Parkhouse N, Le Quesne P M
Department of Surgical Studies, Middlesex Hospital Medical School, London, United Kingdom.
N Engl J Med. 1988 May 19;318(20):1306-9. doi: 10.1056/NEJM198805193182005.
Peripheral neuropathy plays an important part in the development of foot complications in patients with diabetes. We studied the contribution of impairment of the dual sensory and inflammatory function of unmyelinated nociceptive C fibers in the foot complications of diabetes. The integrity of these fibers was assessed objectively by measuring axon reflex vasodilation in response to stimulation with 10 percent acetylcholine introduced by electrophoresis. This was related to the non-neurogenic capacity of the vessels to dilate in response to a mechanical stroke. These measurements were made on the soles of the subjects' feet. The function of the nociceptive C fibers was abnormal in 1 of 14 patients with longstanding diabetes who had no foot complications, 3 of 9 patients with diabetes and skin sepsis, 8 of 11 patients with typical neuropathic plantar ulcers, and all of 8 patients with neuroarthropathy. In patients with longstanding diabetes but no foot complications, the mean ratio of neurogenic to non-neurogenic vasodilation was not significantly different from that in controls; however, it was significantly lower in the other three groups (P less than 0.01 for those with sepsis; P less than 0.001 for those with ulcer or arthropathy). Impairment of the neurogenic vasodilator response, or flare, correlated with the clinical diminution of pain sensation. This study suggests that the loss of both components of nociceptive C-fiber function--neurogenic inflammation and pain sensation--is an important factor in the development of foot complications in diabetes.
周围神经病变在糖尿病患者足部并发症的发生发展中起重要作用。我们研究了无髓伤害性C纤维的双重感觉和炎症功能受损在糖尿病足部并发症中的作用。通过电泳导入10%乙酰胆碱刺激来测量轴突反射性血管舒张，以此客观评估这些纤维的完整性。这与血管对机械性轻划作出反应而扩张的非神经源性能力有关。这些测量是在受试者的脚底进行的。在14例无足部并发症的长期糖尿病患者中，有1例伤害性C纤维功能异常；在9例糖尿病合并皮肤脓毒症患者中，有3例异常；在11例典型神经性足底溃疡患者中，有8例异常；在8例神经性关节病患者中，全部异常。在无足部并发症的长期糖尿病患者中，神经源性血管舒张与非神经源性血管舒张的平均比值与对照组相比无显著差异；然而，在其他三组中该比值显著降低（脓毒症患者P<0.01；溃疡或关节病患者P<0.001）。神经源性血管舒张反应或 flare 的受损与疼痛感觉的临床减退相关。这项研究表明，伤害性C纤维功能的两个组成部分——神经源性炎症和疼痛感觉——的丧失是糖尿病足部并发症发生发展的一个重要因素。
