疼痛治療研究進(jìn)展【精品(存儲版)
【正文】 citation at site of axonal injury IIIIIII I II IIII 外周神經(jīng)損傷后中樞延遲痛產(chǎn)生 ... 參與 : ? 幻覺痛 ? 皰疹痛 ? 三叉神經(jīng)痛 Transient injurydischarge following nerve trauma Spinal Sensitization IIIIIIIIII Hyperactivity II III IIIII Delayed apoptosis Inhibitory Neuron 損傷 疼痛和感染 損傷治愈但疼痛信號持續(xù)存在 CNS結(jié)構(gòu)發(fā)生改變引起神經(jīng)傳遞變化 慢性疼痛 觸摸痛 疼痛過敏 疼痛播散 （摘自 Marcus , 2022） 慢性疼痛是一種疾病 痛與大腦 Following arm amputation, face area expands into hand area on the ?cortical map“ 皮 層 上的 軀 體感 覺 分布 圖 截肢者 Following arm amputation the face area is expanding into the hand area, as assessed by brain imaging. This reanization of sensory topography is correlated with the incidence and severity of phantom limb pain Flor et al. 1995 中樞神經(jīng)運(yùn)動控制系統(tǒng)異化痛覺可能需要多種神經(jīng)塑形 運(yùn)動控制系統(tǒng)的正反饋導(dǎo)致痛覺的上調(diào) M. Zimmermann, 19781999 Sensitization of reflex transmission From brain: ? Guarding behavior ? Behavioral therapy ? Positive cognitions Joint nociceptors Trigger point infiltration Positive feedback by increased muscle contraction Motor neuron Inhibitory neurons activated by: ?Analgesic drugs ?Antispastic drugs ?TENS Nociceptors of muscle and tendon 運(yùn)動控制系統(tǒng)的失調(diào)放大痛 ... ? 過度的肌緊張 ? 關(guān)節(jié)強(qiáng)直 ? 收縮肌與拮抗肌的失平衡 ? 防護(hù)行為 ? 沒有運(yùn)動的學(xué)習(xí)行為 ? 日常生活的千篇一律 發(fā)射控制 學(xué)習(xí)行為 ... 均增加了痛敏 慢性持續(xù)痛的軀體動力學(xué)和心理放大反饋 Hasenbring et al., Der Schmerz 15, 2022, 442 K 鰎 p e r l i ch e F o l g e nE i n sch r 鋘 ku n g d e r B e w e g l i ch ke i tS ch o n h a l t u n gM u ske l u n d L e i st u n g ssch w 鋍 heP sy ch o so zi a l e F o l g e nV e r l u st d e r S e l b st w i r ksa m ke i tA n g st / D e p r e ssi o nK r a n kh e i t sg e w i n nS ch m e r zSt 鋜 ke , D a u e rA u sl 鰏 e r e i n e r S ch m e r ze p i so d e Trigger by Initial Pain Episode Pain Intensity, Duration Somatic Consequences Guarding Behavior Decreased Mobilty Decreased Muscle Strength Psychosocial Consequences Loss of Self Efficacy Anxiety/Depression Secondary Social Gain Examples: Low Back Pain, Fibromyalgia 痛與抑郁 , 通常并存的疾病 誰為先 ? 慢性痛 – 抑郁的癥狀 Blumer and Heilbronn 1981, Pain a variant of depression ? 抑郁 – 慢性痛的轉(zhuǎn)歸 W246。ckgrats Vertebral disk and protrusion Nerve sensitization by nucleus pulposus material Facet joint Spinal nerve Dura 一氧化氮合酶 mRNA在軸突損傷部位蓄積 Ventral caudal thalamus 皮層 間腦 中腦 髓質(zhì) 脊髓 背角 傳遞 A 疼痛的中樞傳遞 外周神經(jīng)纖維 Brain 交感神經(jīng)纖維 疼痛信息的中樞處理過程 ? 神經(jīng)系統(tǒng)的可塑性和中樞神經(jīng)系統(tǒng)的敏化 坐骨神經(jīng)痛的多樣生理病理機(jī)制 Baron 2022 傷害性成份 : 受到刺激的 C類傷害性感受器 Cfiber A?fiber 神經(jīng)病理性成份 1: 椎間盤突出導(dǎo)致的神經(jīng)根受壓 神經(jīng)病理性成份 2: 炎性介質(zhì) TNFα 損壞神經(jīng)根 Intervertebral disc Central sensitization Cfiber “混合性疼痛” , 一個(gè)新的臨床術(shù)語 雖然所有的傷害性感受器都是游離的神經(jīng)末梢 ,但是依據(jù)軸突可以將它們分為兩大類。 Stricharz 2022 風(fēng)濕性關(guān)節(jié)炎 – 免疫系統(tǒng)激活導(dǎo)致的炎癥 In inflammatory joint diseases cytokines such as TNFα* destroy cartilage and excite the nociceptors TNFα can be inhibited by specific antibody interrupting immune system perpetuation of inflammation a basis for new antirheumatic drugs such as Adalimumab *TNFα = Tumor Necrosis Factor Alpha 雙向的相互作用 神經(jīng)系統(tǒng) – 免疫系統(tǒng) : 炎癥和疼痛的放大 Nerve Cells Immune Cells Cytokines, . TNFα Neuropeptides, NO + + 關(guān)節(jié)傷害性感受器的敏化 work by Schaible and Schmidt 19831998 Sensitization by ? 前列腺素 ? 緩激肽 ? 神經(jīng)肽 ? 細(xì)胞因子 ? ..... 炎癥前的放電 炎癥后的放電 Unphysiological range Flexion Extension Joint capsule Nociceptor 炎癥激活的靜息的傷害性感受器 Afferent fibers Time 脊髓和神經(jīng)受壓迫的多個(gè)部位 R252。hler 1995 Potentiated synaptic transmission Amplitude LTP Cfiber evoked spinal field potential LTP, a model for long term sensitization in the central nervous system Tetanic Cfiber stimulation 100 Hz, 5 sec ... a
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