Bệnh thần kinh ngoại vi

Thoai hoa W aller do Waller mo ta lan dau tien 1856: khi c&t dtit day than kinh, cac sdi true se bi thoai hoa, dac biet tram trong la d phan ngoai vi, lam cho neuron mat han chiic nang

G S T S H O HUTU LlfC fN G

G IA N G V IE N C A O C A P

BENH THAN KINHNGOAI VI

GS.TS HO HOU LtfONGGIANG VIEN CAO CAP

BENH THAN KINH

Chitting I

DAI CITONG VE BENH THAN KINH NGOAI VI

I DAC DIEM CHUNG

Than kinh ngoai vi bao gom cac day, re, dam roi, day than kinh tuy song va cac day than kinh so nao Benh than kinh ngoai vi rat pho bien Theo Ho Hiiu Ludng va cong stf (1991), benh than kinh ngoai vi chiem ty le tifdng doi cao (38,36%) trong cac benh than kinh noi chung, trong do dai dien cho he than kinh ngoai vi chi diidi la hoi chiing that liing - hong (chiem t6i 60,32%) va dai dien cho he than kinh chi tren la hoi chvfng co - vai - canh tay Hoi chiing nay thifdng gap trong hii xiidng sun cot song co (cervical osteochondrosis), chiem 2,53% tong so' benh nhan n&m dieu tri tai Khoa than kinh Benh vien

103 trong 10 nam - tti 1980 den 1989)

Thiidng ton cua he than kinh ngoai vi thifdng dan den nhflng roi loan nang ne cac chilc nang van dong, cam giac

va thiic vat dinh diidng Hon nuia neu la mot thiidng ton trUOng dien thi benh con co the dan den thoai hoa cac day than kinh ngoai vi gay nen thUdng ton than kinh lau dai

II DAC DIEM GIAI PHA u THAN KINH NGOAI VI

Day than kinh song co hai re, re trudc hay re van dong, re sau hay re cam giac Re cam giac co hach gai Hai re chap lai thanh day than kinh song Moi day than kinh song chia ra thanh hai nhanh: nhanh sau phan bo"

3

cho cac cd cham, cd phia sau co va liing Nhutng nhanh trUdc

to hdn phan bo"cho cac cd va da phan trUdc than va chi

Hinh 1.1: So do r l day TK ngoai vi

3 - Hach gai 4 - Nhanh sau cua day TK song

5 - Nhanh tri/dc cua day TK song

6 - Dam roi TK 7 - Day TK song

8 - Nhanh thong trang 9 - Nhanh thong xam

10 - Hach giao cam canh song

Nhiing nhanh trUdc cua khoanh tuy liing hinh thanh

cac day than kinh gian siidn Nhiing nhanh trUdc cua cac

khoanh tuy co, tuy that liing va tuy cung ket hop vdi nhau mot cach nhat dinh hdp thanh nhiJng bo (fasciculi)

cua cac dam roi co - canh tay va that lung - cung Tu dam

roi cho ra nhiing than (trunci) hay day than kinh ngoai

vi Khi cac day than kinh bi thtfdng ton, cC khong nhan diidc kich thi'ch va se bi liet

i ' V I

S lvn

Is)VIII

<fTC&lX

Hinh 1.2: Tuy song,

cac re va dam roi than kinh, lien quan gii/a tuy song vdi cac

re than kinh va cot song.

5

4 -► ■* -> -4 - -—►

Hinh 1.3: Sieu cau true cua day than kinh ngoai vi

(Theo J.D Waggener va Coll 1965)

Da so cac day th in kinh ngoai vi la cac day hon hop bao gom nhflng sdi van dong cua re trvfdc (axon cua te bao suing trade), nhiing sdi cam giac (duoi gai cua cac te bao hach gai) va cac sdi giao cam, doi giao cam (van mach, bai tiet, dinh difdng) tii sifng ben cua chat xam tuy song va chuoi hach giao cam canh song Do do khi day than kinh ngoai vi bi thUdng ton thi gay ra cac roi loan van dong, cam giac, van mach va bai tiet, dinh dUdng.

Axon

Te bao Schwann

Hinh 1.4: Qua trinh phat trien cua te bao Schwann va sdi true

7

Hinh 1.5: So do sieu cau true tren mot that vong Ranvier

(Thiet do difng doc theo J Poirier, 1968)

Dua vao chutc nang va sU co hay khong co bao myelin ngUdi ta phan loai sdi than dinh: sdi A la sdi co bao myelin thuoc he than kinh nao - tuy Sdi B la sdi co bao myelin thuoc he TK thtfc vat, sdi C khong co bao myelin thuoc he than kinh thUc vat

Nhutng sdi A dufdc phan chia thanh Aa, A[3, A,y

Noi chung cac sdi co dUdng kinh cang 16n thi to"c do

d in truyen cang cao, cac sdi co difdng kinh cang be thi toe do dan truyen cang cham Cac sdi 16n lien quan den

chOfc nang van dong va cam giac ban the, cac sdi be tham gia vao chiic nang thUc vat va cam giac dau.

Cac sdi co ki'ch thtfdc khac nhau thi tinh nhay cam doi

BANG 1.1: CAC LOA1 SOI TK 0 DONG VAT CO VU

Loai sdi Bi/dng kinh

(micro - met)

Toe do dan truyen (m/sec)

Chute nang

A alpha (Aa ) 12 - 22 70 - 120 Van dong cd

xtfdng cam giac ban the

hach TK thi/c vat dau, ap life, nhiet.

vdi su: thieu Oxy (hypoxie) va cac thuoc vo cam (anesthesie) cung khac nhau NhiJng sdi truyen cam dau

la nhuing sdi co dadng kinh nho, co myelin (sdi A delta) hoac khong myelin (sdi C) Thuoc vo cam tai cho co the lam mat stf dan truyen cua cac sdi C

9

hi su’THOAi hoA v A tAi sinh c A c sd i th A n kinh

Binh thUdng sdi true dUdc bao quanh bdi cac te bao Schwann xep canh nhau doc theo chieu dai cua no Cac

te bao Schwann chi cach nhau mot khe nho goi la that vong Ranvier

NhvJng sdi khong co myelin, moi te bao Schwann chi cuon quanh mot sdi true va tu phan doan M ot trong nhiing chiic nang cua bao myelin la lam tang nhanh toe

do dan truyen luong than kinh Nhii vay sdi co myelin truyen nhanh hdn nhiing sdi khong co myelin

1 Thoai hoa W aller (do Waller mo ta lan dau tien

(1856): khi c&t dtit day than kinh, cac sdi true se bi thoai

hoa, dac biet tram trong la d phan ngoai vi, lam cho neuron mat han chiic nang sinh ly, sau mot thdi gian dai m6i hoi phuc dUdc:

O than neuron 48 gid sau khi cat, cac the Nissl (nhilng hat mau xam, chiia nhieu phan til ARN (acidribonucleic) co tac dung tong hdp protein) bien mat het, lUdi td TK (nhiing sdi co dtfdng kinh khoang 90A°, dan thanh mot mang lu6i trong than neuron) bi tan vd, than neuron nd ra va nhan bi day lech sang mot ben; neu thUdng ton qua nang thi nhan cung bi tieu tan va neuron hoan toan bi pha huy Thong thUdng tvf ngay thii hai mUdi, d cho cat nhiing tua bao tufdng se raoc ra va b it

d iu thdi ky hoi phuc

- Phan ngoai vi sdi true bi ckt (hinh 1.6): 24 gid sau

khi bi cat, bao myelin bi vd thanh tting mang, sdi true bi tan bien chi con lai mot ong bao Schwann rong cac tg' bao Schwann nd to ra lap ca ong

Pha huy tai cho va phan tan myelin

Loai bo nnhutig manh vun myelin

Viem than kinh khoanh doan quanh sdi true

j Mot te bao Schwann

Cat ngang mot sdi

Soi true dai ra

•>1 '

Tang sinh te bao Sclpvpnn j_ d ^ a ri xg _ cL\6a\ i gan

M ye lin d ifd c tai tao

Thoai hoa Waller

- Su tai sinh cua sdi than kinh xay ra rat cham Nhiing te bao Schwann con lai d cho sdi than kinh bi thoai hoa bat dau phat trien theo hu6ng trung tarn TCf than neuron cac tua bao tUdng bat dau moc ra, moi ngay dai them 0,5mm, mot so" tua chui vao dUdc ong bao Schwann thi dai ra vdi toe do nhanh hdn: 3 den 4mm trong mot ngay, ldp myelin cung dUdc ta; tao Sau khoang 3 thang neuron co the hoan toan hoi phuc nhUng doi khi keo dai hang nam.

2 Viem day than kinh quanh true tifng doan (nevrite sementaire periaxile)

La hau qua cua thUdng ton nguyen phat cua te bao Schwann (hinh 1.6) bieu hien bdi sii mat bao myelin d mot hay nhieu doan

IV PHAN LCAI BENH THAN KINH NGOAI VI

1 Phan loai theo vi tri thiidng ton

Phan loai theo vi tri thifdng ton neuron than kinh

ngoai vi (re, dam roi, day than kinh) Day chi la nhiing

quy u6c tUdng doi vi viem re thifdng lan sang day va ngiidc lai thUdng ton day thiidng lan sang re than kinh.

2 Phan loai theo nguyen nhan thvfOng ton

Benh than kinh ngoai vi co the la nguyen phat hoac thii phat

- Nguyen phat: ThUdng ton b it nguon tif than kinh ngoai vi (vi khuan trUc tiep lam thUdng ton day than kinh hoac chan thUdng trUc tiep gay nen diit, giap day than kinh)

- Thii phat: sau mot thUdng ton cua cot song, nhiem doc chi, asen, thieu vitamin B l (benh Beriberi)

3 Phan loai theo mufc do thiiofng ton

a V i sinh ly hoc

Theo Seddan chia ra ba rmlc do:

Day than kinh bi dilt hoan toan (neurotmesis): bao

va day than kinh deu bi cat va mat tinh dan truyen cua

sdi true, neu khong mo de no! lai thi khong the phuc hoi Dau hieu lam sang dilt hoan toan day than kinh la tat ca cac sdi cd do day than kinh chi phoi deu bi liet roi teo di, mat phan xa gan xUdng, mat cam giac d vung da tUdng

ilng Sau do khu vUc mat cam giac se thu hep lai nhd co cac sdi than kinh lan can Da d vung mat cam giac bi kho

do kha nang bai tiet mo hoi cung bi mat Mat cac song dap ilng khi do dan truyen than kinh Loai thUdng ton nay rat kho hoi phuc va thUdng tao thanh cac u than kinh (neurinoma)

- Day than kinh bi dilt khong hoan toan (axonotmesis):Thoai hoa bao than kinh va mat dan truyen cua sdi true, co dau hieu liet va mat cam giac khong hoan toan, giam bien do dap ting cua cac song than kinh Tuy co kha nang hoi phuc sau mot thdi gian nhUng doi v6i nhiing day than kinh co nhieu sdi giao cam thi co kha nang dan den chilng dau chay (causagie) Sii hoi phuc phu thuoc vao sii tai phan bo cac sdi than kinh Qua trinh nay dien

ra cham keo dai hang thang hoac hang nam vefi toe do 1 - 3mm/24gid

+ Day than kinh khong bi thUdng ton ma chi roi loan chilc nang tam thdi (neuropraxia): khong co thay doi cau true sdi true mac du toe do dan truyen co the bi giam mot thdi gian neu co pho'i hdp mat myelin Khi thUdng ton

13

myelin dUdc hoi phuc hoan toan thi toe do dan truyen se trd lai binh thUdng.

b Ve giai phau benh hoc

- ThUdng ton gidi han d bao (viem quanh day than kinh):

- ThUdng ton d mo ke (viem ke day than kinh).

- ThUdng ton d nhu mo day th in kinh: sdi true nam

d trong bao mat myelin nen co benh canh giong nhu cua thoai hoa W aller sau khi day than kinh bi c it dtit.

c Ve to chiic hoc vd dien sinh ly

*Chia lam 3 loai

- Thoai hoa Waller do ngat doan cua sdi true , sdi

true (thUdng ton vi mach)

Thoai hoa sdi true hifcing tam con goi la hien tUdng chet

ngifdc (dying back) do roi loan chuyen hoa cua neuron

Thdi gian tiem tang keo dai tren 40%

Thdi gian tiem tang cua song F keo dai

tren 40%

Hiem co dien tif phat khi cd nghi

Bien do dien the qiam nhe

Giam (10% - 30%) Keo dai khong ro rang Binh thi/dng

Co khi cd nghi Giam nhieu

Thoai hoa Waller va sdi true thifdng phoi hdp v6i giam bien do dien the hoat dong va co cac bieu hien mat chi phoi than kinh tren dien cd Ngifdc lai mat myelin dac trUng bdi giam toe do dan truyen.

V NGUYEN NHAN THLfONG TON THAN KINH NGOAI VI

Co nhieu nguyen nhan gay thUOng ton TKNV, hay gap la thoai hoa cot song, thoat vi dla dem, nhiem khuan, nhiem doc, chan thUdng, do lanh, do dung thuoc Moi benh TKNV

co the do mot hoac nhieu nguyen nhan chi phoi hdp

1 Viem re than kinh

a Benh can

- Viem mang nao do giang mai, lao, viem mang nao mu

- Chan thUdng

- Thoat vi dla dem chen ep vao re than kinh

Thii phat sau benh Pott, u ngoai tuy, di can ung thu hay viem nao

- Zona

b Giai phau benh hoc

Cac re than kinh khi rdi khoi tuy tao thanh bo sdi than kinh difdc bao boc bdi mang nhen noi tiep vdi mang mem Cac nhom te bao bieu mo phu, cac re than kinh d cac doan noi tao dieu kien tot cho cac qua trinh viem Tuy theo vi tri giai phau ma phan biet ra:

Viem re than kinh co - canh tay

Viem r l than kinh lifng

Viem re than kinh that lifng - cung

15

2 Viem dam roi than kinh

Thudng d mot ben, bat dau bang giai doan dau day than kinh tu phat, tang len khi cii dong va khi de ep vao dam roi, sau do co the la giai doan liet kem theo giam phan xa, teo cd, roi loan cam giac va roi loan dinh dUdng (phu ne, tang tiet mo hoi, roi loan van mach)

Tuy theo khu tru ma phan biet ra cac viem dam roi

co, canh tay, that lifng - cung va then

Dam roi co it khi bi thUdng ton don doc

Dam roi canh tay (C5 - D2) hay bi thUdng ton nhat Nguyen nhan co the la phinh dong mach du6i don, u, thUdng ton hach bach huyet, xUdng sifdn co va cac the khac cua hoi chilng sifdn don Nguyen nhan pho bien nhat la chan thifdng (doi khi kem theo trat khdp vai)

- Dam roi that lifng (L l - L4) n&m d trong va d tren mat cd that lufng (m psoas), co the bi thUdng ton trong viem tlnh mach huyet khoi d vung chau, viem cd that liing, cac u d chau hong nho va gay xvfdng chau.

- Dam roi cung (L5 - S2) n&m tren cd thap (m.piriformis) phla trUdc phu bdi can chau va cac lcip cua mang bung Nguyen nhan thUdng ton cung giong nhu viem dam roi that lifng

Trong thifdng ton do chan thifdng dam roi that lung - cung, ngoai trieu chilng cua dam roi co the co ca trieu chvfng cac re cua duoi ngifa (do keo cang qua mile)

3 Dau day than kinh va viem day than kinh

a Dau day than kinh

Dac diem cua dau day than kinh la dau doc day than kinh, nhieu khi khong co nguyen nhan thuc the ro rang,

khong kem roi loan chtic nang thUc sU d cac cd quan hoac cac cd tUdng ting Cac cdn dau thudng d mot ben, phat sinh do bi kfch thi'ch mot vung nhat dinh Ngoai cdn khong co roi loan khach quan.

Trong thuc te thudng hay gap dau day than kinh hong

to, day than kinh gitia, day than kinh gian sUdn

b Viem day than kinh

TrUdng hdp viem mot day than kinh thudng do cd che

de ep hoac thieu mau cuc bo hoac ca hai yeu to' do gay ra.Giai phau benh hoc:

ThUdng ton co the gidi han (viem quanh day than kinh) hay d mo ke (viem ke day than kinh) d cac sdi than kinh (viem nhu mo day than kinh) Trong hai trUdng hdp dau, thay co dich ri viem v6i nhting bach cau, tang sinh cac nhan Schwann va dtit quang bao myelin Trong viem nhu mo day th in kinh, sdi true ton tai d trong bao mat myelin nen co benh canh giong nhu thoai hoa Waller sau khi c it mot day than kinh ngoai vi

VI CG CHE THl/CfNG TON THAN KINH NGOAI VI

ThufOng ton rieng le mot phan day than kinh ngoai vi hau nhu luon luon do nguyen nhan cd hoc, chan thtfdng

17

tnlc tiep, cang keo hay de ep Cac nguyen nhan nay co the la dot ngot hay tti tti, co the mot lan hay nhieu lan do

vi chan thifdng (micro - traumatismes): hau qua cua cac nguyen nhan nay gay nen:

De ep mot day than kinh trong thoi gian ngan: mat cac chtic nang trong vai phut Cac chtic nang difdc hoi phuc ngay va toan bo neu khong con de ep ntia

De ep trong thdi gian dai hoac vi chan thifdng lap di lap lai: thifdng ton mat myelin tting doan va ngting dan truyen than kinh, thieu sot cac chtic nang than kinh Neu co thifdng ton sdi true thi sU hoi phuc than kinh se

bi keo dai

TrUdng hdp thifdng ton do cang keo hay thieu mau co the gay nen roi loan chtic nang nghiem trong va ben vting do gay cac sdi true va thoai hoa Waller

Sil hoi phuc theo quy luat tai sinh d dau g in (1,5mm mot ngay) Neu khong bi dtit day th in kinh thi sii hoi phuc chtic nang se rat tot Neu bi dtit day th in kinh ma khong khau noi hai d iu bi cat thi svf tai sinh se khong co ket qua

Do roi loan chuyen hoa va benh ly vi mach (xem benh

th in kinh ngoai vi do dai thao difdng)

VII TRIEU CHLTNG LAM SAN G BENH THAN KINH

N G O A I VI

1 Roi loan van dong

Liet mem hay liet cd chi phoi bcii day than kinh bi

thifdng ton

2 Roi loan phan xa

Giam hoac mat phan xa gan xifdng

3 Roi loan cam giac

Dau doc theo diidng di cua day than kinh bi thudng ton

va dau theo vung chi phoi cua nhanh day thin kinh do.Dau khi an vao day than kinh

Giam cam giac hoac tang cam giac (thiidng la tang cam giac dau: hyperalagesia) hay di cam (cam giac te buon, kien bo, kim cham, dau chay, rat)

4 Roi loan dinh diiOng

Teo cd sdm va co phan ting thoai hoa dien

5 Roi loan van mach, thay doi nhiet do da

6 Khong roi loan cd vong (trvf hoi chting duoi ngtfa).

7 Khong co dau hieu thifcfng ton bo thap

VIII LlTONG GIA s ir e c d BANG t a y

1 Cac bac hoat dong cua cd

Galton (1883) nhan thay stic cd d nam gidi tang nhanh tti 2 den 19 tuoi cung vdi sil tang can nang, sau do tang cham hdn va tang dan tdi 30 tuoi roi giam dan tdi 60 tuoi Stic cd cua nti gidi tang vdi nhip do deu dan hdn tti 9

- 1 9 tuoi roi tang cham hdn tdi 30 tuoi, sau do giam dan vdi nhip do nhii d nam gidi Schochrin (1935) nhan thay stic cd d nti gidi kem hdn nam gidi tti 28 - 30% Lovett (1922) da de xuat phildng phap danh gia trong lildng toi

19

da ma mot nhom cd the nang len diidc (trong dieu kien hoat dong kh6p binh thiidng) Lovett va Martin (1915) da

de ra phiidng phap thif nghiem sOfc cd co sxi dung mot loai can lo so Dariels va Werthingham (1956) can cti tren ba yeu to" de phan chia cac bac cd:

- Siic can cua mot cd hay mot nhom cd

- Kha nang di dong cua mot phan cd the khi mot cd hay mot nhom cd co

- Tinh trang co hay khong co co cd trong mot nhom cd.Ngoai cac bac can ban, trong thiic te con co the them cac dau cong hoac trii kem theo Cu the la: siic cd chong lai it hdn cac bac can ban thi them dau trii, neu siic chong lai 16n hdn thi them dau cong vao bac can ban Neu cU dong 16n hdn mot nUa tam hoat dong nhiing khong het tam thi dung bac cd cao hdn va them dau trif NgUdi ta thUdng ghi phoi hdp tam hoat dong vao bac cd

Vi du, tam hoat dong thu dong gap khuyu bi gi6i han d

90 do va benh nhan co the cU dong diidc het tam hoat dong nay khi co liic can, tren sO do se dUdc ghi la 90° F (Fair = kha)

Theo Weller (1973) kham siic cd nen lam cach khoang thdi gian deu nhau va ket qua diidc so sanh v6i lin kham trii6c Kham siic cd bang tay chi co gia tri khi mot ngUdi lam nhieu lan, mot so ngUdi co xu hiidng dat he thong

bac so cao hdn hay thap hdn ngiidi khac, thong thiidng

thi ngiidi nao cung luon luon danh gia siic cd theo mot cap do rieng cua ho Co nhieu he thong khac nhau de danh gia siic cd Tat ca deu co gia tri nhat dinh Ta co the dung mot he thong nao cung dUdc mien la ta luon luon dung mot he thong va ngUdi khac hieu ro y nghia cua no

Ngo The Vinh (1981) cho biet: trong nhiing nam gan day co nhieu dung cu cd hoc va dien tii v6i mile do phiic tap khac nhau diioc ap dung de do siic cd vdi hy vong cung cap diidc nhiing dtf kien co gia tri ve chiic nang, coi

do la mot dong gop quan trong cua cac cong trinh nghien ciiu Tuy nhien, mot chiec may du tinh xao den dau cung khong the phat hien thay cho ngUdi kham tat ca nhiing bien thien te nhi trong t h i nghiem cd May khong the cam nhan ve sii co" gSng cua benh nhan cung nhu khong the phat hien sii khac biet giiia yeu cO do nguyen nhan chiic nang hoac thiic the Them vao do, sii phiic tap ve ky thuat, viec dat co" dinh may tren tOfng phan than the doi hoi mat nhieu thi gid ma cung khong cung cap diidc nhiing dii kien hdn mot cach tUOng xiing Do do phiidng phap thu nghiem siic cd b in g tay luon luon giuf nguyen gia tri hiiu ich trong thiic tien, khong chi quan trong trong lam sang ma ca trong nghien ciiu niia

J Godebout va J.Ster (1976) cho rang: ban danh gia siic cd giup cho viec xac dinh vi tri thiidng ton (d tuy, d dam roi than kinh hay d day than kinh), chi dan nhiing can thiep ngoai khoa, danh gia hoat dong cua khdp va cho phep tien liiOng kha nang hoi phuc chiic nang van dong

Viec liidng gia siic cd la tUdng doi kho khan nen moi tac gia co mot he thong bac rieng bang so" hoac b&ng chii:

N (normal = binh thiidng), G (good = tot), F (fair = kha),

P (poor = kem), T (trace = chut it), 0 (so" khong) (bang 3) Neu dung he thong so 16n thi phiic tap, khong thvic te" lam sang Nhiing neu dung he thong so" be thi khong day

du Ho Hiiu Liidng (1976), tren cd sd nghien ciiu phuc hoi chiic nang van dong cho cac benh nhan liet hai chi dudi

do vet thiidng hoac chan thiidng cot song - tuy song da

21

de xuat he thong tti 0 den 10 de ltfdng gia stic sd va theo doi qua trinh phuc hoi chtic nang van dong, dong thdi can cti vao stic cd ma chia ra 5 do liet (bang 1.3).

Bang 1.3: So sanh cac bac hoat dong cua cd

NCYHQ

T (D

Li/dng 1976

7 (Liet do 1)

F F-

3

6 5 (Liet do 2)

P-3 (Liet do 3)

hoan

5)

Bang 1.4: LUdng gia sUc c d theo he thong so tUO den 10 va 5 do Net

(theo Ho HOfu Ludng 1976) Sifc cd

tu do) thi bien do v ln binh thudng

a Y nghla thi/c tien

Trong phuc hoi chtic nang van dong, dung phifdng phap lifdng gia stic cO, nghla la tinh den stic co con ma khong quan tam den stic cO da mat (do liet) (“it is not what you have lost, but what you have left, that count” -

Dr L Guttmann) Nhu vay tien cho viec danh gia ket qua phuc hoi chtic nang van dong NhUng trong lam sang than kinh lai thudng quan tam den stic cO da mat (do liet) de giup cho viec xac dinh mtic do nang cua benh.

Ltfdng gia stic cO theo he thong so" tti 0 den 10 tUdng

ting v6i 5 do liet cua Ho Htiu Ltfdng (1976) rat thuan tien trong lam sang than kinh cung nhtf trong danh gia phuc hoi chtic nang van dong

b Nghien citu liidng gid siic cd theo he thong so tit 0 den

10 vd 5 do liet titdng ling.

- Ho Htiu Ltfdng da ltfdng gia stic ca theo he thong so tti

0 den 10 va 5 do het ttfdng ting tren 127 benh nhan liet hai chi dtfdi do vet thUOng va chan thifdng cot song - tuy song dtfOc dieu tri tai Khoa than kinh, Khoa phiu thuat than kinh Vien quan y 103, Khoa chan thifdng vien quan y 109, Khu dieu difdng Thuan Thanh (Bac Ninh), Khu dieu difdng Duy Tien, Lam Can (Ha Nam) tti 1976 - 1985)

Doi tifdng nghien ctiu difdc chia thanh ba nhom de co phtfdng phap luyen tap phuc hoi, thich hdp: nhom I (64 benh nhan mdi bi thifdng), nhom II (31 benh nhan bi thifdng da mot nam), nhom III (nhom chting gom 32 benh nhan khong difdc dieu tri phuc hoi chtic nang)

2 LtfOng gia stic cd th eo he th o n g so tti 0 d e n 10 va

5 do liet cu a Ho Htiu LtfOng (1976)

Tat ca benh nhan deu diidc liidng gia stic cd bang tay theo he thong so' tif 0 den 10 va 5 do liet triidc va sau dieu tri phuc hoi chiic nang van dong Liidng gia siic cd dtfdc tien hanh theo mot trinh tii nhat dinh va lap phieu danh gia siic cd, dong thdi so sanh ket qua giiia cac lin kham Phan tich ket qua phuc hoi siic cO sau moi dot tap van dong theo cac nhom benh nhan de danh gia cac phiidng phap phuc hoi van dong.

Tac gia nhan thay kha nang van dong (di chuyen) cua benh nhan phu thuoc vao siic cd con lai hoac do liet (bang 1.5)

Bang 1.5: Kha nSng van dong 0 benh nhan liet hai chi diidi (theo Ho

HuTu Ltfdng) Stfc cd

Neu site cd dai chau con 4 - 3 (liet do 3) co the di chuyen kieu bon thi vdi hai nang va nep dai d hai chan.

25

Danh gia kha nang phuc hoi btfdc di d 37 trUdng

hop liet hai chi dtfdi dtfdc tap luyen muon, Ho Hiiu Ltfdng (1980) nhan thay:

+ Trtfdng hdp stfc cd hai chi dtfdi b&ng 0, benh nhan

co the di chuyen kieu lang ngtfdi vdi hai nang va hai nep dai d chan khi stfc cd bung con 5 - 6/10 (liet do 2)

+ Di kieu bon thi vdi hai nang va hai nep dai d chan khi stfc cd dai chau con 3 - 4/10 (liet do 3)

+ Di vdi hai nang tay, khong c&n nep chan khi stfc

cd ttf dau dtii con 5 - 6/10 (liet do 2)

+ Trtfdng hdp liet cting nhe hai chi dtfdi stfc cd chi con 3 - 4/10 (liet do 3), benh nhan van co the di dtfdc bang hai nang tay (khong can nep chan)

+ Di khong can nang vdi hai nep ngan d chan khi stfc cd dui va cang chan con 3 — 4/10 (liet do 3)

- Tren cd sd nghien ctfu phuc hoi van dong sdm cho 14 thtfdng binh liet hai chi dtfdi do chan thtfdng va vet thtfdng cot song, Ho Htiu Ltfdng (1979) da dtfa ra tieu chuan phan loai mtic do hoi phuc van dong gom 8 do (bang 1.6)

Bang 1.6: Do hoi phuc van dong (theo Ho Htfu Ltfdng, 1979) Hoi phuc Tinh trang van dong Mure do hoi phuc

Do 2 Van dong mot vai cd nhtfng

chtfa van dong dtfdc khuc chi

Hoi phuc rat it

Do 3 Van dong khuc chi nhtfng

chtfa dtfng dtfdc

Hoi phuc it

0 6 7 Di khong nang dtfdc 10 met Hoi phuc rat tot

IX DIEU TRI BENH THAN KINH NGOAI VI

1 Dieu tri theo nguyen nhan

2 Dieu tri trieu chiing

Dieu tri cac trieu cluing hien co cua moi benh nhan Dau than kinh la trieu chiing hay gap va thiidng la nguyen nhan khien benh nhan phai di kham benh

3 Dieu tri chiing dau than kinh ngoai vi:

Phan loai cam giac dau: dau cam thu (nociceptive pain), dau than kinh (neuropathic pain), dau can nguyen tam ly (psychogenic pain)

- Dau than kinh la chiing dau do nhiing thiidng ton cua ban than cac cau true than kinh cam giac (trung tfdng, ngoai vi) Dac diem chinh cua dau than kinh la khu tru tai vung phan bo" cua cac day than kinh hoac lan theo dai phan bo" cam giac cua re than kinh, dau ca d vung giam hay mat cam giac, tang ve dem va dap ting rat kem vdi cac thuoc giam dau truyen thong

Cac loai dau than kinh thudng gap:

Dau than kinh do dai thao dtfdng

Dau th in kinh sau herpes (dau sau khi bi zona)

Dau day V, dau day th in kinh trung gian Wrisberg, dau day thiet h iu , dau day th in kinh hong to, dau day

th in kinh dui, dau day th in kinh then trong, dau day

th in kinh dui bi

Dau chi ma

Dau sau dot quy nao

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Dau do thtfdng ton tuy song

Dieu tri dau than kinh:

Cac thuoc chong tram cam ba vong (amitriptylin).Cac thuoc chong dong kinh (Carbamazepin, Phenytoin, Gabapentin(Neurotin, Aclonium)

Cac thuoc chong loan nhip (Mexiletine)

Giam dau cuc bo va phong be giao cam

Thuoc giam dau ngoai vi (Aspirin, Paracetamol)

Cac phtfdng phap khong dung thuoc

ChUOng I I

CAC PHlfONG PHAP THAM DO DIEN SINH LY TRONG BENH THAN KINH■

NGOAI VI

I LICH SU” CAC PHLfdNG PHAP

Nam 1791, Luigi Galvani (Bologne) da phat hien ra dong dien sinh vat, Dubois Raymond xac nhan rang dong dien do do cd phat ra

Nam 1851, Dubois - Raymond da de xuat phtfdng phap ghi dien cd va da ghi dtfdc ban dien cd dau tien.Nam 1852, Herman von Helmholtz trong khi nghien ctfu dan truyen day than kinh givia, lan dau tien da do dtfdc chinh xac toe dp dan truyen than kinh Sau do nhd cac trang thiet bi ky thuat cua Lippman (1872) va cua

D A rsonval (1910), Piper (1911) da xay dtfng nen nganh khoa hoc "Dien sinh ly than kinh"

Nam 1925, C.S Sherrington de xuat danh ttf "ddn vi van dong" (cau true chtfc nang cua cd)

Nam 1929, Adrian va Bronk che tao ra dien ctfc kim ltfdng ctfc dong true (aiguille coaxiale), dien ctfc nay cho phep ghi dien the hoat dong cua nhom sdi cd Sau do la cac cong trinh cua Denny Brown ve hien ttfdng giat sdi cd (1938), ve co cd (1941) cung cac nghien ctfu cua

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Clemmesen va Kugelberg (B ic Au), Bawens (Anh), Bremer, Desmedt (Bi), Lerique (Phap) da giup Buchthal xay dilng diidc nganh "Dien cd lam sang" vao nam 1949).Nam 1950 Dowson va Scoot da sil dung cac dong dien co tan so thap kich thich he than kinh van dong ngoai vi, cac

cd va he than kinh cam giac d vi tri nong diidi da de xem xet phan ilng dien trong chan doan benh th in kinh - cd.Nam 1948, Hordes, Larabe da nghien cilu dan truyen than kinh van dong

Nam 1962 Gillatt va Thomas dung phiidng phap do

d in truyen th in kinh de nghien cilu cac benh ly cua day

th in kinh ngoai vi va thay rang khi day than kinh bi thiidng ton thi toe do dan truyen cua chung se giam.Nam 1980 Bosch va CS nghien cilu thiidng ton dam roi th in kinh canh tay ve hinh thai va dien sinh ly khi re

th in kinh cam giac bi chen ep Sau do la thdi ky phat trien manh me cua chan doan dien

Phu'dng phap ghi dien th in kinh (neurography) dong vai tro quan trong trong chan doan cac benh TKNV Vdi nhiing tien bo cua cong nghe vi tinh, da co cac he thong khuyech dai cilc nhay va cac he thong dien cilc thuan tien cho phep do dude toe do dan truyen van dong, cam giac cua day TKNV, cac tham kham phan xa nhil phan

xa H, song F va cac phan xa thile vat Phildng phap ghi dien the kich thich (evoked potential:EP) la mot trong nhiing phutdng phap chan doan hien dai, gom co dien the kich thich van dong (motor evoked potential), dien the kich thich cam giac (gom co dien the kich thich thi giac - visual evoked potential: VEP, dien the kich thich

thinh giac - auditory evoked potential:AEP va dien the kich thich cam giac than the somatosensory evoked potential: SSEP).

II DIEN SINH LY TRONG CHAN DOAN BENH THAN KINH NGOAI VI

1 Dien the mang neuron, dan truyen xung dong trong sOi true

a Dien the nghi

Don vi cau true - chile nang cua c0 the don bao cung nhii da bao la te bao Moi te bao la don vi song, co kha nang trao doi chat vdi dich ngoai bao, san xuat cac san pham cua minh va phan chia sinh te bao con

Khi neuron 6 trang thai nghi, dien the 6 mat trong mang te bao am hdn mat ngoai Sii chenh lech dien the nay la do sii chenh lech nong do ion am va ion dutdng gitia trong va ngoai mang te bao Sii chenh lech nong do ion nay la do:

- Trong te bao, nong do protein (mang dien tich am) rat cao va khong the khuyech tan qua mang te bao de ra ngoai diidc nen nong do ion am trong mang cao hOn, ngoai mang te bao

- Sii khuyech tan cua ion Na+ va K+: binh thtfdng hai loai ion nay tham qua mang te bao vdi so' liidng rat it Do nong do ion K+ trong mang cao hdn ngoai mang te bao nen kha nang khuyech tan ion K+ tti trong ra ngoai mang 16n hdn nhieu (100 lan) so vdi ion Na+ di tti ngoai vao trong nen nong do ion am trong mang te bao von da cao lai cang cao hdn so vdi ngoai mang

31

- Bom Na+ - K+: day la ly do chi'nh de tao ra stf chenh ech nong do ion gitfa trong va ngoai mang te bao Bdm nay

loat dong lien tuc (trti khi te bao chet) Cd m6i lan bdm

loat dong co 3 ion Na+ di ra ngoai va chi co 2 ion K+ dtfpc )dm tii ngoai vao trong Noi cach khac, sau moi lan bdm, 6 igoai mang tang them 1 ion dtfOng nen stf chenh lech nong

lo ion am gitfa trong va ngoai mang cang tang len

NhU vay, khi neuron khong hoat dong, dien the mat ,rong am hdn mat ngoai mang neuron (hien ttfdng phan

;tfc) Dien the d mang sdi true la -90mV va d mang than leuron la -65mV

3 Dien the hoat dong

Dien the hoat dong cua mang b it dau bang stf bien doi dot ngot tuf dien the" am, luc nghi sang dien the difdng roi lai rat nhanh trO ve dien the am:

- Giai doan nghi (giai doan phan cue):

+ Vai tro cua kenh natri: la loai kenh co canh cong dien the, cong phia ngoai la cong hoat hoa, cong phi'a trong la :ong khu hoat Khi dien the mang la -90mV, cong hoat hoa dong (Na+ khong vao dtfdc), cong khtf hoat md

+ Vai tro cua kenh kali: cung la kenh co canh cong dien the nhtfng chi co mot cong hoat hoa nam phia trong mang te bao O trang thai nghi cong kenh dong, K* khong ra ngoai dtfdc

- Giai doan tai cilc:

Ngay sau khi md vai phan van giay kenh natri bat dau dong, kenh kali md lam ion K+ khuyech tan nhanh

ra ngoai, tai tao lai trang thai phan ctfc luc nghi ve tri so

-90mV

c Dan truyen xung dong tren sdi true.

Stf lan truyen dien the hoat dong tao nen mot mach dien tai cho gitfa vung dang khtf ctfc va phan mang 6 vung tiep giap Lan song lan truyen nhtf vay goi la xung dong than kinh Khi dien the hoat dong dtfpc tao ra 6 mot diem tren mang neuron, qua trinh khtf ctfc se lan toa toan bo mang theo quy luat "tat ca hoac khong" Dien the hoat dong xuat hien tai mot diem cua spi true se lan toa theo hai phia Dong dien trong te bao chay ttf vung hoat dong (noi ti'ch dien dtfOng) den vung khong hoat dong ben canh (noi ti'ch dien am) Phia ngoai te bao xuat hien mot dong dien chay ngtfpc chieu ttf vung khong hoat dong den vung hoat dong Hien ttfpng nay lam nhtfng vung khong hoat dong 0 hai phia cua vung hoat dong bi khtf ctfc tao nen dong dien chay theo hai htfdng Tuy nhien ve mat sinh ly, xung dong thtfc te chi dan truyen theo chieu thuan

Doi vdi cac spi than kinh khong co myelin, cac xung dong d in truyen theo tting diem mot tren suot chieu dai spi true nen toe do d in truyen khong nhanh

Cac spi th in kinh co myelin, cac xung dong d in truyen theo kieu "nhay coc" qua cac eo Ranvier (do myelin la mot loai chat cach dien, mat khac mang tai eo Ranvier co tmh tham rat cao vdi cac ion (gap 500 lan cac spi khong co myelin) nen toe do dan truyen cua cac spi

33

than kinh co bao myelin cao hon rat nhieu so vdi cac sdi khong co bao myelin.

b

Hin 2.1: Dan truyen nhay cua cac sdi than kinh co myelin, a: dong dien cuc bo, b: kich thich dien gay khCr ctfc d cac eo Ranvier ke can

va dong dien chay theo hai htfdng.

III CHAN DOAN DIEN CO DIEN

1 Nguyen tac

Dung dong dien galvanic (dien mot chieu)

(luc dong va luc md dien) va dong faradic (dien ting)

2 Nofi kich thich

Doi vdi th in kinh: d ndi day than kinh gan da nhat (vi

du ranh tren rong roc doi vdi day than kinh tru)

Doi vdi cO: diem van dong

Neu kich thich ngat quang b ln g dong dien galvanic (dong dien mot chieu) se cd xung chti nhat (hay con goi la xung vuong) Dong dien faradic (dien ting, cd xung dinh nhon hai pha: mot pha am, mot pha dtfdng ldn hdn Binh thtfdng khi kich thich than kinh bang dong dien galvanic

va dong faradic se gay co cd do day than kinh do phan bo Neu kich thich triic tiep vao cO cung gay diidc co cd.

3 Ctfcfng do cd sof (rheobase hay ngifdng kich thich)

Cifdng do cd sd la Clidng do nho nhat de gay diiOc co cd Cac day than kinh co ngifOng kich thich khac nhau diidc tinh b ln g mA (milliampere)

mA

► (b)

Hinh 2.2: Cac loai xung thudng dung trong chan doan dien

a - Xung ch ii nhat b - Xung faradic c - Xung gia faradic

d - Xung ludi cay e - Xung hinh thang

35

BANG 2.1.: NGUCfNG KICH THICH CUA DAY THAN KINH

Day than kinh Ngi/dng kich thich (mA)

4 Thcfi tri (chronaxie):

La thdi gian toi thieu lam cho co cd vdi mot cifdng do gap hai cifdng do cd sd

— Thdi tri day than kinh: theo Bui Thieu Stf va Lai The Vinh binh thifdng thdi tri trung binh cua cac day than kinh la:

Day quay: 0,094 miligiay

Day tru: 0,110 miligiay

Day giiia: 0,124 miligiay

Day chay: 0,141 miligiay

Day mac: 0,125 miligiay

- Thdi tri cac cd: binh thiidng thdi tri cac cd trong cd the tu: 0,08 den 0,72 miligiay

+ Cac cd d co, than va goc chi (vai, canh tay, hong, dui):

Cd mat trtfdc: 0,08 - 0,16 miligiay

Cd mat sau la: 0,16 - 0,32 miligiay

+ Cac cd d dau, mat va d ngon chi (c&ng tay, ban tay, cang chan, ban chan):

Cd mat trtfdc la: 0,16 - 0,32 miligiay

Cd mat sau la: 0,44 - 0,72 miligiay

Khi co hien tufpng thoai hoa than kinh hoan toan thi thdi tri co the tang gap 100 lan so vdi binh thudng Trong qua trinh hoi phuc than kinh, thdi tri se giam dan, nhd vay ta theo ddi dtfdc sii hoi phuc than kinh

IV MOT SO PHAN IfNG DIEN BiNH THUGNG VA BENH LY

1 Phan ling Erb

Binh thiidng khi kich thich bang dong galvanic cd co chdp nhoang va co dac diem la cd co (C) khi dong (D) dien

d am ctfc (A) manh hdn khi dong ctfc dUdng (D) (CDA) > (CDD) Hien ttfdng dao Ion cong thtfc CDD > CDA la phan ling Erb dtfOng tfnh Phan ilng nay xuat hien vai tuan sau thiiOng ton than kinh

37

Phan ting Erb dtfdng tmh thtfdng di kem theo phan ting

co cO cham (phan ting Remark dtfdng tmh) phan anh tinh trang thtfdng ton tram trong cua day than kinh va te bao than kinh

2 Phan ting chieu doc

Binh thtfdng kich thich c0 vdi dong galvanic tai diem van dong thi nhay hon d hai dau cO Nhtfng sau khoang hai thang thtfOng ton day than kinh thi dap ting dan dan ngtfpc lai, den khi dap tfng d dau cd lai nhay hdn d diem van dong thi tao nen trang thai phan tfng chieu doc.

3 Phan ting thoai hoa dien

a Thdi gian xuat hien phan ting thoai hod dien

Co phan tfng thoai hoa dien sau khi thtfOng ton day than kinh (DTK) hoac te bao sting trtfdc tuy 1 2 - 1 5 ngay (bang 2.2).

BANG 2.2: PHAN tTNG THOAI HOA (PUTH) DIEN

Dongfaradic -

DTK

Dong ganvanic -DTK

Dong faradic - cd

Dong galvanic - cd

Binh

thudng

nhoang CDA > COD PUTH 1

phan

Co cd yeu Co cd yeu Co cd yeu Co cd Id dd

COD >COA PUTH

hoan toan

COD > CDA Mat hoan

b Tien trien cua phan ting thoai hod dien

- Thdi ky dau (vai ngay sau thiidng ton te bao than kinh ngoai vi): ngtfdng kich thich day than kinh va cd v&n binh thudng nhUng thdi tri da thay doi, kich thich day than kinh tren cho bi thUOng thay mat hoac giam dan truyen Trong mot so trUdng hpp kich thich day than kinh b&ng dong dien galvanic va faradic deu co phan tfng dien nhay hOn binh thudng (sd do Guilleminot - hinh 2.3)

- Thdi ky toan phat (vai ngay, vai thang, co khi hang nam)

Phan tfng dien galvanic va faradic doi vdi day than kinh giam dan tdi mat han

Kich thich cua cd doi vdi dong dien faradic cung giam dan Rieng doi vdi dong dien galvanic thi dtfdc chia ra ba giai doan:

Tuan le dau: phan tfng giam nhe

Tuan 2,3 den 2 thang: phan tfng lai nhay hOn (ngtfdng kich thich giam xuong)

Sau hai thang: phan tfng giam dan dong thdi xuat hien phan tfng Remark, phan tfng Erb dtfOng tinh CDD > CDA, chi so” ngtfdng faradic/galvanic ldn hdn 2 Thdi tri tang len cao dan roi gitf d mtfc cao, tiep sau dd xuat hien phan tfng chieu doc

Neu tien trien xau dan: tinh chat co cd ngay cang cham dan, phan tfng Erb ngay cang dtfOng tinh manh, phan tfng chieu doc cang ro, sau do dap tfng cua cd doi vdi dong dien faradic mat va tiep theo thi dap tfng cua cd do! vdi dong dien galvanic cung mat h^n

39

Hinh 2.3: Sd do tien trien cua cac kich thich day than kinh va cd

trong phan Cfng thoai hoa dien (theo Guilleminot)

- Phan ling thoai hoa dien hoan toan

Phan tfng thoai hoa dien hoan toan cung chiia han da tien liipng xau Trong qua trinh hoi phuc spi than kinh, phan ling thoai hoa dien hoan toan co the chuyen sang phan ilng thoai hoa mot phan, roi sang ti'nh chiu kich thi'ch binh thudng Nhiing neu trong liet kieu ngoai vi, cd

bi mat than kinh hoan toan tren 1 2 - 1 4 thang (doi khi hdn niia) thi luc do do sii thoai hoa tu ln tien, cac spi cd

bi huy hoai hoan toan, diipc thay doi bang to chiic md va

to chiic lien ket, xuat hien xP chai cd kem theo mat phan ling co doi vdi dong dien galvanic, nghia la mat hoan toan tinh chiu kich thich dien (mat kha nang hiing phan), tinh trang nay chilng to cac bien doi xay ra trong

cd khong cdn kha nang hoi phuc