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7. D. The stellate ganglion (cervicothoracic ganglion or inferior cervical ganglion) is a

sympathetic ganglion formed by the fusion of the inferior cervical and first thoracic

ganglion. Stellate ganglion is located at the level of C7 (seventh cervical vertebra),

anterior to the transverse process of C7, superior to the neck of the first rib, and just

below the subclavian artery. Complications of stellate block include intravascular

injection, intrathecal/epidural injection, bleeding, pneumothorax, brachial plexus

involvement, local anesthetics spread to recurrent laryngeal nerve, and osteomyelitis

or mediastinitis (rarely).

8. D. A spinal cord stimulator is a device used to exert pulsed electrical signals to

the spinal cord to control chronic pain, and additional applications include use in

some motor disorders. Spinal cord stimulation is most effective for neuropathic pain,

of which some common indications include sympathetically mediated pain, phantom

limb pain, ischemic pain due to peripheral vascular disease, peripheral neuropathies,

and visceral pain. Compartment syndrome pain often requires urgent evaluation and

possible need for emergency fasciotomy.

9. D. Hyperalgesia is an exaggerated response to noxious stimuli, an extreme and

exaggerated reaction to a stimulus which is normally painful. Anesthesia dolorosa is

pain in area that has no sensation, is pain felt in an area (usually of the face) that is

completely numb to touch with the pain described as constant, burning, aching, or

severe. Hypalgesia equals reduced sensitivity to pain, the opposite of hyperalgesia.

Allodynia is defined as pain due to a stimulus that does not normally provoke pain.

Temperature or physical stimuli can provoke allodynia (which may feel like a

burning sensation) and can often occur after injury.

10. C. Dysesthesia is an abnormal sensation with or without a stimulus and is defined

as an unpleasant, abnormal sense of touch and often presents as pain (may also

present as an inappropriate, but not discomforting, sensation). Dysesthesia is caused

by lesions of the nervous system (peripheral or central) and involves sensations

(spontaneous or evoked) such as burning, wetness, itching, electric shock, and pins

and needles. Dysesthesia can include sensations in any bodily tissue, including most

often the mouth, scalp, skin, or legs. Paresthesia is abnormal sensation without a

stimulus with a sensation of tingling, tickling, prickling, pricking, or burning of a

person’s skin with no apparent long-term physical effect. The manifestation of a

paresthesia may be transient or chronic. The most familiar kind of paresthesia is the

sensation known as “pins and needles” or of a limb “falling asleep.” Neuralgia is

pain sensation in the distribution of a nerve or a group of nerves (radiculopathy is

pain secondary to nerve roots pathologies). Neuralgia is pain in one or more nerves

caused by a change in neurological structure or function of the nerves rather than by

excitation of healthy pain receptors. Neuralgia falls into two categories: central

neuralgia (the cause of the pain is located in the spinal cord or brain) and peripheral

neuralgia. Hyperesthesia is exaggerated response to mild stimulation or a condition

that involves an abnormal increase in sensitivity to stimuli of the sense.

11. B. Deafferentation pain is a type of neuropathic pain that is associated with loss of

sensory input from the periphery to the central nervous system, such as phantom limb

pain. It is the interruption or destruction of the afferent connections of nerve cells

(e.g., in animal experiments, deafferentation demonstrates the spontaneity of

locomotor movement by the freeing of a motor nerve from sensory components).

12. B. The gasserian ganglion is formed from two roots that exit the ventral surface of

the brainstem at the midpontine level, and these roots pass in a forward and lateral

direction in the posterior cranial fossa across the border of the petrous bone. They

enter a recess called Meckel cave, which is formed by an invagination of the

surrounding dura mater into the middle cranial fossa. The dural pouch that lies just

behind the ganglion is called the trigeminal cistern and contains cerebrospinal fluid.

The gasserian ganglion is canoe-shaped, with the three sensory divisions—the

ophthalmic (V1), the maxillary (V2), and the mandibular (V3)—exiting the anterior

convex aspect of the ganglion. A small motor root joins the mandibular division as it

exits the cranial cavity via the foramen ovale. The gasserian ganglion contains the

cell bodies of sensory fibers of trigeminal nerve. This procedure called a gasserian

ganglion block to treat facial pain is where a small amount of local anesthetic (with

or without steroid) is injected onto the part of the nerve supply to the face called the

gasserian ganglion (located to the back of the face between the ear and eye socket).

13. C. Substance P, glutamate, aspartate, and ATP are among the major excitatory

molecules responsible for pain modulation. Somatostatin, acetylcholine, and

endorphin are among the major inhibitory mediators of pain.

14. D. Norepinephrine, adenosine, and serotonin are among the major inhibitory

neurotransmitters in the pain cascade. However, calcitonin gene-related peptide is an

excitatory neurotransmitter.

15. A. Secondary hyperalgesia is defined as an increase in pain sensitivity when a

noxious stimulus is delivered to a region surrounding, but not including, the zone of

injury (increased pain sensitivity outside of the area of injury or inflammation).

Secondary hyperalgesia, also known as neurogenic inflammation, is associated with

local redness, tissue edema, and sensitization to noxious stimuli. Local anesthetics

injection or capsaicin topical application can diminish these reactions. Secondary

hyperalgesia is a centrally mediated condition that may occur due to injury or

disease in an area of the body. Secondary hyperalgesia is due to central neuron

sensitization and requires continuous nociceptor input from the zone of primary

hyperalgesia for its maintenance. Secondary hyperalgesia implies only mechanical

hyperalgesia (e.g., allodynia and pin prick).

16. D. Certain chronic pain conditions are sympathetically maintained and will

respond to sympathetic blockade, such as complex regional pain syndrome, phantom

limb pain, postherpetic neuralgia, and trigeminal neuralgia. However, acute pain

secondary to pelvic exenteration surgery, although very difficult to treat, is typically

not mediated sympathetically and does not usually respond well to a sympathectomy.

17. D. One of the many reasons acute pain needs to be managed properly is its

systemic effects, which include hypertension, tachycardia, and increased minute

ventilation, can promote ileus and urinary retention, along with the release of

catabolic hormones.

18. C. Piriformis syndrome is a neuromuscular disorder that occurs when the sciatic

nerve is compressed or otherwise irritated by the piriformis muscle, causing pain,

tingling, and numbness in the buttocks and along the path of the sciatic nerve

descending down the posterior lower thigh and into the leg. The sciatic nerve can be

trapped at the sciatic notch and cause impingement syndromes (buttocks and leg

pain).

19. B. The cubital tunnel is a channel that allows the ulnar nerve to travel over the

elbow and is bordered by the medial epicondyle of the humerus, the olecranon

process of the ulna, and the tendinous arch joining the humeral and ulnar heads of the

flexor carpi ulnaris. Cubital tunnel syndrome is a condition brought on by increased

pressure on the ulnar nerve at the elbow, typically against medial epicondyle where

the ulnar nerve passes. This can occur due to chronic compression of this nerve,

positional or due to inappropriate cast/splint placement.

20. D. Myofascial pain syndromes are associated with muscle symptoms such as

spasm, pain, weakness, and stiffness, and associated with autonomic dysfunction

(e.g., vasoconstriction). The trigger points can spontaneously resolve, but may

continue on and become latent and activated at a later time. Myofascial pain needs to

be ruled out in patients with chronic lower back pain as trigger points in quadratus

lumborum, and gluteus medius muscles can be the cause for it. Some systemic

diseases such as connective tissue disease can cause myofascial pain. Poor posture

and emotional disturbances might also instigate or contribute to myofascial pain. The

diagnosis of myofascial pain is by the pain and existence of trigger points.

21. A. Fibromyalgia is characterized by chronic widespread pain and allodynia (a

heightened and painful response to pressure). Its exact cause is unknown, but

believed to involve psychological, genetic, neurobiological, and environmental

factors. Fibromyalgia symptoms are not restricted to pain. Other symptoms can

include debilitating fatigue, sleep disturbances, and joint stiffness. The American

College of Rheumatology diagnosis criterion indicates that the pain be at least

moderate to severe in scale: Widespread Pain Index (WPI) score of 7 or higher and

the Symptom Severity (SS) scale score of 5 or higher. Another category of criteria to

diagnose fibromyalgia includes a WPI of 3 to 6 along with an SS scale score of 9 or

higher. The other two criteria for diagnosis include chronic conditions and absence of

other coexisting chronic pain disorders. Treatment includes pregabalin (Lyrica),

duloxetine (Cymbalta), and milnacipran (Savella) to identify a few options.

22. D. Chronic lower back pain is one of the top reasons for physician office visits

and also one of the greatest reasons for work absence. Lumbosacral strain,

degenerative disk disease, and myofascial syndromes are the most common causes,

and fibromyalgia is not typically associated with a diagnosis of lower back pain.

23. D. Disk herniation at L5–S1 is the most common location of vertebral disk

pathology presenting as back pain (affects the S1 nerve root). Patients often have

associated gluteal pain and numbness along with pain/paresthesia in the posterior

thigh, posterolateral calf, lateral dorsum, and undersurface of the foot. Physical

examination will also identify a diminished plantar flexion of the ankle on the

affected side.

24. B. Disk herniation at L4–L5 is a very common location for such pathology and

affects the L5 nerve root. Patients may present with pain and paresthesia anywhere

along the dermatome distribution of the L5 nerve root (lateral thigh, anterolateral calf,

medial dorsum of the foot, particularly between the first and second toes). The

symptoms of quadriceps femoris muscle weakness would be secondary to pathology

of nerve roots L2–L4.

25. D. Facet joints are formed by the superior and inferior processes of each vertebra.

Facet syndrome is a syndrome in which the zygapophyseal joints (synovial

diarthroses, from C2 to S1) cause back pain. Fifty-five percent of facet syndrome

cases occur in cervical vertebrae, and 31% in the lumbar area. Facet syndrome can

progress to spinal osteoarthritis, which is known as spondylosis. Back pain

secondary to degenerative changes in the facet (zygapophyseal) joints is also called

facet syndrome. It is characterized by near midline pain that may radiate to the

gluteal region, thigh, and knee. Facet syndrome symptoms may worsen by

hyperextension or lateral rotation of the back. Confirmative test is pain relief offered

by intra-articular injection of local anesthetics or blockade of the posterior ramus

medial nerve branch.

26. B. Neuropathic pain is pain caused by damage or disease that affects the

somatosensory system. Neuropathic pain along with components of neuropathic pain

can be associated with several chronic diseases such as diabetes, stroke, spinal cord

pathology, postherpetic neuralgia, multiple sclerosis, cancer pain, or low back pain.

Neuropathic pain is often described as “wax and wane” types of pain symptoms

(e.g., comes and goes), burning, and electrical, as described by patients. Allodynia or

hyperalgesia can often be associated with neuropathic pain.

27. B. Neuropathic pain can be very difficult to treat effectively and often requires

multiple therapeutic modalities for treatment. These include anticonvulsants,

antidepressants, antiarrhythmics, α2

-adrenergic agonists, topical agents, and

analgesics (nonsteroidal anti-inflammatory drugs and opioids). Sympathetic blocks as

well as spinal cord stimulation work for certain patients resistant to pharmacological

interventions.

28. D. Complex regional pain syndrome (CRPS), formerly called reflex sympathetic

dystrophy or causalgia, or reflex neurovascular dystrophy or amplified

musculoskeletal pain syndrome, is a chronic systemic disease characterized by

severe pain, swelling, and changes in the skin. CRPS is expected to worsen over

time. Some forms of CRPS are sympathetically maintained and are therefore

responsive to sympathetic blockade. CRPS type 2 is associated with documented

nerve damage/injury, but not CRPS type 1. CRPS can be associated with either minor

or major surgical procedures or injuries. When the autonomic nervous system is

involved, additional signs and symptoms can include sweating (sudomotor changes),

color, and skin temperature changes, along with trophic changes of the skin, hair, and

nails. Motor strength and range of motion of the extremity may also be affected.

29. D. The general strategy in CRPS treatment is often multidisciplinary, with the use

of different types of medications combined with distinct physical therapies. Physical

therapy plays a central role in the multimodal treatment of CRPS. Therapy is

facilitated with sympathetic blockade or intravenous regional blocks. Physical

therapy typically consists of active movement without weights and desensitization

therapy. If not treated in timely fashion, CRPS can result in functional disability. The

incidence of a cure is about 90% with effective multimodal therapy initiated within 1

month of symptoms.

30. B. Potential complications of a celiac plexus block include postural hypotension

from the visceral sympathectomy and vasodilation due to the local anesthetic

injection. Both the vena cava and the aorta are in close proximity and susceptible to

intravascular injury/injection. Other potential complications include a pneumothorax,

retroperitoneal hemorrhage, injury to the kidneys or pancreas, and sexual

dysfunction. The visceral sympathetic chain is in close proximity, and blockade may

result in unopposed parasympathetic activity that may lead to increased

gastrointestinal motility and diarrhea.

Orthopedic Anesthesia

Thomas Halaszynski

1. The surgeon is performing a right total knee arthroplasty under a combined spinal–

epidural anesthetic. The surgical team is providing you with information that within

the next 15 minutes they plan to place bone cement (polymethylmethacrylate) to

anchor the prosthesis. The most likely clinical side effect that may occur is

A. Hypertension

B. Increased work of breathing and hypercapnia

C. Cardiac arrhythmias

D. Decreased pulmonary shunt

2. Potential complications of use of a pneumatic tourniquet include all of the following,

except

A. Tourniquet pain that is relieved by performing a peripheral nerve block

B. A compression nerve injury

C. Development of arterial thromboembolism

D. Pulmonary embolism

3. A 20-year-old male (status post car accident) sustained a right femur and pelvic

fracture 2 days prior. In the last 24 hours, he has become progressively more short of

breath, requiring 100% FIO2

to maintain an oxygen saturation in the high 80s and is

now becoming more confused and disoriented. Physical exam reveals petechiae on

the anterior chest wall, arms, and conjunctiva along with decreased breath sounds to

auscultation. The most likely diagnosis is

A. Cognitive dysfunction

B. Pulmonary fat embolism

C. Undiagnosed pneumothorax

D. Congestive heart failure

4. Incorrect statement regarding neuraxial anesthesia and deep-vein

thrombosis/pulmonary embolism (DVT/PE) in orthopedic surgical procedures is

A. Neuraxial anesthesia may reduce thromboembolic complications

B. Neuraxial anesthesia may reduce blood loss

C. Neuraxial anesthesia may decrease platelet reactivity

D. Neuraxial anesthesia may increase activity of both factor VIII and von

Willebrand factor

5. On postoperative day 1, an orthopedic surgeon has consulted you about his total

knee arthroplasty patient who is in severe pain and has failed a regimen of patientcontrolled analgesia using morphine. He is now consulting you for an epidural

catheter placement for postoperative pain control, and would like to know for what

time interval once-daily prophylactic low-molecular-weight heparin (LMWH) should

be held prior to performing the epidural procedure:

A. 4 hours and no absolute contraindication to placement of a catheter

B. 6 hours and a relative contraindication to place a catheter

C. 12 hours and no absolute contraindication to placement of a catheter

D. 24 hours and absolute contraindication to place a catheter

6. In the anesthesia preadmission testing clinic, you are assessing a 58-year-old female

with a medical history significant for hypertension, diabetes, fibromyalgia, and

rheumatoid arthritis (RA). The RA is affecting the upper extremities bilaterally and

the cervical spine, but her RA symptoms are well-controlled with methotrexate. She

is now presenting for an elective total hip arthroplasty. The radiographs that should

be ordered to rule out atlantoaxial instability are

A. Lateral view: flexion of the cervical spine

B. Lateral view: extension of the cervical spine

C. No radiographs are indicated since the patient is asymptomatic

D. Lateral view: both flexion and extension of the cervical spine

7. You were involved in a complicated left lower leg procedure (open reduced internal

fixation of proximal tibia–fibula fracture repair), where the final total tourniquet time

was 3 hours 15 minutes. In the postanesthesia care unit, the patient showed no signs

of any peripheral nerve injury of the left lower extremity. However, on postoperative

day 2, you discovered that the patient required hemodialysis secondary to

rhabdomyolysis. Which of the following could be responsible for the

rhabdomyolysis?

A. Compartment syndrome

B. Prolonged tourniquet inflation time

C. Statin medication use that patient started 2 weeks prior

D. All of the above

8. Concurrent administration of all of the following anticoagulants and thrombolytic

therapy should be avoided when planning for neuraxial blockade, except for

A. Fibrinolytic and thrombolytic therapy

B. Thrombin inhibitors (desirudin, lepirudin, bivalirudin, and Argatroban)

C. Therapeutic dosing of low-molecular-weight heparin (LMWH)

D. Subcutaneous heparin daily dose of 10,000 U or less

9. The most correct statement regarding blood loss that may occur in a patient with a

hip fracture is

A. Intertrochanteric > base of femoral neck > subcapital

B. Transcervical > base of femoral neck > subcapital

C. Subtrochanteric > subcapital > transcervical

D. Subcapital > base of femoral neck > transcervical

10. A 76-year-old female is to undergo a right femoral neck fracture repair. You

perform a spinal anesthetic using 1.5 mL 0.5% bupivacaine mixed with 100 μg of

preservative-free morphine. How long should the patient be monitored for

postoperative apnea/hypoventilation secondary to the intrathecal morphine

administration?

A. 3 days

B. 48 hours

C. 12 hours

D. 24 hours

11. A 56-year-old female with medical history significant for obesity (BMI 50),

hypertension, diabetes (IDDM), tobacco abuse, and asthma is scheduled for bilateral

hip replacement surgery. Preoperative laboratory results show a hematocrit (Hct) of

45%, blood urea nitrogen of 25 mg/dL, and creatinine of 1.0 mg/dL. Immediately

following application of cement for the second hip, the patient became hypotension

with sinus tachycardia. Arterial blood gas results reveal an Hct of 23% that responds

to a crystalloid fluid bolus and blood transfusion (2 L crystalloids, 1 L albumin, and

2 U packed red blood cells). The possible cause(s) for the hypotension is/are

A. Hypovolemia and/or low Hct

B. Pulmonary embolism

C. Vasodilation caused by monomer of the bone cement

D. All of the above

12. A 68-year-old female (5’1” and 250 lb) with a medical history of chronic lower back

pain and radiculopathy in the lumbar 4 to sacral 1 vertebral levels presents for

anterior and posterior fusion. Her home medications include methadone 75 mg daily,

oxycodone 10 mg every 3 hours as needed, a fentanyl patch (50 μg/h), and lisinopril

10 mg daily. The patient stated she has 7/10 pain daily. All of the following should

be considered in the perioperative pain management regimen for this patient, except

A. Continue with daily methadone

B. Consider a perioperative ketamine infusion

C. Consider transversus abdominis plane (TAP) block for the anterior abdomen

D. Add ketorolac 30 mg every 6 hours as needed for 14 days

13. You are administering anesthesia for a cervical spine procedure, and the surgeon has

indicated that she plans to monitor somatosensory-evoked potentials (SSEPs) and

motor-evoked potentials (MEPs). Your anesthetic plan includes avoidance of longacting muscle relaxants in addition to avoiding the use of

A. 1 MAC or higher of sevoflurane as needed for maintenance anesthesia

B. Half MAC of nitrous oxide to supplement the inhalation agent

C. Continuous propofol infusion as anesthesia maintenance

D. Dexmedetomidine to smooth out the anesthetic delivery

14. All of the following can be used to assist in reducing the amount of perioperative

surgical blood loss in an orthopedic procedures, except

A. Hemodilution

B. Controlled hypotension

C. Tranexamic acid

D. Aprotinin

15. All of the following statements when positioning patients for spine surgery in the

prone position are true, except

A. The neck should be in neutral position (without hyperextension or hyperflexion)

B. The eyes must be free of pressure and checked periodically

C. The abdomen must always be supported (never permitted to hang freely)

D. The arms are kept at less than 90 degrees of extension and flexion

16. The most incorrect statement regarding postoperative vision loss (POVL) that may

occur during prone positioning in spine surgery patients is

A. Ischemic optic neuropathy accounts for the highest incidence of POVL

B. Ischemic optic neuropathy is associated with decreased ocular perfusion

pressure

C. Prone positioning, greater than 1 L intraoperative blood loss, and surgery lasting

greater than 6 hours represent the highest risk

D. POVL due to central retinal artery occlusion (CRAO) tends to be bilateral

17. After 180 minutes of tourniquet time during a difficult right total knee arthroplasty in

a patient under sedation and intraoperative anesthesia provided by a combined

spinal–epidural, the tourniquet is released and surgical closure is started. The patient

may experience all the following subsequent to tourniquet release, except

A. Hypotension and tachycardia

B. Transient increase of end-tidal carbon dioxide

C. Arrhythmia secondary to increased serum potassium

D. Arrhythmia secondary to increased total serum calcium

18. The most incorrect statement regarding placement of a femoral perineural catheter

for pain management during unilateral knee replacement surgery is that a femoral

nerve block when compared to neuraxial blockade

A. Provides equipotent analgesia

B. Is associated with reduced incidence of pruritus, nausea, and vomiting

C. Is associated with reduced incidence of urinary retention

D. Femoral nerve block when combined with a sciatic nerve block can provide

adequate analgesia for knee surgery

19. A 56-year-old female is scheduled for a right total shoulder replacement in the beach

chair position. Medical history is significant for hypertension, diabetes, and a recent

transient ischemic attack. The surgeon is requesting a hypotensive technique to

reduce intraoperative blood loss. Where is the most optimal location to place the

arterial line transducer?

A. The level of the heart as this is the classic way of measuring

B. The level of the sternum to measure adequate perfusion to the brain

C. Level of the external meatus to monitor brain stem perfusion

D. Level of shoulder to measure adequate shoulder perfusion

20. The anesthetic agent(s) that can cause adverse changes on the wave forms when

monitoring somatosensory-evoked potentials (SSEPs) is/are

A. High concentrations of inhalational agents (reduces wave form amplitude)

B. 1 MAC of nitrous oxide (reduces wave form amplitude)

C. Intravenous anesthesia with ketamine (exaggerates wave forms)