疼痛基础理论及诊疗原则要点.ppt

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Analgesic Dep QiLu Hospital of SDU,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Analgesic Dep QiLu Hospital of SDU,*,疼痛基础理论及诊疗原则,山东大学齐鲁医院疼痛科,1/21/2026,1,Analgesic Dep QiLu Hospital of SDU,1,疼痛基础理论,1/21/2026,2,Analgesic Dep QiLu Hospital of SDU,与生俱来,1/21/2026,3,Analgesic Dep QiLu Hospital of SDU,伴随一生,1/21/2026,4,Analgesic Dep QiLu Hospital of SDU,疼痛历史,6000,年前，,苏美尔,2600,年前，希腊,1800,年前，中国,华陀实施腹部手术,1/21/2026,5,Analgesic Dep QiLu Hospital of SDU,1800,年前，希腊,1846,年，加拿大,1950,年代后期，比利时,保罗杨森博士发现芬太尼,1/21/2026,6,Analgesic Dep QiLu Hospital of SDU,对乙酰氨基酚,扑热息痛，强生公司,美索不达米亚南部地区已经在种植罂粟。,苏美尔人将鸦片称为“快乐植物”,埃及所使用的鸦片传播到希腊和欧洲其它地区,西奥佛雷特斯是第一个在其著作中提到鸦片的人。“鸦片”这个词本身来源于希腊词汇“植物汁液”；因此是罂粟的汁液。,德国科学家,Friedrich,Sertumer,提炼鸦片产生吗啡，“上帝自己的药物”。,吗啡被首次用于分娩,保泰松,Paul Janssen,博士，化学家，药理学家和内科医师,Paul Janssen,博士在比利时合成芬太尼,吲哚美辛,布洛芬,双氯芬酸,萘普生,吡罗昔康,COX-2,抑制剂,万络撤回,疼痛药物发展史,1/21/2026,7,Analgesic Dep QiLu Hospital of SDU,什 么 是 疼 痛,1/21/2026,8,Analgesic Dep QiLu Hospital of SDU,疼痛定义,Conception,疼痛,是,组织损伤或潜在组织损伤,所引起的,不愉快感觉和情感体验,。,世界卫生组织,(WHO,，,1979,年,),国际疼痛研究协会,(IASP,，,1986,年,),1/21/2026,9,Analgesic Dep QiLu Hospital of SDU,定义更新,1995,年美国疼痛学会主席,James Campbell,提出将疼痛列为,第五大生命体征,2001,年亚太地区疼痛论坛提出,“,pain relief is a,basic human right,”,。,“,消除疼痛是患者的,基本权利,”,。,2002,年第,10,届,IASP,大会与会专家达成共识,慢性疼痛是一种,疾病,。,1/21/2026,10,Analgesic Dep QiLu Hospital of SDU,原发病变,原发和继发于疼痛病理改变的症状和体征,继发性疼痛病变,原发病变,症状（包括疼痛）和体征,Changing,1/21/2026,11,Analgesic Dep QiLu Hospital of SDU,疼痛的产生,有害刺激,压力 热 化学 电,组织损伤,介质释放,氢和钾离子，神经递质，激肽,前列腺素,刺激伤害感受器,通过传入,通路,传达到中枢神经系统,1/21/2026,12,Analgesic Dep QiLu Hospital of SDU,致痛物质,1,、,组织损伤：,缓激肽，前列腺素，,5-,羟色胺，组胺，乙酰胆,碱，三磷酸腺苷，钾离子，氢离子等,2,、,感觉神经末梢释放物：,P,物质,降钙素基因相关肽，兴奋性,氨基酸，一氧化氮，甘丙肽，胆囊收缩素，生,长抑素,3,、,交感神经释放物：,神经肽，去甲肾上腺素，花生四烯酸代,谢物等,4,、,神经营养因子,5,、,血管因子：,一氧化氮，激肽类，胺类,6,、,免疫细胞产物：,白介素，肿瘤坏死因子，阿片肽,1/21/2026,13,Analgesic Dep QiLu Hospital of SDU,伤害性感受器,产生痛觉信号的外周换能装置,分布于全身各种组织,(,毛发、指甲）,形态学上是游离或未分化的神经末梢，胞体位于背根神经节,1/21/2026,14,Analgesic Dep QiLu Hospital of SDU,痛觉的传递,传导纤维,：,神经纤维根据其直径大小和电生理特征分为,A,类、,B,类、,C,类。其中,A,纤维和,C,纤维传导痛觉。,A,纤维兴奋阈值低，传导速度快，主要传导快痛。,C,纤维兴奋阈值高，传导速度慢，主要传导慢痛。,1/21/2026,15,Analgesic Dep QiLu Hospital of SDU,传导束,脊髓丘脑束,脊髓网状束,脊髓中脑束,脊髓颈核束,脊髓突触后纤维束,脊髓旁臂杏仁束,脊髓旁臂下丘脑束,脊髓下丘脑束,1/21/2026,16,Analgesic Dep QiLu Hospital of SDU,痛觉中枢,皮层下中枢：丘脑、下丘脑以及脑内部分核团和神经元。整合、调控、感知。,大脑皮质：,312,感觉区和边缘系统。感觉分辨和疼痛反映的最高级中枢。,1/21/2026,17,Analgesic Dep QiLu Hospital of SDU,疼痛传导通路,1/21/2026,18,Analgesic Dep QiLu Hospital of SDU,疼痛形成的神经传导基本过程可分为,4,个阶梯。伤害感受器的,痛觉传感,(transduction),，一级传入纤维、脊髓背角、脊髓一丘脑束等上行束的,痛觉传递,(transmission),，皮层和边缘系统的,痛觉整合,(interpretation),，下行控制和神经介质的,痛觉调控,(modulation),。,疼痛产生过程,1/21/2026,19,Analgesic Dep QiLu Hospital of SDU,疼痛信号的传输,1/21/2026,20,Analgesic Dep QiLu Hospital of SDU,休息一会儿,1/21/2026,21,Analgesic Dep QiLu Hospital of SDU,痛觉调制,Melzack,和,Wall,闸门学说,（脊髓水平）,1/21/2026,22,Analgesic Dep QiLu Hospital of SDU,背角,神经元,神经元递减,谷氨酸,P,物质,神经激肽,A,和,B,谷氨酸,C-,纤维,GABA,，甘氨酸,强啡肽,脑啡肽,中间神经元,生长抑素,背角,的,神经递质和受体,1/21/2026,23,Analgesic Dep QiLu Hospital of SDU,疼痛在背角的调制,1/21/2026,24,Analgesic Dep QiLu Hospital of SDU,疼痛产生的机制,周围神经机制,中枢神经机制,1/21/2026,25,Analgesic Dep QiLu Hospital of SDU,疼痛的发生机制,外周机制：,损伤的外周传入纤维的异位放电,神经元的交互混传即,“,Cross-Talk,”,现象,交感神经对损伤神经元的兴奋作用,1/21/2026,26,Analgesic Dep QiLu Hospital of SDU,疼痛的发生机制,(chronic pain),中枢机制：,脊髓背角神经元的敏化,脊髓抑制性神经元的功能下降,背角神经元的“出芽”现象,1/21/2026,27,Analgesic Dep QiLu Hospital of SDU,疼痛机制,感觉阈,:,受试者首次报告有刺感、温热感的最小刺激量。,痛阈,:,受试者首次报告引起痛觉的最小刺激量。,痛觉过敏,(,hyperalgesia,):,对伤害性刺激产生过强的疼痛反应。,痛觉超敏，,或称痛性感觉异常,(,a,llodynia,),指在非伤害性刺激作用下产生痛觉。,自发痛,(,spontaneous pain,);,指在没有可见的刺激条件下产生的疼痛。,1/21/2026,28,Analgesic Dep QiLu Hospital of SDU,疼痛机制,Cross-talk,现象,Sprout-out,现象,Wind-up,现象,Peripheral sensitization,现象,Central sensitization,现象,Sprout-out,现象,1/21/2026,29,Analgesic Dep QiLu Hospital of SDU,Cross Talk,神经元的交互,混传,现象,:,损伤的神经元或神经纤维因脱髓鞘而绝缘作用减弱,一个神经元或纤维的兴奋常可扩散混传至另一神经元或纤维,形成反复发放冲动的环路,使放电神经元的数目和放电频率被不断放大,从而引起痛觉超敏,1/21/2026,30,Analgesic Dep QiLu Hospital of SDU,Sprout-out,现象,1/21/2026,31,Analgesic Dep QiLu Hospital of SDU,Wind-up,现象,疼痛发生后，中枢神经系统发生可塑性（,plasticity,）变化，脊髓背角神经元兴奋性增强，,“,上扬（,wind-up,）,效应,1/21/2026,32,Analgesic Dep QiLu Hospital of SDU,Peripheral sensitization,现象,在组织损伤和炎症反应时，受损部位的细胞如肥大细胞、巨噬细胞和淋巴细胞等释放多种炎症介质。同时，伤害性刺激本身也可导致神经源性炎症反应，进一步促进炎症介质释放。这些因素使平时低强度的阈下刺激也可导致疼痛，这就是,外周敏化,。,1/21/2026,33,Analgesic Dep QiLu Hospital of SDU,Central sensitization,现象,组织损伤后，不仅受损伤区域对正常的无害性刺激反应增强，邻近部位未损伤区对机械刺激的反应也增强，即所谓的继发性痛觉过敏。这是中枢神经系统发生可塑性（,plasticity,）变化的结果，也即中枢敏化过程。,1/21/2026,34,Analgesic Dep QiLu Hospital of SDU,中枢敏化,1/21/2026,35,Analgesic Dep QiLu Hospital of SDU,疼痛的分类,classification,1,按疼痛的,程度,可分为：轻微疼痛、中等程度疼痛、剧烈疼痛。,2,依疼痛,持续时间和性质,，疼痛可分为,急性疼痛,和慢性疼痛，慢性疼痛又分为,慢性非癌痛,和,慢性癌痛,。,1/21/2026,36,Analgesic Dep QiLu Hospital of SDU,3,按疼痛的,组织器官、系统,分为：躯体痛、内脏痛和中枢痛。,躯体痛 疼痛部位在浅部或较浅部，性质局部性、疼痛剧 烈、定位清楚。,内脏痛 为深部痛，性质隐痛、胀痛、牵拉痛或绞痛，定位不准确。,中枢痛 指脊髓、脑干、丘脑和大脑皮质等神经中枢疾病出现的疼痛。,1/21/2026,37,Analgesic Dep QiLu Hospital of SDU,4,按疼痛在躯体的,解剖部位,可分为头痛、颌面痛、颈项痛、肢体痛、胸痛、腹痛、腰背痛、肛门会阴痛等。,5,按,病理学特征,疼痛可以分为伤害感受性疼痛,(,nociceptive,pain),和,神经病理性疼痛,(,neuropathic,pain),(,或两类的混合性疼痛,),。,1/21/2026,38,Analgesic Dep QiLu Hospital of SDU,伤害感受性疼痛,(,nociceptive,pain,),由直接有害刺激造成，是机体防御机制的关键组成部分，与组织损伤或炎症有关，又称为炎症性疼痛。,神经病理性疼痛,(,neuropathic,pain,),外周或中枢神经系统损伤所致，与损伤区域外触觉和温觉反应异常有关，包括一系列疼痛综合征，比如复杂的区域疼痛综合症、幻肢痛、癌性疼痛、,AIDS,痛、三叉神经痛和带状疱疹后神经痛等。,1/21/2026,39,Analgesic Dep QiLu Hospital of SDU,再休息一会儿,1/21/2026,40,Analgesic Dep QiLu Hospital of SDU,疼痛的评估,1/21/2026,41,Analgesic Dep QiLu Hospital of SDU,疼痛的主观性,“,只有,患者,知道疼痛的强度和频率,疼痛是患者的所言,。,”,1/21/2026,42,Analgesic Dep QiLu Hospital of SDU,数字分级法,(,numeric rating,scales,NRS,）,用,0-10,的数字代表不同程度的疼痛，,0,为无痛，,10,为最剧烈疼痛，让患者自己圈出一个最能代表其疼痛程度的数字。,1/21/2026,43,Analgesic Dep QiLu Hospital of SDU,(2),口述言词评分法,(,verbal rating scales,，,VRS,法,),0,级：无疼痛。,I,级,(,轻度,),：有疼痛但可忍受，生活正常，睡眠无干扰。,II,级,(,中度,),：疼痛明显，不能忍受，要求服用镇痛药物，睡眠受干扰。,III,级,(,重度,),：疼痛剧烈，不能忍受，需用镇痛药物，睡眠受严重干扰可伴自主神经紊乱或被动体位。,1/21/2026,44,Analgesic Dep QiLu Hospital of SDU,(3),视觉模拟法,(,visual analogue scale,，,VAS,),划一条长线,(,一般长为,10cm),，一端代表无痛，另一端代表剧痛，让患者在线上最能反应自己疼痛程度之处划一交叉线。评估者根据患者划的位置估计患者的疼痛程度。,1/21/2026,45,Analgesic Dep QiLu Hospital of SDU,(4),疼痛强度评分,Wong-,Bakcr,脸,适用于,3,岁及以上人群,1/21/2026,46,Analgesic Dep QiLu Hospital of SDU,(5),疼痛问卷表,麦吉尔疼痛问卷表（,MPQ),简化麦吉尔疼痛问卷表,(SF-MPQ),简明疼痛问卷表,(BPQ),亦称科明疼痛调查表,(BPI),1/21/2026,47,Analgesic Dep QiLu Hospital of SDU,其他方法,45,区体表面积评分法,多因素疼痛评分法,临床疼痛测量法,术后痛,Prince-Henry,评分法,行为疼痛测定法,1/21/2026,48,Analgesic Dep QiLu Hospital of SDU,神经内分泌系统,免疫系统,运动系统,泌尿系统,消化系统,心血管系统,呼吸系统,凝血系统,精神情绪反应,疼痛,疼痛对机体的影响,1/21/2026,49,Analgesic Dep QiLu Hospital of SDU,疼痛对呼吸系统的影响,呼吸加深加快,呼吸肌僵硬、无法咳嗽，清除呼吸 道分泌物,组织缺氧、血液中碳酸浓度浓度升高,肺扩张不全,1/21/2026,50,Analgesic Dep QiLu Hospital of SDU,急性疼痛对心血管系统影响,心跳加快，心律不齐,心脏负荷增加，心肌耗氧量增加，增加心,肌缺血及心肌梗塞的危险性,静脉淤血、血小板凝集造成静脉栓塞甚至中风,1/21/2026,51,Analgesic Dep QiLu Hospital of SDU,急性疼痛对肌肉骨骼系统影响,肌肉张力增加,肌肉痉挛,呼吸辅助肌僵硬致换气量减少,尿道及膀胱肌运动力减弱导致尿液储留,活动力减弱，易产生疲倦感,1/21/2026,52,Analgesic Dep QiLu Hospital of SDU,疼痛慢性迁延的恶性循环,疼痛,运动受限,有所缓解,肌肉紧张,睡眠休息不安,疼痛导致活动减少,日常活动受限,慢性迁延,疼痛障碍,硬化,无法工作,无用,/,残疾,1/21/2026,53,Analgesic Dep QiLu Hospital of SDU,疼痛诊疗原则,1/21/2026,54,Analgesic Dep QiLu Hospital of SDU,疼痛诊断,病史采集,一般资料,发病的原因或诱因,病程,疼痛特征,既往史,个人史和家族史,1/21/2026,55,Analgesic Dep QiLu Hospital of SDU,体格检查,全面检查,专科检查,1/21/2026,56,Analgesic Dep QiLu Hospital of SDU,辅助检查,影像学检查,：,X,ray,、,B,超、,CT,、,MRI,、,ECT,等,实验室检查,血常规、血沉、,CRP,、风湿系列、,HLA-B27,等,1/21/2026,57,Analgesic Dep QiLu Hospital of SDU,疼痛治疗原则,诊断明确,综合治疗,安全有效,1/21/2026,58,Analgesic Dep QiLu Hospital of SDU,大脑皮层,丘脑,边缘系统,后根神经节,交感神经节,非甾体类抗炎药激素类药,神经阻滞,经皮电刺激,脊丘束,硬膜外激素、局麻药,三环系统药物,阿片类药物,精神治疗,心理治疗,有髓神经纤维,无髓神经纤维,交感神经纤维,上行传导束,下行传导束,伤害,疼 痛 治 疗,非甾体类抗炎药和激素类药物,的作用位点在伤害性刺激损伤的外周区域；,经皮电刺激,对有髓神经纤维有作用；,交感神经阻滞,可以阻断交感神经的疼痛传导；,脊髓丘脑侧束是,硬膜外激素和麻醉药,的作用部位；,丘脑是,阿片类药物,的作用靶位。,心理治疗,干扰对疼痛的理解则在大脑皮质水平。,三环类药物和其它抗抑郁药物,在于影响下传到脊髓后根的下行传导束，且它们也作用于脊髓后根神经节,1/21/2026,59,Analgesic Dep QiLu Hospital of SDU,治疗目标,缓解疼痛,改善睡眠,提高生活质量,1/21/2026,60,Analgesic Dep QiLu Hospital of SDU,谢谢,1/21/2026,61,Analgesic Dep QiLu Hospital of SDU,