BAO CAO KHOA HOC k
Nhung thach thut trong dau than kinh
I. DINH NGHIA VA SINH LY BENH CUA OAU THAN KINH
Dau than kinh la mdt ITnh vUe y hpe phUe tap vdddikhimahd
Nhieu yeu td gdp phan eho su ma hd nay, trong dd ed viee sU dung hoan ddi eac thudt ngO lien quan den dau. Vi vdy, de lam rd va chuan hda tU ngO, bai viet nay trinh bay mpt sd djnh nghTa dau ca ban da 6ddc ddt ra gan day bdi Lien minh qudc te ve dau thdn kinh (ICNeP). Benh hpe eua dau than kinh eung se dddc xem xet qua, gidi thich ly do tai sao cdc bae sT nen tap trung nhieu ban v^ ede trieu chUng va ea ehe eu the eua nd, hon Id vao b^nh nguyen.
1. Oau thdn kinh va dau tiep nhan (Nociceptive)
Dau tiep nhdn la mpt phdn Ung sinh ly phO hpp vdimdtkiehthiehdau.Ddylaloaidauthudngcdthe kiem sodt duac vdi thude giam dau thdng thudng.
Nguac lai, dau can nguydn than kinh la mdt phdn Ung khong thfch hop gdy ra bdi mdt ton thuong hoae rdi loan chUe nang trong he than kinh ngoai bien hoae trung uong. Do dau than kinh cd the bi^u hien tu nd nhU Id: hoae dau md khdng cd tdc nhdn kfeh thfeh (dau khdng do kfeh thfeh dau) va / hoac Id dau qud mUe goi ra sau mdt kfeh thfeh (dau do kfeh thich dau). Dau khdng do kich thfeh bao gom cdc trieu ehUng sau:
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• Oau bdng rat, lien tue
• Dau nhu bj ban, dau nhdi, tUng eon
•Dau nhu dien giat
• Dj edm (paraesthesias)
• Loan edm (dysaesthesias) 2. Dau cap va dau man tinh
Dau cap tfnh thudng k^o ddi it hem 3-6 thang, trong khi dau man tfnh, Id tai phat va keo ddi them it nhdt 3-6 thang sau khi cdn dau ban dau da dUoc gidi quyet.
Nguoe lai, dau do kich thfch dau md ta cdc dau hieu do bdc sT gay ra sau khi kich thfch co hpe, nhiet hoae hda chat vd thudng lien quan den tang cam gide dau hyperalgesia hoae allodynia (khae nhau vi ngudng dau).
3.Di cdm vd loan cdm
Dj edm md ta cam giac bat thudng nhu"kien bd""te nhu ktm ehfch", ngUa ram ran hay ndng bdng, va loan cam de cap den cam giac bat thudng, khdng de chju.
4.Tang cdm dau: hyperalgesia va allodynia NhUng thudt ngU nay thudng dUOe sU dung thay the eho nhau, nhung thuc su rat khac nhau.
Hyperalgesia de cap den mdt phdn Ung binh thudng, dau tang len do mdt kfeh thieh dau, ngUac lai vdi allodynia, khi mdt kfch thfeh thdng thudng khdng gdy hat lai dUOe edm nhan la dau
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5. Tam quan trong cua cac cd che Theo kinh dien, eae bae sT dieu tr| dau can nguyen than kinh t h u d n g sU dung each tiep can dinh hudng benh, nghla Id, mpi benh nhdn vci dau than kinh do ddi thao dudng deu nhan duoc phuong phdp dieu tri gidng het nhau. Tuy nhien, nhUng benh nhan nay tuy do cung benh ly nhung t h u d n g xuat hien eae trieu chUng rat khac nhau va dap dag vdi dieu tri eung khae nhau, vi vdy qudn ly benh phufe tap. Rd rang rang, eac bdc sT ngdy nay nen dp dung mdt phuang phap tiep cdn dua tren ea che de lua chpn dieu tri. Hieu rd ve benh ly ca bdn eua eae loai dau khde nhau la ehia khda de lua ehpn dieu trj thieh hpp nhat eho benh nhan
Cae ea ehe ea ban cua eae trieu ch Ung dau can nguyen than kinh la:
• Nhay cdm ngoai vi
• Phdng dien lac chd
•Nhayedm trung uong
•Tdi t d chUc t n j n g uong cua scfi Ap
• Mat kiem soat Uc che
6. Tang cdm dau (Hyperalgesia) do nhietva CO hoc
Hyperalgesia dupe eho Id phat sinh tU cdc nhay cdm ngoai vi. Thdng thudng, kfeh thich dau gdy ra eac xung ddng tmyen den tuy sdng dpe theo cdc soi tiep nhan hudng tam A5 va C. Sau chan thucfng ddy than kinh, eac te bao viem tiet cae chat t n j n g gian viem ra ngoai vi, chang ban n h u chat P va bradykinin, lam tang dp nhay cam eua cdc loai soi nay. Vi vhy, khi kfch thfch se gay dau, mac du trong thuc te, hp cd mdt ngudng kfeh boat dau thap hon.
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T e n o d y n i a
Allodynia phUe t a p han va Hen quan den mfit sd ca ehe, bao g d m :
I.I.Nhgycdm trung t/Cfng cda sai AB M d t loat cdc bien ed sinh hda t r o n g he thong than kinh t r u n g u o n g lam t a n g d a p Ung cua he t h d n g tiep nhdn de cdc te bdo t h a n kinh sCfng lung phdn Ung sai lech doi vdl m d t kfeh thfch binh t h u d n g v d hai. Allodynia gay ra bdi cache nay t h u d n g lien quan vdi cdc trieu ehUng dau t U p h a t .
7.2. Tdi to didc trung dOng cua sdi AB Benh nhan vdi allodynia khdng t u phat cd the ed mdt cd ehe dau qua trung gian sol All. Soi dau trong tCiy sdng cd t h e Xo chUc lai de cae phan cCia tuy sdng binh t h u d n g nhdn 6dac nhQng xung ddng ed hai t U sai C ngoai bien nay nhdn 6ddc thdng tin lien quan den kfch thfeh vd hai tUdau tan cua serf AB mpe vdo t r o n g sUng tren sau ton t h u a n g than kinh.
8. Mat kiem scat ijTc che
Sau ehan t h u a n g than kinh, kiem sodt Uc che cd the b| mat hoac bj suy gidm tai tuy sdng, gay ra eac te bao thdn kinh sCfng lung phdn Ung qu^
mUe trong dap Ung dau vdo hUdng tdm.
9. Nhay cdm ngoai bien ci^a thu the tiep nhan [nociceptors]
Xem t h e m "hyperalgesia do kfeh thieh eo hoc va nhiet"
10. Dj cam va loan cdm
Day cd the Id d o phdng dien lac ehd tU phdt dpe theo soi AG, vd di kem vdi su tfeh t u eCia eac kenh natri (hfmhl).
11 .Dau bdng rat lien tue
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edm ti^p nhdn ngoai vi, phdng dien lac cho trong sai C hoae mdt kiem sodt Ue che.
12. Dau nhu ban, dau nhoi
Phdng dien lac eho trong spi tiep nhan duae eho la chju trdch nhiem eho loai dau ndy (Hinh 1).
IS.IVluc ti6u la cac trieu chCfng, khdng phdi benh
Tdm tdt tren eho thay eae trieu ehUng dau do than kinh cd Xhi kix hap vdi mdt sd dudng than kinh va cd che sinh benh, dd ehi ra rang mdt loai thude ed the se khdng ed hieu lue cho tat cd.
Trong thue t^, benh nhan vdi nhieu trieu ehUng se ddi hdi sCr dung nhi^u loai thude, nhUng ehu yeu van la thude lam gidm dau.
II. D|NH NGHIA M O T Sti Hdi CHUlNG DAU T H ^ KINH THUdNG GAP
1. Dau sau nhiim Herpes
Ld mdt hdi chUng dau xdy ra sau nhiem herpes zoster cap tinh (benh Zona). Nd dddc djnh nghTa Id sUdau k^o ddl ban 3 thang sau khi ton thuong dd Idnh, dau lien tue, ndng rat hoac ngUa tCfng cdn, dau nhdi dCf dpi. Allodynia va hyperalgesia cOng ed the xdy ra.
2. Benh than kinh ngoai bien hay dau do ddi thao difdmg
Tdn thuang thdn kinh sp, thUc vdt, ngoai bien cd lien quan vdi benh ddl thdo dUdng. Thudng Id ket qud eua t6n thuang vi mach lien quan den cdc maeh mdu nhd nudi dudng eac ddy than kinh. NgUdi ta ude tfnh rdng ed han 50% benh nhdn dai thdo dudng bj benh than kinh trong sudt cudc ddi eua hp, mac du khdng phdi tat ed d^u dau. Bdnh than kinh gay dau thudng dddc md td nhu Id dau ndng d ban tay vd ban chan.
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Cdm gide bdng rdt, ngUa ran vd allodynia thudng duac ghi nhan
3. Dau day than kinh sinh ba (V3) B^nh dnh hudng den bat ky mdt trong 3 nhdnh cua ddy than kinh ndm d hai ben mat, va ddi khi cd the dnh hUdng den 2 nhdnh eung mdt lue. Dau mdt ben eua ddy V3 ed the lan rdng den ma, mui, mieng vd /hoac cd ham. Bieu hien dau nhdi, nhu bj bdn, dien giat ed the keo ddi Xd vdl giay den vai phut. Dau ed th^ duac gdy ra khi kfeh thfeh mdt diem tren mat, mdi, nudu rang, hoac bang cdch cUddng cd mat, nhU nhai.
4. Dau day than kinh toa
Dau tU lung lan den mdng va chan.Dau cung ed the lan xudng dudi gdi vd den ban ehan, ed the te hay yeu co cdng ehan. Nguyen nhdn thUcmg gap nhdt la thodt vj dTa dem.
S.Dausaudotquy
La mdt tinh trang dau trung Udng ndng va thudng gap. Dae Xrdng bdi dau d eac vung co the bj mat chi phdi cam giac do sUgian doan cua dudng cam gide gal doi thj do dot quy.
6. Hoi chi]fng dau vung phufe tap La mdt loat eae hdi ehUng cd the gap sau ehan thuong, thudng dO dpi. Dau thudng lien tue, bdng rat, dau nhdi, va dau nhU maeh ddp, ed the ket hop vdi nhtjfng tdn thuang than kinh tu trj vd md tai noi tdn thuang. Thudng bdt dau vai ngdy den vai tuan sau khi bi thuang, va van edn keo dai sau khi ehan thuang da lanh. Dau cd xu hudng lan xuong toan bp mdt khu vUc gidi phau, chang ban nhutUchdn lan d^n bdn chdn. Nhdm eae trieu chUng ndy eung dUOe gpi Id "loan dudng giao cdm phdn xa" bode "causalgia".
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7. Dau chi tren
Hay gap la hdi ehUng dng co tay va khuiy-u tay quan vgt. Hdi chUng dng ed tay do ehen ep ddy than kinh giOa khi di qua dng eo tay bj hep bao gdm xuang vd ddy chang ngang ca tay.
NhUng nguyen nhan phd bien: sU dung qua mUe, chdn thuang, ma sat, gay xuong, giOf nude vd cdc cU ddng manh. Trieu chUng dau tien cua hdi chUng ong co tay la te d bdn tay, ngdn tay cai, ngdn trd va ngdn gliJfa, sau do nhanh ehdng dau lan het vung.
IILDANHGIADAU:SUrDyNGTHANGDIEMDAU La ede edng eu ed sdn de danh gia chat luong, cudng dp, vj trf va kieu dau. Quan trong la eung cap mpt easd, hoae trUdc khi dieu tri, danh gid va sU dung cung mdt thang diem de theo ddi dap Ung dieu trj cUa benh nhdn theo thdi gian. Mdt so trong nhUng edng eu thudng duac sU dung de ddnh gid dau than kinh duac md ta d day.
1.Thang diem phan loai dau
Thang diem nay dung tU ngO de md ta mUe dp hoae eUdng dp eua dau. Vi du, eUdng dp dau cdthe duac danh gia tren thang diem phan loai 4 diem nhU: khdng dau = 0, nhe dau = 1, vUa dau = 2 va dau nang = 3.
7.7. Thang dCiem ddnh gid bdng mdt thddng [Visual analogue scales (VAS)]
VAS Id mdt trong nhCfng thang diem dan gian nhat va ddac sCf dung phd bien nhat. Benh nhan duac yeu cdu phan dp dau eua hp tren mdt dudng ngang 100mm, vi du, 0 mm tUOng duang vdi khdng dau va 100 mm tuong duong vdi dau nhieu nhat (Hinh 1 ).Diem cung cd the duoc phan tUOcm (khdng dau) den 10 em (dau nhieu nhat).
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Them nOa, VAS edn dung de danh gid hieti qud cOa dieu tri, 0mm la gidm dau hoan toan va 100mm Id khdng giam dau.
Hmh 1. Vi du cua Thang diem ddnh gid bdng mdt thddng
Khdng dau Dau dddrA
0 100 Gidm dau hodn toan Khdno gidm dau
0 100 Chu y: Doan thdng phai ddi dung 100mm
1.2. Thang diem ddnh gid dau bdng fdir ndj [Verbal rating scales]
TUdng tu nhu VAS. Tuy nhien, mUe dp dau duoe ddnh gid tren thang diem tU 0 den 10, (0=
khdng dau va 10= dau dOddi).
1.3. Bdng cdu hdi dau cua McGIII (MPQ) Bdng nay bao gdm mdt loat cdc cdu hdi mo td cdm giac dau, dnh hudng eua dau va danh gl^
dau, eiJng vdi thang diem cudng dd vd cdc cau hdi khac. Benh nhdn hoan thanh bdng edu h6i, bao gdm 4 phan:
Vj tri dau Md ta cam gidc
Cac kieu dau, va thay doi theo thdi gian CUdng dp eCia con dau tren thang diem tCr 1 (dau nhe) den 5 (dUddi)
MPQ la mdt bang cau hdi toan dien ddnh gia dau tdng the. Vi vay. Id mot eong eu nhay edm de ddnh gid dieu tri gidm dau. Tuy nhien, sU phufe tap eUa edu hdi gidi han Ung dung eua nd trong thue hdnh Idm sang hang ngdy.
1.4. Thang diem dau than kinh [The Neuropathic Pain Scale (NPS)]
Dddc thiet ke dae biet de danh gid dau trong hdi ehUng dau than kinh, va da duae xdc nhdn la Website: hoithankinhhocvietnam.com.vn
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nhay c3m de danh gia ket qua dieu trj. NPS bao gom 10 cau hoi danh gia cudng do, mi^c do I<h6 chiu, chat luong va trinh tu thdi gian cCia con dau (Hinh 2).
Hinh 2: Cdu hdi mdu ve thang dilm dau thdn kinh
1. Hdy cho chung tdi biit dng/bdSaudffddinhi/thendo?
l o h I 2 | 3 | 4 | 5 | 6 | 7 | 8 l T T 1 5 1
Khong dau Bau den mute l<hong the chju duoc 2. Hay cho chdng tdi biet 6ng/bdcdm thay Oau nhdi nhtt thi ndo?
| 0 h | 2 | 3 | 4 | 5 | 6 ! 7 | 8 | 9 | T o 1
Khong nhoi Nhoi din rnCtc khong the chju duoc (nhu dao dSm) 3. Hdy cho chung tdi biit Cng/bdcdmthdyndngnhuthindo?
I 0 I 1 I 2 I 3 I 4 I 5 I 6 I 7 I 8 I 9 I 1^1
Khdng ndng Ndng d^n mUe khdng the chju dddc (nhu lUa ddt) 2. Nhdt ky cua benh nhan
Bdnh nhdn cd the thudng xuyen ghi lai eac con dau thdnh nhdt ky d nha. Dieu nay eung cap mdt edng eu hCfu fch vd dang tin cdy 6i ddnh gid dau tren mdt eo sd lien tue ban so vdi hdi Uc eCia benh nhan tai thdi diem tham kham. Nhdt ky ed the bao gdm cUdng dd dau, tan sd, thdi gian va ede mdi quan h^ hdnh vi va chUc nang.
3. Thang do chat luong song (QoL) Cd nhieu thang QoL khde nhau.
Thang Short -form-36 (SF-36) la rat phd bien vd thudng xuyen dupc sUdung trong eac thUnghlem lam sdng. SF-36 bao gdm 36 eau hdi ddnh gia 8 ITnh vUe eua chat lUOng song: hoat ddng the chat, dau ea the, vai trd eua th^ chdt, sUc khde tdm than, vai trd cdm xue, chUe nang xa hdi, dau hieu sinh tdn (vitally) vd sUc khde ndi ehung. SF-36 eung cap mdt bUe tranh toan dien cCia QoL. Vi vdy, di^u trj gidm dau nen cd tdc ddng tfeh cUe tr§n tong the QoL.
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