NCS Pain Management in Neurology 3 — Questions and Answers
Question 1: A patient with trigeminal neuralgia fails carbamazepine. Which second-line medication is most appropriate?
- Amitriptyline
- Oxcarbazepine (Correct answer)
- Gabapentin as monotherapy
- Tramadol
Correct answer: Oxcarbazepine
Oxcarbazepine has similar sodium channel blocking efficacy to carbamazepine with a more favorable side-effect profile, making it the preferred second-line agent.
Question 2: Which quantitative sensory testing (QST) finding is most characteristic of small-fiber neuropathy causing neuropathic pain?
- Elevated vibration detection threshold
- Elevated cold detection threshold and impaired heat pain threshold (Correct answer)
- Abnormal two-point discrimination
- Reduced nerve conduction velocity
Correct answer: Elevated cold detection threshold and impaired heat pain threshold
Small-fiber neuropathy impairs Aδ and C fibers, elevating cold detection thresholds and altering heat pain thresholds on QST.
Question 3: A 55-year-old develops post-herpetic neuralgia. Which topical agent is FDA-approved as first-line for localized neuropathic pain?
- Topical diclofenac gel
- Lidocaine 5% patch (Correct answer)
- Topical ketamine cream
- Topical baclofen
Correct answer: Lidocaine 5% patch
The lidocaine 5% patch is FDA-approved for post-herpetic neuralgia and provides targeted sodium channel blockade with minimal systemic absorption.
Question 4: The pain of central post-stroke syndrome (CPSP) most commonly follows infarction involving which brain region?
- Frontal lobe
- Thalamus (especially VPL nucleus) (Correct answer)
- Basal ganglia
- Cerebellum
Correct answer: Thalamus (especially VPL nucleus)
Thalamic infarction, particularly of the ventroposterolateral nucleus, is the most common lesion site in CPSP due to disruption of spinothalamic input processing.
Question 5: Which intervention is considered when spinal cord stimulation (SCS) is indicated for failed back surgery syndrome?
- Electrode placement at cervical C2 level
- Electrode placement covering the thoracic cord at T8-T10 (Correct answer)
- Intrathecal baclofen pump
- Stereotactic radiosurgery
Correct answer: Electrode placement covering the thoracic cord at T8-T10
For failed back surgery syndrome with leg pain, SCS electrodes are typically placed at T8-T10 to cover the lower extremity dermatomes.
Question 6: Which pain assessment tool is most validated for use in patients with moderate-to-severe cognitive impairment who cannot self-report?
- Numeric Rating Scale (NRS)
- Visual Analog Scale (VAS)
- Pain Assessment in Advanced Dementia (PAINAD) (Correct answer)
- McGill Pain Questionnaire
Correct answer: Pain Assessment in Advanced Dementia (PAINAD)
PAINAD uses observable behaviors (breathing, vocalization, facial expression, body language, consolability) to assess pain in cognitively impaired patients.
Question 7: A patient with fibromyalgia has failed multiple pharmacological treatments. Which non-pharmacological intervention has the strongest evidence base for fibromyalgia?
- Transcranial magnetic stimulation (TMS)
- Aerobic exercise (Correct answer)
- Opioid rotation
- Spinal cord stimulation
Correct answer: Aerobic exercise
Graded aerobic exercise is supported by strong evidence and EULAR guidelines as a cornerstone treatment for fibromyalgia pain and fatigue.
NCS Pain Management in Neurology 3
A patient with trigeminal neuralgia fails carbamazepine.
Which second-line medication is most appropriate?