103年 - 103 台灣疼痛醫學會專科醫師考題#125057

1. About image-guided lumbar sympathetic block, which the following indication is not proper? (A) Sympathetically maintained pain (B) Reflex sympathetic dystrophy (C) Phantom low limb pain (D) Raynaud's disease (E) Chronic pancreatitis

2. Based on clinical situations, which kind of opioids owns the highest oral bioavailability? (A) Hydromorphone (B) Morphine (C) Pethidine (meperidine) (D) Oxycodone (E) Tramadol

3. Which following item is not a criterion for the diagnosis of migraine? (A) Aggravation by or causing avoidance of routine physical activity (B) Unilateral location (C) Moderate or severe pain intensity (D) Throbbing/stabbing quality (E) All are criteria for diagnosis of migraine

4. A disadvantage to using carbamazepine is: (A) High dependency potential. (B) Hematological side effects. (C) Increased pain. (D) It is not as effective as other drugs. (E) Severity of depression.

5. A 52-year-old man complains of a sudden onset of severe, stabbing pain in the left jaw and cheek that subsides in less than a minute. He is pain-free during the intervals between attacks. Activities such as combing his hair and shaving can cause the onset of this facial pain. He is otherwise healthy. The most likely diagnosis is (A) trigeminal neuralgia (B) atypical facial pain (C) postherpetic neuralgia (D) vascular facial pain

6. A patient suffered from chronic low back pain with radiating to buttock, poster lateral thigh and lateral aspect of lower leg. Muscle weakness was observed in the extensor hallucis longus and tibialis anterior. Which lumbosacral root compression is the most likely ? (A) L2 root compression (B) L3 root compression (C) L4 root compression (D) L5 root compression (E) S1 root compression

7. Which neurological signs and symptoms of complex regional pain syndrome (CRPS) among the followings is the highest ? (A) Hyperesthesia/allodynia (B) Coordination deficits (C) Tremor (D) Muscle spasm (E) Paresis

8. Pain is a frequent consequence of spinal cord injury (SCI). Which of the following statement is least likely: (A) Below-level neuropathic pain is most likely described as severe or excruciating months or years following initial injury. (B) Damage to the spinothalamic tracts is an important ingredient in the development of neuropathic pain following SCI. (C) Chronic musculoskeletal pain is common in tetraplegic patients after SCI. (D) Patients with cervical SCI are at risk of developing CRPS affecting upper limbs. (E) Below-level neuropathic pain is also referred to deafferentation pain. 2

9. Neuropathic pain: (A) Occurs only in laboratory animals. (B) Occurs under conditions of normal peripheral and central nervous system function. (C) Typically responds favorably to opioid analgesics. (D) Typically responds favorably to NSAIDs. (E) Often responds favorably to adjuvant analgesics.

10. Which of the following is the acceptable statement about neurodestructive RF lesions? (A) These temperatures are resulted from friction heat. (B) The size of RF lesion with 22 gauge RF needle is around with a radius of 5 mm (C) The heat is generated on the tip of RF needle. The RF needle then heat up the tissues. (D) The RF permanent neurodestructive lesion is formed when neural temperatures exceed 42°C (E) All of the above

11. The innervation of deep somatic tissue like muscle and joint is quite complex. Which of the following description is not appropriate? (A) The nociceptors are predominantly activated by non-physiological stimuli which may cause damage to the structures (e.g. overload, twisting, strong pressure, ischemic contraction). (B) During inflammation or after trauma, nociceptors of joint and muscle show pronounced sensitization, in particular for mechanical stimuli. (C) Descending inhibition is enhanced during chronic inflammation but seems to be normalized during acute inflammation. (D) Both primary afferent fibers as well as sympathetic reflexes may aggravate inflammatory lesions. (E) Reduced release of hormones from the hypothalamic-pituitary-adrenal (HPA) axis such as cortisol, adrenal androgens and testosterone may cause a relative loss of anti-inflammatory activity.

12. Which of the following statements concerning the difference between phenol and alcohol when used in neurolytic blocks is/are FALSE?. (A). Phenol takes 15 minutes for neurolysis whereas alcohol's neurolytic effect is immediate. (B) Phenol usually does not produce pain on injection. (C) Intrathecal alcohol is hypobaric, whereas phenol is hyperbaric. (D) Phenol is approximately twice as efficacious as alcohol.

13. When will you make a surgical suggestion as you manage a patient with neck or low back pain? (A) Intractable symptoms for one week (B) No changes in physical findings and no response to conservative management for two weeks (C) Obvious radicular sign without findings of correctable anatomical problem for more than one month (D) No improvement with progressive neurologic deficit in two weeks (E) Mild improvement for more than one month but less than three months

14. For which of the following types of pain are antiepileptic drugs most commonly used? (A) Acute pain (B) Cancer pain (C) Chronic pain syndrome (D) Neuropathic pain (E) Nociceptive pain

15. How do you think of placebo effect to a particular therapy? (A) It is ethically unjustifiable. (B) It is deceptive on purpose. (C) It is not based on the evidence of neurobiology. (D) Infusion could add to the efficacy of the same drug when given orally. (E) It is not necessary to communicate why a particular therapy being used.

16. About chemical neurolytic nerve blocks, which one of following statements is wrong? (A) Phenol or ethanol is usually used for chemical denervation. (B) The duration of these blocks is often disappointingly brief. (C) They may induce deafferentation-neuropathic type pain. (D) They are often indicated for patients with chronic pain and a normal life expectancy. (E) They can be used in patients with advanced cancer disease.

17. Arrange the pain intensity of the following conditions from the strongest to the least according to long form McGill Pain Questionnaire. 1. Labor pain, 2 Amputation of digit, 3. Male low abdominal surgery 4. Fracture : (A) 1＞2＞3＞4 (B) 2＞1＞4＞3 (C) 2＞1＞3＞4 (D) 1＞2＞4＞3 (E) None of above is right

18. Choice a wrong description about complex regional pain syndrome (CRPS): (A) CRPS I develop more often than CRPS II (B) CRPS is characterized by pain, abnormal regulation of blood flow and sweating, edema of skin and subcutaneous tissue. (C) Sympathetic paravertebral ganglia blockade has no effect on CRPS. (D) Transcutaneous electrical nerve stimulation (TENS) may be effective in some cases. (E) Epidural spinal cord stimulation has shown efficacy in some cases

19. Choice a wrong description about pain following spinal cord injury (SCI): (A) Pain exists only at the level or below the level of injury cord. (B) The pain after SCI was composed of both nociceptive and neuropathic pain. (C) Psychological issues have tremendous importance in the expression of pain. (D) Tricyclic antidepressants may be effective for neuropathic SCI pain. (E) Clonidine administered spinally play some roles for SCI pain

20. Which of the following treatment is NOT the indication for limbs pain induced by increased spasticity after C7 incomplete spinal cord injury? (A) Joint positioning and range-of-motion (ROM) exercises. (B) Treat underlying spasticity-triggering events (infection, pressure ulcer, etc). (C) Serial casting or dynamic splinting to relieve already-occurred contractures. (D) Oral narcotics, like codeine or tramadol. (E) Anti-spasticity blocks via Botulinum toxins, phenol, or ethanol.

21. Which of the following describing the phenomenon of Wind-Up is right? (A) a form of heterosynaptic activity-dependent plasticity (B) elicited by repeated A-β-fiber stimuli (C) a co-release with glutamate of neuromodulators such as substance P and calcitonin gene-related peptide (CGRP) from the nociceptor central terminals (D) NMDA receptor is not recruited (E) all of the above are right

22. During peripheral sensitization of nociceptors, which of the coupling is wrong? (A) prostaglandin E2 (PGE2) EP receptor (B) bradykinin B2 receptor (C) heat TRPV1 receptor (D) ATP P2Y re (E) all of the above are right

23. Spinothalamic tract is the pathway most closely associated with pain. Which region in the spinal grey matter is the main origin of the spinothalamic tract to transmit pain? (A) lamina I (B) lamina II (C) lamina VII (D) lamina VIII (E) lamina X

24. Which of the following is the acceptable statement about pathogenesis of FMS? (A) There is evidence to suggest that FMS is a disorder of abnormal processing of sensory information within the central nervous system. (B) Several neurochemical mediators of pain, substance P, nerve growth factor, dynorphin A, glutamate, nitric oxide, serotonin and noradrenaline are viewed as pronociceptive because they carry or amplify afferent signals, leading to the brain perception of increased pain. (C) The elevation of cerebrospinal fluid substance P in FMS is due to lowered activity of cerebrospinal fluid substance P esterase because the rate of cleavage of libeled substance P by FMS cerebrospinal fluid was lower than normal. (D) In different subtypes of FMS, it is believed that nerve growth factor may be responsible for the elevated cerebrospinal fluid substance P through its effects on central sensitization and neuroplasticity. (E) A specific Gi-protein-coupled receptor in peripheral blood leukocytes was found to be dysfunctional in patients with FMS. This resulted in lower baseline, also depressed intracellular levels of cyclic AMP and proposed as a diagnostic test for FMS.

25. When the administration of opioids failed to manage pain or the dose of opioids are noted to escalate, the following differential diagnosis should be considered, except: (A) Limited absorption of oral preparations-vomiting or gastric stasis. (B) Pain poorly responsive to opioids alone- such as Neuropathic pain (C) Pharmacological factors: Opioid-induced hyperalgesia and allodynia (D) Psychological factors: Distress, Anxiety or Depression (E) All of the above should be considered

26. Nociceptive pain: (A) Occurs only in laboratory animals. (B) Occurs under conditions of normal peripheral and central nervous system function. (C) Typically responds poorly to opioid analgesics. (D) Typically responds poorly to NSAIDs. (E) Typically responds favorably to adjuvant analgesics.

27. A patient had chronic pain over the neck, medial scapula, anterior chest, medial aspect of arm and forearm. Horner's syndrome was also noted. Which root compression is the most likely? (A) C5 root compression (B) C6 root compression (C) C7 root compression (D) C8 root compression (E) T1 root compression

28. The formal presentation of Myofascial Pain syndrome diagnostic criteria includes each of the following, EXCEPT (A) Resolution of the symptoms after Trigger Point Injection with local anesthetic (B) Referral pain is evident (C) Twitch response and Trigger Points are the common features (D) Limited ROM of the affected muscle or muscles (E) Widespread body pain

29. A parturition of heroin abuse history ask for painless labor, which one is improper? (A) Meperidine (B) Continuous epidural analgesia (C) Nitrous oxide (D) Butorphanol (E) Intrathecal morphine

30. Correct comparisons between osteoarthritis (OA) and rheumatoid arthritis (RA) dose not include: (A) Steroids and the newer drugs that focus on controlling cytokines, such as tumor necrosis factor (TNF), may reduce pain in OA and RA (B) OA mainly involve the joints and RA may present extra-articular features (C) OA appears to be a mechanically driven, and RA presents an immunologically driven disorder (D) Pain management is similar in RA and OA, but the main focus is on controlling the disease process through the use of disease-modifying antirheumatic drugs (DMARDs) (E) Female sex is a common factor in either OA or RA j

31. A 27-year-old woman with a history of malignant melanoma and multiple subcutaneous metastases has been successfully managed with slowly increasing doses of MS-Contin (Morphine SR), in conjunction with doxepin and ibuprofen. She calls the pain center to complain of a new onset of increasing nausea, vomiting, and headaches, as well as poor pain control. The most appropriate immediate action would be to (A) speak with the patient by telephone and tell her to increase the MS-Contin (B) see the patient as soon as possible to determine if there is a new, treatable source of pain (C) schedule the patient for an evaluation in your office within the week (D) switch to a fentanyl patch since the patient is nauseated and may be unable to take oral analgesics (E) add ondansetron for nausea and vomiting so she is able to continue to take oral analgesics

32. Regarding the actions of spinal and supraspinal analgesia for opioids, which of the following statement is most likely: (A) Opioid receptors are mostly located at a predominantly (70%) postsynaptic location on the central terminals of only small diameter nociceptive primary afferents. (B) The contribution of kappa, delta and mu receptors to the total opiate binding throughout the spinal cord is estimated to be delta ＞ mu ＞kappa. (C) Opioids inhibit OFF cells via GABA neurons and activate ON cells in the rostromedial medulla (RVM) leading to changes in spinal descending controls. (D) Nitric oxide (NO) is required for the 5-HT-mediated inhibition of PAG output and reversal of antinociception. (E) Fibers descending from the PAG to the dorsal horn of the spinal cord are mostly enkephalinergic, lycinergic and GABAergic.

33. Regarding NSAIDs or Coxibs, which of the following statement is least likely: (A) Ketorolac is one of the acidic anti-inflammatory analgesics with high potency and fast elimination. (B) Paracetamol is an non-acidic antipyretic analgesic with weak inhibition on cyclooxygenase. (C) The analgesic effect, as demonstrated by number-needed-to-treat (NNT), of oral Tramadol (100 mg) is better than oral Celecoxib (400 mg). (D) Topical NSAIDs are effective in strains and sprains and in arthritic conditions. (E) Paracetamol is an alternative for analgesic in patients with exacerbation of asthma.

34. Regarding antidepressant analgesics, which of the following statement is least likely: (A) According to NNT data in treating postherpetic neuralgia, imipramine has slightly better analgesic effect than oxycodone. (B) Desipramine (25-300 mg/day, oral) has low potency of anticholinergic effect and sedation. (C) Fluoxetine (5-40 mg/day, oral) has no anticholinergic and sedative effects. (D) Venlafaxine is relatively free of muscarinic cholinergic, histaminic and alpha-adrenergic receptor effects. (E) The analgesic effect of antidepressants in treating neuropathic pain is dependent of its antidepressant action.

35. Which of the following statement concerning "phantom limb pain" is most likely: (A) Phantom pain is the painful sensations referred to the amputation stump (B) Phantom pain may enhance with time (C) Preamputation pain increases the risk of phantom pain (D) Phantom pain can be prevented by a preoperative epidural blockade (E) Postamputation pain can be easily treated by analgesia

36. Which of the following statement concerning "cytokines" is least likely: (A) Cytokines mediate the communication from the immune system to the peripheral nervous system and CNS, and to endocrine systems (B) IL-1, IL-6 and TNF-α are pro-inflammatory cytokines (C) Intraperitoneal injection of IL-1β in rats generate hyperalgesia that can not be abolished by vagotomy (D) Bradykinin activates macrophages that release TNF-α, which sensitizes nociceptors by the production of IL-6 and IL-1β (E) IL-6 and TNF-α, released intraneurally by macrophages, are involved in neuropathic pain

37. Ramsay Hunt syndrome (herpes zoster oticus) occurs when herpes zoster involves the: (A) gasserian ganglion (B) geniculate ganglion (C) ciliary ganglion (D) sphenopalatine ganglion (E) trigeminal nerve

38. In neuropathic pain, the hyperexcitability demonstrated by wide-dynamic range cells in the dorsal horns seems to be related to increase basal release of excitatory amino acids, such as (A) Dopamine (B) Glutamate. (C) Acetylcholine. (D) GABA. (E) Norepinephrine.

39. Which of the following statement concerning "central pain" is least likely: (A) Central pain is defined as pain caused by a lesion or dysfunction in the CNS (B) The most common cause is traumatic spinal cord injuries (C) In stroke the onset of pain is early (D) In stroke the pain is most frequently a hemipain (E) Central pain is dominated by abnormalities in the sensibility to temperature

40. The current guidelines on the management of acute low back pain in primary care include the following, EXCEPT (A) Reassure patients because the prognosis is most favorable (B) Advise or encourage complete bed rest (C) Prescribe analgesics medication if necessary (D) Encourage to stay active (E) Consider spinal manipulation (chiropractic) for pain relief

41. 下列有關 Phantom pain 的敘述何者正確? (A) 所有截肢病患都會出現 Phantom pain (B) 常見 Telescoping phenomenon (患肢感覺 shrinkage, 甚至縮進 stump 內) (C) 早期給予大劑量強效嗎啡止痛可以降低 Phantom pain 發生機率 (D) 病人若出現 radiating, lancinating or paroxysmal pain, 首選治療藥物是大劑量 Gabapentin, 可從每天 1200mg 作為起始劑量 (E) Physical therapy 例如 massage, manipulation 或 acupuncture, hypnosis 等整合療法對 Phantom pain 無效

42. 下列有關脊髓損傷後的慢性疼痛之敘述何者錯誤? (A) 脊髓損傷節段以下由於已無知覺,因此不會有疼痛感覺,脊髓損傷後的慢性疼痛都是 at-level neuropathic pain. (B) 脊髓損傷後的慢性疼痛常合併有重度憂鬱等的情緒面向 (C) 脊髓損傷後的慢性疼痛依舊可以使用脊椎內嗎啡幫浦作為止痛處置,然常效果不盡理想,需要合併給予如 clonidine 等輔助性藥物 (D) 心理諮商訪談及認知行為療法是脊髓損傷後的慢性疼痛常用且效果顯著的治療 (E) 脊髓損傷後的慢性疼痛不全然是 Neuropathic,有部分是 chronic musculoskeletal pain

43. Which medication below is not suggested in fibromyalgia syndrome (FMS): (A) Non-steroidal anti-inflammatory drugs (ibuprofen, naproxen) (B) Pregabalin (C) Tricyclics (amitriptyline, nortriptyline, doxepin, cyclobenzaprine) (D) Opioids (E) All of the above treatments are suggested for pain management of OA

44. A 61-year-old woman presents to the pain clinic with a chief complaint of left shoulder and arm pain 3 years after undergoing radiation therapy for breast cancer. Physical examination reveals lymphedema of the left axilla with noticeable skin changes. Examination of the left supraclavicular area precipitates a sharp pain that radiates down her left arm. Which of the following is her likely diagnosis? (A) Tumor metastasis (B) Cervical radiculopathy (C) Reflex sympathetic dystrophy (D) Thromboangiitis obliterans (E) Radiation-induced plexopathy

45. A 26-year-old weight lifter felt a sharp pain in the neck, radiating to the dorsal aspect of the forearm during his workout. Over the next few days he noted progressive numbness of the thumb and index finger. He also complained of decreased ability to perform bicep curls. On examination by his primary care doctor, a markedly diminished biceps reflex was found. Which of the following is the most likely cause of the patient's problem? (A) Facture C5 vertebra (B) C5-C6 disc protrusion (C) Facet syndrome at C5-6 (D) Compression of the C5 nerve root by an osteophyte

46. Which of the following statements regarding corticosteroid use is NOT true? (A) 30-50% of patients on chronic oral corticosteroid therapy suffer from osteoporotic fractures. (B) Corticosteroid users are at increased risk of NSAID-related GI bleeding. (C) Corticosteroid use can be associated with weight gain, hypertension and hyperglycemia. (D) Osteoporosis is only a concern in patients who have been on corticosteroids for over 12 months.

47. Which statement about Trigeminal autonomic cephalgias (TAC) is wrong? (A) Oxygen inhalation is a safe and effective method for acute treatment of cluster headache (B) Midbrain and pontine activation play a pivotal role in either initiation or termination of the acute attack of migraine (C) The forehead, temporal, orbit and occiput are the most frequent sites of hemicrania continua (D) Paroxysmal hemicrania responds in a dramatic and absolute fashion to indometacin (E) Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) syndrome is usually maximal in the ophthalmic distribution of trigeminal nerve

48. Tension-type headache (TTH) is an ill-defined and heterogeneous syndrome. Hence, its managements are associated multiple models. Which statement is wrong? (A) Combination of analgesic with muscle relaxants is the most effective therapy with scientific evidence (B) Ibuprofen can be considered the first choice for TTH (C) Tricyclic antidepressants are the most widely used first-line therapeutic and prophylactic agents (D) Relaxation and EMG biofeedback therapies have been proven to treat TTH (E) The adjunction of caffeine significantly increases the efficacy of ibuprofen only

49. As we know, bone scan is the most common diagnostic tool for bone metastasis. Which limitation is incorrect? (A) Bone scan is characterized by high sensitivity and high specificity (B) Any positive findings should be corresponded to painful sites with further evaluation of CT or plain radiographs (C) Bone scan doesn't evaluate the structural integrity (D) Most common pattern of metastasis in bone scan is "hot spot" with radioisotope accumulation for new bone reaction (E) Some cancers may not show "hot spot" pattern, such as melanoma and multiple myeloma

50. Descending inhibitory pathways typically involve which of the following neurochemical mechanisms EXCEPT? (A) Noradrenergic (B) Enkephalinergic (C) Serotonergic (D) Cholinergic