（优质医学）手术后慢性疼痛的防治.ppt

现实功能的改变，之后为结构的改变 * * 由于存在神经损伤和之后重塑，使得术后的痛觉感知过程发生了很大变化。到底朝哪个方向重塑仍就是个谜团，导致治疗效果的不确定性 都是影响神经重塑的因素 * 神经病理性疼痛主要的特征应该是阵发性疼痛和感觉缺失 * * Table 2. Recommendations in the prevention and management of post-surgical NP Risk factors (marking patients with high-risk factors for developing persisting post-surgical pain and follow up after discharge) Preoperative risk factor Women, younger age Pain before surgery Preoperative chronic pain Preoperative anxiety and fear Site (e.g. thoracotomy, sternotomy,major limb amputation) and extent of surgery Low income, low self-rated health and lack of education Postoperative Unrelieved pain risk factor Severe pain Most analgesics consumed (7 days) Reoperations Prevention and management Intraoperative Use least painful surgical approach (e.g. keyhole) with acceptable exposure Use multimodal pharmacological analgesia in addition to afferent neural blockade Postoperative Continue analgesia well into the postoperative period 特别是神经阻滞，到底镇痛时间应该多长，会有差异，因为手术创伤不同引起的伤害性刺激传入会不同 * * Measure pain levels Bedside neurological examination if NP is suspected Discharge Follow up after discharge Use antidepressants (tricyclics) and anticonvulsants (gabapentin and pregabalin) as first-line coanalgesics * 疼痛信号的传递依赖于神经系统的完整性 病生理基础 中枢敏化 炎症→IL6、TNF、COX2、PGE 周围神经损伤→兴奋与抑制失衡→兴奋性和抑制性神经元坏死，神经重塑 NGF水平↑ Yi Feng, Hui Ju The Journal of Pain 2008;9(1):45-52 Henrik Kehlet Lancet 2006; 367: 1618–25 tRNA Na?ve 1 Hr 2 Hrs 4 Hrs 6 Hrs 24 Hrs 12 Hrs 48 Hrs COX-2 * na?ve C28+ 坐骨神经冷冻后脊髓背角神经元内NGF 表达 28 d after cryoneurolysis * NGF 27kD→ GAPDH 36kD→ C28+组大鼠脊髓背角的NGF含量显著高于C28-组大鼠，P 0.05。 C28- C28- C28- C28- C28+ C28+ C28+ C28+ 结 果 * 手术创伤应激后超敏反应 * 当重度疼痛超过24h以上就会发生神经重塑使神经系统结构和功能发生变化1,2 当疼痛超过一年，大多数患者会出现抑郁、焦虑3,4 1. P M Arnstein, Journal of Neuroscience Nursing 1997：179-186; 2. T J Coderre , Pain 1993：259-284. 3. W E Broadhead JAMA 1990(264) 2524-2528; 4.