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McGraw-Hill Specialty Board Review Pain Medicine

Salahadin Abdi, Pradeep Chopra, Howard Smith

Chapter 8

Pain Management Techniques - all with Video Answers

Educators

Chapter Questions

01:12

Problem 626

Which of the following is the most common microbe that grows in cultures of infected intrathecal pump wounds?
(A) Pseudomonas species
(B) Escherichia coli
(C) Staphylococcus aureus
(D) Staphylococcus epidermid is
(E) None of the above

Joanna Quigley
Joanna Quigley
Numerade Educator

Problem 627

You think a patient has developed an intrathecal catheter-tip inflammatory mass. What signs and symptoms would support this finding?
(A) Diminishing analgesic effects
(B) Pain that mimics nerve root compression
(C) Pain that mimics cholecystitis
(D) A and B
(E) A, B, and C

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01:17

Problem 628

Advantages of intrathecal drug-delivery are
(A) the first-pass effect can be avoided
(B) intrathecal morphine is 300 times as effective as oral morphine for equipotent pain treatment
(C) the number of central nervous system (CNS) derived side effects can be reduced
(D) B and C
(E) A, B, and C

Asma Venkitta
Asma Venkitta
Numerade Educator

Problem 629

Which one of the following is not an item to contemplate prior to placing an intrathecal pump?
(A) Does the patient have an acceptable physiologic explanation for the pain syndrome
(B) Does the patient have a life expectancy of 3 months or longer
(C) Psychologic clearance is not needed in the patient with cancer pain
(D) How old is the patient
(E) Has the patient been reasonably compliant with past treatment recommendations

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Problem 630

Prior to implanting an intrathecal pump many practitioners perform an intrathecal medication trial. Significant parameters to consider include
(A) delivery site
(B) type of medication
(C) whether the patient should be admitted
(D) A and B
(E) A, B, and C

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01:47

Problem 631

When dealing with an infection, which of the following would favor explanting the intrathecal device?
(A) Associated bleeding
(B) The presence of a seroma
(C) The presence of a hygroma
(D) The presence of necrotic tissue around the wound
(E) All of the above

Eric Goldman
Eric Goldman
Numerade Educator

Problem 632

You have separately tried maximum doses of morphine and hydromorphone, in a patient's intrathecal pump without any efficacy. According to the 2007 Polyanalgesic Consensus Guidelines, which one of the following would not be an accepted "next" step?
(A) Switch to morphine plus bupivacaine
(B) Switch to ziconotide
(C) Switch to clonidine
(D) Switch to fentanyl
(E) Switch to hydromorphone plus ziconotide

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03:14

Problem 633

Ziconotide was approved for infusion into the cerebrospinal fluid (CSF) using an intrathecal drug-delivery system by the Food and Drug Administration (FDA) in 2004. Its proposed mechanism of action is
(A) it blocks sodium channels
(B) it blocks $\alpha 2 \delta$ voltage-gated calcium channels
(C) it blocks $\mathrm{N}$-type calcium channels
(D) it blocks $\gamma$-aminobutyric acid $\left(\mathrm{GABA}_{\mathrm{B}}\right)$ receptors in the spinal cord
(E) none of the above

Jessica Wooten
Jessica Wooten
Numerade Educator

Problem 634

Neurology consults you on a 65-year-old female with breast cancer that has diffusely metastasized to her bones. She has had an intrathecal pump for 4 months, and has just been diagnosed with meningitis. Which of the following is true?
(A) The pump must be removed
(B) Enteral antibiotics must be initiated immediately
(C) If the infection is sensitive to vancomycin, and the patient refuses pump removal, intrathecal vancomycin may be administered
(D) Intravenous (IV) vancomycin plus epidural vancomycin has not been found to be effective in resolving infection
(E) All of the above

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Problem 635

A 72-year-old male with end-stage metastatic prostate cancer has a life expectancy of 6 months. Which of the following is true with regards to managing his intrathecal drug-delivery system?
(A) Treatment decisions should be made based on the 2007 Polyanalgesic Consensus Guidelines for management of chronic, severe pain
(B) Fentanyl is considered a first-line medication
(C) Droperidol may be used, intrathecally, as a first-line medication for nausea
(D) A different algorithm is applied when a patient's life expectancy is less than 18 months
(E) None of the above

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Problem 636

Granulomas have been found to occur with all medications used intrathecally, EXCEPT
(A) clonidine
(B) sufentanil
(C) baclofen
(D) fentanyl
(E) B and D

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Problem 637

Match the associated side effects with the intrathecal medication that causes it. Each choice can be used once, more than once, or not at all, and each question can have more than one answer.

Urinary retention

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Problem 638

Match the associated side effects with the intrathecal medication that causes it. Each choice can be used once, more than once, or not at all, and each question can have more than one answer.

Extrapyramidal side effects

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Problem 639

Match the associated side effects with the intrathecal medication that causes it. Each choice can be used once, more than once, or not at all, and each question can have more than one answer.

Hypotension

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Problem 640

Match the associated side effects with the intrathecal medication that causes it. Each choice can be used once, more than once, or not at all, and each question can have more than one answer.

Auditory disturbances

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Problem 641

Match the associated side effects with the intrathecal medication that causes it. Each choice can be used once, more than once, or not at all, and each question can have more than one answer.

Sedation

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Problem 642

Match the associated side effects with the intrathecal medication that causes it. Each choice can be used once, more than once, or not at all, and each question can have more than one answer.

Nausea

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Problem 643

Match the associated side effects with the intrathecal medication that causes it. Each choice can be used once, more than once, or not at all, and each question can have more than one answer.

Worsening of depression
(A) Opioids
(B) Bupivacaine
(C) Baclofen
(D) Clonidine
(E) Droperidol
(F) Ketamine
(G) Midazolam

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Problem 644

A 43-year-old female has 8-month history of axial low back pain and pain radiating to the left leg. The magnetic resonance imaging (MRI) of lumbosacral spine shows severe degenerative disc disease at L3-4 through L5-S1 with mild disc protrusions at these levels. She is a possible candidate for
(A) transforaminal epidural steroid injection
(B) facet joint medial branch diagnostic block
(C) spinal cord stimulator (SCS) trial
(D) all of the above
(E) none of the above

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Problem 645

The causes of axial low back pain are
(A) sacroiliac (SI) arthropathy
(B) internal disc disruption
(C) quadratus lumborum and psoas syndrome
(D) all of the above
(E) none of the above

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Problem 646

The false-positive rate of diagnostic lumbar facet medial branch blocks are
(A) $8 \%$ to $14 \%$
(B) $15 \%$ to $22 \%$
(C) $3 \%$ to $5 \%$
(D) $25 \%$ to $41 \%$
(E) $41 \%$ to $50 \%$

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Problem 647

Percentage of cases where the pain relief is caused by placebo response following interventional procedures are
(A) $12 \%$
(B) $35 \%$
(C) $20 \%$
(D) $15 \%$
(E) $28 \%$

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Problem 648

The complication of sphenopalatine ganglion radiofrequency thermocoagulation is
(A) infection
(B) epistaxis
(C) bradycardia
(D) all of the above
(E) none of the above

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00:29

Problem 649

The complication of third occipital nerve (TON) radiofrequency thermocoagulation is
(A) change in taste
(B) ataxia
(C) dysphagia
(D) all of the above
(E) none of the above

Joanna Quigley
Joanna Quigley
Numerade Educator
04:47

Problem 650

Positive lumbar provocative discogram for mechanical disc sensitization includes reproduction of patient's pain with injection of the contrast in nucleus pulposus at what pressure above the "opening pressure"?
(A) $<30$ psi
(B) $<100$ psi
(C) $<10$ to $15 \mathrm{psi}$
(D) $<50$ psi
(E) $<70$ psi

Mayukh Banik
Mayukh Banik
Numerade Educator

Problem 651

The technique of cervical discography includes needle entry through the skin from the
(A) anterior right side of the neck
(B) posterior right side of the neck
(C) anterior left side of the neck
(D) posterior left side of the neck
(E) median posterior side of the neck

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01:34

Problem 652

When performing intralaminar cervical epidural steroid injections without fluoroscopic guidance, the chances of having false positive loss of resistance are close to
(A) $15 \%$
(B) $25 \%$
(C) $35 \%$
(D) $50 \%$
(E) $40 \%$

Manisha Sarker
Manisha Sarker
Numerade Educator
00:15

Problem 653

When performing intralaminar cervical epidural steroid injections, the unilateral contrast (and medication) spread is expected in what percentage of cases?
(A) $50 \%$
(B) $30 \%$
(C) $25 \%$
(D) $10 \%$
(E) $40 \%$

Victoria Moyer
Victoria Moyer
Numerade Educator

Problem 654

Which of the following is a complication of lumbar sympathetic block?
(A) Genitofemoral neuralgia
(B) Retrograde ejaculation
(C) Intravascular injection
(D) All of the above
(E) None of the above

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Problem 655

What is the best method for evaluating the adequacy of lumbar sympathetic block?
(A) Increase in temperature by $2^{\circ} \mathrm{F}$
(B) Increase in temperature by $5^{\circ} \mathrm{F}$
(C) Increase in temperature by $10^{\circ} \mathrm{F}$
(D) Temperature change
(E) Decrease in temperature by $2^{\circ} \mathrm{F}$

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Problem 656

Stellate ganglion is located between the
(A) $\mathrm{C} 6-\mathrm{C} 7$
(B) C7-T1
(C) $\mathrm{C} 5-\mathrm{C} 7$
(D) $\mathrm{C} 5-\mathrm{C} 6$
(E) $\mathrm{T} 1-\mathrm{T} 2$

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Problem 657

In relation to the stellate ganglion the subclavian artery is located
(A) anteriorly
(B) posteriorly
(C) laterally
(D) medially
(E) none of the above

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00:42

Problem 658

Despite satisfactory stellate ganglion block for sympathetic-mediated pain, the pain relief in upper extremity is inadequate. The technical
explanation for this may lie in inadequate spread of local anesthetics to
(A) C5 nerve root
(B) inferior cervical ganglion
(C) first thoracic ganglion
(D) T2 and T3 gray communicating rami
(E) C7 nerve root

Joanna Quigley
Joanna Quigley
Numerade Educator

Problem 659

When performing lumbar discography, the "opening pressure" is the recorded pressure signifying
(A) first appearance of the contrast in nucleus pulposus
(B) opening of the annular tear to the contrast
(C) reproduction of concordant pain
(D) resting pressure transduced from the nucleus
(E) a dural leak

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Problem 660

Intradiscal electrothermal coagulation (IDET) outcomes are adversely affected by
(A) appearance of the disc on T2-weighted MRI images
(B) obesity
(C) age
(D) coexisting radicular pain
(E) gender

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Problem 661

When performing lumbar discography, in relation to the laterality of pain, which of the following should be the needle entry site?
(A) Ipsilateral
(B) Contralateral
(C) Laterality does not make a difference
(D) Guided by MRI images
(E) None of the above

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Problem 662

A patient with painful sacroiliac joint syndrome had only short-term relief with two sacroiliac (SI) injections using local anesthetics and steroids. Which of the following is the next treatment option?
(A) SI joint fusion
(B) S1, S2, S3, S4 radiofrequency denervation
(C) L5, S1, S2, S3 radiofrequency denervation
(D) L4, L5, S1, S2, S3 radiofrequency denervation
(E) None of the above

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Problem 663

Which of the following includes published complications that may follow cervical transforaminal epidural steroid injection?
(A) Epidural abscess
(B) Neuropathic pain
(C) Quadriplegia and death
(D) All of the above
(E) None of the above

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Problem 664

In order to minimize the risk for complications when cervical transforaminal epidural steroid injection is performed how should the needle be positioned in relation to the neural foramina?
(A) Anteriorly
(B) Posteriorly
(C) Superiorly
(D) Inferiorly
(E) None of the above

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Problem 665

The single-needle approach to medial branch block diagnosis in comparison to standard multiple-needle approach
(A) causes less discomfort for the patient
(B) decreases the volume of local anesthetics used for the skin and subcutaneous tissues
(C) takes less time to perform
(D) all of the above
(E) none of the above

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Problem 666

The incidental intrathecal overdose of intrathecal morphine while performing a pump refill should be treated by
(A) intrathecal and IV naloxone
(B) airway protection
(C) possible irrigation of the CSF with saline
(D) all of the above
(E) none of the above

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01:01

Problem 667

While analyzing a malfunctioning SCS implanted device, a sign of lead breakage or disconnect is a measured impedance of
(A) $<1500 \Omega$
(B) $>1500 \Omega$
(C) $<4000 \Omega$
(D) $>4000 \Omega$
(E) $<500 \Omega$

Narayan Hari
Narayan Hari
Numerade Educator
01:34

Problem 668

Accurate placement of a stimulator lead for occipital nerve peripheral stimulation is
(A) posterior to the $\mathrm{C} 3$ spinous process
(B) lateral to the pedicles of $\mathrm{C} 2$ and $\mathrm{C} 3$
(C) $2 \mathrm{~mm}$ lateral to the odontoid process
(D) posterior to the $\mathrm{C} 2$ spinous process
(E) none of the above

Sulav Pokhrel
Sulav Pokhrel
Numerade Educator

Problem 669

Adequate SCS introducer needle epidural space at entry level for the desired coverage of the foot pain is
(A) L3-4 interspace
(B) L1-L2 interspace
(C) T12-L1 interspace
(D) T8-T9 interspace
(E) T10-T11 interspace

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Problem 670

The placement of SCS electrodes for coverage of intractable chest pain caused by angina should be at the epidural level of
(A) $\mathrm{T} 6$
(B) $\mathrm{C} 4-\mathrm{C} 5$
(C) $\mathrm{T} 1-\mathrm{T} 2$
(D) $\mathrm{C} 6-\mathrm{C} 7$
(E) $\mathrm{C} 3-\mathrm{C} 4$

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Problem 671

Most effective approach for performing lumbar epidural steroid injections is
(A) caudal
(B) interlaminar
(C) paramedian approach
(D) transforaminal
(E) Taylor approach

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Problem 672

During interlaminar epidural steroid injections contrast should be
(A) used in the anteroposterior view
(B) used in the lateral view
(C) used in oblique view
(D) no contrast should be used
(E) A, B, and C

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Problem 673

Which of the following is the most likely complication after successful SCS implant?
(A) Infection
(B) Persistent pain at the implant site
(C) Lead breakage or migration
(D) CSF leak requiring surgical intervention
(E) Paralysis or severe neurologic deficit

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Problem 674

Which of the following is the most accurate statement regarding efficacy of SCS?
(A) For failed back surgery patients, SCS in addition to conventional medical management can provide better pain relief and improve health-related quality of life as compared to conventional medical management alone
(B) SCS is inefficacious for the indication of angina pectoris
(C) SCS for CRPS is efficacious for only about a year only then the efficacy diminishes
(D) SCS is not an effective treatment for sympathetically mediated pain
(E) Nociceptive pain is considered a better indication for SCS than neuropathic pain

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01:09

Problem 675

Which of the following is not a relative contraindication to SCS?
(A) Unresolved major psychiatric comorbidity
(B) A predominance of nonorganic signs
(C) Spinal cord injury or lesion
(D) Alternative therapies with a risk to benefit ratio comparable to that of SCS remain to be tried
(E) Occupational risk

Asma Venkitta
Asma Venkitta
Numerade Educator
04:30

Problem 676

Which of the following statements is most accurate regarding cost-effectiveness of SCS?
(A) Nobody opines of its cost-effectiveness and the issue has not been addressed in literature
(B) The literature is clear and consistent; SCS is not cost-effective
(C) Although published conclusions may vary, a consensus of professionals has determined that SCS stimulation is not cost-effective
(D) Although published conclusions may vary, a consensus of professionals has determined that SCS is cost-effective for certain indications
(E) All published literature on the topic concludes that SCS is cost-effective

Samriddhi Singh
Samriddhi Singh
Numerade Educator
05:35

Problem 677

Which of the following are specifications for current SCS systems?
(A) Constant voltage, pulse width up to 2000 milliseconds
(B) Constant current, volume less $10 \mathrm{~cm}^3$ (volume less than a standard matchbook)
(C) Constant resistance, pulse width up to 1000 milliseconds, cordless recharging
(D) Constant current, pulse width up to 1000 milliseconds, cordless recharging
(E) Constant current and constant resistance, cordless recharging, pulse width up to 1000 milliseconds

Khoobchandra Agrawal
Khoobchandra Agrawal
Numerade Educator
02:39

Problem 678

Which of the following is true?
(A) Dorsal column pathways do not play a role in visceral pain and therefore there is no role of SCS for visceral pain
(B) Pelvic pain has been demonstrated to consistently fail treatment with SCS
(C) The midline dorsal column pathway has been the proposed target for stimulation for chronic visceral pain
(D) Pelvic pain stimulation can best be achieved by first targeting the S2 foramen in a retrograde approach
(E) There is no therapeutic potential for treatment of chronic visceral pelvic pain with SCS

Qudsiya Anis
Qudsiya Anis
Numerade Educator
03:00

Problem 679

Which of the following is the best answer regarding lead geometry and spacing?
(A) The goal of SCS in treatment of bilateral lower extremity neuropathy pain is most frequently to stimulate the dorsal roots rather than the dorsal columns
(B) Tight lead spacing increases the ratio of dorsal column to dorsal root stimulation
(C) Too much stimulation of the dorsal columns results in motor side effects
(D) As the distance from the contact to the spinal cord increases, stimulation becomes more specific for the dorsal columns as opposed to the dorsal roots
(E) Rostrocaudal contact size (contact length) is less important than lateral contact size (contact width)

Rikhil Makwana
Rikhil Makwana
Numerade Educator
01:43

Problem 680

The gate control theory is one postulated mechanism of action for SCS. Which 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 smalldiameter afferents equally

Varsha Aggarwal
Varsha Aggarwal
Numerade Educator

Problem 681

Which of the following is most accurate regarding indications for SCS?
(A) Nociceptive pain is traditionally considered a better indication than neuropathic pain
(B) Receptor mediated pain is traditionally considered a better indication than neurogenic pain
(C) SCS tends to more effectively treat sympathetically mediated pain than pain of the somatic nervous system
(D) Intractable angina is not effectively treated with SCS
(E) Persisting neuropathic extremity pain following spinal surgery is a better indication than pain of CRPS

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02:06

Problem 682

Which of the following correctly arranges intraspinal elements from highest to lowest conductivity?
(A) CSF, longitudinal white matter, gray matter, transverse white matter, dura
(B) Longitudinal white matter, gray matter, CSF, transverse white matter, dura
(C) Longitudinal white matter, transverse white matter, dura, gray matter, CSF
(D) Gray matter, longitudinal white matter, transverse white matter, CSF, dura
(E) Dura, transverse white matter, gray matter, longitudinal white matter, CSF

Jordan Gross
Jordan Gross
Numerade Educator
02:50

Problem 683

Which of the following is the most accurate explanation why thoracic level cord stimulator leads do not commonly stimulate intrathoracic structures such as the heart?
(A) Thoracic placement of SCS leads is contraindicated and is therefore not a clinically used technique
(B) The CSF is highly conductive and therefore diverts the stimulation into a different direction
(C) The stimulation is very specific for neural tissues rather than visceral tissues
(D) The dura has a very low conductivity and therefore insulates visceral structures from stimulation
(E) The vertebral bone has a very low conductivity and therefore insulates visceral structures from stimulation

Bryan Valdivia
Bryan Valdivia
Numerade Educator
02:50

Problem 684

Which of the following best describes the proposed mechanism of action of SCS?
(A) There is evidence that during SCS large myelinated afferent fibers are activated in an antidromic manner
(B) There is a measurable increase in endogenous opioids in response to SCS
(C) Spinothalamic tract activation during SCS leads to an analgesic effect
(D) SCS causes an inhibition of ascending and descending inhibitory pathways
(E) SCS has no effect on abnormal A- $\beta$ activity

Bryan Valdivia
Bryan Valdivia
Numerade Educator
04:39

Problem 685

Which of the following is true?
(A) Phenol theoretically carries a higher risk for neuroma formation than alcohol
(B) Radiofrequency ablation is particularly useful for field neurolysis
(C) Phenol is a particularly useful neurolytic agent for localized targets
(D) Alcohol is a particularly useful neurolytic agent because there is no pain upon injection
(E) Phenol causes wallerian degeneration

Yogesh R
Yogesh R
Numerade Educator
01:19

Problem 686

Which of the following is most painless upon delivery?
(A) Phenol
(B) Alcohol
(C) Radiofrequency
(D) Cryoanalgesia
(E) Cold knife excision of a nerve

Lottie Adams
Lottie Adams
Numerade Educator
01:19

Problem 687

Which of the following neurolytic techniques is most concerning for the side effect of arrhythmia?
(A) Laser neurolysis
(B) Cryoanalgesia
(C) Radiofrequency
(D) Alcohol
(E) Phenol

Lottie Adams
Lottie Adams
Numerade Educator

Problem 688

Which of the following statements is the most accurate comparison of radiofrequency ablation and cryoablation?
(A) Cryoanalgesia probes are generally smaller in diameter than the large-diameter probes used for radiofrequency procedures
(B) One disadvantage of cryoanalgesia technique is the operator must support a heavier instrument while maintaining the probe tip in accurate position
(C) The cryolesion and the radiofrequency lesion are similar in size
(D) Cryoanalgesia and radiofrequency lesion techniques have equal precision capability
(E) Cryoanalgesia is inferior to radiofrequency ablation because cryoanalgesia causes wallerian degeneration

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04:02

Problem 689

Which of the following is most accurate regarding the electric field generated at the tip of a radiofrequency electrode?
(A) Flat conductors generate larger, stronger electric fields than round conductors
(B) With round conductors, the charge density is directly proportional to the radius of the circle
(C) The electric field around a radiofrequency cannula is more dense around the exposed shaft and becomes less dense at the tip
(D) Voltage, current, and power are the three basic variables governing formation of heat surrounding a radiofrequency cannula tip
(E) The heat lesion formed around the radiofrequency cannula is slightly pearshaped with the base of the pear around the proximal end of the active tip and less projection of the heat at the needle tip

Kai Chen
Kai Chen
Princeton University

Problem 690

Which of the following is the most accurate statement regarding neuraxial neurolysis?
(A) Phenol has significant proven benefit over alcohol
(B) The technique is $100 \%$ efficacious
(C) The average pain relief is less than 6 months
(D) Bladder paresis and motor weakness occurs in close to $100 \%$ of those treated with neuraxial neurolysis
(E) Epidural neurolysis has a proven favorable risk to benefit ratio compared to subarachnoid neurolysis

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Problem 691

While performing an intradiscal radiofrequency procedure using a posterior-oblique approach, the needle tip is advanced into the annulus fibrosus using fluoroscopic guidance. Impedance is noted. The needle tip is then advanced a little further. A drop in impedance is noted. Which of the following is the most likely explanation?
(A) Malfunction of radiofrequency machine
(B) Needle-tip entry into CSF
(C) Needle-tip entry into spinal cord
(D) Needle-tip has dry blood on it
(E) Needle-tip entry into nucleus pulposus

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Problem 692

Which of the following is appropriate safety consideration when performing a radiofrequency ablation procedure?
(A) Motor stimulation is not needed if meticulous fluoroscopic technique is used
(B) A radiofrequency probe should be the length of the cannula or shorter, but never longer than the cannula
(C) The pain physician should always turn off a patient's sensing pacemaker prior to a radiofrequency procedure
(D) Complications during radiofrequency ablation are rare and need not be considered prior to the procedure
(E) A SCS should be turned off prior to a radiofrequency procedure

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00:33

Problem 693

Coulomb per kilogram $(\mathrm{C} / \mathrm{kg})$ is
(A) the unit used to measure electrical charge produced by $\mathrm{x}$ - or $\gamma$-radiation similar to previous roentgen unit
(B) used to measure dose equivalent
(C) the daily radiation exposure per kilogram of body weight
(D) the intensity of radiation
(E) used to measure the amount of radiation absorbed

Paul Gabriel
Paul Gabriel
Numerade Educator
02:49

Problem 694

Gray (Gy) is used to measure
(A) yearly background exposure
(B) absorbed dose
(C) dose equivalent
(D) daily radiation exposure
(E) yearly radiation exposure

Bin Chen
Bin Chen
Numerade Educator

Problem 695

Maximum total permissible dose equivalents (in $\mathrm{mSv}$ ) for a year is
(A) $75 \mathrm{mSv}$
(B) $100 \mathrm{mSv}$
(C) $150 \mathrm{mSv}$
(D) $50 \mathrm{mSv}$
(E) $25 \mathrm{mSv}$

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Problem 696

How low should a clinician's hourly radiation exposure be?
(A) Less than $0.01 \mathrm{mSv} / \mathrm{h}$
(B) Less than $0.05 \mathrm{mSv} / \mathrm{h}$
(C) Less than $0.15 \mathrm{mSv} / \mathrm{h}$
(D) As low as reasonably achievable
(E) Less than $0.25 \mathrm{mSv} / \mathrm{h}$

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Problem 697

Most operator exposure during fluoroscopically guided blocks is when
(A) the lateral views are taken
(B) the $\mathrm{x}$-ray tube is above the patient
(C) the patient is obese
(D) the anteroposterior views are taken
(E) none of the above

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01:42

Problem 698

The intensity of scattered beam is greater at the radiation entrance on the skin than exit site
(A) 3 times
(B) 10 times
(C) 30 times
(D) 985 times
(E) 1000 times

Farhana Sharmin
Farhana Sharmin
Numerade Educator
05:32

Problem 699

Average patient radiation exposure dose during pain procedures is
(A) 10 times less than during angiography
(B) same as during angiography
(C) 10 times more than during angiography
(D) less than computed tomographic (CT) scanning
(E) 20 times more than during angiography

Khoobchandra Agrawal
Khoobchandra Agrawal
Numerade Educator
01:26

Problem 700

Radiation dose to the patients and medical personnel can be reduced by
(A) decreasing the distance between the image intensifier and the patient
(B) increasing the distance between the image intensifier and the patient
(C) using continuous fluoroscopy
(D) oblique views
(E) none of the above

Joanna Quigley
Joanna Quigley
Numerade Educator
02:17

Problem 701

Personnel radiation protection can be achieved by
(A) lead aprons
(B) glasses
(C) increased distance from the $x$-ray
(D) all of the above
(E) none of the above

Sima Sarker
Sima Sarker
Numerade Educator

Problem 702

Lead aprons should be always hung:
(A) So that space is saved
(B) As the lead can be broken if folded
(C) They can be safely folded as well
(D) So they can be conveniently available
(E) None of the above

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Problem 703

A patient with severe spasticity is a candidate for an intrathecal baclofen pump. He and his family have heard that "these pumps get infected." How do you respond?
(1) Device-related infection is the most common, potentially reducible, serious adverse event associated with intrathecal pumps
(2) The majority of infections occur at the lumbar site
(3) Management of infections associated with drug-delivery systems usually involves the administration of antibiotics and explantation of the device
(4) The chances of the pump getting infected are minimal and the family should only focus on the benefits that the device provides

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Problem 704

When trialing intrathecal medication and placing intrathecal pumps, which of the following is considered good technique?
(1) Antibiotics are given during the course of the trial, and for 7 to 10 days after permanent implant
(2) If the entry point is above L2, the patient should be conversant, and the angle of entry should be as shallow as possible
(3) Placing the patient in the lateral decubitus position with the hips flexed, and the knees bent
(4) Electrocautery is now considered the gold standard for controlling bleeding

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Problem 705

Which of the following is (are) disease state(s) that are amenable to treatment by intrathecal drug-delivery system?
(1) Intractable spasticity related to cerebral palsy and spinal cord injuries
(2) Interstitial cystitis
(3) Cancer-related syndromes
(4) Rheumatoid arthritis

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Problem 706

A 56-year-old female who had an intrathecal pump placed secondary to metastatic renal cell carcinoma is having pain equivalent to a 6 on the visual analog scale (VAS). What is the proper titration regimen?
(1) Increase dose $10 \%$ to $25 \%$ over 3 to 4 days
(2) Increase dose $25 \%$ to $50 \%$ daily
(3) Hourly rates should be adjusted $35 \%$ to $50 \%$ twice daily until pain relief is achieved
(4) A therapeutic bolus should be considered

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Problem 707

A 52-year-old female with pancreatic cancer and her family are trying to decide between continued medical management for pain versus an intrathecal drug-delivery system. Believing that this patient would most benefit from an intrathecal pump, you tell them that studies have shown that
(1) overall toxicity is better with intrathecal pumps
(2) pain relief is better with intrathecal pumps
(3) intrathecal pumps improve fatigue and level of consciousness in patients versus medical management
(4) there is a trend to increased survival in patients who have intrathecal pumps versus those continuing with medical management

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00:25

Problem 708

Third occipital nerve
(1) innervates $\mathrm{C} 2-3$ facet joint
(2) curves around superior articular process of the $\mathrm{C} 2$ vertebrae
(3) curves around superior articular process of the C3 vertebrae
(4) innervates $\mathrm{C} 3-4$ facet joint

Andrei Demkov
Andrei Demkov
Numerade Educator
02:20

Problem 709

For the peripheral stimulation of the occipital nerve
(1) the electrode should be parallel to the occipital nerve in the occipital area of the scull
(2) only a "paddle-" type electrode should be used
(3) the entry site of the introducer needle should be at T1-T2 level
(4) the electrode should be placed subcutaneously at the $\mathrm{C} 1-\mathrm{C} 2$ level

Rachel Griffin
Rachel Griffin
Numerade Educator

Problem 710

T2 and T3 sympathetic block
(1) is used for treatment of upper extremity complex regional pain syndrome (CRPS)
(2) will help by denervating the Kuntz nerves
(3) can lead to pneumothorax
(4) should avoid radiofrequency of T2 and T3 sympathetic ganglia

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Problem 711

Vertebroplasty may be indicated for
(1) multiple myeloma
(2) chronic compression fractures of vertebral body
(3) osteolytic metastatic tumors
(4) facet arthropathy

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Problem 712

Complications from vertebroplasty include
(1) pulmonary embolus
(2) intradiscal leak of polymethyl methacrylate
(3) paraplegia
(4) psoas muscle leak of polymethyl methacrylate and femoral neuropathy

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Problem 713

Which of the following is (are) correct with regards to piriformis muscle injection?
(1) Should be done at medial part of a muscle
(2) Botox can be used
(3) Nerve stimulation may aid in muscle location
(4) Identification of the muscle can be done through rectal examination

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Problem 714

SI joint pain
(1) is transmitted by the S1-S4 levels of spinal nerves
(2) has been treated by the SI joint fusion
(3) can be relieved by blind steroid injections
(4) is transmitted by L4 medial branch, L5 dorsal ramus, and S1-3 lateral branches

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01:22

Problem 715

Celiac plexus block can be performed by
(1) anterior approach
(2) retrocrural approach
(3) anterocrural approach
(4) lateral approach

John Nicolle
John Nicolle
Numerade Educator

Problem 716

Ganglion impar block
(1) is indicated for testicular pain
(2) is indicated for sympathetically maintained pain in perineal area
(3) is best performed by anococcygeal approach
(4) can be complicated by perforation of rectum

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Problem 717

With cervical interlaminar epidural steroid injection
(1) loss of resistance technique can be inaccurate in up to $50 \%$ cases
(2) unilateral medication spread can be achieved in $50 \%$ cases
(3) contrast spread should be checked in lateral views
(4) transforaminal approach is safer than interlaminar

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Problem 718

Which of the following includes complication(s) of intrathecal pump?
(1) Granuloma formation
(2) CSF leak
(3) Pump rotation
(4) Hormonal imbalance

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Problem 719

In relation to increased pain in patient with intrathecal opioid delivery which of the following is (are) true?
(1) It can mean progression of disease
(2) Catheter kink should be considered
(3) One should look for withdrawal symptoms
(4) Opioids should be increased first

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01:21

Problem 720

Which of the following is (are) drug(s) used in decompressive neuroplasty?
(1) Hyaluronidase
(2) Hypertonic saline
(3) Steroids
(4) Local anesthetics

Maryam Riaz
Maryam Riaz
Numerade Educator

Problem 721

SCS been used for the treatment of
(1) interstitial cystitis
(2) postlaminectomy syndrome
(3) CRPS
(4) sympathetically mediated pain

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Problem 722

Spinal cord stimulation
(1) should be used early in the course of the postherpetic neuralgia pain syndrome
(2) has been found efficacious for the failed back surgery syndrome
(3) has been used for peripheral vascular disease and ischemic disease
(4) has a proven and elucidated mechanism of action

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01:34

Problem 723

The transverse tripolar SCS arrangement
(1) involves a central anode surrounded by cathodes
(2) contributes maximum dorsal column stimulation with minimal dorsal root stimulation
(3) is most frequently used to improve stimulation of the feet
(4) usually involves an octapolar spinal midline lead and two adjacent quadripolar leads

Sulav Pokhrel
Sulav Pokhrel
Numerade Educator

Problem 724

Which of the following is (are) true for SCS for the indication of angina pectoris?
(1) Improves exercise capacity
(2) Probably only helps for a year and then the stimulator should be removed
(3) In addition to providing antianginal effects it also provides a reduction in ischemia
(4) Is contraindicated because it masks significant ischemic events

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Problem 725

Which of the following is (are) the risk(s) associated with SCS?
(1) Epidural hematoma
(2) Spinal cord injury
(3) Implanted pulse generator failure
(4) Electromechanical failure of lead or extension cable

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Problem 726

Which of the following is (are) true regarding SCS for visceral pain?
(1) SCS suppresses visceral response to colon distention in animal models
(2) SCS is a first-line treatment for visceral pain
(3) Case studies have indicated SCS may be helpful for visceral pain but at this time there is a lack of supporting randomized controlled trials
(4) A good lead placement for stimulation of chronic pancreatitis would logically be around T12 or L1

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01:28

Problem 727

Which of the following is (are) the best answer(s) regarding lead spacing and electrical fields created by a dual-lead stimulation system as pictured?
(1) With larger distances between anodes and cathodes, the electric field tends to form a sphere
(2) With tighter lead spacing and smaller distances between anodes and cathodes, the electric field is pulled towards the anode
(3) Tight lead spacing increases the ratio of dorsal column to dorsal root stimulation
(4) The anode is the positive contact and the cathode is the negative contact

Khoobchandra Agrawal
Khoobchandra Agrawal
Numerade Educator

Problem 728

Which of the following should be considered when selecting patients for SCS?
(1) Disease pathology
(2) Untreated drug addiction
(3) Patient comorbidities
(4) Physician's monthly case quota

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Problem 729

Which of the following is (are) considered indication(s) for SCS?
(1) Phantom limb pain
(2) Spinal cord injury pain
(3) Intractable abdominal or visceral pain
(4) Neurogenic thoracic outlet syndrome

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Problem 730

Which of the following is (are) true regarding the history of electrical stimulation for the treatment of pain?
(1) Electrical stimulation for the treatment of pain dates back to the first century ad when electrical fish were documented to be used in the treatment of gout
(2) Implantable SCS were used for treatment of pain for a decade prior to the published gate control theory of pain
(3) Early stimulation case reports were of peripheral nerve stimulation; later emphasis turned toward SCS
(4) Psychiatric and/or psychologic screening evaluation prior to implants was a new idea imposed upon physicians by health maintenance organizations in the 1990s

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Problem 731

Which of the following is (are) accurate statement(s) regarding neuromodulation of the sacral nerves?
(1) Sacral neuromodulation is not effective for idiopathic urinary frequency
(2) Both percutaneous and surgical lead placement techniques have been described
(3) Must be performed by a surgeon because only a surgical technique is available
(4) Urgency and urge incontinence are indications

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01:02

Problem 732

Which of the following is (are) true regarding radiofrequency procedures?
(1) Pulsed radiofrequency lesioning temperature goal is generally around $42^{\circ} \mathrm{C}$ to $43^{\circ} \mathrm{C}$
(2) Prior to application of the radiofrequency lesion, sensory testing should be applied at $2 \mathrm{~Hz}$
(3) The standard pulsed radiofrequency lesion is $500,000 \mathrm{~Hz}$ for 20 milliseconds pulses once every 0.5 second for 90 to 240 seconds
(4) Prior to application of the radiofrequency lesion, motor testing should be applied at $50 \mathrm{~Hz}$

Narayan Hari
Narayan Hari
Numerade Educator
01:02

Problem 733

Which of the following element(s) is (are) necessary to complete a radiofrequency circuit?
(1) The radiofrequency generator
(2) Insulated needle cannula with radiofrequency probe
(3) Dispersive electrode (grounding pad)
(4) The patient

Narayan Hari
Narayan Hari
Numerade Educator
01:01

Problem 734

Which of the following is (are) the possible mechanism(s) of action of radiofrequency ablation?
(1) Vascular injury causing endoneural edema
(2) Formation of a static electric field
(3) Lipid extraction with protein precipitation
(4) Generation of heat

Narayan Hari
Narayan Hari
Numerade Educator

Problem 735

Which of the following is (are) the most accurate answer(s) regarding radiofrequency treatment of the SI joint?
(1) Evidence is strong for efficacy of radiofrequency ablation techniques for SI joint pain
(2) The universally accepted screening protocol prior to SI joint injection involves SI tenderness, positive SI provocative maneuvers, and two positive local anesthetic-only SI joint injection procedures
(3) There is no evidence for the role of pulsed radiofrequency treatment of SI joint pain
(4) Radiofrequency treatment of sacral lateral branches have been proposed for efficacious treatment of SI joint pain

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04:59

Problem 736

Purported advantages of percutaneous radiofrequency lesions over other neuroablative techniques include
(1) predictable and quantifiable lesions
(2) avoids the extensive soft tissue damage of surgical techniques
(3) ability to confirm needle-tip proximity to sensory and motor nerves
(4) ability to cover a wide field

Noah Boudrie
Noah Boudrie
Numerade Educator

Problem 737

Which of the following is (are) accurate regarding the history of ablation techniques?
(1) Norman Shealy reported the first use of radiofrequency lesioning for treatment of facet pain in 1975
(2) The first report of percutaneous radiofrequency lesioning for treatment of pain came in 1981
(3) Slappendel reported the first clinical use of pulsed radiofrequency lesioning in 1997
(4) Although a modern cryoneuroablation device was developed and refined in the 1960s, the application for pain management gained popularity in the 1980 s

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Problem 738

Which of the following is (are) accurate regarding lesion size?
(1) The size of a continuous radiofrequency lesion depends on temperature induced
(2) The size of a continuous radiofrequency lesion depends on the width of the needle
(3) A $2 \mathrm{~mm}$ cryoanalgesia probe forms an ice ball about $5.5 \mathrm{~mm}$ thick
(4) A $1.4 \mathrm{~mm}$ cryoanalgesia probe forms an ice ball about $3.5 \mathrm{~mm}$ thick

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01:24

Problem 739

Which of the following is (are) components of a cryoanalgesia system?
(1) Outer tube with smaller inner tube
(2) Pressurized gas in inner tube
(3) Fine aperture in tip of inner tube which allows gas to rapidly expand in tip of outer tube
(4) Fine aperture in tip of outer tube which allows gas to escape the tube system

Ajay Singhal
Ajay Singhal
Numerade Educator

Problem 740

Which of the following is (are) potential neuroablative procedure treatment options?
(1) Radiofrequency ablation of the L2 ramus communicans for treatment of L4-L5 discogenic pain
(2) Phenol neurolysis for treatment of the lumbar sympathetic plexus for treatment of CRPS of the lower extremity
(3) Radiofrequency ablation for treatment of the lumbar sympathetic plexus for treatment of CRPS of the lower extremity
(4) Cryoablation for the treatment of pain owing to superior gluteal nerve entrapment

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Problem 741

Which of the following is (are) potential advantage(s) of pulsed radiofrequency procedure over continuous radiofrequency ablation?
(1) Pulsed radiofrequency procedure is virtually painless as compared to continuous radiofrequency ablation during which patients often complain of pain
(2) Overwhelming evidence of greater efficacy with pulsed radiofrequency procedure over continuous radiofrequency ablation
(3) As compared to pulsed radiofrequency ablation, continuous radiofrequency ablation of lumbar medial branches carries a higher risk of inducing spinal instability secondary to multifidus muscle denervation
(4) Complications caused by needle injury of tissues is less with pulsed radiofrequency procedure compared to continuous radiofrequency ablation

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01:02

Problem 742

Which of the following is (are) correct regarding impedance measurement during radiofrequency procedures?
(1) While performing a radiofrequency procedure, the lower the impedance value the better the expected outcome
(2) Impedance measurement can detect needle-tip entry into different mediums such as vascular structures or periosteum
(3) Impedance values are neither customary nor necessary when using fluoroscopic guidance
(4) Impedance measurement can detect breaks or short circuits in the electrical circuit

Narayan Hari
Narayan Hari
Numerade Educator