神经病理性疼痛概念与诊断李焰生.pptVIP

神经病理性痛诊断分级流程 主诉疼痛 可能的神经解剖分布的疼痛， 及病史提示相关疾病或病变 不像是 非 是 可能神经病理性痛 证实检查： A 感觉体征，位于病变神经分布区 B 诊断性检查证实有能解释神经病理性痛的疾病或病变 无 两者皆有: 肯定 一项符合： 很可能 伴随痛性神经病的其他表现 失眠 焦虑 抑郁 体重下降 生命质量下降 Gilron, I. et al. CMAJ 2006;175:265-275 神经病理性痛治疗流程 考虑非药物治疗（如理疗、心理干预）早期选择 封闭治疗以促进康复（如复杂区域疼痛综合症） 如是PHN或局灶神经病 可以表面用利多卡因 起始一线治疗： 加巴喷丁、普加巴林、TCA、SNRI 无效、部分有效或其他诊断 无效、不能耐受 部分有效 转换其他一线药 增加其他一线药 无效、不能耐受 部分有效 单用曲马多或阿片类 加用曲马多或阿片类 转诊、三线药、介入干预等 无效、不能耐受 谢谢 * The perception of pain is supported by a system of sensory neurons (nociceptors), and neural afferent pathways that specifically respond to potentially noxious, tissue damaging stimuli There is no objective indicator for pain and experts agree that the best clinical approach in most circumstances is to assume that the patient is reporting a true experience, even in the absence of an obvious demonstrable source of tissue injury. Accepting a patient’s complaint of pain as valid does not necessarily lead to the initiation of a specific treatment, but it is a useful beginning in developing an effective physician-patient dialogue. Clinically, pain can be labeled “nociceptive” if it can be inferred that the pain is related to the degree of receptor stimulation by processes causing tissue injury. Nociceptive pain involves the normal activation of the nociceptive system by noxious stimuli. Nociception consists of four processes: transduction, transmission, perception, and modulation. Normal somatosensory processing involves interaction between afferent systems activated by tissue injury and accompanying inflammation. The primary afferent system includes nociceptors (A-delta and C- fibers), signal processing in the dorsal horn of the spinal cord, ascending neural pathways, and thalamic and other specialized brain structures. Peripheral nociceptors are lightly myelinated or non-myelinated ends of primary afferent nociceptive (sensory neurons). Peripheal nociceptors have various response characteristics and they can be found in skin, muscle, joints, and some visceral tis