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Pain Q&A

Pain Q&A

If you would like a more precise answer about the cause of your pain, take our Diagnostic Paradigm($49.95), which has 72 questions concerning your pain with 2008 possible answers. The diagnoses from this test correlate with the diagnoses from Johns Hopkins Hospital staff members 95% of the time.

# 1- Question:  If I have low back pain, and my MRI shows a bulging or herniated disc, can this disc be the cause of my low back pain?

  1. Yes, definitely. The MRI is never wrong.
  2. Not necessarily. The MRI is sometimes wrong.
  3. No, MRI disc results do not correlated with clinical symptoms

2) Answer: Not necessarily. In an article by Jensen (Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS, Magnetic resonance imaging of the lumbar spine in people without back pain., N Engl J Med. Jul 14;331(2):69-73..1994) his group reported that in a sample of 91 patients, WITHOUT any back pain, 27 of these patients have a bulging or herniated disc on MRI images. Therefore, 30% of the time (27/91) the MRI shows a disc abnormality, but the patient does not have any symptoms. Therefore, for discs in the lower back, the MRI has a false positive rate of 30%.

#2- Question:  I have pain in my arm or leg but my EMG/nerve conduction studies are normal. I know I have real pain. Why aren’t my EMG/nerve conduction studies abnormal? What is really wrong with me?

  1. EMG/nerve conduction studies really measure the nerves which control your muscles, not the nerve that carry the message of pain. Therefore, this is the wrong test to use to measure pain.
  2. b) The studies were not done properly and need to be redone
  3. c)   The doctor did not interpret the test correctly
  4. d) You can’t measure pain.

1)Answer:  Electromyographic studies and nerve conduction studies primarily measure motor fiber (the nerves that move your muscles) conduction speed. Peripheral nerves are really a collection of both sensory (pain, hot, cold, vibration), and motor (muscle) nerves. If you cut a nerve in half, and look at the various types of nerve fibers within a nerve, over 90% of the nerve fibers are motor fibers, and less than 10% are sensory nerve fibers. Therefore, you can have extensive damage to the sensory nerves, but still have normal electrical activity in a “nerve.”

# 3- Question:  When the MRI doesn’t shows a bulging or herniated disc, and I know I hurt, what percent of the time is the MRI wrong?

  1. 10%
  2. 27%
  3. 56%
  4. 78%

4) Answer: 78%. Sandu at Cornell reported that in 53 patients with severe back pain had normal MRIs of their back, but when they received a test which stimulated the pain fibers in the disc level that corresponded with the level where they experienced pain, (a provocative discogram), this test found that 41 of the 53 (78%) reported this test duplicated their pain (Sandhu HS, Sanchez-Caso LP, Parvataneni HK, Cammisa FP Jr, Girardi FP, Ghelman B., Association between findings of provocative discography and vertebral endplate signal changes as seen on MRI., J Spinal Disord., Oct;13(5):438-43, 2000). Therefore, the MRI has a false negative rate of 78%. Brathwaite found comparable results (Braithwaite I, White J, Saifuddin A, Renton P, Taylor BA. Vertebral end-plate (Modic) changes on lumbar spine MRI: correlation with pain reproduction at lumbar discography, Eur Spine J., 7(5):363-8, 1998).

# 4- Question: Is there any difference between a CT and a 3D-CT?

  1. 100% of the time there is no difference
  2. 100% of the time there is very little difference
  3. 100% of the time there is significant differences
  4. 56%-76% of the time there are significant differences.

4) Answer: 56%-76% of the time there are significant differences. The CT is a widely used test for determining bony lesions, and solid lesions in the lung, liver, brain, kidney and other parts of the body. However, in research from Johns Hopkins University School of Medicine, Zinreich, the acting head of neuroradiology, Long the former chairman of neurosurgery and Davis, their orthopedic colleague, evaluated 100 patients with severe back pain, who had a normal CTs of the back, and no history of prior surgery. When a 3D-CT reformatting was done, bony lesions were discovered in 56% of the patients. In 100 patients who had prior surgery on their back, and who still had symptoms of pain, but had a normal CT, the 3D-CT found bony lesions, missed by the regular CT, 76% of the time. (Zinreich, J., Long, D., Davis, R., et al, Three dimensional CT imaging on post-surgical “Failed Back” Syndrome, Comput Assist. Tomograph, 14:574-580, 1990).

#5- Question: What percent of the time are chronic pain patients misdiagnosed?

  1. .the doctor is always right
  2. Rarely, less than 10% of the time.
  3. Maybe 20% of the time
  4. 40%-67% of the time for most post-traumatic chronic pain patients

4) Answer: There is a 40%-67% chance that a chronic pain patient is misdiagnosed or undiagnosed i.e. has an overlooked diagnosis. (Hendler, N, and Kozikowski, J, Overlooked Physical Diagnoses in Chronic Pain Patients Involved in Litigation, Psychosomatics, Vol. 34, #6, pp. 494-501, Nov.-Dec. 1993, Hendler, N, Bergson, C, and Morrison, C, Overlooked Physical Diagnoses in Chronic Pain Patients Involved in Litigation, Part 2, Psychosomatics, Vol. 37, #6, pp. 509-517, November-December. 1996). In the case of RSD (CRPS) this misdiagnosis rate may reach 71%, (Hendler, N, Differential Diagnosis of Complex Regional Pain Syndrome, Pan-Arab Journal of Neurosurgery, pp 1-9, October, 2002.) and if there is an electrical shock or lightning strike involved in the cause of the injury, the misdiagnosis rate may reach over 90% (Hendler, N., Overlooked Diagnosis in Electric Shock and Lightning Strike Survivors, Journal of Occupational and Environmental Medicine, 47, No. 8, pp. 796-805, Aug. 2005).

#6- Question: Is there a test to measure sensory nerve damage?

  1. No-you can’t measure pain
  2. Yes, the EMG-nerve conduction test
  3. Yes, the Neurometer test
  4. Yes the EEG

 3) Answer: Yes the Neurometer test. This is a sensory test that measures just the three types of sensory nerve fibers which are the A beta, A delta and C fibers, which have relative sizes of a fire hose, a garden hose, and a soda straw. This is called a current perception threshold test (CPT) and this demonstrates damage to the sensory nerves, by measuring the ability to detect electric shock, which is a sensory phenomenon, using the specific frequencies detected by each of the three sensory nerves. The machine that makes these measurements is a Neurometer, and is made in Baltimore, Maryland. (Katims, JJ, Electrodiagnostic functional sensory evaluation of the patient with pain: A review of the neuroselective current perception threshold (CPT) and pain tolerance threshold (PTT), Pain Digest, 8:219-230, 1998).

#7- Question: Are X-rays of any use in detecting pathology in chronic neck and back pain patients?

  1. yes you can always find pathology on X-rays
  2. most of the time you can find what is wrong using X-rays.
  3. Some of the time you can find painful problems in the neck and back using X-rays
  4. No, X-rays are of little or no use for neck and back pain diagnosis.

4) Answer: In many studies of the value of X-rays, an anatomical test that detects bony pathology, the correlation between the subjective symptoms, and the findings on X-ray fairly well indicate that X-rays are of little use in accessing objective pathology in the neck and lower back, because there are too many other structures, other that bony lesions, that can cause pain, which just do not show up on X-ray. (Peterson, et. al., Spine # 28 (2) pp 129-33, ’03).

#8- Question: Can a disc that is not herniated cause pain?

  1. .the disc has to be herniated to cause pain
  2. Internal disc disruption can cause pain
  3. A bulging disc always causes pain
  4. A degenerated disc always causes pain.

 2) Answer: Internal disc disruption. A disc is like a jelly doughnut, with the annulus being the doughnut, and the nucleus pulposa being the jelly inside a doughnut. A herniated disc is when the jelly squirts out of the doughnut. Most physicians do not know that there are pain fibers in the rear one third of the annulus, or the doughnut portion, that, when anatomically compressed, mechanically disrupted, or chemically irritated, will produce pain that feels exactly like a herniated disc pushing on a nerve root. However, this “internal disc disruption,” i.e. the herniation of the nucleus pulposa into the posterior portion of the annulus, does not show up on the anatomical tests such as MRI, CT or myelogram, because there is no anatomical distortion the annulus, and no protrusion of the nucleus pulposa (jelly) beyond the annulus (doughnut). A disc can be bulging or degenerating, but unless the damage extends into the posterior fibers, there is no pain. (Bogduk and McGuirk, Pain Research and Clinical Management, Vol. 13, p.119-122, Elsevier, 2002).  

#9- Question: Is it normal to get depressed because of pain?

  1. No, this is a “depressive equivalent” meaning your depression is causing pain.
  2. Only if you have psychological problems
  3. Yes, most patients get depressed

3) Answer: Psychiatric problems arise as the result of chronic pain. (Hendler, N, Depression Caused by Chronic Pain, J. of Clinical Psychiatry, Vol. 45, pp. 30-36, 1984, Hendler, N, Chapter 1, The Four Stages of Pain, in Diagnosis and Treatment of Chronic Pain, Edited by N. Hendler, D. Long, and T. Wise, John Wright/PSG, Littleton, Mass, pp. 1-8, 1982). Hendler reported that 77% of patients seen at Mensana Clinic had coexisting depression and chronic pain, but when questioned about pre-existing depression, 89% of the patients had never had significant depression before the onset of their pain (Hendler, N, Validating and Treating the complaint of Chronic Pain: The Mensana Clinic Approach, in Clinical Neurosurgery, Edited by P Black, Williams and Wilkens, Baltimore, Vol. 35, Chapter 20, pp. 385-397, 1989).

#10- Question What is the difference between anatomical and physiological testing?

  1. Anatomical testing takes a picture, and physiological testing measures a reaction
  2. There is no difference. A test is a test.

1) Answer: Very often, physicians fail to recognize the distinction between anatomical tests, and physiological tests, which is a critical issue, since each category of testing provides a different answer to the same question. An anatomical test merely takes a picture of a structure, while a physiological test records a person’s response to an event. As an example, X-rays, CT, and MRI are merely anatomical tests, because all they do is take a picture. However, a bone scan, or Indium 111 scan, or PET scan or Gallium scan takes a picture of the physiological uptake of various chemicals, and nerve conduction velocity studies measure the speed of response to a nerve when you put an electrical current into it.

#11- Question: What is meant by the medical term “convergence,” and why is this important?

  1. it means there is compression of a blood vessel
  2. It means multiple causes produce the same clinical picture
  3. It means that one symptom is the same as the other
  4. It means that nerves cross at the midline

2) Answer: Convergence means that multiple events produce the same results. As an example, pain in the little and ring finger can be caused by ulnar nerve entrapment or nerve root compression at C6-7 or even thoracic outlet syndrome. Clearly, this has clinical significance, because understanding the concept of convergence helps with clinical diagnoses. It is like having a flat tire. You can have a nail in the tire, a cut side wall, a leaky valve stem, or a broken bead. You could have two or three or more things wrong, and if you fix only one thing, you still have a flat tire.

#12- Question: What is meant by the medical term “divergence,” and why is this important?

  1. It means the same pathology produces different results.
  2. It means nerves don’t cross at the midline
  3. It means symptoms are different
  4. It means a blood vessel is twisted.

1) Answer: Divergence means that multiple, and different events are produced by the same etiological cause. As an example, damage to the vagus nerve can produce esophageal spasm, hyper-acidity in the stomach, or rapid heart rate. Clearly, this has clinical significance, because understanding the concept of divergence helps with clinical diagnoses.

#13- Question: What is a provocative discogram?

  1. it is a new dance
  2. It is a physiological test, that measures the pain response in a disc.
  3. It is a swollen disc
  4. It is a picture of a disc with dye in it.

2) Answer: Central to understanding the value of the provocative discogram the concept that pain is a physiological condition, not an anatomical event. While the use of an MRI can detect only anatomical distortions, the use of the provocative discogram, which is a physiological test, is more reliable for diagnosing chronic pain. A disc is like a jelly doughnut, with the annulus being analogous to a doughnut, and the nucleus pulposa being analogous to the jelly inside a doughnut. Most physicians do not know that there are pain fibers in the rear one third of the annulus, or the doughnut portion, that, when anatomically compressed, mechanically disrupted, or chemically irritated, will produce pain that feels exactly like a herniated disc pushing on a nerve root. However, this “internal disc disruption,” i.e. the herniation of the nucleus pulposa into the posterior portion of the annulus, does not show up on the anatomical tests such as MRI, CT or myelogram, because there is no anatomical distortion the annulus, and no protrusion of the nucleus pulposa (jelly) beyond the annulus (doughnut). (Bogduk and McGuirk, Pain Research and Clinical Management, 13, p.119-122, Elsevier, 2002). To perform a provocative discogram, a needle is inserted into the posterior portion of the disc, and saline is injected. If the saline injection reproduces the pain the patient normally feels, then the disc is the one causing the pain, regardless of the anatomical picture of the disc.

#14 Question: What is “Internal Disc Disruption?”

  1. damage to the vertebral body
  2. another name for a herniated disc
  3. a protrusion of the nucleus pulposa into just the annulus
  4. damage to the internal discs in the thoracic region

3) Answer: A disc is like a jelly doughnut, with the annulus being analogous to a doughnut, and the nucleus pulposa being analogous to the jelly inside a doughnut. Most physicians do not know that there are pain fibers in the rear one third of the annulus, or the doughnut portion, that, when anatomically compressed, mechanically disrupted, or chemically irritated, will produce pain that feels exactly like a herniated disc pushing on a nerve root. However, this “internal disc disruption,” i.e. the herniation of the nucleus pulposa into the posterior portion of the annulus, where the pain fibers are, does not show up on the anatomical tests such as MRI, CT or myelogram, because there is no anatomical distortion the annulus, and no protrusion of the nucleus pulposa (jelly) beyond the annulus (doughnut). (Bogduk and McGuirk, Pain Research and Clinical Management, 13, p.119-122, Elsevier, 2002).

#15 Question: Can Waddell signs predict secondary gain or malingering in a patient?

  1. yes, the show a patient is faking
  2. no they only show a patient is histioni

2) Answer: Waddell signs are a group of 8 physical findings divided into 5 categories, the presence of which has been alleged at times to indicate the presence of secondary gain and malingering. These consist of hitting a person on the top of the head, and having the patient experience back pain, etc.(Waddell, G., McCullock, J.S., Kummel, E., Venner, R.M. “Nonorganic Physical Signs in Low Back Pain,” SPINE, Vol. 5, pp. 117-125, 1980). However, in a meta-analysis of 16 studies, Fishbain could not find any predictive value nor correlation with other studies to detect malingering. (Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS., Is there a relationship between nonorganic physical findings (Waddell signs) and secondary gain/malingering? Clin J Pain. 2004 Nov-Dec;20(6):399-408). This group did find a correlation between Waddell signs and a histrionic personality.

#16-Question: Are epidurals effective for reducing neck and back pain?

  1. always
  2. most of the time
  3. Rarely

3) Answer: Not really. In a study of 300 patients, after 2 to 6 weeks, most epidural blocks loose their effectiveness. There was no efficacy at 3 months, 6 months or 1 year after injection. The epidurals had no impact on day to day functioning, the need for surgery or long term pain control. (Hampton, Tracy, Epidurals’ benefit for back pain questioned, JAMA, Vol. 297 # 16, pp: 1757-1758, April 25, 2007), (Landau WM, Nelson DA, Armon C, Argoff CE, Samuels J, Backonja MM., Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology, Neurology. 2007 Aug 7;69(6):614)

 

#17-Question: What are facet blocks?

  1. blocks of the disc
  2. blocks of the vertebral body
  3. block of the facet joints between the vertebral bodies.
  4. A wedge you insert into the facets

3) Answer: Facet blocks mean injecting a local anesthetic agent, such as bupivocaine, next to the part of the vertebral body called the facet. The facet is a bony joint that keeps the vertebral body from moving too far side to side in the lumbar region, and too far up and down in the cervical region. The block typically lasts only one hour, and tells the doctor if the facet joint or excessive movement around the joint, is the source of the pain.

#18 – Question: Why do you do a facet block?

  1. to open the space between the vertebral bodies.
  2. To block the sensory nerves going to the facet joint
  3. To block the disc
  4. To numb broken bones in the spine.

2) Answer: Since the facet is a bony joint that keeps the vertebral body from moving too far side to side in the lumbar region, and too far up and down in the cervical region, any excessive motion around this joint will produce pain that is localized to the joint area. A facet block typically lasts only one hour, and tells the doctor if the facet joint or excessive movement around the joint, is the source of the pain. Typical radiological findings suggesting the need for a facet block are facet hypertrophy, or anteriolythesis, or retrolysthesis on flexion-extension X-rays.

 

#19-Question: What are root blocks?

  1. blocks of the disc
  2. blocks of the vertebral body
  3. block of the nerve root emerging between the vertebral bodies.
  4. A wedge you insert into the nerve root

3) Answer: Root blocks mean injecting a local anesthetic agent, such as bupivocaine, next to the part of the vertebral body called the foramen, which is formed by an upper and lower facet. The foramen is where the nerve root exits from the spinal canal, and then goes to either the lumbar or cervical plexus. The block typically lasts only one hour, and tells the doctor if the neural foraminal stenosis or excessive movement around the joint, is the source of the pain.

#20– Question: Why do you do a root block?

  1. To open the space between the vertebral bodies.
  2. To block the sensory part of the nerve root to stop pain.
  3. To block the disc
  4. To numb broken bones in the spine.

2) Answer: Since the neural foramen is an opening between two vertebral bodies, if the opening is too small, or if the vertebral body move too far side to side in the lumbar region, and too far up and down in the cervical region, any excessive motion around this joint will produce pain in the distribution of the nerve root. A root block typically lasts only one hour, and should block only the sensory (pain) nerves. It tells the doctor if the neural foraminal stenosis is clinically significant, i.e. bone is pushing on the nerve root causing pain, or if excessive movement around the joint is the source of the pain. Typical radiological findings suggesting the need for a root block are facet hypertrophy, or anteriolythesis, or retrolysthesis on flexion-extension X-rays, neural foraminal stenosis on MRI or CT, or disc herniation compressing the nerve root.

#21-Question: What is a peripheral nerve block?

  1. block of the mixed motor/sensory nerve after the plexus
  2. block of the periphery
  3. block of the sympathetic nerves
  4. block of the plexus

1) Answer: A peripheral nerve block mean injecting a local anesthetic agent, such as bupivocaine, next to a mixed motor/sensory peripheral nerve. A mixed peripheral nerve is one that emerges after the lumbar or cervical plexus, and this nerve typically carries mostly motor fibers, and some sensory fibers. The peripheral nerve block typically lasts only one hour, and tells the doctor if the source of the leg or arm pain is occurring after the lumbar or brachial plexus. Usually only the sensory component of the nerve is blocks, but if too much anesthetic agent is used, then you will also get motor nerve blockage.

#22– Question: Why do you do a peripheral nerve block?

  1. To open the space between the vertebral bodies.
  2. To block the sensory part of the mixed motor/sensory peripheral nerve to stop pain.
  3. To block muscles of the affected lim
  4. To numb broken bones in the fingers and toes.

2) Answer: Nerve roots leave the spinal cord, and mix in either the lumbar or brachial plexus, emerging as mixed peripheral nerves, having both motor and sensory contributions from various nerve roots. A mixed peripheral nerve block typically lasts only one hour, and tells the doctor if damage to the nerve after emerging from the plexus is clinically significant, and the source of the pain. There are no typical radiological findings suggesting the need for a mixed peripheral nerve block. There best way to detect peripheral nerve damage to the motor component is EMG, nerve conduction velocity studies. To tell if the is damage to the sensory component, use the current perception threshold test with a Neurometer machine. Even if both of these tests are normal, it is still worth while to do a peripheral nerve block, because the real information of value is “if you block the sensory component of pain, will the pain stop?

#23 –Question: What is a two poster brace?

  1. It is a brace that is hung over a two poster bed
  2. It is a brace for the neck with a bar in the front and back of the neck
  3. It is a brace for the back with a bar in the front and back of the lower back
  4. It is a brace used for posting in horse back riding

2) Answer: A two poster brace is a brace that supports the neck both front and back. This is the most rigid and reliable of the bracing devices for the neck. The brace has metal supports, and straps that adjust across the shoulders. The brace should be adjusted so that there is slight pressure at the back of the head but little pressure on the chin, and no movement of the head should be detected when the brace is worn. If the brace provides relief, then this is an indication that there is excessive motion around the spinal segments of the neck.

#24 –Question: Why use a two poster brace?

  1. To stop the patient from moving his/her head back and forth
  2. To help with posting when riding
  3. To support a 2 poster bed to make it more comfortable for sleep
  4. To ease up back pain.

1) Answer: A two poster brace is a brace that supports the neck both front and back. This is the most rigid and reliable of the bracing devices for the neck. By holding the neck rigidly, and preventing movement, a doctor can tell if preventing motion will reduce the pain in the neck and or in the neck and arms. If the brace helps, then the doctor knows that the source of the pain is excessive motion around the joints, or vertebral bodies of the neck, and the patient would benefit from trials with facet blocks, and if these don’t last, then a fusion (Long, D, Davis, R, Speed, W, and Hendler, N, Fusion for Occult Post-traumatic Cervical Facet Injury, Neurosurgery Quarterly, Vol. 16, No 3, pp 129-134, Sept. 2006)

 

#25 Question– What is a body jacket with a thigh spika?

  1. An armored jacket with a thigh holster for a pistol used by the FBI
  2. A jacket used by lumber men with spikes at thigh level to help climb trees
  3. A rigid fiberglass lumbar brace with an extension to hold one thigh steady.
  4. A brace with extensions holding both thighs steady

3) Answer: A body jacket with a thigh spika is a full body cast, for the lower back, with an extension that goes down the leg that does not have pain. If a patient has pain in both legs, then the spika should be placed on the leg with less pain. The thigh spika body jacket is the only low back brace that stabilizes L5-S1 lumbar segment, which is where 87% of all low back and leg pain occurs.

#26 – Question: Why use a body jacket with thigh spika?

  1. To stop a patient from moving both legs.
  2. To stop a patient from moving the L5-S1 spinal segment to see if this instability is the source of back and leg pain
  3. To protect the patient on DEA drug raids, and to provide an easy access to his pistol.
  4. To keep the patient from moving his/her though

 2) Answer: The thigh spika body jacket is the only low back brace that stabilizes L5-S1 lumbar segment, which is where 87% of all low back and leg pain occurs. If the patient improves after a 3 day trial in the brace, then the doctor knows that there is excessive mobility in the lumbar spine, and the patient would probably benefit from facet blocks, and if these don’t last, then a fusion.

#27 Question: After being hit in the rear in an automobile accident, what is the most common pathology of “whiplash” injury.

  1. A broken vertebra
  2. A herniated disc
  3. Temporo-mandibular joint syndrome
  4. Torn ligaments of the vertebra in the neck

 4) Answer: Most often, ligaments of the vertebral bodies of the neck are stretched and torn, and this produces damage to the facet joints of the upper neck, which causes long lasting and headaches, unresponsive to medical treatment, that may persist for 6 months or longer after the accident. (Long, D, Davis, R, Speed, W, and Hendler, N, Fusion for Occult Post-traumatic Cervical Facet Injury, Neurosurgery Quarterly, Vol. 16, No 3, pp 129-134, Sept. 2006).

 

#28 Question: What are the most consistent clinical signs and symptoms, therefore the requisite signs and symptoms, of Complex Regional Pain Syndrome Type I (CRPS I) (RSD)? (One or more answers are correct)

  1. thermal allodynia
  2. mechanical allodynia
  3. circumferential pain
  4. swelling and discoloration
  5. Constant pain

1, 2, 3, 5) Answer: While the International Association for the Study of Pain (IASP) lists a set of criteria, many of the symptoms and signs are subjective and can be found in other disorders. Additionally, many of the signs and symptoms are inconsistent. Therefore, there are many flaws in the clinical signs and symptoms used in this classification system. Hendler listed specific clinical features, which are the most consistent, to help identify and differentiate CRPS I from other disorders. (Hendler, N., Differential diagnosis of complex regional pain syndrome type I (RSD), Pan-Arab Journal of Neurosurgery, Vol. 6, No. 2, pp1-9, October, 2002) These are:

  • circumferential pain, i.e pain that goes around the entire limb, or hand or foot,
  • Constant pain
  • allodynia to light touch, which is also seen in nerve entrapments, and radiculopathies (mechanical allodynia)
  • allodynia to cold or heat, which seems to be specific for CRPS I (thermal allodynia)
  • no weakness in the affected limb
  • no numbness in the affected limb
  • the ability to spread from one side to the other with a mirror image reproduction of the pain.
  • The ability to ascend or descend to the other limb on the same side.

#29 Question: What laboratory studies are useful for diagnosing CRPS I (RSD)? (one or more answers)

  1. MRI
  2. CT scan
  3. Bone scan
  4. Sympathetic blocks
  5. Thermography
  6. Phentolamine test

3,4,6) Answer: Phentolamine testing, which is an intravenous injection of a pure alpha 1 blocking agent, should give 100% relief for a brief period of time, lasting about 30 minutes. (Raja, S, and Hendler, N, Sympathetically Maintained Pain, Current Practice in Anesthesiology, Ed. David Rogers, Mosby-Year Book, Inc, pp. 421-425, 1990) Bier blocks may provide localized relief on a short term basis, which is diagnostic (Hendler, N.: Complex Regional Pain Syndrome, Type I and II, Chapter 36, in Weiner’s Pain Management, seventh edition, Mark V. Boswell and B. Eliot Cole, Editors, CRC Press, Boca Raton, 2006). Sympathetic blocks, if done properly, are a useful diagnostic tool (Hendler, N., Differential diagnosis of complex regional pain syndrome type I (RSD), Pan-Arab Journal of Neurosurgery, Vol. 6, No. 2, pp1-9, October, 2002, Stanton-Hicks, M, Baron, R, Boas, R., Gordh, T, Harden, N, Hendler, N., Kolzenburg, M, Raj, P, and Wilder, R, Complex Regional Pain Syndromes: Guidelines for therapy, The Clinical Jounral of Pain, 14: 155-166, 1998). The way to determine if a sympathetic block is effective is to measure increase temperature in the affected limb after the block. If the limb does get warm, then, by definition, the block was effective. Only if the limb is warm should the block be considered effective, and then the doctor can determine if the patient had 100% total relief of the pain for the period of time while the limb was warm (usually ½ hour to one hour). If the limb doesn’t get warm, the block should be repeated. Bone scans have variable results, depending on the stage of the CRPS I (Hendler, N., Differential diagnosis of complex regional pain syndrome type I (RSD), Pan-Arab Journal of Neurosurgery, Vol. 6, No. 2, pp1-9, October, 2002).

#30-Question: What signs and symptoms do you never see in CRPS I (RSD)? (One or more answers)

  1. swelling
  2. numbness
  3. loss of toe nails or finger nails
  4. molted skin

2, 3) Answer: EMG, nerve conduction velocity studies are never abnormal in CRPS I. (Hendler, N., Differential diagnosis of complex regional pain syndrome type I (RSD), Pan-Arab Journal of Neurosurgery, Vol. 6, No. 2, pp1-9, October, 2002). There is never any numbness associated with CRPS I. (Hendler, N., Differential diagnosis of complex regional pain syndrome type I (RSD), Pan-Arab Journal of Neurosurgery, Vol. 6, No. 2, pp1-9, October, 2002). If the pain is in the distribution of a mixed peripheral nerve, this is not CRPS I. (Hendler, N., Differential diagnosis of complex regional pain syndrome type I (RSD), Pan-Arab Journal of Neurosurgery, Vol. 6, No. 2, pp1-9, October, 2002). If there is not 100% total relief of all pain with a good sympathetic block that warms the limb, then this is not CRPS I. (Hendler, N., Differential diagnosis of complex regional pain syndrome type I (RSD), Pan-Arab Journal of Neurosurgery, Vol. 6, No. 2, pp1-9, October, 2002). A decrease in temperature is seen in nerve entrapments and radiculopathies, as well as CRPS I. (Uematsu, S, Hendler, N, Hungerford, D, Long, D, and Ono, N, Thermography and electromyography in the differential diagnosis of chronic pain syndromes and reflex sympathetic dystrophy, Electromyogr. Clinic. Neurophysiol, Vol. 21, pp 165-182, 1981).

#31-Question: What other disorders get mistakenly called CRPS I? (one or more answers)

  1. Mixed peripheral nerve entrapments
  2. Radiculopathies
  3. Thoracic outlet syndrome
  4. Vascular insufficiencies

1,2,3,4) Answer: Mixed peripheral nerve entrapments, radiculopathies, thoracic outlet syndrome, and disrupted discs with either Internal disc disruption (IDD) or herniated nucleus pulposa, and some vascular insufficiencies (Hendler, N., Differential diagnosis of complex regional pain syndrome type I (RSD), Pan-Arab Journal of Neurosurgery, Vol. 6, No. 2, pp1-9, October, 2002). 

#32-Question: Can you ever have both CRPS I and nerve entrapment in the same limb?

  1. Never
  2. Rarely, less than 10% is there ever a mixture of nerve entrapments and RSD
  3. 26% of the time there is a mixture of nerve entrapment and RSD
  4. 71% of the time there is a mixture of nerve entrapment and RSD

3) Answer: Hendler reported that only 1 case of 38 (3%) of the patients referred to Mensana Clinic with the referral diagnosis of CRPS I actually had just CRPS I. (Hendler, N., Differential diagnosis of complex regional pain syndrome type I (RSD), Pan-Arab Journal of Neurosurgery, Vol. 6, No. 2, pp1-9, October, 2002). 27 of the 38 patients (71%) had just nerve entrapment syndrome, and no signs or symptoms of CRPS I, while 10/38 (26%) had a mixture of both nerve entrapments and CRPS I, and 16/38 (42%) had thoracic outlet syndrome alone or in combination with CRPS I, which was not properly diagnosed (Hendler, N., Differential diagnosis of complex regional pain syndrome type I (RSD), Pan-Arab Journal of Neurosurgery, Vol. 6, No. 2, pp1-9, October, 2002).

#33 Question: Once you have clearly established the diagnosis of CRPS I, what is the best treatment?

  1. amputation of the limb
  2. sympathetic blocks
  3. sympathectomy
  4. discectomy and fusion

2, 3) Answer: A series of six to ten sympathetic block may treat the CRPS I. (Stanton-Hicks, M, Baron, R, Boas, R., Gordh, T, Harden, N, Hendler, N., Kolzenburg, M, Raj, P, and Wilder, R, Complex Regional Pain Syndromes: Guidelines for therapy, The Clinical Jounral of Pain, 14: 155-166, 1998). If these do not work, then a sympathectomy would be the next treatment of choice, on the same side as the pain (Hendler, N., Differential diagnosis of complex regional pain syndrome type I (RSD), Pan-Arab Journal of Neurosurgery, Vol. 6, No. 2, pp1-9, October, 2002). If the pain returns, then a series of contra-lateral blocks should be used as a diagnostic tool, and if they are effective, then a contra-lateral sympathectomy should be performed. (Hendler, N., Differential diagnosis of complex regional pain syndrome type I (RSD), Pan-Arab Journal of Neurosurgery, Vol. 6, No. 2, pp1-9, October, 2002). Only if that fails, a trial with an epidural stimulator may provide symptomatic relief, (Stanton-Hicks, M, Baron, R, Boas, R., Gordh, T, Harden, N, Hendler, N., Kolzenburg, M, Raj, P, and Wilder, R, Complex Regional Pain Syndromes: Guidelines for therapy, The Clinical Jounral of Pain, 14: 155-166, 1998) but looking for a disorder other than CRPS I may prove more beneficial, (Hendler, N., Differential diagnosis of complex regional pain syndrome type I (RSD), Pan-Arab Journal of Neurosurgery, Vol. 6, No. 2, pp1-9, October, 2002). 

#34 Question: Is physical therapy any good for treating CRPS I?

  1. Never
  2. All the time
  3. 50% of the time
  4. 75% of the time

1) Answer: Since CRPS I is misdiagnosed 71% of the time, and is really nerve entrapment, there is no way to confirm that what the physical therapist is treating really is CRPS I. Moreover, there are no comprehensive studies to confirm the efficacy of physical therapy for CRPS I.

#35 Question: How do you diagnose sensory nerve entrapments? (one or more answers)

  1. EMG/nerve conduction velocity studies
  2. Mixed peripheral nerve block
  3. Neurometer studies
  4. Sympathetic nerve blocks

2,3) Answer: Clinically, the patient should experience pain, numbness or tingling and sometimes weakness in the distribution of a mixed peripheral nerve, and the pain should temporally resolve, for a 1/ 2 hour or more, with the block near the nerve with 0.5% bupivocaine, .5 cc. CPT (Neurometer) sensory testing may help identify the damaged nerve.

#36 Question: How do you treat mixed peripheral nerve entrapment syndromes?

  1. cut the nerve
  2. cut away scar tissue from the epinuerium
  3. use Capsaisin to kill the small C fibers which carry the message of pain
  4. take Vitamin B6 50mg four times a day

2) Answer: A surgeon should be able to identify the scarring of the epineurium that has trapped the nerve, and remove the scarring. Sometimes surgeons wrap the nerve in fat to prevent the reformation of scar tissue.

#37 Question: How do you properly use a Transcutaneous Electrical Stimulator (TENS)?

  1. put the electrodes over the painful area
  2. turn up the current until you just can’t stand the pain, and leave it on until the batteries run out
  3. put electrodes between the brain and the pain, and set the current for the highest rate, lowest pulse width, and voltage to the level where you feel a gentle humming, buzzing sensation
  4. Put the electrodes on either side of the temples and set the voltage high enough to make your eyes tear

3) Answer: The TENS unit can provide symptomatic and temporary relief for mixed peripheral nerve entrapment syndromes. The important clinical consideration is the placement of the electrodes. Electrodes should be placed perpendicular to the suspected damaged mixed peripheral nerve, between the source of the pain, and the spinal cord (between the brain and the pain). Electrodes should never be placed over the painful site, since this will worsen the pain. The pulse width should be set as low as possible, and the frequency as high as possible, and the voltage adjusted until the patient begins to feel a gentle buzzing sensation in the nerve producing the pain.

#38 Question: For what diagnoses do you implant an epidural stimulator? (One or more answers)

  1. arachnoidtis
  2. CRPS I (RSD)
  3. Collapsed vertebra
  4. Low back pain

1, 2) Answer: An epidural stimulator is a symptomatic treatment for a variety of chronic pain conditions. So, when a condition will no longer respond to surgery, when surgical risks are too great, when a condition may not be surgically correctable, then consider an epidural stimulator. Typically, it may prove useful for arachnoiditis, CRPS 1 that did not respond to sympathectomies, nerve root damage and some peripheral nerve entrapments. The epidural stimulator is not particularly useful for neck or back pain, but is better for limb pain.

#39 –Question: When do you use epidural morphine pumps?

  1. arachnoidtis
  2. CRPS I (RSD)
  3. Collapsed vertebra
  4. Low back pain

1,2) Answer: An epidural morphine pump is a symptomatic treatment for a variety of chronic pain conditions. So, when a condition will no longer respond to surgery, when surgical risks are too great, when a condition may not be surgically correctable, and when the condition has not responded to an epidural stimulator, then consider an epidural morphine pump. Typically, it may prove useful for arachnoiditis, CRPS 1 that did not respond to sympathectomies, nerve root damage and some peripheral nerve entrapments. The epidural morphine pump may be useful for neck or back pain, but is better for limb pain.

 

#40 Question: Is there ever a case where narcotics do not help control pain? One or more answers

  1. CRPS 1
  2. Headaches
  3. Post herpetic neuralgia
  4. Post-operatively

1,3) Answer: Yes. There are a number of articles in the literature that suggest that narcotics are not as effective in neuropathic pain as they are for musculoskeletal pain. More recent articles have suggested that narcotics may help neuropathic pain, but the preponderance of articles suggest otherwise. Neuropathic pain is a pain caused by damage to nerves, and involves nerve entrapments, radiculopathies, CRPS, post herpetic pain, post-syphilitic pain (tabes dorsalis), pain after electrical shock or lightning strike, and peripheral neuropathies.

#41 Question: How do you diagnosis facet syndrome?

  1. facet syndrome shows up on X-rays
  2. It is a clinical diagnosis confirmed by facet blocks
  3. Get an MRI
  4. Get a CT

2) Answer: Facet syndrome typically is localized to pain in a spinal column level, but may radiate down the arms or legs or across the ribs. Typically, the pain is made worse with extension, and better by flexion, and is temporarily relieved for 1 to 2 hours, by facet blocks.

#42 Question: How do you treat facet syndrome?

  1. narcotics
  2. wear a brace all the time
  3. facet joint denervation
  4. Transcutaneous electrical stimulator

3) Answer: Facet syndrome typically is localized to pain in a spinal column level, but may radiate down the arms or legs or across the ribs. Typically, the pain is made worse with extension, and better by flexion, and is temporarily relieved for 1 to 2 hours, by facet blocks. If these facet blocks are effective, then facet denervation (thermo-coagulation, or cryo-coagulation) have a 40% chance of giving up to 2 years of relief, before they have to be repeated. In extreme cases, where the facet syndrome is due to excessive instability, then a fusion may be needed.

#43 Question: Is physical therapy any good for helping patients with chronic back, neck and limb pain?

  1. 100% effective.
  2. Only if associated with weight loss, and daily exercise
  3. Never demonstrated effectiveness in chronic pain
  4. Only if used with traction and braces

3) Answer: While physical therapy may be useful for post-surgical rehabilitation, or for typical sprain or strain recovery, there are no articles in the medical literature that support the notion that physical therapy can provide long term benefit for someone with musculoskeletal pain that has lasted for more than three months, and no evidence that physical therapy helps neuropathic pain of any sort.

#44 Question: What is the difference between musculoskeletal pain and neuropathic pain, and why is this important?

  1. There is no difference
  2. Muscle pain responds to muscle relaxants, and neuropathic pain responds to anti-convulsants
  3. Muscle pain responds to TENS units and neuropathic pain does not
  4. Only neuropathic pain responds to surgery.

Answer: Neuropathic pain is pain that is created by damage to any type of nerve structure. Neuropathic pain is caused by nerve entrapments, radiculopathies, CRPS, post herpetic pain, post-syphilitic pain (tabes dorsalis), pain after electrical shock or lightning strike, and peripheral neuropathies. Musculoskeletal pain is pain due to damage to the bone or muscles or ligaments that hold the bone together, or the tendons that attach the muscle to the bone. The type of injury determines the type of medication selected to control the pain, and the type of treatment to pursue.

#45 Question: What is allodynia?

  1. This means “another type of force.”
  2. This means “a painful response to a normally non-painful stimulus”
  3. This means “a newly discovered type of dinosaur.”
  4. This means “a mechanical abnormality”

2) Answer: Allyodinia is defined as a painful response to a normally non-painful stimulus. As an example, dropping cold ice water on the back of a patient’s hand normally doesn’t cause pain. When it does, this is cold thermal allodynia. Blowing a hair dryer on the back of a patient’s hand normally doesn’t cause pain, but if it does, this is hot thermal allodynia. Stroking the back of a patient’s hand with a cotton swab normally doesn’t cause pain, but if it does, this is mechanical allodynia. Dropping alcohol on the back of a patient’s hand normally doesn’t cause pain, but since the alcohol causes cooling of the hand, this is cold thermal allodynia. However, if there is no response to the cold, but within 30- 60 seconds there is a response of pain, this is chemical allodynia.

#46 Question: Is what medical conditions do you find mechanical allodynia? One or more answers

  1. broken vertebral body
  2. CRPS I (RSD)
  3. Nerve entrapments
  4. radiculopathies

2,3,4) Answer: Thermal allodynia, both cold and hot, is found in CRPS I and CRPS II. Mechanical allodynia is found in nerve entrapments, radiculopathies, and CRPS I and II. Chemical allodynia is found in CRPS I and II.

#47 Question: How long can sprains or strains last?

  1. one day
  2. no more than 6 weeks
  3. 3 months
  4. can take as long as a year

2) Answer: A sprain, which is damage to the ligaments that hold bones together, usually around a joint, like the ankle, knee or wrist, or a strain, which is damage or overstretching of the muscle or tendon that hold the muscle to the bone, are self-limiting diseases, that should repair themselves in 3 to 6 weeks at the very most. If pain persists beyond that period of time, then it is highly unlikely that the problem causing the pain is a sprain or strain.

#48 Question: If a chronic pain has been called a sprain or strain, but it has lasted longer than 6 weeks, what it the source of the pain?

  1. an undetected broken bone
  2. a torn or avulsed ligament
  3. cancer
  4. Damage to the cortex of the bone

2) Answer: There are multiple injuries that are often called sprains and strains, and really are not. Classically, a patient may hurt their back or neck, and be told it is just a sprain or strain. However, if the pain lasts longer than 6 weeks, the injury could be a facet syndrome, a internal disc disruption, a torn ligament, creating excessive motion in a spinal segment, or joint, or a host of other diagnoses. For a comprehensive analysis of the problem, the use of the Mensana Clinic Diagnostics Diagnostic Paradigm and Treatment Algorithm is suggested. This test is available over the Internet in 8 languages (English, Spanish, Italian, French, German, Portuguese, Arabic and Russian) and takes the patient about 40 to 70 minutes to complete the test. Go to dmpdiagnostics.com A narrative summary, and diagnosis is emailed back to the you within 5 minutes of completion of the test. Then you take the test results to your doctor.

#49 Question: What is thoracic outlet syndrome?

  1. where your heart has reduced output
  2. A syndrome where you have reduced breathing
  3. A syndrome where you have pain in the thoracic spine
  4. A syndrome where you have pain and numbness down your arm, worsened by use over your head.

Answer: It is a clinical condition, where the nerve roots from the cervical spinal cord C4 T1 come together and mix in the brachial plexus, which is found in the area between the neck and the armpit. The plexus passed through the anterior and median scalene muscle, at a point over the first rib. The nerves then emerge from the plexus as mixed motor-sensory peripheral nerves, such as the ulnar nerve, the radial nerve, the median nerve, etc. Also the artery and vein that supply the arm pass through the brachial plexus. Thoracic outlet syndrome is caused by compression of the brachial plexus nerve or by compression of the artery and vein. Typically this occurs after “whiplash” injuries from auto accidents, excessive use of the arms, or stretch injury to the arm. Clinically, it manifests as weakness, pain and numbess down the arm, typically worsend with use of the arm over your head. Only 10% of thoracic outlet cases involve vascular compression, and 67% of cases are post traumatic in origin. (Dellon, A.L., Hendler, N., Hopkins, J.E.T., Karas, A.C., Campbell, J.N.: “Team management of Patients with Diffuse Upper Extremity Complaints.” Maryland Medical Journal. Vol. 35, No. 10:849-852, October, 1986.) (Empting-Koschorke, L.D., Hendler, N., Kolodny, A.L., Kraus, H.: “Tips on Hard-to-Manage Pain Syndromes.” Patient Care. Vol. 24, No. 8:26-46, April 30, 1990)

#50 Question: How do you diagnosis thoracic outlet syndrome?

  1. MRI of the neck
  2. MRI of thoracic outlet
  3. EMG/nerve conduction velocity studies
  4. Do a Roos manuever

4) Answer: The clinical symptoms of thoracic outlet syndrome are pins and needles into the little and ring finger, numbness in the arm when the patient uses their arms over their head, the arm falling asleep, with tingling down the arm with use over the patient’s head, weakness in the arm, and pain. The best clinical test is the Roos maneuver, where you ask the patient to hold their arms up for three minutes. If the symptoms are reproduced, this helps confirm the diagnosis of thoracic outlet syndrome. Finally, compression of the brachial plexus by putting pressure in the armpit, to see if this reproduces the symptoms is another good clinical test. EMG/Nerve conduction velocity studies are virtually useless, because the measurement across the brachial plexus (Erb’s point) is so short, that the studies are unreliable. Trigger point injections, with bupivicaine, into the anterior and medial scalene muscles to take the muscle out of spasm produce temporarily relief, and help to confirm the diagnosis. Since only 10% of thoracic outlet syndrome cases have vascular compression, the use of the Adson maneuver to measure loss of pulse is not a good test, since the doctor will miss 90% of the cases that have only nerve compression, without vascular compression. (Dellon, A.L., Hendler, N., Hopkins, J.E.T., Karas, A.C., Campbell, J.N.: “Team Management of Patients with Diffuse Upper Extremity Complaints.” Maryland Medical Journal. Vol. 35, No. 10:849-852, October, 1986.) (Empting-Koschorke, L.D., Hendler, N., Kolodny, A.L., Kraus, H.: “Tips on Hard-to-Manage Pain Syndromes.” Patient Care. Vol. 24, No. 8:26-46, April 30, 1990).

#51 Question: How do you treat thoracic outlet syndrome.

  1. Removal of the first rib surgically
  2. Exercise
  3. Physical therapy
  4. Have patient hold weights and let his/her arms hand down

1) Answer: The treatment that is most effective is surgery through the armpit to remove the first rib, to decompress the plexus. Additionally, surgery on the plexus itself to remove scar tissue off the nerve, using the supra-clavicular approach, is also helpful. (Dellon, A.L., Hendler, N., Hopkins, J.E.T., Karas, A.C., Campbell, J.N.:”Team Management of Patients with Diffuse Upper Extremity Complaints.” Maryland Medical Journal. Vol. 35, No. 10:849-852, October, 1986.) (Empting-Koschorke, L.D., Hendler, N., Kolodny, A.L., Kraus, H.: “Tips on Hard-to-Manage Pain Syndromes.” Patient Care. Vol. 24, No. 8:26-46, April 30, 1990)

#52 Question: What is carpel tunnel syndrome?

  1. entrapment of the ulnar nerve at the elbow
  2. entrapment of the tibial nerve at the ankle
  3. entrapment of the median nerve at the wrist
  4. contractures of the ligaments of the hand, causing a “claw hand.”

3) Answer: Carpel tunnel syndrome is caused by compression of the median nerve at the wrist. It may occur after repetitive motion, or grasping activity, or repetitive lifting. Working on a computer keyboard with the wrist hyper-extended for long periods of time can produce carpel tunnel syndrome. Also, hypothyroidism can cause carpel tunnel.

#53 Question: How do you diagnosis carpel tunnel syndrome?

  1. MRI of the wrist
  2. CT of the wrist
  3. Bone scan
  4. Nerve block of the median nerve

4) Answer: The symptoms of carpel tunnel are pins and needles and tingling into all fingers of the hand, after use of the hand, or hyper-extension. Have the patient hyper-extend their wrist, and then tap on the middle of the wrist where it joins the bottom of the hand. If this reproduces the pins and needles and pain, this is a positive Tinel sign, and diagnoses carpel tunnel syndrome. Very often people told they have fibromyalgia really have carpel tunnel syndrome. Also use current perception threshold testing, EMG/nerve conduction velocity testing if there is weakness, and nerve blocks around the median nerve at the wrist, to confirm the diagnosis. (Sarmer S., Yavuzer G., Kucukdeveci A., Ergin S., Prevalence of carpal tunnel syndrome in patients with fibromyalgia, Int, Jul 22(2): pp. 68-70, 2002, Perez-Ruiz F. , Calabozo M., Alonso-Ruiz A., Herrero A., Ruiz-Lucea E., Otermin I., High prevalence of undetected carpal tunnel syndrome in patients with fibromyalgia syndrome, J. Rheumatol., Mar 22(3): pp. 501-4, 1995).

#54 Question: How do you treat carpel tunnel syndrome?

  1. Physical therapy
  2. Treating patient for Vitamin B12 deficiency
  3. Controlling blood sugar levels
  4. Decompression of the median nerve at the wrist using surgery

Answer: Conservative treatments consist of wrist braces and Vit. B 6 50mg four times a day. Try this for 2 months. If there is entrapment of the median nerve, then surgical decompression is the only way to relief the symptoms. Thyroid studies, including T3, T4, TSH, thyroid binding globulin, and thyroid antibodies should be done. If there is evidence of hypothyroidism, thyroid replacement therapy should be instituted.

#55 Question: What is lateral femoral cutaneous nerve entrapment (meralgia paresthetica)?

  1. Nerve entrapment of the motor nerve at the back of the thigh
  2. Nerve entrapment of the sensory nerve on the outside of the thigh
  3. Nerve entrapment of the genito-femoral nerve in the groin
  4. Compression of the femoral nerve by the quadriceps muscle

2) Answer: Lateral femoral cutaneous nerve entrapment is caused by compression of the lateral femoral cutaneous nerve at the anterior-lateral thigh. It may occur after repetitive trauma, such as hitting the outside of the patient’s hip, and is often occupationally related. Chronic meralgia paresthetica, not related to traumatic or lesion-producing compression of the nerve, is associated with obesity, pregnancy, tight-fitting garments, as well as specific duty uniform belts used by police officers and carpenters. Recently, body armor used by US troops in Iraq, ( Fargo MV, Konitzer LN., 172nd Stryker Brigade Combat Team, Baghdad, Iraq. Meralgia paresthetica due to body armor wear in U.S. soldiers serving in Iraq: a case report and review of the literature.Mil Med. 2007 Jun;172(6):663-5), and tight fitting pants (Moucharafieh R, Wehbe J, Maalouf G. Meralgia paresthetica: a result of tight new trendy low cut trousers (‘taille basse’). Int J Surg. 2008 Apr;6(2):164-8. Epub 2007 Apr 14) have been identified as causes.

#56 Question: How do you diagnosis lateral femoral cutaneous nerve entrapment (meralgia paresthetica)?

  1. MRI of the groin
  2. CT of the groin
  3. Bone scan
  4. Nerve block of the lateral femoral cutaneous nerve

4) Answer The symptoms of lateral femoral cutaneous nerve entrapment are pins and needles and tingling into the outside of the thigh and top of the thigh. The doctor should tap on outside of the thigh at the level of the most extended part of the hip. If this reproduces the pins and needles and pain, this is a positive Tinel sign, and diagnoses lateral femoral cutaneous nerve entrapment. Also use current perception threshold testing, EMG/nerve conduction velocity testing if there is weakness, and nerve blocks around the lateral femoral cutaneous nerve entrapment, to confirm the diagnosis.

#57 Question: How do you treat lateral femoral cutaneous nerve entrapment?

  1. implantable morphine pump
  2. epidural stimulator
  3. surgical decompression of the lateral femoral cutaneous nerve
  4. exercise
  5. C) Answer: Conservative treatments consist of avoiding tight trousers, local steroid infiltration and weight reduction. If there is entrapment of the lateral femoral cutaneous nerve entrapment, then surgical decompression is the only way to relief the symptoms (Ducic I, Dellon AL, Taylor NS., Decompression of the lateral femoral cutaneous nerve in the treatment of meralgia paresthetica. Reconstr Microsurg. 2006 Feb;22(2):113-8).

#58 Question: What is temporomandibular (TMJ) joint syndrome?

  1. Damage to the ligaments and/or disc of the joint between the skull and the head of the jaw causing a click when you open your jaw.
  2. Damage to the temple joint with pain in the eyes
  3. Damage to the jaw requiring tooth extraction
  4. Damage to the temporal teeth causing jaw pain

1) Answer: Damage to the ligaments and/or disc of the joint between the skull and the head of the jaw. The temporomandibular (TMJ) joint is a very unusual joint. It is formed by the head of the condoyle of the jaw (mandible) inserting into a recess in the skull right beneath the temporal bone. The jaw bone is held to the skull by this joint, and the ligaments that hold the jaw to the skull are the strong lateral temporomandibular ligaments and two weaker medial ligaments(Guralnick, W, Kaban, L, and Merrill, R, Temporomandibular joint afflictions, New England Journal of Medicine, Vol. 299, No. 3, pp 120-129, July 20, 1978). The nerves that supply the joint are the auriculotemporal and massetric branches of the third division of the trigeminal nerve (Guralnick, W, Kaban, L, and Merrill, R, Temporomandibular joint afflictions, New England Journal of Medicine, Vol. 299, No. 3, pp 120-129, July 20, 1978).

#59 Question: How do you diagnosis temporomandibular (TMJ) joint syndrome? One or more answers

  1. X-rays of the teeth
  2. CT of the jaw
  3. MRI with the jaw open and shut
  4. Clinically, by detecting a click on opening and shutting the jaw.

3, 4) Answer: Facial pain, in the cheek, in the area of the joint, in the jaw line, ringing in the ear, dizziness, in the temple and clicks in the jaw on opening or closing the jaw are typical. (Gelb, H, TMJ Syndrome: The tell-tale click, Behavioral Medicine, March, 1978). TMJ is often diagnosed as something else, such as Menierre’s syndrome, or trigeminal neuralgia. (Commentary, The Great Imposter: Diseases of the Temporomandibular (TMJ) joint, JAMA, Vol. 235, No. 22, May 31, 1976). Sometimes MRIs with the jaws open and shut will reveal a displaced meniscus, between the jaw and the skull. Injection of ¼ cc of .05% bupivicaine in the the sternocleidomastoid muscle may give temporary relief, thereby confirming the diagnosis.

#60 Question: How do you treat temporomandibular (TMJ) joint syndrome?

  1. Grind the teeth to allow the jaw to close properly
  2. The use of over the door traction
  3. A bite plate
  4. Extraction of the wisdom teeth
  5. C) Answer: Muscles relaxants and anti-inflammatory drugs such as iboprophen, or naproxen are helpful. Guralnick, W, Kaban, L, and Merrill, R, Temporomandibular joint afflictions, New England Journal of Medicine, Vol. 299, No. 3, pp 120-129, July 20, 1978). The use of a Kil-Brux night guard may help. The dentist should never grind down the teeth, which alters the bite and repositions the jaw. Only in rare instances is surgery recommended, and rarely does it improve the condition.

#61 Question: What is trigeminal neuralgia?

  1. pain in the pathway of the trigeminal nerve (the 5th cranial nerve)
  2. motor weakness of the trigeminal nerve
  3. tingling in the pathway of the trigeminal nerve
  4. eyelid drooping and facial weakness

A)Answer: There are two main etiologies to the pain of trigeminal neuralgia. The pain can be constant, or intermittent, and follows the path of the sensory branches of the trigeminal nerve, into the forehead, along the cheek bone, or in the jaw line or any combination of the three (Empting, L, Hendler, N, Kolodny, L, Kraus, H, Tips on hard to manage pain syndromes, Patient Care, page 26-46, April 30, 1990). One etiology is compression of the trigeminal nerve by the middle cerebral artery in the skull (Sekula RF, Marchan EM, Fletcher LH, Casey KF, Jannetta PJ. Microvasculardecompression for trigeminal neuralgia in elderly patients. J Neuro Neurosurg.2008 Apr;108(4):689-91), and the other is a herpetic-like viral irritation of the trigeminal nerve. (Empting, L, Hendler, N, Kolodny, L, Kraus, H, Tips on hard to manage pain syndromes, Patient Care, page 26-46, April 30, 1990).

#62 Question: How do you diagnose trigeminal neuralgia?

  1. The location of the pain, and the hyperalgesia associated with the pain
  2. The MRI findings of a tumor on the trigeminal nerve
  3. EMG/nerve conduction velocity findings
  4. The skin lesions associated with the pain and weakness

1)Answer: The pain can be constant, or intermittent, and follows the path of the sensory branches of the trigeminal nerve, into the forehead, along the cheek bone, or in the jaw line or any combination of the three (Empting, L, Hendler, N, Kolodny, L, Kraus, H, Tips on hard to manage pain syndromes, Patient Care, page 26-46, April 30, 1990). The pain is sensitive to light touch, and may occur in burst of pain, rather than being constant. It is important to differential post-herpetic from intra-cranial etiologies, so an MRI of the brain, with thin-sections (2 mm slices), through the trigeminal nerve, and an MRA may be helpful in differentiating the post-viral etiology from the compression of the nerve by the blood vessel.

#63 Question: What is the treatment of trigeminal neuralgia?

  1. It depends on the etiology, whether it is surgical or medical
  2. Deep brain stimulation with electrodes
  3. Cutting the trigeminal nerve
  4. Ultraviolet light shinned on the face

1)Answer: Since there are two main etiologies to the pain of trigeminal neuralgia, there are two types of treatment. If the etiology is compression of the trigeminal nerve by the middle cerebral artery in the skull, then the treatment is intra-cranial decompression of the nerve, by inserting a sponge between the artery and the nerve (Sekula RF, Marchan EM, Fletcher LH, Casey KF, Jannetta PJ. Microvasculardecompression for trigeminal neuralgia in elderly patients. J Neuro Neurosurg.2008 Apr;108(4):689-91). If the etiology is due to a herpetic-like viral irritation of the trigeminal nerve. (Empting, L, Hendler, N, Kolodny, L, Kraus, H, Tips on hard to manage pain syndromes, Patient Care, page 26-46, April 30, 1990), then the treatment is the use of medications. Some people respond to low dose anti-depressants, but the most useful medication is an anti-convulsant, such as gaba-pentin (Neurontin), or Tegretol. . Anti-viral drug, such as acyclovir will also help. Rarely, radio-frequency lesions of the retro-gausserian ganglion can be employed if all else fails.

#64 Question: What is post-herpetic neuralgia (shingles)?

  1. Every case has skin lesions
  2. It is a variant of small pox
  3. It is a viral infection of the sensory branch of mixed motor-sensory nerves
  4. It is weakness in the muscles of the face

3)Answer: The pain can be constant, or intermittent, and follows the path of the sensory branches, usually along the ribs. (Empting, L, Hendler, N, Kolodny, L, Kraus, H, Tips on hard to manage pain syndromes, Patient Care, page 26-46, April 30, 1990). Only 50% -60% of the cases have skin eruptions, but most patients have been exposed to chicken pox. The etiology is herpetic-like viral irritation of the sensory branches of these nerves. (Empting, L, Hendler, N, Kolodny, L, Kraus, H, Tips on hard to manage pain syndromes, Patient Care, page 26-46, April 30, 1990).

# 65 Question: How do you diagnose post-herpetic neuralgia (shingles)?

  1. There are always skin lesions along the ribs
  2. The distribution of the pain along the ribs
  3. There is always discolored skin
  4. Trouble breathing due to weakness of the diaphragm

2)Answer: The distribution of the pain is usually along the sensory branches of the intercostals nerves, along the ribs. It typically occurs in older people who have been exposed to chicken-pox (varicella). Classically there is a skin eruption, that darkens the skin, and appears crusty, but this occurs only 50%-60% of the time. The skin lesion may last weeks to months, and the pain may last weeks to years.

#66 Question: What is the treatment of post-herpetic neuralgia?

  1. Cut the injured nerve
  2. Use anti-convulsants, anti-virals and TENS units
  3. Radio-frequency lesions of Erbs point
  4. Use gentian violet on the skin lesions

2)Answer: Since the etiology is due to a herpetic-like viral irritation of the inter-costal nerve. (Empting, L, Hendler, N, Kolodny, L, Kraus, H, Tips on hard to manage pain syndromes, Patient Care, page 26-46, April 30, 1990), then the treatment is the use of medications. Some people respond to low dose anti-depressants, but the most useful medication is an anti-convulsant, such as gaba-pentin (Neurontin) or Tegretol. Occasionally, the use of a transcutaneous electrical stimulator (TENS) with give symptomatic relief. Anti-viral drug, such as acyclovir will also help.

#67 Question: What is Eagles syndrome (ES)?

  1. A bony lesion of the shoulder in the shape of an Eagles wing, causing arm pain
  2. An elongation of the stylo-hyoid bone, causing pain with swallowing
  3. Pain in the ear associated with dizziness
  4. Pain in the eye with swallowing.

2)Answer: ES is characterized by an a specific orofacial pain secondary to calcification of the stylohyoid ligament or elongated styoid process. In about 4% of general population an elongated styloid process occurs, while only about 4% of these patients are symptomatic. The stylo-hyoid bone is considered abnormal if it is greater than 25 mm. in length., (Casale M, Rinaldi V, Quattrocchi C, Bressi F, Vincenzi B, Santini D, Tonini G, Salvinelli F.Atypical chronic head and neck pain: don’t forget Eagle’s syndrome. Eur Rev Med Pharmacol Sci. 2008 Mar-Apr;12(2):131-3).

#68 Question: What are the symptoms of Eagles syndrome (ES) and how do you diagnosis it?

  1. The symptoms are pain with swallowing and you diagnose it with X-rays showing a stylo-hyoid bone longer than 25mm, and putting your finger into the mouth of the patient and pushing on the stylo-hyoid bone, reproducing the pain.
  2. An MRI of the skull showing an eagle-like outline at the optic chiasm
  3. Electro-nystagmography with warm water producing nystagmus
  4. Having the patient stand with his/her hands in front of them and closing their eyes to see if they get dizzy.

A)Answer: The patient has a sensation of a foreign body localized at the tonsillar fossa, associated with a dull intermittent pain. Pain is usually worse with swallowing. A bony projection is usually palpable with bimanual trans-oral exploration. Basically, you put your finger in the mouth of the patient, down their throat, and push towards the outside, where the stylohyoid bone is. If this reproduces the pain, this confirms the diagnosis. A lateral radiograph and a computed tomography scan of head and neck will show an elongated styloid process of at least 25 mm. (Casale M, Rinaldi V, Quattrocchi C, Bressi F, Vincenzi B, Santini D, Tonini G, Salvinelli F.Atypical chronic head and neck pain: don’t forget Eagle’s syndrome. Eur Rev Med Pharmacol Sci. 2008 Mar-Apr;12(2):131-3).

#69 Question: How do you treat Eagles syndrome (ES)?

  1. Excision of the Eagle-like bony lesion from the shoulder blade
  2. Neurosurgical exploration of the positive MRI results of the potic chiasm
  3. Cleaning the ear of ear wax to stop the pressure on the ear drum
  4. Excision of the bony elongation in the throat.

4)Answer: Medical treatment represents the first choice, using non-steroidal anti- inflammatory drugs. If this is not effective, then surgical styloid process resection, in the case of persistence or ingravescence of the complaint, is the only option (Casale M, Rinaldi V, Quattrocchi C, Bressi F, Vincenzi B, Santini D, Tonini G, Salvinelli F.Atypical chronic head and neck pain: don’t forget Eagle’s syndrome. Eur Rev Med Pharmacol Sci. 2008 Mar-Apr;12(2):131-3). 

# 70 Question: What is the cause of fibromyalgia?

  1. A psychosomatic disease
  2. No one really knows the etiology
  3. A variant of Lyme’s disease
  4. A muscle paralysis

2) Answer: No one really understands the etiology of fibromyalgia. Some people think it is related to thyroid disease, others relate it to a post-traumatic etiology, while some authors think it is a variant of Lyme’s disease, or even post-viral or psychological. (Sterre A.C., Current Understanding of Lyme Disease, Pract. (Off Ed), Apr 15:28(4): pp. 37-44, 1993, Garrison R.L., Breeding P.C., A metabolic basis for fibromyalgia and its related disorders: the possible role of resistance to thyroid hormone, Med Hypotheses, Aug 61(2): pp.182-9, 2003, Turk D.C., Okifuji A., Starz T.W., Sinclair J.D., Effects of type of symptoms onset on psychological distress and instability in fibromyalgia syndrome patients, Pain Dec 68(2-3): pp. 423-30, 1996, Waylonis G.W., Perkins R.H., Post-traumatic fibromyalgia: A long-term follow-up, Am J. Phys. Med. Rehabil.May-Dec(73(6): pp. 403-12, 1994)

#71 Question: How do you diagnosis fibromyalgia.?

  1. When a patient has various complaints in the joints and you can’t understand what causes them then it is fibromyalgia
  2. Pain in at least 11 of 18 points on the body, unexplained by other causes
  3. A depressive equivalent, with a history of previous hospitalization for a depressive episode.
  4. Joint pain with swelling in at least 4 joints.

2)Answer: The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia is:

  • History of widespread pain has been present for at least three months.
  • Widespread is defined as pain in both sides of the body, and
  • pain above and below the waist.
  • In addition, axial skeletal pain (cervical spine, anterior chest, thoracic spine or low back pain should be present.
  • Low back pain is considered lower segment pain.
  • Pain in at least 11 of 18 tender point sites on digital palpation:

a) Occiput (2) at the suboccipital muscle insertions.

b) Low cervical (2) at the anterior aspects of the intertransverse spaces at C5-C7.

c) Trapezius (2) at the midpoint of the upper border.

d) Supraspinatus (2) at origins, above the scapula spine near the medial border.

e) Second rib (2) upper lateral to the second costochondral junction.

f) Lateral epicondyl (2) 2 cm distal to the epicondyles.

g) Gluteal (2) in the upper outer quadrants of buttocks in anterior fold of muscle.

h) Greater trochanter (2) posterior to the trochanteric prominence.

i) Knee (2) at the medial fat pad proximal to the joint line.

  • Digital palpation should be performed with the approximate force of 4 kg.
  • A tender point has to be painful at palpation, not just “tender.”

(http://www.nfra.net/Diagnostic.htm) National Fibromyalgia Research Association.

#72 Question: How do you treat fibromyalgia?

  1. Surgical excision of the parathyroid gland
  2. Long term psychotherapy
  3. First, establish the proper diagnosis, using the diagnostic criteria, and then use a variety of medications
  4. Tell the patient to stop using caffeine, stop smoking, stop drinking alcohol and to increase Vitamin B1,2 and 3 intake.

3)Answer: Symptomatic treatment seems to be the only way to proceed, since no-one knows the origin of the disorder. Anti-depressants to help sleep, anti-inflamatory drugs, even thyroid medication have been used with varying degrees of success.

#73: Question: What is slipping rib syndrome (rib tip syndrome)?

  1. There is a big lumps where one ribs slips over one another.
  2. Pain in the lower part of the front of the chest wall, usually post-traumatic.
  3. Where one rib dislocates from the spine, and hangs loose in the chest
  4. A syndrome where the chest wall muscle slip over the rib

2)Answer: Pain in the lower part of the front of the chest wall. The floating ribs are usually 9, 10 11 and 12, and these do not attach to the sternum. The rib tip, at the front of the chest wall, angles upward and attached by a cartilaginous connection to the rib above it. Displacement of the rib tip is the etiology of slipping rib or rib tip syndrome. It is usually post-traumatic in origin, but can occur after coughing a lot, or a deep breath. (Udermann BE, Cavanaugh DG, Gibson MH, Doberstein ST, Mayer JM, Murray SR. Slipping Rib Syndrome in a Collegiate Swimmer: A Case Report. J. Athl Train, 2005, Jun 40 (2): 120-122)

#74 Question: How do you diagnosis slipping rib syndrome (rib tip syndrome)?

  1. An X-ray of the rib to see if the rib tip in displaced over another rib
  2. An MRI of the rib to see if the rib tip in displaced over another rib
  3. An CT of the rib to see if the rib tip in displaced over another rib
  4. Put your and under the 12th rib and lift up

4)Answer: The doctor should slip his finger tips under the lateral rib cage, at the base of the 12th. Rib, and gently lift up. If this reproduces the symptoms, the patient has slipping rib syndrome. Pain in the lower part of the front of the chest wall.

#75 Question: How do you treat slipping rib syndrome (rib tip syndrome)?

  1. Suture the slipping rib to the rib above it.
  2. Cut out the entire rib
  3. Cut the nerve along the bottom of the rib
  4. Cut the rib tip off

D)Answer: Sometimes, local steroid injections into the rib tips may help, as well as anti-inflammatory drugs, and non-steroidal anti-inflammatory medication. However, for severe cases, excision of the rib tibs, so they no longer push on the sensory nerve of the rib above, seems to be the only solution. (Udermann BE, Cavanaugh DG, Gibson MH, Doberstein ST, Mayer JM, Murray SR. Slipping Rib Syndrome in a Collegiate Swimmer: A Case Report. J. Athl Train, 2005, Jun 40 (2): 120-122)

#76 Question: What is piriformis muscle syndrome (PMS) and the cause of it?

  1. Pain in the shoulder radiating down the arm, due to piriformis muscle entrapment of the shoulder blade, with pain the the shoulder blade.
  2. Pain in the chest wall cause by a combination of a slipping rib, and Tietze syndrome, with pain in the chest wall,
  3. Entrapment of the sciatic nerve between the two heads of the priformis muscle, with pain in the buttock
  4. Entrapment of the common peroneal nerve by the two heads of the piriformis muscle, and pain in the buttock

Answer: MRI abnormality for the PMS were studies in 10 patients. In two of ten people, the MRI demonstrated a bi-gastric appearance of the piriformis muscle with a tendonous portion between the muscle heads and the course of the sciatic/common peroneal nerve through the muscle between the tendonous portions of the muscle. In one patient of the ten, the sciatic/common peroneal nerve passed through the hypertrophied piriformis muscle. In four patients of the ten studied, the MRI showed a hypertrophied aspect of the piriformis muscle and an anteriorly displaced sciatic nerve. (Pecina HI, Boric I, Smoljanovic T, Duvancic D, Pecina M. Surgical evaluation of magnetic resonance imaging findings in piriformis muscle syndrome. Skeletal Radiol. 2008 Jul 12. [Epub ahead of print])

#77 Question: How do you diagnosis piriformis muscle syndrome (PMS)?

  1. Clinical sign of pain in the buttock, worsened by direct pressure, MRI, and relieved by a block of the area
  2. CT of the buttock with use of anti-depressants
  3. Pressure on the ribs reproduces the buttock pain
  4. X-ray of the pelvis and venogram to look for vascular abnormalities

1)Answer: Patients complain of pain locally in the buttock, and radiating down the back of their leg. Pain is worse with sitting. Pressure on the area of the buttock where the piriformis muscle is reproduces the pain down the leg. Injections of ½ cc of .5% bupivocaine into the area of the piriformis muscle gives 1 to 2 hours of relief. MRI confirms the diagnosis in 7 of 10 patients. (Pecina HI, Boric I, Smoljanovic T, Duvancic D, Pecina M. Surgical evaluation of magnetic resonance imaging findings in piriformis muscle syndrome. Skeletal Radiol. 2008 Jul 12. [Epub ahead of print])

#78 Question: How do you treat piriformis muscle syndrome (PMS)?

  1. Exercise with over the leg extension from sitting position
  2. Cold pack with use of anti-inflammatory drugs
  3. Cut the sciatic nerve
  4. Neurolysis (removal of scar tissue) of the sciatic nerve

Answer: Surgical treatment, i.e., a tenotomy (forming a tent) of the piriformis muscle and neurolysis of the sciatic nerve, to free it of scar tissue, resolved symptoms in 10 of 10 reported patients. All symptoms disappeared in 10 of the 10 patients reported. (Pecina HI, Boric I, Smoljanovic T, Duvancic D, Pecina M. Surgical evaluation of magnetic resonance imaging findings in piriformis muscle syndrome. Skeletal Radiol. 2008 Jul 12. [Epub ahead of print])

#79 Question: What is sciatica and the cause of it?

  1. Sciatica is irritation of the sciatic nerve, with resulting pain down the leg, and may be caused by compression of any of the 5 nerve roots which comprise the sciatic nerve.
  2. Sciatica is the old time inflammation of the sciatic nerve due to arthritis and rheumatism.
  3. Sciatica is irritation of the sciatic nerve, with resulting pain down the leg, and may be caused by a herniated disc at L5-S1
  4. Sciatica is irritation of the sciatic nerve, with resulting pain down the leg, and may be caused compression of just the L5-S1 nerve root.

1)Answer: The sciatic nerve is a mixed sensory-motor nerve made up of contributions from the L2, L3, L4, L5 and S1 nerve roots. There are many etiologies to sciatica, including compression between the two heads of the piriformis muscle, as it emerges from the buttock, pelvic compression, and compression of the nerve roots before they enter the pelvic plexus, as well as spinal canal stenosis. Rarely, a tumor may compress the nerve anywhere along its route. True sciatica is different than an L4-5 or L5-S1 radiculopathy, although both will produce pain in the buttock and down the back of the leg. It is important to differentiate between the radiculopathy and the true sciatica, since the treatment is different. 

#80 Question: How do you diagnose sciatica?

  1. MRI showing disc herniation at L5-S1
  2. Bone scan showing irritation of the bone around the L5-S1 neural foramin
  3. Nerve root blocks L1-S1, MRI of L1-S1, and provocative discograms, L1-S1.
  4. Doppler flow studies showing vascular compression of the sciatic artery

3)Answer: Clinically, compression of the sciatic nerve will create pain and in severe cases, weakness down the back of the leg and calf into the foot. The differential diagnosis needs to include evaluation of all of the pre-plexus nerve roots that contribute to the post-plexus mixed sciatic nerve. Very often, an L4-5 or L5-S1 radiculopathy is mistakenly called sciatica. A provocative discogram defines if the pain is discogenic in origin. EMG/Nerve conduction velocity finding, and nerve root blocks of L1 through S1, and blocks of the sciatic nerve will differentiate a nerve root problem, or a mixed sensory motor sciatic nerve problem. MRI findings may reveal piriformis syndrome, or nerve root compression before the plexus, or spinal stenosis. 

#81 Question: How do you treat sciatica?

  1. The treatment depends on the origin of the pathology, since there are multiple causes
  2. L5-S1 disectomy and fusion
  3. L5-S1 disectomy without fusion, and use oral steroids
  4. L4-5 and L5-S1 disectomy and fusion

A)Answer: Again, this depends on the etiology. True sciatica is different than an L4-5 or L5-S1 radiculopathy, although both will produce pain in the buttock and down the back of the leg. You can have an L2-3 or L3-4 root irritation with clinical manifestations of sciatica. It is important to differentiate between the radiculopathy and the true sciatica, since the treatment is different. If the origin is due to post-lumbar plexus entrapment of the sciatic nerve or compression by a tumor, then local decompression is the correct treatment (see piriformis muscle syndrome). However, if the origin is before the plexus, then appropriate treatments for radiculopathies need to be implemented. Oral or epidural steroids have little or no benefit, except for possibly lessening the period of time of the symptoms. (Holve RL, Barkan H.Oral steroids in initial treatment of acute sciatica J Am Board Fam Med. Sep Oct;21(5):469-74. 2008).

#82 Question: What medications do you use to help patients with chronic pain sleep?

  1. Dalmane alone
  2. Xanax or Valium alone
  3. Dalmane or Restoril or Ambien with narcotics
  4. Anti-depressant, which block the reuptake of serotonin, at a high enough dose to promote sleep.

3)Answer: There are four reasons patients do not sleep. They are anxious, they are depressed, they have pain, or they have sleep apnea. Natural sleep is produced by the release of serotonin by neurons in the dorsal raphe nucleus of the reticular activating system.. Most sleep medications work by activity on the GABA synaptic receptor. Activation of this receptor inhibits the release of serotonin. Therefore, using rationale pharmacology, the best medications to help a patient with chronic pain sleep are anti-depressants, which inhibit the pre-synaptic reuptake of serotonin, and allow a person to sleep naturally. They also help to relieve the depression and anxiety found in chronic pain patients, and help pain to some degree. (Hendler, N. Pharmacological Management of Pain, in Practical Management of Pain, third edition, edited by P. Prithvi Raj, MD, Mosby, St Louis, pp 145-155, 2000).

#83 Question: What medications do you use to help a chronic pain patient with depression?

  1. Any type of anti-depressant that works for the patient
  2. Elavil or Desipramine
  3. Ritalin to give patients more energy, and to counteract the depression from narcotics
  4. Parnate or Marplan

1)Answer: It is very natural for chronic pain patients to get depressed. Hendler reported that 89% of chronic pain patients who had never been depressed before there pain, got depressed at the result of their pain. (Hendler, N.: “Validating and Treating the Complaint of chronic Back Pain: The Mensana Clinic Approach.” Clinical Neurosurgery. Vol. 35, Chap. 20:385-397, eds. Black, P., Alexander, E., Barrow, D., et. al., Williams and Wilkins, Baltimore, 1988).Therefore, the use of various types of anti-depressants is useful, especially if they block serotonin reuptake, and are given all at night to may use of their drowsy side-effects. Drugs that work best are Sinequan, Effexor, Desyrel, and Cymbalta, but each person has their own personal differences, so keep trying medications til a suitable one is found. (Hendler, N. Pharmacological Management of Pain, in Practical Management of Pain, third edition, edited by P. Prithvi Raj, MD, Mosby, St Louis, pp 145-155, 2000).

#84 Question: What medications do you use to help a chronic pain patient with anxiety?

  1. Xanax
  2. Valium
  3. Any anti-depressant that works for the patient
  4. Stellazine

Answer: 80% of the symptoms of anxiety and depression overlap, and many of the antidepressants have anti-anxiety properties. So, the use of anti-depressants for anxiety is a logical approach to treating the anxiety associated with chronic pain. (Hendler, N. Pharmacological Management of Pain, in Practical Management of Pain, third edition, edited by P. Prithvi Raj, MD, Mosby, St Louis, pp 145-155, 2000).

#85 Question: What medications do you use for treating the pain itself?

  1. Only narcotics work for pain relief
  2. High does of anti-depressants
  3. Anti-depressants with phenothiazine tranquillizers
  4. The medication depends on the origin of the pain

D)Answer: Again, this depends on the type of pain and the origin of it. If a patient has pain that is primarily neuropathic in origin, such as herpes simplex, or zoster, or nerve entrapments, then using a medication designed to raise the threshold of the nerve membrane to reduce the firing of the nerve is appropriate. In this case you would use anti-convulsants, sometimes in conjunction with anti-depressants. (Hendler, N. Pharmacological Management of Pain, in Practical Management of Pain, third edition, edited by P. Prithvi Raj, MD, Mosby, St Louis, pp 145-155, 2000). On the other hand, if the pain were associated with muscle spasm, then muscle relaxants would be indicated. If the pain were bony in origin, then non-steroidal anti inflammatory drugs would work. Narcotics can provide symptomatic relief for most types of pain, but some people report they do not work well for neuropathic pain. (Hendler, Pharmacological Management of Pain, in Practical Management of Pain, third edition, edited by P. Prithvi Raj, MD, Mosby, St Louis, pp 145-155, 2000).

#86 Question: Why should you not use benzodiazepines for sleep or for anxiety in chronic pain patients?

  1. They cost too much, and you can use phenobarbital instead, which is much cheaper
  2. They cause memory loss, interfere with REM sleep, and are addicting
  3. They interfere with the action of narcotics, and paradoxically make the patient more anxious
  4. Patients get nausea, constipation and flatulence from them

2)Answer: Benzodiazepines may create memory loss and EEG changes, and IQ drops, even more so than narcotics.(Hendler, N., Cimini, C., Ma, T., Long, D.: “A Comparison of Cognitive Impairment Due to Benzodiazepines and to Narcotics.” The American Journal of Psychiatry. Vol. 137, No. 7:828-830, July 1980).Moreover, the benzodiazepines interfere with the release of serotonin, and this may interfere with natural REM sleep, and create depression. Finally, they do have many addicting properties. (Hendler, N. Pharmacological Management of Pain, in Practical Management of Pain, third edition, edited by P. Prithvi Raj, MD, Mosby, St Louis, pp 145-155, 2000).

#87 Question: Why do chronic pain patients get depressed? You may answer one or more answers

  1. Because they can’t sleep at night
  2. Because their sexual activity is compromised
  3. Because they can’t participate in hobbies
  4. All of the above

4)Answer: The short and most obvious answer is “because they have chronic pain,” and have experienced losses as the result of that. Chronic pain produced a set of symptoms, such as sleep disturbance, anxiety, and depression because the person very often has a change in life, style, cannot work, enjoy sex, participate in hobbies, or even take care of their usual tasks at home. (Hendler, N.: “Depression Caused by Chronic Pain.” The Journal of Clinical Psychiatry. Vol. 45, No. 3, Sec. 2:30-36, March, 1984). The patients go through 4 stages in response to their depression, that take 3 to 12 years to traverse. (Hendler, N: “The Four Stages of Pain.” Chapter 1, in Diagnosis and Treatment of Chronic Pain, eds. Hendler, N, Long, D. and Wise, T., Johm Wright/PSG, Boston, 1982).

#88 Question: What is the risk of suicide in chronic pain patients.?

  1. the same as the general population
  2. since they have psychological problems even before their pain, they are mentally unstable, they commit suicide 4 time more frequently that the general population
  3. Two to three times more frequently than the general population
  4. Less frequently than the general population, since they are waiting for their big settlement for their legal cases.

3)Answer: Dr. Fishbain at Unniversity of Miami found that the suicide rate amongst chronic pain patients was 2 times higher than the general population, and if the person was involved in a workers compensation case, then the rate was 3 times higher. (Fishbain, DA, Goldberg, M, Rosomoff, RS, Rosomoff, H, Completed suicide in chronic pain, Clin. J. Pain., March 7 (1), pp. 29-36, 1991).

#89 Question: What percentage of the time are chronic pain patients faking or malingering?

  1. If they are involved in litigation, then 25% of the time they are faking, trying to get a bigger settlement.
  2. If they are not involved in litigation, there are psychological factors such as conversion reaction, about 20 % of the time.
  3. If they are involved in litigation 5%-13% are exaggerating their symptoms.
  4. Since they have secondary gain, at least 50% of the time

3)Answer: A very small percent of the time. Hendler reported that only 6% to 13% of patients are exaggerating their symptoms (Hendler, N., Mollett, A., Viernstein, M., Schroeder, D., Rybock, J., Campbell, J., Levin, S., Long, D.: “A Comparison Between the MMPI and the ‘Mensana Clinic Back Pain Test’ for Validating the Complaint of Chronic Back Pain in Women.” Pain. No. 23:243-251, 1985. Hendler, N, Cashen, A, Hendler, S, Brigham, C, Osborne, P, LeRoy, P., Graybill, T, Catlett, L., Gronblad, M. A Multi-Center Study for Validating The   Complaint of Chronic Back, Neck and Limb Pain Using “The Mensana Clinic Pain Validity Test.” Forensic Examiner, Vol. 14, # 2, pp. 41-49, Summer 2005). However, the incidence of true conversion was less than 1 time in 6,000 cases (Hendler, N., Filtzer, D., Talo, S., Panzetta, M., Long D.: “Hysterical Scoliosis Treated with Amobarbital Narcosynthesis.” The Clinical Journal of Pain. Vol. 2, No. 3:179-182, 1987). 

#90: Question What is the best test to tell if a chronic pain patient is faking or malingering?

  1. Waddell signs
  2. Magill-Melzeck
  3. MMPI
  4. Mensana Clinic Pain Validity Test

4)Answer: The Mensana Clinic Pain Validity Test is the only test that can tell if patients are faking or malingering. Many researchers and clinician have used the MMPI, but there are no articles in the literature proving the MMPI can predict organic pathology, and three articles showing that the MMPI does not, on a consistent basis, predict the presence or absence of organic pathology. It can be found at www.MensanaDiagnostics.com (Hendler, N., Mollett, A., Viernstein, M., Schroeder, D., Rybock, J., Campbell, J., Levin, S., Long, D.: “A Comparison Between the MMPI and the ‘Mensana Clinic Back Pain Test’ for Validating the Complaint of Chronic Back Pain in Women.” Pain. No. 23:243-251, 1985, Hendler, N., Mollett, A., Talo, S., Levin, S.: “A Comparison Between the Minnesota Multiphasic Personality Inventory and the ‘Mensana Clinic Back Pain Test’ for Validating the Complaint of Chronic Back Pain.” Journal of Occupational Medicine. Vol. 30, No. 2:98-102, February, 1988, Hendler, N., Mollett, A., Viernstein, M., Schroeder, D., Rybock, J., Campbell, J., Levin, S., Long, D.: “A Comparison Between the MMPI and the ‘Hendler Back Pain Test’ for Validating the Complaint of Chronic Back Pain in Men.” The Journal of Neurological & Orthopaedic Medicine & Surgery. Vol. 6, Issue 4:333-337, December, 1985).

#91 Question: What does the Mensana Clinic Pain Validity Test tell you?

  1. If a patient does or doesn’t have psychological problems
  2. If the patient does or doesn’t have real organic pathology
  3. If the patient does or doesn’t need medication to get well
  4. If the patient does or doesn’t have litigation involved in their case.

2)Answer: The Mensana Clinic Pain Validity Test can predict which patient will have an abnormality on at least one objective medical test, designed to measure organic pathology, with 95% accuracy, and who will not have any abnormalities with 85% accuracy, regardless of pre-existing or co-existing psychopathology. The test can be administered over the Internet, and is found at www.MensanaDiagnostics.com. (Hendler, N. and Baker, A., An Internet questionnaire to predict the presence or absence of organic pathology in chronic back, neck and limb pain patients, Pan Arab Journal of Neurosurgery, April, 2008).

#92 Question: How longer will it take for my patients to take the Mensana Clinic Pain Validity Test over the Internet?

  1. 10-20 minutes for each test
  2. 25-50 minutes
  3. 60-120 minutes
  4. d) at least 120 minutes or more

 1)Answer: The Mensana Clinic Pain Validity Test can be administered over the Internet by any person with a computer with Internet access, by going to www.MensanaDiagnostics.com, once an account has been established. A charge card can be used to pay for the test. The test will take 10 to 20 minutes for your patient to complete depending on how quickly they can read, or if the test has to be read to them. It is available in English, and Spanish. Results would be emailed back to the physician in 5 minutes. (Hendler, N. and Baker, A., An Internet questionnaire to predict the presence or absence of organic pathology in chronic back, neck and limb pain patients, Pan Arab Journal of Neurosurgery, April, 2008).

#93 Question: Since 40%-67% of chronic pain patients are misdiagnosed, is there a way for me to check my diagnosis for my chronic pain problem that is a good as a doctor?

Answer: Yes, by using the Mensana Clinic Diagnostic Paradigm. Go to www.dmpdiagnostics.com The Mensana Clinic Diagnostic Paradigm can be taken over the Internet by any person with a computer with Internet access. There is a 95% correlation between Diagnostic Paradigm diagnoses and the diagnoses of Johns Hopkins Hospital staff members. A charge card can be used to pay for the test. The test will take 40 to 80 minutes for you to complete depending on how many medical complaints you have, how quickly you can read, or if the test has to be read to you. It is available in English, Spanish, Arabic, French, Italian, German, Russian, and Portuguese. Results would be emailed back to the test taker in 5 minutes. (Hendler, N., Berzoksky, C. and Davis, R.J. Comparison of Clinical Diagnoses Versus Computerized Test Diagnoses Using the Mensana Clinic Diagnostic Paradigm (Expert System) for Diagnosing Chronic Pain in the Neck, Back and Limbs, Pan Arab Journal of Neurosurgery, pp:8-17, October, 2007.) There is a 40%-67% chance that a chronic pain patient is misdiagnosed or undiagnosed i.e. has an overlooked diagnosis. (Hendler, N, and Kozikowski, J, Overlooked Physical Diagnoses in Chronic Pain Patients Involved in Litigation, Psychosomatics, Vol. 34, #6, pp. 494-501, Nov.-Dec. 1993, Hendler, N, Bergson, C, and Morrison, C, Overlooked Physical Diagnoses in Chronic Pain Patients Involved in Litigation, Part 2, Psychosomatics, Vol. 37, #6, pp. 509-517, November-December. 1996). In the case of RSD (CRPS) this misdiagnosis rate may reach 71%, (Hendler, N, Differential Diagnosis of Complex Regional Pain Syndrome, Pan-Arab Journal of Neurosurgery, pp 1-9, October, 2002.) and if there is an electrical shock or lightning strike involved in the cause of the injury, the misdiagnosis rate may reach over 90% (Hendler, N., Overlooked Diagnosis in Electric Shock and Lightning Strike Survivors, Journal of Occupational and Environmental Medicine, Vol. 47, No. 8, pp. 796-805, Aug. 2005).

#94 Question: How can I find out the proper diagnostic studies and treatments or surgeries to utilize for each diagnosis. Pick one or more answers

  1. Take the diagnoses of the Diagnostic Paradigm from www.dmpdiagnostics.com/store to your doctor and ask him to order the appropriate tests. Tell him that these diagnoses correspond to diagnoses of Johns Hopkins Hospital staff members 95% of the time, based on published articles.
  2. Take the full Diagnostic Paradigm and Treatment Algorithm at www.MensanaDiagnostcs.com , and show your doctor the diagnoses and tests, which correlate with diagnoses and tests from Johns Hopkins Hosptial staff members 95% of the time, based on published articles.
  3. Go to outstanding medical centers, such as Mayo Clinic, Johns Hopkins Hospital, Yale University, Harvard University (Massachusetts General or Beth Israel) University of Pennsylvania (HUP), Stanford, UCLA, etc.
  4. All of the above

4)Answer: The Mensana Clinic Diagnostic Paradigm and Treatment Algorithm gives a treatment algorithm for each of the diagnoses it generates, which starts with the easiest tests to conduct, and then depending on results, progressed through to more complex and invasive tests, finally ending with surgery if indicated. This information is available at www.MensanaDiagnostics.com. Alternately, you can take the results of the Diagnostic Paradigm from http://www.dmpdiagnostics.com/store to your doctor. Diagnoses from the Diagnostic Paradigm correlate with the diagnoses of Johns Hopkins Hospital staff members 95% of the time.(Hendler, N., Berzoksky, C. and Davis, R.J. Comparison of Clinical Diagnoses Versus Computerized Test Diagnoses Using the Mensana Clinic Diagnostic Paradigm (Expert System) for Diagnosing Chronic Pain in the Neck, Back and Limbs, Pan Arab Journal of Neurosurgery, pp:8-17, October, 2007.)

#95 Question: How can I be sure the diagnoses on the Mensana Clinic Diagnostic Paradigm and Treatment Algorithm are the right ones?

  1. Based on articles published in the medical literature, there is a 95% correlation between the diagnoses of the Diagnostic Paradigm and those of Johns Hopkins Hospital staff members.
  2. Because you can always believe everything you see on the Internet
  3. Based on articles in the medical literature, the diagnoses of the Diagnostic Paradigm correspond to those of Mayo Clinic staff members 93% of the time
  4. Based on articles published in the medical literature, there is a 95% correlation between the diagnoses of the Diagnostic Paradigm and those of Georgetown Hosptial staff members.

1)Answer: In the article published about the Mensana Clinic Diagnostic Paradigm and Treatment Algorithm, results on the Internet test were compared to the clinical diagnoses of a Johns Hopkins Hospital staff member, and there was a 95% correlation between diagnoses. . (Hendler, N., Berzoksky, C. and Davis, R.J. Comparison of Clinical Diagnoses Versus Computerized Test Diagnoses Using the Mensana Clinic Diagnostic Paradigm (Expert System) for Diagnosing Chronic Pain in the Neck, Back and Limbs, Pan Arab Journal of Neurosurgery, pp:8-17, October, 2007.)

#96 Question: How can I be sure the recommended treatment on the Mensana Clinic Diagnostic Paradigm and Treatment Algorithm, that I get from the Treatment Algorithm at www.MensanaDiagnostics.com are the right ones?

  1. Because the test was developed at Johns Hopkins Hospital
  2. Evidence Based Medicine, which uses published outcome studies to compare results from one medical center to national norms.
  3. Because the test was developed at Mayo Clinic
  4. Because the test results were presented at the Harvard School of Cybermedicine

Answer: Evidence based medicine. Mensana Clinic published outcome studies, showing the efficacy of its techniques. As an example, most workers compensation insurance carriers report that if a patient is out of work for 2 years or more, the chance of returning to work is less than 1%. However, using the Mensana Clinic techniques, for the same type of patients, the return to work was 19.5% for workers compensation, 62.5% for auto accident cases, and there was a 90% reduction in the use of medication and a 45% reduction in the number of doctor visits (Hendler, N.: “Validating and Treating the Complaint of Chronic Back Pain: The Mensana Clinic Approach.” Clinical Neurosurgery. Vol. 35, Chap. 20:385-397, eds. Black, P., Alexander, E., Barrow, D., et. al., Williams and Wilkins, Baltimore, 1988).

#97 Question: What are the symptoms of a C2 headache and what is the cause of a C2 headache?

  1. The symptoms are pain above the eye, and back of the neck in the apex of the posterior triangle and it is cause by root irritation of the C2 nerve due to excessive motion and damage to the C2-C3 facet joints
  2. Pain in the cheek with radiation into the teeth, caused by irritation to the trigeminal nerve
  3. Pain in the ear with trouble swallowing, cause by irritation to the glossopharyngeal nerve.
  4. Deviation of the tongue, and change in smell caused by damage to the frontal lobes.

1)Answer: Most often, damage to the facet joints of the upper neck produce long lasting and headaches, unresponsive to most medication, that may persist for 6 months or longer after a neck injury. (Long, D, Davis, R, Speed, W, and Hendler, N, Fusion for Occult Post-traumatic Cervical Facet Injury, Neurosurgery Quarterly, Vol. 16, No 3, pp 129-134, Sept. 2006) Occasionally, entrapment of the C2 nerve may occur at the apex of the posterior triangle, which is at the top of the back of the sterno-cleido mastoid muscle, and the top of the front of the trapezius muscle. The Spurling maneuver (hitting the person on the top of the head to see if it reproduces the pain) should be negative, since this is indicative of disc disease.

#98 Question: How do you diagnose C2 headache:

  1. Put your finger in the ear on the affected side and swallow. If this worsens the pain, this a C2 headache
  2. If there is a click when opening the jaw, and ringing in the ear.
  3. Put pressure on the apex of the posterior triangle, and if it reproduces the pain, then try an injection at the apex of the posterior triangle.
  4. Get an MRI and CT of the C2-C5 vertebral bodies and if there is a vertebral body compression this diagnoses C2 headache

3)Answer: Pressure at the apex of the posterior triangle will reproduce the pain normally felt. The pain usually is at the back of the neck, and may radiate to the eye, or over the eyebrow. Injection of ½ cc of .5% bupivicaine will give ½ to 1 hour relief and confirm the diagnosis. A two poster brace is a brace that supports the neck both front and back and also give relief. This is the most rigid and reliable of the bracing devices for the neck. By holding the neck rigidly, and preventing movement, a doctor can tell if preventing motion will reduce the pain in the neck and or in the neck and arms. Trials with facet blocks C2-C5 and root blocks C2-3, C3-4 and C4-5 help to confirm diagnosis. (Long, D, Davis, R, Speed, W, and Hendler, N, Fusion for Occult Post-traumatic Cervical Facet Injury, Neurosurgery Quarterly, Vol. 16, No 3, pp 129-134, Sept. 2006).

#99 Question: What is the treatment for a C2 headache?

  1. A trial with C2-C4 facet blocks, and if these work, facet denervation. If the facet denervations do not last, then a posterior fusion is indicated.
  2. A neck brace for 6 weeks
  3. Cutting the C2 nerve root
  4. A bite guard to wear at nightAi

Answer: Most often, damage to the facet joints of the upper neck produce long lasting and headaches, unresponsive to medical treatment, that may persist for 6 months or longer after the accident. (Long, D, Davis, R, Speed, W, and Hendler, N, Fusion for Occult Post-traumatic Cervical Facet Injury, Neurosurgery Quarterly, Vol. 16, No 3, pp 129-134, Sept. 2006). If the brace helps, then the doctor knows that the source of the pain is excessive motion around the joints, or vertebral bodies of the neck, and the patient would benefit from trials with facet blocks, and if these don’t last, then a posterior fusion is indicated. (Long, D, Davis, R, Speed, W, and Hendler, N, Fusion for Occult Post-traumatic Cervical Facet Injury, Neurosurgery Quarterly, Vol. 16, No 3, pp 129-134, Sept. 2006)

#100 Question: Out of all the chronic pain patients, what percentage of the time do patients get depressed from their chronic pain?

  1. 15 %
  2. 30%
  3. 47%
  4. 79%

4) Answer: Hendler reported that 79% of chronic pain patients get depressed as the result of their chronic pain, and more importantly, 89% of the patients who do get depressed had never been depressed before the onset of their pain. (Hendler, N.: “Validating and Treating the Complaint of Chronic Back Pain: The Mensana Clinic Approach.” Clinical Neurosurgery. Vol. 35, Chap. 20:385-397, eds. Black, P., Alexander, E., Barrow, D., et. al., Williams and Wilkins, Baltimore, 1988). It takes 6 months to 36 months before the symptoms of depression appear. (Hendler, N: “The Four Stages of Pain.” Chapter 1, in Diagnosis and Treatment of Chronic Pain, eds. Hendler, N, Long, D. and Wise, T., Johm Wright/PSG, Boston, 1982).

 

#101 – Question: What is causing the ringing in my ear?

  1. Too much aspirin
  2. Temporomandibular joint syndrome, which is damage to the joint between the jaw and the skull
  3. A tumor of the 8th cranial nerve, called an acoustic neuroma
  4. Nerve damage to the 8th cranial nerve called Mienere’s syndrome
  5. Any of the above

5) Answer: Any of the medical problems are possible causes for ringing in your ear.