pain medicine 问答题

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。

mycookqi

11. Blood supply to the spinal cord is by脊髓的血供来自于
(A)  two posterior spinal arteries and two anterior spinal arteries 两条脊椎后动脉和两条脊椎前动脉
(B)  two posterior spinal arteries and one anterior spinal artery 两条脊椎后动脉和一条脊椎前动脉
(C)  branches of the lumbar arteries 腰动脉分支
(D) radicularis magna (artery of Adamkiewicz) and two posterior spinal arteries 大前根动脉（Adamkiewicz动脉）和两条脊椎后动脉
(E)  internal iliac arteries 髂内动脉
11.  (B) The blood supply to the spinal cord is primarily by three longitudinally running arteries— two  posterior  spinal  arteries  and  one  anterior spinal artery.  The anterior spinal artery supplies approximately 80% of the intrinsic spinal cord vasculature.  It  is  formed  by  the  union  of  a  branch from the terminal part of each vertebral artery. It  actually  consists  of  longitudinal  series  of  longitudinal  series  of functionally individual blood vessels with wide variation  in  lumen  size  and  anatomic  discontinuations.脊髓的血供主要是三条纵向行走的动脉---两条脊椎后动脉和一条脊椎前动脉。脊椎前动脉的血供占脊髓固有血管的80%.是由每根椎动脉终末分支汇合组成的。包括在不同血管的纵向行走部分，这些血管大小、解剖走向变异较大。
  The  spinal  cord  has  three  major  arterial supply  regions:  C1  to  T3  (cervicothoracic region), T3 to T8 (midthoracic region), and T8 to the conus (thoracolumbar region). There is a poor anastomosis between these three regions. As  a  result  the  blood  flow  at  the  T3  and  T8 levels is tenuous. In spinal stenosis, especially in the lower cervical region, the anterior spinal artery  may  be  compressed  by  a  dorsal  osteophyte and a HNP leading to the anterior spinal syndrome (loss of motor function).脊髓有三个主要的动脉供应区：C1 -T3 （颈胸段），T3 -T8 （中胸段）和T8-圆锥（胸腰段）。在这三个区域的血管吻合较少，因此T3和T8水平的供血少。在椎间狭窄中，特别是下颈椎椎管狭窄中，骨赘和髓核突出会压迫脊椎前动脉从而引起脊髓前动脉综合症（运动功能丧失）。
  There are two posterior spinal arteries that arise  from  the  posterior  inferior  cerebellar arteries.两条脊髓后动脉起源于小脑后下动脉。
  The  three  longitudinal  arteries  are  reinforced  by  “feeder”  arteries.  They  are  spinal branches  of  the  cervical,  vertebral  posterior intercostal,  lumbar,  and  lateral  sacral  arteries. Approximately six or seven of these contribute to the anterior spinal artery and another six or seven  to  the  posterior  spinal  arteries,  but  at different levels. The largest of these arteries is known as the radicularis magna or the artery of Adamkiewicz. 除三根纵行动脉，还有颈椎后椎体间动脉、腰动脉、骶外侧动脉发出的分支供应脊髓。大约有6-7支这样的分支汇入脊椎前动脉，在不同节段水平另有6-7支加入脊椎后动脉。其中最大的动脉是大前根动脉（Adamkiewicz动脉）

mycookqi

12. The  most  common  origin  of  the  artery  of Adamkiewicz is Adamkiewicz 动脉最常见的起源在
(A)  between T4 and T6
(B)  at T7
(C)  between T8 and L3
(D)  at L4
(E)  at L5

12.  (C) The  artery  of Adamkiewicz  originates  on the  left  between  the  T8  and  L3  level  in  most cases.  This  is  the  largest  of  the  feeder  arteries that  supplies  the  anterior  spinal  artery.  The artery of Adamkiewicz enters through an intervertebral foramen between T8 and L3 to supply the lumbar enlargement.
  In  a  small  percentage  of  cases  (15%)  the take  off  is  higher  at  T5.  In  this  case  a  slender contribution  from  the  iliac  artery  enlarges  to compensate for the increased blood flow to the lumbar portion of the cord and the conus.
  The cervical portion up to the upper thoracic region, the anterior spinal artery receives contributions  from  the  subclavian  arteries.  By the  time  the  blood  reaches  the  T4  segment  it becomes tenuous. Although, the T4 to T9 area of the  spinal  cord  receives  blood  from  the  feeder vessels, it is relatively small.多数情况下，Adamkiewicz 动脉起源于T8-L3节段的左侧。这是汇入脊髓前动脉中最大的一支。Adamkiewicz 动脉穿过T8-L3的椎间孔供应脊髓腰膨大段。少数情况下（15%）,其起源可高达T5，此时来这髂动脉的细小分支变得粗大以代偿供应脊髓腰段和圆锥的血流。在颈段和上胸段，锁骨下动脉分支汇入脊椎前动脉，到T4阶段时，血流变得稀少。T4-T9节段的脊髓也有支线血管供应，但相对较小。