112年 - 112 台灣疼痛醫學會專科醫師考題#116972

1.Which of the following drug is categorized as Agonist-Antagonist and should "Not" be used in opioid tolerant patients. (A) Morphine (B) Tramadol (C) Nalbuphine (D) Hydromorphone (E) Methadone

2. Which one of the following nociceptors is confirmed by microneurography with psychophysical experiments? (A) Rapidly adapting (flutter, vibration) and slowly adapting (pressure) cutaneous echanoreceptors, (B) Aδ-mechanonociceptors (AM [mechano]； sharp pain), (C) C-polymodal nociceptors (CM [mechano] H[heat]； dull, burning [heat] pain), (D) Muscle nociceptors (cramping pain). (E) All of the above

3. Which of following description about opioid receptors is "Incorrect" ? (A) Opioid receptors belong to the superfamily of G protein–coupled receptors (GPCR) (B) Opioid receptors are coupled to Gs protein to trigger downstream signaling. (C) Overall opioid receptor activation leads to inhibit neuronal activity (D) In spinal cord level, opioid receptors are located mostly in the superficial dorsal horn (E) Endogenous opiates maybe released by immune cells and work on both central and peripheral opioid receptors.

4. Which of following description about non-steroidal anti-inflammatory drugs (NSAIDs) pharmacology is "Correct"? (A) NSAIDs work by inhibiting the inflammation associated enzyme cyclooxygenase and lipoxygenase (B) Perioperative use of NSAIDs will not increase the risk of surgical site bleeding (C) NSAIDs will not have drug-drug interaction with anticoagulant (such as warfarin) (D) Cyclooxygenase-2 (Cox-2) is the inducible isoform of cyclooxygenase but is constitutively expressed in certain tissues such as brain and kidney (E) Compared with non-selective NSAIDs, long term use of Cox-2 inhibitors will significantly reduce the risk of serious cardiovascular events, renal failure or congestive heart failure.

5. Which of following description about using anticonvulsants (used as Analgesic Drugs is "Correct"? (A) Most commonly used anticonvulsants as analgesics appear to work through potentiation of voltage-gated sodium and calcium channels (B) Sodium channel subtype 1.4 &1.5 are highly expressed in neuronal cell and could be the drug target for anticonvulsant medication (C) Gabapentinoid (Gabapentin & Pregabalin) works on GABA receptor (D) Topiramate works only on voltage-gated sodium channel (E) Lamotrigine and Phenytoin work on voltage-gated sodium channels Ans: E Chap 35&36

6. For peripheral pain mechanisms and nociceptor sensitization, which one of the following statement is wrong? (A) Sensory neurons commonly identified as nociceptors are those with myelinated (A-fiber) axons, big cell body diameters (＞ 50 μm), that terminate in the deep layers of the spinal cord dorsal horn. (B) The presence or absence of certain markers (e.g., the tetrodotoxin (TTX)-resistant sodium channel NaV1.8, the transient receptor potential vanilloid receptor TRPV1) have been used to identify subsets of nociceptors. (C) More recently, with the ability to analyze many genes expressed in a single cell, patterns of gene expression have been used to further define subpopulations of nociceptors. (D) With respect to cell body size and myelination, it should be appreciated that there exist some large diameter cells with heavily myelinated and rapidly conducting axons that have been documented functionally to be nociceptors. (E) Many non-nociceptors have unmyelinated axons, and thus, axon myelination or cell diameter cannot be applied as reliable criteria to define a nociceptor.

7. For substrates of spinal cord nociceptive processing, which one of the following statement is wrong? (A) The dorsal root ganglion and brainstem nuclei are home to second-order neurons, the first step of central nervous system (CNS) processing. (B) Although it seems like a simple statement that pain-related second-order neurons are the neurons which receive primary afferent input related to tissue damage (i.e., from nociceptors), it must be accepted that this statement may or may not be wholly true because in certain pathologic states, pain can be evoked by non–tissue-damaging stimuli (allodynia). (C) A proto-oncogene, c-fos, is activated after potentially tissue-damaging stimuli are applied to most tissues. (D) A systematic comparison study of Fos and pERK as markers of spinal nociceptive activation revealed greater specificity for activity in nociceptive pathways (vs. nonnociceptive activation) using pERK. (E) Analgesic pharmacologic manipulations such as systemic morphine reduce both the total number of labeled neurons and the total Fos or pERK content of the spinal cord following a noxious stimulus.

8. Which of following description about "antidepressant analgesic" is "Correct"? (A) In terms of treatment efficacy (smaller number needed to treat NNT), pregabalin is much better than tricyclic antidepressant and listed as first line therapy for neuropathic pain (B) In terms of treatment efficacy (smaller number needed to treat NNT), SSRI is better than SNRI for common neuropathic pain such as postherpetic neuralgia or painful diabetic polyneuropathy (C) Venlafaxine is effective for treatment of neuropathic pain associated with breast cancer. (D) For painful diabetic neuropathy, comparison of amitriptyline and pregabalin showed no difference in pain relief but fewer adverse effects with pregabalin. (E) All of above

9. About diagnostic nerve blocks, which one of following statements is wrong? (A) May help in locating the origin of pain. (B) Pain originating from malfunctioning CNS pain modulation may also be relieved by a peripheral nerve block. (C) Repeated diagnostic blocks are mandatory before any attempted chemical or physical denervation. (D) Are reliable as prognostic aids for neurolytic procedures. (E) Pain relief from a saline block does not indicate a psychogenic pain or malingered pain.

10. For substrates of spinal cord nociceptive processing, which one of the following statement is wrong? (A) The spinal cord is segregated into areas that, on gross examination, appear as white and grey matter and consist of predominantly myelinated nerve fiber tracts and cell bodies, respectively. (B) The morphology of neurons in the grey matter of the spinal cord differs depending on location. (C) Using Rexed’s cytoarchitecture-based classification system, there are at least 10 different layers or laminae of neurons—of which the first six (I to VI) are termed the ventral horn of the spinal cord (D) Lamina II is called the substantia gelatinosa due to its gross jellylike appearance in fresh cut tissue. (E) For Lamina X, neurons are arranged around the central canal of the spinal cord. P40-41, C

11. About the failed back surgery syndrome (FBSS), which one of the following procedure may be the last to be considered due to possible poor response? (A) caudal steroids injection (B) epidural adhesive lysis (C) spinal cord stimulation (D) radiofrequency denervation (E) lumbar sympathetic block

12.關於複雜性疼痛症候群(Complex Regional Pain Syndrome, CRPS)之診斷下列敘述何者不恰當？ (A)使用 1994 IASP criteria 敏感性很低常會造成 false negative (B) thermography 或 bone scan 等檢查可提供客觀的臨床證據，但並非診斷的必要條件 (C)診斷 CRPS 主要依靠臨床診斷 (D)目前主流診斷依據為 Budapest Criteria (E) Budapest Criteria 以感覺、血管收縮、催汗與水腫、運動與營養等四項分為徵候與症狀做為臨床診斷表準

13. Which of the following is not true about chronic pelvic pain without pathology (CPP)? (A) CPP is defined as non-menstrual pelvic pain of 6 or more months’ duration that is severe enough to cause functional disability or to require medical or surgical treatment. (B) CPP is common and estimated to account for 40% of all gynecologic diagnostic laparoscopies. (C) A history of childhood physical and/or sexual abuse has been correlated with the development of CPP. (D) The best evidence-based management of patients with CPP is multidisciplinary care.. (E) All of the answers above are correct.

14.對於幻肢痛的預防與治療下列何者為正確？ (A)周術期使用硬膜外注射、周邊神經導管止痛等等方式可完全避免幻肢痛 (B)若發生僅需選擇一種病患認為最有效的治療即可，無須使用多模式治療 (C)抗憂鬱藥、抗癲癇藥、opioid 與 ketamine 都是藥物治療的選項 (D)脊隨神經刺激器(SCS)，用於幻肢痛完全沒效果

15. Which of the following painful disorder is more common in male patients than in female patients? (A) migraine (B) rheumatoid arthritis (C) irritable bowel syndrome (D) coronary artery disease (older than 60 years old)

16.關於複雜性局部疼痛之藥物治療考量下列何者錯誤？ (A) significant osteopenia, trophic change 可使用 calcitonin 或 bisphosphonates (B)發炎與水腫可長期慢性使用 corticosteroids (C)嚴重輕觸痛(allodynia)或痛覺敏感(hyperalgesia)可使用 Gabapentin (D) profound vasomotor disturbance 可考慮使用鈣離子阻斷劑治療 (E)憂鬱焦慮與失眠可使用鎮定劑治療

17. nonsteroidal anti-inflammatory drugs (NSAIDs)藥物之作用過程當中，產生下列何者具有 vasodilatation、抑制胃酸分泌的作用？ (A) PGI2 (B) PGD2 (C) PGE2 (D) TXA2 (thromboxane A2) (E) NO

18.叢發性頭痛(cluster headache)急性發作時，下列何種藥物不具治療角色? (A)皮下注射 sumatriptan (B)經鼻給予 zolmitriptan (C)經鼻給予 lidocaine 至翼齶窩（pterygopalatine fossa） (D)靜脈注射 dihydroergotamine (E)口服 verapamil

19.下列有關於 2015 年美國 FDA 對於 NSAID 之警語中，何者為非？ (A) Patients prescribed NSAIDs following a first hear attack were not more likely to die within that first year compared to patients who did not receive NSAIDs. (B) NSAID use increase risk of heart failure (C) There is insufficient evidence to determine the risk of individual NSAIDs (D) NSAIDs use in patients with risk factors for heart disease increase the likelihood of heart attack or stroke (E) NSAIDs increase the risk of heart attack/stroke regardless of existing heart disease

20.關於下肢神經疼痛相關敘述，何者有誤? (A)坐骨神經包含的神經根有 L4, L5, S1, S2, and S3 神經根 (B)有少數(11%)梨狀肌分作兩個部分，主要是因為坐骨神經的腓神經會在梨狀肌區域就被區分出來，走在梨狀肌的中間，故把梨狀肌分成兩個部分 (C)坐骨神經病變是下肢最常見的神經病變 (D)坐骨神經病變的表徵和症狀包括無力、踝關節反射受損、感覺異常、感覺喪失，和(或)神經分佈區產生疼痛 (E)梨狀肌徵候群最常見的症狀是臀部深部酸痛，通常伴有患側跛行和無法久坐

21.關於頸因性頭痛的敘述，何者有誤? (A)目前針對源自上頸肌(upper cervical muscles)、橫韌帶或翼狀韌帶(transverse or alar ligaments)或硬腦膜(dura mater)的頭痛，尚未開發和驗證診斷測試 (B)對於椎間盤引起的疼痛，椎間盤刺激是唯一可用的診斷測試 (C)最常見的、有紀錄可查的頸源性頭痛來源是 C0-C1 關節。它是大約 56%的揮鞭傷後頭痛患者的疼痛來源 (D)對於臨床診斷的頸源性頭痛的治療，沒有藥物被證明有效，肉毒桿菌毒素注射無效，唯一有一致的證據是運動鍛鍊，可以提供一些療效 (E)C2-C3 關節突關節引起的頭痛，目前最佳的證據是使用高頻熱凝術治療第三枕神經

22. According to the long-form McGill Pain Questionnaire (MPQ) pain rating index scores, which of the following acute pain status is rated the highest pain score? (A) Amputation of digit (B) Labor pain (C) Abdominal gynecological surgery (D) Fracture. (E) Lower abdominal surgery (males)

23.關於椎管內止痛藥的敘述，下列何者有誤? (A)硬膜外止痛中使用的局部麻醉劑可能會阻斷交感神經並導致低血壓 (B)使用單獨的鴉片類藥物(opioids)的硬膜外止痛不太可能導致低血壓 (C)在停止硬膜外止痛約 2 小時後，如果有持續或加重的運動功能降低，並且應將脊柱血腫、脊柱膿腫和鞘內導管移位作為鑑別診斷的一部分 (D)椎管內單劑量鴉片類藥物給藥，大約有 20%至 50%的患者可能會發生與其相關的噁心和嘔吐 (E)與使用嗎啡進行硬膜外止痛相比，單獨使用芬太尼(fentanyl)或與局部麻醉劑合併使用無法降低噁心和嘔吐的發生率

24.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). information within the central nervous system. (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.

25.關於 referred pain 和 radicular pain 的敘述，何者有誤? (A) Radicular pain is lancinating in quality, like an electric shock, and travels into the lower limb along a narrow band (B) Somatic referred pain is perceived as a dull, aching sensation； it radiates slowly over relatively wide areas (C) The causes of somatic referred pain and radicular pain are quite different, and their mechanisms are different (D) The mechanism of radicular pain is irritation of the dorsal root ganglion of a spinal nerve (E) This is correct that somatic referred pain does not extend below the knee and that, therefore, pain below the knee must be radicular in origin.

26.關於 neuraxial opioid 敘述，下列何者有誤? (A)與口服或注射鴉片類藥物相比，使用局部麻醉劑於硬膜外和周邊神經阻滯技術可提供更好的鎮痛效果 (B)確定鴉片類藥物臨床藥理學的最重要因素之一是其脂溶性程度 (C)親水性鴉片類藥物，例如 fentanyl，傾向於保留在 CSF 內並產生延遲作用與持續時間較長的止痛作用 (D)與單獨使用局部麻醉劑或鴉片類藥物相比，局部麻醉劑-鴉片類藥物組合可提供更好的術後止痛效果 (E)腎上腺素可改善硬膜外止痛，可增加感覺阻滯，一般以 2 至 5 μg/mL 的濃度給藥，但也與運動功能阻滯惡化有關

27.Which of the following description about autonomic, endocrine and immune interactions in pain is correct? (A)Signaling from the immune system to the CNS via vagal afferents and possibly small-diameter afferents innervating somatic tissues to induce sickness behavior (B) Modulation of the immune system and the inflammatory response by CNS circuits that control the production and release of neuroendocrine hormonal mediators in the sympathoadrenal stress axis (C)Coupling of the sensory nociceptive and sympathetic efferent components of the peripheral nervous system in the setting of inflammation and nerve injury to produce sympathetically maintained pain (D) All of above

28.Which one of the following statements is wrong? (A) All nociceptors are myelinated. (B) Following a cutaneous injury, enhanced pain in response to cutaneous stimuli, called hyperalgesia, develops at the site of injury (primary hyperalgesia) and in the surrounding uninjured skin (secondary hyperalgesia). (C) Tissue injury leads to enhanced responsiveness of nociceptors, called sensitization, which accounts for primary hyperalgesia. (D) When nerves are severed, spontaneous activity and ectopic mechanical, thermal, and chemical sensitivity develop in the injured nociceptors.

29.Which one of the following statements is wrong? (A) The perception of pain arising from a noxious stimulus starts with conversion of the energy of the stimulus into an electrical signal in the primary afferent neurons innervating the site of the stimulus. (B) This process of energy conversion is called transduction. (C) The three general modalities of noxious stimuli that impinge on the body are chemical, thermal, and mechanical. (D) Specific proteins or groups of proteins called transducers underlie the process of transduction. (E) All of the above are correct.

30.急性下背痛有許多可能的診斷，下列敘述何者有誤? (A)背痛可能是引起腹膜後炎症的內臟疾病（如胰腺炎）的一個特徵，但在這些疾病中，背痛通常是腹痛的附加症狀 (B)動脈瘤可能以背痛為唯一症狀。事實上，背痛是大部分因主動脈瘤破裂而突然死亡的患者的唯一症狀 (C)醫學影像學上的脊椎退行性變化、脊椎前移和椎弓峽部骨折，與腰痛在統計學上或臨床上有顯著性相關。因此，這些情況都是診斷疼痛的原因 (D)腰椎感染通常在發病時是很難發現，疼痛可能是唯一的特徵 (E)急性腰痛的病因經常不明。造成這種情況的主要原因是常規的檢查，例如醫學成像，無法確定骨折、惡性腫瘤或感染以外的背痛原因

31.Which one of the following statements is wrong? (A) Pain and hyperalgesia arise in part from the action of inflammatory mediators on the peripheral terminals of nociceptive neurons. (B) The list of inflammatory mediators may include arachidonic acid metabolites, bradykinin, adenosine triphosphate and nitric oxide. (C) A series of inflammatory cytokines and chemokines, such as tumor necrosis factor-α and interleukin-1β, and growth factors, particularly nerve growth factor, are capable of changing the response properties of pain-signaling neurons. (D) The inflammatory mediators may activate nociceptive terminals or regulate gene expression of nociceptors. (E) All of the above are correct.

32.Which of the following symptom is not often seen in patients with physical dependence (abstinence syndrome -(withdrawal) ) ? (A) abdominal cramps (B) constipationn (C) vomiting (D) pupil dilatation (E) sweating

33.以下為 failed back surgery syndrome 常見的鑑別診斷與其常見症狀,下列何者配對有誤? (A) Lateral canal stenosis: relief with sitting (B) Painful discs: relief with sitting (C) Neuropathic pain: Leg pain Burning dysesthesia (D) Recurrent HNP: Vary with location. Leg pain ＞ LBP (E) SI joint pain: Gluteal pain with referral to leg and groin

34.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.

35.以下各種 Nonsteroidal Anti-Inflammatory Drug 何者可能產生 hepatotoxicity 的機率最高? (A) Indomethacin (B) Diclofenac (C) Naproxen (D) Ibuprofen (E) Meloxicam

36.Which of the following combination of lesion site with referral site describing pain referral is not common in cancer patients suffering from cancer pain? (A) (Diaphragmatic irritation) and (Shoulder) (B) (Urothelial tract) and (Inguinal region and genitalia) (C) (C7–T1 vertebrae) and (Interscapular) (D) (L1–2) and (Sacroiliac joint and hip) (E) all of the above are common found in patients with cancre pain

37.下列 opioid 中,何者可能產生 QT prolonged, 甚至導致 torsade de pointes 這種致命性心律不整? (A) Meperidine (B) Methadone (C) Tramadol (D) Buprenorphine (E) Butorphanol

38.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

39. Which one of the following statement about the pathophysiology of herpes zoster is wrong? (A) Herpes zoster most commonly manifests in the distribution of a single dorsal sensory or cranial nerve ganglion. (B) Why the reactivation of virus occurs in one ganglion when latent virus is present throughout the patient’s sensory ganglia is clear. (C) Declining cellular immunity is a major risk factor for reactivation of the virus, which is thought to occur when cell-mediated immunity falls below a critical level. (D) This impression is supported by evidence that even individuals with adequate levels of serum antibodies to varicella-zoster virus (VZV) antigen can, over time, exhibit T cells with reduced ability to proliferate and defend against VZV infections. (E) Cell-mediated immunity appears to play a crucial role in preventing reactivation of latent VZV.

40. 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

41. 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

42.有關 Post-stroke pain 之疼痛症狀類型中，下列描述何者最不適合？ (A) Central post-stroke pain 屬於 neuropathic type (B) Shoulder pain 不屬於 neuropathic type (C) Musculoskeletal pain 不屬於 neuropathic type (D) Headache 屬於 neuropathic pain (E) Spasticity 不屬於 neuropathic type

43.Neuropathic pain 有多種不同原因,治療藥物的選擇必須依照病因決定,請問下列敘述,何者錯誤? (A) Amitriptyline 對 Spinal cord injury 的 neuropathic pain 治療效果不佳 (B) Amitriptyline 對 phantom limb pain 的治療效果不佳 (C) Venlafaxine 對 postmastectomy syndrome 的治療效果不佳 (D) Selective Serotonin and Norepinephrine Reuptake Inhibitors 治療 painful diabetic neuropathic pain 的 NNT (number needed to treat) 比 TCA 小 (E) Selective Serotonin and Norepinephrine Reuptake Inhibitors(SNRI)一般比 Selective Serotonin Reuptake Inhibitors(SSRI)對 neuropathic pain 的治療效果好

44.對於催眠,雖然很多人只當它是類似一種魔術表演,但目前越來越多研究證實催眠確實有止痛效果,那麼以下所列疾病或狀況是目前有較多研究證實催眠有效的? (A) Burns (B) Pediatric Pain (C) Cancer (D) Osteoarthritis (E)以上皆是

45.以下那個選項不是發生 local anesthetics systemic toxicity (LAST)時的正確處理? (A) Suppress seizures: Benzodiazepines preferred (B)使用 amiodarone 做為第一線 antiarrhythmic (C)避免使用 calcium channel blockers, beta blockers (D)若使用 lipid emulsion 解毒,病人回復 hemodynamic stable 即立即停止繼續給予 lipid emulsion (E) Maximum dose lipid emulsion 大約 12 mL/kg IV

46. Which of the anticonvulsants has the highest quality of evidence supporting its tolerability and efficacy in reducing SCI neuropathic pain? (A) Pregabalin (B) Gabapnetin (C) Lamotrigine (D) Valproic acid (E) Carbamazepine

47. In addition to A tender spot is found with palpation, with or without referral of pain (“trigger point”). Which of the following symptoms by patient during palpation of tender spot is not commonly found? (A) Muscle stiffness or spasm (B) Limited range of motion of an associated joint (C) Pain worsens at rest (D) Palpation of taut band and/or nodule associated with tender spot (E) All of the above are common found

48. Which of the following syndromes associated with cancer therapy is seldom found? (A) Postsurgical Syndromes: Postamputation pain (B) Postchemotherapy Pain: Peripheral neuropathy (C) Postradiation Therapy Pain: Radiation fibrosis of brachial or lumbosacral plexus (D) Post Target Therapy Pain: Myofascial pain syndromes (E) All of the above are common found

49. Which of the following descriptions for Transdermal therapeutic system fentanyl (fentanyl-TTS) patches is not correct after application? (A) a lag time of approximately 2 hours before plasma levels of fentanyl are detected and detected therapeutic levels after 12 to 16 hours (B) After system removal, serum fentanyl concentrations decline gradually and has an apparent t1/2 of 17 hours (C) Prolonged exposure to heat or use in patients who are febrile can cause a toxic overdose (D) should not be used in patients who are not opioid-tolerant, for acute pain issues (E) All of the above are correct descriptions

50.有關局部麻醉藥，下列何處注射之後之系統性吸收最快？ (A) Tracheal (B) Caudal (C) Subcutaneous (D) Epidural (E) Brachial plexus

112年 - 112 台灣疼痛醫學會專科醫師考題#116972

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