Nasman Puar
nyeri.
·Difus dan kurang terlokalisasi. Biasanya terasa berasal dari midline atau
anterior dan posterior.
·Menjalar ke lokasi lain. Biasanya bersifat segmental dan superficial,
misalnya pada otot, kulit atau keduanya dan diinervasi oleh nervus spinalis
Descending
modulation Dorsal Horn
Spinothalamic
Peripheral
tract
nerve
Trauma
Peripheral
nociceptors
Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.
TRANSDUCTION
Transduksi
Mechanical
Pressure
Adalah proses
dimana suatu
rangsang nyeri
(noxious stimuli) Heat
diubah menjadi
suatu aktifitas listrik
pada ujung-ujung
Chemical
saraf sensoris.
Nociceptor, sensory receptor with high
treshold activation and sensitive to trauma
tissue and prolonged non-noxious stimuli
A-delta nociceptor : mechanically sensitive
C nociceptor : polymodal thermal, chemical
and mechanical
Sensitisasi Perifer
Primary hyperalgesia
Inflammatory response release intracellular contents
( potassium, bradykinin, prostaglandin )
Increase sensitivity nociceptors
Secondary hyperalgesia
Vasodilatation and mast cell degranulation ; pro-
inflammatory agent ( histamine , serotonin ) sensitize
nociceptor
Sleeping nociceptor
Transmission
Transmisi
Adalah proses
perambatan suatu
impuls nyeri melalui
serabut saraf sensoris
menyusul proses
transduksi.
Transmission
Axon primary afferent
Dorsal root ganglia
Second order neuron ( lamina I,II and V )
NS ( nociceptive specific , lamina I )
WDR ( non specifec nociceptive , all lamina esp. V )
Glutamate is main transmitter and AMPA
receptors involve in Acute Pain
Ascending central pain pathway
Neospinathalamic pathway
Palaeospinoreticulodiencephalic pathway
Ascending Pathways
5 ascending pathways have been recognized.
1. SPINOTHALAMIC TRACT
Discriminative pathway location of pain
2. SPINORETICULAR TRACT
Emotional aspect of pain (“suffering pathway”)
4. SPINOMESENCEPHALIC TRACT
• Behavioral response
5. SPINOHYPOTHALAMIC TRACT
Sensational from the skin, lips & sex organs
Modulasi Modulation
Merupakan interaksi antara
sistem analgesik endogen
(endogen opioid,
seretonergik dan
noradrenergik) dengan input
nyeri yang masuk ke kornu
posterior.
Kornu posterior merupakan
“GATE” yang dapat ditutup
oleh endogeneous analgesia.
(Gate Controlled Theory)
Descending Inhibitory Pathways
SS cortex, hypothalamus, PAG, NRM
Descend via dorsolateral funiculus to spinal cord
( projection to lamina I and V )
3 system
Opioid systems ( hypothalamus, amygdala, NRM,
DHN )
Noradrenergic neurons ( LC )
Serotonergic neurons ( NRM )
inhibitory process counterbalance nociceptive
signaling
Sensitisasi Sentral
Tachykinin (Substance P, Neurokinin A)
Presynaptic neurons Glutamate
Mg2+
G G
Na+
Ca 2+
Ca2+
Depolarisasi
Protein Kinase C
Postsynaptic neurons
41
Central sensitisation
A state of spinal neuron hyperexcitability
Increase responsiveness to innocuous stimuli
Repeat stimulation C nociceptors “wind up “
Changes in DHN
Reduction threshold response
Increase magnitude and duration response to stimuli above
threshold
Expansion DHN receptive field
Clinically manifest
Hyperalgesia
Allodynia
Persistent pain
Referred pain
Persepsi Perception
Adalah hasil akhir
dari proses interaksi Pain
Brain
yang kompleks dan Perception
44
Terima kasih