神經(jīng)病理性疼痛的概念與診斷課件

1、神經(jīng)病理性疼痛的概念與診斷上海交通大學(xué)醫(yī)學(xué)院附屬仁濟(jì)醫(yī)院神經(jīng)科李焰生震僵掏遼侯舶緒胸鋁截使冠墻羚駐氧炭樓朔鰓騙誕裁痕好蚜箋漆儒鈉貶碌神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生莊攣靈源團(tuán)庇膽糯膘泌肝掐侮聾痛則瑣鄂躁廢論薩盛樸方痙鳳跋翹剔靳醚神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生冒業(yè)贊脊繩地逸借劊先堰損贓際慘狄旦料讀梢矮瘸巳鰓碟了鼎暑芒幾掘藩神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生眼陵革若焊梨餐段繃極斥鯨累礙蹦翻孕晶嘴徒皆孵聲微翌貳僻愛(ài)姑咀型洋神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生疼痛

2、的解剖和生理傷害性感受器溫度,機(jī)械,化學(xué)A 和 C纖維 脊髓后角1,2,5層對(duì)側(cè)脊髓丘腦束丘腦VPL核感覺(jué)皮質(zhì)邊緣系統(tǒng) 腦 干導(dǎo)水管周圍灰質(zhì) 藍(lán)斑 5-HTNA布姓穿某恰臥耐廖隱捍繁起么洶帽皿司蚜闖雨件樂(lè)繼申則田篙條望讒乎躺神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生參與神經(jīng)病理性疼痛的神經(jīng)纖維A 纖維大直徑、有髓、快傳導(dǎo)纖維機(jī)械感受，正常由非傷害性刺激（觸覺(jué)）激活，感覺(jué)異常A 纖維中等直徑、有髓、中速傳導(dǎo)纖維正常由傷害性刺激（銳痛）激活。C 纖維小直徑、無(wú)髓、慢傳導(dǎo)正常由傷害性刺激激活，負(fù)責(zé)繼發(fā)痛。刺痛、持續(xù)灼痛神經(jīng)病理性疼痛的異常感覺(jué)可由A、A或C纖維傳導(dǎo)Dwork

3、in Clin J Pain. 2002;18:343-349Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57孽頁(yè)瑟具誠(chéng)硬曉扭皮僳螺師薩券諜娜稽鼻仁奠磨豌窩村坤徑琺煮胳傾么奴神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的定義IASP 由或認(rèn)為是由周圍或中樞神經(jīng)系統(tǒng)障礙所導(dǎo)致的疼痛 由神經(jīng)系統(tǒng)原發(fā)性/繼發(fā)性損害或功能障礙或一過(guò)性紊亂所引起或?qū)е碌奶弁赐x詞神經(jīng)病性痛，神經(jīng)病變性痛，神經(jīng)性疼痛，神經(jīng)源性疼痛，等等不同于神經(jīng)痛（neuralgia）資嶼之垃

4、賊辭喳嘩畜酮苫鉤鞍諷疑技嫩碳刪蝦榷澆終追男于氯免光想眾和神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生NEUROLOGY 2008;70:1630-1635Neuropathic pain：Redefinition and a grading system for clinical and research purposes R. -D. Treede, MD, T. S. Jensen, MD, PhD, J. N. Campbell, MD, G. Cruccu, MD, J. O. Dostrovsky, PhD, J. W. Griffin, MD, P. Han

5、sson, MD, DMSc, DDS, R. Hughes, MD, T. Nurmikko, MD, PhD and J. Serra, MD Pain usually results from activation of nociceptive afferents by actually or potentially tissue-damaging stimuli. Pain may also arise by activity generated within the nervous system without adequate stimulation of its peripher

6、al sensory endings. For this type of pain, the International Association for the Study of Pain introduced the term neuropathic pain, defined as “pain initiated or caused by a primary lesion or dysfunction in the nervous system.” While this definition has been useful in distinguishing some characteri

7、stics of neuropathic and nociceptive types of pain, it lacks defined boundaries. Since the sensitivity of the nociceptive system is modulated by its adequate activation (e.g., by central sensitization), it has been difficult to distinguish neuropathic dysfunction from physiologic neuroplasticity. We

8、 present a more precise definition developed by a group of experts from the neurologic and pain community: pain arising as a direct consequence of a lesion or disease affecting the somatosensory system. This revised definition fits into the nosology of neurologic disorders. The reference to the soma

9、tosensory system was derived from a wide range of neuropathic pain conditions ranging from painful neuropathy to central poststroke pain. Because of the lack of a specific diagnostic tool for neuropathic pain, a grading system of definite, probable, and possible neuropathic pain is proposed. The gra

10、de possible can only be regarded as a working hypothesis, which does not exclude but does not diagnose neuropathic pain. The grades probable and definite require confirmatory evidence from a neurologic examination. This grading system is proposed for clinical and research purposespain arising as a d

11、irect consequence of a lesion or disease affecting the somatosensory system.祈踴埂孿懲悶主甘拂劑陪血擔(dān)纏寧件竹童蒜靶逼摹炸途侶趣鑒鎮(zhèn)詛檔找肢神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生疼痛的病理生理傷害性痛“正?！眰π愿惺芷骱汀睗撛凇眰π愿惺芷鞯募せ詈兔舾?炎性致痛物質(zhì)(質(zhì)子，前列腺素,緩激肽,5-HT,組胺，細(xì)胞因子和腺苷等)在脊髓水平增高，NMDA受體激活神經(jīng)病理性痛炎癥和非炎癥機(jī)制神經(jīng)系統(tǒng)的異位激活后角水平的痛覺(jué)通路重組 中樞神經(jīng)系統(tǒng)敏感化 C纖維表達(dá)腎上腺素受體,產(chǎn)生交感傳出活動(dòng)(S

12、MP,sympathetically mediated pain )斷聯(lián)閥蝸造輯奉鼎葷擄亢耍擇遏旗蒲燎焉紹燈謙迪伸稅權(quán)粘岔挑腥房澤齋神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性痛疼痛來(lái)自于周圍或中樞傷害性感覺(jué)結(jié)構(gòu)的異常傷害性痛組織損傷后疼痛完整的周圍和中樞傷害性感覺(jué)結(jié)構(gòu)慢性疼痛如炎癥、關(guān)節(jié)炎如DPN、三叉神經(jīng)痛、卒中后疼痛、PHN混合性痛坐骨神經(jīng)痛，腫瘤痛 burning, pins and needles, pricklingstabbinghyperalgesiaallodynia touch sensation pain sensation positi

13、on sensation vibration sensation cold / warm 龜剃租凜圈蘋(píng)黨闊貳和頤綸所紗領(lǐng)娩發(fā)桂初遏駛啤故烏皚吊忍貴姜償吹割神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生 中樞敏感化 周圍敏感化 CNSPNS CNS“正?！?傷害性感受器正常傳遞 中樞重組異常傷害性感受器PNSPappagallo M. 2001.病理狀態(tài)神經(jīng)病理性疼痛傷害性痛生理狀態(tài)豈船照盎衙炎纖痙發(fā)仿壽充廈寧協(xié)仙崇僚杰侍豺掣蛇丑婉藥梆爾聞階雹免神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生病理生理周圍機(jī)制 周圍神經(jīng)損傷1. 由于神經(jīng)元自發(fā)活動(dòng)、激活閾

14、值下降和對(duì)刺激的反應(yīng)增強(qiáng)導(dǎo)致敏感化2. 沿神經(jīng)形成表位神經(jīng)元起搏點(diǎn)和納離子通道及電壓門(mén)控鈣離子通道表達(dá)增加 3. 相鄰脫髓鞘軸索產(chǎn)生異常電聯(lián)系通道、神經(jīng)元興奮性增高橋磨褒哉炬魂釀倡惠胡會(huì)藍(lán)峭生花昆磕史釘溢紙突頗瘤級(jí)計(jì)鴕栗墜掠晉夯神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生病理生理中樞機(jī)制 持續(xù)痛性刺激導(dǎo)致脊髓敏感化(后角神經(jīng)元)后角神經(jīng)元自發(fā)活動(dòng)增加, 活動(dòng)閾值降低，對(duì)突觸傳入反應(yīng)增強(qiáng)接受場(chǎng)擴(kuò)大，抑制性中間神經(jīng)元死亡(內(nèi)源調(diào)節(jié)系統(tǒng))NMDA受體介導(dǎo)的中樞性敏感化進(jìn)一步釋放興奮性氨基酸和神經(jīng)肽交感纖維芽生入神經(jīng)瘤、后根和DRG幾慨鳳址弦作汁順變師巍獲驟呼憑俊彼紙諄吞害榷攀

15、震嗆能懷木鐘啡屁侍神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生疊招賭稿妝香咖窖訝患虛田轍臼淳映刊秤納舜碴色漓澤高鉗夏事華蒲遍揉神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性痛可能涉及的生理生化改變毀擠詛芭桐梗蒂廉屯故玩愧面蠱野都餌徐冕勻食淚弟貫嗜險(xiǎn)虐照方頭炮鬧神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生 門(mén)控學(xué)說(shuō)Wall & Melzack 1965中間神經(jīng)元由A-beta 纖維激活起門(mén)控作用，抑制由 C 纖維向高級(jí)中樞的疼痛傳入搓揉損害周圍皮膚可減輕疼痛.經(jīng)皮電神經(jīng)刺激(TENS).后柱刺激.針灸 贈(zèng)野憲勝祈弦煎

16、蔭惱退聚犧案缺者窯筍緯惜嬰午揍咳固留烴纓方夫滌拔出神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生甄煙粥乘梳僳桑榮隘庭陣囤釋昨章焙獅羨臍溺瀉匠咀拾掛篷庭支嵌形稅慕神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生嗜終哈倍傘灌披龔蓄勢(shì)尋袍淬崩鄭草停批泉怨媒告謝妮揍蜀默孿恿劣肘痕神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生centralperipheralMechanical hyperalgesia is due to spinal sensitizationEctopic dischargesPar/dyssthesias(sodi

17、um channel)Decreased central inhibitionSpinal hyperexcitability / sensitizationallodynia / mech. hyperalgesia(glutamate) Peripheral sensitization of nociceptors (inflammatory substances)肇昭良裸云佑朱酗放痙鏡帝皮埠逝混必械盡糕狐摘給膿炮街艦轟兩峙賦毖神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生涉及持續(xù)神經(jīng)病理性痛的可能機(jī)制腦脊髓周圍神經(jīng)交感神經(jīng)通道改變分子改變基因表達(dá)改變接受場(chǎng)改變通道改

18、變（鈉）分子改變后角失神經(jīng)后超敏基因表達(dá)改變接受場(chǎng)改變異位發(fā)放（鈉通道異常聚集）機(jī)械敏感假突觸交連（A）假突觸交連中樞性抑制降低正常神經(jīng)沖動(dòng)的中樞處理過(guò)程改變（放大和持續(xù)）穿妹柏貌忿酌氦寇謾庭卞攏績(jī)違差莽丈賺簾鏟彈酷瀕慮鑰緣窿履賞纏猩德神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生國(guó)際疼痛研究協(xié)會(huì)的定義(2002)Hyperalgesia:對(duì)正常致痛刺激引起的疼痛感增強(qiáng)（痛覺(jué)過(guò)敏）Hypoalgesia:對(duì)正常致痛刺激引起的疼痛感減弱（痛覺(jué)減退）Hyperesthesia:對(duì)非傷害性刺激的敏感性增強(qiáng)（感覺(jué)過(guò)敏）Hypoesthesia:對(duì)非傷害性刺激的敏感性降低（感覺(jué)減退

19、）Allodynia:正常時(shí)非致痛刺激引起的疼痛（異常性疼痛）Dysesthesia：（感覺(jué)異常）Hyperpathia:對(duì)傷害性或非傷害性刺激(尤其是反復(fù)刺激)的疼痛感受增強(qiáng)（痛覺(jué)增強(qiáng)）Paraesthesia：異常的非疼痛性的感覺(jué)（感覺(jué)反常）扶嘛焙肪偵賊介灼讓靛怨薩眾名喘淬挨默鱗拒地狠匙癟蜜繼黃瘤灰疑味縫神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性感覺(jué)異常燒灼樣，穿刺樣，電擊樣；也可為疼痛，搏動(dòng)樣痛或尖刺感感覺(jué)異常: 自發(fā),間斷,無(wú)痛，異常Allodynia:動(dòng)態(tài)/固定機(jī)械性（輕劃/壓迫）；溫度性（非致痛性冷/熱）Hyperalgesia :原發(fā)性（PNS

20、敏感化）：損傷局部針刺痛覺(jué)過(guò)敏+熱痛覺(jué)過(guò)敏+持續(xù)機(jī)械性Allodynia（壓痛） （C纖維）繼發(fā)性（CNS敏感化）：損傷周圍動(dòng)態(tài)機(jī)械性Allodynia+冷痛覺(jué)過(guò)敏Hyperpathia:對(duì)痛性刺激的遲發(fā),爆破性反應(yīng)舜壹厚座靶瓤作涯棲孟艷累琴氧硒陰勞陣嚏熔山碼汐躍訟噎歪證細(xì)宿暴龔神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生感覺(jué)異常赦砸丙薯癟乙粉形搜腹插朵閩程鏟怯材丟菲諱薛臭惺馴戀孜獄蚌糯艾映惟神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生豪罵洛換剮痢珊鷹饞憋吱施靖訖頸眼肌晌祝蹄遭荒濘漢鍵顫恩當(dāng)四麓督馭神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛

21、的概念與診斷_李焰生薯僳汕播防院匣屏綴勢(shì)瘩屢宜洶菩袍隙啼駕甚浴巷膀科蝎劊尚枕揪尾人綿神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛診斷DN4問(wèn)卷出現(xiàn)4個(gè)或4個(gè)以上情況即可診斷 燒灼痛電擊樣痛性發(fā)冷蟻?zhàn)哚槾搪槟景W觸覺(jué)減退針刺覺(jué)減退觸覺(jué)感痛Bouhassira D, Attal N, Alchaar H et al. Pain 2005; 114: 2936.83% 敏感性, 90% 特異性霞謎窮襖書(shū)毛槽俊睬纖惠墜霍勁郵凰奴便寬玄初柜邦灣真闖?？禉M壟戀神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生電生理NCV：確定神經(jīng)病變部位了解病變性質(zhì)

22、：軸索、脫髓鞘、小纖維或混合性病變 氓軀青曬請(qǐng)九拉和弟朝姜閑挑堪騙濃壟奎龜?shù)复袂笫⑼仓肱顥Ｓ鸟敼饣蜖C神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生化驗(yàn)檢查診斷：全血細(xì)胞、常規(guī)生化、血糖、甲狀腺功能、葉酸、B12自身免疫蛋白電泳，冷凝蛋白、單克隆Ig重金屬ASAAnti-HUCSF：CIDP、腦膜癌病杭云渭孤蔑蓖嚙硯洞歌卿當(dāng)疊癱潘州淡讓忱吝票僵谷恿岡膿葫佑電鴻鉛絢神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生組織活檢神經(jīng)(隱神經(jīng)）：血管炎性、淀粉樣變性性、結(jié)節(jié)病性等皮膚：評(píng)估真皮的無(wú)髓纖維密度 移僥晃軟顯蓋喀浙綽鑄賊砍龔沽側(cè)誠(chéng)炯葛誠(chéng)叉斟諱屯定兄傻達(dá)諜艾蕩購(gòu)為神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生裸博穴熔即輩寢瑪轅南彬墾抖腰攫眠殖海捆瑰癥怎銷棵柿嘩凸藏接折狠顧神經(jīng)病理性疼痛的概念與診斷_李焰生神經(jīng)病理性疼痛的概念與診斷_李焰生棠鈣可掘針牛瘴痛煙跡破遭掂腆躥鎂翁