Chapter 3. Pain Pathophysiology Flashcards Preview

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Flashcards in Chapter 3. Pain Pathophysiology Deck (50):
1

91. Common causes of acute abdominal pain in
adults include
(A) intussusception in an adolescent patient
(B) abdominal aortic aneurysm in an adult
population, which most likely presents
with excruciating abdominal pain
(C) diabetic ketoacidosis in an elderly
patient without a previous history of
diabetes
(D) drug-induced pain from polypharmacy
that is rarely a cause of abdominal pain
in the elderly
(E) interstitial cystitis

91. (C) Diabetic ketoacidosis needs to be ruled out (in
addition to myocardial infarction, pneumonia,
pyelonephritis, and inflammatory bowel disease)
as a cause of abdominal pain. The most common
cause of abdominal pain in infants is intussusception.
Although abdominal aortic aneurysms,
which are a manifestation of atherosclerosis, do
occur in an adult population, they usually do not
present with specific clinical symptom of abdominal
pain. Finally, drug-related abdominal pain is
very common in the elderly

2

92. A 35-year-old woman has right arm pain.
Which of the following statements regarding
her pain is true?
(A) It is more likely she will have arterial thoracic outlet syndrome than neurogenic thoracic outlet syndrome
(B) If it began in the ulnar nerve distribution after an injury to the ulnar nerve, she may have complex regional pain
syndrome (CRPS) type I
(C) If she also has pain radiating into her occiput, she may have involvement of the sensory portion of the C1 nerve
(D) If she has clawing of the small finger, the median nerve is likely involved
(E) The ulnar nerve is commonly compressed at the cubital tunnel

92. (E)
A. The majority of cases of thoracic outlet
syndrome are categorized as neurogenic
thoracic outlet syndrome.
B. CRPS type II is when an identifiable neural
injury is present.
C. The first cervical nerve does not have a
sensory branch.
D. Ulnar neuropathy often has clawing of the
small finger.

3

93. You suspect a patient is having cluster headaches.
The most convincing evidence of this type of
headache would be if
(A) the patient is female
(B) although it is worse on the right side of the head, the symptoms are usually bilateral
(C) the headaches are occurring at the same time each night
(D) the patient is having a rebound headache due to excessive use of medication and the most likely underlying recurring headache is a cluster headache
(E) the patient is urinating frequently and
has blurry vision

93. (C)
A. Cluster headaches occur predominantly in
males.
B. Cluster headaches occur unilaterally and
are accompanied by lacrimation, nasal congestion,
conjunctival injection, and ptosis.
Patients tend to get clusters of headaches
occurring the same time daily (often at night).
C. Patients tend to get cluster headaches the
same time daily (often at night).
D. Patients with rebound headaches are often
overmedicating an underlying migraine
headache.
E. Patients with cluster headache do not routinely
experience polyuria or changes in
visual acuity.

4

94. Which of the following statements about migraine
headache is true?
(A) Recent evidence has supported the notion that cortical spreading depression is the mechanism of migraine headache
(B) Activation of cortical spreading depression
has become an interesting target for preventive migraine treatment
(C) Current evidence shows a clear causal relationship between cardiac right-toleft shunt (RLS) and migraine headaches
(D) Migraine pathophysiology involves the trigeminovascular system but not central nervous system (CNS) modulation of the pain-producing structures of the
cranium
(E) More than 90% of migraineurs have auras

94. (A)
A. The recent discovery of multiple point
mutations in familial hemiplegic migraine
has led to the suggestion that migraine and
its variants may be caused by a paroxysmal
disturbance in ion-translocating mechanisms.
Mutations associated with familial
hemiplegic migraine render the brain more
susceptible to prolonged cortical spreading
depression caused by either excessive synaptic
glutamate release or decreased removal of
glutamate and potassium from the synaptic
cleft, or persistent sodium influx.
B. Suppression of cortical spreading depression
has become an interesting target for
preventive migraine treatment. Prolonged
treatment with β-blockers, valproate, topiramate,
methysergide, or amitriptyline
reduced the number of potassium-evoked
cortical spreading depressions and elevated
the electrical stimulation threshold for
the induction of cortical spreading depression
in rats. Recent imaging studies in
patients suffering from migraine without
aura also points to the presence of silent
cortical spreading depression as an underlying
mechanism. Repeated waves of
cortical spreading depression may have
deleterious effects on brain function, and
perhaps cause silent ischemic lesions in
vulnerable brain regions such as the cerebellum
in susceptible individuals.
C. There is an association between RLS and
migraine. The relationship between RLS
and migraine is further supported by the
disappearance and improvement of migraine
symptoms after closure of the foramen ovale.
Nonetheless, the mechanism as well as the
question about causality of this association
has to be further elucidated.
D. Migraine pathophysiology has been
demonstrated to involve the trigeminovascular
system and CNS modulation of the
pain-producing structures of the cranium.

5

95. A patient you are seeing recently began experiencing
low-back pain. You suspect zygapophysial
joint arthropathy as the primary cause of the
symptoms. Which of the following can be said
about this disease process?
(A) Predisposing factors include spondylolisthesis
and old age; however, degenerative
disc pathology is not a risk factor
(B) The key to diagnosing zygapophysial
joint arthropathy is the historic and
physical examination
(C) An accepted method for diagnosing
pain arising from the lumbar facet joints
is with low-volume intra-articular or
medial branch blocks because of the low
false-positive rate
(D) Cadaveric studies of the facet joints in
patients with suspected arthropathy
have revealed histologic changes
(E) Its clinical presentation is characterized
as a radicular pattern

95. (D)
A. The onset of lumbar facet joint pain is usually
insidious, with predisposing factors
including spondylolisthesis, degenerative
disc pathology, and old age.
B. The existing literature does not support the
use of historic or physical examination findings
to diagnose lumbar zygapophysial
joint pain.
C. The most accepted method for diagnosing
pain arising from the lumbar facet joints is
with low-volume intra-articular or medial
branch blocks, both of which are associated
with high false-positive rates.
D. Histologic studies of the facet joints in
patients with suspected arthropathy have
revealed pathology.

6

96. Which of the following statements regarding
postmastectomy neuromas is true?
(A) In general, neuromas are palpable
(B) Neuromas form with mastectomy but
usually not with lumpectomy
(C) Neuromas are most likely the cause of a
painful scar
(D) Resection should not be considered for
an intercostal neuroma
(E) None of the above

96. (C)
A. Neuromas can form whenever peripheral
nerves are severed or injured. Macroneuromas
consist of a palpable mass of
tangled axons unable to regenerate to their
target, fibroblasts, and other cells, whereas
microneuromas contain small numbers of
axons and may not be palpable.
B. Both mastectomy and lumpectomy leave a
scar in which neuromas can form. Chronically
painful scars can develop after mastectomy
and lumpectomy, and abnormal
neuronal activity originating in neuromas
or entrapped axons within this scar tissue
is the likely mechanism of such pain.
Neuroma pain may be more common following
lumpectomy than mastectomy.
C. Axons entrapped within these scars
can cause spontaneous pain and severe
mechanosensitivity.
D. Anecdotal reports suggest that resection of
intercostal neuromas may alleviate chronic
pain after breast cancer surgery.

7

97. You suspect nerve root impingement in the cervical
spine. Which of the following physical
findings would support this diagnosis?
(A) You suspect C1 nerve root involvement and the patient has numbness over the occiput
(B) You suspect C6 nerve root involvement and the patient has loss of the biceps reflex
(C) You suspect C7 nerve root involvement and the patient has loss of strength in the deltoid
(D) Carpal tunnel syndrome (CTS) would
be excluded by a normal examination of
the abductor pollicis brevis (APB)
(E) You suspect C8 nerve root involvement
and the patient has numbness in the lateral
aspect of the forearm

97. (B)
A. The C1 nerve root has no sensory component.
B. C6 radiculopathy can be accompanied by
a loss of bicep reflex.
C. With C7 nerve roots, paresis affects the finger
and wrist flexors and extensors. The triceps
reflex is also innervated by the C7
nerve root; the deltoid is innervated by C5,
C6 nerve roots.
D. Although the median nerve (which is affected
in CTS) innervates the APB as well as the
opponens pollicis, a normal motor examination
does not exclude the possibility of CTS.

8

98. Which is the following statements regarding
neck pain is true?
(A) Peer reviewed literature suggests that
there may be short-term benefit derived
from treatment with acupuncture
(B) Neck pain following an
acceleration/deceleration injury most
commonly involves the lower cervical
spine
(C) If you suspect an acute cervical disc herniation,
it is important to ask about
bowel and bladder incontinence because
of the risk of cauda equina syndrome
(D) A patient with neck pain alone may
meet the criteria for fibromyalgia
(E) CTS cannot have associated neck pain

98. (A)
A. Peer-reviewed literature suggests that
acupuncture is effective in the short-term
management of low-back pain, neck pain,
and osteoarthritis involving the knee.
However, the literature also suggests that
short-term treatment with acupuncture
does not result in long-term benefits. Data
regarding the efficacy of acupuncture for
dental pain, colonoscopy pain, and intraoperative
analgesia are inconclusive. Studies
describing the use of acupuncture during
labor suggest that it may be useful during
the early stages, but not throughout the
course of labor. Finally, the effects of
acupuncture on postoperative pain are
inconclusive and are dependent on the timing
of the intervention and the patient’s
level of consciousness.
B. Upper cervical pain is most common with
involvement of the suboccipital area as
well as the C2-3 dermatomes.
C. In cauda equina syndrome, there is acute
loss of function of the neurologic elements
below the termination of the spinal cord.
This occurs at the level of the lumbar spine.
D. In 1990, the American College of Rheumatology
(ACR) established criteria for classifying
patients with fibromyalgia which
consists of tenderness in 11 of 18 standardized
tender points. Only six to eight are located
in the neck and associated structures.
E. CTS can have associated neck pain.

9

99. Which of the following statements regarding
fibromyalgia is true?
(A) Two central criteria for fibromyalgia are
chronic widespread pain (CWP) defined
as pain in all four quadrants of the body
and the axial skeleton for at least
2 years, and the finding of pain by 25-kg
pressure on digital palpation of at least
11 of the 18 defined tender points
(B) It is generally agreed that abnormal
CNS mechanisms are responsible for all
of the symptoms of fibromyalgia
(C) There are both primary and secondary
fibromyalgia syndromes
(D) Fibromyalgia symptoms generally
resolve if a rheumatic process is identified
and treated appropriately
(E) Most of fibromyalgia patients are male

99. (C)
A. The two operational criteria are chronic
widespread pain (CWP) defined as pain in
all four quadrants of the body and the axial
skeleton for at least 3 months, and the finding
of pain by 4-kg pressure on digital palpation
of at least 11 of 18 defined tender
points.
B. The exact pathogenesis of fibromyalgia has
not been cleared up yet, but according to
the currently held view a variety of biological,
psychological, and social factors play a
role in the manifestation of the disorder.
Among other things, inflammatory, traumatic,
and immunological processes; static
problems; endocrine disorders; and depressions,
anxiety conditions, and stress factors
are thought to trigger the syndrome. Adysfunction
of the central affective and/or
sensory pain memory may possibly be at
work in the different illnesses mentioned
above, which then results in fibromyalgia
pain.
C. In principle, fibromyalgia can be categorized
as primary or secondary fibromyalgia. In
primary fibromyalgia, which is much more
common than the secondary type, even the
most careful work-up will not reveal any
definitive organic factor triggering the syndrome.
With secondary fibromyalgia, on the
other hand, the underlying disease, such as
inflammatory rheumatic processes or collagenosis
can be diagnosed with relative
ease.
D. Symptoms associated with fibromyalgia
often do not disappear when the rheumatic
processes have subsided, suggesting that
some central mechanisms may be responsible
for the persistence of generalized pain
and hyperalgesia, possibly due to a disorder
of the central affective pain memory
and/or the memory of sensory pain or else
to latent peripheral immunological processes.
It is precisely this coexistence of pain and
hyperalgesia in secondary fibromyalgia
associated with systemic inflammatory
rheumatic diseases, which proves that pain
and sensitivity to pain cannot be separated
strictly in fibromyalgia.

10

100. Which of the following statements regarding
endometriosis is true?
(A) The etiology is unclear but it has recently
been demonstrated that retrograde
menstruation is most likely not the
cause
(B) Oral contraceptives tend to exacerbate pain symptoms
(C) The “gold standard” diagnosis of the disease remains magnetic resonance imaging (MRI) of the abdomen
(D) If endometriosis is diagnosed at the time of laparoscopy, laparoscopic surgery should be the first choice of treatment
(E) Endometriosis pain does not follow menstrual cycle

100. (D)
A. Endometriosis is the presence of endometrial
glands and stroma outside the endometrial
cavity and is a common cause of pelvic
pain. The etiology is unknown, although
the theory of retrograde menstruation is the
prevailing theory.
B. Oral contraceptives, androgenic agents,
progestins, and gonadotropin-releasing
hormone (GnRH) analogs have all been
used successfully in treating the symptoms
of endometriosis.
C. The “gold standard” of diagnosis is
laparoscopy with direct visualization.
D. If endometriosis is diagnosed at the time of
laparoscopy, laparoscopic surgery should
be the first choice of treatment, especially
in women of reproductive age with an
endometrioma.

11

101. A 28-year-old female enters your clinic with
upper extremity symptoms. You suspect thoracic
outlet syndrome because
(A) she fractured her clavicle and developed
symptoms afterward
(B) she has had sensory symptoms along
her lateral forearm for some time
(C) radiographs confirm she does not have
cervical ribs
(D) she has symptoms consistent with a
chronic upper trunk brachial plexopathy
(E) all of the above

101. (A)
A. The most frequently fractured bone in the
body is the clavicle and the most common
cause is a fall or blow on the point of the
shoulder. In most instances, clavicular fractures
do not involve nearby structures, and
their healing is uneventful, except for possibly
some residual deformity. Occasionally,
however, the blood vessels and the brachial
plexus elements situated between the midportion
of the clavicle and the first thoracic
rib are injured secondarily. This generally
occurs in adults, most often following
midshaft displaced fractures. This type of
neurovascular injury often is referred to as
traumatic TOS.
B. The majority of patients report having had
sensory disturbances for long periods
before that point. The earliest and most common symptoms are intermittent aching
or paresthesias along the medial arm and
forearm, sometimes extending into the
medial hand and fingers. Hand cramping
with use sometimes appears later in the
course. Although these symptoms, particularly
the intermittent aching, may be present
for years, they rarely are bothersome
enough to cause the patient to seek medical
care.
C. Plain cervical spine radiographs are important
for diagnosis of thoracic outlet syndrome.
Typically, a rudimentary cervical
rib or an elongated C7 transverse process is
found ipsilateral to the affected limb.
Cervical ribs frequently are present bilaterally,
and often the one on the contralateral,
uninvolved, side is larger. This is inconsequential,
however, because the cervical ribs
themselves do not compromise the proximal
lower trunk axons; instead, it is a radiolucent
band extending from the tip of the
rudimentary cervical rib to the first thoracic
rib that does so. In some patients, cervical
ribs are difficult to visualize unless special
radiograph views are used.
D. This rare disorder manifests as a very
chronic lower trunk brachial plexopathy,
most commonly caused by congenital
anomalies.

12

102. A 55-year-old homeless woman presents to the
emergency room (ER) by ambulance in an
unconscious state. The emergency medical technician
(EMT) reports discovering the patient
while she was experiencing a grand mal seizure.
She has no identifying information and is unaccompanied
in the ER. An examination of the
woman reveals that she has bilateral mastectomies.
When the patient wakes up, she reports
having severe pain in her ribs and along her
spinal column that is getting progressively
worse. Which of the following statements is true?
(A) Bisphosphonates not only can treat the
bony metastases of breast cancer but can
reverse osteonecrosis of the jaw often
seen in this type of cancer
(B) A large number of patients with breast
cancer have osteolytic metastatic disease
involving the bony skeleton
(C) Placebo-controlled trials with oral or
intravenous (IV) bisphosphonates have
shown that prolonged administration
can reduce the frequency of skeletonrelated
events by 80%
(D) Hypercalcemia is the most frequent
symptom of bone metastases
(E) This patient’s most significant issue is
most likely opiate dependence

102. (B)
A. Bisphosphonates are effective for the management
of hypercalcemia of malignancy
and bone metastases. This group of drugs
has improved the quality of life in many
patients with proven efficacy in limiting pain
and skeleton-related events. Osteonecrosis of
the jaws is a recognized complication of bisphosphonate
therapy.
B. In some studies, up to 75% of patients with
breast cancer will have metastatic disease.
The bony skeleton is frequently involved.
On radiologic examination, these metastases
are predominantly osteolytic.
C. Placebo-controlled trials with oral or IV bisphosphonates
have shown that prolonged
administration can reduce the frequency of
skeleton-related events by 30% to 40%.
D. Pain is the most frequent symptom of
bone metastases and can significantly alter
the quality of life of cancer patients.
Hypercalcemia classically occurs in 10% to
15% of the cases.
E. This patient likely has a history of breast
cancer and now may have diffuse metastases
in both her brain and skeletal system.
She requires a detailed evaluation.

13

103. Which of the following statements is true
regarding arthritis?
(A) The biologic precursor to gout is elevated
serum glutamic acid levels
(B) In psoriatic arthritis the distal interphalangeal
joints are regularly involved
(C) The onset of polyarthritis in rheumatoid
arthritis (RA) is usually rapidly progressive
and initially affects the small joints
of the hands and feet
(D) Inflammatory markers such as the erythrocyte
sedimentation rate (ESR) or
C-reactive protein (CRP) are abnormal
in about 95% of patients with early RA
(E) None of the above

103. (B)
A. The biologic precursor to gout is elevated
serum uric acid levels (ie, hyperuricemia).
B. In psoriatic arthritis, the distal interphalangeal
joints are regularly involved. The
disease can also focus on the larger joints
of the lower extremities.
C. The onset of polyarthritis in RA is insidious
in about three-quarters of patients and
initially affects the small joints of the hands
and feet (metacarpophalangeal, proximal
interphalangeal and metatarsophalangeal
joints) before spreading to the larger joints.
D. Inflammatory markers such as the ESR or
CRP are normal in about 60% of patients
with early RA.

14

104. Apatient enters your office complaining of leg
pain after having a sural nerve biopsy. Which of
the following statements is true about this type
of complex regional pain syndrome (CRPS)?
(A) Increased tremor has been documented
in the context of this type of CRPS
(B) This is most likely CRPS type I
(C) This type of CRPS has been described to
occur after stroke
(D) The CNS does not appear to be involved
in the pathophysiology of CRPS
(E) All of the above

104. (A) This is most likely a case of CRPS type II.
A. CRPS is a painful disorder that develops as a
disproportionate consequence of traumas.
These disorders are most common in the
limbs and are characterized by pain (spontaneous
pain, hyperalgesia, allodynia); active
and passive movement disorders (including
an increased physiological tremor); abnormal
regulation of blood flow and sweating;
edema of skin and subcutaneous tissues;
and trophic changes of skin, organs of the
skin, and subcutaneous tissues.
B. CRPS type I (previously known as reflex
sympathetic dystrophy) typically develops
after minor trauma with no obvious or
a small nerve lesion (eg, bone fracture,
sprains, bruises, skin lesions, or surgery).
C. CRPS type I can also develop after remote
trauma in the visceral domain or even
after a CNS lesion (eg, stroke). Important
features of CRPS type I are that the severity of symptoms is disproportionate to the
severity of trauma and pain has a tendency
to spread distally in the affected limb. The
symptoms are not confined to the innervation
zone of an individual nerve. Thus, all
symptoms of CRPS type I may be present
irrespective of the type of the preceding
lesion.
D. Research is beginning to uncover that the
CNS is actively involved in CRPS pathophysiology.
Nerve cells, microglia, and
astrocytes all may be involved.

15

105. Which of the following statements is true regarding
pain in the context of human immunodeficiency
virus (HIV)/acquired immunodeficiency
syndrome (AIDS)?
(A) Distal symmetrical polyneuropathy is
the most common peripheral nerve disorder
associated with HIV
(B) Headache is the second most common
of the AIDS-related pain syndromes
(C) Progressive polyradiculopathy is most
commonly associated with herpes virus
(D) Kaposi sarcoma has been shown to
cause muscular pain but not bone pain
(E) None of the above

105. (A)
A. Distal symmetrical polyneuropathy is the
most common peripheral nerve disorder
associated with HIV.
B. Headache is the most common of the
AIDS-related pain syndromes. Common
causes include cerebral toxoplasmosis.
C. Progressive polyradiculopathy is most commonly
associated with cytomegalovirus
infection. Symptoms include flaccid paralysis
and pain with sensory disturbance.
D. Kaposi’s sarcoma can cause both muscular
and bone pain through infiltration.

16

106. Which of the following statements about central
pain is correct?
(A) Central pain occurs with stroke and
spinal cord injury (SCI) but not with
multiple sclerosis
(B) In syringomyelia, central pain is often
the first symptom of the disease
(C) The pathophysiology of pain associated
with SCI has yet to be completely elucidated,
but supraspinal pathways, not
spinal pathways, are most likely
involved
(D) After injury to the CNS, it is the denervated
synaptic sites that serve an
inhibitory role preventing the development
of central pain
(E) All of the above

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

17

107. A 35-year-old female with chronic low-back
pain comes to see you in your office for the
first time. You immediately notice her unusual
affect and behavior. Which of the following
statements is true?
(A) Patients with somatization disorder,
hypochondriasis, factitious physical disorders,
and malingering may have pain
complaints as part of their illness
(B) Malingerers, by definition, are not consciously
aware of their motivation
(C) Other psychiatric disorders, such as
depression, anxiety, and panic attacks,
may strongly influence chronic pain
without directly causing it; posttraumatic
stress disorders do not usually impact a
pain complaint
(D) One of the main differences between
pain associated with malingering and
pain associated with anxiety is that in
malingering, complaints or symptoms
go beyond what should be expected
from a specific disease process
(E) None of the above

107. (A)
A. Common psychiatric conditions that often
feature pain as part of the illness are somatization
disorder, hypochondriasis, factitious
physical disorders, and malingering.
B. One of the ways to distinguish between
these condition is whether there is conscious
awareness (or lack of awareness) of
both motivation and symptom production.
Malingerers have a conscious awareness
and motivation for a pain complaint.
C. Other psychiatric disorders may strongly
influence chronic pain without directly
causing it—depression, anxiety, panic, and
posttraumatic stress disorders.
D. Chronic pain complaints often reflect or are
influenced by psychiatric factors. Physicians
commonly encounter “illness-affirming
behaviors” in which patient complaints or
symptoms go beyond what should be
expected from a specific disease process.
This is true of both anxiety and malingering.

18

108. Apatient is referred to you by a dentist friend.
This patient is having pain in and around her
mouth on one side. Which of the following
statements is true?
(A) Primary burning mouth syndrome is a
chronic, idiopathic intraoral pain condition
that is not accompanied by clinical
lesions; some consider it a painful
neuropathy
(B) Increasing evidence suggests that very
few cases of trigeminal neuralgia that
are classified as idiopathic are caused by
compression of the trigeminal nerve by
an aberrant loop of artery or vein
(C) About 40% of patients with multiple
sclerosis develop trigeminal neuralgia
(D) Trigeminal neuralgia can occasionally be
present over the occiput
(E) All of the above

108. (A)
A. Primary burning mouth syndrome is a
chronic, idiopathic intraoral pain condition
that is not accompanied by clinical lesions
but some consider it a painful neuropathy.
The symptoms are often described as continuous,
spontaneous, and often intense
burning sensation in the mouth or tongue.
B. Increasing evidence suggests that 80% to
90% of cases that are technically still classified
as idiopathic are caused by compression
of the trigeminal nerve close to its exit from
the brainstem by an aberrant loop of artery
or vein.
C. Less than 10% of patients will have symptomatic
disease associated with an identifiable
cause other than a vascularcompressive
lesion—usually a benign tumor or cyst—or
multiple sclerosis. About 1% to 5% of
patients with multiple sclerosis develop
trigeminal neuralgia.
D. Trigeminal neuralgia, by definition, has to
be in the distribution of the trigeminal
nerve (not the distribution occipital nerve).
Trigeminal neuralgia is defined as paroxysmal
attacks of pain lasting from a fraction of
a second to 2 minutes that affect one ormore
divisions of the trigeminal nerve. Diagnostic
criteria for classic trigeminal neuralgia:
• Pain has at least one of these characteristics:
intense, sharp, superficial, or stabbing precipitated
from trigger areas or by trigger factors.
• Attacks are similar in individual patients.
• No neurological deficit is clinically evident.
• Not attributed to another disorder.

19

109. A patient is referred to you with facial pain.
Which of the following statements is true?
(A) The pain of glossopharyngeal neuralgia
is very similar to that of trigeminal neuralgia
but affects anterior two-thirds of
the tongue, tonsils, and pharynx
(B) Giant cell arteritis is a vasculitic condition
that can lead to visual loss but has
never been reported in a case of stroke
(C) Cervical carotid artery dissection most
commonly presents with neck, head, or
facial pain
(D) Pure facial pain is rarely associated with
sinusitis alone
(E) None of the above

109. (C)
A. The pain of glossopharyngeal neuralgia is
very similar to that of trigeminal neuralgia
but affects posterior-third of the tongue,
tonsils, and pharynx.
B. Giant cell arteritis is a common systemic
vasculitis in the elderly. It is commonly
associated with visual loss and strokes, so it
must be diagnosed and treated aggressively.
Temporal artery biopsy is the gold standard
in the diagnosis of giant cell arteritis.
Steroids are a common mode of treatment.
C. Cervical carotid artery dissection most
commonly present with head, facial, or
neck pain. Other commonly seen symptoms
include Horner syndrome, pulsatile
tinnitus, and cranial nerve palsy.
D. Pure facial pain is most often caused by
sinusitis and the chewing apparatus, but
also a multitude of other causes.

20

110. A 47-year-old woman comes into the ER complaining
of a vague sense of nausea and heart
palpitations. She has a history of chronic refractory
angina. Which of the following statements
regarding chest pain is false?
(A) In acute coronary syndrome men are
more likely to present with chest pain,
left arm pain, or diaphoresis and
women may present with nausea
(B) To consider the diagnosis of cardiac syndrome
X, this patient would have to
have an abnormal coronary arteriography
(C) Controlled studies suggest that in
patients with chronic refractory angina,
spinal cord stimulation (SCS) provides
symptomatic relief that is equivalent to
that provided by surgical or endovascular
reperfusion procedures, but with a
lower rate of complications and
rehospitalization
(D) The mechanism of action of spinal cord
stimulation in treating angina is not yet
completely defined
(E) None of the above

110. (B)
A. There are gender differences in the presentation
of acute coronary syndrome. Men
are more likely to present with chest pain,
left arm pain, or diaphoresis. Nausea is
more common in women.
B. Cardiac syndrome X is angina-like chest
pain in the presence of a normal coronary
arteriography. Although symptoms in
cardiac syndrome X are often noncardiac,
a sizable proportion of patients have
angina pectoris due to transient myocardial
ischemia.
C. Despite sophisticated medical and surgical
procedures, including percutaneous endovascular
methods, a large number of
patients suffer from chronic refractory
angina pectoris. Improvement of pain relief
in this category of patients requires the use
of adjuvant therapies, of which spinal cord
stimulation (SCS) seems to be the most
promising. Controlled studies suggest that
in patients with chronic refractory angina,
SCS provides symptomatic relief that is
equivalent to that provided by surgical or
endovascular reperfusion procedures, but
with a lower rate of complications and
rehospitalization. Similarly, SCS proved
cost effective compared to medical as well
as surgical or endovascular approaches in a
comparable group of patients.
D. Using SCS for the treatment of angina is
still met with reluctance by the medical
community. Reasons for this disinclination
may be related to incomplete understanding
of the action mechanism of SCS.

21

111. Which of the following statements regarding
knee pain is true?
(A) Children and adolescents who present
with knee pain are likely to have one of
three common conditions: patellar subluxation,
tibial apophysitis, or pseudogout
(B) A patient with a history of diabetes who
presents with acute onset of pain and
swelling of the joint with no antecedent
trauma is likely to have a patellofemoral
pain syndrome
(C) In pseudogout calcium pyrophosphate
crystals are the causative agents
(D) You would not expect to see cystic
changes on radiography of a knee with
suspected osteoarthritis
(E) All of the above

111. (C)
A. Children and adolescents who present
with knee pain are likely to have one of
three common conditions: patellar subluxation,
tibial apophysitis, or patellar tendonitis.
Additional diagnoses to consider
in children include slipped capital femoral
epiphysis and septic arthritis. Pseudogout
is more likely present in older adults.
B. Infection of the knee joint may occur in
patients of any age but is more common in
those whose immune system has been
weakened by cancer, diabetes mellitus,
alcoholism, acquired immunodeficiency
syndrome, or corticosteroid therapy. The
patient with septic arthritis reports abrupt onset of pain and swelling of the knee with
no antecedent trauma.
C. Acute inflammation, pain, and swelling
in the absence of trauma suggest the possibility
of a crystal-induced inflammatory
arthropathy such as gout or pseudogout.
Gout commonly affects the knee. In this
arthropathy, sodium urate crystals precipitate
in the knee joint and cause an intense
inflammatory response. In pseudogout, calcium
pyrophosphate crystals are the
causative agents. On physical examination,
the knee joint is erythematous, warm, tender,
and swollen. Even minimal range of
motion is exquisitely painful.
D. Osteoarthritis of the knee joint is a common
problem after 60 years of age. The patient
presents with knee pain that is aggravated
by weight-bearing activities and relieved by
rest. The patient has no systemic symptoms
but usually awakens with morning stiffness
that dissipates somewhat with activity. In
addition to chronic joint stiffness and pain,
the patient may report episodes of acute
synovitis. Findings on physical examination
include decreased range of motion, crepitus,
a mild joint effusion, and palpable
osteophytic changes at the knee joint.
Radiographs show joint-space narrowing,
subchondral bony sclerosis, cystic changes,
and hypertrophic osteophyte formation.

22

112. Apatient comes into your clinic complaining of
right foot pain. Which of the following would
be a correct diagnosis?
(A) The most commonly seen neuropathy in
diabetes, because the symptoms are unilateral
(B) Plantar fasciitis, because the patient
develops the symptoms after prolonged
activity
(C) Morton neuroma, because it is located
on the heel
(D) Tarsal tunnel syndrome, compression of
the posterior tibial nerve as it passes by
the medial malleolus
(E) None of the above

112. (D)
A. Distal symmetric polyneuropathy is the
most common neuropathy in diabetes
(which would affect both legs symmetrically).
There are other neuropathic entities
that occur in diabetes, such as mononeuropathy,
which could affect one foot.
B. The plantar fascia is frequently a site of
chronic pain. Patients typically complain
of pain that starts with the first step on
arising in the morning or after prolonged
sitting. Pain onset is usually insidious but
also may commence after a traumatic
injury. Diagnosis is made by eliciting pain
with palpation in the region of origin of the
plantar fascia. Pain may be worsened by
passive dorsiflexion of the foot.
C. The interdigital spaces of the foot are sites
for the occurrence of painful neuromas, a
condition termed Morton neuroma. The
second and third common digital branches
of the medial plantar nerve are the most
frequent sites for development of interdigital
neuromas.
D. The tarsal tunnel is formed by the medial
malleolus and a fibrous ligament, the flexor
retinaculum. The posterior tibial nerve
passes through the tunnel and can be compressed
by any condition that reduces the
space of the tunnel. The medial plantar, lateral
plantar, and calcaneal branches of the
posterior tibial nerve innervate the base of
the foot.

23

113. A35-year-old woman comes to your clinic complaining
of pelvic pain. Which of the following
is important to consider during her evaluation?
(A) Endometriosis is the most common
cause of pelvic pain in women
(B) Endometriosis most likely does not have
an inflammatory component
(C) Endometriosis has been shown to be
primarily dependent on blood levels of
the hormone progesterone
(D) An inflammatory process would be supported
by findings of a decrease of
interleukin 8 in testing of peritoneal
fluid
(E) All of the above

113. (A)
A. Endometriosis is the commonest cause of
chronic pelvic pain in women. It is characterized
by the presence of uterine endometrial
tissue outside the uterus, most commonly
in the pelvic cavity. The disorder mainly
affects women of reproductive age.
B. Endometriosis has been described as a
pelvic inflammatory process with altered
function of immune cells and increased
number of activated macrophages in the
peritoneal environment that secrete various
local products, such as growth factors and
cytokines.
C. Endometriosis is estrogen-dependent, and
traditional treatments have aimed to
decrease production of estrogens such as
estradiol. However, the exact mechanism
by which estrogens promote endometriosis
is unclear and suppression of estrogens
has variable effects.
D. Endometriotic lesions themselves secrete
proinflammatory cytokines such as interleukin
8 (IL-8), which recruit macrophages
and T cells to the peritoneum and mediate
inflammatory responses.

24

114. An 85-year-old man comes to your clinic having
recovered from “a bad pneumonia” recently.
He now complains of chest pain. Which of the
following statements is false?
(A) While the parietal pleura does not contain
any nociceptive innervation, the
visceral pleura does
(B) Viral infection is the most common
cause of pleurisy
(C) A description of pain with coughing
would be consistent with pleurisy
(D) Pulmonary embolism is a possible cause
of these symptoms
(E) None of the above

114. (A)
A. The visceral pleura do not contain any
nociceptors or pain receptors. The parietal
pleura is innervated by somatic nerves that sense pain when the parietal pleura is
inflamed. Inflammation that occurs at the
periphery of the lung parenchyma can
extend into the pleural space and involve
the parietal pleura, thereby activating the
somatic pain receptors and causing pleuritic
pain.
B. Viral infection is one of the most common
causes of pleurisy. Viruses that have been
linked as causative agents include influenza,
parainfluenza, coxsackieviruses, respiratory
syncytial virus, mumps, cytomegalovirus,
adenovirus, and Epstein-Barr virus. Additionally,
pleurisy may be the first manifestation
of some less common disorders.
C. Pleuritic pain typically is localized to the
area that is inflamed or along predictable
referred pain pathways. Patients’ descriptions
of the pain are consistent in most
cases of pleurisy. The classic feature is that
forceful breathing movement, such as taking
a deep breath, talking, coughing, or
sneezing, exacerbates the pain.
D. The differential diagnosis of chest pain in this
patient should include myocardial infarction,
endocarditis, pulmonary embolism,
pneumonia, and pneumothorax. Pulmonary
embolism can cause pleurisy

25

115. Which of the following statements regarding
repetitive strain injuries is true?
(A) Repetitive strain injury does not include
the specific disorder cubital tunnel syndrome
(B) Repetitive strain injury is a controversial
diagnosis partially because there are few
studies showing an association between
physical risk factors and injury
(C) Psychosocial factors are more clearly
correlated than physical risk factors in
repetitive strain injury
(D) The “unifying hypothesis” of repetitive
strain injury states that most often these
diseases can be demonstrated to be due
to focal injury
(E) All of the above

115. (B)
A. Repetitive strain injury includes specific
disorders such as CTS, cubital tunnel syndrome,
Guyon canal syndrome, lateral
epicondylitis, and tendonitis of the wrist
or hand.
B. Ample evidence exists for the association
between physical risk factors such as
repetitive movements, poor posture, and
inadequate strength and the occurrence of
repetitive strain injury.
C. The effects of work-related and psychosocial
factors are not as clear as those of physical
factors, although high workload, stress,
and physical or psychological demands,
low job security, and little support from colleagues
might be important.
D. Several hypotheses for the pathophysiology
of repetitive strain injury exist, but none
has been strongly supported by scientific
evidence. Despite initial distal presentation,
this disorder seems to be a diffuse
neuromuscular illness. Mechanical (elastic
deformation of connective tissue due to
increased pressure within muscles) and
physiological (electrochemical and metabolic
imbalances) reactions might cause
damage to muscle tissue and lead to complaints
of strain. Continuous contraction of
muscles from long-term static load with
insufficient breaks could result in reduced
local blood circulation and muscle fatigue.
Consequently, pain sensors in the muscles
could become hypersensitive, leading to a
pain response at low levels of stimulation.
Other hypotheses suggest frequent cocontractions
in muscles or changes in proprioception
as the source of injury. There is no
unifying hypothesis.

26

116. A 56-year-old woman comes into your clinic
complaining of chest pain on the left. She has a
history of breast cancer with mastectomy and
radiation treatment. She may still have
chemotherapy. Which of the following statements
is true?
(A) As treatments for breast cancer have
advanced in the past decade, the incidence
of this type of pain has plummeted
(B) The incidence of peripheral neuropathy
would be higher with cisplatin than
with paclitaxel
(C) With chemotherapy, there is a higher incidence
of motor than sensory neuropathy
(D) Axillary dissection poses risks to the
intercostobrachial nerve and the medial
cutaneous nerve of the arm
(E) All of the above

116. (D)
A. Chronic pain following surgical procedures
for breast cancer was once thought to
be rare. The results of recent studies, however,
suggest that the incidence of chronic
pain following breast cancer surgery may
be more than 50%. Although most surgical
advances are less invasive and have fewer
complications, the rapid pace of change in
treatment complicates outcome research.
B. Peripheral neuropathy, often painful, is
common after paclitaxel, a second-line therapy
for metastatic disease, and also occurs
with other chemotherapeutic agents. The
incidence of peripheral neuropathy is lower
with platinum compounds like cisplatin.
C. Sensory neuropathies are more common in
chemotherapy than motor neuropathies.
D. Axillary dissection poses risks to the intercostobrachial
nerve, from stretch during
retraction as well as from frank transection.
Many patients will be left with an
area of numbness on the upper inner arm,
signifying damage to the intercostobrachial
nerve, but only a minority of these
will be painful. Other nerves at risk for
damage from axillary dissection include
the medial cutaneous nerve of the arm, which contains fibers from C8 and T1 and
arises from the medial cord of the brachial
plexus. It can be harmed during section of
the tributaries of the axillary vein, leaving
patients with sensory loss on the lower
medial skin of the upper arm. Pain accompanied
by sensory loss in one of these areas
provides the basis for a diagnosis of injury
to these specific nerves.

27

117. A52-year-old obese male with a 5-year history
of diabetes is complaining of foot pain. Which
of the following statements is false?
(A) If this patient has “large-fiber” nerve
dysfunction, it may include weakness
(B) Blood sugar abnormalities have been
shown to correlate with degree of nerve
dysfunction
(C) Neuropathy has been described in the
context of diabetes and blood sugar
levels less than the criteria for diabetes
mellitus as defined by the American
Diabetes Association have not been
shown to correlate with neuropathy
(D) Small fiber neuropathy can have autonomic
features
(E) None of the above

117. (C)
A. Peripheral nerves are composed of largeand
small-diameter nerve fibers. Symptoms
associated with large-diameter nerve fiber
dysfunction include weakness, numbness,
tingling, and loss of balance, while those
associated with small-diameter nerve
fiber damage include pain, anesthesia to
pin and temperature sensation, and autonomic
dysfunction (eg, changes in local
vasoregulation).
B. Diabetes duration and blood sugar control
correlate with the development of neuropathy.
C. Neuropathy with a predilection for smalldiameter
nerve fibers can appear with
impaired glucose tolerance, a prediabetic
state that does not meet the criteria for diabetes
mellitus as defined by the American
Diabetes Association. Although this neuropathy
is usually milder than the neuropathy
seen in frank diabetes mellitus,
impaired glucose tolerance has been associated
with severe painful polyneuropathy
without another known etiology.
D. As these painful symptoms often result
from small-diameter nerve fiber dysfunction,
patients may have accompanying
abnormalities of autonomic function in the
feet (eg, decreased sweating, dry skin, and
impaired vasomotor control).

28

118. An 85-year-old woman comes into your clinic
with chronic pain over her left breast for more
than 1 year. The symptoms began after she
broke out in a rash in the same distribution.
Which of the following statements is true?
(A) Zoster reactivation is always accompanied
by a rash
(B) Zoster reactivation may occur two to
three times for a healthy individual
(C) Post herpetic neuralgia (PHN) is pain
that persists for more than 120 days
(D) The incidence of PHN is expected to
remain stable in the future
(E) All of the above

118. (C)
A. Reactivation of the varicella-zoster virus
can cause dermatomal pain without a rash
in a process termed “zoster sine herpete.”
This cannot be made on the basis of clinical
presentation alone and would require
evidence of concurrent viral reactivation.
B. Zoster reactivation typically occurs once for
an individual. Atypical manifestations that
occur in immunocompromised patients
include prolonged course, recurrent lesions,
and involvement of multiple dermatomes.
Diagnostic laboratory tests are recommended
when herpes simplex must be ruled out
(eg, recurrent rash or sacral lesions) and for
patients with atypical lesions.
C. Until recently, these definitions have been
arbitrary, but the results of recent research
now provide support for the validity of
distinguishing between three phases of
pain in affected and adjacent dermatomes:
(1) herpes zoster acute pain (also termed
acute herpetic neuralgia), defined as pain
that occurs within 30 days after rash onset;
(2) subacute herpetic neuralgia, defined as
pain that persists beyond the acute phase
but that resolves before the diagnosis of
PHN can be made; and (3) PHN, defined
as pain that persists 120 days or more after
rash onset.
D. It can also be predicted that the number of
adults developing herpes zoster in the
United States may increase as a consequence
of reduced opportunities for subclinical
immune boosting resulting from
near-universal varicella vaccination of children.
Recent data showing an increase in
herpes zoster in the United States are consistent
with this prediction. An increase in
the incidence of herpes zoster could be offset
by zoster vaccination, but the extent to
which widespread herpes zoster vaccination
will occur is presently unknown.

29

119. Apatient comes into your clinic without a referral.
He has a long history of chronic pain. He
reports having some implantable device but he
is unsure what it is. On examination, you find a
surgical scar over the left lower quadrant of his
abdomen. Over the past several weeks he has
been developing worsening lower extremity
pain. Your examination reveals spasticity. Which
of the following is important to consider?
(A) If the patient is getting intrathecal morphine,
the rate of infusion would not
have any impact on his complaint
(B) If this patient has an intrathecal pump,
only intrathecal morphine has been
shown to result in granuloma formation
(C) A microscopic investigation of an
intrathecal morphine related granuloma
would reveal necrotic tissue without
immune cells
(D) Morphine is a hydrophilic molecule
(E) All of the above

119. (D) This patient has evidence of having an
intrathecal pump with granuloma formation.
A. There is a strong relationship between higher
doses of intrathecal morphine and granuloma
formation. The notion that high-dose
morphine is causative is not universally
accepted. Some authors have suggested that
long-term administration of opiates may
lead to localized fibrosis and the formation
of a granulomatous mass surrounding the
catheter tip.
B. There have been cases of granuloma formation
reported involving the intrathecal infusion
of baclofen. These lesions did not
appear to cause any compression of the
spinal cord or neurological deficits, resolved
when the catheter tip was replaced, and
could represent a different disease process.
C. Microscopic pathology of intrathecal morphine
related granulomas often reveals
necrotic tissue surrounded by macrophages,
plasma cells, eosinophils, or lymphocytes.
Nearby vessels may be surrounded by
mononuclear inflammatory cells consisting
predominantly of plasma cells. Gross pathologic
examination of catheter tip granulomas
related to intrathecal morphine infusions
often demonstrates the mass conforming to
the distal portion of the catheter.
D. Because of its (morphine) hydrophilic structure,
it has a prolonged duration of action
and due to the drug’s high localization; its
analgesic effect is maximized at a lower
dose. This results in a lower incidence of
systemic side effects, reduces drug dependence,
and does not significantly influence
motor, sensory, or sympathetic reflexes.

30

120. The patient from question 119, relates that over
the past decade he has had three back surgeries.
This is why he thinks that the intrathecal
pump was implanted. He reports that the first
back surgery helped him for 6 months but the
symptoms returned. The subsequent back surgeries
only made his symptoms worse. Which
of the following statements regarding this
patient’s condition is true?
(A) In failed back surgery syndrome (FBSS),
the most common structural cause of
symptoms has been shown to be foraminal
stenosis
(B) In FBSS, pure psychogenic pain is somewhat
common
(C) In the context of chronic pain, an
improvement of 30% is usually considered
satisfactory
(D) Failed back surgery syndrome, for the
most part, implies a specific anatomical
derangement
(E) None of the above

120. (C)
A. In the three studies that looked at the causes
of FBSS, the most common structural
causes of FBSS are foraminal stenosis (25%-
29%), painful disc (20%-22%), pseudarthrosis
(14%), neuropathic pain (10%), recurrent
disc herniation (7%-12%), iatrogenic instability
(5%), facet pain (3%), and sacroiliac
joint (SIJ) pain (2%), among some others.
B. Most patients with refractory low-back pain
have symptoms of at least one major psychiatric
disorder, most commonly depression,
substance abuse disorder or anxiety
disorder. Pure psychogenic pain (pain disorder,
psychological type) is rare in patients
with FBSS. All patients have some pain
behavior, which may be appropriate or
inappropriate.
C. In patients with chronic pain, an improvement
in visual analog scale (VAS) score of
1.8 U, equivalent to a change in pain of
about 30%, may be considered a satisfactory
result.
D. FBSS is a nonspecific term that implies that
the final outcome of surgery did not meet
the expectations of both the patient and the
surgeon that were established before
surgery.

31

121. Which of the following statements is false
regarding pain and pregnancy?
(A) One of the common causes of pain in
early pregnancy includes stretch and
hematoma formation in the round
ligaments
(B) Radicular symptoms usually suggest a
herniated disc
(C) Pregnancy is not an absolute contraindication
to radiography
(D) Migraine headaches rarely begin during
pregnancy
(E) All of the above

121. (B)
A. True, this process usually begins at 16 to
20 weeks. In early pregnancy it is important
to exclude unruptured ectopic pregnancy
and ovarian torsion.
B. Radicular symptoms are common during
pregnancy; there is a low incidence of herniated
disc associated with these complaints.
C. Limited plain radiographs that are considered
vital may be okay to perform during
pregnancy according to some studies.
D. It is true that if a new onset migraine
occurs during pregnancy, one should
investigate a secondary cause (including
consideration for an MRI).

32

122. A 10-year-old boy with a diagnosis of sickle cell
disease comes into your clinic. Which of the following
statements is true regarding his condition?
(A) A vasoocclusive crisis commonly
involves the back, legs, and eyes
(B) Acute pain in patients with sickle cell
disease is caused by ischemic tissue
injury resulting from the occlusion of
macrovascular beds by sickled erythrocytes
during an acute crisis
(C) When a vasoocclusive crisis lasts longer
than 7 days, it is important to search for
other causes of bone pain
(D) Patients with homozygous sickle cell and
sickle cell–β-thalassemia have a lower
frequency of vasoocclusive pain crises
than patients with hemoglobin sickle cell
and sickle cell–β-thalassemia genotype
(E) None of the above

122. (C)
A. A vasoocclusive crisis most commonly
involves the back, legs, knees, arms, chest,
and abdomen. The pain generally affects
two or more sites. Bone pain tends to be
bilateral and symmetric. Recurrent crises in
an individual patient usually have the same
distribution.
B. Acute pain in patients with sickle cell
disease is caused by ischemic tissue injury
resulting from the occlusion of microvascular
beds by sickled erythrocytes during
an acute crisis. Acute bone pain from
microvascular occlusion is a common reason
for emergency department (ED) visits
and hospitalizations in patients with sickle
cell disease. Obstruction of blood flow
results in regional hypoxemia and acidosis,
creating a recurrent pattern of further
sickling, tissue injury, and pain. The severe
pain is believed to be caused by increased
intramedullary pressure, especially within
the juxta-articular areas of long bones, secondary to an acute inflammatory
response to vascular necrosis of the bone
marrow by sickled erythrocytes. The pain
may also occur because of involvement of
the periosteum or periarticular soft tissue
of the joints.
C. When a vasoocclusive crisis lasts longer than
7 days, it is important to search for other
causes of bone pain, such as osteomyelitis,
avascular necrosis, and compression deformities.
When a recurrent bone crisis lasts for
weeks, an exchange transfusion may be
required to abort the cycle.
D. Patients with homozygous sickle cell and
sickle cell–β-thalassemia have a higher frequency
of vasoocclusive pain crises than
patients with hemoglobin sickle cell and
sickle cell–β-thalassemia genotype.

33

123. You enter a clinic’s examination room to do a
new evaluation on a patient. You find the patient
leaning back on the chair in a deep sleep. Upon
waking the patient up, you immediately notice
an inappropriate affect and decreased movement
of the right arm and leg. Which of the
following statements is false?
(A) Sleep disturbance, which can occur in
the context of depression, can cause
chronic pain
(B) The diagnostic criteria of substance abuse
includes recurrent substance use in situations
where it is physically hazardous
(C) The diagnostic criteria of substance
dependence includes recurrent substance
use in situations where it is physically
hazardous
(D) Conversion disorder is voluntary
(E) None of the above

123. (B)
A. Depression produces well documented
disturbances to sleep architecture including
reduced slow-wave sleep and early
onset rapid-eye-movement (REM) sleep.
Sleep disturbance has been well documented
in fibromyalgia.
B. This is one of the Diagnostic and Statistical
Manual of Mental Disorders (Fourth Edition)
(DSM-IV) diagnostic criteria of substance
abuse.
C. This is not included as one of the DSM IV
diagnostic criteria for substance dependence.
D. Conversion disorder is an alteration in
voluntary motor or sensory function that
suggests a neurologic or general medical
condition.

34

124. A patient comes into your clinic several years
after sustaining a SCI. He complains of pain in
multiple areas of his body. Which of the following
statements is true regarding this patient’s
pain?
(A) Chronic pain is a major complication of
SCI with approximately two-thirds of all
SCI patients experiencing some type of
chronic pain and up to one-third complaining
that their pain is severe
(B) Central pain is the only cause of pain in
patients with SCI
(C) Cervical spine injuries have the highest
incidence of central pain of all the spinal
cord injuries
(D) Central pain that occurs at the level of
the SCI is because of nerve root damage
(E) All of the above

124. (A)
A. Chronic pain is a major complication of
SCI with approximately two-thirds of all
SCI patients experiencing some type of
chronic pain, and up to one-third complaining
of that their pain is severe. The
prevalence of pain after SCI often increases
with time after injury.
B. In addition to central pain, there are multiple
types of pain that develop after SCI
including musculoskeletal, visceral, and
peripheral neuropathic pain.
C. Central pain has been reported with injury
to all levels of the spinal cord. There is conflicting
evidence in the literature as to the
level of injury that results in greatest frequency
or severity of central pain, whether
incomplete spinal cord lesions may result
in a higher incidence of central pain or
whether there is a link between type of
injury and the development of central pain.
D. Central neuropathic pain after SCI has
been categorized based on the location of
the complaint as either at the level of the
injury or below the level of the injury.
Although it may be difficult to distinguish
the two clinically (and both may be present
in the same patient), central pain that
occurs at the level of injury is because of
segmental spinal cord damage, and not
because of nerve root damage.

35

125. The patient from the previous question used to
be an anatomy and physiology teacher at a
local college and is asking about some details
about the mechanism of central pain in spinal
cord injury (SCI). Which of the following explanations
would you not give him?
(A) Prolonged high intensity noxious stimulation
activates the N-methyl-Daspartate
(NMDA) receptors which
induces a cascade that may result in
central sensitization
(B) Abnormal sodium channel expression
may be involved
(C) Thalamic neurons thought to be
involved in the generation of pain
undergo changes after SCI
(D) Thalamic neurons in SCI are relay
stations for pain signals but not pain
generators
(E) All of the above

125. (D)
A. Physiologic changes occur to the nociceptive
neurons in the dorsal horn following
SCI including an increase in abnormal
spontaneous and evoked discharges from
dorsal horn cell. Noxious stimulation
causes primary afferent C-fibers to release
excitatory amino acid neurotransmitters in
the dorsal horn. Prolonged high intensity
noxious stimulation activates the NMDA
receptors which induces a cascade that
may result in central sensitization.
B. On a molecular level, abnormal sodium
channel expression within the dorsal horn
(laminae L1-L4) bilaterally has been implicated
as a major contributor to hyperexcitability.
These pain relay neurons tend to
show increase activity with noxious and
nonnoxious stimuli thus serving as a pain
amplifier.
C. Thalamic neurons appear to undergo
changes after SCI in both human and animal
models. In the animal model, enhanced
neuronal excitability in the VPL has been
demonstrated directly and as well as indirectly;
enhanced regional blood flow has been found in the rate VPL after SCI suggesting
increased neuronal activity.
D. Much like the neurons in the dorsal horn,
the thalamic neurons after SCI show
increased activity with noxious and nonnoxious
stimuli. VPL neurons are spontaneously
hyperexcitable following SCI
without receiving input from the spinal
cord neurons suggesting that the thalamus
may act as a pain-signal generator in central
pain accompanying SCI.

36

126. Chronic pancreatitis is the progressive and permanent
destruction of the pancreas resulting in
exocrine and endocrine insufficiency and, often,
chronic disabling pain. Which of the following
statements about chronic pancreatitis is incorrect?
(A) Excessive alcohol use plays a significant
role in up to 70% of adults with chronic
pancreatitis, whereas genetic and structural
defects predominate in children
(B) The pain with chronic pancreatitis is
commonly described as midepigastric
postprandial pain that radiates to the
back and that can sometimes be relieved
by sitting upright or leaning forward
(C) Autoimmune pancreatitis accounts for
up to 5% of cases
(D) Because of its uniform presentation
most cases of chronic pancreatitis are
diagnosed
(E) None of the above

126. (D)
A. Excessive alcohol use plays a significant
role in up to 70% of adults with chronic
pancreatitis. Genetic and structural defects
predominate in children.
B. Patients may have recurrent episodes of
acute pancreatitis, which can progress to
chronic abdominal pain. The pain is commonly
described as midepigastric postprandial
pain that radiates to the back and that
can sometimes be relieved by sitting upright
or leaning forward. In some patients there is
a spontaneous remission of pain by organ
failure (pancreatic burnout theory). Patients
may also present with steatorrhea, malabsorption,
vitamin deficiency (A, D, E, K, and
B12), diabetes, or weight loss. Approximately
10% to 20% of patients may have exocrine
insufficiency without abdominal pain.
C. Autoimmune pancreatitis accounts for 5%
to 6% of chronic pancreatitis and is characterized
by autoimmune inflammation,
lymphocytic infiltration, fibrosis, and pancreatic
dysfunction.
D. Because of its varied presentation and
clinical similarity to acute pancreatitis,
many cases of chronic pancreatitis are not
diagnosed

37

127. The definition of pain that is endorsed by the
International Association for the Study of Pain
is “Pain is an unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in terms of
such damage.” There are a host of physiologic
mechanisms by which injuries lead to nociceptive
responses and ultimately to pain. That
being said, not all nociceptive signals are
perceived as pain and not every pain sensation
originates from nociception. Which of the
following statements regarding pain is false?
(A) Mainly two types of pain receptors are
activated by nociceptive input. These
include low-threshold nociceptors that
are connected to fast pain-conducting A-δ
fibers, and high-threshold nociceptors
that conduct impulses in slow (unmyelinated)
C fibers
(B) Many neurotransmitters (ie, glutamate
and substance P) are able to modulate
postsynaptic responses with further
transmission to supraspinal sites (thalamus,
anterior cingulated cortex, insular
cortex, and somatosensory cortex) via
ascending pathways
(C) Prolonged or strong activity of dorsal
horn neurons caused by repeated or sustained
noxious stimulation may subsequently
lead to increased neuronal
responsiveness or central sensitization
(D) Windup refers to a mechanism present
in the peripheral nervous system in
which repetitive noxious stimulation
results in a slow temporal summation
that is experienced in humans as
increased pain
(E) Substance P is an important nociceptive
neurotransmitter. It lowers the threshold
of synaptic excitability, resulting in the
unmasking of normally silent interspinal
synapses and the sensitization of
second-order spinal neurons

127. (D)
A. Mainly two types of pain receptors are
activated by nociceptive input. These
include low-threshold nociceptors that are
connected to fast conducting A-δ pain
fibers, and high-threshold nociceptors that
conduct impulses in slow (unmyelinated)
C fibers. Within the dorsal horn of the
spinal cord, these pain fibers synapse with
spinal neurons via synaptic transmission.
B. Many neurotransmitters (ie, glutamate
and substance P) are able to modulate the
postsynaptic responses with further transmission
to supraspinal sites (thalamus,
anterior cingulated cortex, insular cortex,
and somatosensory cortex) via the ascending
pathways.
C. The simplest form of plasticity in nervous
systems is that repeated noxious stimulation
may lead to habituation (decreased response)
or sensitization (increased response).
Prolonged or strong activity of dorsal horn
neurons caused by repeated or sustained
noxious stimulation may subsequently lead
to increased neuronal responsiveness or central
sensitization. Neuroplasticity and subsequent
CNS sensitization include altered
function of chemical, electrophysiological,
and pharmacological systems. These
changes cause exaggerated perception of
painful stimuli (hyperalgesia), a perception
of innocuous stimuli as painful (allodynia),
and may be involved in the generation of
referred pain and hyperalgesia across multiple
spinal segments. While the exact mechanism
by which the spinal cord becomes
sensitized or in “hyperexcitable” state currently
remains somewhat unknown, some
contributing factors have been proposed.
D. Windup refers to a central spinal mechanism
in which repetitive noxious stimulation
results in a slow temporal summation
that is experienced in humans as increased
pain. In 1965, animal experiments showed
for the first time that repetitive C fiber
stimulation could result in a progressive
increase of electrical discharges from the
second-order neuron in the spinal cord.
This mechanism of pain amplification in
the spinal cord is related to temporal summation
of second pain or windup. Second
pain, which is more dull and strongly related
to chronic pain states, is transmitted
through unmyelinated C fibers to dorsal
horn nociceptive neurons. During the C
fibers transmitted stimuli, NMDA receptors of second-order neurons become activated.
It is well-known that NMDA activation
induces calcium entry into the dorsal horn
neurons. Calcium entry into sensory neurons
in the dorsal horn induces activation
of nitric oxide (NO) synthase, leading to
the synthesis of NO. NO can affect the
nociceptor terminals and enhance the
release of sensory neuropeptides (in particular,
substance P) from presynaptic neurons,
therefore contributing to the development of
hyperalgesia and maintenance of central
sensitization.
E. Substance P is an important nociceptive
neurotransmitter. It lowers the threshold of
synaptic excitability, resulting in the
unmasking of normally silent interspinal
synapses and the sensitization of secondorder
spinal neurons. Furthermore, substance
P can extend for long distances in the
spinal cord and sensitize dorsal horn neurons
at a distance from the initial input
locus. This results in an expansion of receptive
fields and the activation of wide dynamic
neurons by nonnociceptive afferent
impulses.

38

128. The presence of several pain inhibitory and
facilitatory centers in the brainstem is well recognized.
Which of the following regarding
these systems is incorrect?
(A) The dorsolateral funiculus is involved in
a pathway for descending pain inhibitory
systems
(B) One function of the descending inhibitory
pathway is to expand the excitation of
the dorsal horn neurons
(C) The activity in descending pathways is
not constant but can be modulated, for
example, by the level of vigilance or
attention and by stress
(D) Certain cognitive styles and personality
traits have been associated with amplification
of pain and its extension in the
absence of tissue damage. These include
somatization, catastrophizing, and
hypervigilance
(E) All of the above

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

39

129. Which of the following statements is incorrect
regarding the mechanisms of neuropathic pain?
(A) Injured and neighboring noninjured
sensory neurons can develop a change
in their excitability sufficient to generate
pacemaker-like potentials, which evoke
ectopic action potential discharges, a
sensory inflow independent of any
peripheral stimulus
(B) Central sensitization represents a state
of heightened sensitivity of dorsal horn
neurons such that their threshold of activation
is reduced, and their responsiveness
to synaptic inputs is augmented
(C) After peripheral nerve injury C fiber
input may arise spontaneously and
drive central sensitization
(D) The negative symptoms of neuropathic
pain, such as allodynia, essentially
reflect loss of sensation owing to
axon/neuron loss
(E) All of the above

129. (D)
A. Injured and neighboring noninjured sensory
neurons can develop a change in
their excitability sufficient to generate
pacemaker-like potentials, which evoke
ectopic action potential discharges, a sensory
inflow independent of any peripheral
stimulus. These changes may manifest at
the site of the injury, at the neuroma, and
in the DRG. Ectopic input is most prominent
in A fibers but also occurs to a more
limited extent in cells with unmyelinated
axons (ie, C fibers).
B. Central sensitization represents a state of
heightened sensitivity of dorsal horn neurons
such that their threshold of activation
is reduced, and their responsiveness to
synaptic inputs is augmented. There are two
forms of central sensitization; an activitydependent
form that is rapidly induced
within seconds by afferent activity in nociceptors
and which produces changes in
synaptic efficacy that last for tens of minutes
as a result of the phosphorylation and
altered trafficking of voltage- and ligandgated
ion channel receptors, and a transcription-
dependent form that takes some
hours to be induced but outlast the initiating
stimulus for prolonged periods.
C. After peripheral nerve injury C fiber input
may arise spontaneously and drive central
sensitization.
D. Peripheral neuropathic pain, that clinical
pain syndrome associated with lesions to
the peripheral nervous system, is characterized
by positive and negative symptoms.
Positive symptoms include spontaneous
pain, paresthesia, and dysesthesia, as well
as a pain evoked by normally innocuous
stimuli (allodynia) and an exaggerated or
prolonged pain to noxious stimuli (hyperalgesia/
hyperpathia). The negative symptoms
essentially reflect loss of sensation
due to axon/neuron loss; the positive
symptoms reflect abnormal excitability of
the nervous system.

40

130. Which of the following statements about prolonged
opiate use is false?
(A) A patient who maintains the same dose
of opiate over a prolonged period of time
is not at risk for developing tolerance
(B) Patients who receive long-term opiate
therapy may be at risk of developing a
paradoxical opioid induced pain
(C) Pharmacologic induction of pain may
occur through activation of the rostral
ventromedial medulla
(D) There is evidence that over the long
term, opiates suppress pain by upregulation
of spinal dynorphin, and
enhanced, evoked release of excitatory
transmitters from primary afferents
(E) None of the above

130. (D)
A. It is well recognized that the prolonged
use of opioids is associated with a requirement
for ever-increasing doses in order to
maintain pain relief at an acceptable and
consistent level. This phenomenon is
termed analgesic tolerance. All patients on
opiates are at risk to develop tolerance.
B. Tolerance may also be related to a state of
hyperalgesia that results from exposure to
the opioid itself. Patients who receive longterm
opioid therapy sometimes develop
unexpected, abnormal pain. Similar paradoxical
opioid-induced pain has been confirmed
in a number of animal studies, even
during the period of continuous opioid
delivery. This has been termed opiateinduced
hyperalgesia (OIH).
C. A number of recent studies have demonstrated
that such pain may be secondary to
neuroplastic changes that occur in the
brain and spinal cord. One such change
may be the activation of descending pain
facilitation mechanisms arising from the
rostral ventromedial medulla (RVM).
D. Opioids elicit systems-level adaptations
resulting in pain due to descending facilitation,
upregulation of spinal dynorphin,
and enhanced, evoked release of excitatory
transmitters from primary afferents. These
adaptive changes in response to sustained
exposure to opioids indicate the need for
the evaluation of the clinical consequences
of long-term opioid administration.

41

131. An anatomy/physiology professor sees you in
clinic. You believe he meets criteria for CRPS.
He has several questions about the autonomic
nervous system. Which of the following would
you highlight to him as a significant difference
between the peripheral pathways of the autonomic
and somatic motor nervous system?
(A) Unlike the somatic motor system which
has its motor neurons in the CNS, the
motor neurons of the autonomic nervous
system (ANS) are located in the
periphery
(B) The peripheral efferent pathways of the
somatic motor nervous system has two
components: a primary presynaptic or
preganglionic neuron, and a secondary
postsynaptic or postganglionic neuron
(C) The cell bodies of somatic motor nerves
forms aggregates in the periphery called
ganglia
(D) There are no significant differences
(E) All of the above

131. (A)
A. Unlike the somatic motor system which has
its motor neurons in the CNS, the motor
neurons of the ANS are located in the
periphery.
B. The peripheral efferent pathways of both
the sympathetic and parasympathetic
nervous system have two components: a
primary presynaptic or preganglionic neuron,
and a secondary postsynaptic or postganglionic
neuron.
C. The cell bodies of the autonomic postganglionic
neurons are arranged in aggregates
known as ganglia, wherein the synapses
between pre- and postganglionic neurons
take place. The transmission of signal from
the CNS synapses at an autonomic ganglia
in the periphery prior to reaching the target
organ.
D. There are multiple differences between the
two systems. Some of the important points
are highlighted above.

42

132. The professor from question 131 has several
more questions about the autonomic nervous
system. You would make all of the following
statements about the sympathetic and parasympathetic
divisions of the autonomic nervous
system, EXCEPT
(A) the parasympathetic preganglionic fibers
travel from the CNS to synapse in ganglia
located close to their target organs
(B) while sympathetic nerve fibers are distributed
throughout the body, parasympathetic
fibers generally only innervate
visceral organs
(C) the preganglionic sympathetic neurons
have their cell bodies in the gray matter
of the brainstem and their fibers travel
with the oculomotor, facial, glossopharyngeal,
and vagus nerves
(D) the efferent portion of the sympathetic
division of the ANS includes preganglionic
neurons, the two paravertebral
(lateral) sympathetic chains, prevertebral
and terminal ganglia, and postganglionic
neurons
(E) none of the above

132. (C)
A. The parasympathetic preganglionic fibers
travel from the CNS to synapse in ganglia
located close to their target organs. In most
areas, parasympathetic innervation tends
to be more precise than sympathetic innervation.
B. Sympathetic fibers are generally distributed
throughout the body. Parasympathetic
fibers are generally only innervating the visceral
organs.
C. The preganglionic parasympathetic neurons
have their cell bodies in the gray matter
of the brainstem and their fibers travel
with the oculomotor, facial, glossopharyngeal,
and vagus nerves. The preganglionic
fibers from the oculomotor, facial, and
glossopharyngeal nerves synapse in the
ciliary, sphenopalatine, otic, and submaxillary
ganglia, all of which are located in
the head. From these ganglia, the postganglionic
fibers travel to the target organs
(eg, the lacrimal and salivary glands).
D. The efferent portion of the sympathetic division
of the ANS consists of preganglionic neurons, the two paravertebral (lateral) sympathetic
chains, prevertebral and terminal
ganglia, and postganglionic neurons.

43

133. A patient with a history of cancer comes to
your clinic complaining of neck, shoulder, and
arm pain. Which of the following is an important
consideration?
(A) Most tumors that affect the brachial
plexus are from skin cancer
(B) The most common presenting complaint
of a tumor affecting the brachial plexus
is pain
(C) Radiation induced plexopathy has not
been shown to be dependent on dose of
radiation
(D) Clinically, it is nearly impossible to distinguish
between neoplastic and radiation
plexopathy
(E) All of the above

133. (B)
A. Most tumors involving the brachial plexus
originate from the lung or breast and as a
result often invade the lower plexus, particularly
the inferior trunk and medial cord.
B. Pain was the most common presenting
symptom (75%) in a large study of neoplastic
brachial plexopathy and usually
was located in the shoulder and axilla.
Radicular pain was often distributed along
the medial aspect of the arm and forearm
into the fourth and fifth fingers. Motor and
reflex findings commonly (75%) were in
the lower plexus distribution (especially
C8-T1). Most remaining patients had signs
of more widespread (C5-T1) plexus
involvement.
C. Radiotherapy can produce plexus injury by
both direct toxic effects on axons and on the
vasa nervorum, with secondary microinfarction
of nerve. Neurotoxicity is doserelated
for greater than 1000 cGy, pathologic
changes can be observed in Schwann cells,
endoneurial fibroblasts, and vascular and
perineural cells. Administration of 3500 Gy
has produced injury to anterior and posterior
nerve roots in rodents.

44

134. A patient with a history of multiple sclerosis
comes into your office for an initial consult.
She is wheelchair bound and has an intrathecal
pump. She skipped the last appointment with
her previous pain physician because she “did
not like his bed-side manner.” She cannot recall
exactly, but it probably has been 3 months since
she saw a pain physician. Which of the following
is an important consideration?
(A) A withdrawal syndrome from intrathecal
baclofen (ITB) may include respiratory
depression and hypotonia
(B) ITB is a calcium channel blocker that
acts primarily at the dorsal root ganglion
(DRG)
(C) Withdrawal syndromes from ITB can be
fatal
(D) Symptoms of ITB overdose include pruritus
and hyperthermia
(E) All of the above

134. (C)
A. Overdose of baclofen causes side-effects
that range from drowsiness, nausea,
headache, muscle weakness, and lightheadedness
to somnolence, respiratory
depression, seizures, rostral progression of
hypotonia, and loss of consciousness progressing
to coma. There are a range of
symptoms with withdrawal as well; pruritus
without rash, diaphoresis, hyperthermia,
hypotension, neurological changes,
including agitation or confusion, sudden
generalized increase in muscle tone, spasticity,
and muscle rigidity. With severe withdrawal,
rhabdomyolysis and multiple organ
failure can occur.
B. Baclofen is a γ-aminobutyric acid (GABA)
analogue that has inhibitory effects on
spinal cord reflexes and brain. The precise
mechanism of action of baclofen as a muscle
relaxant and antispasticity agent is not
fully understood. Baclofen inhibits both
monosynaptic and polysynaptic reflexes at
the spinal cord level, possibly by decreasing
excitatory neurotransmitter release
from primary afferent terminals, although
actions at supraspinal sites may also contribute
to its clinical effects. Baclofen also
causes enhancement of vagal tone and
inhibition of mesolimbic and nigrostriatal
dopamine neurons (directly or via inhibiting
substance P).
C. ITB withdrawal syndrome has been fatal
in some cases. Differential diagnoses
include malignant hyperthermia, neuroleptic-
malignant syndrome, autonomic
dysreflexia, sepsis, and meningitis.
D. Refer to explanation A.

45

135. A hearing impaired patient with severe learning
disabilities comes to your office accompanied
by his mother. The day prior to seeing
you, the patient had a translaminar lumbar
epidural steroid injection for low-back pain at
a “major medical center” and the physician
performing the procedure said it was a perfect
injection. The patient is not able to communicate
proficiently at his baseline. The mother
reports that since the injection was done, the
patient appears more comfortable lying down
than standing. He is groggy and keeps his eyes
closed for most of your interaction, but he has
been up most of the night. The patient has a
low-grade fever and mild tachycardia. His neck
is somewhat stiff but he is otherwise uncooperative.
Which of the following is the most
appropriate next step of management?
(A) Place an IV line to prepare the patient
for a blood patch
(B) Explain to the mother that the patient
should exhaust conservative therapy for
48 to 72 hours prior to considering a
blood patch
(C) Send the patient to the ER for immediate
performance of a lumbar puncture
(D) Schedule the patient for an MRI of the
lumbar spine
(E) Initiate high-dose narcotic therapy

135. (C)
A. Although a post–lumbar puncture headache
is a possibility, other processes including a
CNS infection must be excluded.
B. In general, prior to treating a post–lumbar
puncture headache, conservative management
should be trialed for at least 48 hours.
C. The most appropriate step.
D. MRI of the lumbar spine does not have a
role at this stage.
E. High-dose narcotic therapy does not have
a role at this stage.

46

136. A physician is performing a cervical transforaminal
epidural steroid injection at the C4-5
level. After the needle is placed in what the practitioner
believes is an appropriate position, he
removes the stylet and gets return of pulsating
red blood. This would be most concerning if
(A) the needle is in the anterior neuroforamen
(B) the needle is in the posterior neuroforamen
(C) no need for concern, as the practitioner
is only planning on injecting triamcinolone
(D) the patient is feeling new radicular pain
symptoms that are severe in the C5 dermatome
(E) the patient has a significant history of
vasovagal responses

136. (A)
A. Cervical transforaminal epidural steroid
injections are controversial for several reasons.
One of the major concerns is the potential
involvement of the vertebral artery,
which lies in the anterior neuroforamen.
B. See explanation A.
C. Injecting triamcinolone, which is a particulate
steroid, could be problematic, especially
if the steroid were to enter the vertebral
artery circulation.
D. Patients experiencing radicular symptoms
in the course of a transforaminal procedure
may suggest involvement of a nerve root.
E. If the patient has a history of vasovagal
responses, appropriate planning should
be made to manage these symptoms
should they occur during the procedure.

47

137. Which of the following statements is true
regarding phantom limb pain and stump pain?
(A) Mastectomy has been documented to
lead to phantom sensation in the breast
in well more than 90% of cases
(B) Phantom sensations are almost always
more vivid in the distal extremity
(C) All amputees that have neuromata have
stump pain
(D) Phantom limb sensations usually
change with time; the distal part of the
limb usually disappears first
(E) None of the above

137. (B)
A. Mastectomy has been reported to lead to
phantom sensation in 22% to 64% of
women who have had the operation.
B. Phantom sensations are present in the
majority of amputees; the sensation is
almost always more vivid in the distal
extremity. The vast majority of these
patients do not have phantom limb pain.
C. Stump pain is perceived to be present in
the existing body part in the region of
amputation; it is often associated with palpable
neuromata at the amputation site—
however, all amputees have neuromata
and not all amputees have stump pain.
D. Phantom limb sensations “telescope” with
time—the proximal part of the limb disappears
first.

48

138. A 35-year-old ex-football player enters your
office complaining of shoulder pain. Which of
the following statements is true of his condition?
(A) A complaint along the deltoid has been
shown to correlate with rotator cuff
pathology
(B) A history of a thyroid disorder could
suggest dysfunction of the acromioclavicular
joint
(C) Acromioclavicular joint pathology usually
presents with diffuse shoulder pain
(D) If the pain began before the age of 30,
this would most fit the clinical picture of
a rotator cuff tear
(E) All of the above

138. (A)
A. The location of the pain can be helpful for
diagnosis. Anterior-superior pain often can
be localized to the acromioclavicular joint,
whereas lateral deltoid pain is often correlated
with rotator cuff pathology. Neck
pain and radiating symptoms should be
explored because cervical pathology can
mimic shoulder pain. Typically, pain that
radiates past the elbow to the hand is not
related to shoulder pathology. However, it
is not uncommon to have pain that radiates
into the neck because the trapezius muscle
often spasms in patients with underlying
chronic shoulder pathology. The presence
of both is more likely to be related to cervical
pathology. Dull, achy night pain is often
associated with rotator cuff tears or severe
glenohumeral osteoarthritis
B. The patient’s medical history, including
joint problems, can help to narrow the differential
diagnosis. Autoimmune diseases
and inflammatory arthritis can affect the
shoulder, resulting in erosions and wear in
the glenohumeral joint, whereas diabetes
and thyroid disorders can be associated
with adhesive capsulitis.
C. Acromioclavicular joint pathology is usually
well localized. A history of an injury to
the joint (shoulder separation), heavy
weight lifting, tenderness to palpation at
the acromioclavicular joint, pain with crossbody
adduction testing, extreme internal
rotation, and forward flexion are consistent
with the diagnosis. Radiographs may be
difficult to interpret because most patients
have acromioclavicular osteoarthritis by
the age of 40 to 50 years. A distal clavicle
lysis or an elevated distal clavicle supports
the diagnosis, whereas the absence of tenderness
to palpation at the acromioclavicular
joint is inconsistent with the diagnosis.
D. Rotator cuff disorders that affect the function
of the rotator cuff include a partial or
complete tear, tendinitis or tendinosis, and
calcific tendinitis. Initially, it is more important
to differentiate this group of disorders
from the other groups than it is to identify
the specific diagnosis. Typically, the patients
are older than 40 years and complain of pain
in the lateral aspect of the arm with radiation
no farther than the elbow. Weakness, a
painful arc of motion, night pain, and a positive
impingement sign are components of
the history and physical examination that
are consistent with this diagnosis. Findings
that are inconsistent with this diagnosis
include being younger than 30 years, having
no weakness, and presenting no impingement
signs. Positive radiographs can be
helpful to diagnose calcific tendinitis, acromial
spur, humeral head cysts, or superior
migration of the humeral head, but are typically
normal.

49

139. You suspect nerve root impingement in the
lumbar spine. Which of the following physical
findings would support this diagnosis?
(1) You suspect L2 nerve root involvement
and the patient has weakness of hip
flexion and sensory loss on the lateral
aspect of the calf
(2) You suspect L4 nerve root involvement
and the patient has weakness of leg
extension and loss of patellar reflex
(3) You suspect L5 nerve root involvement
and the patient cannot dorsiflex his big
toe and has a loss of the Achilles reflex
(4) You suspect S1 nerve root involvement
and the patient has loss of sensation
over the bottom of the foot. Achilles
reflex is normal

139. (C)
1. L2 nerve: weakness of hip flexion (iliopsoas)
and sensory loss on anterior groin
and thigh. No deep tendon reflex.
2. L4 nerve: weakness of leg extension
(quadriceps), ankle dorsiflexion (tibialis anterior); sensory loss medial calf/foot; loss
of patellar reflex.
3. L5 nerve: weakness of dorsiflexion of big
toe (EHL) sensory loss lateral aspect of calf
and dorsum of foot. No deep tendon reflex.
4. S1 nerve: weakness of toe walking (gastrocnemius);
sensory loss on dorsum of foot, loss
of Achilles reflex. This is correct because the
reflex does not have to be decreased/lost to
suspect this nerve root’s involvement. The
sensory abnormality is enough.

50

140. Which of the following structures that play a
role in the neurobiology of addiction are properly
linked?
(1) Nucleus locus ceruleus—arousal, attention,
and anxiety
(2) Anterior cingulate cortex—functional
part of limbic system
(3) Amygdala—mediates drug craving
(4) Nucleus accumbens—one of the brain’s
reward centers

140. (E) Addiction is a disease of the CNS. All substances
of abuse activate essentially the same
neuroanatomic structures. All of the structures
listed above are properly linked.