周围神经病定位诊断流程,3步让你轻松掌握

2021-12-06 Dr.Wu彤彤 MedSci原创

周围神经病变是周围神经受损的结果,由各种病因引起的周围神经系统结构或功能损害的疾病总称,每一根周围神经中含有的神经纤维种类和数量不同,因而可出现运动、感觉、自主神经功能、温度、反射障碍等一种或多种临床

周围神经由运动、感觉及自主神经构成。周围神经病变是周围神经受损的结果,由各种病因引起的周围神经系统结构或功能损害的疾病总称,每一根周围神经中含有的神经纤维种类和数量不同,因而可出现运动、感觉、自主神经功能、温度、反射障碍等一种或多种临床症状。对于周围神经病的诊断,首先要详细的询问患者的发病过程及既往病史,在此基础上进行详细的体格检查,才能做出准确的定位。

 

                      

周围神经——12对颅神经,31对脊神经。脊神经构成成分有躯体运动、躯体感觉、内脏运动和内脏感觉。每根神经可能涉及运动纤维、感觉纤维(大纤维的深感觉、小纤维的痛感觉)和自主神经。周围神经疾病的定位诊断不仅仅要定位在周围神经,定在哪一根神经,更要定位是运动损害、感觉损害还是自主损害。大纤维的运动和感觉都是有髓纤维,我们要确定是脱髓鞘还是轴索,是远端还是近端的;分布是对称的还是不对称的,是单发还是多发。

 

因此要做出周围神经病变的定位诊断。我们要了解周围神经的结构、功能和分布。

 

 

结构分而言,周围神经分为大纤维(Aa 和 Ab,有髓纤维)和小纤维(Ad 和 C 纤维,薄髓或无髓纤维)。

 

 

功能而言主要分为运动、感觉和自主神经,其中运动神经主要为大纤维,传导本体感觉的感觉神经为大纤维,传导温觉和痛觉的感觉神经为薄髓或无髓纤维,自主神经为薄髓或无髓纤维。

 

这些知识可以帮助我们理解为何脱髓鞘病变为主者大多运动和深感觉受累明显,而小纤维轴索病变为主者则以浅感觉受累为主(这当然不是绝对,但属于大概率情况)

 

 

分布而言:

 

神经元:运动神经元(脊髓前角)、脊髓后根神经节

 

神经根:周围神经与中枢神经连接部

 

神经丛:脊神经前支在颈、臂、腰骶部相互交织成丛

 

神经干:由神经丛发出分支如正中神经、尺神经、桡神经

 

 


 

 

 

 

 

 

 鉴别(临床):轴索变性与脱髓鞘

 

 

分析起病方式及病程(急性、亚急性、慢性;稳定型、进展型、缓解-复发型、复发进展型)

 

起病方式对定性诊断的提示

 

 

 

无论临床还是电生理,都是周围神经病变在不同维度的投射,如果不断彼此印证match,寻找其间的关联,就可以给出病变结构的推测。因此具备精湛的专业知识、培养缜密的临床思路、不断印证不同维度的信息,才是保证临床定位诊断决策力之正道!

 

参考文献:
[1] Crone C et al. Diagnosis of acute neuropathies. J Neurol, 2007, 254:1151-1169.

[2] Strand NH, et al. Mechanism of Action of Peripheral Nerve Stimulation. Curr Pain Headache Rep 2021 May 11;25(7).

[3] 周淑新等,周围神经病:鉴别诊断和管理.[J]中国全科医学杂志,2010.12 (13)12A.

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  2. [GetPortalCommentsPageByObjectIdResponse(id=1748302, encodeId=3f6c1e483020f, content=<a href='/topic/show?id=15b33952464' target=_blank style='color:#2F92EE;'>#周围神经#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39524, encryptionId=15b33952464, topicName=周围神经)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f00136108751, createdName=Smile2692, createdTime=Wed Feb 16 00:24:43 CST 2022, time=2022-02-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1078701, encodeId=85e310e870176, content=马住, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20211216/f6dd6c8554814fbfb70b0651a0bcbf30/fa8b5a728dd44d8bb8a7656b816bbdff.jpg, createdBy=74425448792, createdName=ms5000001708621883, createdTime=Fri Dec 10 10:32:34 CST 2021, time=2021-12-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1491428, encodeId=2948149142887, content=<a href='/topic/show?id=5316e4387aa' target=_blank style='color:#2F92EE;'>#神经病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=74387, encryptionId=5316e4387aa, topicName=神经病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1ab48885684, createdName=axin012, createdTime=Wed Dec 08 08:24:43 CST 2021, time=2021-12-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1077838, encodeId=e51110e783861, content=学习运用起来, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7e831560211, createdName=ZYY7209, createdTime=Tue Dec 07 19:52:51 CST 2021, time=2021-12-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1077464, encodeId=58f110e746447, content=牛,实在繁杂,太难了<a href='/topic/show?id=89593953049' target=_blank style='color:#2F92EE;'>#周围神经病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39530, encryptionId=89593953049, topicName=周围神经病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=47814065247, createdName=么么大啵狼, createdTime=Mon Dec 06 19:37:06 CST 2021, time=2021-12-06, status=1, ipAttribution=)]
    2021-12-10 ms5000001708621883

    马住

    0

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    2021-12-08 axin012
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    2021-12-07 ZYY7209

    学习运用起来

    0

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    2021-12-06 么么大啵狼

    牛,实在繁杂,太难了#周围神经病#

    0

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