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Acute neuropathic and persistent postacute pain
Published in Pamela E. Macintyre, Stephan A. Schug, Acute Pain Management, 2014
Pamela E. Macintyre, Stephan A. Schug
Nociceptive pain is the most common type of pain seen in the acute clinical setting and its treatment is therefore the primary focus of this book. Neuropathic pain is defined as “pain caused by injury or disease of the somato-sensory nervous system” (Jensen et al., 2011). It is also referred to as neurogenic pain, deafferentation pain, neuralgia, neuralgic pain, and nerve pain. It is the pathophysiological consequence of multiple changes in the peripheral and central nervous systems that occur after nerve injury (Cohen and Mao, 2014) (see Table 12.1).
Surgical and Other Procedures
Published in Harold G. Koenig, Chronic Pain, 2013
This procedure is used for the treatment of central and peripheral types of deafferentation pain (where pain is disconnected from its peripheral source as seen in certain neuropathic pain syndromes). In one of the few studies examining this procedure, four patients with thalamic (central) pain and four patients with peripheral deafferentation pain had electrodes implanted in their interhemispheric fissures to treat lower extremity pain. Six of eight patients experienced pain reduction from this procedure (two each with excellent, good, and fair relief). Two of the four cases of deafferentation pain had excellent results. They concluded that motor cortex stimulation was effective in relieving these types of pain.7
Peripheral neuropathies
Published in Peter R Wilson, Paul J Watson, Jennifer A Haythornthwaite, Troels S Jensen, Clinical Pain Management, 2008
Ravikiran Shenoy, Katherine Roberts, Praveen Anand
Brachial plexus injury leading to spinal cord avulsion produces a constant crushing and intermittent shooting pain, which is often intractable. Pain in patients with brachial plexus injury can be severe, disabling, and persist for years. Pain tends to be worse in patients who do not show recovery. Deafferentation pain is particularly difficult to treat. It is suggested that this pain might be alleviated after successful repair with intercostal nerve transfer, and coincides with or is preceded by the return of function.53
painPREDICT: first interim data from the development of a new patient-reported pain questionnaire to predict treatment response using sensory symptom profiles
Published in Current Medical Research and Opinion, 2019
T. R. Tölle, R. Baron, E. de Bock, R. Junor, C. Dias Barbosa, S. F. Marshall, B. Arnould, R. Freynhagen
The second sensory symptom profile was mainly characterized by numbness and pain in numb areas. Patients in this group also had high levels of burning and tingling sensations and some sudden pain. On the other hand, these patients reported low levels of evoked pain. This group was called “Deafferentation pain”.
Interventional pain management in patients with cancer-related pain
Published in Postgraduate Medicine, 2020
Surgical neuroablative procedures were the mainstay of cancer pain management prior to the WHO ladder and opioids being the analgesic of choice. Various neurosurgical procedures were used to disrupt neural pathways in the brain and spinal cord in patients with terminal cancer to provide relief from intractable pain. Most of the procedures have been discontinued because the quality of evidence is poor consisting of a plethora of case reports/case series, few retrospective studies, fewer prospective blinded comparative studies and very few prospective, blinded randomized placebo-controlled studies [18]. Midline myelotomy is still used, albeit rarely, in cases of intractable visceral pain. Median tractotomy and thalamotomy are rarely carried out, though there is some renewed interest in cingulotomy. DREZ lesions are carried in a few centers for pain due to traumatic brachial plexus avulsion rather than for cancer pain and pituitary alcohol injections are no longer practised. Percutaneous cordotomy were the most commonly performed procedure and is still being practised regularly in a few centers[19]. The lateral spinothalamic tract on the contralateral side is disrupted by a radiofrequency lesion at C1-2 level for managing unilateral pain below C4 and beyond six inches from the midline. The commonest indications are pain from brachial plexus or chest wall invasion, malignant pleural mesothelioma, and tumor infiltration of ilium and lumbosacral plexus. When effective, it provides good analgesia and about 30% of patients would discontinue their opioids. Percutaneous cordotomy was traditionally performed using fluoroscopy and lately under CT guidance; more recently an endoscopic-guided technique under direct vision is claiming better safety profile [7]. Complications include cord edema resulting in ipsilateral motor weakness, pain on the side of cordotomy, and failure of the procedure. Severe and refractory deafferentation pain has been reported in patients who have survived for more than two years. Open cordotomies are rare and considered only when bilateral cordotomies are required; the second or sometimes both lesions are done at C6 level to protect diaphragmatic function.
Sensory profiles are comparable in patients with distal and proximal entrapment neuropathies, while the pain experience differs
Published in Current Medical Research and Opinion, 2018
Brigitte Tampin, Jan Vollert, Annina B. Schmid
Despite comparable pain thresholds in QST, patients with CR reported higher pain intensities and more patients were classified by painDETECT as having neuropathic pain. In addition, patients with CR experienced more severe pain attacks and pain evoked by slight pressure. Previous studies using cluster analyses revealed a similar self-assessed sensory profile of severe painful attacks and pressure-induced pain in patients with lumbar radiculopathy20,21. It is difficult to draw firm conclusions about potential pathomechanisms responsible for this pattern that seems more pronounced in patients with proximal entrapment neuropathies. It is however consistent with a previously reported potentiated neuroinflammation at the level of the dorsal root ganglia following proximal nerve injury8,9. Neuroinflammation has been strongly implicated with axonal ectopic activity and neuropathic pain behavior in rodents37, and may explain the heightened pain experience in patients with CR. Another likely explanation is the presence of deafferentation pain caused by a lack of peripheral input on second order spinal neurons12. The disrupted connection between the primary afferent cell body and the second order neuron in CR may lead to substantial adaptations within the spinal sensory circuitries12. Deafferentation pain is often resistant to peripherally acting pain medications such as topical lidocaine or non-steroidal anti-inflammatories38, but may be influenced by centrally acting drugs such as antidepressants or opioids, which are not usually prescribed in patients with CTS, but have shown benefit in patients with CR38. As such, deafferentation pain might explain the higher levels of spontaneous pain associated with a predominant loss of function phenotype in patients with CR. Alternatively, an increased expression of voltage-gated sodium channels at demyelinated sites with subsequent axonal hyperexcitability has also been suggested to underlie painful attacks39. Whether such changes are more likely to happen in peripheral rather than centrally projecting axons remains to be investigated. Notably, more patients with CR were prescribed antiepileptics, which produce a frequency-dependent voltage-gated sodium channel block.