i cng v au

ThS H Phm Thc Lan Mc tiu:

1. Nu c nh ngha ca au theo Hip hi Quc t v au (IASP). 2. M t c cc loi si thn kinh dn truyn cm gic au. 3. Trnh by c cc ng dn truyn cm gic au. 4. Trnh by c c ch kim sot au. 5. Nu c phn loi au. 6. Trnh by c tnh cht v nguyn nhn ca au do kch thch trc tip cm th quan 7. Trnh by c tnh cht v nguyn nhn ca au do nguyn nhn thn kinh. 8. Trnh by c cc bc nh gi au. 9. Trnh by phn loi au u ca Hip hi au u th gii (HIS). 10. Lit k nhng triu chng bo hiu nguyn nhn nguy him ca au u. 11. Trnh by tiu chun chn on Migrain. 12. Trnh by nhng c im ca au u tension. 13. Nu c cc yu t nguy c tin lng nng ca au lng cp. 14. Nu c cc yu t tin lng nh ca au lng cp. 15. Trnh by c cc triu chng gp trong chn p r thn kinh tht lng- cng 16. Nu c ch nh ca cc xt nghim chn on hnh nh dng trong chn on au lng. 17. Nu c cc nguyn nhn thng gp ca au lng. 18. Nu c cc yu t nguy c tin lng nng ca au c. 19. Trnh by c cc triu chng gp trong chn p r thn kinh c. 20. Nu c cc nguyn nhn thng gp ca au c.

1.

i cng.
1.1. nh ngha: Theo Hip hi Quc t v au (IASP), au l mt kinh nghim kh chu v cm gic v cm xc, lin kt vi mt tn thng m thc th hoc tim tng. au l kt qu tng hp ca nhiu yu t : sinh hc ( tn thng m), tm l ( lo u, s hi, trm cm), x hi ( Hnh 1-1.).

H.1-1. Cc yu t hnh thnh au 1.2. Sinh l dn truyn cm gic au: 1.2.1. ng dn truyn cm gic au: Cc u tn cng thn kinh m da, c, khp, ni tng, cn gi l cm th quan (nociceptor), tip nhn cc thng tin v kch thch au ( bao gm nhit, c hc, ho cht, cc yu t gy vim nh serotonin, bradykinin, histamin). Cc thng tin v cm gic au c dn truyn tip theo trong si trc hng tm s cp bao gm cc loi si thn kinh A, A , C v si giao cm (Hnh 1-2), n sng sau tu sng.

H 1-2. Si trc hng tm s cp bao gm cc loi si thn kinh A, A , C v si giao cm. c im cc loi si c trnnh by trong (Bng 1) c im ng knh Bao myelin Kch thch chuyn bit Cm gic to ra A Ln +++ Xc gic Xc gic A Trung bnh + Xc gic mnh au ngn C Nh Xc gic mnh, nhit, Ho hc au di

Ti sng sau tu sng, cc si thn kinh hoc: cc si kch thc trung bnh A v nh C synapse vi neurons sng sau tu sng , sau bt cho qua sng trc tu sng v i ln i th, v no theo b tu h i trc bn (anterilateral spinothalamic tracts), m nhn cm gic s, au, nhit. Nu cc cm th quan da, c, xng, khp rt nhy vi cc kck thch nhit, c hc, ho hc, th cc cm th quan ni tng khng p ng vi cc kch thch ny, ngoi tr khi c tnh trng vim, di nh hng ca cc cht bradykinin, prostaglandin, leukotrien. Khi cc thng tin v cm gic au s dn truyn ti hch sng sau tu sng, v bt cho qua sng trc tu sng , i ln i th, v no theo b tu h i trc bn. cc si kch thc ln A ti nhn gracile v cuneate tu sng, bt cho qua ng gia v i ln theo b si trong (medial lemniscus) ti i th, v no, m nhn cm gic p sut, rung ng, nh vi, nh dng (cm gic su). (Hnh 1-3& 1-4)

H 1-.3: Phn b thn kinh giao cm ti tu sng. Ti vng u mt, tip nhn cm gic do dy thn kinh s sinh 3 (cranial nerve trigeminal) m nhn. Cc thng tin v cm gic au c dn truyn xung nhn thn kinh ti tu sng, sau bt cho qua ng gia v i ln i th, v no theo b si sinh 3 (trigeminal lemniscus) nm bn trong b tu h i trc bn.

H 1-4: ng dn truyn cm gic t tu sng ln no 1.2.2. C ch kim sot au: Ti tu: cht P ( gm 11 acid amine) c tng hp ti hch sng khi c kch thch cm th quan c vai tr tng xung ng dn truyn thn kinh, b c ch bi endorphins Ti no: t no c nhng ng dn truyn xung c ch xung ng cm gic au. Nh ng dn truyn t vng trn v h i ti t bo cht xm ca no gia (the periaqueductal gray matter of the midbrain), sau dn truyn tip ti cht trng sau bn ca tu sng, v tn cng ti neurons sng sau tu sng. (Hnh 1-5.). Bn cnh , cn c cc ng c ch xut pht t mt s nhn thn kinh thn no. Cc ng c ch ny c cht dn truyn thn kinh bao gm endorphin, serotonin, norepinephrine.

H1-5: Cc ng c ch cm gic au 1.3. Phn loi au: au c th c phn thnh hai loi chnh: 1.3.1. au do kch thch trc tip cm th quan (nociceptive): v d nh Tnh cht : Thng c m t nh dao m, xon vn, Ko di lin tc hoc xy ra tng cn Cng thay i Khm thn kinh bnh thng Nguyn nhn: Kch thch c hc quan trng: vt thng, gy xng, bng. Tn thng m: vim nhim, thiu mu nh cn au tht ngc, vim d dy

1.3.2. au do nguyn nhn thn kinh (neuropathic): do tn thng h thn kinh ngoi bin hoc trung ng Tnh cht: au lin tc, rt bng au tng cn nh in git au km d cm: t rn, cm gic kin b Khm thn kinh: pht hin bt thng Gim hoc mt cm gic. Tnh trng nhy cm, tng cm gic au khng tng ng vi tn thng thc th au c th khng xut hin cng lc vi tn thng m au c khuynh hng tng dn v khnng t khi. Nguyn nhn: - Do tn thng thn kinh ngoi vi: au sau on chi, hin tng chi o au sau Zona au do chn p r thn kinh ( hi chng thn kinh to) au do vt thng lm ko dn hoc t dy thn kinh au sau phu thut thn kinh Bnh l thn kinh do chuyn ho ( vim thn kinh ngoi bin trong i tho ng), nhim c ( ru, ho cht) - Do tn thng thn kinh trung ng Tai bin mch mu no vng i th hoc di l au sau chn thng tu sng hoc chn p tu. 1.4. nh gi au: 1.4.1. Cc bc thm khm lm sng: Hi bnh s: ch - Cc yu t lin quan n au: Cch khi pht v thi gian cn au ko di V tr v hng lan Tnh cht Cng Yu t lm tng hoc gim au Triu chng i km - Tnh trng tm l, cm xc ca bnh nhn: lo u, s hi, trm cm - Hon cnh gia nh , x hi ca bnh nhn Khm thc th: ch Du thn kinh ch im Bnh l h thng 1.4.2. Mc tiu ca thm khm lm sng: Chn on chng au Chn on nguyn nhn au Nhn dng bnh i km nh gi yu t tm l, x hi.

1.4.3. nh gi mc au:

Thang nh gi mt phng din - Thang din ngn n thun: i vi mc au: khng au, nh, va, nng i vi mc gim au: khng gim, t, trung bnh, ht au. - Thang s: s dng s t 0 n 4, hoc 0 n 10 din t mc au. Thang nh gi a phng din: bng cu hi Mac Gill Pain Thang nh gi hnh vi, thi Thang nh gi tm l

2.

au u
2.1. i cng: au u l nguyn nhn thng thng nht khin bnh nhn phi tm n s chm sc y t. 2.2. Phn loi: Theo phn loi ca Hip hi au u th gii (IHS), au u c phn lm 2 nhm, nguyn pht v th pht (Bng 2-1.)

Bng 2-1. Nhng nguyn nhn thng gp ca au u Nguyn pht Loi Migraine Tension-type Cluster Idiopathic stabbing % 16 69 0.1 2 Th pht Loi Nhim trng Chn thng u Ri lon mch mu Xut huyt di mng nhn % 63 4 1 <1

Exertional 1 U no 0.1 Source: After J Olesen et al: The Headaches. Philadelphia, Lippincott, Williams & Wilkins, 2005

2.3. nh gi lm sng au u cp (Bng 2-2):

Table 2-2. Nhng triu chng ch im nguyn nhn nguy him ca au u au u xu i (tng cng ) au u d di ngay khi khi pht C du thn kinh khu tr St hoc triu chng ton thn khng gii thch c Nn i xut hin trc au u au u tng khi ho, gp ngi, nng vt nng au u lm mt ng hoc xut hin ngay khi thc dy C bnh h thng c bit

Tui > 55 au i km vi tng nhy cm khu tr, nh vng ng mch thi dng

Khi c cc triu chng trn, bnh nhn cn c ch nh cc xt nghim cn thit cho chn on nhanh nh CT, MRI, v ngay c chc dch no tu. Thng l au u th pht. 2.4. Hi chng au u nguyn pht : 2.4.1 Migrain: Thng gp n (15%) hn nam (6%). Thng i km vi cc triu chng: bun nn, nn i, nhy cm vi nh sng, m thanh, hot ng (Bng 2-3). Thng khi pht sau nhng yu t kch thch nh ng sng, m thanh, i dng, stress, lm vic gng sc, thay i thi tit, chu k kinh nguyt, ru bia. L bnh lnh tnh, hay ti pht. Bng 2-3. Nhng triu chng thng gp trongau u Migrain nng Triu chng Bun nn S nh sng au u nh Da u nhy cm Nn i Nhn m Hoa mt M tm thi D cm Chong vng Ri lon tri gic Hn m Co git L ln Tiu chy S BN b nh hng, % 87 82 72 65 56 36 26 10 33 33 18 10 4 4 16

Tiu chun chn don Migrain (Bng 2- 4)

Bng 2-4 Tiu chun chn don Migrain au u ti pht, ko di 472 h bnh nhn khng c triu chng thc th, khng c nguyn nhn no khc ca au u, v:

C t nht 2 trong s cc triu chng sau: au u 1 bn Cm gic p nhp Gia tng theo hot ng Mc trung bnh hoc nng

Km vi 1 trong cc triu chng sau: Bun nn / nn i S nh sng S m thanh

2.4.2. au u tension: L nguyn nhn thng gp nht ca au u. N thng gp hn nam, ngi tr thng gp hn ngi ln tui L tnh trng au u mn tnh c im au nh p cht 2 bn u Thng din tin t t, mc au tng gim trong ngy. au lin tc hoc tng giai on, ko di nhiu ngy Thng khng km cc triu chng: bun nn, nn i, nhy cm vi nh sng, m thanh, hot ng. 3.

au lng:
3.1. i cng: au lng l mt trong nhng nguyn nhn thng thng khin bnh nhn phi tm n s chm sc y t. Khong 60-80% dn s th gii tri qua au lng 1 ln trong cuc i. Chi ph cho au lng M ln n ~ 100 t USD hng nm, gm chi ph y t trc tip v chi ph cho mt kh nng lao ng. 3.2. Thm khm lm sng: Trc tin cn nhn din cc yu t nguy c ca bnh l nn nguy him (Bng 3-1). Khi c cc triu chng trn, bnh nhn cn c ch nh cc xt nghim cn thit cho chn on nhanh nh CT, MRI. Bng 3-1. au lng cp: Yu t tin lng nng Bnh s au tng lc ngh hoc ban m Tin s: ung th Tin s bnh nhim trng trc (phi, ng niu, da) Tin s chn thng B tiu Tui > 50 Tin s dng corticosteroid Tin s khim khuyt thn kinh tin trin Khm thc th St khng tm c nguyn nhn St cn

au khi g trn vng ct sng Khi u vng bng, khung chu Du hiu Patrick (+) Du hiu Lasegue (+) Du thn kinh khu tr (+) ng thi c nhng du hiu cho thy au lng c hc lnh tnh,thng t khi trong vng 6 tun (Bng 3-2) Bng 3-2. au lng cp: Yu t tin lng nh au tng khi hot ng, gim khi ngh Khi pht t ngt, thng xut hin sau khing vc hoc ci xung C giai on ti pht Tui 20-50 au khu tr lng Khng du hiu chn p thn kinh Tng trng tt

Tin lng tt (90% t khi trong 6 tun)

au ch im (referred pain): tn thng c quan trong bng hoc khung chu, nhng biu hin au lng. au c c im khng b nh hng bi t th. Ngc li, c th bnh l ct sng nhng li au vng hng hoc mt trc i. au lan theo r thn kinh: Thng au chi v au lan t vng tht lng xung chn theo vng phn b thn kinh. au theo t th, nhng t th no lm cng r thn kinh lm au tng. Ho, ht hi, co c bng c th lm au tng. au thng km theo cm gic t u chi. 3.3. Triu chng thc th: Nhn: Thay i cong sinh l ca ct sng (g, vo, mt cong sinh l). S: pht hin tnh trng co cng ca khi c cnh sng, im au khi n chn dc ct sng, im li ra sau ca t sng Khm cc ng tc vn ng ca ct sng ( ci, nga, nghing , quay) Khm du hiu thn kinh: Lasegue, c ng bn chn, phn x gn xng, tnh trng teo c, yu c Cc hi chng thng gp c trnh by trong (Bng 3-3) Bng 3-3 Du hiu chn p r thn kinh R thn kinh L2 L3 Phn x Vn ng c Psoas (gp khp hng) Psoas (gp khp hng) T u i (gp u gi) Phn b au Mt trc i Mt trc i, u gi

R thn kinh

Phn x

Vn ng c

Phn b au

Khp i L4 u gi T u i (gp u gi) Khp i Chy trc (gp bn chn) L5 Mc (dui bn chn)b Chy trc (gp bn chn) C mng (dng khp hng) Gp ngn chn S1 C chn C dp (dui bn chn) Gp ngn chn C mng ln (dui khp hng) Lng bn chn, bp chn, i sau, mng Bp chn, mu bn chn, mt sau i, mng u gi, bp chn Mt trc bn i

3.4. Chn on hnh nh: Xquang ct sng tht lng thng nghing CT MRI ct sng: ch nh cho nhng bnh nhn c du hiu tin lng nguy him Bone scanning (x hnh xng): pht hin c bnh l ung th, vim xng EMG (o in c): ch nh cho bnh nhn c du hiu chn p r thn kinh 3.5. Cc nguyn nhn thng gp ca au lng (Bng 3-4): Bng 3-4 Nguyn nhn ca au lng Bm sinh hoc mc phi Spondylolysis (hu t sng) v spondylolisthesisa (trt t sng) Kyphoscoliosis (g vo ct sng) Spina bifida (gai i ct sng) Chn thng nh Bong gn Gy t sng ( do long xng) Thot v a m Bnh l thoi ho Vim khp Vim ct sng dnh khp

Vim khp dng thp Abscess ngoi mng cng Vim xng tu t sng Vim a sng nhim trng Ung th Nguyn pht Di cn Chuyn ho Long xng X ho xng (e.g., bnh Paget) Khc Ti phnh ng mch ch bng Tiu ho: bnh l d dy, t trng, gan mt Thn, tit niu: si, lao, vim thn b thn Sinh dc: u nang bung trng, u x t cung, au bng kinh Tm l, t th

4.

au c
4.1. i cng: au c t ph bin nh au lng. 90% do nguyn nhn c hc: Th pht sau s dng qu mc ( ngi lm vic ko di) Sau chn thng Tn thng cu trc gii phu 50% gim triu chng trong 2-4 tun, a s t khi trong 2-3 thng 4.2. Thm khm lm sng: Cc du hiu tin lng nng (Bng 4-1)

Bng 3-1. au c: Yu t tin lng nng

Triu chng ton thn St , m hi ban m St cn Tin s Ung th, i tho ng, AIDS Dng corticosteroid au vng c c c im Tng v m Tng khi ngh ngi, nm nghing au lan ti cu trc ngoi c Triu chng thn kinh Yu, lit chi B tiu Triu chng chn p thn kinh (Bng 4-2)

Bng 4-2 du hiu chn p r thn kinh c R C5 Phn x Nh u Vn ng c Trn gai (dng cnh tay) Di gai (xoay ngoi cnh tay) Deltoid (dng cnh tay) Nh u (gp cnh tay) C6 Nh u Nh u (gp cnh tay) Quay sp (xoay trong cng tay) C7 Tam u Tam u (dui cnh tay) Dui c tay Dui ngn tay C8 Dui ngn tay Dng ngn 1,2,5 Ngn 4,5, mt trong cnh tay Mt sau cnh tay, cng tay, mt ngoi bn tay Mt ngoi cnh tay, ngn tay 1,2 Phn b au Mt ngoi cnh tay, vng lin b vai

4.3. Nguyn nhn thng gp ca au c (Bng 4-3) Bng 4-3. Nguyn nhn thng gp ca au c

T th

Chn thng c (Whiplash injury) Sa a m (Disc prolapse) Thoi ho (Cervical spondylosis) Nhim trng Vim ct sng Vim khp t pht thiu nin Vim khp dng thp Polymyalgia rheumatica Long xng (Osteoporosis) Nhuyn xng (Osteomalacia) Bnh Paget Di cn Myeloma Fibromyalgia Torticollis Vng hng Hch c Rng au tht ngc Phnh ng mch ch ngc U nh phi (Pancoast tumour) C honh

Vim nhim

Chuyn ho

Ung th

Khc

au ch im

TI LIU THAM KHO: 1. Harrisons Principle of Internal medicine 17th Edition. 2008. 2. Davidsons Principles and Practice of Medicine 20th Edition 2007.

3. Lange Pathophysiology 2006