31. epidural steroid injection 治療邏輯是針對椎間盤 nucleus pulposus 所釋放的發炎物質，下列 數種發炎物質 何者與椎間盤突出最沒有直接相關性？
(A) phospholipase A2
(B) caspase
(C) interleukins ( 1α, 1β, 6)
(D) tumor necrosis factor
(E) nitric oxide

27. 下列何者非為催眠(Hypnosis)在疼痛醫學中可能的應用範圍？ (A) Cancer pain management (B) Perioperative anxiolysis (C) Chronic low back pain (D) Local anesthetic systemic toxicity (E) Headache

28. 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

29. 關於癌症相關的骨頭疼痛，下列敘述何者不適當 (A) 癌症骨轉移最常見的位置是脊椎骨，一旦發現有骨轉移後，對於病患的產生癌症相關 併發症和存活時間會有明顯的改變 (B) 在動物癌症骨轉移模型，無論是 osteolytic 或是 osteoblastic model，都可以看到骨頭有 destructive injury。 (C)過去研究發現 periosteum(骨膜)有豐富的交感與感覺神經纖維，另外 bone marrow 和 mineralized bone 也是有交感與感覺神經纖維分布，所以 bone pain 也就是 neuropathic pain。 (D) Cyclooxygenase (COX)-2-specific inhibitors 對於 bone pain 病患的使用上是比 nonselective NSAIDs 安全，此外抑制 COX-2 也可以抑制 tumor burden，osteoclastogenesis，以及 bone destruction。 (E) Intravenous zoledronic acid 已被證實對於 solid tumor 病患，可以降低骨骼相關併發症。

30. Pain disorder may result in the sleep problem, and which of the sleep pattern is not often seen in patients: (A) acute pain following surgical procedures is associated with reduced and fragmented sleep (B) acute postsurgical pain may result in diminished amounts of slow wave and rapid eye movement (REM) sleep (C) patients with chronic pain may suffered from reduced sleep efficiency and altered sleep architecture (increased wakefulness and stage 1 non-REM sleep) (D) subjects subjected to noxious stimuli during all stages of sleep will demonstrate a sleep awakening response and a moderate level of cortical arousal. (E) all of the above are common found in pain patients

32. 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.

33. 關於頭頸癌症病人的的敘述，下列何者不恰當？ (A) 頭頸癌病人的疼痛問題，可能是腫瘤本身、化學治療、放射治療、或是手術造成的 (B) 粘膜炎(mucositis)的疼痛機制可能是黏膜產生潰瘍，暴露出神經末梢，使得黏膜表面變 得對疼痛敏感。 (C) 可以用來處置粘膜炎(mucositis)產生的疼痛，包括 topical benzydamine、乳狀鎂(milk of magnesia)、口服 acetaminophen, NSAIDs，甚至是嗎啡類藥物。 (D) 住院的癌症病患如果有嚴重的粘膜炎(mucositis)，可以考慮使用 Intravenous Patient-controlled analgesia (IVPCA) with morphine。 (E) 粘膜炎(mucositis)在頭頸癌病人很常發生，常會造成疼痛問題，是無法預防的 p.

34. Choice a right description about treatment of cancer pain. (A) Because of the complexity of cancer pain, 3 analgesic ladder from WHO was not useful. (B) Surgery, Chemotherapy and radiotherapy are not the analgesic titration for cancer pain. (C) Only 10-20% of patients ultimately require regular strong opioids. (D) Constipation is common for opioid use, but laxative can be used only when symptom exists. (E) None of above is right

35. About the intrathecal drug delivery system, which of the following statements is NOT correct? (A) It places medication directly into the cerebrospinal fluid that surrounds the spinal cord. (B) Morphine delivered directly to the intrathecal space is particularly effective because it does no have to circulate systemically to reach the CSF and the dorsal horn of the spinal cord. (C) As a result, much smaller doses are needed (e.g., approximately 1/30 of an oral morphine dose), and the frequency of side effects is reduced. (D) Advantages of intrathecal therapy in pain includes effective pain relief, reduced side effects for patients, reduced consumption of systemic medication, improved ability to perform ADLs, and enhanced quality of life.

36. 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

37. Which of the followings clinical indicators with its suspected pathology for spinal pain is suggested to receive X-ray for first line test? (A) fracture due to severe trauma (B) aortic aneurysm with cardiovascular risk factors (C) weight loss due to tumor (D) susecpted infection with fever, sweating (E) x-ray is not a first line test for the above causes of spinal pain