pain medicine 问答题

mycookqi

1. Nutrition  to  the  lumbar  intervertebral  disc  is
from the（腰椎间盘的营养是来自）
(A)  posterior spinal artery 脊髓后动脉
(B)  internal iliac artery 髂内动脉
(C)  lumbar artery 腰动脉
(D)  anterior spinal artery 脊髓前动脉
(E)  abdominal aorta 腹主动脉
1.  (C) The lumbar arteries supply the vertebrae at various levels.  Each lumbar artery  passes posteriorly around the related vertebra  and supplies branches into the vertebral body. The terminal branches form a plexus of capillaries below each  endplate.  The disc is a  relatively avascular structure. Nutrition to the disc is by diffusion from the  endplate capillaries and blood vessels in the outer annulus fibrosus. Passive diffusion of fluids into the proteoglycan matrix is further enhanced  by  repeated compression  of  the  disc  by  repeated  flexion-extension of the spine associated with activities of daily living which pumps fluid in and out of the  disc.  The  abdominal  aorta  does  not provide any direct blood supply to the intervertebral disc.四对腰椎动脉供给不同节段的椎骨。 每个腰椎动脉向后通过在相应的椎骨周围，并将分支供应到椎体中。 末端分支在每个终板下方形成毛细血管丛。 椎间盘是一种相对无血管的结构。 椎间盘的营养是来自端板毛细血管和纤维外血管。 日常生活活动相关联的脊柱的反复屈曲 - 伸展反复压缩椎间盘，从而进一步增强了液体被动扩散向椎间盘的蛋白多糖基质中，从而将液体营养泵入和流出椎间盘。 腹主动脉并不为椎间盘提供任何直接的血流供应。

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2. A 65-year-old man presents with symptoms of pain in the cervical region. He also complains of radiation of his pain along the lateral part of his right forearm. He has a magnetic resonance imaging (MRI) of the cervical region with evidence of a herniated disc between the fifth and the sixth cervical vertebra. The nerve root that is most likely compressed is一名65岁男子出现颈部疼痛症状。他还抱怨右前臂外侧的放射痛。他对颈部区域进行磁共振成像（MRI），证实第五颈椎和第六颈椎之间有椎间盘突出。最可能压缩的神经根是
(A)  fourth cervical nerve root 第四颈神经根
(B)  fifth cervical nerve root 第五颈神经根
(C)  sixth cervical nerve root第六颈神经根
(D)  seventh cervical nerve root第七颈神经根
(E)  first thoracic nerve root第一胸椎神经根
2.  (C) Disc  herniations  in  the  cervical  region  are relatively less common than the lumbar region. In the cervical region the C5, C6, and C7 intervertebral disc are most susceptible to herniation. The C6  and  C7  intervertebral  disc  herniation  is  the most  common  cervical  disc  herniations.  In  the cervical region each spinal nerve emerges above the  corresponding  vertebra. An intervertebral disc  protrusion  between  C5  and  C6  will  compress the sixth cervical spinal nerve. There are seven cervical vertebra and eight cervical spinal nerves. These patients characteristically present with pain in the lower part of the posterior cervical  region,  shoulder,  and  in  the  dermatomal distribution of the affected nerve root.颈椎间盘突出症相对腰椎并不常见。在颈部区域，C5，C6和C7椎间盘最容易发生突出。 C6和C7椎间盘突出症是最常见的颈椎间盘突出症。在颈部区域，每个脊神经出现在相应的椎骨上方。 C5和C6之间的椎间盘突出将压迫第六颈椎神经。颈椎有七个颈椎和八个颈椎神经。这些患者特征性地表现为后颈下部，肩部和受累神经根的皮支支配区域的疼痛。https://pan.baidu.com/s/16CbJ4L-0BIMaZmaqTIcZDg

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3. The most common presenting symptom of rheumatoid arthritis is 类风湿性关节炎的最常见症状是
(A) pain in the small joints of the hand 手部小关节疼痛
(B) neck pain 颈部疼痛
(C) knee pain 膝盖疼痛
(D) low back pain 腰痛
(E) hip pain  髋痛

3. (B) Neck pain is the most common presenting symptom of rheumatoid arthritis (RA). Approximately 50% of the head’s rotation is at the
atlantoaxial joint, the rest is at the subaxial cervical spine. The atlantoaxial joint complex is made up of three articulations. The axis articulates with the atlas at the two facet joints laterally and another joint posterior to the odontoid process. A bursa separates the transverse band of the cruciate ligament from the dens. RA affects all three joints. The articulations formed by the uncinate processes, also known as the joint of Luschka, are not true joints and do not have synovial membrane. Hence, they are not subject to the same changes as seen in RA. RA is an inflammatory polyarthritis that typically affects young to middle-aged women. They present with a joint pain and stiffness in the hands. Typically the first metacarpophalangeal joint is affected whereas in osteoarthritis the carpometacarpal joint is affected. They have a history for morning stiffness. Almost 80% of these patients have a positive rheumatoid factor.  颈部疼痛是类风湿性关节炎（RA）最常见的症状。大约50％的头部旋转发生于寰枢关节，其余部分位于其它颈椎。寰枢关节由三个关节组成。轴与两侧小关节侧面的寰椎关节和齿状突后的另一关节。寰椎横韧带中部向上下方各发出一条纵行纤维束与寰椎横韧带共同构成的寰椎十字韧带。 RA影响所有三个关节。钩突关节，也称为Luschka关节，不是真正的关节，也没有关节囊。因此，它们不受RA的影响。RA是一种炎症性多发性关节炎，通常影响年轻至中年女性。他们出现手指关节疼痛和僵硬。通常，RA患者第一掌指关节受到影响，而在骨关节炎患者中，主要是腕掌关节受到影响。RA有晨僵的历史。RA患者中80%有类风湿因子阳性。

mycookqi

4. The  usual  site  of  herniation  of  a  cervical intervertebral disc is 颈椎间盘最常见的突出部分是
(A)  posterior 后侧
(B)  lateral 横侧
(C)  posterolateral 后外侧
(D)  anterior 前侧
(E)  anterolateral 前外侧
4.  (C) The uncinate processes are bony protrusions located  laterally  from  the  C3  to  C7  vertebrae. They prevent the disc from herniating laterally. The posterior longitudinal ligament is the thickest in the cervical region. It is four to five times thicker  than  in  the  thoracic  or  lumbar  region. The nucleus pulposus in the cervical disc is present at birth but by the age of 40 years it practically  disappears.  The  adult  disc  is  desiccated and ligamentous. It is mainly composed of fibrocartilage and hyaline cartilage. After the age of 40 years, a herniated cervical disc is never seen because there is no nucleus pulposus. The most common  cervical  herniated  nucleus  pulposus
(HNP) occurs at C6 to C7 (50%) and is followed by C5 to C6 (30%).
钩椎关节是位于C3至C7椎骨侧缘的椎体钩够成。 它们可以防止椎间盘向旁侧突出。 后纵韧带是颈部最厚的。 它是胸部或腰部的厚度的4到5倍。 颈椎间盘髓核在出生时是存在的，但在40岁时，它实际上消失了。 成人椎间盘变干燥和韧带化。 它主要由纤维软骨和透明软骨组成。 在40岁之后，由于没有髓核，所以从未见过突出的颈椎间盘突出症。 最常见的颈椎髓核突出（HNP）发生在C6至C7（50％），然后是C5至C6（30％）。

mycookqi

5. The carotid tubercle (Chassaignac tubercle) is  located at the 颈动脉结节位于     
(A)  transverse process of the C6 vertebra  C6椎骨的横突
(B)  facet joint of the C5 and C6 vertebra C5与C6椎骨的小关节
(C)  facet joint of the C6 and C7 vertebra C6与C7椎骨的小关节
(D)  transverse process of the C7 vertebra C7椎骨的横突
(E)  transverse process of the C5 vertebra C椎骨的横突
5.  (A) The carotid tubercle (Chassaignac tubercle) lies 2.5 cm lateral to the cricoid cartilage. It lies over  the  transverse  process  of  the  C6  vertebra and can be easily palpated anteriorly. The carotid tubercle  is  an  important  landmark  for  stellate ganglion blocks.颈动脉结节（Chassaignac结节）位于环状软骨外侧2.5厘米处。 它位于C6椎骨的横突上，从前面可以很容易地触诊。 颈动脉结节是星状神经节阻滞的重要标志。

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6. The stellate ganglion is located 星状神经节
(A)  anterior to the transverse process of the C6 vertebra  C6椎骨横突的前面
(B)  posterior to the subclavian artery 锁骨下动脉后面
(C)  anterior to the transverse process of the C5 vertebra C5椎骨横突的前面
(D)  anterior to the neck of the first rib and the transverse process of the C7 vertebra第一肋骨颈和C7横突前面
(E)  anterior to the transverse process of the first thoracic vertebra 第一胸椎横突前面
6.  (D) The stellate ganglion is the inferior cervical ganglion.  The  cervicothoracic  ganglion  is  frequently formed by the fusion of the inferior cervical ganglion and the first thoracic ganglion. It is located anteriorly on the neck of the first rib and the  transverse  process  of  the  C7  vertebra.  It  is oval in shape and 1” long by 0.5” wide. The ganglion is bound anteriorly by the subclavian artery, posteriorly  by  the  prevertebral  fascia  and  the transverse process, medially by the longus colli muscle, and laterally by the scalene muscle. The classical stellate ganglion block is done one level above the location of the stellate ganglion (it lies at the C7 level and the block is done at the C6 level).  Typically  the  classical  stellate  ganglion block is performed with the patient supine, however,  immediately  after  the  block  the  patient  is repositioned to a sitting position. The vertebral artery travels anteriorly over the stellate ganglion at  C7  but  at  C6  the  artery  moves  posteriorly. Incidence of phrenic nerve block is almost 100%。
6.（D）星状神经节是下颈椎神经节。颈胸神经节通常通过下颈神经节和第一胸神经节的融合形成。它位于第一肋骨颈和C7椎骨的横突前方。它呈椭圆形，长1英寸，宽0.5英寸。神经节前与锁骨下动脉相连，后与椎前筋膜和横突相连，内侧与颈长肌相连，外侧与斜角肌相连。经典的星状神经节阻滞在星状神经节的位置上一颈椎进行（位于C7水平，而阻滞位于C6水平）。通常，经典的星状神经节阻滞是在患者仰卧的情况下进行的，然后，在阻滞后立即将患者重新回到坐位。椎动脉在C7处在星状神经节前方行进，但在C6处，动脉向后移动。膈神经阻滞的发生率几乎为100％。

mycookqi

7. Features  of  Horner  syndrome  consist  of  the following, EXCEPT 霍纳综合症的表现包括以下，除了
(A)  ptosis上睑下垂
(B)  anhydrosis 无汗症
(C)  miosis 瞳孔缩小
(D)  enophthalmos 眼球内陷
(E)  mydriasis 瞳孔放大
7. (B) Horner syndrome consists of ptosis (drooping of the upper eyelid), miosis, (constriction of the pupil) and enophthalmos (depression of the eyeball into the orbit) only. Anhydrosis, nasal congestion, flushing of the conjunctiva and skin, and increase in temperature of the ipsilateral arm and hand are not features of Horner syndrome. The cervical portion of the sympathetic nervous system extends from the base of the skull to the neck of the first rib, it then continues as the thoracic part of the sympathetic chain. The cervical sympathetic system consists of the superior, middle, and inferior ganglia. In most people the inferior cervical ganglia is fused with the first thoracic ganglia to form the stellate ganglion. It lies over the neck of the first rib and the transverse process of C7, behind the vertebral artery 。霍纳综合征仅包括上睑下垂（上眼睑下垂），瞳孔缩小（瞳孔收缩）和眼球内陷（眼球萎缩进入眼眶）。 无汗状，鼻塞，结膜和皮肤充血，同侧手臂和手的温度升高不是霍纳综合征的特征。 颈部交感神经系统从颅底延伸到第一肋的颈部，然后继续连接胸部交感神经链。 颈交感神经系统由上，中，下神经节组成。 在大多数人中，下颈神经节与第一胸神经节融合以形成星状神经节。 它位于第一肋骨颈和C7的横突上，位于椎动脉后面。 （ps 个人觉答案有误）

mycookqi

8. A 35-year-old woman with Complex Regional Pain Syndrome type I of the right upper extremity develops miosis, ptosis, and enophthalmosafter undergoing a stellate ganglion block. She does not notice any significant pain relief. No significant rise in skin temperature was recorded in the right upper extremity. What is the most likely cause?一名患有右上肢I型复杂区域疼痛综合征的35岁女性患者，在接受星状神经节阻滞后，出现瞳孔缩小，上睑下垂和眼球内陷。 她没有感受到任何明显的疼痛缓解。 右上肢皮肤温度并没有显着升高。 最可能的原因是什么？(A) Inadequate concentration of the local anesthetic 局部麻醉剂浓度不足
(B) Intravascular injection 血管内注射
(C) Subarachnoid block 蛛网膜下腔阻滞
(D) Anomalous Kuntz nerves 异常Kuntz神经
(E) Inadvertent injection of normal saline  无意中注射生理盐水

8. (D) The sympathetic supply to the upper extremity is through the grey rami communicantes of C7, C8, and T1 with occasional contributions from C5 and C6. This innervation is through the stellate ganglion. Blocking the stellate ganglion would effectively cause a sympathetic denervation of the upper extremity. In some cases the upper extremity maybe supplied by the T2 and T3 grey rami communicantes. These fibers do not pass through the stellate ganglion. These are Kuntz fibers and have been implicated in inadequate relief of sympathetically maintained pain despite a good stellate ganglion block. These fibers can be blocked by a posterior approach. Successful block of the sympathetic fibers to the head is indicated by the appearance of Horner syndrome. Successful block of the sympathetic block of the upper extremity is indicated by a rise in skin temperature, engorgement of veins on the back of the hand, loss of skin conductance response and a negative sweat test. Alternatively, it is conceivable that the patient has sympathetic independent pain.


对上肢的交感神经供应是通过C7，C8和T1的神经，偶尔来自C5和C6。这种神经是经过星状神经节。阻断星状神经节将有效地引起上肢的交感神经去神经支配。在某些情况下，上肢可能由T2和T3灰支支配。这些纤维不通过星状神经节。尽管有良好的星状神经节阻滞，但这些称为是Kuntz纤维，并未阻滞，交感神经性疼痛并不缓解。这些纤维可以通过后路方法阻滞。霍纳综合征的出现表明成功阻断了支配头部的交感神经纤维。上肢交感神经被成功阻滞表现为皮肤温度升高，手背静脉充盈，皮肤电导反应丧失和发汗试验阴性。或者，可以想象患者具有交感神经无关的疼痛。

mycookqi

9.The greater occipital nerve is a branch of  枕大神经是以下哪个神经的分支
(A) posterior ramus of C2 C2后支
(B) posterior ramus of C1 C1后支
(C) anterior ramus of C1  C1前支
(D) anterior ramus of C2  C2前支
(E) trigeminal nerve   三叉神经

(A) The skin over the posterior part of the neck, upper back, posterior part of the scalp up to the vertex is supplied segmentally by the posterior rami of the C2 to C5. The greater occipital nerve is a branch of the posterior of ramus of C2. The lesser occipital nerve is a branch of the posterior ramus of C2 and C3. Headaches due to occipital neuralgia are characterized by either continuous pain or paroxysmal lancinating pain in the distribution of the nerve. The etiology of occipital neuralgia is compression of the C2 nerve root, migraine, or nerve entrapment. An occipital nerve block maybe performed as a diagnostic or therapeutic measure. The trigeminal nerve does not contribute to the greater occipital nerve  颈后部，上背部，头后面至头顶，是由C2到C5神经后支节段性支配。枕大神经是C2神经后支的分支。枕小神经是C2和C3神经后支的分支。枕神经痛的特征是在神经分布区持续性或是阵发性的撕裂性疼痛。引起枕神经痛的原因有C2神经受压，偏头痛，神经卡压。枕神经阻滞可以作为诊断或治疗的手段。三叉神经并未发出枕大神经。

mycookqi

10. A 66-year-old woman presents with pain in the posterior cervical region for the last 1 year. It radiates to the right shoulder, lateral upper arm, and right index finger. She also complains in the medial part of the right scapula and anterior shoulder. On physical examination, she
has numbness to the index and middle fingers of the right hand and weakness of the triceps muscle. The most likely cause of her pain is
一名66岁的女性近一年来出现颈后区疼痛，可放射到右肩、上臂外侧和右手食指。同时伴右肩胛骨内侧和前肩部的疼痛。查体，患者右手食指和中指有麻木感、三角肌无力。最有可能引起该患者疼痛的原因是
(A) herniated nucleus pulposus of the C5 to C6 disc causing compression of the C5 nerve rootC5/C6之间椎间盘突出的髓核压迫C5神经根
(B) herniated nucleus pulposus of the C5 to C6 disc causing compression of the C6 nerve rootC5/C6之间椎间盘突出的髓核压迫C6神经根
(C) herniated nucleus pulposus of the C6 to C7 disc causing compression of the C7 nerve rootC6/C7之间椎间盘突出的髓核压迫C7神经根
(D) herniated nucleus pulposus of the C6 to C7 disc causing compression of the C6 nerve rootC6/C7之间椎间盘突出的髓核压迫C6神经根
(E) muscle spasm 肌肉痉挛
10.  (C) The pattern of pain helps identify the cervical disc causing the most problems. HNP are more common in the lumbar region. The cervi- cal nerve roots exit above the vertebral body of the  same  segment.  The  C7  nerve  root  exits between the C6 to C7 vertebra.疼痛的类型有助于明确导致问题的原因在椎间盘。腰椎间盘突出更加常见。颈椎神经根位于同一节段椎体的上方。C7神经根位于C6和C7椎体之间。