上海交通大学：《诊断学》课程PPT教学课件（英语版）Chapter 21 Referred pain

Referred pain Because of this convergence and the fact that the spinal neurons are most often activated by inputs from the skin activity evoked in spinal neurons by input from deep structures is mislocalized by the patient to a place that is roughly coextensive with the region of skin innervated by the same spinal segment Coronary ischemic pain usually radiates to medial side of arm and fingers, which were supplied by 6th-8th cervical (or T1 T2)over the left side

• Because of this convergence and the fact that the spinal neurons are most often activated by inputs from the skin, activity evoked in spinal neurons by input from deep structures is mislocalized by the patient to a place that is roughly coextensive with the region of skin innervated by the same spinal segment • Coronary ischemic pain usually radiates to medial side of arm and fingers, which were supplied by 6th~8th cervical (or T1~T2) over the left side Referred pain

The convergence-projection hypothesis of referred pain Skin Viscus Anterolateral Tract Axon

The convergence-projection hypothesis of referred pain

Pain modulation .Brain circuits modulate the activity of the pain transmission pathways One circuit has links in the hypothalamus midbrain and medulla It controls spinal pain-transmission neurons through a desending pathways eIt is bidirectional produce analgesia or increase pain

Pain modulation •Brain circuits modulate the activity of the pain￾transmission pathways •One circuit has links in the hypothalamus, midbrain, and medulla •It controls spinal pain-transmission neurons through a desending pathways •It is bidirectional produce analgesia or increase pain

Transmission system for nociceptive messages F Cx Hyp Cx Thalamus MIDBRAIN Spinothalamic Reticulothalamic MEDULLA SPINAL CORD

Transmission system for nociceptive messages

Pathophysiology Different organs may respond to different stimuli GI system: sensitive to inflammation, ischemia, spasm Insensitive to cutting heart sensitive to acute ischemia Integumentary stimuli at lowest level of intensity, evoke sensations of touch, pressure, warmth and cold Noxious stimuli increased to the point approaching tissue destruction, pain is added

Pathophysiology •Different organs may respond to different stimuli GI system: sensitive to inflammation, ischemia, spasm insensitive to cutting heart: sensitive to acute ischemia •Integumentary stimuli at lowest level of intensity, evoke sensations of touch, pressure, warmth and cold •Noxious stimuli increased to the point approaching tissue destruction, pain is added

Clinical characteristics character of pain spastic pain Intermittent inflammatory persisting Localization of pain usually in the diseased part it may be referred

Clinical characteristics •Character of pain spastic pain: intermittent inflammatory: persisting • Localization of pain: usually in the diseased part it may be referred

Clinical characteristics Quality and intensity of pain peptic ulcer: gnawing b urine anginal pain: distress, dull pain whith heavy quality The following are important severit duration frequency special time of occurrence

Clinical characteristics •Quality and intensity of pain peptic ulcer: gnawing burning anginal pain: distress, dull pain whith heavy quality The following are important: severity duration frequency special time of occurrence

Clinical characteristics Referred pain aggravating and relieving factors anginal pain: provoked by exertion, cold emotional upset relieved by rest, nitroglycerine ulcer pain: relieved by ingestion of food

Clinical characteristics •Referred pain •Aggravating and relieving factors anginal pain: provoked by exertion, cold, emotional upset relieved by rest, nitroglycerine ulcer pain: relieved by ingestion of food

Headache e Unpleasant sensations in the regions of cranial vault, usually reflects as a symptomatic expression of disease or some minor tension of fatigue It may also reflect serious disease intracranially 90%of individuals have at least one headache per year

Headache •Unpleasant sensations in the regions of cranial vault, usually reflects as a symptomatic expression of disease or some minor tension of fatigue •It may also reflect serious disease intracranially • 90% of individuals have at least one headache per year

Etiology Intracranial disease Extracranial disease ° Systemic disease neurosis

Etiology •Intracranial disease •Extracranial disease •Systemic disease •Neurosis