NEUROPATHIC PAIN
Susi Aulina
Makassar September 16th, 2006
Sub Division of Pain
Dept. of Neurology Faculty of Medicine
Hasanuddin University
INTRODUCTION
NEUROPATHIC PAIN (Ne P) can be defined as :
PAIN ASSOCIATED WITH A
FUNCTIONAL ABNORMALITY OF THE
NERVOUS SYSTEM (Field 1907)
ANY PART OF THE NERVOUS SYSTEM
(peripheral, central or autonomic) MAYBE
DISRUPTED
INTRODUCTION
cont’d
CHARACTERISTICALLY : The pain persists
for months or years
THE ETIOLOGY OF NeP IS DIVERSE but the
pathophysiological mechanisms are thought to
be similar whatever the etiology (Teng and
Mekhail, 2003)
CLINICAL FEATURE (FIELDS 1987)
ABSENCE OF ONGOING NOR
NEUROLOGICAL TISSUE DAMAGED
ABNORMAL UNPLEASANT SENSATION
(DYSESTHESIA)
BURNING OR ELECTRICAL QUALITY IN
OCCASION : PAROXYSMAL, BRIEF,
SHOOTING or STABBING QUALITY
CLINICAL FEATURE
cont’d
THERE IS NO ABSOLUTE TEMPORAL
RELATIONSHIP TO THE ORIGINATING
NEURAL TRAUMA : days, weeks, months or
even years later.
PAIN MAYBE FELT IN A REGION OF
SENSORY DEFICIT
NON-NOXIOUS STIMULI MAY BE PAINFUL
(allodinia)
CLINICAL FEATURE
cont’d
NOXIOUS STIMULI MAY PRODUCE GREATER
THAN NORMAL RESPONSE (hyperalgesia)
AN INCREASE IN THE INTENSITY OF PAIN
WITH REPEATED STIMULI
THE PAIN MAY PERSIST AFTER THE
REMOVAL OF STIMULI
CLINICAL FEATURE
Neuropathic Pain
Stimulus-independent pain Stimulus-evoked pain
non-noxious Noxious
Continous
stimulus stimulus
Paroxysmal
Mechanical Therma Mechanical Thermal
Allodinia Allodinia Hyperalgesia Hyperalgesia
Dynamic Static Dynamic Static
Hyperalgesia >< Allodynia
Non noxious
stimulus Noxious stimulus
Hyperalgesia Normal
Respons
Allodinia
Stimulus Intensity
Martin, 1998.
Alodinia
Nerve injury triggers central reorganization on dorsal horn
of spinal cord
normal A
Superficial
Midline
C
Ganglion radiks dorsalis
deep
after injury
Woolf, 1994.
Hyperalgesia
Mechanism : peripheral sensitization
Vasodilatasi
Hiperalgesia
6
5
4 Hyperalgesia
Edema 3
2
1
Continuous
noxious stimuli
Fields, 1987; Willis, 1992.
CLINICAL FEATURE
cont’d
THE RANGE OF SEVERITY OF PAIN IS WIDE IT
MAY BE SO EXTREME AS TO TOTALLY CONSUME a
PATIENT’S LIFE
NeP must be differentiated from NOCICEPTIVE PAIN
(NoP)
DD is IMPORTANT because NoP and NeP respond to
different treatment modalities
CLINICAL FEATURE
cont’d
NoP :
is mediated by activation of pain receptors
by algogenic substances (histamine, bradykinin,
substance P, etc)
can be further classified as :
Somatic (localized aching or throbbing)
Or visceral (colicky) pain
Examples of NoP : post operative pain, arthritis
Gabapentin
ETIOLOGY OF
NEUROPATHIC
PAIN
• NeP is :
– initiated or caused by :
a primary lesion or dysfunction
in the nervous system
• Any condition that damages neural tissue
or impairs its function
can be a source of NeP
• > injury > metabolic derangement
> inflammation > toxins
> ischemia > tumor
> primary neurologic disease, etc.
MECHANISMS of NEUROPATHIC
PAIN (Woolf and Mannion, 1999)
The pathophysiology of Ne P is COMPLEX
Involving both peripheral and central
mechanisms
DIFFERENT MECHANISMS MAY COEXIST
IN A SINGLE PATIENT and PERHAPS
CHANGE OVER TIME.
PERIPHERAL MECHANISMS
Sensitization of primary afferent
nociceptor terminals :
Ectopic activity
Alteration of neurotransmitter
Coupling between the sympathetic and
sensory nervous system
CENTRAL MECHANISMS
Anatomical reorganization
Ectopic activity
Loss of segmental inhibition
Sensitization of spinal neurons
TREATMENT of NEUROPATHIC
PAIN
Regardless of the cause, Ne P :
Affects multiple aspects of patient’s life
Hence, the management of Ne P :
Involves a multidisciplinary approach
TREATMENT of Ne P
cont’d
The “ideal” team should comprise :
Neurologists
An experienced phycisian in the evaluation
diagnosis and treatment of pain.
A psychiatrist or psychologist experienced in
cognitive and behavioural therapy
A team of therapists
Neurosurgeons
Pain anesthetist
TREATMENT of Ne P
cont’d
The tools that a pain team implements include use
of both :
– Non-interventional therapies
(pharmacological, psychological and physical
therapy)
– Interventional therapies.
The overall objectives are : (Teng and Mekhail, 2003)
– to minimize pain
– to restore normal functional capacity and
quality of life
PHARMACOLOGICAL TREATMENT
Woolf and Mannion (1999) have suggested :
• targeting treatment based on the mechanism
(s) involved
• at present : treatment mainly depends on
empirical symptomatic treatment with a
multitude of medications that affect neuronal
function
PHARMACOLOGICAL TREATMENT
cont’d
There are several categories of
medications that can be used in Ne P :
– Antidepressants
– Anticonvulsant
– Local anesthetics
– Sympatholytics
– Opioids
Guidelines for drug treatment of neuropathic pain
Adjuvan Therapy for Neuropathic Pain
based on mechanisms
Inhibisi Otak
desenden
TCA
Tramadol
Lesi
NE/5HT Th/ Opioid
Reseptor dll
opioid GABAPENTIN
Okskarbazepin
Sensitisasi
Medulla Lamotrigin
sentral Th/ Ketamin
Spinalis (NMDA, Dextrome-
Sensitisasi perifer/ ion Na Calcium) thorphan
GABAPENTIN
Karbamazepin
Th/ Okskarbazepin
FENITOIN
Meksiletin
Lidokain, dll
Beydoun, 2002; modifikasi penulis
Mechanism of action of Tricyclic anti depressant
NO
BRAIN
PAIN
PAIN
PAIN
Inhibisi
Descenden
NE/SHT Th/ TCA
Tramadol
Reseptor Opioid
Opoid DLL
Medula
Spinalis
Sensitisasi perifer ion Na
Beydoun, 2002
Modifikasi Meliala, 2003
Mechanism of action of anti convulsant (1)
NO
NO PAIN
BRAIN
PAIN
PAIN
PAIN
Inhibisi
Descenden
NE/SHT
Reseptor
Opoid
Medula
Spinalis
Sensitisasi perifer ion Na
GABAPENTIN
KARBAMAZEPIN
OKSKARBAZEPIN
Th/ FENITOIN
MEKSILETIN
LIDOKAIN Beydoun, 2002
DLL Modifikasi Meliala, 2003
Mechanism of action of anti convulsant (2)
NO
BRAIN
PAIN
PAIN
Inhibisi
descenden
NE/SHT
Reseptor
Opoid
GABAPENTIN
Okskarbazepin
Medula Sensitisasi Th/
Lamotrigin
Ketamin
Spinalis Sentral Dextrometorphan
Sensitisasi perifer Metorphan
ion Na DLL
(NMDA,
Calcium)
Beydoun, 2002
Modifikasi Meliala, 2003
Severe side effect of carbamazepine
Steven Johnson Syndrome
© 2001-04, Johns Hopkins University School of Medicine
PAIN ASSESSMENT
Visual Analog Scale (VAS)
Numeric Pain Rating Scale (NPRS)
Faces Pain Rating Scale (for children)
Teng and Mekhail (2003)
cont’d :
3. Combination therapy is frequently necessary
to to achieve adequate pain relief.
Choose combination of medications with
different mechanisms of action but not the
some adverse effects
PSYCHOLOGICAL TREATMENT
The goal : to modulate pain at spinal and
supraspinal level
The first step is to decrease or to
eliminate depression
The methods for example : cognitive
behavioural therapy (CBT) and hypnosis
PSYCHOLOGICAL TREATMENT
cont’d
CBT :
are multimodal treatment packages
combine education about pain and training
in a variety of cognitive and behavioural
coping skills
PHYSICAL TREATMENT
• Pain modulation : thermal modalities,
Trans cutaneous
Electrical Nerve
stimulation (TENS),
acupuncture
• Muscle exercises
• Vocational rehabilitation
INTERVENTIONAL TREATMENTS
These procedures include :
• nerve blocks (somatic/sympathetic blocks)
• a tunneled epidural catheter for long term
temporary treatment
• neurostimulation (typically with an implantable
spinal cord stimulator)
• an intrathecal pump.
SUMMARY :
STRATEGIES FOR Ne P MANAGEMENT
Less invasive Most invasive
Psychologic/physical therapy
Topical therapy
Oral therapy
Injection therapy
Interventional therapy
