Pain Medicine Specialty Board Review
Terms in this set (32)
1. Nutrition to the lumbar intervertebral disc is
(A) posterior spinal artery
(B) internal iliac artery
(C) lumbar artery
(D) anterior spinal artery
(E) abdominal aorta
(C) The lumbar arteries supply the vertebrae
at various levels. Each lumbar artery passes
posteriorly around the related vertebra and
supplies branches into the vertebral body. The
terminal branches form a plexus of capillaries
below each endplate. The disc is a relatively
avascular structure. Nutrition to the disc is by
diffusion from the endplate capillaries and
blood vessels in the outer annulus fibrosus.
Passive diffusion of fluids into the proteoglycan
matrix is further enhanced by repeated
compression of the disc by repeated flexionextension
of the spine associated with activities
of daily living which pumps fluid in and out
of the disc. The abdominal aorta does not
provide any direct blood supply to the intervertebral
What is the most common cervical disc herniation?
C6 & C7
4. The usual site of herniation of a cervical
intervertebral disc is
C) The uncinate processes are bony protrusions
located laterally from the C3 to C7 vertebrae.
They prevent the disc from herniating laterally.
The posterior longitudinal ligament is the thickest
in the cervical region. It is four to five times
thicker than in the thoracic or lumbar region.
The nucleus pulposus in the cervical disc is present
at birth but by the age of 40 years it practically
disappears. The adult disc is desiccated
and ligamentous. It is mainly composed of fibrocartilage and hyaline cartilage. After the age of 40 years, a herniated cervical disc is never seen
because there is no nucleus pulposus. The most
common cervical herniated nucleus pulposus
(HNP) occurs at C6 to C7 (50%) and is followed
by C5 to C6 (30%).
6. The stellate ganglion is located
(A) anterior to the transverse process of the
(B) posterior to the subclavian artery
(C) anterior to the transverse process of the
(D) anterior to the neck of the first rib and
the transverse process of the C7 vertebra
(E) anterior to the transverse process of the
first thoracic vertbra
D) The stellate ganglion is the inferior cervical
ganglion. The cervicothoracic ganglion is frequently
formed by the fusion of the inferior cervical
ganglion and the first thoracic ganglion. It is
located anteriorly on the neck of the first rib and
the transverse process of the C7 vertebra. It is
oval in shape and 1" long by 0.5" wide. The ganglion
is bound anteriorly by the subclavian artery,
posteriorly by the prevertebral fascia and the
transverse process, medially by the longus colli
muscle, and laterally by the scalene muscle. The
classical stellate ganglion block is done one level
above the location of the stellate ganglion (it lies
at the C7 level and the block is done at the C6
level). Typically the classical stellate ganglion
block is performed with the patient supine, however,
immediately after the block the patient is
repositioned to a sitting position. The vertebral
artery travels anteriorly over the stellate ganglion
at C7 but at C6 the artery moves posteriorly.
Incidence of phrenic nerve block is almost 100%.
Absolute central lumbar spinal stenosis is defined as (A) less than 8 mm diameter (B) less than 10 mm diameter (C) less than 12 mm diameter (D) pain at rest (E) pain with ambulation
B) The spinal canal is nearly round in shape; it is 12 mm or more in the anteroposterior diameter. Relative stenosis is defined as midline sagittal diameter of < 12 mm. The reserve capacity is reduced and any small disc herniation and mild degenerative changes may cause symptoms. Absolute stenosis is defined as a sagittal diameter < 10 mm.
15. The principal action of the quadratus lumborum muscle is (A) lateral flexion of the lumbar spine (B) axial rotation of the lumbar spine (C) extension of the lumbar spine D) fixation of the 12th rib during respiration (E) forward flexion of the lumbar spine
D) The principal action of the quadratus lumborum (QL) muscle is to fix the 12th rib during respiration. It is a weak lateral flexor of the lumbar spine. The QL is a flat rectangular muscle that arises below from the iliolumbar ligament and the adjacent iliac crest. The insertion is into the lower border of the 12th rib and the transverse processes of the upper four lumbar vertebrae. Patients with spasm of the QL muscle usually present with low back pain. They have difficulty turning over in bed, increased pain with standing upright. Coughing or sneezing may exacerbate their pain. These patients respond well to trigger point injections and stretching.
16. The following structure passes under the inguinal ligament: (A) Inferior epigastric artery (B) Lateral femoral cutaneous nerve (C) Obturator nerve (D) Intra-articular nerve of the hip joint (E) Sciatic nerve
B) The structures that pass under the inguinal ligament, medial to lateral are: femoral vein, femoral artery, inguinal nerve, femoral nerve, and lateral femoral cutaneous nerve. The following muscles also pass under the inguinal ligament: pectineus, psoas major, iliacus. The inferior epigastric artery passes under the rectus sheath. The obturator nerve passes through the obturator foramen. The sciatic nerve is located posteriorly.
19. In the dorsal horn of the spinal cord: (A) Cells from lamina I and II project to the hypothalamus (B) Stimulation of lamina I and II produces pain (C) Lamina I and II are found in the thoracic segment of the spinal cord only (D) Discharge from lamina I and II decreases as a noxious stimulus increases (E) Wide dynamic range (WDR) neurons are located predominantly in lamina I and II
B) The Rexed laminae is a complex of 10 layers of grey matter located in the spinal cord. They are labeled as I to X. Laminae I to VI are in the dorsal horn and VII to IX are in the ventral horn. Lamina X borders the central canal of the spinal cord. Lamina I is also known as the posteromarginal nucleus. The neurons in lamina I receive input mainly from Lissauer tract. They relay pain and temperature sensation. Lamina II is known as substantia gelatinosa. The neurons contain μ- and κ-opioid receptors. C fibers terminate in the substantia gelatinosa. Lamina I and II are found along the entire spinal cord. The neurons in lamina I project to the thalamus. WDR neurons are concentrated in lamina V.
57. There are several subtypes of N-methyl-Daspartate
(NMDA) receptors. They are
(A) NR1, NR2 (A, B, and C)
(B) NR1, NR2 (A, B, C, and D)
(C) NR1, NR2 (A, B, and C), and NR3
(A and B)
(D) NR1, NR2 (A, B, C, and D), and NR3
(A and B)
(E) NR1, NR2 (A, B, C, and D), NR3
(A and B), and NR4 (A and B)
(B) There is accumulating evidence to implicate
the importance of NMDA receptors to the
induction and maintenance of central sensitization
during pain states. However, NMDA
receptors may also mediate peripheral sensitization and visceral pain. NMDA receptors are composed of NR1, NR2 (A, B, C, and D), and
NR3 (A and B) subunits, which determine the
functional properties of native NMDA receptors.
Among NMDA receptor subtypes, the
NR2B subunit- containing receptors appear particularly important for nociception, thus leading to the possibility that NR2B-selective antagonists
may be useful in the treatment of chronic pain.
21. Neuropraxia is
(A) anatomical disruption of a nerve
(B) loss of conduction of a nerve
(C) pain due to peripheral nerve injury
(D) muscle tremor
(E) increased conduction of a nerve
(B) Neuropraxia is a nerve damage without any
disruption of the myelin sheath. There is an
interruption in conduction of nerve impulses.
There is a transient loss of motor conduction.
Little to no sensory conduction is affected. This
is a common sports injury.
22. The following are true about pain, EXCEPT
(A) transmitted faster through C fibers
(B) some pain may travel through the
(C) μ-receptors when stimulated in the
brain produce analgesia
(D) intractable pain due to cancer cannot be
effectively treated by hypophysectomy
(E) transmitted slower through C fibers
22. (A) C-fibers are unmyelinated and hence have
a slow conduction velocity ( 2 m/s). All sensory
transmission takes place through the dorsal
column. Hypophysectomy can be performed for
23. A-δ fibers:
(A) Are unmyelinated
(B) Are low-threshold mechanoreceptors
(C) Increase their firing as the intensity of
the stimulus increases
(D) Do not respond to noxious stimuli
(E) Are thick nerves
23. (C) A-δ fibers are thin, myelinated fibers, hence
have a faster conduction velocity than C fibers.
They are high threshold mechanoreceptors.
They are associated with sharp pain, temperature,
cold, and pressure sensations
39. The principal action of the piriformis muscle is
(A) lateral flexion of the hip
(B) external rotation of the femur
(C) extension of the hip
(D) internal rotation of the femur
(E) knee flexion
39. (B) The piriformis muscle rotates the extended
thigh externally and abducts the flexed thigh. It
does not cause flexion of the knee, extension of
the thigh, lateal flexion of the thigh. Aspasm of
the piriformis muscle may present as buttock
pain. The piriformis muscle can be tested clinically
by asking the subject to abduct the thigh
58. Sodium channels are also important in neurotransmission
through the dorsal root ganglion
(DRG). How many different types of sodium
channels have been identified?
E) Voltage-gated sodium channels underlie
the electrical excitability demonstrated by
mammalian nerve and muscle. Nine voltagegated
sodium channels are expressed in complex
patterns in mammalian nerve and muscle.
Six have been identified in the DRG. Three
channels, Nav1.7, Nav1.8, and Nav1.9, are
expressed selectively in peripheral damagesensing
neurons. Nav1.8 seems to play a specialized
role in pain pathways.
59. Ziconotide, found in snail venom, acts primarily
on which type of calcium channel?
A) The nonopioid analgesic ziconotide has been
developed as a new treatment for patients with
severe chronic pain who are intolerant of and/or
refractory to other analgesic therapies. Ziconotide
is the synthetic equivalent of a 25-amino-acid
polybasic peptide found in the venom of the
marine snail Conus magus. In rodents, ziconotide
acts by binding to neuronal N-type voltagesensitive
calcium channels, thereby blocking
neurotransmission from primary nociceptive
afferents. Ziconotide produces potent antinociceptive
effects in animal models and its efficacy
has been demonstrated in human studies.
60. Pretreatment with an NMDA antagonist prior
to inflammation has been shown to
(A) enhance central sensitization
(B) attenuate central sensitization
(C) have no effect on central sensitization
(D) enhance peripheral sensitization
(E) attenuate peripheral sensitization
(B) Pre-treatment with an NMDA antagonist
attenuates the central sensitization from inflammation.
61. NMDA receptor channels are usually inactive
and blocked by zinc and magnesium ions.
Adepolarization of the cell membrane removes
these ions and allows influx of which ions?
(D) Sodium and calcium
(E) Sodium and chloride
(C) NMDA receptor ion channel has binding
sites for zinc, magnesium, and phencyclidine,
which are inhibitory. A depolarization causes
removal of zinc and magnesium allowing
largely calcium and to much lesser extent
sodium ions to influx, initiating intracellular
62. Nociceptive stimuli cause increased activity in
the cerebral cortex in
(A) a focal area around the central gyrus
(B) widespread areas in the temporal cortex
(C) a focal area around the posterior cortical
(D) widespread areas in the frontal cortex
(E) a focal area in the thalamus
(B) Noxious stimuli cause widespread activation
of cortical area. Increasing stimulus intensity
activates increasing number of areas within
the cortex. Other areas of the brain are not
involved in the interpretation of the noxious
68. Which of the following induce pain in hollow
2&4, Hollow viscera are insensitive to normally
noxious stimuli that elicit pain in other somatic
structures. However certain stimuli like ischemia,
necrosis, inflammation, distension, and compression
do elicit painful response from a viscus
69. Viscera are supplied by sympathetic nerves
which contribute to pain generation and transmission.
They release several chemical substances
including the following:
1,2,3 In the viscera, sympathetic nerve terminals,
mast cells, and epithelial cells, including
enterochromaffin cells in the gastrointestinal
tract, release a variety of bioactive substances,including noradrenaline, histamine, serotonin, adenosine triphosphate (ATP), glutamate, NGF, and tryptase. Resident leukocytes and macrophages attracted to an area of insult collectively contribute products of cyclooxygenase and lipoxygenase, including prostaglandin I2, prostaglandin E2, hydroxyeicosatetraenoic acids
(HETEs), and hydroperoxyeicosatetraenoic
(HPETEs), and a variety of cytokines, reactive
oxygen species, and growth factors. Some of
these chemicals can directly activate visceral
afferent terminals (eg, serotonin, ATP, and glutamate), whereas others probably play only a
sensitizing role (eg, prostaglandins, nerve
growth factor, and tryptase).
These are some of the excitatory neurotransmitters:
71. 1\3 Glutamate and aspartate are the main excitatory neurotransmitters, whereas GABA and
glycine are inhibitory neurotransmitters.
72. NMDA receptor blockade in the spinal cord
(1) inhibition of pain transmission
(2) modulation of pain transmission
(3) reduction in pain transmission
(4) does not have a role in pain transmission
1&3 NMDAreceptor activation causes increased
pain transmission whereas its blockade attenuates
pain transmission. There are four receptor
types for glutamate and aspartate in the
somatosensory system. The class of receptors
best activated by NMDA is termed the NMDA
receptor. The NMDAreceptor is usually considered
as recruited only by intense and/or prolonged
somatosensory stimuli. This characteristic
is due to the NMDAreceptor's well-known magnesiumblock that is only relieved by prolonged depolarization of the cell membrane.
73. The subunit most relevant in nociception is
2&4 NMDA receptors are critically involved in
the induction and maintenance of neuronal
hyperexcitability after noxious events. Until recently, only central NMDA receptors were a
primary focus of investigations. With the recognition
of peripheral somatic and visceral
NMDA receptors, it is now apparent that the
role of NMDA receptors in pain is much greater
than thought previously. Over the past decade,
accumulating evidence has suggested that the
NR2B subunit of NMDA receptor is particularly
important for pain perception. Given the small
side-effect profile and good efficacy of NR2Bselective
compounds, it is conceivable that
NR2B-selective blockade will emerge as a
viable strategy for pharmacological treatment
78. Windup is a phenomenon that occurs due to
constant input of C-fiber activity to the spinal
cord. This phenomenon defines
(1) reduction in excitability of spinal neurons
in the DRG
(2) increase in excitability of spinal neurons
in the DRG
(3) reduction in excitability of spinal neurons
in the dorsal horn
(4) increase in excitability of spinal neurons
in the dorsal horn
Windup refers to the progressive increase
in the magnitude of C-fiber evoked responses
of dorsal horn neurons produced by repetitive
activation of C-fibers. Neuronal events leading
to windup also produce some of the classical
characteristics of central sensitization including
expansion of receptive fields and enhanced
responses to C but not A δ-fiber stimulation.
79. Primary inhibitory neurotransmitters include
Primary inhibitory neurotransmitters of the
somatosensory system include the amino acids
glycine and GABA. Glycine is particularly
important at spinal levels, while GABA is the
chief inhibitory transmitter at higher levels.
Three types of GABA receptors have been identified.
GABAA receptor is linked with a chloride
channel and modulated by barbiturates, benzodiazepines,
and alcohol. Selective GABAA
agonists include muscimol and selective antagonists
include gabazine. The GABAB receptor has
been associated with both a potassium ionophore
and G protein-linked complex. Baclofen is a selective
GABAB receptor agonist and phaclofen is a
selective antagonist. Finally the newly described
GABAC receptor has also been described as associated
with a potassium channel ionophore.
Glutamate and aspartate are excitatory neurotransmitters.
Excitatory neuropeptides in the CNS include
(1) Substance P
(3) Neurokinin A
The excitatory neuropeptides in the somatosensory
system include substance P and neurokinin A.
These peptides are especially concentrated in primary
afferent fibers but also present in intrinsic
neurons of the spinal dorsal horn and thalamus.
The inhibitory neuropeptides at spinal levels
include somatostatin, the enkephalins, and possibly
dynorphin. These peptides are contained in
both intrinsic neurons of the dorsal horn and in
the fibers descending to the dorsal horn from various
81. Serotonin is released as mediator as a result of
tissue injury from which of the following?
(2) Muscle cells
(3) Mast cells
(4) White blood cells
81. (1/3) Serotonin is one of many mediators that are
released from platelets (rats and humans) and
mast cells (rats) in injured and inflamed tissues.
In situ hybridization, studies have shown that
DRG neurons normally express mRNA for
5-HT1B, 5-HT1D, 5-HT2A, 5-HT2B, 5-HT3B, and
5-HT4 receptors. Many of the excitatory actions
of serotonin have been ascribed to the ligandgated
5-HT3 receptor, but there is good evidence
that serotonin can activate and sensitize nociceptors
by actions on G protein-coupled receptors.
5-HT2 receptors are expressed largely
in (calcitonin gene-related peptide) CGRPcontaining,
small-diameter sensory neurons,
and their activation produces thermal hyperalgesia.
5-HT2 receptors are usually linked to
the phospholipase C pathway. Activation of
5-HT2 receptors depolarizes capsaicin-sensitive
DRG neurons by reducing a resting potassium
potential, and such an effect could contribute to
both excitation and sensitization.
82. Protease-activated receptors (PAR) were detected
in which of the following?
(2) Endothelial cells
(4) Nervous system
Four types of G protein-coupled PARs have
been identified (PAR1-PAR4). These receptors
are activated by a unique mechanism whereby
extracellular, soluble, or surface-associated proteases cleave at specific residues in the extracellular N-terminal domain of the G protein to
expose a novel N-terminal sequence, which
acts as a tethered ligand that activates the
receptor by binding to other regions of the protein. These agonist effects can be mimicked by
short synthetic peptides based on the sequence
of the tethered ligands of the different PARs.
PAR1, PAR2, and PAR4 are activated by thrombin
produced during the blood-clotting cascade,
while PAR3 activation is triggered by
tryptase, which is known to be released from
mast cells in inflammatory conditions, as well
as the blood-clotting factors VIIa and Xa. In
this way, PARs are activated as a result of tissue
damage and inflammation. Because activation
involves an irreversible enzymatic cleavage,
restoration of PAR sensitivity requires internalization of the receptors and insertion of new receptor into the plasma membrane. PARs were initially detected in platelets, endothelial cells, and fibroblasts, but are now known to also be expressed in the nervous system. PAR1 and
PAR2 are expressed on peripheral sensory neurons. PAR2 is expressed in about 60% of rat
DRG neurons, where it is found mainly in the small to medium-sized neurons, with a significant
number coexpressing substance P and
83. Increased nerve growth factor (NGF) levels
observed after inflammatory stimuli result
from increased synthesis and release of NGF
from cells in the affected tissue. Large number
of stimuli can alter NGF production including:
(1) 2IL-1β, IL-4, IL-5
(2) Tumor necrosis factor α (TNF-α), transforming
growth factor β (TGF-β)
(3) Platelet-derived growth factor
(4) Epidermal growth factor
(all are correct) NGF levels increase during inflammation.
NGF is a critical mediator of inflammatory pain.
NGF clearly has a powerful neuroprotective
effect on small-diameter sensory neurons, and
NGF levels have been shown to change in a
number of models of nerve injury. However, its
exact role in the development of neuropathic
pain is at present unclear. Blocking NGF bioactivity
(either systemically or locally) largely
blocks the effects of inflammation on sensory
nerve function. Elevated NGF levels have been
found in a variety of inflammatory states in
humans, including in the bladder of patients
with cystitis, and there are increased levels in
synovial fluid from patients with arthritis.
84. Endogenous opioid peptides are important in
nociceptive perception and modulation. These
include which of the following?
all are correct. The contribution of endogenous opioid
peptides to pain modulation was first suggested
by reports that stimulation-produced
analgesia in animals and humans is reduced by
the narcotic antagonist naloxone. Naloxone
also worsens postoperative pain in patients
who have not received exogenous opioid therapy,
thus establishing the relevance of endogenous
opioids to common clinical situations.
Peptide transmitters and hormones are derived
by the cleavage of larger, usually inactive,
precursor. Met- and leu-enkephalin are derived
from a common precursor, preproenkephalin,
each molecule of which generates multiple
copies of met-enkephalin and one of leuenkephalin.
β-Endorphin is cleaved from a
larger precursor protein, proopiomelanocortin,
which also gives rise to adrenocorticotrophic
hormone and several copies of melanocytestimulating
hormone. Two copies of dynorphin
(A and B) and α-neoendorphin are generated
from a third endogenous opioid precursor molecule
85. Nociceptors are specific receptors within the
superficial layers of the skin.
(B) Nociceptors are free nerve endings and do
not have any specific receptors, but are activated
by a tissue injury due to mechanical,
thermal, or chemical stimuli
91. Common causes of acute abdominal pain in
(A) intussusception in an adolescent patient
(B) abdominal aortic aneurysm in an adult
population, which most likely presents
with excruciating abdominal pain
(C) diabetic ketoacidosis in an elderly
patient without a previous history of
(D) drug-induced pain from polypharmacy
that is rarely a cause of abdominal pain
in the elderly
(E) interstitial cystitis
(C) Diabetic ketoacidosis needs to be ruled out (in
addition to myocardial infarction, pneumonia,
pyelonephritis, and inflammatory bowel disease)
as a cause of abdominal pain. The most common
cause of abdominal pain in infants is intussusception.
Although abdominal aortic aneurysms,
which are a manifestation of atherosclerosis, do
occur in an adult population, they usually do not
present with specific clinical symptom of abdominal
pain. Finally, drug-related abdominal pain is
very common in the elderly.
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