30. A. The brachial plexus nerve root/trunk is usually positioned between the anterior
and middle scalene muscles. When local anesthetics are placed between these two
muscle bundles, it is commonly referred to as an interscalene block.
31. B. Bilateral supraclavicular blockade can significantly increase the risk of
symptomatic phrenic nerve palsy. Methemoglobinemia can happen in patients with
certain local anesthetics, but usually not from ropivacaine administration. LAST can
occur from administration of toxic doses of any local anesthetic, but is most often an
acute event from systemic administration.
32. C. The witnessed respiratory depression is most likely due to diaphragm palsy
and the urgent need for ventilation assistance until resolution of phrenic nerve
dysfunction. An appropriate option would be to intubate the patient and provide any
necessary sedation and then extubation upon evidence of recovery of diaphragm
33. B. Femoral and proximal sciatic nerve block together can often provide for
excellent perioperative pain control and can facilitate physical therapy with a
reduced incidence of interference with ambulation. These peripheral regional
techniques can be particularly useful in patients with difficulty or contraindications
34. C. Shoulder surgery is one of the upper extremity procedures that can often be
associated with nerve injuries secondary to patient pathology, surgical
manipulation(s), surgical trauma, brachial plexus nerve stretching or compression,
etc. If such an injury was due to performance of the peripheral nerve block and/or
catheter placement, it often tends to involve more isolated nerve roots/trunks of the
brachial plexus from the interscalene approach rather than diffuse influences at more
distal levels of the plexus. Surgical complications of the brachial plexus often tend to
be more diffuse and less selective. Nerve-conduction studies and EMG should be
considered rather than merely delineating an etiology of the injury.
35. A. The sciatic nerve supplies all of the motor innervation and the majority of the
sensory innervation to the lower extremities below knee except the medial side of the
lower extremity that is innervated by the saphenous nerve.
36. B. Bupivacaine is best known for its high cardiovascular toxicity, although any of
the local anesthetic medications listed above can result in LAST. One of the reported
advantages of ropivacaine over bupivacaine is its relatively lowered incidence of
cardiovascular toxicity. The other listed local anesthetic medications tend to have
neurological toxicity prior to progressing toward cardiovascular collapse.
37. B. A femoral block for hip surgical procedures have intrinsic limitations as does
not completely cover ALL dermatome distributions of the hip. A properly placed and
functioning lumbar plexus blockade/catheter will cover the femoral, obturator, and
lateral femoral cutaneous nerve and often provides for better pain control of the hip
in conjunction with a sciatic/sacral nerve plexus block.
38. B. The femoral nerve provides sensory innervation to the anterior and medial thigh
above the knee, and medial side of the lower extremity below the knee. The femoral
nerve innervates and supplies motor control of the anterior quadriceps muscles above
the knee and no motor innervation below the knee.
39. B. Sciatic nerve blockade provides sensory loss to the posterior thigh by blocking
the posterior cutaneous nerve along with everything below the knee, except for the
medical lower leg, which is innervated by the saphenous nerve.
40. A. The most likely cause is secondary to axillary lymph node dissection–related
brachial plexus injury. The level of paravertebral blocks was at T3–T5; therefore, the
brachial plexus should not be affected (C4–T1) by the paravertebral-injected local
41. C. Paravertebral blockade provides mostly for somatic-induced pain with little
42. D. Neurologic injuries secondary to positional, compressional, ischemic injury
often creates a more diffuse type of an injury pattern similar to the one described in
the question. If the neurologic injury were due to complications from placement of a
single-shot supraclavicular blockade or local anesthetic used during block placement,
then these types of injuries would tend to have a more isolated pattern. Peripheral
nerve block injuries from a supraclavicular block would be more likely to result in
evidence of an injury pattern isolated to the trunks or divisions of the brachial plexus,
and the patient would typically reveal symptoms above elbow as well. Without any
adjuvant, ropivacaine block will not last as long as 72 hours.
43. A. Axillary block is typically performed at the level of the individual peripheral
nerve branches of the brachial plexus, specifically the radial, median, and ulnar
44. B. Supraclavicular approach to blockade of the brachial plexus carries a high risk
of pneumothorax followed by the interscalene approach. This pneumothorax risk has
brachial plexus is commonly performed with ultrasound guidance.
45. B. All of the above adjuvant medications, except ketamine, are commonly used in
peripheral nerve blocks to improve the density and prolong the duration of nerve
blockade efficacy. Ketamine, along with ephedrine, when mixed with local
anesthetics during a peripheral nerve block has been studied in animal models and
was deemed to offer little to no additional benefits or synergistic effects.
46. B. Sartorius muscle twitch could be secondary to stimulation of a small branch
from the femoral nerve that innervates the sartorius muscle or secondary to direct
muscle stimulation. The femoral nerve is usually positioned more lateral and deeper
to this small branch that originates from the femoral nerve which innervates the
47. C. A potential advantage of paravertebral blockade compared to neuraxial
blockade is a reduced incidence of creating an intense sympathectomy resulting in
hemodynamic compromise. However, when bilateral paravertebral blocks are
performed, the potential exists that epidural spread could be significant, resulting in
an observation of a moderate BP decrease.
1. At what time frame following the postsurgical period does persistent postsurgical
pain become defined as being “chronic pain”?
2. Both surgical trauma and anesthetic administration techniques can modulate which
of the following human stress responses?
3. Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used as part of
“multimodal” analgesic therapy; some of the potential advantages include all of the
A. Decreases opioid requirements
B. Can decrease postoperative pain intensity
C. Indirect effect of decreasing opioid-related side effects
4. Type(s) of symptomatic pain conditions that best describes “chronic” pain often
C. Neuropathic or nociceptive pain
5. At what levels does the modulation of pain by electrical stimulation result in the
activation of inhibitory fibers?
6. Activation of which of the following mechanisms and/or pathways best describes
“central sensitization” at the level of the spinal cord?
A. Second-order wide dynamic range neurons
7. A 26-year-old female undergoes a left stellate ganglion block for treatment of
complex regional pain syndrome of the left hand. Twenty minutes after the block is
placed, skin temperature in the left arm rises from 33 to 36.5°C. Venous
engorgement of the left arm and hand, left eye papillary constriction, and drooping of
the eyelid are observed. The pain is not relieved. Which of the following can best
A. Pain-carrying fibers originated from right stellate ganglion
B. Pain-carrying fibers originated from middle cervical ganglion
C. Pain-carrying fibers originated from inferior cervical ganglion
D. Pain-carrying fibers originated from second thoracic ganglion
8. Chronic pain indications for insertion of a spinal cord stimulator include all of the
B. Complex regional pain syndrome
C. Chronic visceral pelvic pain
10. Incorrect statement related to the definition of an abnormal sensation is
A. Dysesthesia is an abnormal sensation with or without a stimulus
B. Paresthesia is abnormal sensation without a stimulus
C. Neuralgia is due to abnormality in nerve roots
D. Hyperesthesia is an abnormal sensation of exaggerated response to mild
11. Which of the following clinical diagnoses best describes deafferentation pain?
12. Gasserian ganglion block is most commonly used for neuropathic pain located in
which of the following nerve distributions?
13. Major excitatory neurotransmitters responsible for pain modulation include all the
14. All the following are inhibitory neurotransmitters in the pain pathway, except
D. Calcitonin gene-related peptide
15. Incorrect statement regarding secondary hyperalgesia is
A. It is caused by neurogenic inflammation
B. It is associated with Lewis’ triple response
C. It is increased by injection of local anesthetics
D. It is increased by application of capsaicin
16. Types of pain disorders that are commonly treated using “sympathetic blockade”
include all of the following, except
A. Complex regional pain syndrome
D. Acute pain due to pelvic exenteration
17. Systemic responses of the human body that can develop secondary to symptoms of
acute pain include all of the following, except
A. Hypertension and tachycardia
B. Increased work of breathing
18. A 56-year-old man presented to his primary care physician with a complaint of right
buttock and right leg pain along with numbness and tingling sensations. He was
subsequently diagnosed with a piriformis syndrome (trapped nerve). The nerve(s)
responsible for this diagnosis is/are
A. Femoral and saphenous nerves
D. Obturator and femoral nerves
19. A 56-year-old patient with a past medical history of hypertension, diabetes, and
alcohol abuse presents to the operating room for a right-elbow open reduction
internal fixation, secondary to a motor vehicle accident that occurred 24 hours ago.
On postoperative day 1, the patient complains of right fourth and fifth digit numbness
and minor pain. A diagnosis of cubital tunnel syndrome has been made. The nerve
20. Incorrect statement regarding myofascial pain is
A. Myofascial pain is associated with muscle discomfort (pain, stiffness,
B. Patient may have several trigger points producing pain upon stimulation
C. Systemic diseases such as connective tissue disease may cause myofascial pain
D. Myofascial pain is never associated with autonomic dysfunctions
21. The diagnosis of fibromyalgia includes all of the following, except
B. Pain lasts more than 3 months
C. No other pathologies can explain or contribute to the pain
D. Frequent association with psychiatric diagnosis
22. Common causes for lower back pain include all of the following, except
23. A 68-year-old male presents to his primary care physician’s office with a major
complain of back pain radiating into the gluteal region and pain in the distribution of
the plantar surface of the foot on the same side. The patient’s physical examination
reveals decreased plantar flexion of the foot. An MRI will most commonly show a
24. Disk herniation at L4–L5 of the vertebral column often presents with all of the
following clinical symptoms, except
A. Diminished dorsiflexion of the foot
B. Quadriceps femoris muscle weakness
C. Posterior-lateral thigh pain
D. Dorsal foot pain between first and second toes
25. Facet syndrome is characterized by all the following, except
A. Pain relieved by local anesthetic injection of the medial branches of the
posterior rami of spinal nerves
B. Pain relieved by an intra-articular injection of the zygapophyseal joints
C. Pain can be exacerbated by overextension and lateral rotation of back
D. Pain is sympathetically mediated
26. Incorrect statement regarding neuropathic pain is
A. It includes pain associated with stroke, spinal cord injury, and diabetic
B. It is not associated with low back pain or multiple sclerosis
C. Neuropathic pain can be paroxysmal
D. Neuropathic pain can be associated with hyperpathia
27. Regarding the treatment of neuropathic pain, the correct statement is
A. Narcotics is the most effective and “first-line” treatment option
B. It is most optimally treated with multimodal therapies
C. Sympathetic blockade will eliminate all neuropathic pain
D. Spinal cord stimulator is not an effective therapy
28. Pathological features of complex regional pain syndrome include all the following,
A. It is sympathetically mediated
B. It is often associated with documented nerve injury
C. It is only associated with major injuries (never from minor procedures)
D. It is not associated with evidence of skin color, hair, and temperature changes
29. Incorrect statement regarding treatment of complex regional pain syndrome (CRPS)
A. Efficacious treatment with multimodal therapy early in the diagnosis (within 1
month of symptom) is most effective
B. It responds well to sympathetic blockade
C. If not treated properly and in a timely fashion, CRPS can result in functional
D. Patients need to refrain from physical therapy until the pain syndrome is
30. Possible complications to disclose when obtaining an anesthesia consent from a
patient prior to performance of a celiac plexus block include all of the following,
A. Postural hypotension and lightheadedness
B. Constipation and urinary retention
C. Vena cava and aortic vascular injury
1. C. Persistent postsurgical pain is defined as chronic pain that continues beyond the
usual recovery period of 1 to 2 months following surgery (well past the normal
convalescence period expected for a particular/specific surgical procedure). Chronic
pain is defined as pain that has lasted longer than 3 to 6 months, though some other
investigators have placed the transition from acute to chronic pain at 12 months. The
incidence of persistent postsurgical pain can often exceed an incidence of 30% after
certain high-risk/surgically invasive procedures such as amputations, thoracotomy,
mastectomy, and inguinal hernia repair. Acute pain will typically last less than 30
days, chronic pain to more than 6 months duration, and subacute pain lasts from 1 to
6 months. A popular alternative definition of chronic pain involving no arbitrarily
fixed durations is “pain that extends beyond the expected period of healing.”
2. D. Many perioperative factors can produce significant influence toward amplifying
or decreasing the surgical stress response(s) such as neuroendocrine, metabolic, and
inflammatory changes. These factors can be further modified by patient-specific
contributions such as anxiety/depression, surgical history, surgical technique (open
vs. laparoscopy), and anesthetic techniques (general vs. regional).
3. D. NSAIDs have not only many of the above-identified advantages, but also
several potential side effects that the practitioner must remain cognizant of such as
risk of gastrointestinal bleeding, renal injury, and the potential to impair wound
4. C. Chronic pain is most often defined as neuropathic and/or nociceptive in nature.
Chronic pain may be divided into nociceptive pain—caused by activation of
nociceptors—and neuropathic pain—caused by damage to or malfunction of the
nervous system. Neuropathic pain is divided into peripheral (within the peripheral
nervous system) and central (originating from the brain/spinal cord). Peripheral
neuropathic pain is often described as burning, tingling, electrical, stabbing, and/or
pins and needles sensation(s). Nociceptive pain is divided into superficial or deep,
and deep pain into deep somatic and visceral pain. Superficial pain is initiated by
activation of nociceptors in the skin or superficial tissues. Deep somatic pain is
initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels,
and muscles, and is described as dull, aching, poorly-localized pain. Visceral pain
“referred” pain when damaged or inflamed, where the sensation is located in an area
distant from the site of pathology or injury.
5. D. Modulation of pain can happen centrally or peripherally. It can occur at the
nociceptor level peripherally or centrally either in the spinal cord or in supraspinal
structures. These modulation effects can be either inhibitive or facilitative. In the
brain and the spinal cord, much of the information from the nociceptive afferent
fibers results from excitatory discharges of multireceptive neurons. Pain information
in the central nervous system is controlled by ascending and descending inhibitory
pathways (using endogenous opioids or other endogenous substances). In addition, a
powerful inhibition of pain-related information occurs in the spinal cord. These
inhibitory systems can be activated by brain stimulation and peripheral nerve
stimulation. However, pain is a complex perception that is influenced also by prior
experience and by the context within which the noxious stimulus occurs. This
sensation is also influenced by emotional state.
6. D. Central sensitization is an enhancement in the function of neurons and circuits in
nociceptive pathways, caused by increases in membrane excitability and synaptic
efficacy as well as reduced inhibition and is a manifestation of the plasticity of the
somatosensory nervous system in response to activity, inflammation, and neural
injury. Central sensitization is responsible for hyperalgesia and there are three
mechanisms that have been identified at the level of spinal cord: (1) windup of
second-order wide dynamic range neurons, (2) dorsal horn neuron receptor field
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