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1. What structures are present at the C2-3 level of the spinal cord?
   a. the spinal tract of V
   b.  the (spinal) accessory nucleus
   c.  the spinal nucleus of V
   d. the dorsolateral tract (Lissauer)
   e. the thoracic nucleus (nucleus dorsalis, Clarke’s column)
   f.  the substantia gelatinosa
   g.  all of the above are correct
   h. all of the above are correct, except d
   i.  all of the above are correct, except e
   
   
   
2. Which of the following transmitters is (are) involved in descending modulatory nociceptive pathways?
   a. Substance P
   b. Norepinephrine
   c.  CGRP
   d. Serotonin
   e. all of the above are correct
   f.   only a and c are correct
   g. only b and d are correct



3. Which of the following statements concerning the somatic sensory pathways is (are) true?
   a. The axons of the second-order neurons cross the midline.
   b.  First-order neuron cell bodies are located in the nucleus gracilis and the spinal nucleus of V.
   c.  Third-order neuron cell bodies are located in the thalamus.
   d. all of the above are correct
   e. only a and c are correct



4. Which of the following tracts would be considered to be “upper motor neuron” pathways?
   a. corticonuclear (corticobulbar) tract
   b. reticulospinal tracts
   c.  vestibulospinal tract
   d. corticopontine tracts
   e. only a, b, and c are correct



5. The corticonuclear (corticobulbar) fibers of the pyramidal system:
   a. supply the motor nuclei of cranial nerves V, X, and XII in the brain stem
   b. are both crossed and uncrossed prior to entering the cranial nerve nuclei
   c.  originate from the lower part of the precentral gyrus
   d. all of the above are correct
   e. only a and c are correct



6. A lower motor neuron facial weakness:
   a. is always due to a lesion of the facial nerve (VII) after it leaves the pons
   b. consists of a weakness of the lower facial muscles contralateral to a lesion in the brain
   c.  is due to the fact that the part of the facial nucleus supplying the lower facial muscles receives a direct (monosynaptic) input from upper motor neuron axons
   d. all of the above are correct
   e. none of the above are correct



7. The muscle stretch reflex (eg, those examined during deep tendon reflex testing):
   a. is a two-neuron, monosynaptic reflex
   b. employs large diameter (Ia, Aα) afferent nerve fibers with receptors in the neuromuscular spindles
   c.  utilizes alpha motor neurons in lamina IX of the anterior horn of the spinal cord in the efferent limb of the reflex arc
   d. all of the above are correct
   e. only a and c are correct



8. Characteristics of a "lower motor neuron lesion" include:
   a. weakness
   b. hyperreflexia
   c.  increased muscle tone (spasticity)
   d. extensor plantar reflex
   e. all of the above are correct



9. Concerning the corticospinal tracts:
   a. They contain axons arising from the premotor area (area 6), the supplementary motor area, and the parietal lobe (areas 3, 1, 2, 5), as well as the primary motor cortex (area 4).
   b. The anterior corticospinal tract mainly supplies lower motor neurons innervating hand and foot muscles.
   c.   Many of the axons in the lateral corticospinal tract destined to control finely coordinated hand movements synapse directly (monosynaptically) with lower motor neurons innervating intrinsic hand muscles.
   d. all of the above are correct
   e. only a and c are correct



10. A patient comes to the emergency room with weakness of the right upper and lower limbs and is unable to move either eye to the right (and therefore both eyes are deviated to the left).  Which of the following statements is (are) true?
    a. The lesion involves a large area of the left frontal lobe.
    b.   The patient probably also has weakness of all of the facial muscles on the left side.
    c.    The patient probably understands you when you talk to him but cannot produce speech himself.
    d.  The lesion involves the lower pons on the left side.
    e. only b and d are correct
    f.   only a and c are correct
    
    
CASE STUDY (Questions 11 and 12 below): A patient presents with the recent onset of ptosis and miosis of the left eye, without any other signs or symptoms. Examination showed the left pupil to be
3 mm and the right pupil to be 5 mm. There was a 2 mm ptosis of the left eyelid.


11. Which of the following locations and/or structures could be involved by the pathological process?
    a. descending sympathetic fibers in the left lateral tegmentum of the pons or medulla (central Horner’s syndrome, 1st order neuron)
    b. left apex of the lung (preganglionic Horner’s syndrome, 2nd order neuron)
    c.   left internal carotid artery pericarotid sympathetic plexus (postganglionic oculosympathetic paresis, 3rd order neuron)
    d.  all of the above are correct



12. Oculosympathetic pupillary testing was performed.  When 4% cocaine eye drops were placed in each eye, the left pupil did not dilate (3 mm), but the right pupil dilated (8 mm).  After full recovery, 1% hydroxyamphetamine eye drops were placed in each eye.  The left pupil remained at 3 mm, but the right pupil again dilated (7 mm).  Given these data, which of the following pathological processes caused this patient’s findings?
    a. occlusion of the left posterior inferior cerebellar artery (PICA)
    b. left apical lung carcinoma
    c.    dissection of the left internal carotid artery in the cavernous sinus
    d. all of the above are correct
    e.  none of the above are correct



13. The neocerebellum (lateral cerebellar hemisphere):
    a. receives its afferent input from the contralateral pontine nuclei via the middle cerebellar peduncle
    b. is related to the dentate nucleus of the cerebellum
    c.  functions by projecting back up to the motor cortex (precentral gyrus) of the cerebrum, and thereby exerts its control of motor activity by influencing the activity of the pyramidal system (corticospinal and corticonuclear tracts)
    d.  all of the above are correct
    e.  only a and c are correct


14. Which statement(s) concerning the cerebellum is (are) true?
a. It functions below the level of conscious awareness.
b. Its functions include maintenance of equilibrium; regulation of muscle tone, posture, and balance; and regulation of the timing and precision of movements.
c.  One side of the cerebellum is related to the ipsilateral side of the body.
d.   all of the above are correct
e.   only a and c are correct


15. Damage to the flocculonodular lobe and/or vermis of the cerebellum:  
    a. results in impairment of limb movements and coordination
    b. results in difficulty maintaining balance and equilibrium when walking or sitting
    c.  interrupts cerebellar efferent pathways (output) from the dentate nucleus to the thalamus
    d. all of the above are correct
    e. only a and c are correct
    
    


16. The posterior spinocerebellar tract:
    a.  has its cell bodies of origin in the ipsilateral thoracic nucleus (nucleus dorsalis, Clarke’s column)
    b. enters the cerebellum through the inferior cerebellar peduncle and ends in the cortex of the vermis (paleocerebellum)
    c.    carries information concerning muscle tone and unconscious proprioception
    d.  all of the above are correct
    e. only a and c are correct



17. The Purkinje cells (piriform neurons) of the archicerebellum (flocculonodular lobe)
    a. project primarily to the fastigial nucleus
    b. synapse with axons of granule cells that receive input from the contralateral
        pontine nuclei
    c.  are excitatory to the neurons of the dentate nucleus
    d. only a and c are correct
    e. only b and c are correct
    
    


18. Decorticate (flexor) posturing:
    a. is due to a lesion above the red nucleus of the midbrain
    b. results, in part, from preserved function of the lateral vestibular nucleus and the (lateral) vestibulospinal tract, which is excitatory to extensor muscle groups and inhibitory to flexor muscle groups (especially in the lower limbs)
    c.  results, in part, from preserved function of the corticospinal, rubrospinal, and corticoreticular (especially those to the medullary reticular formation) fibers, which are excitatory to flexor muscle groups and inhibitory to extensor muscle groups (especially in the upper limbs)
    d. all of the above are correct
    e. only a and c are correct
    
    


19. Which of the following areas or structures receive direct efferent output from
    the lateral globus pallidus (or pars externa; GPe)?
    a. thalamus (ventral lateral and ventral anterior nuclei)
    b. substantia nigra
    c.   subthalamic nucleus
    d. all of the above are correct
    e. only a and c are correct
    
    


20. The major afferent input into the striatum (caudate nucleus and putamen) is:
    a. from the globus pallidus
    b. inhibitory using acetylcholine as a neurotransmitter
    c.  from the cerebral cortex
    d. excitatory using GABA as a neurotransmitter
    e. only c and d are correct



21. Which of the following statements concerning the function of the basal nuclei is (are) true?
    a. The basal nuclei integrate input from the spinal cord, cerebellum, red nucleus, and visual and auditory systems.
    b. The basal nuclei function in parallel with the neocerebellum by exerting their influence on the cerebral cortex rather than directly on the brain stem or spinal cord lower motor neurons.
    c.  The basal nuclei are important in regulating the timing and precision of discrete limb movements, eye movements, and vocalization.
    d. The basal nuclei act on or affect motor activity on the ipsilateral side of the body.
    e.  none of the above are correct


22. Which of the following structures are part of the “direct pathway” of basal nuclei (ganglia) connections?
    a. lateral globus pallidus (or pars externa; GPe)
    b. medial globus pallidus (or pars interna; GPi)
    c.  subthalamic nucleus
    d. striatum (caudate and putamen)
    e. all of the above are correct
    f.  only a and c are correct
    g. only b and d are correct
    
    
Extended Matching Set - For each of the 4 questions below, indicate the letter of the most closely related item from the list. Each option may be correct for more than one question.


23. Carries conscious proprioception (joint position sense) from the left upper limb.
    a. Left medial lemniscus
    b. Dorsal roots of right C5-T1 spinal nerves
    c.  Right fasciculus gracilis
    d. Right spinothalamic tract at the level of the T10 spinal cord
    e. Left ventral posteromedial (VPM) nucleus of the thalamus
    f.  Right spinal lemniscus in the medulla
    g. Left fasciculus cuneatus
    h. Left spinal lemniscus in the midbrain
    
    
24. Carries pain and temperature from the right upper and lower limbs.
    a. Left medial lemniscus
    b. Dorsal roots of right C5-T1 spinal nerves
    c.  Right fasciculus gracilis
    d. Right spinothalamic tract at the level of the T10 spinal cord
    e. Left ventral posteromedial (VPM) nucleus of the thalamus
    f.  Right spinal lemniscus in the medulla
    g. Left fasciculus cuneatus
    h. Left spinal lemniscus in the midbrain
    
    


25. Receives pain and temperature information from the right side of the face.
    a. Left medial lemniscus
    b. Dorsal roots of right C5-T1 spinal nerves
    c.  Right fasciculus gracilis
    d. Right spinothalamic tract at the level of the T10 spinal cord
    e. Left ventral posteromedial (VPM) nucleus of the thalamus
    f.  Right spinal lemniscus in the medulla
    g. Left fasciculus cuneatus
    h. Left spinal lemniscus in the midbrain
    
    


26. Carries vibratory sensation from the right lower limb only.
    a. Left medial lemniscus
    b. Dorsal roots of right C5-T1 spinal nerves
    c.  Right fasciculus gracilis
    d. Right spinothalamic tract at the level of the T10 spinal cord
    e. Left ventral posteromedial (VPM) nucleus of the thalamus
    f.  Right spinal lemniscus in the medulla
    g. Left fasciculus cuneatus
    h. Left spinal lemniscus in the midbrain

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