Chapter 6. Types and Pain Flashcards Preview

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Flashcards in Chapter 6. Types and Pain Deck (270):
1

332. A45-year-old patient with metastatic breast carcinoma
is prescribed 30 mg of sustained-release
morphine (MS Contin) twice a day and one
15-mg tablet of immediate-release morphine
(MSIR) every 6 hours as needed for breakthrough
pain. On her routine follow-up visit she
reports that she routinely uses MSIR four times
a day with satisfactory pain control on most days
and no major side effects. What would be your
best course of action in this situation?
(A) Prescriptions should be left unchanged
(B) MS Contin should be changed to 40 mg
of OxyContin twice a day and 5 mg of
oxycodone every 6 hours as needed for
breakthrough pain
(C) Fentanyl patch of 25 μg/h should
replace MS Contin with 15 mg of MSIR
every 6 hours as needed for breakthrough
pain
(D) MS Contin should be increased to 60 mg
twice a day with MSIR 15 mg every
6 hours as needed for breakthrough pain
(E) MS Contin should be increased to
60 mg twice a day, and MSIR should be
discontinued

332. (D) If a patient routinely uses breakthrough
medications, the daily total amount should be
converted to a sustained-release dose and
added to the current maintenance dose.

2

333. Approximately in what percentage of patients
with malignancies does pain unrelated to cancer
occur?
(A) Less than 2%
(B) 3%
(C) 7.5%
(D) 11%
(E) 25%

333. (B) Approximately 3% of pain syndromes in
cancer patients are unrelated to the underlying
malignancy or cancer treatment. Most commonly,
pain is caused by degenerative disc disease,
arthritis, fibromyalgia, or migraine and
has often predated the diagnosis of cancer.

3

334. There is a significant incidence of neuropathic
pain in a cancer patient with brachial plexopathy.
The etiology of the brachial plexopathy in such
a patient may be caused by direct tumor infiltration
or radiation fibrosis. Electrophysiologic
evaluation with nerve conduction velocity (NCV)
study and electromyography (EMG) helps to
distinguish between the two etiologies. Which of
the following findings of NCV/EMG is the most
helpful to differentiate between the direct tumor
infiltration and the radiation fibrosis etiologies of
brachial plexopathy?
(A) Segmental nerve conduction slowing
(B) Myokymia
(C) Fibrillation potentials
(D) Positive sharp waves
(E) Decreased amplitude of the compound
muscle action potential (CMAP)

334. (B) Segmental nerve conduction slowing, fibrillation
potentials, positive sharp waves, and
decreased amplitude CMAPs are all helpful in
determining the presence of brachial plexopathy
in general. Myokymia is present in 63% of
patients with radiation fibrosis induced
brachial plexopathy. Brachial plexopathy
caused by direct tumor infiltration has a low
incidence of myokymia. Myokymia is a continuous
but brief involuntary muscle twitching
that gives the appearance of wormlike rippling
of the muscle. It

4

335. If bony metastases are present, which primary
cancer location has the best 5-year survival
prognosis?
(A) Myeloma
(B) Breast
(C) Prostate
(D) Thyroid
(E) Kidney

335. (D) A5-year survival for a cancer patient with
documented skeletal metastases varies widely
depending on location of the primary tumor:
myeloma—10%; breast—20%; prostate—25%;
lung—less than 5%; kidney—10%; thyroid—
40%; melanoma—less than 5%.

5

336. The most frequent spinal cord symptom or sign
in patients with carcinomatous meningitis is
(A) nuchal rigidity
(B) back pain
(C) reflex asymmetry
(D) positive straight leg raise test
(E) weakness

336. (C) Reflex asymmetry occurs in 67% of patients
with carcinomatous meningitis and is the most
frequent spinal cord–related sign. The frequency
of nuchal rigidity, back pain, positive straight leg raise test, and weakness is 11%,
25%, 13%, and 33%, respectively.

6

337. Which of the following would most likely be
responsible for the central pain syndrome?
(A) Epidural spinal cord compression
(B) Metastatic bony destruction of the
vertebrae with a nerve root compression
(C) Metastatic involvement of the cranial
nerves
(D) Carcinomatous meningitis
(E) Radiation myelopathy

337. (E) Central pain syndromes are relatively rare in
cancer patients. Although epidural spinal cord
compression is almost always painful, central pain
is not the predominant symptom. Nociceptive
input from progressive bony destruction by
metastases is the usual cause of pain, with or without
concurrent radicular pain from nerve root
compression. Radiation myelopathy is the central
pain syndrome.

7

338. The majority of patients with epidural metastasis
have the following pattern of pain:
(A) Local
(B) Radicular
(C) Referred
(D) Funicular
(E) All of the above

338. (A) The most common pattern of pain in patients
with epidural metastasis is local. Local pain over
the involved vertebral body, which results from
the involvement of the vertebral periosteum, is
dull and exacerbated by recumbency.
Radicular pain from compressed or damaged
nerve roots is usually unilateral in the
cervical and lumbosacral regions and bilateral
in the thorax. The pain is experienced in the
overlying spine, deep in certain muscles supplied
by the compressed root, and in the cutaneous
distribution of the injured root.
Referred pain has a deep aching quality
and is often associated with tenderness of
subcutaneous tissues and muscles at the site
of referral. The typical examples of referred
pain pattern include buttocks and posterior
thigh pain with lumbosacral spine involvement;
pain in the flank, groin, and anterior
thigh in the upper lumbar spine involvement;
midscapular and shoulder pain in the cervicothoracic
epidural disease.
Funicular pain usually occurs some distance
below the site of compression and it has hot or cold qualities in a poorly localized nondermatomal
distribution. It presumably results
from compression of the ascending sensory
tracts in the spinal cord.

8

339. All of the following are true about the World
Health Organization (WHO) analgesic ladder,
EXCEPT
(A) it is a method for relief of cancer pain
based on a small number of relatively
inexpensive drugs
(B) it has three steps
(C) step one involves the use of opioids
(D) it suggests to use only one drug from
each group at a time
(E) it is a simple and effective method for
controlling cancer pain

339. (C) The WHO analgesic ladder is based on the
premise that most patients throughout the world
gain adequate pain relief if health care professionals
learn how to use a few effective and
relatively inexpensive drugs well. Step 1 of the
ladder involves the use of nonopioids. If this
step is ineffective, go to step 2 and add an
opioid for mild to moderate pain. Step 3 substitutes
an opioid for moderate to severe pain
in step 2. Only one drug from each group
should be used at a time. Adjuvant drugs can
be used in all steps.

9

340. The following are all true about methadone,
EXCEPT
(A) it has a highly variable oral bioavailability
(B) it is a low cost medication
(C) it has no known active metabolites
(D) it has N-methyl-D-aspartate (NMDA)
receptor agonist properties
(E) it has high lipid solubility

340. (D) Methadone has a variable oral bioavailability
between 41% and 99% and, therefore,
should be started with extra caution (low initial
dose and slow subsequent increases).
Methadone differs from all other opioids by its
noncompetitive antagonist activity at the
NMDAreceptors. Activation of NMDA receptors
has been shown to play a role in development
of tolerance to analgesic effects of
opioids, as well as in the pathologic sensory
states, such as neuropathic pain, inflammatory
pain, ischemic pain, allodynia, and spinal
states of hypersensitivity.

10

341. 58-years-old patient with metastatic prostate
cancer is taking sustained-release morphine
(MS Contin) every 8 hours with a total daily
dose of 225 mg with optimal pain control.
Because of some circumstances, he has to be
converted to transdermal therapeutic system
fentanyl (TTS-fentanyl). What is the correct
dose of fentanyl patch equivalent to the current
dose of MS Contin for this patient?
(A) 25 μg/h every 72 hours
(B) 50 μg/h every 48 hours
(C) 75 μg/h every 72 hours
(D) 100 μg/h every 48 hours
(E) 125 μg/h every 72 hours

341. (C) As a rough guide for conversion, the 8-hourly
dose of MS Contin (225/3 = 75 mg in this case)
can be considered equal to the micrograms per
hour dose of TTS-fentanyl. In one study, most
people had satisfactory pain profiles with frequency
of administration of every 3 days. Only
in 24% of subjects in the study required different
frequency of administration varying from
48 to 60 hours.

11

342. Which of the following is true with respect to
central pain syndromes?
(A) The most common cause of central pain
state are lesions located in the brainstem
(B) The Wallenberg syndrome (lateral
medullar syndrome) is characterized by
contralateral facial sensory loss and
Horner syndrome
(C) The most common lesions that produce
thalamic pain syndrome are infarctions
(D) Spinal cord lesions rarely cause sensory
deficits
(E) Central pain syndromes of spinal origin
usually respond to epidural steroids

342. (C)
A. The most common cause of central pain
states are spinal cord lesions.
B. The Wallenberg syndrome is usually vascular
in origin, and characterized by crossed
sensory findings that include ipsilateral
facial sensory loss, Horner syndrome, and contralateral body impairment of pain and
temperature loss.
C. The most common lesions that produce thalamic
pain syndrome are infarctions, followed
by arteriovenous malformations (AVMs),
neoplasms, abscesses, plaque of multiple
sclerosis, traumatic injury, and others.
D. Spinal cord lesions are the most common
cause of central pain syndromes and present
with areas of sensory loss resulting
from disruption of the spinothalamic tract.
E. The treatment of central pain of spinal origin
is complex with poor response to most
forms of therapy.

12

343. Peripheral neuropathy is a common pain syndrome
characterized by which of the following?
(A) Asymmetric paresthesias and proximal
motor impairment
(B) Proximal more than distal sensory
impairment
(C) Most peripheral neuropathies may be
classified as demyelinating, axonal, or
mixed
(D) Peripheral mononeuropathy is the most
common peripheral nerve disease in
patients with long-standing diabetes
mellitus
(E) Nerve conduction studies only measure
conduction through small unmyelinated
fibers, so impairment of the fast
conducting fibers may go undetected

343. (C) Sensory symmetric impairment is commonly
seen distally with progression to more
proximal areas of the limbs as the disease progresses.
Peripheral polyneopathy is the most
common initial manifestation of diabetes mellitus.
The nerve conduction studies measure
only the fastest conducting fibers, leaving
injury of small-diameter fibers, which transmit
pain sensations, undiagnosed.

13

344. Events seen in the development of neuropathic
pain are
(A) following nerve injury, there is a
decreased activity of the sodium channels
which allows for abnormal conduction
through pain facilitating fibers
(B) wide dynamic range neurons in the
dorsal horn respond with increased
frequency as the intensity of the
repeated afferent stimulus increases
(C) an increase in potassium channels would
facilitate an amplified afferent activity
(D) C-polymodal nociceptors are activated
by low-threshold mechanical, thermal,
and chemical stimuli
(E) γ-aminobutyric acid (GABA) and
glycine are released in the dorsal horn
and augment the response of second
order neurons

344. (B) Following nerve injury there is an increase
in the expression of sodium channels in the
neuroma and in the DRG. Consistent with the
role of sodium channels in the development of
neuropathic pain is blockage of their activity by
low plasma concentrations of lidocaine. A reduction
in potassium channel activity leads to
increased afferent activity. The largest population
of afferent axons is C-polymodal nociceptors
that are activated by high-threshold
mechanical, thermal, and chemical stimuli.

14

345. Examples of neuropathic pain conditions include
all, EXCEPT
(A) complex regional pain syndrome (CRPS)
(B) diabetic peripheral neuropathy
(C) postherpetic neuralgia (PHN)
(D) Raynaud phenomenon
(E) phantom limb pain

345. (D) Raynaud phenomenon is not a neuropathic
pain condition, but rather a vascular condition
(although, potentially sympathetically mediated
and/or sustained).

15

346. Which of the following conditions is more
likely to be associated with neuropathic pain?
(A) Traumatic nerve injury
(B) Stroke
(C) Syringomyelia
(D) Multiple sclerosis
(E) Large myelinated fiber neuropathy

346. (C) Although not completely known some conditions
predispose to the development of neuropathic
pain. The relative frequency is 5% for
patients with traumatic nerve injury, 8% for
patients after stroke, 28% for patients with multiple
sclerosis, and 75% for patients with
syringomyelia. Neuropathies with predominant involvement of large myelinated fibers are usually
not painful.

16

347. A patient with CRPS responds well to sympathetic
ganglion block. The results of this block
can lead you to say which of the following
about this particular pain condition?
(A) It is vascularly mediated
(B) It is sympathetically mediated
(C) It is sympathetically maintained
(D) It is less severe than previously thought
(E) It will not respond well to spinal cord
stimulation

347. (C) We do not know if it is sympathetically
mediated (B) from the block since this does not
provide evidence of etiology. We do not know
the involvement of vascularity since the block
is affecting sympathetic outflow and precludes
vascular evidence (which could be mediated by
a host of other physiologic events). There is no
clinical evidence to support a less severe case (D)
and, the evidence suggests that it will respond
to spinal cord stimulation (E).

17

348. Neuropathic pain can result in which of the
following condition?
(A) Central sensitization
(B) Allodynia
(C) Hyperalgesia
(D) B and C
(E) A, B, and C

348. (E) Central sensitization is the reason for many
of the symptoms including allodynia and
hyperalgesia. Therefore, all are correct.

18

349. Potential neurophysiologic mechanisms underlying
the development of neuropathic pain
include
(A) microglial activation in the spinal cord
(B) cytokine production in the spinal cord
(C) decreased glutamate release in the
spinal cord
(D) A and C
(E) A and B

349. (E) Cytokines are inflammatory mediators
released by a variety of cells that regulate the
inflammatory response. Systemic or local injection
of cytokines in animal models causes mechanical
and thermal hyperalgesia. Cytokines may cause
excitation of nociceptors via the release of other
mediators, like prostaglandins. At the level of the
CNS, cytokines may be liberated by microglial
cells. The best studied excitatory amino acid is
glutamate. Glutamate may bind to ionotopic or
metabotropic glutamate receptors. Peripheral and
central activation of those receptors induces pain
behaviors in animals. All basic science evidence
suggests (A) and (B), but does not suggest (C).

19

350. When the stimulus of light touch exerts pain
which of the following is exhibited?
(A) Hyperalgesia
(B) Allodynia
(C) Hypereflexemia
(D) Paresthesia
(E) Hypertouchemia

350. (B) Following tissue damage, there is a decrease
of the threshold for noxious stimuli (hyperalgesia),
which may be associated to perception of
pain to normally innocuous stimuli. This phenomenon
is termed allodynia. Allodynia is most
likely caused by plastic changes at the level of the
primary sensory fibers and spinal cord neurons.

20

351. Phantom pain refers to
(A) any sensation of the missing limb,
except pain
(B) painful sensations referred to the
missing limb
(C) spontaneous movement of the stump
ranging from small jerks to visible
contractions (jumpy stump)
(D) pain referred to the amputation stump
(E) B and D

351. (B) Phantom sensation: any sensation of the
missing limb, except pain (A).
Stump contractions: spontaneous movement
of the stump ranging from small jerks to
visible contractions (jumpy stump) (C).
Stump pain: pain referred to the amputation
stump (D).

21

352. A 74-year-old male has a left lower extremity
amputation after a long bout with uncontrolled
diabetes mellitus (DM). What are the chances
that this patient will develop phantom pain?
(A) 33%
(B) 49%
(C) 55%
(D) 90%
(E) 75%

352. (E) While ranges between 2% and 88% are
quoted in the literature, most current studies state that between 60% and 80% of patients
will develop phantom pain after amputation.

22

353. A vascular surgeon consults the pain team on
a patient who is scheduled to undergo an
amputation secondary to peripheral vascular
disease. The patient has read about phantom
pain on the Internet and would like to know
when it would likely start. You tell the vascular
surgeon that
(A) the onset of phantom pain is usually
within the first week after amputation
(B) most studies have shown that phantom
pain will start between 2 and 4 weeks
after an amputation for peripheral
vascular disease
(C) the likelihood of her developing
phantom pain in the first 6 months after
amputation is low, but increases drastically
between 6 and 9 months
(D) the onset will likely be delayed for years
(E) none of the above

353. (A) Prospective studies in patients undergoing
amputation mainly because of peripheral vascular
disease have shown that the onset of
phantom pain is usually within the first week
after amputation.
However, in a retrospective study of individuals
who were congenital amputees or
underwent amputation before the age of 6 years,
Melzack and coworkers found that the mean
time for onset of phantom limb pain was 9 years
in the group of congenital amputees and 2.3 years
in the group of individuals with early amputations.
[Jensen TS, Krebs B, Nielsen J, et al.
Phantom limb, phantom pain, and stump pain
in amputees during the first 6 months following
limp amputation.

23

354. The patient mentioned in the previous question
develops early and severe phantom pain:
(A) The patient is more likely to suffer from
long-standing pain
(B) The patient is less likely to suffer from
long-standing pain
(C) The patient is more likely to suffer incapacitating
pain for 1 year that will
subside rather abruptly
(D) It is likely that the patient will develop
neuropathic pain in the extremity
contralateral to the amputation
(E) The pain will likely be refractory to
treatment with anticonvulsants

354. (A) Patients who develop early and severe
phantom pain are more likely to suffer from
chronic pain, whereas individuals who are
pain-free at the beginning are less likely to
develop significant pain. However, prospective
studies with a maximum follow-up period of
2 years suggest that phantom pain may diminish
with time.

24

355. The number of amputees who have severe
phantom limb pain is
(A) 20% to 30%
(B) 60% to 80%
(C) 5% to 10%
(D) 1% to 2%
(E) 45% to 55%

355. (C) While phantom limb pain is seen in 60% to 80% of amputees, only 5% to 10% have severe pain.

25

356. Preamputation pain
(A) is more likely to lead to phantom pain if
the amputation is traumatic
(B) may sensitize the nervous system,
explaining why some individuals may
be more susceptible to development of
chronic phantom pain
(C) is more likely to lead to phantom pain if
the amputation is secondary
(D) is similar in character and localization to
the subsequent phantom pain in 80% of
patients
(E) is less likely to lead to phantom pain if the
amputation is in the upper extremities

356. (B) Some retrospective studies, but not all have
pointed to preamputation pain as a risk factor
for phantom pain. It has been hypothesized that
preoperative pain may sensitize the nervous
system, explaining why some individuals may
be more susceptible to development of chronic
pain.
A. It has been noted that patients with traumatic
amputations, who had no pain prior
to the amputation, develop pain to the same
extent as patients with preoperative pain
who endure amputations after significant
medical pathology.
C. There is no correlation between the development
of phantom pain and whether the
amputation was primary or secondary.
Primary amputation is when the limb is lost
at the time of the injury. Secondary amputation
is when the limb is surgically removed
in a hospital.
D. Phantom pain may mimic preamputation
pain in both character and localization.
Preamputation pain may persist in some
patients, but it is not the case in the majority
of patients.
E. Site of amputation has not been found to
have a role in determining whether preamputation
pain leads to phantom pain.

26

357. A 25-year-old left lower extremity amputee
returns from Iraq. He experiences phantom
pain, but is attempting to move forward in life.
To ease his transition back into society which of
the following is the next best step?
(A) He should take as long as possible to
grieve before he finds new employment
(B) He should initially use a cosmetic
prosthesis before embarking on the task
of learning to use a functional one
(C) He should absolutely refuse to ever
have spinal anesthesia as it may worsen
phantom pain
(D) He should learn coping strategies as
phantom pain is a psychological
disturbance
(E) None of the above

357. (E)
A. Amputees who experienced a long delay
between the amputation and return to
work, had difficulty in finding suitable
jobs, and had fewer opportunities for
promotion.
B. The use of a functionally active prosthesis
as opposed to a cosmetic prosthesis may
reduce phantom pain.
C. Spinal anesthesia in amputees may precipitate
transient, difficult to treat phantom
pain. Given the low incidence of recurrent
phantom limb pain with spinal anesthesia,
its transient nature, and the fact that it can
be treated if it occurs, it has been concluded
that spinal anesthesia is not contraindicated
in patients with previous
lower limb amputation.
D. While there is no evidence that phantom
pain represents a psychological disturbance,
it may be triggered and precipitated
by psychosocial factors. It has been shown
that coping strategies are important for the
experience of phantom pain Research has
indicated that the way individuals cope
with pain may influence pain, and physical
and psychological adjustment.

27

358. Stump pain and phantom pain are often
confused. There are, however, notable differences.
Which of the following is true?
(A) Unlike phantom pain, stump pain
occurs in the body part that actually
exists, in the stump that remains
(B) Stump pain typically is described as a
“sharp,” “burning,” “electric-like,” or
“skin-sensitive” pain
(C) Stump pain is usually caused by a
neuroma
(D) Surgical revision of the stump or
removal of the neuroma is sometimes
considered when treating stump pain
(E) All of the above

358. (E) Stump pain is located at the end of an amputated
limb’s stump. Unlike phantom pain, it
occurs in the body part that actually exists, in the
stump that remains. It typically is described as
a “sharp,” “burning,” “electric-like,” or “skinsensitive”
pain. Some patients have spontaneous
movements of the stump, ranging from slight,
hardly visible jerks to severe contractions.
Stump pain results from a damaged nerve
in the stump region. Nerves damaged in the
amputation surgery try to heal and may form
abnormally sensitive regions, called neuromas.
A neuroma can cause pain and skin sensitivity.
Percussion of neuromas may increase
nerve fiber discharge and augmentation of
stump and phantom pain.
No one treatment has been shown to be
effective for stump pain. Because it is a pain
caused by an injured peripheral nerve, drugs
used for nerve pain may be helpful.
If the stump pain affects a limb, revision
of the prosthesis is sometimes beneficial.
Other approaches also are tried in selected
cases, including: nerve blocks, transcutaneous
electrical nerve stimulation, surgical revision
of the stump, or removal of the neuroma (this
procedure may fail because the neuroma can
grow back; some patients actually get worse
after surgery), and cognitive therapies.
Stump pain is common in the early postamputation
period. Stump pain can also persist
beyond the stage of postsurgical healing.
Stump pain and phantom pain are strongly
correlated. Phantom pain subsides with resolution
of stump pain and that it is more prevalent
in patients with phantom pain than in
those without it.
Careful sensory examination of amputation
stumps may reveal areas of sensory abnormalities
such as hypoesthesia, hyperalgesia, or allodynia.
However, a correlation between phantom
pain and the extent and degree of sensory abnormality
has not been established.

28

359. A neuroma is an inflammation of a nerve that
is seen universally after a nerve has been cut
(ie, during an amputation). They show spontaneous
and abnormal evoked activity following
mechanical or chemical stimulation from
the periphery. This results from
(A) an increased and novel expression of
sodium channels
(B) hyperexcitability changes and
reorganization of the thalamus
(C) an increase in potassium efflux
(D) increased activity in afferent C fibers
(E) A and D

359. (E) The ectopic and increased spontaneous and
evoked activity from the periphery is assumed
to be the result of an increased and also novel
expression of sodium channels.
Local anesthesia of the stump may reduce
or abolish phantom pain temporarily.
Decreasing peripheral output by locally anesthetizing
stump neuromas with lidocaine
reduced tap-evoked stump pain. On the other
hand, there was a clear increase in pain when the potassium channel blocker, gallamine was
injected in the perineuromal space. Both findings
support the premise that abnormal input
from peripheral nociceptors plays a role in
pain generation.

29

360. Some amputees show an abnormal sensitivity
to pressure and to repetitive stimulation of the
stump, which can provoke attacks of phantom
pain. Which of the following is the case in
humans?
(A) It can be reduced by giving the NMDA
antagonist, ketamine
(B) It can only be reduced by terminating
the stimulation
(C) It can be attributed to the general
excitability of spinal cord neurons,
where only C fibers gain access to
secondary pain-signaling neurons
(D) Sensitization of the dorsal horn may be
mediated by glycine and serotonin
(E) All of the above

360. (A) The pharmacology of spinal sensitization
entails an increased activity in NMDA
receptor–operated systems, and many aspects
of the central sensitization can be reduced by
NMDA receptor antagonists In amputees, the
evoked pain from repetitive stimulation can be
reduced by the NMDA antagonist ketamine
B. Terminating the stimulation is not the only
way to reduce the pain.
C. After a nerve is injured, there is an increase
in the general excitability of spinal cord
neurons, where C fibers and A-δ afferents
gain access to secondary pain-signaling
neurons.
D. Sensitization of dorsal horn neurons is
mediated by release of glutamate and neurokinin.
This sensitization may present in
several ways including: lowered threshold,
increased persistent neuronal discharges
with prolonged pain after stimulation, and
expansion of peripheral receptive fields.
The central sensitization may also be a
result of a different type of anatomical reorganization.
Substance P is normally expressed
in small afferent fibers, but following nerve
injury, it may be expressed in large A-β fibers.
This phenotypic switch of large A-β fibers into
nociceptive-like nerve fibers may be one of
the reasons why nonnoxious stimuli can be
perceived as painful

30

361. Of the following, which does not play a role in
the mechanism for generating phantom pain?
(A) Peripheral sensitization
(B) Central sensitization
(C) Cortical reorganization
(D) Increased thalamus response to
stimulation
(E) Sympathetic inhibition

361. (E)
E. The sympathetic nervous system may play
a role in generating and, in uparticular, in
maintaining, phantom pain.
After limb amputation and deafferentation
in adult monkeys, there is reorganization of the
primary somatosensory cortex, and while these
changes may be unique to the cortex, they may
also be, at least in part, the result of changes at
the level of the thalamus and perhaps even
brain stem or spinal cord. After dorsal rhizotomy,
the threshold to evoke activity in the
thalamus and cortex decreased, and the mouth
and chin invade cortices corresponding to the
representation of arm and fingers that have lost
their normal afferent input. In humans similar
reorganization has been observed. In the thalamus,
neurons that normally do not respond to
stimulation in amputees begin to respond and
show enlarged somatotropic maps. A cascade
of events seems to be involved in generating
phantom pain and it starts in the periphery,
spinal cord, brain stem, thalamus, and finally
ends in the cerebral cortex.

31

362. Pharmacologically treating phantom pain is
not easy. Which of the following medications
has not proven to be effective in well-controlled
trials?
(A) Tramadol
(B) Gabapentin
(C) Memantine
(D) Amitriptyline
(E) A and C

362. (C)
A. and D. Tramdol and amitriptyline have been
found to be efficacious in treating phantom
and stump pain in treatment naive patients.
B. Gabapentin has been noted to be better
than placebo in reducing phantom pain.
Failure to pharmacologically provide pain
relief should not be accepted until opioids
have been tried. Intravenous (IV) and oral
morphine have been shown to decrease phantom
pain. Case reports have indicated that
methadone may also be helpful.
Other trials have not reported the same
the success with an oral NMDA antagonist,
memantine.
Suggestions for the treatment of postamputation
pain (no evidence) (Note: it is important
to differentiate between early postoperative
pain and chronic pain [pain persisting more
than 4 weeks], and stump and phantom pain):
Early postoperative pain
Stump pain
Conventional analgesics
• Acetaminophen
• NSAIDs
• Opioids
+/− combined with epidural pain treatment
Stump and phantom pain
If neuropathic pain clearly exists (paroxysms
or abnormal stump sensitivity)—trial
with TCAs or anticonvulsants.
Chronic pain
Stump pain
• Local stump surgery: if obvious stump
pathology is present, revisions should be
considered; surgery should be avoided in
cases of sympathetically maintained pain.
• Local medical treatment: topical lidocaine or
capsaicin can be tried in those who have
stump pain but no obvious stump pathology.
Stump and phantom pain (medical treatment,
in order of preference)
• Gabapentin 1200 to 2400 mg/d, slow titration.
Max dose of 3600 mg/d.
• TCAs (imipramine, amitriptyline, nortriptyline)
100 to 125 mg/d, slow titration. Check
electrocardiogram (ECG) before starting.
Monitor plasma levels with dose greater
than 100 mg/d. If sedation is wanted,
amitriptyline should be used.
• If the pain is mostly paroxysmal, lancinating,
or radiating:
• Oxcarbazepine 600 to 900 mg/d. Start at
300 mg and increase by 300 mg daily.
• Carbamazepine 450 mg/d. Start dose
150 mg, daily increments of 150 mg.
Monitor plasma levels after 10 days on
maximum dose.
• Lamotrigine 100 to 200 mg/d. Start dose
25 mg/d, slow titration with increments
of 25 mg/14 days (to avoid rash).
• Opioids (long-acting) or tramadol.
• If none of the above has an effect, refer the
patient to the pain clinic.
• In pain center: can perform IV lidocaine
trial or ketamine trial. If the lidocaine test is
positive—reconsider anticonvulsants. If the
ketamine test is positive: consider memantine
or amantadine.
Physical therapy encompassing massage,
manipulation, and passive range of motion
may prevent trophic changes and vascular
congestion in the stump. Transcutaneous electrical
nerve stimulation, acupuncture, ultrasound,
and hypnosis, may have a beneficial
effect on stump and phantom pain.

32

363. A65-year-old Vietnam War veteran with a left
below the knee amputation and phantom pain
has surgery on an amputation neuroma. He
should expect
(A) excellent resolution of his phantom pain
(B) short-term pain relief
(C) a likely infection and subsequent
complicated hospital course
(D) decreased pain only if he receives a
40-minute infusion of diphenhydramine
within 24 hours of the surgery
(E) none of the above

363. (B) Surgery on amputation neuromas and more
extensive amputation were accepted treatment modalities for stump and phantom pain in the
past. Today, stump revision is probably done
only in cases of obvious stump pathology, and
in properly healed stumps there is almost never
an indication for proximal extension of the
amputation because of pain. Surgery should
be avoided in cases of sympathetically maintained
pain. Surgery may produce short-term
pain relief but pain often reappears. The results
of other invasive procedures such as dorsal
root entry zone lesions sympathectomy and
cordotomy have generally been nontherapeutic,
and most of them have been abandoned.

33

364. Apatient has tingling sensations in a phantom
limb that are uncomfortable and annoying
but do not interfere with activities or sleep.
According to the Sunderland classification of
patients with phantom pain, what group is this
patient in?
(A) Group I
(B) Group II
(C) Group III
(D) Group IV
(E) None of the above

364. (B) Classification of patients with phantom
pain:
Group I: Mild intermittent paresthesias that
do not interfere with normal activity, work, or
sleep.
Group II: Paresthesias that are uncomfortable
and annoying but do not interfere with activities
or sleep.
Group III: Pain that is of sufficient intensity,
frequency, or duration to be distressful; however,
some patients in this group have pain
that is bearable, that intermittently interferes
with their lifestyle, and that may respond to
conservative treatment.
Group IV: Nearly constant severe pain that
interferes with normal activity and sleep.

34

365. The gate-control theory of pain has been used
to explain phantom limb pain. It states that
(A) following significant destruction of
sensory axons by amputation, wide
dynamic range neurons are freed by
inhibitory control
(B) self-sustaining neuronal activity may
occur in spinal cord neurons
(C) if spontaneous spinal cord neuronal
activity increases by any amount, pain
may occur in the phantom limb
(D) A and B
(E) A, B, and C

365. (D)
A. and B. The gate control theory of pain, put
forward by Ronald Melzack and Patrick
David Wall in 1962, and again in 1965, is the
idea that the perception of physical pain is
not a direct result of activation of nociceptors,
but instead is modulated by interaction
between different neurons, both paintransmitting
and non–pain-transmitting.
The theory asserts that activation of nerves
that do not transmit pain signals can interfere
with signals from pain fibers and
inhibit an individual’s perception of pain. It
has been used to explain phantom limb
pain. Following marked destruction of sensory
axons by amputation, wide dynamic
range neurons are freed by inhibitory control. Self-sustaining neuronal activity may then
occur in spinal cord neurons.
C. If the spontaneous spinal cord neuronal
activity exceeds a critical level, pain may
occur in the phantom limb.
This loss of inhibitory control may lead to
spontaneous discharges at any level in the
CNS and may explain the lack of analgesia in
paraplegics with phantom body pain after
complete cordectomy Pain increases after
blocking conduction are in line with the theory,
as continued loss of peripheral sensory
input would lead to further disinhibition.
Sodium thiopental perpetuates CNS inhibition
and has been reported to end phantom
limb pain during spinal anesthesia. Melzack
R, Wall PD. Mechanisms: a new theory. Agate
control system modulates sensory input from
the skin before it evokes pain perception and
response. Science. 1965;150(3699).

35

366. All of the following are true about primary
dysmenorrhea, EXCEPT
(A) pain is transmitted via the thoracolumbar
spinal segments and pelvic afferents
(B) the etiology of pain includes myometrial
contractions leading to intense intrauterine
pressure and uterine hypoxia
(C) prostaglandins and leukotriene production
that sensitizes afferent pelvic nerves
is part of its pathogenesis
(D) endometriosis and adenomyosis are its
most common causes
(E) altered central receptivity of the afferent
input from the pelvis is thought to be
relevant in its development

366. (D) Primary dysmenorrhea is defined as
menstrual pain without pelvic pathology.
Endometriosis and adenomyosis are the most
common causes of secondary dysmenorrhea.

36

367. All of the following are true about chronic
endometriosis, EXCEPT
(A) ovaries, cul-de-sac, uterine tubes, surface
of the bowel are among the most common
sites of pathologic implantation of
the functioning endometrial tissue
(B) retrograde menstruation, lymphatic
spread, and hematogenous spread of the
endometrial tissue are all thought to
play a role in endometriosis etiology
(C) pain occurs only with menses
(D) definitive diagnosis can be made by visualization
of the characteristic lesions without
a mandatory histologic confirmation
(E) leuprolide acetate (Lupron) may be an
effective treatment of the symptoms of
chronic endometriosis

367. (C) The pain of endometriosis can occur with
menses or sexual intercourse or can always be
present. It can also mimic any known pelvic
pathology. Answers A, B, D, and E are all correct.

37

368. All of the following are correct, EXCEPT
(A) pudendal nerve takes origin from S2, S3,
and S4 roots bilaterally
(B) bilateral denervation of the inferior
hypogastric nerves is as effective as a
lumbar epidural block with respect to
sensory input from the uterus and cervix
(C) many patients with hymenal neuropathy
are so emotional and complain so
violently that the pelvic examination is
not possible
(D) patients with sympathetic pelvis syndrome
have a deep pain in the pelvis
not associated with physically
detectable abdominal wall or muscle
tenderness
(E) ilioinguinal and iliohypogastric neuropathy
is rarely associated with the surgeries
in the lower abdominal wall area

368. (E)

38

369. All of the common reasons for the inadequate
management of acute pain in a hospital setting
are true, EXCEPT
(A) the common idea that pain is merely a
symptom and not harmful in itself
(B) the fact that opioids have no potential
for addiction when administered strictly
for acute pain
(C) lack of understanding of the pharmacokinetics
of various agents
(D) lack of appreciation of variability in
analgesic response to opioids
(E) prescription of inappropriately low
doses of opioids and thinking that
opioids must not be given more often
than every 4 hours

369. (B) Opioids have the potential for addiction
even when administered for acute pain.
However, it is the exaggerated common fear
of the potential for addiction to opioids that
often interferes with adequate pain management.
The rest of the answers are correct.

39

370. The following are true about pathologic
(nonphysiological) pain, EXCEPT
(A) it occurs in the context of central
sensitization
(B) it occurs in the context of peripheral
sensitization
(C) it outlasts the stimulus
(D) it spreads to nondamaged areas
(E) it is elicited by A-δ and C fibers, but not
A-β fibers, which transmit touch sensation

370. (E) It is recognized that long-term changes
occur within the peripheral and central nervous
system following noxious input. This neuroplasticity
alters the body’s response to usual
peripheral sensory input. In pathologic pain
conditions, stimulation of A-β fibers, normally eliciting response to touch, may elicit pain.

40

371. Perioperative administration of NSAIDs
(A) does not reduce the demand for opioids
during and after the surgery
(B) is contraindicated because of increased
possibility of bleeding
(C) has synergistic effect with opioids
(D) has its analgesic effect only through
peripheral mechanisms
(E) is not associated with the concerns for
postoperative bleeding

371. (C) Even though there have been some concerns
regarding the risks of perioperative NSAIDs, including intra- and postoperative bleeding,
they continue to have a useful role. Combination
of NSAIDs and opioids has a synergistic
analgesic effect, as they act at the different sites
of pain pathways. More new evidence is emerging
that NSAIDs exert their analgesic effects also
through the central mechanisms.

41

372. All of the following are true about the NMDA
receptors, EXCEPT
(A) they are involved in development of
“windup” facilitation
(B) NMDA agonists reduce development of
tolerance to opioids
(C) NMDA receptors are involved in
development of central sensitization
(D) NMDA receptors are involved in
changes of peripheral receptive fields
(E) NMDA receptors are involved in
induction of oncogenes and long-term
potentiation

372. (B) It has been demonstrated that the administration
of an NMDA antagonist reduces the
development of tolerance to morphine. The rest
of the answers are correct.

42

373. As compared with somatic pain, all of the following
are true about visceral pain, EXCEPT
(A) it may follow the distribution of a
somatic nerve
(B) it is dull and vague
(C) it is often periodic and builds to peaks
(D) it is often associated with nausea and
vomiting
(E) it is poorly localized

373. (A) The following are the usual features of the
somatic pain: well localized, sharp and definite,
often constant (sometimes periodic); it is rarely
associated with nausea usually when it is deep
somatic pain with bone involvement; it may be
following the distribution of a somatic nerve.
In contrast, the visceral pain: is poorly localized,
diffuse, dull, and vague; it is often periodic and
builds to peaks (sometimes constant); it is often
associated with nausea and vomiting.

43

374. The following statements are true regarding
preemptive analgesia, EXCEPT
(A) preemptive analgesia is helpful in
reducing postoperative pain in part by
reducing the phenomenon of central
sensitization
(B) early postoperative pain is not a significant
predictor of long-term pain
(C) local anesthetics, opioids, and NSAIDs
can be used for preemptive analgesia
(D) preemptive analgesia may have the
potential to prevent the development of
chronic pain states
(E) preemptive analgesia is thought to
reduce neuroplastic changes in the
spinal cord

374. (B) It has been demonstrated that early postoperative
pain is a significant predictor of longterm
pain. The rest of the answers are correct.

44

375. The following statements are true regarding
multimodal analgesia, EXCEPT
(A) it may include NSAIDs, acetaminophen,
local anesthetics, and opioids in the
same patient
(B) it is beneficial because of the synergistic
action of the individual medications
with different sites of action along the
pain pathways
(C) it is not very valuable owing to an
increase in the incidence of side effects
(D) it facilitates early mobilization of the
postsurgical patient
(E) it expedites return to normal parenteral
nutrition

375. (C) Multimodal analgesia makes it possible to
significantly reduce the total consumption of
opioids intra- and postoperatively. Therefore,
opioid side-effects are minimized, including
inevitable opioid-induced GI stasis that delays
the resumption of normal enteral nutrition after
surgery.

45

376. All of the following statements about PHN are
correct, EXCEPT
(A) midthoracic dermatomes is one of the
most common sites for PHN
(B) men are affected more often than
women in a ratio of 3:2
(C) ophthalmic division of the trigeminal
nerve is one of the most common sites
for PHN
(D) PHN may occur in any dermatome
(E) PHN has an incidence of 9% to 14.3%

376. (B) PHN affects women more often than men, in a ratio of approximately 3:2. The rest of the answers are correct.

46

377. PHN is defined as
(A) any pain associated with the herpes
zoster
(B) pain caused by herpes zoster for more
than 1 month
(C) persistent pain with a significant
neuropathic component in a dermatomal
distribution
(D) pain caused by herpes zoster for more
than 3 months
(E) neuropathic pain in midthoracic dermatomes
caused by herpes simplex virus

377. (B) PHN is defined as pain caused by herpes zoster for more than 1 month.

47

378. Which of the following is true about the management
of PHN?
(A) Approximately 40% of patients with
PHN have either incomplete or no relief
from treatment
(B) Prevention of herpes zoster is not nearly
as important as a multimodal treatment
of PHN
(C) Current multimodal treatment of PHN
is nearly 100% effective, independent of
the duration of the symptoms
(D) Current multimodal treatment of PHN
is nearly 100% effective as long as it is
started within the first month of the
symptoms of PHN
(E) Current multimodal treatment of PHN
is nearly 100% effective as long as it is
started immediately after the first
symptoms of herpes zoster

378. (A) As many as 40% of patients with PHN have
either incomplete or no relief from treatment.
Because of this, the future may lie with prevention
through vaccination and early aggressive treatment
of herpes zoster with antivirals and analgesics
to reduce the extent of the nerve damage
and sensitization that may correlate with PHN.

48

379. The following are true about the use of antidepressants
in treatment of PHN, EXCEPT
(A) amitriptyline has been shown to be
effective in treatment of PHN, but has
significant limitations in the long term
because of its side effects
(B) selective serotonin reuptake inhibitors
(SSRIs) have been found to be equally or
more effective in treatment of PHN than
the older generation of tricyclic antidepressants
(TCAs) or selective norepinephrine
reuptake inhibitors (SNRIs)
(C) SNRIs have been shown to be more effective
than placebo in treatment of PHN
(D) antidepressant therapy in PHN is built
on sound, scientific basis
(E) one of the significant side effects of
TCAs is their anticholinergic properties

379. (B) Experience with serotonergic antidepressants,
such as clomipramine, trazodone, nefazodone,
fluoxetine, and zimelidine, in PHN
has been disappointing. The evidence supporting
the use of noradrenergic agents is more
compelling. The rest of the answers are correct.

49

380. Which of the following is true about use of
opioids in the treatment of PHN?
(A) The use of opioids is not justified for
nonmalignant pain
(B) Opioids tend to be less effective for the
treatment of neuropathic pain than
nonneuropathic pain
(C) Opioids were not found to be useful in
the treatment of PHN
(D) The use of opioids should be avoided in
combination with antidepressants
because of the risk of excessive central
nervous system (CNS) suppression
(E) The use of opioids in PHN should be
avoided owing to the increased
potential of addiction

380. (B) There has been evidence that opioids do not relieve neuropathic pain as well as nonneuropathic pain. However, there is also evidence that opioids have been successfully used for the treatment of PHN.

50

381. Which of the following is the most common cause
of autonomic neuropathy in the developed
world?
(A) Leprosy
(B) Diabetes mellitus (DM)
(C) Human immunodeficiency virus (HIV)
infection
(D) Heavy metal poisoning
(E) Idiopathic etiology

381. (B) DM is the most common cause of autonomic
neuropathy, and peripheral neuropathy
in general, in the United States, as well as in the
rest of the developed world. Leprosy is the
most common cause of peripheral neuropathy
in the world.

51

382. Diabetic amyotrophy
(A) has a poor prognosis
(B) has better prognosis when it involves
upper extremities
(C) usually resolves within 1 to 2 years
spontaneously
(D) has better prognosis when the symptoms
do not involve pain
(E) it is directly related to hyperglycemia

382. (C) Diabetic amyotrophy starts with pain and
involves the lower extremities. It has a good
prognosis and usually resolves spontaneously
in 12 to 24 months. It is not directly related to
hyperglycemia.

52

383. The following are true about the distal sensorimotor
polyneuropathy, EXCEPT
(A) it is the most common neuropathic
manifestation of both type 1 and type 2
diabetes
(B) it starts distally and spreads proximally
(C) initial symptoms may involve
numbness and tingling in the toes or
feet
(D) it is a length-dependent neuropathy
(E) it is usually asymmetrical

383. (E) Distal sensorimotor polyneuropathy is a
symmetrical length-dependent process with
dying-back or dropout of the longest nerve
fibers—myelinated and unmyelinated. All
other answers are correct.

53

384. The prevalence of diabetic neuropathy in DM patients is
(A) less than 1% at diagnosis of DM, rising
to 10% in patients diagnosed for longer
than 5 years
(B) about 10% at diagnosis of DM, rising to
more than 50% in patients diagnosed for
longer than 5 years
(C) about 50% at diagnosis of DM, rising to
almost 100% in patients diagnosed for
longer than 5 years
(D) about 50% at diagnosis of DM, and does
not change significantly with time
(E) no such studies have been done so far

384. (B) It is generally agreed that the prevalence of
neuropathy is about 10% at diagnosis of DM,
rising to 50% or more in patients diagnosed for
longer than 5 years

54

385. Patients with diabetic distal sensorimotor
polyneuropathy initially may complain of
numbness and tingling in the toes or feet,
which then slowly spreads proximally over
months to years. Eventually, numbness and
tingling appear in the fingertips, as the symptoms
of diabetic polyneuropathy progress to
(A) ankle
(B) knee
(C) mid-thigh
(D) buttock and groin
(E) abdomen

385. (B)

55

386. Which of the following is the most widely
accepted cause of trigeminal neuralgia?
(A) Demyelinating conditions, as trigeminal
neuralgia is most common in patients
with multiple sclerosis
(B) Direct trauma of the trigeminal ganglion
at the level of the foramen ovale, before
branching into its three branches
(C) Arterial cross-compression of the
trigeminal nerve in the posterior fossa
(D) Tumors of the posterior fossae
(E) Poor vascular supply to the affected
trigeminal branch

386. (C) It is accepted that the most common cause
of trigeminal neuralgia is arterial crosscompression
of the trigeminal nerve in the posterior
fossa, as suggested by Jannetta in 1982.
Electron microscopy of trigeminal nerve biopsies
taken from patients with trigeminal neuralgia
has shown areas of axonal swelling and demyelination
adjacent to the area of arterial compression.
Although trigeminal neuralgia is more
common in patients with multiple sclerosis,
only a small portion of patients with trigeminal neuralgia suffer from multiple sclerosis and
does not explain the majority of the cases.

56

387. Which of the following is true regarding medical
management for the treatment of trigeminal
neuralgia?
(A) Anticonvulsant medications are usually
considered as the second line of treatment
(B) Beneficial effects of carbamazepine are
better in elderly patients
(C) Risk of side effects of carbamazepine
increase with age
(D) Carbamazepine has proven to be the
most effective treatment for trigeminal
neuralgia, independently of the sideeffect
profile
(E) Because of the unlikelihood of serious
side effects with surgery, all patients
should consider this option first

387. (C) Carbamazepine is likely to be beneficial in
up to 70% of the patients. Incidence of side effects
is often higher in elderly patients especially if the
drug escalation is too fast. Allergic rash is seen in
up to 10% of the patients and high concentration
of the drug may be associated with fluid retention
promoting cardiac problems. Carbamazepine is a
potent hepatic enzyme inducer which can potentially
lead to undesirable drug-to-drug interactions.
Although microsurgical exploration of the
posterior fossa is the highly successful, it is a
major surgery with 0.5% risk of mortality and
major morbidity. The effectiveness of pimozide
for trigeminal neuralgia is better than carbamazepine,
but the high frequency of side effects
limits its clinical use.

57

388. The gasserian ganglion
(A) receives exclusively proprioceptive information
from the muscles of mastication
(B) the mandibular branch is located medial
to the ophthalmic branch
(C) the two medial branches are sensory
while the lateral branch is partially
motor
(D) the ganglion lies out of the cranium, in
the Meckel cave
(E) the foramen rotundum is used as landmark
for the blockage of the trigeminal
ganglion

388. (C) The trigeminal ganglion receives sensation
from the oral mucosa, scalp, nasal areas, face,
and teeth. Proprioceptive information is transmitted
into the ganglion from the mastication
and extraocular muscles. The peripheral
branches of the ganglion are the ophthalmic,
the maxillary, and the mandibular, which are
organized somatotropically, with the ophthalmic
branch located dorsally, the maxillary
branch is intermediate, and the mandibular
nerve is located ventrally. The gasserian ganglion
lies within the cranium, in the middle
cranial fossa. The posterior border of the ganglion
includes the dura of the Meckel cave. The
landmark to perform the trigeminal ganglion
block is the foramen ovale and not the foramen
rotundum.

58

389. Which of the following is true regarding the
diagnosis of trigeminal neuralgia?
(A) The diagnosis must be confirmed with
magnetic resonance imaging (MRI) to
detect vascular trigeminal nerve compression
(B) Sensory evoked potentials is the most
sensitive test to perform the diagnosis
(C) The diagnosis is clinical and tests are
only necessary to rule out associated
conditions
(D) To accurately diagnose the condition, it
is necessary to correlate clinical findings
with MRI and sensory evoke potential
tests
(E) None of the above

389. (C) The diagnosis of trigeminal neuralgia is
eminently clinical and further tests are necessary
only to rule out associated conditions.
When the condition is found, MRI and evoked
potential testing are strongly recommended to
rule out secondary causes. Clinically the onset of
trigeminal neuralgia is around the age of 50 years,
more common in females, almost exclusively
unilateral with a paroxysmal nature.

59

390. Giant cell arteritis is characterized by which of
the following?
(A) Affects almost exclusively Asian
population
(B) As other forms of vasculitis, giant cell
arteritis commonly involves skin,
kidneys, and lungs
(C) Males are more commonly affected
(D) It is more common in older patients,
with a peak incidence between 60 to
75 years of age
(E) Visual loss is the presenting symptom in
over 50% of the patients

390. (D) The giant cell arteritis affects almost exclusively
the white population although it can occur in worldwide. Unlike other forms of vasculitis
it rarely affects skin, kidneys, or lungs.
Females are affected 3 times more often than
males. Visual loss is now considered to affect
between 6% to 10% of patients in most series.

60

391. According to the International Headache
Society Diagnostic Criteria, analgesic rebound
headache is
(A) headache that resolves or reverts within
2 weeks after discontinuation of the suspected
medication
(B) headache that worsens after intake of
analgesics and reduces in intensity and
frequency with reduction in the analgesic
dose
(C) the intensity of the headache decreases
in intensity proportionally to the
decrease in the dose of analgesic
(D) headache greater than 15 days per
month that has developed or markedly
worsened during medication overuse
(E) headache that increases in intensity with
the use of morphine, most likely
because of the cerebral vasodilation
mediated by histamine release

391. (D) Analgesic rebound headache resolves or
reverts to its previous pattern within 2 months
of discontinuing of the overused medication.

61

392. Cluster headaches are characterized by
(A) lancinating unilateral headache that is
commonly triggered by stress factors
(B) the pain is strictly unilateral and autonomic
symptoms occur ipsilateral to the
pain
(C) the onset is slow with progressive worsening
of the pain over several hours
with an attack usually lasting 3 to
4 days
(D) melatonin is commonly indicated as
therapy for the acute attack
(E) cluster headaches are more common in
elderly patients

392. (B) The first statement better describes trigeminal
neuralgia. Cluster headache affects more
males than females with a 5:1 ratio and can
begin at any age. Attacks are severe, stabbing,
screwing, unilateral pain, occasionally preceded
by premonitory symptoms, with sudden
onset, and rapid crescendo. Therapeutic interventions
for the acute attack include oxygen,
triptans, dihydroergotamine, ketorolac, chlorpromazine,
or intranasal lidocaine, cocaine, or
capsaicin. Melatonin has been found to be
moderately effective as a preventive treatment
in episodic and chronic cluster headache

62

393. Which of the following describes the pathophysiologic
changes seen in migraine?
(A) Inflammation of hypothalamic structures
leads to low threshold stimulation
of vascular and meningeal tissues
(B) Central sensitization mediated by attribution
to activation of β-fibers in the
trigeminal system, mediates extracranial
hypersensitivity
(C) Large cerebral vessels, pial vessels, large
sinuses, and the dura, are innervated by
fibers originating from the sphenopalatine
ganglion
(D) Activation and threshold reduction of
the trigeminocervical complex by its
most caudal cells
(E) In acute attacks, a marked reduction in
vasoactive substances, including substance
P, calcitonin gene related peptide (CGRP),
and nitric oxide is commonly seen

393. (D) Sterile neurogenic inflammation is often
seen after stimulation of the trigeminal ganglion,
which innervates large cerebral vessels,
pial vessels, large sinuses, and the dura via
unmyelinated C fibers. In acute attacks of
migraine, substance P, CGRP, and nitric oxide
mediate the neurogenic inflammation

63

394. Which of the following is correct regarding
headache?
(A) Migraine is the most common form of
headache
(B) Tension-type headache (TTH) is commonly
aggravated by physical exercise
(C) The presence of nausea, vomiting,
photophobia, or phonophobia excludes
the diagnosis of TTH
(D) The most common form of migraine is
associated with aura
(E) Comorbid conditions associated with
chronic migraine include depression,
anxiety, and panic disorders

394. (E) TTH is the most common type of headache.
Aura is present in only 20% of patients suffering
from migraine. Although chronic daily
headache diagnostic criteria for probable TTH
requires no nausea or vomiting as one of the
criteria or absence of photophobia, or phonophobia,
nausea may be seen in 4.2% of patients
with TTH, while phonophobia is reported in
10.6% of them.

64

395. Hundred precent oxygen inhalation is a safe
and effective method for acute treatment of
(A) chronic daily headache
(B) TTH
(C) migraine with aura
(D) cluster headache
(E) glossopharyngeal neuralgia

395. (D) Inhalation of 100% oxygen at 7 to 12 L/min
is effective in treating the majority of cluster
headache sufferers when used continuously
for 15 to 20 minutes. Generally oxygen inhalation
is not considered to be effective in any
other form of primary neurovascular headache.

65

396. The Ramsay Hunt syndrome is caused by the
infection of the varicella-zoster virus of the
(A) sphenopalatine ganglion
(B) gasserian ganglion
(C) geniculate ganglion
(D) glossopharyngeal ganglion
(E) stellate ganglion

396. (C)

66

397. Which of the following characterizes the spontaneous
intracranial hypotension (SIH)?
(A) Is the same entity as post–dural puncture
headache (PDPH)
(B) Headache is consistently unilateral
(C) Orthostatic headache is pathognomonic
(D) Patients complain of bitemporal headache
(E) To confirm the diagnosis, it is required
that cerebrospinal fluid (CSF) opening
pressures be below 60 mm H2O

397. (C) PDPH and SIH are two distinct clinical entities
with similar presentation. The headache is
always bilateral, located in the occipital and/or
frontal area. Although low CSF pressure is
often noted, it is not necessary to confirm the
diagnosis.

67

398. A 20-year-old male presents to the clinic with
complaints of moderate headaches located
bilateral in the forehead, parietal, and occipital
areas. The pain is dull and continuous and not
associated with nausea, vomiting, photophobia,
and phonophobia. The patient recalls that
the symptoms started 1 year ago and have been
constant since they started. No abnormalities
where observed on physical examination, sinus
computed tomography (CT), or brain MRI. The
patient has occasionally tried over-the-counter
analgesics with no relief. Which of the following
is the most likely diagnosis?
(A) Status migrainosus
(B) Rebound headache
(C) New daily persistent headache
(D) Cluster headache
(E) Classical migraine

398. (C) New daily persistent headache is a chronic,
unremitting headache of sudden onset, daily
pattern. The duration of the headache should be
at least 3 months. Some important features
include its moderate severity, bilateral location,
and lack of nausea, vomiting (N/V), photophobia,
and phonophobia (P/P). On the other hand,
status migrainosus is a severe debilitating
migraine, associated with N/V, P/P, and with
duration longer than 72 hours but that typically
do not exceed 2 weeks. The other diagnoses are
not consistent with the symptoms.

68

399. Which of the following is a theory that may
explain the presence of aura?
(A) Cortical spreading depression
(B) The vascular theory
(C) Hormonal fluctuation
(D) Estrogen withdrawal
(E) Cerebral idiopathic hypertension

399. (A) The previously known classic migraine
(migraine with aura) is preceded by visual aura
that starts 20 to 40 minutes before the migraine
and is characterized by spreading scintillations
reflecting a slow propagation of neuronal and
glial excitation emanating from one occipital
lobe. Cortical spreading depression (CSD) presents
with dramatic shifts in cortical steady
potential (DC), temporary increases in extracellular
ions and excitatory neurotransmitters
(glutamate), and transient raise, followed by
sustained decrease in cortical blood flow. The
vascular theory proposed that migraine with
aura is caused by intracranial cerebral vasoconstriction
and the headache by reactive
vasodilation. Despite that, the theory can not
explain the prodromal symptoms or why some
antimigraine medications are not effective.
Hormonal fluctuations and estrogen withdrawal
may explain the higher incidence of
migraine in female patients during their reproductive
years, but are not related to the presence
of aura. Cerebral idiopathic hypertension
is a form of headache of unknown etiology

69

400. Chronic low back pain and neck pain persists
1 year or longer in what percentage of patients?
(A) 5% to 10%
(B) 15% to 20%
(C) 20% to 25%
(D) 25% to 60%
(E) 60% to 75%

400. (D) The published literature commonly states
that 80% to 90% of low back pain resolves in
about 6 weeks, irrespective of the administration
or type of treatment, with only 5% to 10%
of patients developing persistent back pain. Contrary to this assumption, actual analysis of
research evidence shows that chronic low back and neck pain persist 1 year or longer in 25% to 60% of adult and/or elderly patients.

70

401. The prevalence of zygapophysial (facet) joint
involvement in low back pain is
(A) 5% to 10%
(B) 10% to 15%
(C) 15% to 45%
(D) 50% to 60%
(E) 65% to 70%

401. (C) Based on evaluations utilizing controlled diagnostic
blocks, the prevalence of zygapophysial or
facet joint involvement has been estimated to be
between 15% and 45% in heterogeneous groups of
patients with chronic low back pain.

71

402. A 58-year-old with metastatic lung cancer suddenly
complains of severe back pain. Symptoms
of early spinal cord compression include all of the
following, EXCEPT
(A) rapid onset
(B) symmetric and profound weakness
(C) spasticity
(D) increased deep tendon reflexes
(E) urinary retention and constipation

402. (E) The clinical picture of metastatic epidural
spinal cord compression is uniformly reported
as pain, weakness, sensory loss, and autonomic
dysfunction. Metastatic epidural spinal cord
compression initially presents with severe back
pain in 95% of cases. After weeks of progressive
pain, the patient may develop weakness, sensory
loss, autonomic dysfunction, and reflex
abnormalities. Bladder and bowel dysfunction
are rarely presenting symptoms, but may
appear after sensory symptoms have occurred.
The exception to this generalization develops
with compression of the conus medullaris,
which presents as acute urinary retention and
constipation without preceding motor or sensory
symptoms

72

403. Specific indications for discography include all
of the following, EXCEPT
(A) further evaluation of abnormal discs to
assess the extent of abnormality
(B) patients with persistent, severe symptoms
in whom other diagnostic tests
have revealed clear confirmation of a
suspected disc as the source of pain
(C) assessment of patients who have failed
to respond to surgical procedures to
determine if there is possible recurrent
disc herniation
(D) assessment of discs before fusion to
determine if the discs within the proposed
fusion segment are symptomatic
(E) assessment of minimally invasive surgical
candidates to confirm a contained
disc herniation or to investigate contrast
distribution pattern before intradiscal
procedures

403. (B) Patients with severe, persistent symptoms
(discogenic in origin) that have been confirmed
by other diagnostic evaluations do not need to
undergo further evaluation by discography.
Specific uses for discography include, but are
not limited to: further evaluation of demonstrably
abnormal discs to help assess the extent of
abnormality or correlation of the abnormality
with clinical symptoms (in case of recurrent pain
from a previously operated disc and a lateral
disc herniation); patients with persistent, severe
symptoms in whom other diagnostic tests have
failed to reveal clear confirmation of a suspected
disc as the source of pain; assessment of
patients who have failed to respond to surgical
procedures to determine if there is painful
pseudoarthrosis or a symptomatic disc in a posteriorly
fused segment, or to evaluate possible
recurrent disc herniation; assessment of discs
before fusion to determine if the discs within the
proposed fusion segment are symptomatic and
to determine if discs adjacent to this segment are normal; and assessment of minimally invasive
surgical candidates to confirm a contained disc
herniation or to investigate contrast distribution
pattern before intradiscal procedures.

73

404. The following signs and symptoms are consistently
found with cervical radiculopathy, EXCEPT
(A) gait disturbances
(B) normal muscle tone
(C) negative Babinski test
(D) weak tendon reflexes
(E) positive axial compression test (Spurling
maneuver)

404. (A) Gait disturbances are a feature of cervical
myelopathy, not radiculopathy. Other signs and
symptoms of cervical radiculopathy include
upper extremity sensory disturbances and muscle
weakness.

74

405. All of the following are reasons associated with
smoking as a risk factor for low back pain,
EXCEPT
(A) mineral content of the lumbar vertebrae
is decreased
(B) fibrinolytic disc activity is altered
(C) blood flow and nutrition to the disc are
diminished
(D) disc pH is higher
(E) increased degenerative changes of the
lumbar spine

405. (D) Experimental studies have given support to
the hypothesis that blood flow and nutrition to
the disc are diminished in smokers, the pH of
the disc is lowered, disc mineral content is
lower, fibrinolytic activity is changed, and there
are increased degenerative changes seen in the
lumbar spine.

75

406. All of the following treatments have strong evidence
to back their use when treating acute
low back pain, EXCEPT
(A) muscle relaxants effectively reduce low
back pain
(B) bed rest is effective for treating low back
pain
(C) continuing normal activity gives equivalent
or faster recovery from acute low
back pain
(D) NSAIDs prescribed at regular intervals
are an effective treatment for acute low
back pain
(E) different types of NSAIDs are equally
effective at treating low back pain

406. (B) There is strong evidence from randomized
controlled trials that bed rest is not effective
for treating acute low back pain.

76

407. Age-related changes in the intervertebral discs
include all of the following, EXCEPT
(A) the dimensions of the lumbar intervertebral
discs decrease with age
(B) collagen lamellae of the annulus fibrosis
increases in thickness
(C) distinction between the nucleus pulposus
and annulus fibrosis becomes less
apparent
(D) the nucleus pulposus is less able to
transmit weight directly
(E) 80% of nucleus pulposus cells in the elderly
exhibit necrosis

407. (A) Narrowing of the intervertebral discs has
long been considered one of the signs of pathologic
aging of the lumbar spine, but recent data
has shown that notion to be untrue. Large-scale
postmortem analysis have shown lumbar disc
height and diameter to actually increase with
age. The anterior-posterior diameter increases
by about 10% in females and 2% in males. Disc
height has been shown to increase by about
10% in most lumbar discs.

77

408. Radiculopathy is a neurologic condition associated
with all of the following characteristics,
EXCEPT
(A) numbness
(B) weakness
(C) pain
(D) compression of axons
(E) ischemia of axons

408. (C) Radiculopathy is a condition in which conduction
within the axons of a spinal nerve or its
roots are blocked. It can result in numbness
and weakness secondary to conduction block
in sensory and motor neurons respectively.
Conduction blockade can be caused by compression
or ischemia. It is important to make
the distinction that radiculopathy does not
cause pain. It may, however, be associated with
pain.

78

409. Adverse effects of epidurally administered
steroids include all of the following, EXCEPT
(A) Cushing syndrome
(B) osteoporosis
(C) avascular bone necrosis
(D) hypoglycemia
(E) suppression of the hypothalamus-pituitary
axis

409. (D) The major theoretical complications of corticosteroid
administration include suppression
of pituitary-adrenal axis, hypercorticism,
Cushing syndrome, osteoporosis, avascular
necrosis of bone, steroid myopathy, epidural lipomatosis, weight gain, fluid retention, and
hyperglycemia.

79

410. Relative contraindications to epidural steroid
injections include
(A) preexisting neurologic disorder (ie, multiple
sclerosis)
(B) sepsis
(C) therapeutic anticoagulation
(D) localized infection at injection site
(E) patient refusal

410. (A) Absolute contraindications to epidural
steroid injections include sepsis, infection at
injection site, therapeutic anticoagulation, and
patient refusal. Relative contraindications
include preexisting neurologic conditions, prophylactic
low-dose heparin, thrombocytopenia,
and uncooperative patients.

80

411. L4-L5 disk herniation with L5 nerve root
involvement includes
(A) numbness over the medial thigh and knee
(B) weakness with dorsiflexion of great toe
and foot
(C) difficulty walking on toes
(D) pain in lateral heel
(E) quadriceps weakness

411. (B) L4-L5 disc herniation with L5 nerve root
involvement involves: pain over the sacroiliac
joint, hip, lateral thigh, and leg; numbness
over the lateral leg and first three toes; weakness
with dorsiflexion of great toe and foot;
difficulty walking on heels; possible foot
drop; and internal hamstring reflex diminished
or absent. Numbness over the medial
thigh and knee, and quadriceps weakness are
indicative of L3-L4 disc herniation with L4
nerve root involvement. Difficulty walking
on toes and lateral heel pain are common
with L5-S1 disk herniation involving the S1
nerve root.

81

412. In patients with chronic low back pain, the
prevalence of sacroiliac joint pain is
(A) 10%
(B) 15%
(C) 20%
(D) 25%
(E) 30%

412. (B) Fifteen percent of patients with chronic low
back pain have sacroiliac joint pain.

82

413. Spondylolysis
414. Spondylolisthesis
415. Kissing spines
416. Radiculopathy
417. Radicular pain
(A) Neurologic condition in which conduction
is blocked to the axons of a spinal
nerve or its roots. It results in numbness
and weakness
(B) An acquired defect caused by fatigue
fracture of the pars interarticularis
(C) Pain that arises as a result of irritation of
a spinal nerve or its roots
(D) Displacement of a vertebrae or the
vertebral column in relationship to the
vertebrae below it
(E) Periostitis of spinous processes or
inflammation of the affected ligament

413 to 417. 413 (B); 414 (D); 415 (E); 416 (A); 417 (C)
Spondylolysis is an acquired defect that results
from a fatigue fracture of the pars interarticularis
(the part of the lamina that intervenes
between the superior and inferior articular
processes on each side). Spondylolisthesis is
the displacement of a vertebrae or the vertebral
column in relationship to the vertebrae below.
Kissing spines (also known as Baastrup disease)
affects the lumbar spinous processes.
Excessive lumbar lordosis or extension injuries
to the lumbar spine cause adjacent spinous
processes to clash and compress the intervening
interspinous ligament. This results in a
periostitis of the spinous process or inflammation
of the affected ligament. Radiculopathy is
a neurologic condition in which conduction
blocks the axons of a spinal nerve or its roots
that results in numbness and weakness.
Radicular pain is pain that arises as a result of
irritation of a spinal nerve or its roots.

83

418. Evidence regarding the value of epidural injections
for the management of chronic spinal
pain demonstrates the following:
(A) Limited with interlaminar lumbar
epidural steroid injections for short-term
relief of lumbar radicular pain
(B) Strong with interlaminar lumbar
epidural steroid injections for long-term
relief of lumbar radicular pain
(C) Moderate for lumbar transforaminal
epidural steroid injections for short-term
relief of lumbar radicular pain
(D) Strong for lumbar transforaminal
epidural steroid injections for long-term
relief of lumbar radicular pain
(E) Strong for caudal epidural steroid
injections for short-term relief of lumbar
radiculopathy and post–lumbar
laminectomy syndrome

418. (E) In managing lumbar radicular pain with
interlaminar lumbar epidural steroid injections,
the evidence is strong for short-term relief and
limited for long-term relief. In managing cervical
radiculopathy with cervical interlaminar
epidural steroid injections, the evidence is moderate.
The evidence for lumbar transforaminal
epidural steroid injections in managing lumbar
radicular pain is strong for short-term and moderate
for long-term relief. The evidence for cervical
transforaminal epidural steroid injections
in managing cervical nerve root pain is moderate.
The evidence is moderate in managing lumbar
radicular pain in post–lumbar laminectomy syndrome.
The evidence for caudal epidural steroid
injections is strong for short-term relief and moderate
for long-term relief, in managing chronic
pain of lumbar radiculopathy and post–lumbar
laminectomy syndrome.

84

419. All of the following statements regarding intervertebral
disc innervation are true, EXCEPT
(A) nerve plexuses that innervate the intervertebral
discs are derived from dorsal rami
(B) in normal lumbar intervertebral discs,
nerve fibers are only found in the outer
third of the annulus fibrosis
(C) discs painful on discography and
removed with operation have nerve
growth deep into the annulus and into
the nucleus pulposus
(D) disc fissuring is a trigger for neoinnervation
of a disc
(E) the anterior and posterior nerve
plexuses accompany the anterior and
posterior longitudinal ligaments

419. (A) The sources of the nerve endings in the
lumbar discs are two extensive microscopic
plexuses of nerves that accompany the anterior
and posterior longitudinal ligaments. The nerve
plexuses that innervate intervertebral discs are
derived from the lumbar sympathetic trunks.
The dorsal rami supply innervation to the muscles
of the back and zygapophysial joints. In
normal lumbar intervertebral discs, nerve fibers
are only found in the outer third of the annulus
fibrosis. Discs painful on discography and
removed with operation have nerve growth
deep into the annulus and into the nucleus pulposus.
Disc fissuring is a trigger for neoinnervation
and neovascularization of a disc.

85

420. Three days after a lumbar epidural steroid injection
was given, a 57-year-old male complains
of fever and severe back pain over the site where
the injection was given. Two days later, the back
pain has progressively worsened, and a severe
radiating pain goes down the right leg and knee.
Which of the following is the most likely complication
of the epidural steroid injection?
(A) Epidural abscess
(B) Epidural hematoma
(C) Arachnoiditis
(D) Anterior spinal artery syndrome
(E) Cauda equina syndrome

420. (A) Development of an epidural abscess is a
very rare complication of epidural steroid injections.
It needs to be recognized and treated
quickly to avoid irreversible injury. Symptoms
of an epidural abscess include severe back pain
that is followed by radicular pain 3 days later.
The initial back pain may not become evident
for several days after the injection.

86

421. X-ray imaging is recommended for which of
the following cause of low back pain?
(A) Disc bulging
(B) Cauda equina syndrome
(C) Spondylolisthesis
(D) Lateral disc herniation
(E) Spinal cord tumors

421. (C) Plain x-rays are recommended for possible
fractures, arthropathy, spondylolisthesis, tumors,
infections, stenosis, and congential deformities.
CT images are recommended for bone/joint
pathologies, lateral disc herniations, stenosis
(ie, spinal canal, neuroforaminal, lateral recess),
and for those in which an MRI is contraindicated.
MRI is recommended for disc herniations,
spinal stenosis, osteomyelitis, tumors (ie, spinal
cord, nerve roots, nerve sheath, paraspinal soft
tissue), and cauda equine syndrome.

87

422. Which of the following nerve root and muscle
motion combinations is correct?
(A) L2—leg extension
(B) L3—heel walking
(C) L4—toe walking
(D) L5—first toe dorsiflexion
(E) S1—hip flexion

422. (D) The L2 nerve root is involved with hip flexion,
L3 with leg extension, L4 with heel walking,
L5 with first toe dorsiflexion (and heel
walking), and S1 with toe walking

88

423. Which of the following is the most frequent
complication of a laminotomy with discectomy?
(A) Recurrent disc herniation
(B) Infection
(C) Dural tear
(D) Neural injury
(E) Failed back surgery syndrome (FBSS)

423. (C) Laminotomy with discectomy has a low infection
rate, statistically. The most frequent complication
is a dural tear. Neural injury may occur as
a result of a dural tear and may cause long-term
pain and neurologic deficit. Recurrence of the
herniation occurs in approximately 5% of cases.
Infection and neural injury occurs in less than
0.5% of cases.

89

424. Which of the following includes conservative
treatment for FBSS?
(A) Discectomy
(B) Chemonucleolysis
(C) Rehabilitation
(D) Laminectomy
(E) Fusion

424. (C) Conservative treatment is usually the first
treatment of choice for patients presenting with
FBSS. It consists of medical management of
contributing factors (ie, depression, obesity,
smoking), rehabilitation, and behavior modification
(ie, alcohol or drug dependency).

90

425. Favorable prognostic indicators for patients
undergoing repeated lumbosacral surgery include
all of the following, EXCEPT
(A) female sex
(B) satisfactory outcome from prior surgeries
(C) operative findings of disk herniation
(D) epidural scarring requiring lysis of
adhesions
(E) radicular pain

425. (D) Many prognostic indicators have been
implicated in patients undergoing repeat lumbosacral
spine surgery. They may or may not be
significant for each patient and should be taken
into context for the particular patient. Women
have been found to have better outcomes than
men. Patients with a history of favorable outcomes
from prior surgeries tend to have better
outcomes as well. A history of few previous
surgeries, operative/myelographic findings of
disc herniation, and a history of working
immediately prior to surgery are all favorable
prognostic indicators. Less favorable prognostic
indicators include epidural scarring that
requires lysis of adhesions and pseudoarthrosis
of a prior fusion.

91

426. Waddell signs were developed to help identify
nonorganic causes of low back pain. They
include all of the following, EXCEPT
(A) tenderness
(B) stimulation
(C) distraction testing
(D) regional disturbance
(E) underreaction

426. (E) Waddell signs are used to help diagnose
nonorganic low back pain complaints. Each of
the five findings is considered positive if present.
Three positive findings are considered highly
suggestive of a nonorganic source of pain:
1. Tenderness: does not follow dermatomal or
referral patterns and is hard to localize.
2. Stimulation testing: stimulating distant
sites should not cause discomfort.
3. Distraction testing: findings when testing the
same site are inconsistent when the patient’s
attention is distracted.
4. Regional disturbance: motor and sensory
testing yield nonanatomic findings.
5. Overreaction: inappropriate verbal remarks
or facial expressions, withdrawal from touch,

92

427. A25-year-old male presents with progressively
worsening neck and back pain and stiffness
over 4 months that improves with light exercise
and warm showers. Which of the following is
the most likely diagnosis?
(A) Rheumatoid arthritis
(B) Ankylosing spondylitis
(C) Psoriatic arthritis
(D) Klippel-Feil syndrome
(E) Reiter syndrome

427. (B) Ankylosing spondylitis is characterized by
pain and stiffness in young males (typically
ages 17-35 years) more often than females. It is
worse in the morning and improves with mild
exercise. The pain will typically last for at least
3 months and be diffuse in nature affecting the
low back and spine. Rheumatoid arthritis is an
inflammatory polyarthritis that affects middleaged
women more often than men. It typically
presents with morning stiffness that improves
as the day progresses, and the spine is not
affected until late in the disease. Psoriatic
arthritis is characterized by inflammation of
the skin and joints that typically presents in
the fourth and fifth decades of life. Klippel-Feil
syndrome is a congenital disorder that is characterized
by abnormal fusion of two or more
bones in the cervical spine. Reiter syndrome is
a reactive arthritis that is characterized by a
triad of symptoms: nongonococcal urethritis,
conjunctivitis, and arthritis.

93

428. Which of the following is a major criteria for
cervicogenic headache?
(A) Bilateral head or face pain without
sideshift
(B) Pain is superficial and throbbing
(C) Restricted neck range of motion
(D) Pain relief with digital pressure to
cervical vertebrae
(E) Lack of relief from anesthetic blockade

428. (C) The three major criteria for cervicogenic
headache include (1) signs and symptoms of
neck involvement (precipitation of head pain
by: neck movement and/or sustained awkward
head positioning, by external pressure over the
upper cervical or occipital region on the symptomatic
side; restriction of the range of motion in
the neck; ipsilateral neck, shoulder, or arm pain
of a rather vague nonradicular nature or, occasionally,
arm pain of a radicular nature); (2) confirmatory
evidence by diagnostic anesthetic
blockades; and (3) unilaterality of the head pain
without sideshift. Head pain characteristics
include moderate-severe, nonthrobbing, and
nonlancinating pain, usually starting in the neck,
episodes of varying duration, or fluctuating,
continuous pain. Other characteristics of some
importance: only marginal effect or lack of effect
of indomethacin, only marginal effect or lack of
effect of ergotamine and sumatriptan, female
sex, not infrequent occurrence of head, or indirect
neck trauma by history, usually of more
than only medium severity.

94

429. Neurogenic claudication can be distinguished
from vascular claudication by which of the
following?
(A) Leg tightness
(B) Pain alleviated with standing
(C) Pain exacerbated with lumbar flexion
(D) No change in pain with exercise
(E) Pain exacerbated with lying supine

429. (D) Neurogenic claudication pain is secondary
to nerve root compression rather than lack of
blood supply that is seen with vascular claudication.
The pain is exacerbated by standing
erect and downhill walking. Improvement
comes with lying supine more than lying in
the prone position, sitting, squatting, and
lumbar flexion. Neurogenic claudication is not
made worse with biking, uphill walking, and
lumbar flexion, unlike vascular claudication.
It is not alleviated with standing.

95

430. Neck pain has been suggested to have a multifactorial
origin. Which of the following statements
regarding neck pain is true?
(A) Workplace interventions are not effective
at reducing neck pain
(B) Normal degenerative changes in the
cervical spine are a risk factor for pain
(C) Physical activity does not protect
against neck pain
(D) Precision work does not increase the
risk of neck pain
(E) Social support in the workplace does
not affect neck pain

430. (A) Neck pain has been suggested to have multifactorial
etiologies. Risk factors for neck pain
that cannot be modified include age, sex, and
genetics. There is no evidence that normal cervical
spine degenerative changes are a risk
factor for neck pain. Modifiable risk factors for
neck pain include smoking and exposure to
environmental tobacco. Participation in physical
activity seems to offer a protective effect.
High quantitative job demands, low social support
at the workplace, inactive work position,
repetitive work, and meticulous work increases
the risk of neck pain. There is a lack of evidence
that workplace interventions are successful
in decreasing neck pain in employees.

96

431. In patients with neck pain, what is more
predictive at excluding a structural lesion or
neurologic compression than at diagnosing any
specific etiologic condition?
(A) MRI
(B) Discography
(C) Blood tests
(D) Physical examination
(E) Electrophysiology

431. (D) In patients with neck pain, the physical
examination is more predictive at excluding a
structural lesion or neurologic compression
than at diagnosing any specific etiologic condition
in patients with neck pain. Other assessment
tools (ie, electrophysiology, imaging,
injections, discography, functional tests, and
blood tests) lack validity and utility.

97

432. All of the following characteristics are associated
with a poor prognosis for neck pain, EXCEPT
(A) prior neck pain
(B) pain resulting from an accident
(C) passive coping techniques
(D) middle age
(E) compensation

432. (B) Most people with neck pain do not experience
a complete resolution of symptoms.
Between 50% and 85% of those who experience
neck pain at some initial point will report neck
pain again 1 to 5 years later. These numbers
appear to be similar in the general population, in
workers, and after motor vehicle crashes. The
prognosis for neck pain also appears to be multifactorial.
Younger age was associated with a
better prognosis, whereas poor health and prior
neck pain episodes were associated with a
poorer prognosis. Poorer prognosis was also
associated with poor psychologic health, worrying,
and becoming angry or frustrated in
response to neck pain. Greater optimism, a
coping style that involved self-assurance, and
having less need to socialize, were all associated
with better prognosis. Specific workplace or
physical job demands were not linked with
recovery from neck pain. Workers who engaged
in general exercise and sporting activities were
more likely to experience improvement in neck
pain. Postinjury psychologic distress and passive
types of coping were prognostic of poorer
recovery in WAD. There is evidence that compensation
and legal factors are also prognostic
for poorer recovery from WAD.

98

433. Which of the following is the most common
complication of fluoroscopically guided interlaminar
cervical epidural injections?
(A) Nonpositional headache
(B) Vasovagal reactions
(C) Increased neck pain
(D) Fever
(E) Dural puncture

433. (C) The reported complications of fluoroscopically
guided interlaminar cervical epidural
injections are increased neck pain (6.7%), nonpositional
headaches (4.6%), insomnia the night
of the injection (1.7%), vasovagal reaction reactions
(1.7%), facial flushing (1.5%), fever on the
night of the procedure (0.3%), and dural puncture
(0.3%). The incidence of all complications
per injection is 16.8%.

99

434. A 54-year-old female complains suddenly of
inability to move her legs after a transforaminal
epidural steroid injection. On further examination,
she is found to have intact light touch
sensation, sphincter disturbance, and loss of
pain and temperature sensation. What is the
most likely diagnosis?
(A) Cauda equina syndrome
(B) Epidural hematoma
(C) Epidural abscess
(D) Transient paraplegia
(E) Anterior spinal artery syndrome

434. (E) Anterior spinal artery syndrome classically
presents in older patients with abrupt motor
loss, sphincter disturbance, and nonconcordant
sensory examination with preservation of sensation
to light touch but loss of pain and temperature.
It may also occur during aortic
procedures. When anterior spinal artery syndromes
occur during or after transforaminal
epidural steroid injection, the patient may have
abrupt back or abdominal pain after injection.
An MRI will demonstrate a T2 signal change
consistent with cord ischemia/infarct. Anterior
spinal artery ischemia may be caused by arteriosclerosis, tumors, thrombosis, hypotension, air or fat embolism, toxins, or other causes. Particulate (steroid) substances, arterial injury, or vascular spasm are other potential causes and have been implicated as significant possibilities for the occurrence of ischemic events after transforaminal
epidural steroid injections.

100

435. A57-year-old diabetic male presents with a new
onset of neck pain over the past several hours;
the pain is beginning to move down each arm
equally. Two days ago he had a cervical epidural
injection which he receives periodically for a herniated
disc. On physical examination, his temperature
is 102.4°F, his cervical spine is exquisitely
tender to palpation and he complains of radicular
pain down both arms. The most likely organism
causing this presentation is
(A) Pseudomonas
(B) Escherichia coli
(C) Streptococcus pneumoniae
(D) Hemophilus influenza
(E) Staphylococcus aureus

435. (E) A spinal epidural abscess must be recognized
promptly and treated quickly, otherwise
extreme morbidity can result. It may be separate
or associated with vertebral osteomyelitis.
Diabetic, alcoholic, IV drug using patients, and
immunocompromised patients are all at
increased risk. Staphylococcus aureus is the most
common organism involved. An affected patient
usually presents with neck pain that rapidly
progresses to radicular symptoms. Quadriplegia
can result if left untreated. Treatment involves
surgical removal and antibiotic management.

101

436. The following statements are true regarding
the pathologic mechanism in HIV-related neuropathy,
EXCEPT
(A) HIV is found within endoneurial
macrophages
(B) HIV is found within Schwann cells
(C) antisulfatide antibodies are one of the
humoral factors responsible for
demyelinating diseases in AIDS patients
(D) secretion of cytokines by the HIVinfected
glial cells may generate tissuespecific
autoimmune attack
(E) the pathologic mechanisms in HIV-related
neuropathies are not well understood

436. (B) The pathophysiology of HIV-related neuropathies
is still not well understood. The current
understanding is that it is not related to the direct
effect of the virus itself. HIV is not found within
ganglionic neurons of Schwann cells, but only in
endoneurial macrophages, which may generate
a tissue-specific autoimmune response by secretion
of cytokines, which, in turn, promotes trafficking
of activated T cells and macrophages
within the endoneurial parenchyma.

102

437. Pain syndromes of neuropathic nature occur
in approximately 40% of AIDS patients with
pain. Several types of peripheral neuropathies
have been described in patients with HIV and
AIDS. The most common painful neuropathy
encountered in patients with HIV and AIDS is
(A) mononeuritis multiplex
(B) polyradiculopathy
(C) cauda equina syndrome
(D) painful toxic neuropathy
(E) predominantly sensory neuropathy of
AIDS

437. (E) The predominantly sensory neuropathy of
AIDS affects up to 30% of people with HIV
infection and AIDS and is the most commonly
encountered.

103

438. The most important pathophysiologic event
in sickle cell anemia, which explains most of
its clinical manifestations, is vascular occlusion.
The following are the pathophysiologic
processes that lead to vascular occlusion in
patients with sickle cell disease (SCD), EXCEPT
(A) erythrocyte dehydration
(B) distortion of the shape of erythrocytes
(C) polymerization of the sickle cell hemoglobin
on deoxygenation
(D) decreased deformability of erythrocytes
(E) decreased stickiness of erythrocytes

438. (E) The primary process that leads to vascular
occlusion is the polymerization of sickle cell
hemoglobin on deoxygenation, which in turn
results in distortion of the shape of red blood
cells (RBCs), cellular dehydration, decreased
deformability, and increased stickiness of RBCs,
which promotes their adhesion to and activation
of the vascular endothelium.

104

439. Aphysician has to exercise extra caution when
attributing SCD patient’s complaints of pain
to behavioral deviations, such as drug-seeking
behavior, because
(A) patients in real pain, such as sickle cell
pain, do not develop addiction to opioids
(B) most patients with SCD have substance
abuse and addiction, as they are
exposed to opioids early in life
(C) there is a higher incidence of controlledsubstance
diversion in SCD patients
(D) sickle cell pain could be the prodrome
of a serious and potentially fatal complication
of SCD
(E) severe pain, such as sickle cell pain,
should only be managed by an experienced
physician subspecializing in pain
management

439. (D) SCD is unlike other pain syndromes where
the provider can make decisions on treatment
based solely on the pain and its associated
behavior. A primary care physician, for example,
taking care of a middle-aged patient with
job-related low back pain may decide to expel the patient from his or her care if the patient in
question demonstrates suspicious drug-seeking
behavior. Doing the same with patients who
have SCD could be counterproductive. There
are anecdotes of patients with SCD who were
dismissed from certain programs only to be
found dead at home within 24 hours after dismissal
or to be admitted to other hospitals with
serious complications. Sickle cell pain could be
the prodrome of a serious and potentially fatal
complication of SCD in some patients.

105

440. What makes the pain of SCD unique in its
acuteness and severity?
(A) SCD patients tend to have a decreased
threshold to pain because of prolonged
and early exposure to severe pain in life
(B) SCD patients have increased tolerance to
opioids and opioid-related hyperalgesia
(C) SCD pain pathophysiology involves a
combination of ischemic tissue damage
and secondary inflammatory response
(D) Repetitive SCD crises lead to ischemic
damage of the CNS and subsequent
central sensitization to pain
(E) SCD patients tend to anticipate and
respond with a spectacular behavioral
manifestation to pain, because of its
cyclic feature

440. (C) Tissue ischemia caused by vascular occlusion
resulting from in situ sickling causes
infarctive tissue damage, which in turn initiates
a secondary inflammatory response. The secondary
response may enhance sympathetic
activity by means of interactions with neuroendocrine
pathways and trigger release of
norepinephrine. In the setting of tissue injury,
this release causes more tissue ischemia, creating
a vicious cycle. It is the combination of
ischemic tissue damage and secondary inflammatory
response that makes the pain of SCD
unique in its acuteness and severity.

106

441. At initial presentation, objective signs of a
painful SCD crisis, such as fever, leukocytosis,
joint effusions, and tenderness, occur in
(A) less than 10% of patients
(B) about 25% of patients
(C) about 50% of patients
(D) about 75% of patients
(E) more than 90% of patients

441. (C) Objective signs of a painful crisis, such as
fever, leukocytosis, joint effusions, and tenderness,
occur in about 50% of patients at initial
presentation.

107

442. What percentage of hospital admissions in adult
SCD patients result from acute sickle cell pain?
(A) Less than 10%
(B) About 25%
(C) About 50%
(D) About 75%
(E) More than 90%

442. (E) Pain is the hallmark of SCD, and the acute
sickle cell painful episode (painful crisis) is the
most common cause of more than 90% of hospital
admissions among adult patients who
have SCD.

108

443. Which of the following is true regarding treatment
of sickle cell pain with NSAIDs?
(A) They should be completely avoided
because of potential side effects
(B) They should not be administered
continuously for more than 5 days
(C) They should be administered only in
combination with opioids
(D) They should not be administered
continuously for more than 1 month
(E) Potential morbidity from their side
effects in SCD patients is the same as in
the general population

443. (B) NSAIDs have potentially serious, systemic
adverse effects. They include gastropathy,
nephropathy, and hemostatic defects. It is
advisable not to administer them continuously
for more than 5 days to patients with SCD.

109

444. Pharmacologic management of SCD pain
includes three major classes of compounds:
nonopioids, opioids, and adjuvants. Nonopioids
include acetaminophen, NSAIDs, topical agents,
tramadol, and corticosteroids. The following is
true about Tramadol, EXCEPT
(A) it inhibits neuronal reuptake of
serotonin and norepinephrine
(B) it acts as a weak μ-receptor agonist
(C) it does not have a “ceiling” effect
because of its safe side-effect profile
(D) it is not associated with an addiction
potential
(E) it is a centrally acting analgesic

444. (D) Tramadol is a synthetic, centrally acting
analgesic that is not chemically related to opioids.
It acts as a weak agonist with preferential affinity
to the μ-receptors. Moreover, it inhibits
neuronal reuptake of both serotonin and norepinephrine
and stimulates the release of serotonin.
Thus, it has functional properties of an opioid and an antidepressant. This drug
received an initial enthusiastic reception based
on the perception that it was not associated with
clinically significant respiratory depression or
addiction potential. However, this enthusiasm
waned after reports indicated that seizures may
be an adverse effect and that abuse potential is increasing.

110

445. All of the following are true about chronic pain
in the spinal cord injury (SCI) patient, EXCEPT
(A) approximately two-thirds of all SCI
patients suffer from chronic pain
(B) approximately one-third of SCI patients
with pain have severe pain
(C) pain in SCI patients may lead to severe
depression and even suicide
(D) because of the overwhelmingly significant
impairment of other important
functions, pain is only a minor consideration
in an SCI patient
(E) pain in SCI interferes with rehabilitation
and activities of daily living (ADLs)

(D) Chronic pain is a major complication of
SCI. Epidemiologic studies indicate that
approximately two-thirds of all SCI patients
suffer from chronic pain out of which one-third
have severe pain. Pain interferes with rehabilitation,
daily activities, quality of life, and may
have significant influence on mood leading to
depression and even suicide.

111

446. In an SCI patient, chronic pain secondary to
overuse is common in
(A) neck
(B) lower back
(C) shoulders and arms
(D) hips and thighs
(E) knees and feet

446. (C) Musculoskeletal pain is common in both
the acute and chronic phase of SCI. Chronic
pain secondary to overuse is common in shoulders
and arm, and vertebral column pain may
occur because of the secondary changes following
fractures and fixation, mechanical instability,
and osteoporosis.

112

447. Autonomic dysreflexia usually occurs after an
SCI at
(A) any level
(B) above C4
(C) above C7
(D) above T6
(E) above L1

447. (D) Autonomic dysreflexia may complicate SCI
patients with a lesion above the splanchnic outflow
(sixth thoracic level).

113

448. The following is true regarding the visceral pain
in an SCI patient, EXCEPT
(A) it is unlikely that visceral pain may
occur in the absence of any abdominal
organ dysfunction
(B) the pattern of visceral pain is not
affected in an SCI patient, because it is
transmitted through the sympathetic
system, which usually bypasses the site
of injury
(C) autonomic dysreflexia cannot be
triggered by visceral pain
(D) visceral pain is always present in an SCI
patient as part of the central pain
syndrome
(E) increases in spasticity or autonomic
reactions may be the only indications of
abdominal organ dysfunction

448. (E) Visceral pain usually presents as dull or
cramping abdominal uncomfortable and
painful sensations, which may be associated
with nausea and autonomic reactions. It is
likely that visceral pain may occur in the
absence of any abdominal organ dysfunction,
and may in some cases represent a neuropathic
type of pain. SCI patients may not have the
typical signs of abdominal illness, and they
should be carefully examined whenever any
new pain or changes in existing pain occur.
Increases in spasticity, pain at any location, or
autonomic reactions may be the only indications
of abdominal organ dysfunction.

114

449. Neuropathic pain in SCI is divided into abovelevel,
at-level, and below-level types. Depending
on the type of pain, nerve root injury (peripheral
component), and/or SCI (central component)
may contribute to the pain. Which of the following
is true?
(A) Below-level pain has only peripheral
component
(B) At-level pain has only peripheral component
(C) Below-level pain is usually caused by
compressive mononeuropathy
(D) Below-level pain is usually caused by
CRPS
(E) At-level pain may have both peripheral
and central components

449. (E) Above-level neuropathic pain includes pain
caused by compressive mononeuropathies
(particularly carpal tunnel syndrome) and
CRPS. While below-level pain is considered to
be a central pain caused by the spinal cord trauma, at-level pain may have both peripheral
(nerve root) and central (spinal cord) components
that are difficult to separate.

115

450. One of the characteristics of stimulus-evoked
neuropathic pain in SCI can be temporal summation
of pain. Temporal summation of pain is
defined as
(A) elicitation of pain by nonnoxious
stimulation
(B) pain continuing after stimulation has
ceased
(C) an increased pain response to a noxious
stimulus
(D) abnormal increase in pain with each
repetitive stimulation
(E) pain felt in a place apart from the
stimulated area

450. (D) Answers (A), (B), (C), and (D) define allodynia,
aftersensation, hyperalgesia, and referred
pain, respectively.

116

451. An axonal injury triggers a Wallerian degeneration,
which is defined as
(A) degeneration of the portion of the axon
separated from the neuronal body by
the injury
(B) degeneration of the injured neuron distal
and proximal to the level of injury
(C) atrophy of the motor unit supplied by
the injured neuron
(D) dying of the body of the neuron, which
lost its axon
(E) degeneration of the secondary afferent
neuron because of the absence of the
input from the injured primary afferent
neuron

451. (A)

117

452. Which of the following is true about the central
cord syndrome?
(A) It is the injury of the mid-portion of the
spinal cord, usually around T6 level
(B) Upper extremities are affected more
than lower
(C) It is very uncommon
(D) Patient usually presents with absent
perianal sensation
(E) It is usually associated with complete SCI

452. (B) Central cord syndrome is one of the incomplete
SCI syndromes. It is the most common
pattern of injury, representing central gray
matter destruction with preservation of only
the peripheral spinal cord structures, the sacral
spinothalamic and corticospinal tracts. The
patient usually presents as a quadriplegic with
perianal sensation and has an early return of
bowel and bladder control. Any return of
motor function usually begins with the sacral
elements (toe flexors, then the extensors), followed
by the lumbar elements of the ankle,
knee, and hip. Upper extremity functional
return is generally minimal and is limited by
the degree of central gray matter destruction.

118

453. A common sensory symptom in patients with
CRPS is hyperpathia which may be defined as
(A) normally innocuous stimuli are perceived
as painful
(B) exaggerated pain perception after a noxious
stimulus at the site of injury
(C) exaggerated pain perception after a noxious
stimulus in the area surrounding
the primary affected skin
(D) exaggerated delayed painful perception
after a noxious stimulus
(E) unpleasant abnormal sensation, whether
spontaneous or evoked

453. (D) Sensory symptoms and signs in CRPS
include spontaneous pain, hyperpathia, allodynia,
and hyperalgesia. Answer (A) is the definition
of allodynia, answer (B) defines primary
hyperalgesia, and answer (C) is secondary
hyperalgesia. Answer (E) is the definition of
dysesthesia. Dysesthesia maybe spontaneous.

119

454. Common findings in patients with CRPS I
include
(A) symmetrical distal extremity pain
(B) pain intensity that is usually proportional
to the intensity of the initiating
event
(C) nearly all patients with CRPS I having
sweating abnormalities
(D) sensory abnormalities that are most
often proximal
(E) consistency between the inciting lesion
and the spatial distribution of the pain

454. (C) CRPS I is a painful condition following an
injury, which may not even be a neuropathic
pain, as not obvious lesion is present. Patients
with this condition develop asymmetrical distal
extremity pain, which is disproportionate to the
intensity of the initiating event. Sensory abnormalities
appear early in the course of the disease
and are more pronounced distally. No clear relationship
between the injury and the area of pain
distribution exist. Sweating abnormalities,
whether hypohidrosis or hyperhidrosis are
present in nearly all patients with CRPS I.

120

455. Late changes observed in patients with CRPS I
include
(A) sensory abnormalities
(B) warm extremities
(C) distal swelling
(D) trophic changes
(E) increased dermal blood flow

455. (D) Trophic changes, particularly abnormal
hair growth, fibrosis, decreased dermal blood
flow, thin glossy skin, and osteoporosis are more common in long standing cases, while
the others described present in acute phases of
the disease.

121

456. Which of the following is true in relation to
CRPS?
(A) Males are more commonly affected than
females
(B) CRPS II is more common than CRPS I
(C) Three bone scan showing unilateral
periarticular uptake is mandatory to
confirm CRPS diagnosis
(D) The diagnosis of CRPS is mainly clinical
(E) The mean age group is between 15 and
25 years

456. (D) The diagnosis of CRPS I and II follows the
IASP clinical criteria. Bone scintigraphy may be
a valuable tool to rule out other conditions.
CRPS I is more common than CRPS II and the
female to male ratio is from 2:1 to 4:1.

122

457. Which of the following is the diagnostic criteria
that differentiates CRPS II from CRPS I?
(A) Triple-phase bone scan showing diffuse
spotty osteoporosis
(B) Weakness of all muscles of the affected
extremity
(C) Sweating abnormalities
(D) Lesion of a peripheral nerve structure is
mandatory
(E) Paresis

457. (D) The symptoms of CRPS II are similar to
those of CRPS I, except that in CRPS II, there
must be a lesion of a peripheral nerve structure
and subsequent focal deficit are mandatory for
the diagnosis.

123

458. Patients with CRPS exhibit significant psychologic
findings, including
(A) the most common psychiatric comorbidities
are anxiety and depression
(B) increased incidence of somatization in
patients with CRPS than to patients
with chronic low back pain
(C) psychiatric problems are the cause of
CRPS
(D) CRPS is a psychogenic condition
(E) maladaptive behaviors in CRPS patients
indicate the presence of psychopathology

458. (A) The majority of patients with CRPS present
with significant psychologic distress, being the
most frequent anxiety and depression. Current
evidence is against the theory that CRPS is a
psychogenic condition. The pain in CRPS is the
cause of psychiatric problems and not vice
versa. When compared to patients with low
back pain, CRPS patients showed a higher frequency
of somatization, but other psychologic
parameters were similar.

124

459. The Lewis triple response consists of the following,
EXCEPT
(A) activation and sensitization of cutaneous
C fibers elicit local edema
(B) reddening of the skin at the site of the
stimulus
(C) spreading flare
(D) local peripheral vasoconstriction mediated
by the release of substance P

459. (D) Activation and sensitization of cutaneous C
fibers elicit a response consisting of a wheal
(local edema), a reddening of the skin at the site
of stimulus, and a spreading flare, were the
responses described by Lewis (1927). [Lewis T.
The blood vessels of the human s

125

460. The diagnosis of myofascial pain syndrome is
confirmed when
(A) the myofascial trigger point is identified
by palpation
(B) a patient has a widespread muscle
condition
(C) a patient is diagnosed with fibromyalgia
first
(D) regional muscle spasms are noted
(E) none of the above

460. (A) Muscle pain tends to be dull, poorly localized,
and deep in contrast to the precise location
of cutaneous pain. The diagnosis of
myofascial pain syndrome is confirmed when
the myofascial trigger point is identified by
palpation. An active myofascial trigger point is
defined as a focus of hyperirritability in a
muscle or its fascia that causes the patient pain.
B. Myofascial pain syndrome is usually
thought of as a regional pain syndrome in
contrast to fibromyalgia as a widespread
syndrome; however, as many as 45% of
patients with chronic myofascial pain syndrome
have generalized pain in three or four
quadrants. Hence, regional pain syndromes should raise a suspicion of myofascial pain
syndrome, but patients with widespread
musculoskeletal pain can also have
myofascial pain syndrome.
C. The American Pain Society showed general
agreement with the concept that myofascial
pain syndrome exists as an entity distinct
from fibromyalgia.
D. Systemic palpation differentiates between
myofascial

126

461. Four experienced physicians examine a patient.
They all identify the same precise localization
of trigger points within a muscle. The minimum
criteria that must be satisfied in order to
distinguish a myofascial trigger point from any
other tender area in muscle are
(A) a taut band and a tender point in that
taut band
(B) a local twitch response
(C) referred pain
(D) reproduction of the person’s symptomatic
pain
(E) A and C

461. (A) The minimum criteria that must be satisfied
in order to distinguish a myofascial trigger
point from any other tender area in muscle are
a taut band and a tender point in that taut
band. The existence of a local twitch response,
referred pain, or reproduction of the person’s
symptomatic pain increases the certainty and
specificity of the diagnosis.

127

462. A23-year-old female is found to have a trigger
point in the left trapezius muscle. With regard
to electrical characteristics of the trigger point,
which of the following is false?
(A) A characteristic electrical discharge
emanates from the trigger point
(B) Spontaneous EMG activity typical of
end-plate noise occurring in myofascial
trigger points has been further confirmed
in a study of young subjects with
chronic shoulder and arm pain
(C) The sympathetic nervous system does
not have a modulating effect on the
motor activity of the trigger point
(D) End-plate noise without spikes was
found at trigger point sites to a significantly
greater degree than at end-plate
zones outside of trigger points, and not
at all in taut band sites outside of an
end-plate zone
(E) All the above statements are true

462. (C)
D. This statement is true. End-plate noise is
characteristic of, but not restricted to, the
region of the myofascial trigger point.
Hence, an objective EMG signature of the
trigger point is now available for diagnostic
and research purposes.

128

463. Manual therapy is one of the four basic treatment
options used for inactivating trigger
points. Some practitioners also incorporate the
stretch and spray technique. It is therapeutic
(A) because like with other soothing sprays,
the placebo effect is extremely high
(B) because the vapocoolant spray stimulates
thermal and tactile A-β skin receptors,
thereby inhibiting C fiber and A-δ
fiber afferent nociceptive pathways and
muscle spasms, myofascial trigger
points, and pain when stretching
(C) because the vapocoolant is focused
specifically on the trigger point
(D) because therapists don’t have to be as
liberal when passively stretching
patients
(E) B and D

463. (B)
A. There is no reason to believe that the
placebo effect is unusually high with this
or other soothing sprays.
B. The stretch and spray technique combines
the use of a vapocoolant spray with passive
stretching of the muscle. Application of
vapocoolant spray stimulates temperature
and touch A-β skin receptors, thereby inhibiting
C fiber and A-δ fiber afferent nociceptive
pathways and muscle spasms, myofascial
trigger points, and pain when stretching
C. The patient is positioned comfortably and
the muscle involved is sprayed with a
vapocoolant spray, and then the muscle is
stretched passively. With the muscle in the
stretched position, the spray is applied again
over the skin overlying the entire muscle,
starting at the trigger zone and proceeding in the direction of, and including, the
referred pain zone. After, the area is heated
with a moist warm pack for 5 to 10 minutes.
The patient is encouraged to perform full
range of motion exercises with the body
part. This technique can be used in physical
therapy as a separate modality or following
myofascial trigger point injections.
D. It is expected that therapists can be more
liberal once the spray has been applied
owing to less patient discomfort.

129

464. Which of the following is not an effective
myofascial release technique?
(A) Strumming
(B) Perpendicular and oscillating
mobilizations
(C) Therapeutic ultrasound
(D) Connective tissue massage
(E) Pétrissage

464. (C) Myofascial release techniques and sustained
pressure may soften and relax contracted
and hardened muscles. The principle of
the least possible force is applied, instead of
applying high stress to the muscle. Effective
myofascial release techniques include strumming.
Strumming is when a finger runs across
a taut band at the level of the trigger point over
the nodules from one side of the muscle to the
other. The operator’s fingers pull perpendicularly
across the muscle rather than along the
length of the fibers. When the nodule of the
trigger point is encountered, light pressure is
maintained until the operator senses tissue
release. Other techniques include perpendicular
and oscillating mobilizations, tissue rolling,
connective tissue massage, and deep muscle
massage consisting of effleurage (stroking massage
technique) and pétrissage (kneading massage
technique).
After superficially passing over the muscles
and adjacent muscles, massage therapy
can be applied directly to the taut band and
trigger points. Exercise and massage helped to
reduce the number and intensity of trigger
points, but the addition of therapeutic ultrasound
did not improve the outcome.

130

465. Trigger points can theoretically be related to
underlying articular dysfunction. Joint and
muscular dysfunction is closely related and
should be considered as a single functional
unit. It has been noted that
(A) restrictions in joint capsules inhibit
function for those muscles overlying
the particular joint, but muscle
dysfunction does not result in joint
capsule restrictions
(B) restrictions in joint capsules do not
inhibit adjacent muscles, nor does
muscular dysfunction result in joint
capsule restrictions
(C) restrictions in joint capsules inhibit muscle
function for those muscles overlying
the particular joint. Conversely, muscle
dysfunction results in joint capsule
restrictions
(D) restrictions in joint capsules do not
severely limit the overlying muscles;
however, muscle dysfunction does
regulate joint capsule range of motion
(E) muscle dysfunction does not result in
joint capsule range of motion

465. (C) When treating myofascial pain, the physician
must evaluate and, if indicated, treat both soft
tissue and joint dysfunction. Restrictions in joint
capsules hinder the function of the muscles that
overlie the joint, while muscle irregularities result
in joint capsule restrictions. Zygapophyseal joints
may have pain referral patterns that are analogous
to myofascial trigger points. The limited
range of motion and weakness that results from this somatic dysfunction that affects muscles and joints can be reversed easily by manual therapy.

131

466. An administrative assistant presents with a
number of upper back trigger points. She is scheduled
for dry needling. What is the most common
indication for this therapeutic modality?
(A) Relief of an acute myofascial pain syndrome
(B) To identify a myofascial trigger point as
the cause of a particular pain
(C) To eliminate a trigger point permanently
(D) Inactivation of myofascial trigger points
to facilitate physical therapy
(E) None of the above

466. (D) Answers A., B., and D. are the therapeutic,
diagnostic, and adjunctive indications for
myofascial trigger point needling, respectively,
with D. being the most common appropriate
use of this technique. Rarely is dry needling
done to eliminate a trigger point permanently,
although, this can happen when the myofascial
pain syndrome is acute.
Inactivation of the myofascial trigger
point appears to be the result of the mechanical
action of the needle in the trigger point
itself, because it also occurs when no medication
is used. However, using local anesthetics
is more comfortable for the patients and
results in longer lasting pain reduction.
After pinpointing and manually stabilizing
the trigger point in the taut band with the fingers,
the needle is quickly passed through the skin and
into the trigger zone. Alocal twitch response or
a report of referred pain indicates that the trigger
zone has been entered. One-tenth to 0.2 mL
of local anesthetic can be injected. The needle
is pulled back to just below the skin, the angle is
changed, and it is once again inserted through
the muscle to another trigger zone. In this way a
funnel-shaped volume of muscle can be evaluated
without withdrawing the needle through the
skin. The trigger zone is explored this way until
no further local twitch responses are obtained. By
this time, the taut band is usually gone and the
spontaneous pain of the trigger point has subsided.
Experienced patients know when trigger
points have been inactivated.

132

467. Randomized, double-blind, controlled studies
have shown that adding which of the following
medications to local anesthetics increases the
pain relief obtained from myofascial trigger
point injections?
(A) Steroids
(B) Ketorolac
(C) Vitamin B12
(D) Diphenhydramine
(E) None of the above

467. (E)
A., B., and C. While direct needling of myofascial
trigger points appears to be an effective
treatment, there is insufficient evidence that
needling therapies have efficacy beyond
placebo. These researchers also found no
evidence to suggest that the injection of one
material was more effective than another.
They found no advantage to adding steroids,
ketorolac, or vitamin B12 to local anesthetic.
Steroids actually have the disadvantage
that they are locally myotoxic and that repeated administration can produce all the
unwanted side effects associated with
steroids. For those who are allergic to local
anesthetics, saline or dry needling can be
used.
D. No studies have been done to confirm or
refute that diphenhydramine increases the
efficacy of myofascial trigger points.

133

468. Which of the following is not a complication of
trigger point injections?
(A) Local hemorrhage into muscle
(B) Infection
(C) Transient nerve block
(D) Syncope
(E) Torticollis

468. (E) Complications of trigger point injections:
• Local bleeding into muscle
• Local swelling
• Painful contraction of a taut band from
inadequate myofascial trigger point inactivation
(missing the trigger point)
• Infection
• Perforation of a viscous body, most commonly
the lung
• Nerve injury from direct trauma by the needle
• Transient nerve block
• Syncope
• Allergic reaction from the anesthetic
Torticollis is a contraction, often spasmodic,
of the muscles of the neck, chiefly those
supplied by the spinal accessory nerve; the
head is drawn to one side and usually rotated
so that the chin points to the other side. While
missing the trigger point during needling can
cause a painful contraction of a taut band, torticollis
has not been noted.

134

469. Two days after a trigger point injection, a patient
presents to your office irate. He claims that the
trigger point injection has not helped him whatsoever.
Which one of the following is not a likely
reason why you are having this problem?
(A) You missed the trigger point during
needling
(B) The patient is not motivated to improve
(C) You injected the secondary or satellite
trigger point and not the primary
trigger point
(D) Insufficient muscle stretching in the
clinic after the injection
(E) Not enough stretching by the patient at
home

469. (B) Answers (A), (C), (D), and (E) are all causes
of trigger point failure.
C. Myofascial adhesions can possibly develop
with secondary or “satellite” trigger points in
nearby muscles. Trigger points appearing in
muscles that are part of a functional unit
must be treated together. Muscles that work
together as agonists or in opposition as
antagonists, constitute a functional muscle
unit. For example the trapezius and levator
scapula muscles work together as agonists
in elevation of the shoulder, but are antagonists
in rotation of the scapula, the trapezius
rotating the glenoid fossa upward and the
levator scapula rotating it downward.

135

470. Mechanical precipitating factors can cause
unrelenting musculoskeletal pain. The major
mechanical factors that practitioners must consider
in treating myofascial pain syndrome
include anatomic variations, poor posture, and
work-related stress. Of the anatomic variations,
which of the following are the most common?
(A) Leg length discrepancy and small
hemipelvis
(B) Short femur syndrome
(C) Long great toe syndrome
(D) Kyphosis
(E) All of the above

470. (A) The most common anatomic variations that
constitute mechanical factors precipitating
myofascial pain are: leg length discrepancy and
small hemipelvis, short upper arm syndrome,
and the long second metatarsal syndrome.
The leg length disparity syndrome produces
a pelvic tilt that results in a cascade of
chronic contraction and activation of a chain of
muscles in an attempt to straighten the head
and level the eyes. The quadratus lumborum
and paraspinal muscles contract to correct the
deviation of the spine caused by the pelvic tilt.
Unwarranted loading perpetuates myofascial
trigger points and may result in low back,
head, neck, and shoulder pain. Trigger points
in these persistently shortened and constantly
contracted muscles are not easily inactivated
until the muscles are unloaded. The quadratus
lumborum is less likely to develop trigger
points during the teenage years, and typically,
unilateral low back pain is located on the side
of the shorter leg because of early shrinking of
the ipsilateral annulus fibrosis. In adults, it
occurs on the side of the longer leg, caused by
later spondylitic changes and quadratus lumborum
shortening. A true leg length incongruity
can be corrected by placing a heel lift on
the shorter leg. The asymmetry caused by a
small hemipelvis is corrected by placing an
ischial or “butt” lift under the ischial tuberosity.
Short upper arms cause forward shoulder
roll, pectoral muscle shortening, and abnormal
loading of the neck and trunk muscles as
the individual attempts to find a comfortable
position when seated.
Along second metatarsal bone obscures the
stable tripod support of the foot produced by
the first and second metatarsal bones anteriorly
and the heel posteriorly. In contrast, in this condition,
weight is carried on a knife-edge from
the second metatarsal head to the heel, overstressing
the peroneus longus that attaches to
the first metatarsal bone. Diagnostic callus formation
takes place in the abnormally stressed
areas: under the second metatarsal head, and
on the medial aspect of the foot at the great toe
and first metatarsal head. Correction is accomplished
with support under the head of the first
metatarsal.

136

471. What nutritional or hormonal factors have
repeatedly been found to be low in persons
with persistent myofascial pain?
(A) Iron
(B) Folic acid
(C) Vitamin B12
(D) Thyroid hormone
(E) All of the above

471. (E)
A. In women with chronic coldness and
myofascial pain, ferritin has been found to
be below 65%, largely because of an iron
intake that is insufficient to replace menstrual
loss. GI blood loss caused by antiinflammatories
and parasitic diseases can
also cause ferritin to be low. Ferritin represents
the tissue bound nonessential iron stores
in the body that supply the essential iron
for oxygen transport and iron-dependent
enzymes. Fifteen to 20 ng/mL is low and
anemia is common at levels of 10 ng/mL or
less. The association between depleted iron
and chronic myofascial pain hints that ironrequiring
enzymatic reactions may be limited
in these people, which may produce an
energy crisis in muscle when it is overloaded
and thereby produce metabolic stress.
Myofascial trigger points will not easily
resolve in such instances, and iron supplementation
in patients with chronic myofascial
pain syndrome and serum ferritin levels
below 30 mg/mL prevents or corrects these
symptoms.
B. and C. Folic acid and vitamin B12 function
not only in erythropoiesis but also in central
and peripheral nerve formation. Preliminary
studies have shown that 16% of patients
with chronic myofascial pain syndrome
either were deficient in vitamin B12 or had
insufficient levels of vitamin B12, and that
10% had low serum folate levels.
D. Hypothyroidism can be suspected in
chronic myofascial pain syndrome when
coldness, dry skin/hair, constipation, and
fatigue are also present. One study, found
that under these circumstances (chronic) it
occurred in 10% of patients. The myofascial
trigger points tend to be more extensive in
hypothyrotic patients. Hormone replacement
may resolve many myofascial complaints
and perpetuate a more permanent
healthy state by allowing the implementation
of physical therapy and trigger point
inactivation.
Also common in chronic musculoskeletal
pain: low vitamin D, recurrent candida yeast
infections, elevated uric acid levels, parasitic
infections (especially amebiasis), Lyme disease,
osteoarthritis, rheumatoid arthritis, Sjögren
syndrome, carpal tunnel syndrome, and peripheral
neuropathy secondary to DM.
The postlaminectomy syndrome is frequently
caused by myofascial trigger points.

137

472. Biologic aberrations seen in most patients with
fibromyalgia include all of the following, EXCEPT
(A) lowered pain thresholds to pressure
induced pain
(B) disordered sleep as evidenced by
polysomnography
(C) increased spinal fluid levels of
substance P
(D) decreased spinal fluid levels of nerve
growth factor (NGF)
(E) no physiological or biochemical
evidence for central sensitization

472. (D) Biologic abnormalities that are detected in
most fibromyalgia patients include
• Dysfunctional sleep by polysomnography
• Physiological or biochemical evidence for
central sensitization
• Temporal summation or second pain
• Lowered thresholds to pressure-induced
pain detected by brain imaging
• Low levels of the biogenic amines to drive
descending inhibition of nociception
• Elevated spinal fluid levels of substance P
• In primary fibromyalgia only, elevated
spinal fluid levels of NGF

138

473. Of the following criteria, which are absolutely
necessary for the classification of fibromyalgia
syndrome?
(A) Widespread pain for at least 3 months
(B) Pain sensitivity to 4 kg of digital
pressure at a minimum of 11 of 18
anatomically defined tender points
(C) Diagnosis after the age of 18 years
(D) A and B
(E) A, B, and C

473. (D) The American College of Rheumatology
sanctioned a study that led to the criteria for
diagnosing fibromyalgia: a history of widespread
pain for at least 3 months and pain sensitivity
to 4 kg of digital pressure at 11 or more
of 18 anatomically defined tender points. The
criteria displayed sensitivity and specificity of
88.4% and 81.1%, respectively, for patients
with fibromyalgia against normal control
and disease control subjects with other painful
conditions.

139

474. Which of the following is not one of the 18 potential
locations for tender points in fibromyalgia?
(A) Occiput, at the suboccipital muscle
insertion
(B) Low cervical, at the anterior aspects of
the intertransverse spaces at C5-C7
(C) Lumbar paraspinal musculature, from
the level of L3 to L5
(D) Lateral epicondyle, extensor muscle,
2 cm distal to the epicondyle
(E) Knees, at the medial fat pad proximal to
the joint line and condyle

474. (C) In addition to the four areas mentioned
in the question stem, five other locations
exist:
1. Trapezius, at the middle of the upper muscle
border
2. Supraspinatus, near the origins, above the
spine of the scapula
3. Second rib, upper surface just lateral to the
second costochondral junction
4. Gluteal, in upper outer quadrants of buttocks
in anterior fold of muscle
5. Greater trochanter, posterior to the trochanteric
prominence

140

475. A 60-year-old female recently diagnosed with
fibromyalgia has been exhibiting signs of anxiety
and depression and is now in treatment.
This situation
(A) makes perfect sense because fibromyalgia
is a psychogenic disorder
(B) relates to the fact that a subgroup of
fibromyalgia patients concurrently have
depression and anxiety, although an
affective disorder is unlikely to cause
fibromyalgia
(C) demonstrates a patient who is less likely
to exhibit signs of depression than one
who has not sought out medical care
(D) exhibits a patient who was probably
abused as a child
(E) none of the above

475. (B)
A. and B. Fibromyalgia is no longer considered
a psychogenic disorder, however,
there is a subgroup of fibromyalgia patients
with associated depression or anxiety.
C. It is believed that fibromyalgia patients
who have had medical treatment are more
apt to exhibit symptoms of depression than
those in the community who have not.
D. Sexual abuse in childhood is no longer
considered a legitimate hypothesis for the
origination of fibromyalgia.

141

476. Which of the following does not occur often
as a clinical manifestation of the fibromyalgia
syndrome?
(A) Irritable bladder syndrome
(B) Irritable bowel syndrome
(C) Urinary urgency
(D) Dizziness and light-headedness
(E) A and D

476. (E) The female urethral syndrome or irritable
bladder syndrome constitutes urinary frequency,
dysuria, suprapubic discomfort, and
urethral pain despite sterile urine.

142

477. A 50-year-old female with fibromyalgia complains
of trouble sleeping. You are not surprised
as it is well-known that these patients
(A) awaken in the morning feeling stiff,
cognitively sluggish, and unrefreshed
by their sleep
(B) commonly awaken feeling distressingly
alert after only a few hours of sleep
(mid insomnia) and then are unable to
sleep soundly again until near morning
(terminal insomnia)
(C) don’t have trouble napping during the
day
(D) A and B
(E) A, B, and C

477. (E)
A., B., and C. Most patients (90%) with
fibromyalgia have trouble sleeping. Some
have difficulty getting to sleep (initial insomnia),
while the majority awaken feeling alarmingly
alert after only a few hours of sleep (mid
insomnia) and are then unable to sleep
soundly again until near morning (terminal
insomnia). They usually awaken in the morning
feeling incredibly stiff (lasts 45 minutes
to 4 hours), mentally listless, and unrefreshed
by their sleep. Hence, it is surprising that they
have difficulty napping during the day.
Moldofsky (2002) observed that 60% of
fibromyalgia patients exhibit an electroencephalogram
(EEG) pattern of sleep architecture
called alpha wave intrusions of deep, delta
wave, non–rapid eye movement sleep, which
relates to subjective fatigue and psychologic
distress but is not specific for fibromyalgia. Its
prevalence in the healthy general population
or in those with insomnia or dysthymia is
only 25%. [

143

478. Which one of the following statements is false
regarding fatigue in fibromyalgia?
(A) It should always be attributed to the
fibromyalgia itself
(B) It is rarely induced by medications
(C) It manifests as a feeling of weakness as
opposed to the feeling of tiredness felt
in chronic fatigue syndrome
(D) A and B
(E) A, B, and C

478. (E) Approximately 80% of patients with
fibromyalgia have fatigue, while a small percentage
of these actually meet the criteria for
chronic fatigue syndrome (CFS). CFS is thought
to affect approximately 4 per 1000 adults. For
unknown reasons, CFS occurs more often in
women and in adults in their 40s and 50s. The
illness is estimated to be less prevalent in children
and adolescents, but study results vary as
to the degree. CFS often manifests with widespread
myalgia and arthralgia, cognitive difficulties,
chronic mental and physical exhaustion,
often severe, and other characteristic symptoms
in a previously healthy and active person. There
remains no assay or pathologic finding which is
widely accepted to be diagnostic of CFS. It
remains a diagnosis of exclusion based largely
on patient history and symptomatic criteria,
although a number of tests can aid diagnosis.
The fatigue of CFS is a feeling of weakness,
while the fatigue of fibromyalgia is a feeling of
tiredness. Fatigue may result from sedating
medications (ie, TCAs being used for the treatment
of insomnia in fibromyalgia). The rest of
the differential diagnosis is quite extensive and
must take into account:
• Sleep disorders
• Chronic infections
• Autoimmune disorders
• Psychiatric comorbidities
• Neoplasia

144

479. Secondary fibromyalgia refers to
(A) fibromyalgia that does not interfere with
a patient’s functioning
(B) fibromyalgia that occurs in the setting of
another painful condition or inflammatory
disorder
(C) a multifocal pain syndrome that occurs
only after a patient has been diagnosed
with dysthymia
(D) fibromyalgia that meets all the other
characteristics of the disease but only
produces between 8 and 10 tender
points
(E) none of the above

479. (B) The rest of the answers are blatantly wrong.
Secondary fibromyalgia may not be clinically distinguishable
from that of primary fibromyalgia.
Examples of secondary fibromyalgia:
• Rheumatoid arthritis patients have fibromyalgia
30% of the time
• Systemic lupus erythematosus (SLE) 40%
• Sjögren syndrome 50%
• Lyme disease 20%; the symptoms of
fibromyalgia may develop 1 to 4 months after
infection, often in association with Lyme
arthritis. The signs of Lyme disease will normally
resolve with antibiotics, but the
fibromyalgia symptoms can persist
• Chronic hepatitis
• Inflammatory bowel disease
• Tuberculosis
• Chronic syphilis
• Bacterial endocarditis
• AIDS
• Hypothyroidism
• Hypopituitarism
• Hemochromatosis
Patients with rheumatic disease and concomitant
fibromyalgia experience joint pain
out of proportion to their synovitis. The practitioner
should treat each of the conditions
separately, because increasing the dosage of
antirheumatic medications in the absence of
active inflammation might have minimal effect
on the pain augmented by the fibromyalgia.

145

480. Avery inquisitive 40-year-old female, recently diagnosed with fibromyalgia, states that she has been reading about her condition on the Internet. She wants to know about substance P.
You tell her that
(A) substance P is a pronociceptive neurochemical
mediator of pain because it
carries or amplifies afferent signals
(B) substance P levels in the patients with
fibromyalgia have been found to be significantly
higher in the CSF, serum, and
urine
(C) the elevation of substance P in the CSF
is a result of lowered CSF substance P
esterase
(D) the elevation in CSF substance P is
indicative of fibromyalgia
(E) A and B

480. (A)
A. There are several neurochemical mediators
of pain that appear to be factors in the
pathogenesis of fibromyalgia:
• Substance P
• NGF (elevated in primary fibromyalgia, but
not secondary)
• Dynorphin A (normal or elevated in
fibromyalgia)
• Glutamate
• Nitric oxide
• Serotonin (decreased in fibromyalgia)
• Noradrenaline (its inactive metabolite is
significantly lowered in fibromyalgia)
Substance P, NGF, dynorphin A, glutamate,
and nitric oxide are considered pronociceptive
because they transmit or intensify afferent
signals, leading to the brain perceiving
increased pain. On the other hand, serotonin,
noradrenaline, the amino terminal peptide
fragment of substance P, and endogenous opioids
are considered to be antinociceptive
because they hinder the transmission of nociceptive
signals.
B. All studies on substance P in fibromyalgia
patients have found significantly higher
average concentrations (two- to threefold)
of substance P than in the CSF of healthy
control subjects. However, the levels in
other bodily fluids like saliva, serum, and
urine, have been normal in fibromyalgia.
C. The increased substance P is not because of
decreased CSF substance P esterase activity,
because the rate of cleavage of labeled substance
P was found to be normal. In primary
fibromyalgia, it is believed that NGF
may be responsible for the elevated CSF
substance P through its effects on central
sensitization and neuroplasticity.
D. Increased CSF substance P is not specific
to fibromyalgia as it is also seen in painful
rheumatic diseases irrespective of whether
they have fibromyalgia. In patients that
were status post–total hip replacement,
elevated substance P prior to the procedure
normalized after the surgery when
the pain was gone. Certain chronic conditions
such as low back pain and diabetic
neuropathy present with lower than normal
CSF substance P levels.

146

481. The management objectives for fibromyalgia
are
(A) not specific because there is still no cure
(B) reestablish emotional balance
(C) improve sleep
(D) restore physical function
(E) all of the above

481. (E) There is no current cure for fibromyalgia, so
its management is
• Nonspecific
• Multimodal
• Expectant
• Symptomatic
The goals are to
• Decrease pain
• Enhance sleep
• Reinstate physical function
• Maintain social interaction
• Restore emotional balance
• Decrease the excessive use of health care
resources
The best way to achieve these goals is through
a multidisciplinary approach of
• Education
• Exercise
• Physical therapy
• Medications
• Social support

147

482. The shared decision concept
(A) is a method where half of the treatment
decisions come from the physician and
half come from the ancillary staff (physical
therapists, massage therapists, etc)
(B) improves both patient and physician
satisfaction
(C) must be used on selective patients
because cultural background, beliefs, and
religion can all inhibit its effectiveness
(D) A and B
(E) A, B, and C

482. (B) The shared decision concept emphasizes
the importance of simultaneous exchange of information until an agreement between the
doctor and patient can be achieved concerning
available diagnostic and treatment approaches.
It improves both patient and physician satisfaction,
is preferred by patients, and sets the
stage for better outcomes.
A. The shared decision concept involves the
physician and the patient.
C. The physician may outline the treatment
options with associated risks and benefits,
while the patient may disclose information
about their culture, fears, expectations,
beliefs, and attitudes.

148

483. A 60-year-old female recently diagnosed with
fibromyalgia wants to discuss her treatment
options. She is adamant about not taking medications.
Which one of the following statements
is false regarding her alternatives?
(A) Relaxation techniques like progressive
muscle relaxation, self-hypnosis, or
biofeedback have been recommended
(B) Cognitive behavioral therapies and
support groups are efficacious is some
patients
(C) Aerobic exercise can yield positive
outcomes
(D) Heat and cold applications can provide
relief
(E) Deep massage does more harm than good

483. (E)
A. All these techniques have been recommended
for some patients with fibromyalgia.
Progressive muscle relaxation was
developed by Jacobson, who argued that
since muscular tension accompanies anxiety,
one can reduce anxiety by learning how
to relax the muscular tension. Jacobson
trained his patients to voluntarily relax certain
muscles in their body in order to reduce
anxiety symptoms. He also found that the
relaxation procedure is effective against
ulcers, insomnia, and hypertension. Selfhypnosis
is a naturally occurring state of
mind which can be defined as a heightened
state of focused concentration (trance), with
the willingness to follow instructions (suggestibility).
Biofeedback is a form of alternative
medicine that involves measuring a
subject’s quantifiable bodily functions such
as blood pressure, heart rate, skin temperature,
sweat gland activity, and muscle tension,
conveying the information to the
patient in real time. This raises the patient’s
awareness and conscious control of their
unconscious physiological activities. By providing
the user access to physiologic information
about which he or she is generally
unaware, biofeedback allows users to gain
control of physical processes previously
considered an automatic response of the
autonomous nervous system.
B. Cognitive-behavioral therapies have
improved pain scores, pain coping, pain
behavior, depression, and physical functioning
over several months in fibromyalgia
patients. It is suspected that follow-ups with
booster sessions may prolong the effects.
While some think that support groups perpetuate
griping, a resource-oriented selfsupport
group can help a fibromyalgia
patient come to terms with an illness and
provide invaluable patient education.
C. Aerobic exercise is one of the first nonpharmacologic
strategies promoted for patients
with fibromyalgia. Low-impact aerobics of
sufficient intensity to produce cardiovascular
stimulation can decrease pain, enhance
sleep, improve mood, increase energy,
advance cognition, and better a patient’s
overall outlook. Fibromyalgia patients who
exercise deal better with the disease.
However, a fibromyalgia patient can also
experience increased pain if the exercise regimen
is too strenuous or carried out during
an inopportune time in the treatment. These
patients should begin with low-impact exercises
(ie, aqua therapy). Continuing the
patient on the exercise regimen becomes easier
as the patient’s pain decreases.
D. Heat helps fibromyalgia patients with tenderness,
stiffness, and cephalgia. It can also
calm muscles, ease exercising, and accentuate
a sense of well-being. Cold application
also works.
E. Some patients do obtain relief by light
massages that progress to more deep sedative
ones.

149

484. A PhD student comes with questions. She
wants to know how dopamine and serotonin
play a role in fibromyalgia pathogenesis. You
tell her that
(A) dopamine levels directly correlate with
pain levels
(B) tryptophan, serotonin, 5-hydroxytryptophan,
and 5-hydroxyindole acetic acid
have been found to be decreased in
fibromyalgia patients
(C) the number of tender points in
fibromyalgia patients have not been
found to correlate with the concentration
of serotonin in the serum
(D) dopamine agonists have been found to
decrease pain in fibromyalgia patients
(E) B and D

484. (E)
A. and D. Dopamine is a neurotransmitter best
known for its role in the pathology of schizophrenia,
Parkinson disease, and addiction.
There is also strong evidence for a role of
dopamine in restless leg syndrome, which is
a common comorbid condition in patients
with fibromyalgia. In addition, dopamine
plays a critical role in pain perception and
natural analgesia. Accordingly, musculoskeletal
pain complaints are common among
patients with Parkinson disease, which is
characterized by drastic reductions in
dopamine owing to neurodegeneration of dopamine-producing neurons, while patients
with schizophrenia, which is thought to
arise, at least partly, from hyperactivity of
dopamine-producing neurons, have been
shown to be relatively insensitive to pain.
Interestingly, patients with restless legs syndrome
have also been demonstrated to have
hyperalgesia to static mechanical stimulation.
Fibromyalgia has been commonly
referred to as a “stress-related disorder”
owing to its frequent onset and worsening of
symptoms in the context of stressful events.
It was therefore proposed that fibromyalgia
may represent a condition characterized by
low levels of central dopamine that likely
results from a combination of genetic factors
and exposure to environmental stressors,
including psychosocial distress, physical
trauma, systemic viral infections, or inflammatory
disorders (eg, rheumatoid arthritis,
systemic lupus erythematosus). This conclusion
was based on three key observations:
(1) fibromyalgia is associated with stress;
(2) chronic exposure to stress results in a disruption
of dopamine-related neurotransmission;
and (3) dopamine plays a critical role in
modulating pain perception and central
analgesia in such areas as the basal ganglia
including the nucleus accumbens, insular
cortex, anterior cingulate cortex, thalamus,
periaqueductal gray, and spinal cord. In
support of the “dopamine hypothesis of
fibromyalgia,” a reduction in dopamine synthesis
has been reported after using positron
emission tomography (PET) and demonstrated
a reduction in dopamine synthesis
among fibromyalgia patients in several
brain regions in which dopamine plays a
role in inhibiting pain perception, including
the mesencephalon, thalamus, insular cortex,
and anterior cingulate cortex. A subsequent
PET study demonstrated that, whereas
healthy individuals release dopamine into
the caudate nucleus and putamen during a
tonic experimental pain stimulus (ie, hypertonic
saline infusion into a muscle bed),
fibromyalgia patients fail to release dopamine
in response to pain and, in some cases, actually
have a reduction in dopamine levels
during painful stimulation. Moreover, a
substantial subset of fibromyalgia patients
respond well in controlled trials to pramipexole,
a dopamine agonist that selectively
stimulates dopamine D2/D3 receptors and
is used to treat both Parkinson disease and
restless legs syndrome.
B. Tryptophan is decreased in the serum and
CSF of fibromyalgia patients. Serotonin is low
in fibromyalgia serum. 5-Hydroxytrytophan,
the intermediary between tryptophan and
serotonin, and 5-hydroxyindole acetic
acid, the by-product of serotonin metabolism,
are both low in the CSF of patients
with fibromyalgia. The excretion in urine of
5-hydroxyindole acetic acid was lower than
normal in patients with fibromyalgia, lower
in females versus males, and lower in females
with fibromyalgia versus females who don’t
have fibromyalgia.
C. The numbers of active tender points in
fibromyalgia patients directly correlated
with the concentration of serotonin in
fibromyalgia sera.

150

485. No treatments seem to be working for a 45-
year-old female with a 5-year history of
fibromyalgia. She has talked to a relative who
told her that oxycodone/acetaminophen works
for all pain. How do you respond?
(A) Opioids work but only when a shortacting
medication is combined with a
long-acting medication
(B) In combination with pregabalin and
duloxetine, hydromorphone has displayed
incredible synergy in extremely
depressed fibromyalgia patients
(C) Women with fibromyalgia have reduced
μ-opioid receptor availability within
regions of the brain that normally
process and dampen pain signals
(D) Fibromyalgia is so difficult to treat that
you are willing to try anything that she
thinks may help
(E) You are not opposed to trying opioids,
but the potential hyperalgesia has been
found to be significantly worse in
patients with fibromyalgia

485. (C) Fibromyalgia, a common chronic pain condition
characterized by widespread pain, is
thought to originate largely from altered central
neurotransmission. In this study, a sample of 17
fibromyalgia patients and 17 age- and sexmatched
healthy controls, were compared
using μ-opioid receptor PET. PET scans measure
blood flow in the brain. It was demonstrated
that fibromyalgia patients display
reduced μ-opioid receptor binding potential
within several regions known to play a role in
pain modulation, including the nucleus accumbens,
the amygdala, and the dorsal cingulate.
The reduced availability of the receptors
could result from a reduced number of opioid
receptors, enhanced release of opioids that are
produced naturally by the body, or both.
These findings indicate altered endogenous
opioid analgesic activity in fibromyalgia and
suggest a possible reason for why exogenous
opiates appear to have reduced efficacy in this
population. The reduced availability of the
receptor was associated with greater pain among
people with fibromyalgia.
Answers (A), (B), (D), and (E) have no merit.

151

486. Numerous medications have been used to treat
the insomnia associated with fibromyalgia.
Which one of the following has not been used?
(A) Amitriptyline
(B) Cyclobenzaprine
(C) Fluoxetine
(D) Clonazepam
(E) Pregabalin

486. (C)
A. and B. The sedating tricyclic biogenic amine
reuptake drugs, such as amitriptyline and
cyclobenzaprine, are the most commonly
prescribed medications for fibromyalgia
insomnia. These medications are mostly
used in low doses to improve sleep and to
enhance the effects of analgesics (amitriptyline
10-25 mg at night and cyclobenzaprine
5-10 mg at night). Patients can develop
tachyphylaxis to them, but a 1-month
holiday from the drugs may help restore
effectiveness.
C. SSRIs are so stimulating that they can
interfere with sleep, and should never be
taken at bedtime.
D. Benzodiazepine decrease anxiety and
allow less troubled sleep (alprazolam,
clonazepam). Clonazepam in particular
can help control nocturnal myoclonus
when it is associated with fibromyalgia.
E. Pregabalin is a sedative in addition to an
antinociceptive medication.

152

487. Pathophysiologic components of cancer pain
can be
(1) somatic (nociceptive) pain
(2) sympathetic pain
(3) neuropathic pain
(4) central pain

487. (E)

153

488. The skeletal sites most commonly involved in
osteolytic metastatic processes are
(1) ribs
(2) humerus
(3) femur
(4) tibia

488. (B) In osteolytic bone metastases, the most
commonly involved sites are vertebrae, pelvis,
ribs, femur, and skull. Upper and lower extremity
bones, except femur, are not commonly
involved.

154

489. The primary compression of the spinal cord
from metastatic deposits occurs in
(1) the thoracic spine in 70% of patients
(2) the lumbar spine in 20% of patients
(3) the cervical spine in 10% of patients
(4) multiple sites of the spine in 60% of
patients

489. (A) Multiple sites of metastatic epidural spinal
cord compression occur in 17% to 30% of all
patients. This is particularly common in prostatic
and breast carcinoma and uncommon in
lung cancer.

155

490. In a patient with skeletal metastases, bisphosphonates
(1) inhibit recruitment and function of
osteoclasts
(2) stimulate osteoblasts
(3) have greatest effect in breast cancer and
multiple myeloma
(4) have an acute pain-relieving effect

490. (E) Bisphosphonates decrease resorption of
bone directly, by inhibiting the recruitment and
function of osteoclasts, and indirectly, by stimulating
osteoblasts. In patients with bony
metastases, they are the standard therapy for
hypercalcemia after rehydration, and have the
greatest effect in patients with breast cancer
and multiple myeloma. Bisphosphonates also
have an acute pain-relieving effect, which is
thought to be derived from the reduction of
various pain-producing substances.

156

491. The following substance(s) may be useful in
treating a patient with a malignant disease:
(1) Gabapentin
(2) Amitriptyline
(3) Samarium 153
(4) Hydromorphone

491. (E) Both gabapentin, an antiepileptic drug, and
amitriptyline, TCA, are widely used in treating
neuropathic pain, which is often a significant
component of a cancer pain syndrome.
Samarium 153 belongs to the group of
bone-seeking radiopharmaceuticals emitting
medium- to high-energy beta particle radiation.
The most commonly used agent in this group is
Strontium 89 with a documented pain-relieving
effect in patients with bony metastases.
Samarium 153, rhenium 186, and phosphorus
32 are also available for clinical use.

157

492. The following is (are) the possible compilation(
s) of a neurolytic celiac plexus block:
(1) Persistent diarrhea
(2) Aortic pseudoaneurysm
(3) Intradiscal injection
(4) Damage to the artery of Adamkiewicz

492. E)

158

493. In a cancer pain patient, the following agent(s)
can be used effectively via implantable intrathecal
delivery system:
(1) Opioids
(2) α2-Adrenergic agonists
(3) Local anesthetics
(4) Ziconotide

493. (E) Both gabapentin (an antiepileptic drug) and
amitriptyline (a TCA) are widely used in treating
neuropathic pain, which is often a significant
component of a cancer pain syndrome.
Samarium 153 belongs to the group of
bone-seeking radiopharmaceuticals emitting
medium- to high-energy beta particle radiation.
The most commonly used agent in this group is
Strontium 89 with a documented pain-relieving
effect in patients with bony metastases.
Samarium 153, rhenium 186, and phosphorus
32 are also available for clinical use.

159

494. Which of the following conditions are the possible
complications of chemotherapy in a cancer
patient?
(1) Toxic peripheral neuropathy
(2) PHN
(3) Avascular necrosis
(4) Pseudorheumatism

494. (E)

160

495. As compared to younger subjects which of the
following is correct about older people with
pain?
(1) There may be difficulties in determining
the etiology of pain in older people
(2) Older people generally receive significantly
lower amounts of opioid analgesia
(3) There may be increased potency of
opioids
(4) The majority of older people choose
quantity of life over quality of life

495. (E)

161

496. The goals of palliative care can be summarized
as follows:
(1) To help those who need not die to live,
and to live with the maximum of
freedom from constraints on their
quality of life arising from acute and
chronic conditions of the body
(2) To help those who can no longer live to
die on time—not too early and not late
(3) To help the dying, whether in hospital,
nursing home, hospice, or at home, to
die with dignity and in peace
(4) To administer euthanasia only to the
patients who truly understand the fact
that their condition is terminal and who
personally request it

496. (A)

162

497. Peripheral neuropathy(ies) is (are) characterized
by
(1) sensory loss
(2) fasciculations
(3) dysesthesias
(4) chronic pain

497. (B) In clinical practice, most peripheral neuropathies
do not produce chronic pain as
impairment of nerve fibers carrying nociception
should result in decrease pain perception.
In most neuropathies, all components of the
peripheral nervous system are affected, presenting
with variable sensorimotor deficit and
autonomic dysfunction.

163

498. Area(s) of acute pain processing in cortical and
subcortical regions of the brain as determined
by functional MRI include
(1) anterior cingulate cortex
(2) parietal cortex
(3) prefrontal cortex
(4) hypothalamus

498. (B) The most commonly activated areas during
acute processing of pain in humans are S-I, S-II,
anterior cingulated cortex, insular cortex, prefrontal
cortex, thalamus, and cerebellum.

164

499. Small-diameter peripheral neuropathies are
commonly painful. Example(s) of these neuropathies
include
(1) Ross syndrome (segmental anhidrosis)
(2) Fabry disease
(3) Charcot-Marie-Tooth disease type 1
(4) diabetic neuropathy

499. (C) Many studies suggest that axonal injury
along the nociceptive fiber in the peripheral nervous system is the main cause of neuropathic
pain. Several conditions where the small
fibers are spared support this concept. The
Charcot-Marie-Tooth disease also known as
hereditary motor and sensory neuropathy
where the demyelination is limited to large
myelinated fibers, do not manifest with pain.
Segmental anhidrosis or Ross syndrome where
only autonomic fibers are affected, is also not
painful. On the other hand, conditions affecting
the small nerve fibers, like diabetic neuropathy
or Fabry disease, a rare lipid-storage disorder,
commonly present with pain.

165

500. Chronic renal failure neuropathy is commonly
manifested with
(1) restless leg syndrome
(2) painful neuropathy
(3) distal weakness
(4) selective loss of small nerve fibers

500. (A) Chronic renal failure is associated with
selective loss of large nerve fibers which is
rarely painful. Common symptoms include
restless leg syndrome, distal numbness, and
paresthesias, with distal weakness usually in
the lower extremities.

166

501. Animal studies in neuropathic pain conditions
have shown
(1) intraplantar injections of interleukin
1(IL-1) reduces mechanical nociceptive
threshold
(2) IL-1 hyperalgesia is mediated by
bradykinin B-1 receptors
(3) effects of IL-1 on mechanical hyperalgesia
seems to be mediated by
prostaglandins
(4) IL-1 effects on nociceptions may be
mediated by vagal afferents

501. (E) Cytokines, a heterogeneous group of peptides
activate the immune system and mediate
inflammation. They form a complex bidirectional
system that communicates between the
immune system and the CNS. IL-1 is the most
extensively studied cytokine. Intraplantar as
well as intraperitoneal injections of IL-1 reduce
mechanical and probably thermal nociceptive
threshold, which may be blocked by local
cyclooxygenase inhibitors, supporting the role
of prostaglandins in the process. The communicating
pathway between the peripheral
cytokines and the brain may involve vagal
afferents terminating in the nucleus tractus solitarius
and circumventricular sites that lack a
blood-brain barrier.

167

502. Potential complication(s) of stellate ganglion
block include
(1) pneumothorax
(2) lesion of the recurrent laryngeal nerve
(3) neuritis
(4) Horner syndrome

502. (A) Blockade of the sympathetic innervation
of the head can be documented by the presence
of Horner syndrome, which is characterized
by myosis, ptosis, and enophthalmus.
Associate findings include conjunctival injection,
nasal congestion, and facial anhidrosis.
Horner syndrome is an expected finding after
blockade of the sympathetic afferents to the
face and can not be considered a complication.

168

503. Important factor(s) involved in the development
of neuropathic pain include
(1) behavioral studies have shown that
NMDA is involved in the induction and
maintenance of pain-related behaviors
(2) the spinal N-type voltage-dependent
calcium channels are the predominant
isoform involved in the pre- and postsynaptic
processing of sensory nociceptive
information
(3) tactile allodynia in the spinal nerve ligation
model may be blocked by intrathecal
N-type Ca2+ blockers like ziconotide
(4) after nerve injury there is upregulation
of the NMDA receptors

503. (E) Behavioral studies have shown that activation
of NMDA receptors are required for the
development and maintenance of pain-related
behaviors. Calcium channels are the key ion
involved in the release of transmitters. Different
subtypes of calcium channels (L-, N-, and P/Qtypes)
may have a differential role depending
on the nature of the pain state. The N-type voltagedependent
calcium channels appear to be the
predominant isoform involved in the pre- and
postsynaptic processing of sensory nociceptive
inputs. Animal and clinical studies have shown
partial pain relief with the use of a specific
N-type calcium channel blocker synthetically
derived from a conotoxin, SNX-111. The generic
name of this substance derived from the snail’s
natural conotoxin is Ziconotide.

169

504. Which of the following is (are) effect(s) of
μ-opioid agonists in neuropathic pain conditions?
(1) Decrease dynamic allodynia
(2) Decrease temperature threshold for cold
pain
(3) Decrease static allodynia
(4) μ-Opioid agonists do not have any
beneficial effects in patients with
neuropathic pain conditions

504. (A) The effectiveness of opioid agonists in the
management of neuropathic pain has created
significant controversy over the last two
decades. Recent studies have increased our
understanding about this topic. In patients
with SCI and stroke, IV morphine showed poor
effects in reducing spontaneous pain, but significantly
reduced stroking allodynia. Other
studies used alfentanil in the treatment of neuropathic
pain independently of the etiology
and observed decrease in dynamic, stroking
allodynia, and spontaneous pain, while increase
the temperature at which heat pain was detected
and decrease the temperature at which cold
pain was detected.

170

505. Effect(s) of GABA in the modulation of afferent
nociceptive input include
(1) GABAA produces postsynaptic inhibition
via metabotropic receptors, which
are ligand-gated Cl− channels
(2) the dominant type of inhibition of glutaminergic
excitatory postsynaptic action
potential is produce by GABA and/or
glycine
(3) GABAB and adenosine produce postsynaptic
hyperpolarization by activation
of K+ channels
(4) GABA and glycine produce slow
activation of postsynaptic potentials

505. (A) Action potentials in the dorsal horn neurons
are mediated by glutaminergic excitatory
postsynaptic potentials, this activity may be
inhibited predominantly by the inhibition produced
by GABA and/or glycine which causes
fast inhibition of postsynaptic potentials.
GABAAand glycine receptors are ligand-gated
Cl− channels, while GABAB, adenosine, and
opioids exert their typically produced postsynaptic
hyperpolarization by activation of K+
channels.

171

506. During the windup process
(1) sustained depolarization may recruit K+
channels, leading to decrease in the
intracellular Ca2+ levels
(2) cumulative recruitment of NMDAreceptor
current leads to progressive
relief of the Mg2+ blockade of the
NMDA-receptor pore
(3) more intense or sustained noxious
peripheral stimulation induces a
decrease in the release of neuromodulator
peptides, leading to an excitatory
state
(4) intracellular calcium levels play a major
role in the development of windup

506. (C) More intense or sustained noxious peripheral
stimulation induce primary afferent nociceptors
to discharge at higher frequencies and
to release from central nociceptor terminals
neuromodulator peptides like CGRP, substance
P, and glutamate. As more and more dorsal horn neurons get depolarized, NMDA receptors
open by removing the Mg2+ blockade,
allowing for intracellular calcium levels to
increase. The end result of these intracellular
signaling cascades is windup.

172

507. In patients with PHN
(1) histopathologic studies in patients with
PHN commonly show ganglion cell loss
and fibrosis
(2) sensory loss function in the affected
dermatome with increase heat pain
perception is an almost universal
finding
(3) antiviral drugs used in chronic PHN
usually are ineffective in alleviating
pain
(4) cold stimuli–evoked pain is more common
than heat-evoked pain

507. (B) Histopathological studies in patients with
PHN have found ganglion cell loss and fibrosis
and atrophy of the dorsal horn, DRG, dorsal
root, and peripheral nerves. Up to 30% of
patients with PHN have no loss of sensation in
the affected dermatome demonstrating minimal
or no loss of neuronal function and interestingly
thermal sensory thresholds are not
affected or even decreased. Antiviral drugs
have shown disappointing results in patients
with chronic PHN. Heat hyperalgesia is more
common than cold hyperalgesia, which only
occurs in less than 10% of the patients.

173

508. The Special Olympics has brought together
thousands of people with disabilities. Often
enough, the race times in these events are significantly
better than those of participants in
the traditional games. In addition to undergoing
the same type of grueling training regimens,
however, participants in the Special
Olympics often have to deal with difficulties
performing activities of daily living as well as
comorbidities associated with their primary
disease. The likelihood that an amputee in a
wheelchair race has phantom limb pain would
be decreased if the
(1) participant is a young child
(2) participant is a male
(3) participant is a congenital amputee
(4) amputation is a below the knee amputation
versus an above the knee amputation

508. (B) Phantom pain is equally frequent in men
and women and is not influenced by age in
adults, side or level of amputation, and cause
(civilian versus traumatic) of amputation.
Phantom pain is less frequent in young children
and congenital amputees.

174

509. A triple amputee (bilateral lower extremities,
left upper extremity) presents to the pain clinic
for work-up and treatment of phantom limb
pain. This patient’s pain most likely
(1) occurs intermittently
(2) is primarily localized to the fingers or
palm of the hand in the upper extremity
or toes, feet, or ankles in the bilateral
lower extremities
(3) is of stabbing, shooting, or pins and
needles character
(4) presents with attacks that last several
minutes to an hour

509. (A) Phantom pain is usually intermittent. Only
a few patients are in constant pain. Episodes of
pain are most often reported to occur daily, or
at daily or weekly intervals.
Phantom pain is usually localized to the
distal parts of the missing limb. Pain is normally
felt in the fingers and palm of the hand
in upper limb amputees and toes, foot, or
ankle in lower limb amputees. This may be
because of the larger cortical representation of
the hand and foot as opposed to the lesser representation
of the more proximal parts of the
limb.
The character of phantom pain is usually
described as shooting, pricking, burning, stabbing,
pins and needles, tingling, throbbing,
cramping, and crushing

175

510. True statement(s) about phantom sensations is
(are):
(1) They are less frequent than phantom
pains
(2) They usually appear 1 month after the
amputation
(3) The phantom sensation usually manifests
as enlargement of the missing limb
(4) A common position of the phantom for
upper limb amputees is the fingers
clenched in a fist

510. (D) Phantom sensations are more common than
phantom pain, and are experienced by nearly all
amputees. The incidence of phantom sensations
ranges from 71% to 90%, 8 days to 2 years after
amputation. Duration and frequency, but not
incidence, decrease as time passes. Phantom sensations
are less common in congenital amputees
and in patients who underwent amputation
before the age of 6 years
Nonpainful sensations normally appear
within the first days after amputation. The
amputee often wakes up from anesthesia with
a feeling that the amputated limb is still there.
Just after the amputation, the phantom limb
often resembles the preamputation limb in
shape, length, and volume. As time passes, the
phantom fades, leaving back the distal parts of
the limb. For example, upper limb amputees
may feel hand and fingers, and lower limb
amputees may feel foot and toes.
Commonly, upper limb amputees feel the
fingers clenched in a fist, while the phantom
limb of lower limb amputees is often described
as toes flexed In some cases, phantom sensations
include feeling of movement and posture;
however, in others only suggestions of the
phantom are felt.
Telescoping (shrinkage of the phantom) is
reported to occur in about one-third of patients.
The phantom progressively approaches the
stump and eventually becomes attached to it. It
has even been experienced within the residual
limb. Phantom pain does not retard shrinkage
of the phantom.

176

511. Which of the following is (are) example (s) of
how the peripheral nervous system may play a
role in phantom pain modulation?
(1) Dorsal root ganglion (DRG) cells display
an altered expression pattern of
different sodium channels
(2) Generation, but not maintenance of
phantom pain by the sympathetic
nervous system
(3) Long after limb amputation, injection of
noradrenaline around a stump neuroma
is reported to be intensely painful
(4) Phantom pain is directly related to the
skin temperature of the stump

511. (B) Changes occur in the DRG cells, after a complete
nerve cut. Cells in the DRG show similar
abnormal spontaneous activity and increased
sensitivity to mechanical and neurochemical
stimulation. Local anesthesia of neuromas abolished
tap-induced afferent discharges and tapinduced
accentuation of phantom pain, but
spontaneous pain and recorded spontaneous
activity were unchanged which is consistent
with the activity in DRG cells. DRG cells exhibit
major changes in the expression of sodium channels,
with an altered expression pattern of different
channels.
The sympathetic nervous system may
play a role in generating and especially in
maintaining phantom pain. It was noted that
application of noradrenaline or activation of
the postganglionic sympathetic fibers excites
and sensitizes damaged, but not normal nerve
fibers. Injecting noradrenaline into the skin can reestablish neuropathic pain that has just
been relieved with a sympathetic block and
injecting into a neuroma is reported to be
intensely painful.
The catecholamine sensitivity may also
manifest itself in the skin with a colder limb on
the amputated side, and it has been implied
that phantom pain intensity is inversely related
to the skin temperature of the stump.

177

512. Phantom pains are often a replica of preamputation
pain. It has also been noted that
amputees with phantom pain have more often
suffered from intense and long-lasting preamputation
pain than have patients without phantom
pain. These observations led to the premise
that preemptive analgesia may help decrease
postamputation pain. Of the studies done on
this subject matter
(1) most have been of very poor methodological
quality
(2) the two which included blinding and
randomization showed no significant
differences versus controls
(3) the aim has been to thwart spinal sensitization
by blocking the cascade of intraneuronal
responses that take place after
peripheral nerve injury
(4) the sample size was always greater
than 100

512. (A)
1. Numerous studies on preemptive analgesia
using epidural, epidural/perineural,
and just perineural administration have
been conducted. Only two were noted to
utilize proper patient randomization and
blinding.
2. Persistent pain has been reported in up to
80% of patients after limb amputation. The
mechanisms are not fully understood, but
nerve injury during amputation is important,
with evidence for the crucial involvement
of the spinal NMDA receptor in central
changes. The study objective was to assess
the effect of preemptively modulating sensory
input with epidural ketamine (an
NMDA antagonist) on postamputation
pain and sensory processing.
3. The aim of preemptive analgesia is to avoid
spinal sensitization by blocking, in advance,
the cascade of intra-neuronal responses that
take place after peripheral nerve injury.
True preemptive treatment is not likely possible
in patients scheduled for amputation
as most have been suffering from ischemic
pain and are almost certainly presenting
with preexisting neuronal hyperexcitability.
To conclude: epidural blockade has been
shown to be effective in the treatment of
preoperative ischemic pain and postoperative
stump pain.

178

513. Which of the following dietary modification(s)
should be made to alleviate symptoms of interstitial
cystitis?
(1) Restrict spicy foods
(2) Eliminate alcohol intake
(3) Cease smoking
(4) Increase orange juice intake

513. (A) Acidic foods, such as orange juice, carbonated
drinks, tomatoes, and vinegar may aggravate
the symptoms of interstitial cystitis. Spicy
food, alcohol, coffee, chocolate, tea, cola, and
smoking should also be either restricted or
completely eliminated.

179

514. Sodium pentosan polysulfate (Elmiron)
(1) is an antispasmodic medication
(2) is an oral analogue of heparin
(3) alleviates symptoms of interstitial
cystitis by relaxing smooth musculature
(4) increases antiadherent surface of the
bladder lining

514. (C) Sodium pentosan polysulfate (Elmiron) is
an oral analogue of heparin. Inside the bladder,
it acts as a synthetic glycosaminoglycan layer
and fortifies bladder wall defenses from bacteria
by increasing the antiadherent surface of
the bladder mucosa.

180

515. Which of the following substance(s) is (are)
thought to be involved in descending inhibition?
(1) GABA
(2) Serotonin
(3) Endogenous opioid peptides
(4) Norepinephrine

515. (E) Endogenous opioid peptides as other neurotransmitters,
such as serotonin, norepinephrine,
and GABA, are thought to be involved in
descending inhibition.

181

516. Which of the following is (are) the psychological
factor(s) affecting pain response?
(1) Fear and helplessness
(2) Sleep deprivation
(3) Anxiety
(4) Cultural differences

516. (E) Anxiety, fear, helplessness, and sleep deprivation
are part of the vicious cycle of pain.
Cultural background has been shown to play a
significant role in the individual’s pain response.

182

517. Which of the following is (are) psychological
method(s) for reducing pain?
(1) Placebo and expectation
(2) Psychological support
(3) Procedural and instructional information
(4) Cognitive coping strategies

517. (E)

183

518. Gastrointestinal (GI) impairment in a postsurgical
patient can be
(1) worsened by increased sympathetic
activity because of severe pain
(2) contributed to by administration of
opioids
(3) mitigated by early mobilization of the
patient
(4) worsened by epidural blockade with
local anesthetic

518. (A) There is evidence that pain-related impairment
of intestinal motility may be relieved by
epidural local anesthetics.

184

519. Which of the following feature(s) suggest neuropathic
pain?
(1) Pain in the area of sensory loss
(2) Good response to opioids
(3) Pain in response to nonpainful stimuli
(4) Absence of Tinel sign

519. (B) Pain in the area of sensory loss, also called
deafferentation pain, or anesthesia dolorosa, is
a prominent sign of a neuropathic pain.
Neuropathic pain generally responds less well
to opioid treatment than somatic pain. One of
the significant signs of neuropathic pain is also
allodynia-a painful response to nonpainful
stimuli. Tapping of neuromas produces radiating
electric shock sensation in the distribution
of the damaged nerve is called Tinel sign—
another feature of a neuropathic pain.

185

520. The correct corresponding vertebral levels for
optimal epidural catheter placement for various
surgical procedures are
(1) T10-12 for lower abdominal surgery
(2) T8-10 for upper abdominal surgery
(3) L2-4 for lower extremity surgery
(4) C7-T2 for upper extremity surgery

520. (E)

186

521. Which of the following medications are useful
in an inpatient management of a post–burn
injury pain?
(1) Opioids
(2) Ketamine
(3) Benzodiazepines
(4) Nitrous oxide

521. (E) Post–burn injury pain has two components:
a constant background pain and an intermittent
procedure-related pain. Continuous infusion of
opioids is useful for control of the background
component of pain. Pain related to wound care,
dressing changes, and others (procedure-related
pain) may require brief but profound analgesia.
This may be achieved by administration of
supplemental IV opioids, or addition of the
adjuvant drugs, such as IV ketamine, IV benzodiazepines,
inhaled nitrous oxide-oxygen mixture,
or even general anesthesia.

187

522. In patients with a traumatic chest injuries thoracic
epidural analgesia has been shown to significantly
improve inspiratory effort, negative
inspiratory force, gas exchange, ability to cough,
and ability to clear bronchial secretions. The
following finding may be considered relative
contraindications for epidural analgesia in a
patient with posttraumatic chest injury:
(1) Inadequate coagulation function
(2) Spine fractures
(3) Inadequate intravascular volume
resuscitation
(4) Concomitant head injury

522. (E) All answers are correct. Aconcomitant head
injury may be associated with increased intracranial
pressure, which could be considered a contraindication
for an epidural catheter placement.6yt

188

523. The most common characteristics of pain in
PHN include
(1) steady burning or aching
(2) dull and poorly localized
(3) paroxysmal and lancinating
(4) usually not aggravated by contact with
the affected skin

523. (B) Two types of pain may be found in PHN:
a steady burning or aching, the other, a paroxysmal,
lancinating pain. Both may occur spontaneously
and are usually aggravated by any
contact with the involved skin.

189

524. Which of the following group(s) of medications
was found to be useful in treatment of PHN?
(1) Opioids
(2) Antiepileptic drugs
(3) Topical agents
(4) Antidepressants

524. (E) All of the listed groups of medication were
found to be effective to some extent in the treatment
of PHN. Amultimodal approach seems to
be more effective because of the synergistic
effect different modes of action

190

525. Which of the following is (are) true about interventional
therapy for PHN?
(1) No proven surgical cure for PHN has
been found
(2) Cryotherapy is likely to bring only
short-term relief
(3) Topical lidocaine may provide effective
analgesia for PHN
(4) Transcutaneous nerve stimulation
(TENS) has been shown to give an effective
symptomatic relief in some patients

525. (E)

191

526. Antiviral agents in the acute phase of herpes
zoster
(1) competitively inhibit DNA polymerase,
terminating DNA synthesis and viral
replication
(2) are generally well tolerated
(3) hasten healing of the rash
(4) may reduce the duration of PHN

526. (E)

192

527. Oral steroids for acute herpes zoster
(1) are not currently recommended
(2) may provide pain relief in the acute
phase
(3) have no benefit in prevention of PHN
(4) have almost no side effects in patients
with herpes zoster

527. (A) Oral steroids may provide pain relief in
acute phase of herpes zoster, as well as shorten
the time to full crusting of lesions. However,
controlled trials showed no benefit in the prevention
of PHN. With the development of
antiviral agents, the use of oral steroids is currently
not recommended because of more frequent
side effects

193

528. Which of the following statement(s) is (are)
true about diabetic amyotrophy?
(1) It is commonly associated with pain
(2) It responds well to a complicated multimodal
treatment
(3) Involves weakness and atrophy of the
involved muscles
(4) Sciatic nerve and its supplied muscles
are most commonly affected

528. (B) Diabetic amyotrophy is a condition occurring
in diabetic patients, more commonly with
type-2 diabetes, which begins with pain in the
thighs, hips, and buttocks. Weakness and atrophy
of the proximal pelvic muscles groups,
iliopsoas, obturator, and adductor muscles follows
the painful manifestations. It usually does
not involve sciatic nerve, or distal muscles of
the lower extremity. The therapy for diabetic
amyotrophy is primarily supportive.

194

529. Charcot joint
(1) affects primarily weight-bearing joints
(2) can be caused by multiple causes other
than DM
(3) is related to the destruction of afferent
proprioceptive fibers
(4) is related to the destruction of efferent
neural fibers

529. (A) Neuropathic arthropathy (Charcot joint) develops
most often in weight-bearing joints. The predominant
cause is DM, but also associated with
neuropathic arthropathy are leprosy, yaws, congenital
insensitivity to pain, spina bifida,
myelomeningocele, syringomyelia, acrodystrophic
neuropathy, amyloid neuropathy, peripheral
neuropathy secondary to alcoholism and
avitaminosis, SCI, peripheral nerve injury, postrenal transplant arthropathy, intraarticular
steroid injections, and syphilis. The etiology of
Charcot joint is believed to be related to the
destruction of afferent proprioceptive fibers and
subsequent unrecognized trauma to the joint.

195

530. Which of the following statement(s) about
treatment of diabetic peripheral neuropathic
pain (DPNP) is (are) true?
(1) Most of the antidepressants are Food
and Drug Administration (FDA)
approved for the treatment of DPNP
(2) Most therapies for DPNP result in more
than 90% reduction in pain
(3) Most of the anticonvulsant drugs are
FDA approved for the treatment of
DPNP
(4) NSAIDs are the most commonly utilized
medications

530. (D) Across-sectional, community-based survey
of 255 patients with DPNP recruited through
the offices of endocrinologists, neurologists,
anesthesiologists, and primary care physicians
found that NSAIDs were the most commonly
used medications, with 46.7% reporting their
use. This is despite the fact, that there is little
evidence to support the efficacy of NSAIDs in
DPNP, and that NSAIDs have a high potential
for renal impairment in patients with diabetic
neuropathy.

196

531. Treatment of painful diabetic neuropathy
(PDN) rests on modification of the underlying
disease and control of pain symptoms. In turn,
the modification of the underlying disease
includes strict glycemic control. Which of the
following is (are) true?
(1) Tight glycemic control can halt or slow
the progression of distal sensorimotor
neuropathy
(2) Hemoglobin A1c target should be

531. (E)

197

532. The current treatments of the PDN include
(1) antiepileptic drugs
(2) antidepressants
(3) opioids
(4) aldose reductase inhibitors

532. (A) Given the frequency of imperfect glycemic
control, attempts have been made to identify
oral medications which can target downstream
metabolic consequences of hyperglycemia,
thereby preventing production of reactive
oxygen species, which are felt to contribute to
diabetic neuropathy. Unfortunately, trials of
aldose reductase inhibitors, which decrease
aberrant metabolic flux, have been disappointing
(eg, sorbinil, zopolrestat).

198

533. The convulsive tic
(1) is more severe in males
(2) may indicate the presence of a tumor,
vascular malformation, or ecstatic
dilation of the basilar artery
(3) is because of presence of bilateral facial
spasms
(4) is a result of painful periodic unilateral
facial contractions

533. (B) The combination of trigeminal neuralgia
and hemifacial spasm is known as convulsive
tic. It is reported to be more severe in women
than in men. Occasionally, strong spasms
involve all of the facial muscles unilaterally
almost continuously. Seldom, facial weakness
may be present. Convulsive tic may indicate
the presence of a tumor, vascular malformation,
or ecstatic dilation of the basilar artery,
compressing the trigeminal or facial nerves.

199

534. Which of the following support(s) the diagnosis
of idiopathic trigeminal neuralgia?
(1) Periods of weeks or months without
pain
(2) Increase pain by commonly benign
stimuli, like talking, eating, or washing
(3) Pain often alleviated by sleep
(4) Bilateral pain in the distribution of the
trigeminal nerve, described as shooting
or lancinating

534. (A) The diagnostic criteria for trigeminal neuralgia
are: shooting, electric-like, sharp, severe
pain which last for seconds but sometimes
experienced together with pain-free intervals.
The pain is periodic with weeks or months
without pain. The pain is typically unilateral
and triggered by light touch, eating, talking,
or washing.

200

535. Which of the following is (are) true regarding
trigeminal neuralgia?
(1) Very often, trigeminal neuralgia is the
presenting symptom in patients affected
with multiple sclerosis
(2) Trigeminal neuralgia is 20 times more
common in patients with multiple
sclerosis
(3) Trigeminal neuralgia tends to occur in
the early stages of multiple sclerosis
(4) Bilateral trigeminal neuralgia is seen
more often than expected in patients
with multiple sclerosis

535. (D) Rarely, trigeminal neuralgia is the presenting
symptom of multiple sclerosis. More often,
trigeminal neuralgia presents in patients with
advanced stages of multiple sclerosis.

201

536. The retrogasserian glycerol injection
(1) is a selective neurolytic agent with preference
for sensory fibers, leaving intact
motor neurons
(2) recurrence rates are the highest of all
ablative techniques
(3) sensory loss is almost unseen in patients
after this procedure
(4) sensory loss is less common than with
radiofrequency thermocoagulation

536. (C) Glycerol is a nonselective neurolytic agent.
Although less common than with radiofrequency
thermocoagulation, the frequency of
patients affected by sensory loss is high.
Recurrence rate is the highest among all ablative
techniques.

202

537. Which of the following is (are) true for trigeminal
neuralgia?
(1) Trigeminal neuralgia is the most
common cranial neuralgia
(2) It is more common in females
(3) The highest incidence is in elderly
patients
(4) The disease most frequently linked with
trigeminal neuralgia is multiple sclerosis

537. (E) The trigeminal neuralgia is the most
common cranial neuralgia and its most frequent
form is idiopathic. The incidence of
trigeminal neuralgia is 5.7 per 1000 females
and 2.5 per 1000 in males. Patients with multiple
sclerosis have a higher risk for trigeminal
neuralgia. Other potential relation was found
in patients with family history.

203

538. Potential factors involved in the development
of trigeminal neuralgia include
(1) ion channel upregulation in the area of
the trigeminal injury
(2) focal demyelination
(3) up to 30% of patients with trigeminal
neuralgia have arterial cross compression
at the level root entry zone
(4) cell body degeneration in the trigeminal
complex of the mesencephalon

538. (A) The trigeminal neuralgia is a primary axonal
degenerative disease. The ignition hypothesis
combines the current knowledge of the role of
ion channels in the development of neuropathic
pain. Focal demyelination adjacent to the area of
arterial compression has been shown by electron
microscopy in patients undergoing posterior
fossa surgery. In up to 30% of patients with arterial
cross compression, there is a groove or an
area of discoloration lateral where the root entry
zone would be expected.

204

539. Spontaneous intracranial hypotension (SIH)
(1) the most common site of idiopathic
dural tears is the lower lumbar region
(2) congenital subarachnoid or Tarlov cysts
are a potential site for dural weakness
and rupture
(3) the most obvious difference between
PDPH and SIH, is the lack of postural
symptoms in the second
(4) are no characteristic findings on MRI

539. (C) SIH and PDPH have similar presentation,
pathophysiology, and treatment. The most
important distinction is the initiating event,
which is obvious in PDPH. MRI of the brain
with gadolinium enhancement in patients with
SIH shows meningeal enhancement, and thickening,
and a possible caudad shift of the brain
toward the foramen magnum. The most common
location of spontaneous dural tear is the thoracic
region followed by the cervicothoracic
and thoracolumbar junction regions.

205

540. A common treatment for patients with PDPH is
epidural blood patch (EBP). Which of the following
is (are) true regarding this therapy?
(1) Maintenance of supine position for
2 hours after the patch provides higher
chances for success
(2) As a result of the predominant caudad
spread of the blood after EBP, a level of
placement above the suspected dural
tear is recommended
(3) The effectiveness of EBP is reduced
when the dural tear was caused by a
large-size needle
(4) The long-term relief of an initial EBP is
close to 98%

540. (B) It has been shown that keeping a supine
position for 2 hours after the EBP provides
higher chances of success when compared with
30 minutes. Although initial relief is very high
(close to 100%), the overall long-term relief of PDPH after EBP is between 61% and 75%. The
effectiveness of EBP is reduced when the dural
tear was caused by a large-size needle.

206

541. The incidence of PDPH is between 1% and
75%. Factor(s) that prevent its development at
the time of dural puncture include
(1) use of an interlaminar approach
(2) use of intrathecal catheter
(3) bed rest after the puncture
(4) use of small-gauge spinal needle

541. (C) Two important factors in the prevention of
PDPH are the use of small and blunt bevel
spinal needles. Other factors that may prevent
the development of PDPH include the use of
paramedian approach (with angles of 35° or
greater) and the use of intrathecal catheters. Bed
rest as a preventive measure is not effective.

207

542. Diagnostic criteria for cervicogenic headache
by the International Headache Society and the
International Association for the Study of Pain
(IASP) include
(1) unilateral headache
(2) relief of acute attacks by blocking the
greater occipital nerve with local
anesthetic
(3) aggravation of the headache with neck
movements
(4) decrease range of neck motion

542. (E) Cervicogenic headache is defined as
headache that arises from painful disorders of
structures in the upper neck, which generates
irritation of the upper cervical roots or their
nerve branches. The current classification by
the IHS and the IASP accepts these headaches
to be unilateral or bilateral. All the other
options in the questions are true.

208

543. The cervicogenic headache
(1) has a prevalence of 0.4% to 2.5% in the
general population and may account for
up to 15% to 20% of patients with
chronic headache
(2) is more common in females; a female to
male ratio of 4 to 1
(3) mean age is the beginning of the fourth
decade
(4) is aggravated by neck movement, and
alleviated by occipital nerve block

543. (E) According to the International Headache
Society and the IASP, cervicogenic headache
(CGH) is a pain originated in the neck, mostly
unilateral although it may be bilateral, exacerbated
by neck movement, and alleviated by
local anesthetic block of the occipital nerve.
The prevalence of CGH is 0.4% to 2.5% in the
general population and may account for up to
15% to 20% of patients with chronic headache,
more common in females with a 4:1 ratio and
mean age of patients with 42.9 years.

209

544. The cortical spreading depression
(1) may produce the aura symptoms
(2) produces activation of the trigeminal
nerve endings
(3) consist of decreased cerebral blood flow
spreading forward from the occipital
cortex
(4) is followed by generalized cerebral vascular
dilation that explains the headache

544. (A) During the aura in classic migraine a
decrease in cerebral blood flow decreases
spreads from the occipital cortex. The variation
in the cerebral blood flow causes the aura
and activates trigeminal nerve endings. It is
possible that cortical spreading depression may
stimulate peripheral nerve terminals of the
nucleus caudalis trigeminalis.

210

545. In terms of migraine which of the following is
(are) true?
(1) Migraine with aura is associated with an
increase of cerebral blood flow that
happens after the headache begins
(2) In migraine with aura there is a
decrease of cerebral blood flow that
starts after the headache begins
(3) In migraine without aura there is no
change in cerebral blood flow
(4) In migraine without aura there is
increase of cerebral blood flow before
the headache begins

545. (B) During the aura in classic migraine there is
a decrease in cerebral blood flow.
In patients with classic migraine (migraine
with aura), there is increase of cerebral blood
flow that happens after the headache begins
and this change persist until the headache
resolves. In migraine without aura, there is no
change in cerebral blood flow.

211

546. Migraine is a risk factor for
(1) major depression
(2) manic episodes
(3) anxiety disorders
(4) panic disorders

546. (E) Migraine is a risk factor for affective disorders.
When comparing with nonmigraineurs,
patients with migraine have a 4.5-fold increased
risk of major depression, a sixfold risk of manic
episodes, a threefold increase in anxiety disorder,
and a sixfold prevalence in panic disorder.

212

547. Migraine happens in 18% of women, 6% of
men, and 6% of children. Migraine usually
(1) begins in the first three decades of life
(2) is of higher prevalence in the fifth
decade
(3) decrease symptoms in the last trimester
of their pregnancy in most females
(4) is improved, common after surgical
menopause

547. (A) Although migraine begins in the first three
decades of life, the higher prevalence is in the
fifth one. Family history is a common finding,
and pregnant females often experience worsening
symptoms in the first trimester and
improvement during the third. Many women
experience improvement of their symptoms
after natural, but not surgical menopause.

213

548. Tension-type headache
(1) is the result of sustained contraction of
the pericranial muscles with subsequent
ischemic pain
(2) has more common onset during adolescence
and young adulthood
(3) has increased EMG activity in muscles
with tenderness
(4) reduces CNS levels of serotonin that may
be responsible for abnormal pain
modulation

548. (C) Muscle tenderness is common in patients
suffering from TTH, but is not secondary to
pericranial muscle contraction or ischemic pain
in response to emotion or stress. Increased
EMG activity is independent of tenderness and
pain. Reduced pain threshold observed in
chronic TTH may be the result of low CNS
levels of serotonin. Although TTH can begin at
any age, the most common onset is during adolescence
and young adulthood. The prevalence
of TTH decreases with increasing age.

214

549. For any structure to be deemed a cause of low
back pain, it must have the following characteristic(s):
(1) A nerve supply
(2) Be capable of causing low back pain in
healthy volunteers
(3) Be susceptible to disease or injuries
known to be painful
(4) Be shown to be a source of pain in a
patient using diagnostic techniques of
known reliability and validity

549. (E) For any structure to be considered as a
source for low back pain it must have the following
characteristics: a nerve supply, the capability
of causing low back pain similar to what
is seen clinically (ideally in healthy volunteers),
a susceptibility to disease or injuries known to
be painful, and should be able to be shown as
a source of pain using diagnostic techniques
of known reliability and validity

215

550. Randomized controlled trials (RCTs) have generated
evidence-based conclusions for preventive
interventions back and neck pain. Which
of the following statement(s) is (are) true based
on the evidence of RCTs?
(1) Lumbar supports are not effective in
preventing neck and back pain
(2) Exercise may be effective in preventing
neck and back pain
(3) Back schools are not effective in
preventing back and neck pain
(4) Ergonomic interventions are effective in
preventing back and neck pain

550. (A) There have been RCTs showing that lumbar
supports and back schools are not effective in
preventing back pain. Exercise has been proven
by RCTs to prevent back pain. To date, there are
no RCTs on the effectiveness of ergonomics in
preventing back pain.

216

551. Anomalies of lumbar nerve roots include
which of the following?
(1) Two pairs of nerve roots arise from a
single dural sleeve
(2) A dural sleeve arises from a lower position
in the dural sac
(3) The vertebral foramen is unoccupied by
a nerve or contains a supernumerary set
of roots
(4) Extradural anastomoses between roots
in which a bundle of nerve fibers leaves
one dural sleeve to enter an adjacent one

551. (E) The most significant anomalies of the
lumbar nerve roots are aberrant courses and
anastomoses between nerve roots. Type 1
anomalies are aberrant courses of which there
are two kinds. Type 1A describes two pairs of nerve roots arising from a single dural sleeve,
whereas type 1B defines a dural sleeve arising
from a low position on the dural sac. Type 2
anomalies include those in which the number
of roots in the intervertebral foramen varies.
An empty foramen is classified as type 2A, and
a foramen with extra nerve roots is known as a
type 2B. Type 3 anomalies are those involving
extradural anastomoses between roots in which
a bundle of nerves leaves on dural sleeve to
enter one nearby. Type 3 anomalies may coexist
with type 2 anomalies.

217

552. Low back pain is defined as pain perceived
within a region bounded
(1) superiorly by an imaginary line through
the T12 spinous process
(2) inferiorly by a transverse line through
the posterior sacrococcygeal joints
(3) laterally by the lateral borders of the
erector spinae
(4) within the region overlying the sacrum

552. (E) The IASP published standardized terms to
define low back pain as pain perceived to arise
for lumbar spinal pain and/or sacral spinal
pain. Lumbar spinal pain is defined as pain
perceived to arise from the region bordered
superiorly by an imaginary line through the
T12 spinous process, inferiorly by a line
through the S1 spinous process, and laterally
by the lateral borders of the erector spinae.
Sacral spinal pain is that defined as pain perceived
to arise from the region bordered laterally
by imaginary vertical lines through the
posterior superior and posterior inferior iliac
spines, superiorly by a transverse line through
the S1 spinous process, and inferiorly by a
transverse line through the posterior sacrococcygeal
joints.

218

553. Complications of cervical transforaminal injections
include which of the following?
(1) Cerebellar infarction
(2) Cerebral infarction
(3) Spinal cord infarction
(4) Anterior spinal artery syndrome

553. (E) Transforaminal injections have been the cause
of some of the most worrisome recent complications.
These included cerebellar and cerebral
infarct, SCI, and infarction, massive cerebral
edema, paraplegia, visual defects with occlusion
following particulate depo-corticosteroids, anterior
spinal artery syndrome, persistent neurologic
deficits, transient quadriplegia, cauda
equina syndrome, subdural hematoma, and
paraplegia following intracordal injection during
attempted epidural anesthesia under general
anesthesia.

219

554. Discographic stimulation (formally known as
discography) is considered positive if
(1) adjacent disc stimulation causes pain
(2) thermal stimulation with a wire electrode
causes pain
(3) pain is reproduced at pressures greater
than 80 psi
(4) pain is reproduced at pressures less than
50 psi and preferably less than 15 psi

554. (C) Despite its controversial history, disc stimulation
(formerly known as discography)
remains the only means by which to determine
whether or not a disc is painful. The test is positive
if upon stimulating a disc the patient’s
pain is reproduced provided that stimulation of adjacent discs does not reproduce their pain.
Discs are also considered to be symptomatic
only if pain is reproduced at injection pressures
less than 50 psi and preferably less than 15 psi.
At injection pressures greater than 80 psi, some
discs are painful in normal individuals. The
stimulation of discs has been complemented
by another approach, heating a wire electrode
that has been inserted into a disc annulus.
Heating a disc evokes pain that is perceived in
the back. This pain may also radiate to the
lower extremities and be responsible for
referred pain in the thigh and leg.

220

555. The use of chemonucleolysis for lumbar disc herniations
is indicated for which of the following?
(1) Contained disc protrusions
(2) Extruded disc herniations
(3) Herniations unresponsive to nonsurgical
management
(4) Sequestered disc herniations

555. (B) Chemonucleolysis is indicated for contained
disc protrusions causing sciatic pain that
have been unresponsive to conservative management.
The injection is contraindicated for
extruded and sequestered disc herniations, and
in patients with cauda equine syndrome.
Relative contraindications include previous
chymopapain injections, previous surgery for
lumbar disc herniation, spinal stenosis, severe
degenerative disc or facet osteoarthritis, and
spondylolisthesis.

221

556. Causes of FBSS include which of the following?
(1) Inappropriate selection of patients
(2) Irreversible neural injury
(3) Inadequate surgery
(4) New injury to nerves and spine

556. (E) Inappropriate or premature selection of
patients for surgery is the most common cause
of FBSS. The second most common cause is
persistence of pain secondary to irreversible
neural injury. A less common cause is inadequate
surgery. Lastly, a variant of FBSS results
from new pathologic processes initiated by the
initial surgery.

222

557. Selection criteria for elective lumbosacral spine
surgery include
(1) radicular pain with corresponding
dermatomal segmental sensory loss
(2) abnormal imaging study showing nerve
root compression
(3) signs of segmental instability consistent
with symptoms
(4) success of conservative therapy

557. (A) The American Association of Neurological
Surgeons and the American Academy of
Orthopedic Surgeons have published criteria
for patient selection for elective lumbosacral
spine surgery. They are applicable to new
patients, as well as FBSS patients. They include
the following:
1. Failure of conservative therapy.
2. An abnormal diagnostic imaging study showing
nerve root or cauda equina compression
and/or signs of segmental instability consistent
with the patient’s signs/symptoms.
Radicular pain with one or more of the
following: (a) corresponding dermatomal segmental sensory loss, (b) corresponding
dermatomal motor loss, (c) abnormal deep
tendon reflexes consistent with appropriate
dermatomes.

223

558. The main types of cervical involvement in
rheumatoid arthritis include
(1) atlantoaxial subluxation
(2) cranial settling
(3) subaxial subluxation
(4) occipital condyle fractures

558. (A) There are three main types of cervical
spine involvement in rheumatoid arthritis:
atlantoaxial subluxation, cranial settling, and
subaxial subluxation. The inflammatory
changes affecting synovial joints and bursae
target structures lined with a synovial membrane
in the cervical spine. Patients with cervical
spine involvement are thought to have a
more severe form of rheumatoid arthritis, and
their prognosis is usually worse. Occipital
condylar fractures result from a full-energy
blunt trauma complemented with axial compression,
lateral bending, or rotational injury
to the alar ligament.

224

559. Whiplash and whiplash-associated disorders
(WAD) comprise a range of injuries to the neck
caused by or related to a sudden distortion of
the neck. Characteristics include
(1) spinal cord injury (SCI)
(2) referred shoulder pain
(3) sensory deficits
(4) headaches

559. (E) The Québec Task Force (QTF) was a task
force sponsored by the Société de l’assurance
automobile du Québec, the public auto
insurer in Quebec, Canada. In 1995, the QTF
submitted a report on WADs which made
specific recommendations on prevention, diagnosis,
and treatment of WAD. These recommendations
have become the base for Guideline on
the Management of Claims Involving Whiplash-
Associated, a guide to classifying WAD and
guidelines on managing the disorder. The full
report titled Redefining “Whiplash” was published
in the April 15, 1995 issue of Spine. An
update was published in January 2001.
Four grades of WAD were defined by the
QTF :
Grade 1: Complaints of neck pain, stiffness or
tenderness only but no physical signs are
noted by the examining physician.
Grade 2: Neck complaints and the examining
physician finds decreased range of motion
and point tenderness in the neck.
Grade 3: Decreased range of motion plus neurologic
signs, such as decreased deep tendon
reflexes, weakness, insomnia, and sensory
deficits.
Grade 4: Neck complaints and fracture or dislocation,
or injury to the spinal cord.

225

560. Distraction testing allows an examiner to identify
neurologic and mechanical abnormalities in
the cervical spine. It is characterized by
(1) relief of neck pain
(2) lifting head from the chin and occiput
(3) relief of pressure on zygapophyseal joints
(4) examiner standing in front of a standing
patient

560. (A) The distraction test is performed with an
examiner standing behind a seated patient, lifting
their head from the chin and occiput, and
removing the weight of the head from the neck.
If relief of neck pain occurs, the test might point
to foraminal intrusion on a nerve root as the
source of pain.

226

561. A 45-year-old male with complaints of cervical
neck pain radiating down his left arm is examined
by a physician. With one particular maneuver,
his pain is exactly reproduced. The test(s)
that can reproduce his symptoms include
(1) distraction testing
(2) Valsalva test
(3) spurling maneuver
(4) Adson test

561. (A) Spurling maneuver is used to identify
nerve root compression or irritation. The head
is tilted toward the affected side and manual
pressure is applied to the top of the head.
Radicular pain should be reproduced with
this maneuver. Valsalva test allows a patient to
experience painful or sensory changes when
bearing down. The test increases intrathecal
pressure and exacerbates compression within
the cervical canal caused by tumors, infections,
disc herniations, or osteophyte changes.
The distraction test is performed with an
examiner standing behind a seated patient,
lifting their head from the chin and occiput,
and removing the weight of the head from the
neck. If relief of neck pain occurs, the test
might point to foraminal intrusion on a nerve
root as the source of pain. Adson test is used
to assess vascular compromise because of subclavian
artery impingement from thoracic
outlet syndrome.

227

562. The following are true about HIV infection–
related neuropathies, EXCEPT
(1) inflammatory demyelinating polyneuropathies
occur early in the course of
HIV infection
(2) vasculitis-related neuropathies occur
midcourse in HIV infection
(3) distal sensory neuropathies occur late in
HIV infection
(4) HIV-related neuropathies tend to be
nonspecific to the stage of HIV infection

562. (D) Peripheral neuropathic pain syndromes in
patients with HIV infection tend to be specific
to the stage of HIV infection as outlined in
answers (1) through (3).

228

563. Which of the following is (are) true about the
predominantly sensory neuropathy of AIDS?
(1) The predominant symptom is pain in
the soles of the feet
(2) Ankle jerks are often absent or reduced
(3) As symptoms of the neuropathy progress,
they usually remain confined to the feet
(4) EMG demonstrate sensory, but not
motor involvement

563. (A) In patients with predominantly sensory
neuropathy of AIDS, the complaints are
mostly sensory. However, the NCV and EMG
studies demonstrate both sensory and motor
involvement.

229

564. Which of the following group(s) of medication(
s) is (are) useful in treatment of pain in
HIV and AIDS patients?
(1) Opioids
(2) Anticonvulsants
(3) Psychostimulants
(4) Antidepressants

564. (E) Psychostimulants, such as dextroamphetamine,
methylphenidate, may be useful agents
in patients with HIV infection or AIDS who
are cognitively impaired. Psychostimulants
enhance the analgesic effects of the opioid
drugs. They are also useful in diminishing
sedation secondary to opioids. In addition, psychostimulants
improve appetite, promote sense of well-being, and improve feelings of weakness
and fatigue in patients with malignancies.

230

565. Pathophysiologic tissue injury in SCD generates
multiple pain mediators. The facilitators of
the pain transmission include
(1) bradykinin
(2) serotonin
(3) substance P
(4) dynorphin

565. (B) Tissue injury generates several major pain
mediators, including, but not limited to IL-1,
bradykinin, K+, H+, histamine, substance P, and
CGRP. The pathway for painful stimuli is subject
not only to activators, sensitizers, and facilitators
but also to inhibitors. Serotonin,
enkephalin, β-endorphin, and dynorphin are
endogenous central pain inhibitors.

231

566. Which of the following established four components
of SCD is responsible/associated with
the patient’s pain?
(1) Anemia and its sequelae
(2) Organ failure
(3) Comorbid conditions
(4) Pain syndromes

566. (E) SCD is a quadrumvirate of: (1) pain syndromes,
(2) anemia and its sequelae, (3) organ
failure, including infection, and (4) comorbid
conditions. Pain, however, is the insignia of
SCD and dominates its clinical picture throughout
the life of the patients. Pain may precipitate
or be itself precipitated by the other three components
of the quadrumvirate.

232

567. Which of the following statement(s) is (are)
true about avascular necrosis (AVN) and SCD?
(1) Core decompression is an effective treatment
of late stages of the AVN
(2) Treatment of AVN is mostly
symptomatic
(3) AVN affects mostly femoral head
(4) AVN is the most common complication
of SCD in adults

567. (C) Avascular necrosis is the most commonly
observed complication of SCD in adults.
Although it tends to be most severe and disabling
in the hip area, it is a generalized bone
disorder in that the femoral and humeral heads
and the vertebral bodies may be equally
affected. Treatment of avascular necrosis is
symptomatic and includes providing nonopioid
or opioid analgesics in the early stages of
the illness; advanced forms of the disease
require total joint replacement. Core decompression
appears to be effective in the management
of avascular necrosis if performed
during its early stages

233

568. Which of the following statement(s) is (are)
true about leg ulceration and SCD?
(1) Leg ulcers occur in 5% to 10% of the
adult SCD patients
(2) Skin grafting is a very effective treatment
for chronic leg ulcers in SCD
patients
(3) Many leg ulcers heal within a few
months with good localized treatment
(4) Regranex, used to treat leg ulcers, contains
an autologous platelet-derived
growth factor

568. (B) Leg ulceration is a painful and sometimes
disabling complication of sickle cell anemia
that occurs in 5% to 10% of adult patients with
SCD. With good localized treatment, many
ulcers heal within a few months. Leg ulcers
that persist beyond 6 months may require skin
grafting, although results of this treatment have
been disappointing. Recent advances in management
include the use of platelet-derived
growth factor, prepared either autologously
(Procuren) or by recombinant technology
(Regranex).

234

569. Management of painful vasoocclusive crises in
SCD patients frequently employs supplemental
oxygen. Which of the following is (are) true
about the supplemental oxygen administration
in SCD patients?
(1) Supplemental low-flow oxygen is often
given to patients with SCD painful crisis
in efforts to diminish the number of
reversibly sickled cells
(2) There is little supportive data for the
use of supplemental oxygen in SCD
patients
(3) Routine oxygen administration in the
absence of hypoxemia may impair reticulocytosis
in SCD patients
(4) Routine oxygen administration in the
absence of hypoxemia has no proven
benefit in SCD patients

569. (E)

235

570. Which of the following statement(s) is (are)
true about epidemiology of SCD?
(1) It is the most common hemoglobinopathy
in the United States
(2) The prevalence is significantly higher in
the African American population than
in the general population
(3) It occurs in 0.3% to 1.3% of the African
American population
(4) The prevalence of SCD does not
depend on the ethnic background of
the population

.570. (A) Sickle cell anemia affects millions throughout
the world. It is particularly common among
people whose ancestors come from sub-
Saharan Africa; Spanish-speaking regions
(South America, Cuba, Central America); Saudi
Arabia; India; and Mediterranean countries
such as Turkey, Greece, and Italy

236

571. Which of the following is (are) the measure(s)
used to treat vasoocclusive crises of SCD
during pregnancy?
(1) Aggressive hydration
(2) Supplemental oxygen in patients with
hypoxemia
(3) Partial exchange transfusions
(4) Prophylactic transfusions

.571. (E) General management of vasoocclusive crisis
during pregnancy begins with aggressive
hydration to increase intravascular volume and
decrease blood viscosity. Supplemental oxygen
is essential in those patients with hypoxemia.
Partial exchange transfusions are used to reduce
polymerized hemoglobin S. Prophylactic transfusions
may reduce the incidence of severe sickling
complications during pregnancy.

237

572. When an opioid-tolerant patient in a sickle cell
vasoocclusive crisis is admitted to a hospital,
which of the following step(s) should be taken?
(1) A baseline opioid infusion should be
started immediately at an equianalgesic
dose to patient’s home opioid requirement
(2) A baseline infusion should be supplemented
with a patient-controlled
analgesia (PCA) on demand for breakthrough
pain
(3) As patient’s new opioid requirement
becomes known from the PCA history,
conversion to a combination of longand
immediate-release opioid can be
undertaken
(4) Fast opioid dose increases may lead to
hypoxemia and/or hypercarbia, which
may exacerbate sickling of erythrocytes

572. (E) Some patients with SCD are opioid-tolerant
secondary to their home opioid management.
Therefore, the home opioid requirement should
be taken into account for faster and more efficient
pain control of sickle crisis pain. Opioid
titration, however, may require some additional
care because hypoxemia and hypercarbia
further exacerbate sickling of erythrocytes.

238

573. Autonomic dysreflexia
(1) is usually triggered by a spontaneous
sympathetic discharge above the SCI
level
(2) is rarely associated with headache
(3) is never life-threatening
(4) manifests itself with increased blood
pressure

573. (D) Autonomic dysreflexia is a potential lifethreatening
condition, which is triggered by
sensory input below the lesion and manifests
itself with increased blood pressure, headache,
and a risk of cerebral hemorrhage and seizure.

239

574. Which of the following is (are) true about the
anterior cord syndrome?
(1) It is characterized by complete sensory
loss
(2) Prognosis for motor function recovery is
very poor
(3) It is a complete SCI syndrome
(4) It is characterized by complete motor
function loss

574. (C) Anterior cord syndrome is a common
incomplete cord syndrome. A patient with
anterior cord syndrome may exhibit complete
motor and incomplete sensory loss, with the
exception of retained trunk and lower extremity
deep pressure sensation and proprioception.
This syndrome carries the worst prognosis
for return of function, and only a 10% chance of
functional motor recovery has been reported.

240

575. Which of the following is (are) true about the
posterior cord syndrome?
(1) It is characterized by preservation of
temperature sensation
(2) It is characterized by preservation of
normal gait
(3) It is uncommon
(4) It is characterized by preservation of
proprioception

575. (B) Posterior cord syndrome is a rare incomplete
cord syndrome consisting of loss of the
sensations of deep pressure and deep pain and
proprioception, with otherwise normal cord
function. The patient ambulates with a footslapping
gait similar to that of someone
afflicted with tabes dorsalis.

241

576. Which of the following is (are) true feature(s) of
Brown-Séquard SCI syndrome?
(1) Ipsilateral motor deficit
(2) Contralateral pain sensation deficit
(3) Contralateral temperature sensation
deficit
(4) Uncommonness

576. (E) Brown-Séquard syndrome is an uncommon
incomplete spinal cord syndrome. It is anatomically
a unilateral cord injury, such as a missile
injury. It is clinically characterized by a motor
deficit ipsilateral to the SCI in combination
with contralateral pain and temperature hypesthesia.
Almost all these patients show partial
recovery, and most regain bowel and bladder
function and the ability to ambulate.

242

577. Anticonvulsants are commonly used for the
treatment of neuropathic pain in the SCI patients.
Which of the following correctly describe(s) their
pharmacologic actions?
(1) Modulation of calcium channels
(2) Modulation of sodium channels
(3) Increase of GABA inhibition
(4) Blockade of reuptake of norepinephrine

577. (A) Anticonvulsants have several pharmacologic
actions, such as modulation of sodium
and calcium channels, increasing GABA inhibition,
and suppressing abnormal neuronal
hyperexcitability, which suggest an effect in
neuropathic pain

243

578. Which of the following is (are) the usual symptom(
s) of the autonomic dysreflexia?
(1) Dramatic rise in blood pressure
(2) Flushing and sweating in areas above
the SCI
(3) Marked reduction in peripheral blood
flow
(4) Decline in heart rate

578. (E) Patient with autonomic dysreflexia usually
exhibit decline in heart rate, dramatic changes
in blood pressure, flushing and sweating above
the level of the injury, and a marked reduction
on peripheral blood flow through the reflex
pathways in the preserved vagus nerves.

244

579. Heterotopic ossification (HO) is commonly seen
in patients with traumatic brain injury (TBI),
cerebral vascular accident, burns, trauma, total
joint arthroplasty, and SCI. Which of the following
is (are) true about HO in SCI patients?
(1) It is always painful
(2) Hip is the most commonly affected
(3) It is defined as ossification inside the
joint capsule
(4) Osteoclast inhibitors are use for both
treatment and prophylaxis of HO

579. (C) HO is the formation of mature, lamellar
bone in nonskeletal tissue, usually occurring
in soft tissue surrounding joints. The bone formation
in HO differs from other disorders of
calcium deposition in that HO results in encapsulated
bone between muscle planes, not intraarticular
or connected to periosteum.
In neurogenic HO secondary to TBI or
SCI, the hip is the most common joint affected.
Even though the most common symptom
of HO is pain, it may be painless in patients
with complete SCI.
Etidronate disodium, a bisphosphonate, is
an osteoclast inhibitor. It is structurally similar
to inorganic pyrophosphate and is shown
to delay the aggregation of apatite crystals
into large, calcified clusters in patients with
TBI and SCI. The recommended prophylactic
treatment for HO in SCI is 20 mg/kg/d for
2 weeks, then 10 mg/kg/d for 10 weeks. The
current treatment recommendation for established
HO is 300 mg IV daily for 3 days followed
by 20 mg/kg/d for 6 months in spinal
cord patients.

245

580. CRPS in the initial stages may be associated
with
(1) neurogenic inflammation
(2) higher local levels of tumor necrosis factor
alpha
(3) high systemic CGRP levels
(4) Increase in protein concentration in
fluid of affected joints

580. (E) Localized neurogenic inflammation may
explain the acute edema, vasodilation, and
sweating observed in early stages of CRPS.
Increased protein concentration and synovial
hypervascularization is observed in the intraarticular
fluid of affected joints. Findings that
support the role of neurogenic inflammation
in the generation of CRPS include elevated systemic
levels of CGRP and local increase of
IL-6 and tumor necrosis factor alpha in artificially
produced blisters.

246

581. Which of the following is true about motor
abnormalities in CRPS?
(1) Dystonia of the hand or affected foot
occurs in about 30% of the patients in
the acute stages
(2) Decrease active range of motion and
increase amplitude of physiological
tremor is seen in about 50% of the
patients
(3) They are likely related to an abnormal
peripheral process
(4) They may be explained by abnormalities
in the cerebral motor processing

581. (C) Up to 50% of CRPS patients show decrease
range of motion, increase amplitude of physiologic
tremor, and reduce active motor force,
with dystonia of the affected limb observed in
only 10% of the chronic cases. Those motor
changes are unlikely associated with a peripheral
process and more likely the result of
changes of activity in the motor neurons which
point to abnormalities of cerebral motor processing.

247

582. In terms of CRPS which of the following is (are)
true?
(1) Incidence of CRPS is 20% after brain
lesion
(2) Affected extremities after brain injury
are at higher risk of developing CRPS
than unaffected
(3) CRPS following SCI is frequent
(4) Upper extremities are more commonly
affected than lower extremities

582. (C) It is estimated that the risk of CRPS after
fractures is 1% to 2% and 12% after brain
lesions. Retrospective studies in large cohorts
shows a distribution in the upper and lower
extremity from 1:1 to 2:1. CRPS following SCI
are rare. Affected extremities after brain injury
are more likely affected than unaffected ones.

248

583. Which of the following is true regarding bone
scintigraphy?
(1) The three stages of the three-phase bone
scan include the perfusion, blood-pool,
and mineralization phases
(2) Homogeneous unilateral hyperperfusion
in the perfusion phase is consistent
with CRPS
(3) Homogeneous unilateral hyperperfusion
in the blood-pool phase is consistent
with CRPS
(4) Patients with CRPS show increase unilateral
periarticular trace uptake in the
mineralization phase

583. (E) The three stages of the three-phase bone scan
include the perfusion phase 30 seconds postinjection,
the blood-pool is 2 minutes postinjection,
and mineralization phases is evaluated
3 hours postinjection. Homogeneous unilateral
hyperperfusion in the perfusion and blood-pool
phase is consistent with CRPS and excludes the
differential diagnosis of osteoporosis because of
inactivity. The mineralization phase in patients
with CRPS shows elevated unilateral periarticular
uptake.

249

584. Which of the following is true regarding C fiber
impulses?
(1) After sensitization, antidromic impulses
to peripheral C fiber terminals release
vasoactive substance
(2) Neurally released substances trigger
neurogenic inflammation
(3) Neurogenic inflammation includes
axonal reflex, vasodilation, and plasma
extravasation
(4) C fiber activation peripherally releases
CGRP and substance P

584. (E)

250

585. The major peripheral pathologic finding(s) in
patients with CRPS is (are)
(1) patch atrophy of some muscle cells
(2) capillary microangiopathy
(3) Wallerian degeneration
(4) generalized osteopenia

585. (A) The major peripheral pathologic findings in
CRPS patients include (a) patchy atrophy of
some muscle cells, secondary to disuse and
nerve damage; (b) capillary microangiopathy,
with accelerated turnover of endothelial cells and pericytes; (c) Wallerian degeneration of
several types of axons; and (d) focal osteopenia
in the territory innervated by a damaged nerve,
and synovial cell disorganization and edema.

251

586. Which of the following is (are) true regarding
CRPS?
(1) Medical procedures are the second most
common cause of CRPS
(2) Decrease deep tendon reflexes are a
result of muscle atrophy
(3) Cutaneous dynamic mechanical
allodynia is a hallmark of central
sensitization
(4) Hypoesthesia may be rarely seen in
patients with CRPS

586. (B) Medical procedures are the second most
common cause of CRPS. The finding of exaggerated
deep tendon reflexes in CRPS patients
has been attributed to cortical disinhibition.
Focal deficit of touch (hypoesthesia) were present
in 50% of patients. Brushing skin activates
low threshold mechanoreceptors which under
normal circumstances has no connections with
central pain neurons. Brush evoked pain (cutaneous
dynamic mechanical allodynia)is a hallmark
of central sensitization.

252

587. Characteristics of CRPS I in pediatrics include
(1) CRPS I is more common in girls
(2) the lower extremity is more often
affected
(3) CRPS may have genetic predisposition
(4) CRPS is more common in Hispanics

587. (A) In contrast to CRPS II which has similar
frequencies in boys and girls, CRPS I is more
common in girls with a ratio of 4:1. The lower
extremity is more affected (5:1 ratio). CRPS I is
more common in Caucasians. There is also evidence
that CRPS may have a genetic predisposition,
with increase incidence in patients with
HLAA3, B7, and DR2.

253

588. Characteristics of CRPS II in pediatrics include
(1) the incidence is similar in boys and girls
(2) brachial plexus injury during delivery
commonly leads to chronic pain
(3) Erb palsy do not generally develop
CRPS
(4) patients with Erb palsy need a comprehensive
treatment to avoid the development
of CRPS II

588. (B) The gender distribution of CRPS II in the
pediatric population is roughly similar in
boys and girls. Even though patients with
brachial plexus injury during delivery (Erb
palsy) is common and can lead to prolonged
motor weakness, they rarely develop pain.
Interestingly most of these patients do better
without treatment.

254

589. To confirm the diagnosis of CRPS:
(1) There are no laboratory tests to confirm
the diagnosis
(2) Disturbed vascular scintigraphy is necessary
to make the diagnosis of CRPS
(3) Bone scan is nonspecific for the diagnosis
of CRPS
(4) There is no utility in ordering bone scan
in patients with CRPS

589. (B) The diagnosis of CRPS remains a clinical
decision based on findings in the history and
physical examination. There are no laboratory
tests that can absolutely confirm or exclude
the diagnosis. Although controversial, most
of the authors find that bone scans are quite
nonspecific for the diagnosis of CRPS. Patients
with a clinical diagnosis of CRPS may have
bone scans showing hypofixation or hyperfixation
or may be normal. The primary utility
of the bone scan could be in ruling out
some underlying orthopedic abnormality that
might be triggering neurovascular changes
that may confused the findings with those of
CRPS.

255

590. Which of the following is true regarding movement
disorders in CRPS patients?
(1) Motor dysfunction is the result of
voluntary defensive response to protect
the limb from painful stimuli
(2) Deep tendon reflexes in these patients
are normal to brisk
(3) Movement disorders often happen in
early stages of the disease
(4) Akinesia is a prominent finding in CRPS
patients

590. (C) Movement disorders are an essential feature
of patients with CRPS. Motor dysfunction
is not simply a voluntary defensive response
to protect the limb from painful stimuli, but
may represent the interaction of peripheral and
central mechanisms. Deep tendon reflexes are
often brisk. The prevalence of movement
disorders increases with the duration of the disease.
One characteristic form of these movement
disorders is the presence of inability to
start a movement (akinesia).

256

591. In terms of CRPS and dystonia, which is characterized
by involuntary contractions of one
or more muscles, it can be said that
(1) dystonia is a prominent feature of CRPS
(2) dystonia in patients with CRPS typically
presents with flexure postures
(3) tonic dystonia often spares the first two
digits
(4) extensor postures occur early in the
development of dystonia

591. (A) Dystonia in CRPS patients causes twisting
movements or abnormal postures of the
affected body parts. The most prominent motor
feature is flexor postures (tonic dystonia) of the
fingers, feet, and wrist. Extensor postures occur
but are rare.

257

592. Supraspinal regulatory mechanisms that may
explain some of the features of CRPS include
(1) spread of cortical representation of the
affected limb
(2) patients with generalized dystonia have
increased intracortical excitability to
sensory stimuli
(3) motor cortical disinhibition
(4) early increase activity of the thalamus
contralateral to the affected limb

592. (E) Supraspinal mechanisms play a major role
in the abnormal sensory perception of patients
with CRPS. Segmental dystonia is characterized
by spread of the cortical representation of
the affected extremity and its corresponding
synaptic connections to adjacent cortical areas.
On the other hand, generalized dystonia have
increased intracortical excitability to sensory
stimuli, and motor cortex disinhibition has
been confirmed in CRPS I. PET scan and SPET
have shown increased activity of the contralateral
thalamus in patients in early stages of
CRPS and hypoperfusion in advanced stages.

258

593. Which of the following is (are) myofascial
trigger point characteristic(s)?
(1) Weakness with muscle atrophy
(2) Referral of pain to a distant site upon
activation of the trigger point
(3) Range of motion not restricted
(4) Autonomic phenomenon, such as
piloerection or changes in local
circulation (regional blood flow and
limb temperature) in response to trigger
point activation

593. (C) Myofascial trigger point characteristics:
• Focal severe tenderness in a taut band of
muscle
• Referral of pain to a distant site upon activation
of the trigger point
• Contraction of the taut band (local twitch
response) upon mechanical activation of
the trigger point
• Reproduction of the pain by mechanical
activation of trigger point
• Restriction of range of motion
• Weakness without muscle atrophy
• Autonomic phenomenon such as piloerection
or changes in local circulation (regional
blood flow and limb temperature) in
response to trigger point activation
Individual features of the trigger point are
differentially represented in different muscles.
An examiner should not expect to find each
feature of the trigger point in every muscle by
physical examination.

259

594. The definitive goal of treatment of persons with
myofascial pain syndrome is (are)
(1) restoration of function through inactivation
of the trigger point
(2) restoration of normal tissue mobility
(3) relief of pain
(4) increased range of motion

594. (A) Inactivation of the trigger point is a means
to achieve pain relief, to improve biomechanical
function, and then to improve the ability of
the patient to better perform whatever tasks
have been selected as goals. Relief (not elimination)
of pain or increased range of motion,
both of which can be the result of trigger point
inactivation, are not in themselves the goals of
treatment.

260

595. Inactivation of the myofascial trigger point can
be accomplished
(1) manually
(2) by direct injection of a local anesthetic
into the muscle
(3) by dry needle intramuscular stimulation
of the myofascial trigger point
(4) by correcting structural mechanical
stressors

595. (E) While chronic myofascial pain syndrome
is best treated with a multidisciplinary team
approach including the patient, physicians,
psychologists, clinical social workers, occupational
therapists, physical therapists, ergonomists,
massage therapists, and others actively
involved in patient care; patients with acute
myofascial pain syndrome may only require
treatment by physicians and physical therapists.
Too frequently, patients with chronic
myofascial pain are started too soon on isotonic
training and conditioning, causing further
aggravation of active trigger points and an
increase in pain and dysfunction.
The acute treatment plan may be divided
into a pain-control phase and a training or conditioning
phase. During the pain-control phase,
the most essential component is inactivation of
the trigger point. Patients must change their
behaviors and avoid overstressing their muscles
without becoming excessively inactive. The
pain-control phase must have a definitive endpoint.
If patients do not move beyond the paincontrol
phase to the conditioning phase, patients
can be restricted in their functional abilities and
be at greater risk of reinjury. The training or
conditioning phase follows and it involves therapeutic
exercises, movement reeducation, and
overall conditioning

261

596. With regard to trigger point injections, botulinum
toxin which of the following is true?
(1) Has been tried unsuccessfully in
myofascial trigger point inactivation
(2) Can cause a flulike myalgia
(3) Occasionally causes weakness that is
confined to the area of injection
(4) Is a long-lasting trigger point injection
capable of about a 3 month inactivation
of the trigger point

596. (C) Botulinum toxin has been tried successfully
in myofascial trigger point inactivation; however,
it can cause a flu-like myalgia that lasts
days to a week and sporadically causes weakness beyond the area of injection. It functions as a
long-lasting trigger point injection that can provide
up to 3 months of relief in contrast to the
days to 1-week effect of traditional trigger point
injection with local or no anesthetic.

262

597. A 40-year-old female with chronic myofascial
neck pain wants to go to an acupuncturist. She
should know that
(1) in one study it was found that shallow
needling reduced the pain of chronic
myofascial neck pain
(2) in a randomized, double-blind, shamcontrolled
study, acupuncture was
found to be superior to dry needling in
improving range of motion
(3) in a randomized, double-blind, shamcontrolled
study, acupuncture was found
to be better than placebo when treating
trigger points in chronic neck pain
(4) in a randomized, double-blind, controlled
study, acupuncture was found to
be better than control only when it was
followed by transcutaneous electrical
stimulation

597. (A)
1. Japanese acupuncture or shallow needling
reduced the pain of chronic myofascial
neck pain in one study.
2. and 3. These have been found to be true.
4. While this study does not exist, a technique
of dry needling called intramuscular stimulation
does exist. It involves the insertion of
the needle into the taut band without necessarily
considering the actual trigger
point. It may be combined with electrical
stimulation delivered through the needle
(percutaneous electroneutral stimulation).

263

598. A 40-year-old woman comes to the pain clinic
for initial evaluation. After a thorough history
and physical examination, the patient is diagnosed
with fibromyalgia. Which symptom(s)
would support your diagnosis of fibromyalgia
as opposed to myofascial pain syndrome?
(1) Widespread pain
(2) Irritable bowel syndrome
(3) Distal paresthesias
(4) Occipital headaches

598. (E)

264

599. Which of the following is (are) true of
fibromyalgia?
(1) Adult women are twice as likely to be
affected as adult men
(2) Prevalence peaks in the fourth decade of
life
(3) Many children diagnosed with
fibromyalgia will have worsening of
their symptoms as they reach adulthood
(4) Affects all ethnic groups

599. (D) Fibromyalgia has been found among all
cultures throughout the world with an incidence
of 2% to 12% of the population. In adulthood,
women are affected four to seven times
as often as men. The frequency of fibromyalgia
increases with age and peaks in the seventh
decade of life. In childhood, boys and girls are
affected equally. In contrast to adults, children’s
symptoms may resolve with age.

265

600. Risk factors for the development of fibromyalgia
syndrome include
(1) physical trauma
(2) febrile illness
(3) family history of fibromyalgia
(4) history of sexual abuse

600. (A) Although research is ongoing, the development
of fibromyalgia appears to be increased
if the patient has had a febrile illness, a history
of physical trauma, or a family history of
fibromyalgia syndrome. Approximately onethird
of patients with fibromyalgia report that
another member of their family has previously
been diagnosed with fibromyalgia

266

601. Sleep disturbances are common in patients
with fibromyalgia. Difficulties the patient may
encounter include
(1) problems initiating sleep
(2) awakening in the middle of the night
(3) light, unrefreshing sleep
(4) difficulty napping throughout the day

601. (E) Greater than 90% of patients with fibromyalgia
suffer from chronic insomnia. Some patients
may have problems falling asleep. Other may
awaken a few hours after going to sleep and feel
alert, thus disrupting their sleep throughout the
remainder of the night. After a night of sleep,
patients with fibromyalgia may feel stiff, tired,
and “cognitively sluggish.” These patients also encounter difficulty napping throughout the
day. Patients with fibromyalgia have disrupted
sleep architecture with alpha wave intrusions in deep, delta wave sleep.

267

602. Pathophysiologically, fibromyalgia
(1) is a disorder of abnormal processing of
sensory information within the CNS
(2) exhibits a narrow array of recognized
objective physiological and biologic
abnormalities
(3) patients demonstrate abnormally low
regional cerebral blood flow in thalamic
nuclei and other pain-processing brain
structures that is inversely correlated
with spinal fluid substance P levels
(4) demonstrates abnormal spinal cord
windup

602. (E)
3. In fibromyalgia patients, CT has revealed
unusually low cerebral blood flow in the
thalamic nuclei, the left and right heads of
the caudate nucleus, and the cortex that
correlates with spinal fluid substance P
levels.
4. Windup is a frequency-dependent increase in
the excitability of spinal cord neurons, evoked
by electrical stimulation of afferent C fibers.
Glutamate (NMDA) and tachykinin NK1
receptors are required to generate windup
and therefore a positive modulation between
these two receptor types has been suggested.
Whatever the mechanisms involved in its
generation, windup has been interpreted as a
system for the amplification in the spinal
cord of the nociceptive message that arrives
from peripheral nociceptors connected to C
fibers. This probably reflects the physiological
system activated in the spinal cord after an
intense or persistent barrage of afferent
nociceptive impulses. On the other hand,
windup, central sensitization and hyperalgesia
are not the same phenomena, although
they may share common properties. Spinal
cord windup is abnormal in fibromyalgia
syndrome.
Physical trauma or a fever/infection may
be provisionally related to the onset of
fibromyalgia in over 60% of cases.

268

603. That same patient (who happens to be a neurobiology
graduate student) starts to ask about
the role that cytokines play in fibromyalgia.
You tell her that
(1) IL-8 has been found to be significantly
higher in the serum of fibromyalgia
patients, especially in depressed patients
(2) IL-6 was not found to be increased in
the blood of fibromyalgia patients
(3) the production of IL-8 in vitro is stimulated
by substance P
(4) cytokines do not play a role in the
pathogenesis of fibromyalgia

603. (B) The levels of serum IL-8 were higher in
fibromyalgia patients, and IL-6 was statistically
higher in cultures of fibromyalgia peripheral
blood mononuclear cells compared with in controls.
The IL-8 increase was most dramatic in
depressed patients, but there was also a correlation
with the duration of fibromyalgia and
the pain intensity. The production of IL-8 in
vitro is stimulated by substance P.

269

604. Which of the following medications are FDA
approved for the treatment of fibromyalgia?
(1) Cyclobenzaprine
(2) Duloxetine
(3) Tramadol
(4) Pregabalin

604. (D) Pregabalin has the potential to raise the
threshold for pain fiber depolarization. It is a ligand for the α2δ subunit of voltage-dependent
calcium channel receptors, which has analgesic,
anxiolytic-like, and anticonvulsant activity. It
decreases the release of numerous neuropeptides,
including noradrenaline, glutamate, and
substance P. It has already been approved for
treating partial seizures, pain following the
rash of shingles and pain associated with diabetes
nerve damage (diabetic neuropathy). Two
double-blind, controlled clinical trials, involving
about 1800 patients, support approval for
use in treating fibromyalgia with doses of 300
or 450 mg/d. It is effective in reducing the
severity of body pain, improving quality of
sleep, and reducing fatigue in fibromyalgia
patients. Pregabalin was approved by the FDA
for use in fibromyalgia patients on June 21,
2007.
The most common side effects of pregabalin
include mild to moderate dizziness and
sleepiness. Blurred vision, weight gain, dry
mouth, and swelling of the hands and feet
also were reported in clinical trials. The side
effects appeared to be dose-related. Pregabalin
can impair motor function and cause problems
with concentration and attention. The
FDA advises that patients talk to their doctor
or other health care professional about whether
use of pregabalin may impair their ability to
drive.
1. Cyclobenzaprine, have been used in the
past with success in fibromyalgia patients,
they have not been approved by the FDA.
2. Duloxetine is an FDA-approved treatment for
major depression, neuropathic pain from diabetic
peripheral neuropathy, and generalized
anxiety disorder. The drug is a serotonin and
norepinephrine reuptake inhibitor that
exhibits nearly equal serotonin and noradrenaline
reuptake inhibition. Atrial of duloxetine
for patients with chronic pain and/or major
depression indicated that for the fibromyalgia
patients, 80% of the observed effect on pain is
a direct analgesic effect rather than an indirect
antidepressant effect. Common adverse
events were: nausea, headache, dry mouth,
insomnia, constipation, dizziness, fatigue,
somnolence, diarrhea, and hyperhidrosis.
Two placebo-controlled randomized studies
on the treatment of fibromyalgia-associated
pain with duloxetine have been published.
Both studies demonstrated that duloxetine
treatment improved fibromyalgia-associated
pain in women. However, the medication
has not yet been approved for the treatment
of fibromyalgia. Another type of serotonin
and noradrenaline reuptake inhibitor is represented
by milnacipran, where noradrenaline
reuptake inhibition is favored over that
of serotonin. Some reports state that milnacipran
may also be effective in treating
fibromyalgia body pain.
3. Tramadol has only recently been shown to
improve the pain of patients with fibromyalgia.
It combines weak μ-agonist with
NMDA antagonist and noradrenaline and
serotonin reuptake inhibition. In the combination
preparation that comes with acetaminophen,
a considerable synergy has been
noticed. Nausea and dizziness can be limiting
at first in about 20% of patients, but starting
with just one tablet at bedtime for 1 to
2 weeks can decrease the prevalence and
allow later increases but about one tablet
every 4 days to full therapeutic levels. Atypical
tramadol regimen for fibromyalgia is
300 to 400 mg/d in three or four divided
dosages, concomitant with acetaminophen
at 2 to 3 g/d in divided doses.
Administering 5-hydroxytryptophan can
augment the synthesis of serotonin. Onehundred
milligrams, orally, three times daily
has been shown to be an effective dose in
treating fibromyalgia.

270

605. The pain in fibromyalgia is, at least in part,
mediated by central sensitization. Studies have
shown that
(1) dextromethorphan and ketamine may
improve pain and allodynia in
fibromyalgia patients
(2) the majority of patients with fibromyalgia
that tried ketamine benefited
(3) ketamine’s efficacy was limited because
of its side effects
(4) dextromethorphan had a similar sideeffect
profile

605. (B) Central sensitization can be inhibited by
NMDAreceptor blockade. Two NMDA receptor
antagonists, ketamine and dextromethorphan
(an oral preparation) have been found to
exhibit favorable effects on pain and allodynia
in fibromyalgia patients. With ketamine, 50% of
patients benefited. Fibromyalgia subgroups of
responders and nonresponders were perpetuated
by these findings because all the
fibromyalgia patients in the study were otherwise
comparable. Ketamine’s effectiveness was
limited because of its frequently occurring
psychotropic side effects, such as feelings of unreality, altered body image perception,
aggression, anxiety, nausea, dizziness, and
modulation of hearing and vision.
Dextromethorphan has a better side-effect
profile than ketamine. It was administered
with tramadol to increase the antinociceptive
effect, to hold adverse effects low, and to
decrease the development of opioid tolerance.
A good response was obtained in 58% of the
fibromyalgia patients who tried this regimen.
It may be a consideration for the patients who
respond positively to IV ketamine.