MCQs IN REGIONAL ANAESTHESIA & PAIN THERAPY By Dr. Herman Sehmbi & Dr. Ushma J Shah.

For more information, visit: www.regionalfortrainees.com

Sample Questions
Question 1. Which of the following regarding the structure of local anaesthetic (LA) is FALSE? A. They consist of a hydrophobic aromatic ring and a hydrophilic tertiary amine group held by a hydrocarbon chain. B. All of them exist as a weak acid-base pair in solution except benzocaine. C. They are classified as esters or amides depending upon the type of linkage bond in the hydrocarbon chain. D. Cocaine is synthetically produced. Question 2. Which of the following opioid doses is NOT equivalent to an oral dose of 30 mg morphine? A. 10 mg morphine if given intravenously. B. 15 mg morphine if given intramuscularly. C. 7.5 mg diamorphine if given subcutaneously. D. 30 mg morphine if given subcutaneously. Question 3. Regarding properties of electrical nerve stimulation, which of the following statements is FALSE? A. A shorter pulse width is a better discriminator of needle distance from nerve. B. A square wave pulse is employed. C. Stimulation by cathode is preferred. D. Fixed current is generated. Question 4. Regarding ultrasound waves, which of the following statements is FALSE? A. Wavelength is inversely related to frequency. B. High frequency waves have deeper penetration. C. Linear array probes produce higher frequency ultrasound. D. Curved array probes produce lower frequency ultrasound. Question 5. Which of the following is NOT a risk factor for the development of PDPH? A. Old age. B. Female sex. C. Using a cutting tip needle. D. Previous history of headaches. Question 6. Which of the muscle responses is NOT correctly matched with the troubleshooting actions listed while performing a PNS guided interscalene block? A. Diaphragmatic twitches redirect needle postero-laterally. B. Scapular twitches redirect needle anteriorly. C. Trapezius twitches redirect anteriorly.

D. Pectoral twitches medially.

redirect

needle

Question 7. Which of the following landmarks is NOT needed to perform lumbar plexus block? A. Anterior superior iliac spine. B. Posterior superior iliac spine. C. Iliac crest. D. Spinous processes of Lumbar vertebrae. Question 8. To accept the occurrence of a chronic painful state, a patient must have 3 diagnostic criteria. Newer recommendations have added additional criteria, necessitating the presence of 4 criteria for diagnosis. This will: A. Increase the sensitivity but decrease the specificity. B. Decrease the sensitivity but increase the specificity. C. Have no effect on both sensitivity and specificity. D. Increase both sensitivity and specificity. Question 9. Which of the following regarding epidural haematoma is FALSE? A. Most common in thoracic region. B. Old age increases the chances of epidural haematoma. C. Epidural haematoma usually presents itself after 6-12 hrs of an epidural. D. Magnetic resonance imaging is the investigation of choice. Question 10. Regarding post-herpetic neuralgia, which of the following statement is FALSE? A. It follows acute herpes zoster infection in most instances. B. NSAIDs are very effective in relieving pain. C. Amitryptiline is a first line drug. D. It is hard to treat once established, therefore is best prevented by vaccination.

Sample Answers
Answer 1. (D) Local anaesthetics (LA) are reversible Na+ channel blockers used clinically to produce neuraxial anaesthesia (central or peripheral). The use of leaves of coca plant (erythroxylon coca) for topical anaesthesia was known to Incas. In 1859, Albert Niemann isolated the chief alkaloid of coca, which he named cocaine. In 1884, Carl Koller became the first to use cocaine for ophthalmic anaesthesia. The first synthetic LA was benzocaine (1900). The LA molecule consists of a hydrophobic aromatic ring and a hydrophilic tertiary amine group held by a hydrocarbon chain (with

MCQs IN REGIONAL ANAESTHESIA & PAIN THERAPY By Dr. Herman Sehmbi & Dr. Ushma J Shah. For more information, visit: www.regionalfortrainees.com

MCQs IN REGIONAL ANAESTHESIA & PAIN THERAPY By Dr. Herman Sehmbi & Dr. Ushma J Shah. For more information, visit: www.regionalfortrainees.com an ester or amide linkage); hence classified as esters or amides. Because the tertiary amine group can bind a proton to become a positively charged quaternary amine, all LAs exist as a weak acidbase pair in solution. This is most vital for LA action as it is the cationic species that binds to the Na+ channel from inside the cell. An exception to this is benzocaine which it lacks the tertiary amine. stimulated them but not the sensory fibres. This results in motor responses but not painful paresthesia, which is undesirable anyway. B. Shorter pulse width may be superior to longer ones in estimating needle to nerve distance. SQUARE WAVE CURRENT: a slow rising current allows for accommodation (resulting in difficulty in nerve stimulation) of nerve fibres. This can be avoided by square wave form of applying current (abrupt rise and abrupt fall). CATHODAL STIMULATION: it is preferred to stimulate the nerve with needle as cathode since this then depolarizes it, whereas needle as anode hyperpolarizes the nerve (necessitating application of higher current for stimulation). CONSTANT CURRENT GENERATOR (not fixed): a peripheral nerve stimulator (PNS) should deliver the same current despite changing impedance applied. This is the most important property of the PNS. FREQUENCY: a stimulation frequency of 2 Hz is better than 1 Hz since it allows faster manipulation of needle.

Hadzic A. Textbook of Regional Anesthesia and Acute Pain Management. 1st ed. New York: McGraw-Hill Medical; 2006. p. 106. Mulroy MF, Bernards CM, McDonald SB, Salinas FV. A Practical Approach to Regional Anesthesia. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 1. Answer 2. (D) Table 2.14: Dose equivalence of opioids. Route Ratio Example (compared to oral morphine) Oral Morphine 1:1 30 mg Intravenous 1:3 10 mg Morphine Intramuscular 1:2 15 mg Morphine Subcutaneous 1:2 15 mg Morphine Subcutaneous 1:4 (as 7.5 mg diamorphine diamorphine has 2 molecules of morphine) Perioperative +/- 20% doses Epidural dose is 1:10th of oral (upto 5 mg) while intrathecal is 1:100th (100-200 mcg). Lewis NL, Williams JE. Acute pain management in patients receiving opioids for chronic and cancer pain. Contin Educ Anaesth Crit Care Pain 2005; 5(4):127-29. Answer 3. (D) Desirable properties of electrical nerve stimulation are: SHORT PULSE WIDTH: pulse width refers to the time duration for which the current is applied. Shorter pulse width has 2 advantages: A. Since the motor fibres have a smaller chronaxie, shorter pulse width

Mulroy MF, Bernards CM, McDonald SB, Salinas FV. A Practical Approach to Regional Anesthesia. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p 94-99. Answer 4. (B) Ultrasound waves are sound waves. Wavelength (): distance between two consecutive corresponding points of the same phase. Amplitude (A): maximum height of the wave Frequency (f): number of complete cycles per second. Period (): time taken for one complete wave cycle to occur Velocity (c): speed at which sound waves pass through a medium. It may be calculated using the equation: c = . f Since the velocity within a medium is constant, this implies that wavelength and frequency bear an inverse relationship. Higher frequency beams experience more attenuation (directly proportional) and hence have lesser penetration. They are used for performing superficial blocks (interscalene and supraclavicular). Low frequency beams have better penetration and allow visualisation of deep

MCQs IN REGIONAL ANAESTHESIA & PAIN THERAPY By Dr. Herman Sehmbi & Dr. Ushma J Shah. For more information, visit: www.regionalfortrainees.com

MCQs IN REGIONAL ANAESTHESIA & PAIN THERAPY By Dr. Herman Sehmbi & Dr. Ushma J Shah. For more information, visit: www.regionalfortrainees.com structures (infraclavicular and sciatic nerve blocks). Linear transducers generate high frequency ultrasound, while curved array probes low frequency ultrasound. www.aagbi.org/sites/default/files/199-The-physicsof-ultrasound-part-1.pdf Answer 5. (A) Table 4.2: Risk factors for the development of post dural puncture headache. Patient related: Procedure related: Young adults (vs Larger gauge elderly). needles (vs finer needles). Female sex (vs males). Cutting needles (vs non-cutting). Obstetric patients (vs non-obstetric Higher number of patients). dural punctures. History of previous Insertion of needle headaches. bevel perpendicular to the direction of fibres of Ligamentum flavum (cutting rather than splitting). Non expert operator. Dural puncture following epidural than a spinal (bigger defect). NOTE: Paramedian approaches may allow better sealing of defect lowering the incidence of PDPH. Recently, evidence suggests that threading a catheter into the subarachnoid space may reduce the incidence of PDPH. Hadzic A. Textbook of Regional Anesthesia and Acute Pain Management. 1st ed. New York: McGraw-Hill Medical; 2006. p. 1043. Sharpe P. Accidental dural puncture in obstetrics. Contin Educ Anaesth Crit Care Pain 2001; 1(3):8184. Answer 6. (D) Table 5.6: Trouble-shooting for interscalene block muscle responses. Twitch Interpretation Action (redirect needle) Diaphragm Phrenic n. Postero-lateral stimulation redirection (anterior to anterior scalene). Trapezius Accessory spinal n. Redirect Biceps, deltoid, triceps, pectoral stimulation (posterior to interscalene groove) Dorsal scapular n. (posterior) Thoracodorsal n. (posterior) Long thoracic n. (posterior) All part of Brachial plexus anteriorly.

Scapular

Redirect anteriorly.

Alright to inject at this point.

Hadzic A. Textbook of Regional Anesthesia and Acute Pain Management. 1st ed. New York: McGraw- Hill Medical; 2006. p. 411. Answer 7. (A) The lumbar plexus block is performed at L3-L5 level where the lumbar plexus originates. The aim is to block the three main branches by depositing a large volume of local anaesthetic within the bulk of psoas muscle. The needle pierces skin, subcutaneous fat, erector spinae, quadratus lumborum, and psoas major muscles.

Figure: Landmarks for lumbar plexus block. The patient in positioned laterally (side to be blocked uppermost) and their hips and knees are flexed at right angles, the landmarks include: Line 1: Iliac crest & intercristal line/Tuffiers line (vertical). Line 2: passing through spinous process of L4 & L5 (horizontal). Line 3: parallel to the above line passing through the posterior superior iliac spine (PSIS) (horizontal). Puncture point:

MCQs IN REGIONAL ANAESTHESIA & PAIN THERAPY By Dr. Herman Sehmbi & Dr. Ushma J Shah. For more information, visit: www.regionalfortrainees.com

MCQs IN REGIONAL ANAESTHESIA & PAIN THERAPY By Dr. Herman Sehmbi & Dr. Ushma J Shah. For more information, visit: www.regionalfortrainees.com 1. Winnies: junction of the line 1 & line 3. Anatomical studies suggest that the location of this classic site is in fact too lateral. Capdevillas: The part of the intercristal line between line 2 and line 3 is divided into 3 parts. The puncture point is the junction between lateral and the middle third (as shown). Chayens: caudal to Capdevillas puncture point at L5. Rare complications after a spinal (1:220 000) or an epidural (1:150 000). Mostly associated with the use of anticoagulants. Highest risk with patients receiving thrombolytic therapy. Risk factors include: old age, female sex, anticoagulant therapy, and technical difficulty while performing the block. Is most common at thoracic levels followed by cervicothoracic levels. Presents as a severe, localised, dull back ache 24-48 hrs after the epidural block. Epidural abscess, anterior spinal artery syndrome, surgical spinal cord damage, and exacerbation of underlying neurological diseases are differentials. Magnetic resonance imaging (MRI) is the diagnostic imaging of choice. Surgical decompression is the treatment of choice. Early exploration (within 36 hrs) has a favourable outcome.

2.

3.

Mulroy MF, Bernards CM, McDonald SB, Salinas FV. A Practical Approach to Regional Anesthesia. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 223. Answer 8. (B)

Hadzic A. Textbook of Regional Anesthesia and Acute Pain Management. 1st ed. New York: McGraw- Hill Medical; 2006. pp. 1013-16. Answer 10. (B) Post-herpetic neuralgia (PHN) is a debilitating neuralgia following an acute varicella zoster infection (usually after 6 weeks). Typically, it is confined to a dermatomal distribution of the skin. It is difficult to treat once established. Hence childhood vaccination and early, aggressive treatment of acute herpes zoster infection are vital. Since it is a neuropathic pain, it is treated first with antidepressants (tricyclic antidepressants like amitryptyline) followed by anticonvulsants (gabapentin). Opioids may be needed in some (NSAIDs are rarely useful) Topical local anaesthetics & capsacin may also relieve pain. Intrathecal methylprednisolone with lignocaine as repeated injection can help where non-interventional therapies fail.

Figure: Relationship between cut off criteria, sensitivity and specificity. As can be seen above, having a lax criteria (3 criteria Point A) for diagnosis leads to: More total positive and less total negatives High true positive (high sensitivity) High false positive (low specificity) Low false negative Low true negative On the other hand, using stringent criteria (4 criteria Point B) for diagnosis means: Less total positive and more total negatives Low true positive (low sensitivity) Low false positive (High specificity) High false negative High true negative Hence, adding another criterion as a requirement for diagnosis, will lead to lower true positive rate (low sensitivity) but a lower false negative rate as well (higher specificity). The former situation is desirable in a screening test (high sensitivity) while the latter is desirable in a confirmatory test (high specificity). Answer 9. (C) Regarding epidural haematoma:

Ramamurthy S, Alanmanou E, Rogers JN. Decision Making in Pain Management, 2nd ed. Philadelphia: Mosby; 2006. p. 76.

MCQs IN REGIONAL ANAESTHESIA & PAIN THERAPY By Dr. Herman Sehmbi & Dr. Ushma J Shah. For more information, visit: www.regionalfortrainees.com