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
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
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
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
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
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
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
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
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
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.
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
B. Increased work of breathing and hypercapnia
2. Potential complications of use of a pneumatic tourniquet include all of the following,
A. Tourniquet pain that is relieved by performing a peripheral nerve block
C. Development of arterial thromboembolism
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
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
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
5. On postoperative day 1, an orthopedic surgeon has consulted you about his total
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
B. Prolonged tourniquet inflation time
C. Statin medication use that patient started 2 weeks prior
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
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
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
C. Vasodilation caused by monomer of the bone cement
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
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
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
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
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)
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