Acute and Chronic Pain
Questions
DIRECTIONS (Questions 531-600): Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each case.
531. 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
532. In a patient with skeletal metastases, bisphos-phonates have all of the following effects EXCEPT
(A) inhibiting the recruitment and function of osteoclasts
(B) inhibition of osteoblasts
(C) they have their greatest effect in breast cancer and multiple myeloma
(D) they have an acute pain-relieving effect
533. 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
534. Which one of the following is true regarding seizures as one of the multiple side effects from the use of opioids?
(A) Morphine and related opioids can cause seizure activity when moderate doses are given.
(B) Seizure activity is more likely with meperidine, especially in the elderly and with renal dysfunction.
(C) Seizure activity is mediated through stimulation of N-methyl-D-aspartate (NMDA) receptors.
(D) Naloxone is very effective in treating seizures produced by morphine and related drugs including meperidine.
(E) Seizure activity is most likely related to the fact that opioids stimulate the production of γ-aminobutyric acid (GABA).
535. Windup is a phenomenon that occurs due to constant input of C-fiber activity to the spinal cord. This phenomenon defines
(A) reduction in excitability of spinal neurons in the dorsal root ganglion
(B) increase in excitability of spinal neurons in the dorsal root ganglion
(C) reduction in excitability of spinal neurons in the dorsal horn
(D) increase in excitability of spinal neurons in the dorsal horn
536. The cricoid cartilage corresponds with which vertebra?
(A) C1
(B) C3
(C) C5
(D) C6
(E) C8
537. The lumbar facet joints are oriented
(A) in a coronal plane
(B) in a sagittal plane
(C) 45° off the sagittal plane
(D) 20° off the coronal plane
(E) 20° off the sagittal plane
538. Vertebroplasty is indicated for all of the following conditions EXCEPT
(A) multiple myeloma
(B) chronic compression fractures of vertebral body
(C) osteolytic metastatic tumors
(D) facet arthropathy
539. Ziconotide, found in snail venom, acts primarily on which type of calcium channel?
(A) N-type
(B) T-type
(C) L-type
(D) P-type
(E) Q-type
540. Viscera are supplied by sympathetic nerves that contribute to pain generation and transmission. These nerves release all of the following chemical substances EXCEPT
(A) norepinephrine
(B) histamine
(C) serotonin
(D) epinephrine
541. 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
542. Indications for lumbar sympathetic blockade include all of the following EXCEPT
(A) acute herpes zoster
(B) phantom limb pain
(C) complex regional pain syndrome
(D) lumbar facet syndrome
(E) vascular insufficiency
543. NMDA receptor blockade in the spinal cord
(A) causes inhibition of pain modulation
(B) causes modulation of pain transmission
(C) does not have a role in pain transmission
(D) causes reduction in pain transmission
544. One important characteristic of methadone that has to be considered when prescribing it on an outpatient basis is
(A) there is usually a low chance for interactions on patients taking multiple medications
(B) withdrawal symptoms are as severe as with morphine
(C) it is rarely used in opioid addiction
(D) sedation and respiratory depression can outlast the analgesic action
(E) it allows rapid titration
545. With the use of intrapleural catheters for postoperative pain, all of the following statements are true EXCEPT
(A) the use of parenteral opioids is contraindicated
(B) pneumothorax can occur
(C) the usual dose is 20 to 30 mL 0.5% bupivacaine
(D) the mechanism of action is “unilateral intercostal nerve block”
546. A 35-year-old woman comes to your clinic complaining of pelvic pain. Which one of the following is important to consider during her evaluation?
(A) Endometriosis is the most common cause of pelvic pain in women.
(B) Endometriosis most likely does not have an inflammatory component.
(C) Endometriosis has been shown to be primarily dependent on the blood concentration of progesterone.
(D) An inflammatory process would be supported by findings of a decrease of interleukin-8 in testing of peritoneal fluid.
547. Which one of the following statements regarding fibromyalgia is true?
(A) Two central criteria for fibromyalgia are chronic widespread pain (CWP) defined as pain in all four quadrants of the body and the axial skeleton for at least two years, and the finding of pain by 25-kg pressure on digital palpation of at least 11 of the 18 defined tender points.
(B) It is generally agreed that abnormal CNS mechanisms are responsible for all of the symptoms of fibromyalgia.
(C) There are both primary and secondary fibromyalgia syndromes.
(D) Fibromyalgia symptoms generally resolve if a rheumatic process is identified and treated appropriately.
(E) Most fibromyalgia patients are male.
548. A recommended practice in the management of patients with cancer pain is
(A) less concern regarding side effects than in patients with nonmalignant pain
(B) dosing analgesics only on an as needed basis
(C) considering the use of adjuvant drugs
(D) avoiding opioid drugs due to the potential for development of tolerance
549. An 85-year-old woman comes into your clinic with chronic pain over her left breast for more than 1 year. The symptoms began after she broke out in a rash in the same distribution. Which one of the following statements is true?
(A) Zoster reactivation is always accompanied by a rash.
(B) Zoster reactivation may occur two to three times in a healthy individual.
(C) Post herpetic neuralgia (PHN) is pain that persists for more than 120 days.
(D) The incidence of PHN is expected to remain stable in the future.
(E) PHN should be treated with an antiviral agent like ganciclovir.
550. A 10-year-old boy with a diagnosis of sickle cell disease comes into your clinic. Which one of the following statements is true regarding his condition?
(A) A vaso-occlusive crisis commonly involves the back, legs, and eyes.
(B) Acute pain in patients with sickle cell disease is caused by ischemic tissue injury resulting from the occlusion of macrovascular beds by sickled erythrocytes during an acute crisis.
(C) When a vaso-occlusive crisis lasts longer than 7 days, it is important to search for other causes of bone pain.
(D) Patients with sickle cell disease have a lower incidence of vaso-occlusive disease than patients with β-thalassemia.
551. Complex regional pain syndrome type II (CRPS II) differs from CRPS I because in CRPS II there is
(A) allodynia
(B) movement disorder
(C) sudomotor and vasomotor changes
(D) evidence of major nerve damage
(E) severe swelling
552. What is the primary mechanism by which opioids produce analgesia?
(A) Coupling of opioid receptors to sodium and potassium ion channels, thereby inhibiting neurotransmitter release (pre-synaptic), and inhibiting neuronal firing (postsynaptically)
(B) Coupling of opioid receptor to potassium and calcium channels, thereby inhibiting neurotransmitter release (presynaptic), and inhibiting neuronal firing (postsynaptically)
(C) Coupling of opioid receptors to sodium and calcium channels, thereby inhibiting neurotransmitter release (presynaptic), and inhibiting neuronal firing (postsynaptically)
(D) Coupling of opioid receptors to potassium and calcium channels, thereby inhibiting neuronal firing (presynaptically), and inhibiting neurotransmitter release (postsynaptically)
(E) Coupling of opioid receptors to sodium and calcium channels, thereby inhibiting neuronal firing (presynaptically), and inhibiting neurotransmitter release (postsynaptically)
553. The definition of pain that is endorsed by the International Association for the Study of Pain is, “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” There are a host of physiologic mechanisms by which injuries lead to nociceptive responses and ultimately to pain. However, not all nociceptive signals are perceived as pain and not every pain sensation originates from nociception. All of the following statements regarding pain are true EXCEPT
(A) two types of pain receptors are primarily activated by nociceptive input. These include low-threshold nociceptors that are connected to fast pain-conducting A-δ fibers, and high-threshold nociceptors that conduct impulses in slow (unmyelinated) C fibers
(B) neurotransmitters (e.g., glutamate and substance P) are able to modulate postsynaptic responses with further transmission to supraspinal sites (thalamus, anterior cingulate cortex, insular cortex, and somatosensory cortex) via ascending pathways
(C) prolonged or strong activity of dorsal horn neurons caused by repeated or sustained noxious stimulation may subsequently lead to increased neuronal responsiveness or central sensitization
(D) windup refers to a mechanism present in the peripheral nervous system in which repetitive noxious stimulation results in a slow temporal summation that is experienced in humans as increased pain
(E) substance P is an important nociceptive neurotransmitter. It lowers the threshold of synaptic excitability, resulting in the unmasking of normally silent interspinal synapses and the sensitization of second-order spinal neurons
554. A 32-year-old female develops severe stabbing, “like an ice pick,” pain at the base of tongue after an infratemporal neurosurgical procedure. Pain comes in paroxysms and last a few seconds and is triggered by swallowing, yawning, and coughing. This patient most likely has
(A) trigeminal neuralgia
(B) geniculate neuralgia
(C) glossopharyngeal neuralgia
(D) migraine with atypical aura
(E) cluster headache
555. An advantage of transcutaneous electrical nerve stimulation (TENS) for postoperative pain is
(A) no patient instruction is needed
(B) the absence of opioid-induced side effects
(C) it can be used by patients with pacemakers
(D) it does not require any action on the part of the patient
556. A 31-year-old woman presents to your office with marked pain and swelling in her ankle 6 weeks after an open reduction and internal fixation with casting. On examination, the ankle is warm and erythematous. Lightly touching the ankle with a cotton swab evokes severe, lancinating pain. You suspect CRPS I. As a syndrome, CRPS is diagnosed by
(A) lumbar sympathetic block
(B) phentolamine infusion test
(C) triple phase isotope bone scan
(D) erythrocyte sedimentation rate
(E) history and physical examination
557. Which one of the following statements concerning central pain is true?
(A) Spinal cord injury is the leading cause of central pain in the United States.
(B) Lesions involving spinothalamocortical pathways are necessary and sufficient to cause central pain.
(C) Central pain is a common sequela following neurosurgical procedures.
(D) Motor cortex stimulation is an effective means to treat central pain.
(E) The most typical presentation of central pain is a spontaneous, burning sensation over the entire body contralateral to the lesion site.
558. Epidural steroid injections may be effective in which one of the following conditions?
(A) Herniated nucleus pulposus without neurologic deficit
(B) Ankylosing spondylitis
(C) Fibromyalgia
(D) Functional low back pain
559. A 42-year-old man underwent a celiac plexus block procedure with 20 mL of 50% alcohol. All of the following listed conditions are complications of this intervention EXCEPT
(A) genitofemoral neuralgia
(B) hypertension
(C) diarrhea
(D) paralysis
(E) infection
560. A patient who received 1 mL of 0.25% bupivacaine after negative aspiration following a selective cervical nerve root injection became agitated and then developed generalized tonic-clonic movements. Which one of the following is the most likely explanation?
(A) High spinal anesthetic from accidental intrathecal injection
(B) Anxiety attack from pain during injection
(C) Vertebral artery injection of local anesthetic
(D) Injection into spinal cord
(E) Hypoxia
561. Which one of the following is true regarding oxcarbazepine?
(A) It has more adverse effects than carbamazepine.
(B) It is a sodium channel blocker.
(C) A dose adjustment is unnecessary in a patient with renal insufficiency.
(D) Its most frequent adverse effects is weight loss and dizziness.
562. Spinal cord stimulation (SCS) has been used with success for the treatment of all of the following conditions EXCEPT
(A) failed back surgery syndrome
(B) complex regional pain syndrome
(C) angina
(D) peripheral vascular disease
(E) diffuse chronic pain syndromes
563. A patient with obstructive lung disease develops complex regional pain syndrome involving the right arm after an injury. Treatment of the syndrome may involve all of the following EXCEPT
(A) stellate ganglion block
(B) lumbar sympathetic block
(C) surgical sympathectomy
(D) TENS
564. 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
565. 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 COX inhibitors 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
566. All of the following statements about postherpetic neuralgia (PHN) are correct, EXCEPT
(A) a midthoracic dermatome is one of the most common sites for PHN
(B) men are affected more often than women in a ratio of 3:2
(C) the 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%
567. Which of the following statements is true regarding acetaminophen toxicity?
(A) Acetaminophen is nontoxic until undergoing metabolism.
(B) Oral glutathione is the antidote of choice.
(C) The antidote must be started within 6 h of ingestion in order to be effective.
(D) Vasodilatory β2-adrenoceptor agonists potentiate the antidote efficacy.
568. Which one of the following is true regarding respiratory depression related to the use of opioids?
(A) Opioid agonists, partial agonists, and agonist/antagonists produce the same degree of respiratory depression.
(B) Opioids produce a leftward shift of the CO2 responsiveness curve.
(C) Depression of respiration is produced by a decrease in respiratory rate, with a constant minute volume.
(D) Naloxone partially reverses the opioid-induced respiratory depression.
(E) The apneic threshold is decreased.
569. Of the two principal neurolytic agents, alcohol and phenol,
(A) alcohol has the greater tendency to produce neuritis
(B) alcohol is used in a 6% concentration
(C) phenol has the more rapid onset of action
(D) phenol is used in a 50% concentration
570. Pain theories currently being proposed postulate a
(A) straight stimulus-to-nervous system path
(B) system involving large fibers only
(C) system with inhibition exerted by small fibers
(D) system involving excitatory and inhibitory input with resulting sensation
571. Cluster headaches are characterized by
(A) lancinating unilateral headache that is commonly triggered by stress factors
(B) pain that is strictly unilateral and autonomic symptoms that occur ipsilateral to the pain
(C) slow onset with progressive worsening of the pain over several hours with an attack usually lasting 3 to 4 days
(D) the common use of melatonin as therapy for the acute attack
(E) a higher incidence in elderly patients
572. Which one of the following characterizes spontaneous intracranial hypotension (SIH)?
(A) It is the same entity as post–dural puncture headache (PDPH).
(B) The 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 are below 60 mm H2O.
573. Adverse effects of epidurally administered glucocorticoids include all of the following, EXCEPT
(A) Cushing syndrome
(B) osteoporosis
(C) avascular bone necrosis
(D) hypoglycemia
(E) suppression of the hypothalamic-pituitary axis
574. 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)
575. Which one of the following is true in relation to complex regional pain syndrome (CRPS)?
(A) Males are more commonly affected than females.
(B) CRPS II is more common than CRPS I.
(C) Three-phase 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.
576. In the neurolytic treatment of cancer pain, all of the following are true statements EXCEPT
(A) alcohol injections around a peripheral nerve may produce an uncomfortable neuritis.
(B) bowel and bladder function is almost always preserved.
(C) such treatment should be used only in those with terminal disease.
(D) absence of sensation may be perceived by the patient to be worse than the pain.
577. Advantages of intrathecal drug-delivery are all of the following EXCEPT
(A) the first-pass effect can be avoided
(B) intrathecal morphine is 300 times as effective as oral morphine for equivalent analgesia
(C) the number of CNS-associated side effects can be reduced
(D) the blood brain barrier does not interfere with the CNS uptake of the drug
(E) there is no systemic absorption of drugs administered via the intrathecal route
578. Which one of the following opioids does not produce dose-dependant bradycardia?
(A) Morphine
(B) Fentanyl
(C) Meperidine
(D) Sufentanil
(E) Alfentanil
579. The stellate ganglion is located between
(A) C6-C7
(B) C7-T1
(C) C5-C7
(D) C5-C6
(E) T1-T2
580. Which one of the following statements is false regarding tramadol?
(A) It has opioid characteristics.
(B) There is a dose limit of 400 mg/d.
(C) It is a centrally acting analgesic.
(D) There is no effect on norepinephrine or serotonin neurotransmission.
(E) The drug inhibits the reuptake of norepinephrine and serotonin.
581. The paroxysmal hemicranias are rare benign headache disorders that may typically be associated with all of the following EXCEPT
(A) conjunctival injection
(B) rhinorrhea
(C) ptosis
(D) eyelid edema
(E) monocular blindness
582. All of the following statements regarding the theory and use of acupuncture are true EXCEPT
(A) “qi” is the life force or energy that flows through the body
(B) “qi” influences our health at physical, mental, emotional, and spiritual levels
(C) any excess or deficiency of “qi” will contribute to our health problems
(D) blockage of “qi” may cause pain
(E) acupuncture should not be offered as part of comprehensive pain management until more clinical trials proving its efficacy have been completed
583. The gate control theory is one postulated mechanism of action for spinal cord stimulators (SCS). Which one of the following is the most accurate application of SCS to this postulated mechanism of action?
(A) Activation of large-diameter afferents thereby “closing the gate”
(B) Activation of large-diameter afferents thereby “opening the gate”
(C) Activation of small-diameter afferents thereby “closing the gate”
(D) Activation of small-diameter afferents thereby “opening the gate”
(E) Activation of both large- and small-diameter afferents equally
584. The duration of aspirin effect is related to the turnover rate of COX in different target tissues because aspirin
(A) competitively inhibits the active sites of COX enzymes
(B) nonirreversibly inhibits COX activity
(C) irreversibly inhibits COX activity
(D) noncompetitively inhibits the active sites of COX enzymes
(E) acetylates COX-1
585. Which one of the following best fits the pharmacologic mechanisms of action of traditional nonsteroidal antiinflammatory drugs?
(A) Inhibition of phospholipase A2
(B) Inhibition of COX-2
(C) Inhibition of lipoxygenase
(D) Inhibition of arachidonic acid
(E) Inhibition of prostaglandin G/H synthase enzymes
586. The following statements are true about methadone EXCEPT it
(A) has a highly variable oral bioavailability
(B) is a low cost medication
(C) has no known active metabolites
(D) has N-methyl-D-aspartate (NMDA) receptor agonist properties
(E) has high lipid solubility
587. Ketamine and memantine are NMDA receptor
(A) allosteric regulators
(B) agonists
(D) antagonists
588. Which one of the following is the correct statement regarding the pharmacologic properties of nonselective COX inhibitors?
(A) They readily cross the blood–brain barrier.
(B) Their chemical structure consists of aromatic rings connected to basic functional groups.
(C) They act mainly in the periphery.
(D) They have a high renal clearance.
(E) They are not metabolized by the liver.
589. Occipital neuralgia involves
(A) the greater occipital nerve
(B) the cervical plexus
(C) a pain distribution confined to the occipital area
(D) the scapular nerve
(E) trophic lesions of the skull
590. A tricyclic antidepressant in the secondary amine class is
(A) imipramine
(B) nortriptyline
(C) doxepin
(D) amitriptyline
(E) trazodone
591. Inhibitory substances that are believed to modulate the transmission of nociceptive signals in the dorsal horn of the spinal cord include all of the following EXCEPT
(A) substance P
(B) β-endorphin
(C) dopamine
(D) epinephrine
(E) adenosine
592. Which one of the following is a nociceptor?
(A) Meissner’s corpuscles
(B) Pacinian corpuscles
(C) Merkel’s disks
(D) Free nerve endings on A-delta and C fibers
(E) Golgi–Mazzoni endings
593. All of the following statements are true about myofascial pain EXCEPT
(A) it is dermatomal in distribution
(B) it should be treated early in the course of the disease
(C) injection of local anesthetic may provide relief
(D) the pain can occur in the back, neck, and shoulders
(E) it can sometimes be relieved by simply needling the affected area
594. All of the following are major anatomic structures in the transmission and relay of nociceptive information EXCEPT
(A) spinothalamic tract
(B) locus coeruleus
(C) thalamus
(D) reticular formation
(E) sensory cortex
595. Gabapentin
(A) is structurally unrelated to GABA
(B) acts directly at GABA-binding site in the CNS
(C) inhibits voltage-dependent calcium channels
(D) is the drug of choice for fibromyalgia
596. Advantages of patient-controlled analgesia (PCA) include all of the following EXCEPT
(A) high patient satisfaction
(B) elimination of painful injections
(C) no need to adjust dosing parameters with increasing age
(D) more consistent levels of analgesia
(E) the ability of the patient to titrate pain relief to painful procedures such as chest physical therapy
597. The effectiveness of a neurolytic agent is dependent on all of the following EXCEPT
(A) location of the injection
(B) concentration
(C) histology of the nerve
(D) volume
(E) needle size
598. If a patient undergoing thoracotomy receives intercostal blocks with bupivacaine, his postoperative period will
(A) be little different from controls
(B) show marked improvement in respiratory function over controls
(C) show little difference in vital capacity but marked pain relief
(D) be marked by hyperventilation
(E) be marked by increased incidence of atelectasis
599. The McGill Pain Questionnaire
(A) consists of three major measures
(B) was developed by McGill
(C) is not widely used
(D) is a single-dimensional pain scale
(E) does not ask about the location of pain
600. Which of the following is a true statement concerning the use of epidural morphine?
(A) A biphasic respiratory depression pattern can develop, with the initial phase within 30 min of the bolus dose and a second phase 2-4 h later.
(B) Spinal morphine solutions must be preservative-free while epidural morphine solutions may contain preservatives.
(C) Patients should be closely monitored for 48 hours after the administration of epidural morphine.
(D) Patients may ambulate with assistance after an injection of epidural morphine.
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