards in Chapter 1. Anatomy Deck (45):
1

1. Nutrition to the lumbar intervertebral disc is
from the
(A) posterior spinal artery
(B) internal iliac artery
(C) lumbar artery
(D) anterior spinal artery
(E) abdominal aorta

(C) The lumbar arteries supply the vertebrae
at various levels. Each lumbar artery passes
posteriorly around the related vertebra and
supplies branches into the vertebral body. The terminal branches form a plexus of capillaries below each endplate. The disc is a relatively avascular structure. Nutrition to the disc is by diffusion from the endplate capillaries and blood vessels in the outer annulus fibrosus. Passive diffusion of fluids into the proteoglycan matrix is further enhanced by repeated compression of the disc by repeated flexion extension of the spine associated with activities of daily living which pumps fluid in and out of the disc. The abdominal aorta does not provide any direct blood supply to the intervertebral disc.

2

2. A65-year-old man presents with symptoms of pain in the cervical region. He also complains of radiation of his pain along the lateral part of his right forearm. He has a magnetic resonance imaging (MRI) of the cervical region with evidence
of a herniated disc between the fifth and
the sixth cervical vertebra. The nerve root that
is most likely compressed is
(A) fourth cervical nerve root
(B) fifth cervical nerve root
(C) sixth cervical nerve root
(D) seventh cervical nerve root
(E) first thoracic nerve root

2. (C) Disc herniations in the cervical region are relatively less common than the lumbar region. In the cervical region the C5, C6, and C7 intervertebral disc are most susceptible to herniation. The C6 and C7 intervertebral disc herniation is the most common cervical disc herniations. In the cervical region each spinal nerve emerges above the corresponding vertebra. An intervertebral disc protrusion between C5 and C6 will compress
the sixth cervical spinal nerve. There are
seven cervical vertebra and eight cervical spinal nerves. These patients characteristically present with pain in the lower part of the posterior cervical region, shoulder, and in the dermatomal distribution of the affected nerve root.

3

3. The most common presenting symptom of
rheumatoid arthritis is
(A) pain in the small joints of the hand
(B) neck pain
(C) knee pain
(D) low back pain
(E) hip pain

3. (B) Neck pain is the most common presenting symptom of rheumatoid arthritis (RA). Approximately 50% of the head’s rotation is at the atlantoaxial joint, the rest is at the subaxial cervical spine. The atlantoaxial joint complex is made up of three articulations. The axis articulates with the atlas at the two facet joints laterally and another joint posterior to the odontoid process. A bursa separates the transverse band of the cruciate ligament from the dens. RA affects all three joints. The articulations formed by the uncinate processes, also known as the joint of Luschka, are not true joints and do not have synovial membrane. Hence, they are not
subject to the same changes as seen in RA.
RA is an inflammatory polyarthritis that
typically affects young to middle-aged women.
They present with a joint pain and stiffness in
the hands. Typically the first metacarpophalangeal joint is affected whereas in osteoarthritis the carpometacarpal joint is affected. They have a history for morning stiffness. Almost 80% of these patients have a positive rheumatoid factor.

4

4. The usual site of herniation of a cervical
intervertebral disc is
(A) posterior
(B) lateral
(C) posterolateral
(D) anterior
(E) anterolateral

4. (C) The uncinate processes are bony protrusions located laterally from the C3 to C7 vertebrae. They prevent the disc from herniating laterally. The posterior longitudinal ligament is the thickest in the cervical region. It is four to five times thicker than in the thoracic or lumbar region. The nucleus pulposus in the cervical disc is present
at birth but by the age of 40 years it practically disappears. The adult disc is desiccated and ligamentous. It is mainly composed of fibrocartilage and hyaline cartilage. After the age of 40 years, a herniated cervical disc is never seen because there is no nucleus pulposus. The most common cervical herniated nucleus pulposus (HNP) occurs at C6 to C7 (50%) and is followed by C5 to C6 (30%).

5

5. The carotid tubercle (Chassaignac tubercle) is located at the
(A) transverse process of the C6 vertebra
(B) facet joint of the C5 and C6 vertebra
(C) facet joint of the C6 and C7 vertebra
(D) transverse process of the C7 vertebra
(E) transverse process of the C5 vertebra

5. (A) The carotid tubercle (Chassaignac tubercle) lies 2.5 cm lateral to the cricoid cartilage. It lies over the transverse process of the C6 vertebra and can be easily palpated anteriorly. The carotid tubercle is an important landmark for stellate ganglion blocks.

6

6. The stellate ganglion is located
(A) anterior to the transverse process of the
C6 vertebra
(B) posterior to the subclavian artery
(C) anterior to the transverse process of the
C5 vertebra
(D) anterior to the neck of the first rib and
the transverse process of the C7 vertebra
(E) anterior to the transverse process of the
first thoracic vertbra

6. (D) The stellate ganglion is the inferior cervical ganglion. The cervicothoracic ganglion is frequently formed by the fusion of the inferior cervical ganglion and the first thoracic ganglion. It is located anteriorly on the neck of the first rib and the transverse process of the C7 vertebra. It is oval in shape and 1” long by 0.5” wide. The ganglion
is bound anteriorly by the subclavian artery,
posteriorly by the prevertebral fascia and the
transverse process, medially by the longus colli muscle, and laterally by the scalene muscle. The classical stellate ganglion block is done one level above the location of the stellate ganglion (it lies at the C7 level and the block is done at the C6 level). Typically the classical stellate ganglion block is performed with the patient supine, however,
immediately after the block the patient is
repositioned to a sitting position. The vertebral
artery travels anteriorly over the stellate ganglion at C7 but at C6 the artery moves posteriorly. Incidence of phrenic nerve block is almost 100%.

7

7. Features of Horner syndrome consist of the
following, EXCEPT
(A) ptosis
(B) anhydrosis
(C) miosis
(D) enophthalmos
(E) mydriasis

7. (B) Horner syndrome consists of ptosis (drooping of the upper eyelid), miosis, (constriction of the pupil) and enophthalmos (depression of the eyeball into the orbit) only. Anhydrosis, nasal congestion, flushing of the conjunctiva and skin, and increase in temperature of the ipsilateral arm and
hand are not features of Horner syndrome.
The cervical portion of the sympathetic
nervous system extends from the base of the
skull to the neck of the first rib, it then continues as the thoracic part of the sympathetic chain. The cervical sympathetic system consists of the superior,
middle, and inferior ganglia. In most people
the inferior cervical ganglia is fused with the first thoracic ganglia to form the stellate ganglion. It lies over the neck of the first rib and the transverse process of C7, behind the vertebral artery.

8

8. A 35-year-old woman with Complex Regional Pain Syndrome type I of the right upper extremity develops miosis, ptosis, and enophthalmos after undergoing a stellate ganglion block. She does not notice any significant pain relief. No significant rise in skin temperature was recorded in 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) Inadvertent injection of normal saline

8. (D) 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 fibers do not pass through the stellate ganglion. These are Kuntz fibers and have been implicated in inadequate relief of sympathetically maintained pain despite a good stellate ganglion block. These fibers can be blocked by a posterior approach.
Successful block of the sympathetic fibers
to the head is indicated by the appearance of
Horner 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. Alternatively, it is conceivable that the patient has sympathetic independent pain.

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9. The greater occipital nerve is a branch of
(A) posterior ramus of C2
(B) posterior ramus of C1
(C) anterior ramus of C1
(D) anterior ramus of C2
(E) trigeminal nerve

9. (A) The skin over the posterior part of the neck, upper back, posterior part of the scalp up to the vertex is supplied segmentally by the posterior rami of the C2 to C5. The greater occipital nerve is a branch of the posterior of ramus of C2. The lesser occipital nerve is a branch of the posterior ramus of C2 and C3. Headaches due to occipital neuralgia are characterized by either continuous pain or paroxysmal lancinating pain in the distribution of the nerve. The etiology of occipital neuralgia is compression of the C2 nerve root, migraine, or nerve entrapment. An
occipital nerve block maybe performed as a
diagnostic or therapeutic measure. The trigeminal nerve does not contribute to the greater occipital nerve.

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10. A66-year-old woman presents with pain in the posterior cervical region for the last 1 year. It radiates to the right shoulder, lateral upper
arm, and right index finger. She also complains in the medial part of the right scapula and anterior shoulder. On physical examination, she has numbness to the index and middle fingers of the right hand and weakness of the triceps muscle. The most likely cause of her pain is
(A) herniated nucleus pulposus of the C5 to
C6 disc causing compression of the C5
nerve root
(B) herniated nucleus pulposus of the C5 to
C6 disc causing compression of the C6
nerve root
(C) herniated nucleus pulposus of the C6 to
C7 disc causing compression of the C7
nerve root
(D) herniated nucleus pulposus of the C6 to
C7 disc causing compression of the C6
nerve root
(E) muscle spasm

10. (C) The pattern of pain helps identify the cervical disc causing the most problems. HNP are more common in the lumbar region. The cervical nerve roots exit above the vertebral body of the same segment. The C7 nerve root exits between the C6 to C7 vertebra.

11

11. Blood supply to the spinal cord is by
(A) two posterior spinal arteries and two
anterior spinal arteries
(B) two posterior spinal arteries and one
anterior spinal artery
(C) branches of the lumbar arteries
(D) radicularis magna (artery of
Adamkiewicz) and two posterior spinal
arteries
(E) internal iliac arteries

11. (B) The blood supply to the spinal cord is primarily by three longitudinally running arteries— two posterior spinal arteries and one anterior spinal artery. The anterior spinal artery supplies approximately 80% of the intrinsic spinal cord vasculature.
It is formed by the union of a branch
from the terminal part of each vertebral artery.
It actually consists of longitudinal series of
functionally individual blood vessels with wide
variation in lumen size and anatomic discontinuations. The spinal cord has three major arterial supply regions: C1 to T3 (cervicothoracic region), T3 to T8 (midthoracic region), and T8 to the conus (thoracolumbar region). There is a poor anastomosis between these three regions. As a result the blood flow at the T3 and T8 levels is tenuous. In spinal stenosis, especially in the lower cervical region, the anterior spinal artery may be compressed by a dorsal osteophyte
and a HNP leading to the anterior spinal
syndrome (loss of motor function).
There are two posterior spinal arteries that
arise from the posterior inferior cerebellar
arteries. The three longitudinal arteries are reinforced by “feeder” arteries. They are spinal branches of the cervical, vertebral posterior intercostal, lumbar, and lateral sacral arteries. Approximately six or seven of these contribute to the anterior spinal artery and another six or seven to the posterior spinal arteries, but at different levels. The largest of these arteries is known as the radicularis magna or the artery of Adamkiewicz.

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12. The most common origin of the artery of
Adamkiewicz is
(A) between T4 and T6
(B) at T7
(C) between T8 and L3
(D) at L4
(E) at L5

12. (C) The artery of Adamkiewicz originates on the left between the T8 and L3 level in most cases. This is the largest of the feeder arteries that supplies the anterior spinal artery. The artery of Adamkiewicz enters through an intervertebral foramen between T8 and L3 to supply the lumbar enlargement.
In a small percentage of cases (15%) the
take off is higher at T5. In this case a slender
contribution from the iliac artery enlarges to
compensate for the increased blood flow to the lumbar portion of the cord and the conus.
The cervical portion up to the upper thoracic
region, the anterior spinal artery receives
contributions from the subclavian arteries. By
the time the blood reaches the T4 segment it
becomes tenuous. Although, the T4 to T9 area of the spinal cord receives blood from the feeder vessels, it is relatively small.

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13. The most common location of the dorsal root ganglion is
(A) medial to the pedicle within the lateral
recess
(B) inferolateral to the pedicle
(C) lateral to the superior articular facet of
the corresponding vertebra
(D) directly below the pedicle
(E) medial to the superior articular facet of
the corresponding vertebra

13. (D) In approximately 90% of cases the DRG
lies in the middle zone of the intervertebral
foramen, directly below the pedicle. In approximately, 8% of cases it is inferolateral and in 2% of cases it is medial to the pedicle. The center of the DRG lies over the lateral portion of the intervertebral disc in some cases. Its size increases from L1 to S1 and then progressively decreases till S4. The DRG at S1 is 6 mm in width. The DRG contains multiple sensory cell bodies. It is the site for production of neuropeptides: substance P, enkephalin, VIP (vasoactive intestinal peptides), and other neuropeptides.
The DRG is a primary source of pain when
it undergoes mechanical deformity as by an
osteophyte, HNP, or stenosis. It also produces
pain when it undergoes an inflammatory process either by infection or chemical irritation from a herniated nucleus pulposus, release of local neuropeptides or local vascular compromise.

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14. Absolute central lumbar spinal stenosis is
defined as
(A) less than 8 mm diameter
(B) less than 10 mm diameter
(C) less than 12 mm diameter
(D) pain at rest
(E) pain with ambulation

14. (B) The spinal canal is nearly round in shape; it is 12 mm or more in the anteroposterior diameter. Relative stenosis is defined as midline sagittal diameter of < 12 mm. The reserve capacity is reduced and any small disc herniation and mild degenerative changes may cause symptoms. Absolute stenosis is defined as a sagittal diameter < 10 mm

15

15. The principal action of the quadratus lumborum
muscle is
(A) lateral flexion of the lumbar spine
(B) axial rotation of the lumbar spine
(C) extension of the lumbar spine
D) fixation of the 12th rib during
respiration
(E) forward flexion of the lumbar spine

15. (D) The principal action of the quadratus lumborum
(QL) muscle is to fix the 12th rib during
respiration. It is a weak lateral flexor of the
lumbar spine. The QL is a flat rectangular
muscle that arises below from the iliolumbar
ligament and the adjacent iliac crest. The insertion is into the lower border of the 12th rib and the transverse processes of the upper four lumbar vertebrae. Patients with spasm of the QL muscle usually present with low back pain. They have difficulty turning over in bed, increased pain with standing upright. Coughing or sneezing may exacerbate their pain. These patients respond
well to trigger point injections and stretching.

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16. The following structure passes under the inguinal
ligament:
(A) Inferior epigastric artery
(B) Lateral femoral cutaneous nerve
(C) Obturator nerve
(D) Intra-articular nerve of the hip joint
(E) Sciatic nerve

16. (B) The structures that pass under the inguinal ligament, medial to lateral are: femoral vein, femoral artery, inguinal nerve, femoral nerve, and lateral femoral cutaneous nerve. The following muscles also pass under the inguinal ligament: pectineus, psoas major, iliacus. The inferior epigastric artery passes under the rectus sheath. The obturator nerve passes through the obturator foramen. The sciatic nerve is located posteriorly.

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17. The structure that passes under the flexor
reticulum of the wrist is
(A) median nerve
(B) radial nerve
(C) ulnar nerve
(D) anterior interosseous nerve
(E) extensor digitorum longus

17. (A) The flexor reticulum (retinaculum) is
fibrous band which is attached medially to the
pisiform and the hamate bone. It is attached laterally to the scaphoid and trapezium. The area under the flexor reticulum is known as the carpal tunnel, through which pass flexor tendons of the digits and the median nerve. The radial and ulnar nerves do not pass under the reticulum. The extensor digitorum longus
tendon lies on the dorsum of the wrist.

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18. A boxer complains of pain in his hand after
punching a bag. What is the most likely cause?
(A) Avulsed ulnar ligament
(B) Scaphoid fracture
(C) Fracture of distal radius
(D) Metacarpal fracture
(E) Dislocation of the fifth proximal
interphalangeal joint

18. (D) The boxer’s fracture involves the neck of the metacarpal. This is the most common site for fracture when punching a stationary object. The fracture occurs commonly in the fourth and fifth metacarpal bones. A fracture of the scaphoid bone is usually seen after a fall on the outstretched hand. Fracture of the distal radius is also know as Colles fracture and usually occurs after a fall on the outstretched hand.

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19. In the dorsal horn of the spinal cord:
(A) Cells from lamina I and II project to the
hypothalamus
(B) Stimulation of lamina I and II produces
pain
(C) Lamina I and II are found in the thoracic
segment of the spinal cord only
(D) Discharge from lamina I and II decreases
as a noxious stimulus increases
(E) Wide dynamic range (WDR) neurons are
located predominantly in lamina I and II

19. (B) The Rexed laminae is a complex of 10 layers of grey matter located in the spinal cord. They are labeled as I to X.
Laminae I to VI are in the dorsal horn and VII to IX are in the ventral horn. Lamina X borders the central canal of the spinal cord. Lamina I is also known as the posteromarginal nucleus. The neurons in lamina I receive input mainly from Lissauer tract. They relay pain and temperature sensation. Lamina II is known as substantia gelatinosa. The neurons
contain μ- and κ-opioid receptors. C fibers terminate in the substantia gelatinosa. Lamina I and II are found along the entire spinal cord.
The neurons in lamina I project to the thalamus. WDR neurons are concentrated in lamina V.

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20. In case of an injury of a peripheral nerve:
(A) Wallerian degeneration of the proximal
nerve occurs
(B) The rate of regeneration is 1 mm/d
(C) Sensory nerves regenerate faster than
motor nerves
(D) An inflammatory response occurs
(E) Regeneration of the nerves is faster in
the central nervous system than the
peripheral nervous system

20. (B) Wallerian degeneration results after an axonal injury. It starts within 24 hours of the injury and occurs at the distal end of the cut axon. The rate of regeneration is approximately 1 mm/d. Regeneration in the peripheral nervous system is more rapid than the central nervous system. Motor nerve regenerate earlier than sensory nerves.

21

Neuropraxia is
(A) anatomical disruption of a nerve
(B) loss of conduction of a nerve
(C) pain due to peripheral nerve injury
(D) muscle tremor
(E) increased conduction of a nerve

21. (B) Neuropraxia is a nerve damage without any disruption of the myelin sheath. There is an interruption in conduction of nerve impulses. There is a transient loss of motor conduction. Little to no sensory conduction is affected. This is a common sports injury.

22

The following are true about pain, EXCEPT
(A) transmitted faster through C fibers
(B) some pain may travel through the
dorsal column
(C) μ-receptors when stimulated in the
brain produce analgesia
(D) intractable pain due to cancer cannot be
effectively treated by hypophysectomy
(E) transmitted slower through C fibers

22. (A) C-fibers are unmyelinated and hence have a slow conduction velocity ( 2 m/s). All sensory transmission takes place through the dorsal column. Hypophysectomy can be performed for intractable pain.

23

A-δ fibers:
(A) Are unmyelinated
(B) Are low-threshold mechanoreceptors
(C) Increase their firing as the intensity of
the stimulus increases
(D) Do not respond to noxious stimuli
(E) Are thick nerves

23. (C) A-δ fibers are thin, myelinated fibers, hence have a faster conduction velocity than C fibers. They are high threshold mechanoreceptors. They are associated with sharp pain, temperature,
cold, and pressure sensations.

24

24. All of the following statements are true regarding fentanyl as a good agent for transdermal use,
EXCEPT
(A) low molecular weight
(B) adequate lipid solubility
(C) high analgesic potency
(D) low abuse potential
(E) high molecular weight

24. (E) Fentanyl has a low molecular weight and high lipid solubility; this allows it to be administered by the transdermal route. It interacts primarily with the μ-receptors. It is about 80 times more potent than morphine. The low abuse potential for fentanyl
is a property of the transdermal delivery
system and not of the opioid itself.

25

25. All of the following agents are α2-agonists,
EXCEPT
(A) clonidine
(B) antipamezole
(C) tizanidine
(D) dexmedetomidine
(E) baclofen?????

25. (B) Clonidine, tizanidine, and dexmedetomidine are α2-agonists. Antipamazole is an α2-antagonist.
α2-Agonists have been used in the management of hypertension for many years. Their role has now expanded to chronic pain management and as muscle relaxants. One proposed mechanism of analgesic action of α2-agonists is by reducing sympathetic
outflow by a direct action on the preganglionic
outflow at the spinal level. Clonidine is available in oral, transdermal, and epidural or intrathecal use form. It is used for the treatment of complex regional pain syndromes, cancer pain, headaches, postherpetic neuralgia, and peripheral neuropathy. Tizanidine has been used for painful conditions involving spasticity. Dexmedetomidine is currently used as sedative in the intensive care unit.

26

26. The antidepressant with the lowest sedation
side effect is
(A) desipramine
(B) trazodone
(C) nortriptyline
(D) maprotiline
(E) amitriptyline

26. (A) Tricyclic antidepressants (TCA) have been known to be effective in managing chronic pain. Unfortunately, their side-effect profile very often limits their clinical use. Some of the major side effects include orthostatic hypotension, anticholinergic effects, weight gain, sedation, cardiac conduction disturbances, sexual dysfunction, and
restlessness. TCAs with lower sedating effects include protriptyline, amoxapine, desipramine, and imipramine. Trazodone is an atypical antidepressant. It inhibits serotonin uptake and blocks serotonin 5-HT2 receptors, α1-receptor antagonist.
Its most common side effects are sedation
and orthostatic hypotension. At low doses it is
used as an adjunct for insomnia.

27

Methadone in addition to being a μ-receptor
agonist has been proposed to also act as a
(A) cyclooxygenase 2 (COX-2) inhibitor
(B) sodium-channel blocker
(C) N-methyl-D-aspartate (NMDA) receptor
antagonist
(D) δ-receptor agonist
(E) α2-agonist

27. (C) Methadone is a synthetic opioid derivative which seems to function both as a μ-receptor agonist and an NMDA receptor antagonist. It is equipotent to morphine after parenteral administration. The drug has a tendency to accumulate with repeated administration. It is excreted almost exclusively in the feces and can be given
to patients with compromised renal function;
however, caution should be used.
One of the two rate-limiting steps in prostaglandin synthesis is the conversion of
arachidonic acid to the prostanoid precursor
prostaglandin H2(PGH2) by cyclooxygenase
(COX). COX-2 is an isozyme of COX and mediates responses to inflammation, infection, and injury

28

28. The beneficial effects of epidural administration of steroids have been attributed to all of the following, EXCEPT
(A) inhibit phospholipase A2
(B) improve microcirculation around the
nerve root
(C) NMDA antagonist
(D) block conduction of nociceptive C nerve
fibers
(E) μ-receptor agonist

28. (C) Administration of epidural steroids by
interlaminar or transforaminal approach is one
of the most common approaches to treating
spinal and radicular pain. Steroids decrease
inflammation by inhibiting phospholipase A2,
thus inhibiting the formation of arachidonic acid, prostaglandins, and leukotrienes.
Steroids may reduce inflammatory edema
around the inflamed nerve root and improve
microcirculation. They block the conduction of
nociceptive C fibers. By restricting the formation of prostaglandins they may decrease sensitization of the dorsal horn neurons.

29

29. A22-year-old healthy woman with a history for migraine headaches develops an intense frontal headache after eating ice cream at a party. The pain is sharp and intense. What is the most likely
diagnosis?
(A) Frontal sinusitis
(B) Cold stimulus headache
(C) Conversion headache
(D) Chronic paroxysmal hemicranias
(E) Aneurysm

29. (B) Cold stimulus headache starts with exposure of the head to very cold temperatures as in diving into cold water. An intense focused pain develops in the frontal region when very cold food is ingested. The pain lasts for a short duration of a few minutes. It may be in the frontal or retropharyngeal region. A frontal sinusitis is a persistent frontal headache and does not have an abrupt onset. Conversion headaches are associated with severe behavioral abnormalities. Chronic paroxysmal
hemicrania is very similar to a cluster
headache in the form that it is similar in intensity and location. The attacks are short and frequent. They respond well to indomethacin.

30

30. An 18-year-old woman presents with frequent headaches, each lasting for several days. She has to take time off from school. She describes them as throbbing, localized to the temporal region. They are associated with nausea and vomiting, sensitivity to sound and light. A recent MRI was normal. A diagnostic lumbar puncture done was normal. The most probable cause of her headaches is
(A) migraine without aura
(B) postdural puncture headache
(C) tension-type headache
(D) temporal arteritis
(E) malingering

30. (A) The management of headaches is based on the correct diagnosis. Postdural puncture headaches develop after a dural puncture such as a spinal tap. The pain is usually frontal and occipital. It becomes worse in the upright position
and is relieved significantly with lying
supine. Some patients develop sixth cranial
nerve palsy because of the long intracranial
course of the sixth cranial nerve.
The differentiation between tension-type
headache (TTH) and migraine without aura is
much more difficult. Very often both headaches coexist. TTHs are tightening or pressing in character. They are mild to moderate in intensity and are bilateral. TTH is seldom associated with nausea and in most patients TTH is not greatly exacerbated by physical activity.
Giant-cell (temporal) arteritis affects the
extracranial vessels of the head and arms.
There is tenderness over the scalp. The temporal or occipital arteries are enlarged and tender. They may have visual symptoms including amaurosis fugax, diplopia, and blindness. Most patients also have symptoms of intermittent claudication with chewing. A temporal artery biopsy is diagnostic.
According to the International Headache
Society, headaches are classified into primary
and secondary headache disorders. The primary headache disorders consist of:
Migraine with aura
Migraine without aura
Tension-type headache—chronic and episodic
Cluster headache—chronic and episodic
Primary headaches, such as migraine with or
without aura, tension-type, and cluster headache constitute about 90% of all headaches. Migraine as defined by the International Headache Society is idiopathic, recurring headache disorder
manifesting in attacks lasting 4 to 72 hours.

31

31. The cricoid cartilage corresponds with the
following vertebra:
(A) C3
(B) C4
(C) C5
(D) C6
(E) C7

31. (D) The carotid tubercle (Chassaignac tubercle) lies 2.5 cm lateral to the cricoid cartilage. It is a part of the transverse process of the C6 vertebra and can be easily palpated. The carotid tubercle is an important landmark for stellate ganglion blocks.

32

32. Rotation of the cervical spine occurs at
(A) atlantooccipital joint
(B) atlantoaxial joint
(C) atlantofacet joint
(D) cervical-facet joints at C2-C3
(E) cervical-facet joints at C3-C4

32. (B) The normal cervical spine can rotate
between 160° and 180°. Approximately 50% of
this occurs at the atlantoaxial joint. The rest of
the rotation occurs below that level. Nodding
flexion and extension occurs at the atlantooccipital joint. Rotation occurs at the atlantoaxial joint, especially at the atlantoodontoid joint.

33

33. The nucleus pulposus in the cervical spine is absent after the age of
(A) 20 years
(B) 40 years
(C) 50 years
(D) 60 years
(E) 70 years

33. (B) The nucleus pulposus in the cervical disc is present at birth but by the age of 40 years it practically disappears. The adult disc is desiccated and ligamentous. It is mainly composed of fibrocartilage and hyaline cartilage. After the age of 40 years, a herniated cervical disc is never seen
because there is no nucleus pulposus.
A cleft appears in the lateral part of the
annulus fibrosus at 9 to 14 years. This cleft
gradually dissects toward the midline. By
60 years the annular desiccation is so advanced that a transverse cleft develops from one uncinate
process to the other. The disc is bisected.

34

34. Kuntz nerves are a contribution from
(A) the C5 sympathetic fibers to the upper
extremity
(B) the C6 sympathetic fibers to the upper
extremity
(C) the T1 sympathetic fibers to the upper
extremity
(D) the T2 sympathetic fibers to the upper
extremity
(E) the C7 sympathetic fibers to the upper
extremity

34. (D) 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 fibers do not pass through the stellate ganglion. These are Kuntz fibers and have been implicated in inadequate relief of sympathetically maintained pain despite a good stellate ganglion block. These fibers can be blocked by a posterior approach.

35

35. Achilles reflex is diminished when the following
nerve root is affected:
(A) L3
(B) L4
(C) L5
(D) S1
(E) L2

35. (D) Achilles reflex is also referred to as ankle
jerk reflex. This reflex tests the S1 and S2 nerve
root. The Achilles tendon is tapped while the
foot is dorsiflexed.

Reflex/ Muscle Contraction/ Myotome/ Nerve
Patellar/ Quadriceps femoris /L2, L3, L4/ Femoral
Achilles/ Gastroc and soleus /S1, S2 /Tibial
The Achilles tendon reflex is diminished when
the S1 nerve root is affected.

36

36. The dermatome corresponding to the area over the medial malleolus is
(A) L4
(B) L5
(C) S1
(D) S2
(E) L3

(A) Nerve root and corresponding dermatome
levels:
Level Dermatome
L1 Upper thigh and groin
L2 Mid anterior thigh
L3 Medial femoral condyle
L4 Medial malleolus
L5 Dorsum of the foot at
metatarsal phalangeal joint
S1 Lateral heel
S2 Popliteal fossa

37

37. The medial branch of the dorsal rami innervates the following
(A) multifidus muscle
(B) subarachnoid mater
(C) ligamentum flavum
(D) quadratus lumborum muscle
(E) piriformis muscle

37. (A) The medial branch innervates the facet joint, interspinous ligament and the multifidus muscle. During the stimulation phase of radio frequency of denervation of the medial branch, contraction of the multifidus muscle is often seen.

38

38. The psoas major muscle is
(A) flexor of the spine
(B) flexor of the hip
(C) inserts into the greater trochanter of the
femur
(D) axial rotator of the lumbar spine
(E) extensor of the spine

38. (B) The psoas major muscle arises from the anterolateral aspect of the lumbar vertebrae and inserts into the lesser trochanter of the femur. It is a flexor of the hip but does not flex the lumbar spine. Contraction of the psoas major exerts an
intense compression on the intervertebral discs

39

39. The principal action of the piriformis muscle is
(A) lateral flexion of the hip
(B) external rotation of the femur
(C) extension of the hip
(D) internal rotation of the femur
(E) knee flexion

39. (B) The piriformis muscle rotates the extended thigh externally and abducts the flexed thigh. It does not cause flexion of the knee, extension of the thigh, lateal flexion of the thigh. Aspasm of the piriformis muscle may present as buttock pain. The piriformis muscle can be tested clinically
by asking the subject to abduct the thigh
while seated.

40

40. The lumbar facet joint is innervated by
(A) branches from the dorsal ramus at the
same level and level above
(B) branches from the dorsal ramus at the
same level and level below
(C) branches from the dorsal ramus at the
same level
(D) branches from the dorsal ramus at the
level below and level above
(E) corresponding spinal nerve root

40. (A) The facet joint capsule has a dual nerve
supply. Each facet joint is supplied by the
median branch from the dorsal nerve root at the same level and the level above.

41

41. The lumbar facet joints are oriented:
(A) In coronal plane
(B) In a sagittal plane
(C) 45° off the saggital plane
(D) 20° off the coronal plane
(E) 20° off the saggital plane

41. (C) The cervical facet joints are oriented in a coronal plane to allow for extension, flexion, and lateral bending. The thoracic facets are oriented approximately 20° off the coronal plane. The lumbar facet joints are oriented 45° off the saggital plane.

42

42. The nerve involved in meralgia paresthetica is
(A) lateral femoral cutaneous nerve
(B) medial femoral cutaneous nerve
(C) femoral nerve
(D) obturator nerve
(E) Inguinal nerve

42. (A) The lateral femoral cutaneous nerve arises from L2 and L3. It passes below the inguinal ligament, medial to the anterior superior iliac spine. Meralgia paresthetica is caused by neuritis of the nerve, usually by compression of a tight belt or overhanging abdominal fat.

43

43. The lumbar sympathetic chain lies
(A) anterior to the transverse process of the
lumbar vertebra
(B) anterolateral border of the lumbar
vertebral bodies
(C) anteriorly over the lumbar vertebral
bodies
(D) posteriorly to the abdominal aorta
(E) posteriorly to the inferior vena cava

43. (B) The lumbar sympathetic chain consists of
the preganglionic axons and postganglionic neurons. It lies on the anterolateral border of the vertebral bodies. The aorta is anterior and
medial to the chain.

44

44. A 56-year-old man presents with pain in the left flank. He gives a history of a rash for 1 week. The pain is burning in character and is sensitive to touch. He most likely has
(A) costochondritis
(B) herpes zoster
(C) fractured left rib
(D) postherpetic neuralgia
(E) angina pectoris

44. (D) Postherpetic neuralgia is defined as a syndrome of intractable neuropathic pain persisting for 1 month after the rash following herpes zoster has healed. It has been variably defined as pain persisting beyond 1, 2, or 6 months after the rash. The incidence of postherpetic neuralgia has been
estimated from 9% to 14%. Approximately 50% at 60 years age and 75% at age 70 years who
develop herpes zoster are likely to develop postherpetic neuralgia.

45

45. Pain in the gluteal region produced by hip flexion, adduction, and internal rotation is caused by
(A) sacroiliac joint
(B) obturator muscle
(C) hip joint
(D) piriformis muscle
(E) gluteus medius

45. (D) Stretching the piriformis muscle by flexing, adducting, and internal rotation of the hip, stretches the piriformis muscle. The sacroiliac joint and hip joint are tested using Patrick test. The gluteus medius is more superficial muscle, laterally and does produce pain with the mentioned maneuver.