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1.
Schmerz ; 36(2): 141-149, 2022 Apr.
Artigo em Alemão | MEDLINE | ID: mdl-35316391

RESUMO

Complex regional pain syndrome (CRPS) is a pain disorder that develops in the hands or feet after injury. Currently, two types are differentiated, CRPS I without and CRPS II with nerve lesions as well as with either an initially warm or an initially cold subtype, depending on the clinical symptoms. After trauma a certain amount of inflammatory reaction is considered physiological. In acute CRPS this inflammation persists for months and is maintained by diverse inflammatory mediators in peripheral tissue and in blood. This persisting inflammation leads to a sensitization of the nociceptive system, causes somatic cells to proliferate and gives rise to a disrupted endothelial function. The treatment concept aims to antagonize the pathophysiologic components and includes anti-inflammatory and analgetic treatment, mobilization and restoration of the sensorimotor function of the affected limb.


Assuntos
Causalgia , Síndromes da Dor Regional Complexa , Síndromes da Dor Regional Complexa/diagnóstico , Síndromes da Dor Regional Complexa/terapia , Humanos , Inflamação
2.
Neurosurg Rev ; 45(3): 1923-1931, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35112222

RESUMO

Cluster headache (CH) is a severe trigeminal autonomic cephalalgia that, when refractory to medical treatment, can be treated with Gamma Knife radiosurgery (GKRS). The outcomes of studies investigating GKRS for CH in the literature are inconsistent, and the ideal target and treatment parameters remain unclear. The aim of this systematic review is to evaluate the safety and the efficacy, both short and long term, of GKRS for the treatment of drug-resistant CH. A systematic review of the literature was performed to identify all clinical articles discussing GKRS for the treatment of CH. The literature review revealed 5 studies describing outcomes of GKRS for the treatment of CH for a total of 52 patients (48 included in the outcome analysis). The trigeminal nerve, the sphenopalatine ganglion, and a combination of both were treated in 34, 1, and 13 patients. The individual studies demonstrated initial meaningful pain reduction in 60-100% of patients, with an aggregate initial meaningful pain reduction in 37 patients (77%). This effect persisted in 20 patients (42%) at last follow-up. Trigeminal sensory disturbances were observed in 28 patients (58%) and deafferentation pain in 3 patients (6%). Information related to GKRS for CH are limited to few small open-label studies using heterogeneous operative techniques. In this setting, short-term pain reduction rates are high, whereas the long-term results are controversial. GKRS targeted on the trigeminal nerve or sphenopalatine ganglion is associated to a frequent risk of trigeminal disturbances and possibly deafferentation pain.


Assuntos
Causalgia , Cefaleia Histamínica , Radiocirurgia , Neuralgia do Trigêmeo , Causalgia/etiologia , Causalgia/cirurgia , Cefaleia Histamínica/etiologia , Cefaleia Histamínica/cirurgia , Humanos , Dor/etiologia , Radiocirurgia/métodos , Estudos Retrospectivos , Resultado do Tratamento , Neuralgia do Trigêmeo/cirurgia
3.
Medicine (Baltimore) ; 100(49): e28108, 2021 Dec 10.
Artigo em Inglês | MEDLINE | ID: mdl-34889267

RESUMO

RATIONALE: Complex regional pain syndrome (CRPS) is a painful condition classified as type I or II depending on the absence or presence of nerve injury, respectively. Injury to the lateral dorsal cutaneous nerve (LDCN), a branch of the sural nerve, is a rare occurrence observed after a sprain or procedures conducted on the lateral side of the ankle. PATIENT CONCERNS: A 38-year-old female, who had undergone prolotherapy for a sprain in the lateral side of the left ankle 3 months ago, presented with persistent causalgia and dysesthesia around the injection site. DIAGNOSIS: An electrodiagnostic study was conducted, which confirmed that the patient had peripheral neuropathy of the left LDCN. Considering the digital infrared thermal imaging and three-phase bone scan findings and the clinical presentation, the condition was diagnosed as CRPS type II due to iatrogenic LDCN injury according to the Budapest diagnostic criteria for CRPS. INTERVENTIONS: The patient was treated with steroid pulse therapy, physical therapy, and transcutaneous electrical nerve stimulation, as well as nonsteroidal anti-inflammatory drugs, pregabalin, and tricyclic antidepressants. OUTCOMES: After 1 month of treatment, allodynia of the left foot persisted, but the pain reduced from 6 points to 3 points on the numeric rating scale. Partial recovery of amplitude and conduction velocity was confirmed in the follow-up electrodiagnostic study. LESSONS: LDCN injury should be considered in patients who complain of persistent lateral ankle and foot paresthesia or pain after sprain or procedures performed on the lateral side of the ankle. Early diagnosis and treatment can lead to a good prognosis when the LDCN injury has progressed to CRPS.


Assuntos
Causalgia , Síndromes da Dor Regional Complexa/diagnóstico , Parestesia , Traumatismos dos Nervos Periféricos , Proloterapia/efeitos adversos , Adulto , Síndromes da Dor Regional Complexa/etiologia , Feminino , Humanos , Doença Iatrogênica , Dor , Entorses e Distensões/terapia
4.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-32376193

RESUMO

BACKGROUND AND OBJECTIVES: The treatment of deafferentation pain by spinal DREZotomy is a proven therapeutic option in the literature. In recent years, use of DREZotomy has been relegated to second place due to the emergence of neuromodulation therapies. The objectives of this study are to demonstrate that DREZotomy continues to be an effective and safe treatment and to analyse predictive factors for success. PATIENTS AND METHODS: A retrospective study was conducted of all patients treated in our department with spinal DREZotomy from 1998 to 2018. Bulbar DREZotomy procedures were excluded. A visual analogue scale (VAS) and the reduction of routine medication were used as outcome variables. Demographic, clinical and operative variables were analysed as predictive factors for success. RESULTS: A total of 27 patients (51.9% female) with a mean age of 53.7 years underwent DREZotomy. The main cause of pain was brachial plexus injury (BPI) (55.6%) followed by neoplasms (18.5%). The mean time of pain evolution was 8.4 years with a mean intensity of 8.7 according to the VAS, even though 63% of the patients had previously received neurostimulation therapy. Favourable outcome (≥50% pain reduction in the VAS) was observed in 77.8% of patients during the postoperative period and remained in 59.3% of patients after 22 months average follow-up (mean reduction of 4.9 points). This allowed for a reduction in routine analgesic treatment in 70.4% of them. DREZotomy in BPI-related pain presented a significantly higher success rate (93%) than the other pathologies (41.7%) (p=.001). No association was observed between outcome and age, gender, DREZ technique, duration of pain or previous neurostimulation therapies. There were six neurological complications, four post-operative transient neurological deficits and two permanent deficits. CONCLUSION: Dorsal root entry zone surgery is effective and safe for treating patients with deafferentation pain, especially after brachial plexus injury. It can be considered an alternative treatment after failed neurostimulation techniques for pain control. However, its indication should be considered as the first therapeutic option after medical therapy failure due to its good long-term results.


Assuntos
Neuropatias do Plexo Braquial , Plexo Braquial , Causalgia , Causalgia/etiologia , Causalgia/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Raízes Nervosas Espinhais/cirurgia
6.
Neurobiol Dis ; 143: 104945, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32428552

RESUMO

Deafferentation pain (DP), a typical neuropathic pain, occurs due to peripheral or central sensory nerve injury, which causes abnormal discharge of the upstream neurons or C fibers. Current treatment methods for DP have multiple side effects. Bone marrow mesenchymal stem cells (BMSC) have been used to treat neuropathic pain because of their ability to regulate neuroinflammation. Glial cell-derived neurotrophic factor (GDNF) is a neurotrophic mediator that exerts neuroprotective effects in neurological diseases. In this study, we investigated whether DP could be alleviated by BMSCs and the underlying mechanism. In vitro study, microglia was stimulated by lipopolysaccharide and then co-cultured with BMSC, GDNF or siRNA GDNF-BMSC. In vivo study, BMSC or siRNA GDNF-BMSC was transplanted intramedullarily on the 21st day after DP surgery. The expression of inflammatory-related factors were detected by RT-PCR and ELISA, RT-PCR,flow cytometry and immunofluorescence staining were performed to detect the expression of microglial surface markers, and Western blot was used to detect the expression levels of p-NF-kb, pPI3K, and pAKT. The pain-related behavioral changes were detected 7 days after transplantation. ELISA and RT-PCR results showed that the production of inflammatory cytokines in lipopolysaccharide-stimulated microglia and DP model plasma was downregulated, while anti-inflammatory mediators were upregulated significantly following pretreatment with BMSCs or GDNF. Flow cytometry, immunofluorescence staining, and RT-PCR results showed that BMSCs inhibited the microglial M1 phenotype and promoted the M2 phenotype by secreting GDNF. Furthermore, modulation functions of BMSCs involve inhibiting NF-κB while promoting PI3K /AKT signaling pathway activation. We found that our in vivo DP model was completely deafferent and BMSC administration clearly alleviated symptoms of DP. This function was also, at least partly, achieved by GDNF. The present studies demonstrate that BMSC can inhibit neuroinflammation by transforming microglial destructive M1 phenotype into regenerative M2 phenotype, and thus alleviate DP,likely by suppressing the NF-κB signaling pathway while promoting the PI3K/AKT signaling pathway activation through producing GDNF. The present findings are in support of the potential therapeutic application of BMSCs and the pharmaceutical application of GDNF for DP.


Assuntos
Causalgia/metabolismo , Fator Neurotrófico Derivado de Linhagem de Célula Glial/metabolismo , Células-Tronco Mesenquimais/metabolismo , Microglia/metabolismo , Transdução de Sinais/fisiologia , Animais , Células da Medula Óssea/metabolismo , Regulação para Baixo , Masculino , Transplante de Células-Tronco Mesenquimais , NF-kappa B/metabolismo , Fosfatidilinositol 3-Quinases/metabolismo , Proteínas Proto-Oncogênicas c-akt/metabolismo , Ratos , Ratos Sprague-Dawley , Regulação para Cima
7.
J Pain ; 21(3-4): 262-280, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31493490

RESUMO

Mechanisms of below-level pain are discoverable as neural adaptations rostral to spinal injury. Accordingly, the strategy of investigations summarized here has been to characterize behavioral and neural responses to below-level stimulation over time following selective lesions of spinal gray and/or white matter. Assessments of human pain and the pain sensitivity of humans and laboratory animals following spinal injury have revealed common disruptions of pain processing. Interruption of the spinothalamic pathway partially deafferents nocireceptive cerebral neurons, rendering them spontaneously active and hypersensitive to remaining inputs. The spontaneous activity among these neurons is disorganized and unlikely to generate pain. However, activation of these neurons by their remaining inputs can result in pain. Also, injury to spinal gray matter results in a cascade of secondary events, including excitotoxicity, with rostral propagation of excitatory influences that contribute to chronic pain. Establishment and maintenance of below-level pain results from combined influences of injured and spared axons in the spinal white matter and injured neurons in spinal gray matter on processing of nociception by hyperexcitable cerebral neurons that are partially deafferented. A model of spinal stenosis suggests that ischemic injury to the core spinal region can generate below-level pain. Additional questions are raised about demyelination, epileptic discharge, autonomic activation, prolonged activity of C nocireceptive neurons, and thalamocortical plasticity in the generation of below-level pain. PERSPECTIVE: An understanding of mechanisms can direct therapeutic approaches to prevent development of below-level pain or arrest it following spinal cord injury. Among the possibilities covered here are surgical and other means of attenuating gray matter excitotoxicity and ascending propagation of excitatory influences from spinal lesions to thalamocortical systems involved in pain encoding and arousal.


Assuntos
Causalgia/fisiopatologia , Substância Cinzenta/fisiopatologia , Percepção da Dor/fisiologia , Dor/fisiopatologia , Traumatismos da Medula Espinal/fisiopatologia , Tratos Espinotalâmicos/fisiopatologia , Substância Branca/fisiopatologia , Animais , Causalgia/patologia , Substância Cinzenta/lesões , Humanos , Dor/patologia , Traumatismos da Medula Espinal/patologia , Tratos Espinotalâmicos/patologia , Substância Branca/lesões
8.
J Pain ; 21(3-4): 399-408, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31494275

RESUMO

The ACCURATE randomized, controlled trial compared outcomes of dorsal root ganglion (DRG) stimulation versus tonic spinal cord stimulation (SCS) in 152 subjects with chronic lower extremity pain due to complex regional pain syndrome (CRPS) type I or II. This ACCURATE substudy was designed to evaluate whether therapy habituation occurs with DRG stimulation as compared to SCS through 12-months. A modified intention-to-treat analysis was performed to assess percentage pain relief (PPR) and responder rates at follow-up visits (end-of-trial, 1, 3, 6, 9, 12-months postpermanent implant) for all subjects that completed trial stimulation (DRG:N = 73, SCS:N = 72). For both groups, mean PPR was significantly greater at end-of-trial (DRG = 82.2%, SCS =0 77.0%) than all other follow-ups. Following permanent DRG system implantation, none of the time points were significantly different from one another in PPR (range = 69.3-73.9%). For the SCS group, PPR at 9-months (58.3%) and 12-months (57.9%) was significantly less than at 1-month (66.9%). The responder rate also decreased for the SCS group from 1-month (68.1%) to 12-months (61.1%). After stratifying by diagnosis, it was found that only the CRPS-I population had diminishing pain relief with SCS. DRG stimulation resulted in more stable pain relief through 12-months, while tonic SCS demonstrated therapy habituation at 9- and 12-months. Trial Registration: The ACCURATE study was registered at ClinicalTrials.gov with Identifier NCT01923285. PERSPECTIVE: This article reports on an ACCURATE substudy, which found that long-term therapy habituation occurred at 12-months with SCS, but not DRG stimulation, in patients with CRPS. The underlying mechanisms of action for these results remain unclear, although several lines of inquiry are proposed.


Assuntos
Causalgia/terapia , Terapia por Estimulação Elétrica , Gânglios Espinais , Habituação Psicofisiológica , Avaliação de Resultados em Cuidados de Saúde , Distrofia Simpática Reflexa/terapia , Estimulação da Medula Espinal , Adulto , Idoso , Feminino , Seguimentos , Gânglios Espinais/fisiologia , Habituação Psicofisiológica/fisiologia , Humanos , Neuroestimuladores Implantáveis , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
9.
Sci Rep ; 9(1): 15736, 2019 10 31.
Artigo em Inglês | MEDLINE | ID: mdl-31673034

RESUMO

If health can be defined as adaptability, then measures of adaptability are crucial. Convergent findings across clinical areas established the notion that fractal properties in bio-behavioural variability characterize the healthy condition of the organism, and its adaptive capacities in general. However, ambiguities remain as to the significance of fractal properties: the literature mainly discriminated between healthy vs. pathological states, thereby loosing perspective on the progression in between, and overlooking the distinction between adaptability and effective adaptations of the organism. Here, we design an experimental tapping paradigm involving gradual feedback deprivation in groups of healthy subjects and one deafferented man as a pathological-limit case. We show that distinct types of fractal properties in sensorimotor behaviour characterize, on the one hand impaired functional ability, and on the other hand internal adaptations for maintaining performance despite the imposed constraints. Findings may prove promising for early detection of internal adaptations preceding symptomatic functional decline.


Assuntos
Fractais , Córtex Sensório-Motor/fisiologia , Aclimatação , Estimulação Acústica , Adaptação Fisiológica , Adulto , Causalgia/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem
10.
Clin J Pain ; 35(12): 933-940, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31490205

RESUMO

OBJECTIVES: Complex regional pain syndrome (CRPS) is a painful condition of a limb characterized by a constellation of symptoms. Little is known about the clinical features of pediatric CRPS, with fewer than a dozen studies published to date. The aim of this study was to explore the clinical course of pediatric CRPS, with emphasis on clinical features and disease outcomes. A secondary aim was to discern differences in clinical features of pediatric CRPS with and without related movement disorders, and between children who had a favorable and unfavorable outcome. MATERIALS AND METHODS: We carried out a retrospective chart review of children with CRPS who presented to a pediatric Chronic Pain Clinic in Canada over a 5-year period (2012 to 2016). RESULTS: The study identified 59 children with CRPS (mean age: 12.7±2.5; 74.6% female; 72.9% lower extremity). In total, 87% (n=48) of children experienced complete resolution or significant improvement of CRPS, with a relapse rate of 15%. Overall, 25% (n=15) had a CRPS-related movement disorder. There were no differences in the clinical features of pediatric CRPS with or without related movement disorders. Children who experienced a favorable outcome had a significantly shorter symptom duration at the initial visit in comparison with children who experienced an unfavorable outcome. DISCUSSION: In this cohort, pediatric CRPS was most common in girls around the age of 12, usually in the lower extremity, and most experienced a favorable outcome. Further research is needed to better understand the prognosis and relapse rate of pediatric CRPS.


Assuntos
Síndromes da Dor Regional Complexa/fisiopatologia , Adolescente , Causalgia/complicações , Causalgia/fisiopatologia , Causalgia/psicologia , Criança , Síndromes da Dor Regional Complexa/complicações , Síndromes da Dor Regional Complexa/psicologia , Feminino , Humanos , Extremidade Inferior , Masculino , Transtornos dos Movimentos/complicações , Prognóstico , Recidiva , Distrofia Simpática Reflexa/complicações , Distrofia Simpática Reflexa/fisiopatologia , Distrofia Simpática Reflexa/psicologia , Estudos Retrospectivos , Resultado do Tratamento
11.
Rev. Hosp. Ital. B. Aires (2004) ; 39(3): 81-85, sept. 2019.
Artigo em Espanhol | LILACS | ID: biblio-1048229

RESUMO

El dolor crónico constituye un reto terapéutico especial. Se presenta una revisión narrativa sobre el papel del tratamiento de oxigenación hiperbárica (TOHB) en el tratamiento del dolor neuropático, y sus aplicaciones en dolor crónico, síndromes neurosensitivos disfuncionales y oncodolor. El conocimiento de las indicaciones de TOHB en algiología y su aplicación en la práctica médica puede contribuir a mejorar la calidad de vida del paciente. (AU)


Chronic pain represents a special therapeutic challenge. We present a narrative review on the role of Hyperbaric Oxygen Therapy (HBOT) in the treatment of neuropathic pain, and its applications in chronic pain, dysfunctional neurosensitive syndromes and oncological pain. The knowledge of the indications of HBOT in algiology and its application in medical practice can contribute to improve the quality of life of the patient. (AU)


Assuntos
Dor Crônica/terapia , Oxigenoterapia Hiperbárica/métodos , Membro Fantasma/terapia , Qualidade de Vida , Distrofia Simpática Reflexa/terapia , Cefaleias Vasculares/terapia , Encefalopatias/terapia , Dor Facial/terapia , Fibromialgia/terapia , Causalgia/terapia , Neuropatias Diabéticas/terapia , Edema/terapia , Neuralgia Pós-Herpética/terapia , Dor Crônica/epidemiologia , Dor do Câncer/terapia , Oxigenoterapia Hiperbárica/tendências , Analgesia/métodos , Inflamação/terapia , Neuralgia/terapia
12.
Pain Med ; 20(Suppl 1): S41-S46, 2019 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-31152174

RESUMO

OBJECTIVE: The objective of this study is to review the available evidence for dorsal root ganglion (DRG) stimulation for the treatment of complex regional pain syndrome type II (CRPS II; peripheral causalgia) associated with chronic neuropathic postsurgical pain (NPP). DESIGN: Available literature was identified through a search of the US National Library of Medicine's Medline database, PubMed.gov. References from published articles also were reviewed for relevant citations. RESULTS: The data published to date support the use of DRG stimulation to treat chronic NPP of the groin, knee, and foot. NPP following procedures such as thoracotomy, hernia surgery, and knee replacement surgery were identified as some of the conditions for which DRG stimulation is likely to be effective. CONCLUSION: DRG stimulation is known to be an effective treatment for focal neuropathic pain. Currently, NPP of the foot, groin, and knee all appear to be the conditions with the most clinical experience, backed by a limited but growing body of evidence. However, prospective studies lag behind real-world clinical experience and are needed to confirm these findings.


Assuntos
Causalgia/terapia , Terapia por Estimulação Elétrica/métodos , Gânglios Espinais/fisiologia , Manejo da Dor/métodos , Dor Pós-Operatória/terapia , Dor Crônica/terapia , Humanos , Neuralgia/terapia
13.
World Neurosurg ; 128: e649-e652, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31054337

RESUMO

BACKGROUND: Neuromodulation is an evolving therapy for chronic pain. Aiming to meet the limitations of traditional spinal cord stimulation, dorsal root ganglion (DRG) stimulation targets pain in a dermatomal distribution at the site of pain transmission. Despite these advantages, lead migration is a significant complication that hinders the long-term efficacy of DRG stimulation. This study aims to identify risk factors for lead migration requiring revision in DRG stimulation. METHODS: We performed a retrospective review of all subjects who had DRG stimulators implanted at T10-S2 by a single physician over a 2-year period. Their history was reviewed for the following: age, sex, diagnosis, lead placement, reported symptom relief, complications, and postoperative activity. RESULTS: In total, 19 cases of DRG stimulator implantation were identified. All patients reported pain relief, with 84.2% (16/19) describing >50% relief. In total, 31.6% of patients (6/19) developed lead migration and 15.8% of total implanted leads (9/57) migrated. Of the migrated leads, 4% (4/9) occurred at S1 and 33.3% (3/9) occurred at L4. The underlying etiology of lead migration was clear and preventable in 66.7% of patients (4/6). All patients who developed lead migration were women. CONCLUSIONS: Premature activity, hardware manipulation, and female sex appear to be associated with an increased risk for lead migration. Leads on the S1 and L4 locations may be more likely to migrate. Large trials are necessary to gain a more conclusive understanding of these risk factors for lead migration.


Assuntos
Síndromes da Dor Regional Complexa/terapia , Exercício Físico , Gânglios Espinais , Neuroestimuladores Implantáveis , Falha de Prótese , Dor Abdominal/terapia , Adolescente , Adulto , Idoso , Causalgia/terapia , Terapia por Estimulação Elétrica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Implantação de Prótese , Distrofia Simpática Reflexa/terapia , Reoperação , Fatores de Risco , Estimulação da Medula Espinal , Adulto Jovem
14.
Neuromodulation ; 22(8): 937-942, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30701632

RESUMO

INTRODUCTION: Neuromodulation is an important tool for achieving pain relief in otherwise-intractable neuropathic pain conditions. Dorsal root ganglion (DRG) stimulation, in which primary sensory neurons are stimulated prior to their entry into the spinal canal, provides treatment with high levels of dermatomal specificity and can provide advantages compared to conventional spinal cord stimulation. Although DRG stimulation can produce perceptible paresthesias, many patients operate their systems at subthreshold amplitudes that do not elicit this sensation. Pain relief both with and without paresthesia was investigated in this retrospective analysis. MATERIALS AND METHODS: A retrospective review of all qualifying permanent DRG stimulation systems at a single center over more than a three-year period was completed. Pain (0-10 numeric rating scale) was assessed at baseline, at the end of the trial, and after three, six, and twelve months of treatment. Patients were categorized based on their usage of the stimulator at amplitudes that either did or did not produce paresthesias. RESULTS: Of the 39 patients, 34 (87%) reported having no-paresthesias at any of the follow-up visits. Average pain relief was 73.9% after the trial period and 63.1% after 12 months of treatment. The responder rate (50% or better pain relief) after three months of treatment was more than 80%. Exploratory subgroup analyses showed that similar degrees of pain relief were achieved in numerous body regions and with various pain etiologies. The five patients who reported paresthesias during treatment had pain relief similar to those of the group that did not experience paresthesias. DISCUSSION: Clinically significant and sustained pain relief over more than a period of 12 months was achieved with DRG stimulation programmed at amplitudes below the perceptual level. Thus, the reported analgesia was paresthesia-independent. That good clinical outcomes were observed independent of the generation of paresthesia in DRG stimulation suggests several mechanisms of action, including the inhibition of supraspinal regions involved in somatic paresthesia sensation. The retrospective results presented here posit that future prospective study of DRG stimulation delivered at below the threshold of perceptible paresthesias is warranted.


Assuntos
Gânglios Espinais , Manejo da Dor/métodos , Parestesia/etiologia , Estimulação da Medula Espinal/efeitos adversos , Estimulação da Medula Espinal/métodos , Adulto , Causalgia/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Manejo da Dor/efeitos adversos , Medição da Dor , Percepção da Dor , Parestesia/epidemiologia , Distrofia Simpática Reflexa/terapia , Estudos Retrospectivos , Resultado do Tratamento
15.
Neuromodulation ; 22(8): 930-936, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30624003

RESUMO

OBJECTIVES: This was a sub-analysis of the ACCURATE clinical trial that evaluated the accuracy and necessity of targeting paresthesia coverage of painful areas with dorsal root ganglion (DRG) stimulation vs. tonic spinal cord stimulation (SCS). MATERIALS AND METHODS: On diagrams of the torso and lower limbs, subjects marked where they felt pain at baseline and paresthesias at three months postimplant. Seventy-five subjects (41 DRG and 34 SCS) with diagrams of sufficient quality were scanned, digitized, and included in this analysis. Subject completed diagrams were digitized and superimposed with a grid of 1398 squares. Quantification of the percentage of bodily areas affected by pain and stimulation induced paresthesias was performed. RESULTS: The percent of painful areas covered by paresthesia was significantly lower for DRG subjects than for SCS subjects (13% vs. 28% of the painful regions, p < 0.05), possibly because significantly more DRG subjects felt no paresthesia during stimulation when compared to SCS subjects (13/41 DRG vs. 3/34 SCS) (p < 0.05). The amount of paresthesia produced outside the painful areas (unrequired paresthesia) was significantly lower in DRG subjects than that of SCS subjects. On average, the percent of unrequired paresthesia was only 20% of the subjects' total painful body surface area in the DRG group compared to 210% in the SCS group (p < 0.01). CONCLUSIONS: The results of this ACCURATE study sub-analysis show that DRG stimulation produces paresthesias, on average, that are less frequent, less intense, with a smaller footprint on the body and less dependent on positional changes.


Assuntos
Gânglios Espinais , Manejo da Dor/métodos , Parestesia/etiologia , Estimulação da Medula Espinal/efeitos adversos , Estimulação da Medula Espinal/métodos , Causalgia/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Manejo da Dor/efeitos adversos , Medição da Dor , Percepção da Dor , Parestesia/epidemiologia , Distrofia Simpática Reflexa/terapia , Resultado do Tratamento
16.
PLoS One ; 13(10): e0206141, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30346981

RESUMO

There is a large body of evidence showing substantial sensorimotor reorganizations after an amputation. These reorganizations are believed to contribute to the development of phantom limb pain, but alternatively, pain might influence the plasticity triggered by the deafferentation. The aim of this study was to test whether pain impacts on deafferentation-induced plasticity in the somatosensory pathways. Fifteen healthy subjects participated in 2 experimental sessions (Pain, No Pain) in which somatosensory evoked potentials (SSEPs) associated with electrical stimulation of the ulnar nerve were assessed before and after temporary ischemic deafferentation induced by inflation of a cuff around the wrist. In the Pain session capsaicin cream was applied on the dorsum of the hand 30 minutes prior to cuff inflation. Results show that pain decreased the amplitude of the N20 (main effect of condition, p = 0.033), with a similar trend for the P25. Temporary ischemic deafferentation had a significant effect on SSEPs (main effect of time), with an increase in the P25 (p = 0.013) and the P45 amplitude (p = 0.005), together with a reduction of the P90 amplitude (p = 0.002). Finally, a significant time x condition interaction, reflecting state-dependent plasticity, was found for the P90 only, the presence of pain decreasing the reduction of amplitude observed in response to deafferentation. In conclusion, these results show that nociceptive input can influence the plasticity induced by a deafferentation, which could be a contributing factor in the cortical somatosensory reorganization observed in chronic pain populations.


Assuntos
Causalgia/fisiopatologia , Potenciais Somatossensoriais Evocados , Córtex Somatossensorial/fisiologia , Adulto , Capsaicina/administração & dosagem , Capsaicina/farmacologia , Feminino , Voluntários Saudáveis , Humanos , Masculino , Plasticidade Neuronal , Córtex Somatossensorial/fisiopatologia , Nervo Ulnar/fisiologia , Nervo Ulnar/fisiopatologia , Adulto Jovem
17.
BMJ Case Rep ; 20182018 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-30333197

RESUMO

A 34-year-old man with a history of gunshot wound (GSW) to the right upper chest developed secondary aortic valve endocarditis (AVE) and was treated with an artificial valve placement (AVP). Three months after, he presented to an outpatient pain management clinic right arm pain and was diagnosed with complex regional pain syndrome type II (CRPS II). The patient underwent a diagnostic sympathetic ganglion block, before undergoing endoscopic thoracic sympathectomy surgery. Successful outcomes revealed decreased pain, opioid utilisation and improved tolerance to therapy and activities of daily living. To our knowledge, this is the first case reporting CRPS II arising from a GSW complicated by AVE followed by AVP, which emphasises how unforeseen syndromes can arise from the management of seemingly unrelated pathology. This case demonstrates the importance of timely and proper diagnosis of uncharacterised residual pain status post-trauma and differential diagnosis and management of chronic pain syndromes.


Assuntos
Valva Aórtica/microbiologia , Causalgia/diagnóstico , Endocardite Bacteriana/cirurgia , Endocardite/etiologia , Próteses Valvulares Cardíacas/efeitos adversos , Ferimentos por Arma de Fogo/complicações , Adulto , Valva Aórtica/patologia , Braço/patologia , Causalgia/etiologia , Causalgia/cirurgia , Diagnóstico Diferencial , Endocardite/tratamento farmacológico , Endocardite/microbiologia , Humanos , Masculino , Dor/diagnóstico , Dor/etiologia , Simpatectomia/métodos , Resultado do Tratamento , Ferimentos por Arma de Fogo/patologia , Ferimentos por Arma de Fogo/cirurgia
18.
Curr Pain Headache Rep ; 22(6): 45, 2018 May 23.
Artigo em Inglês | MEDLINE | ID: mdl-29796941

RESUMO

PURPOSE OF REVIEW: Since the early 1990s, motor cortex stimulation (MCS) has been a unique treatment modality for patients with drug-resistant deafferentation pain. While underpowered studies and case reports have limited definitive, data-driven analysis of MCS in the past, recent research has brought new clarity to the MCS literature and has helped identify appropriate indications for MCS and its long-term efficacy. RECENT FINDINGS: In this review, new research in MCS, repetitive transcranial magnetic stimulation (rTMS), and transcranial direct current stimulation (tDCS) are analyzed and compared with historical landmark papers. Currently, MCS is effective in providing relief to 40-64% of patients, with decreasing analgesic effect over time addressed by altering stimulation settings. rTMS and tDCS, two historic, non-invasive stimulation techniques, are providing new alternatives for the treatment of deafferentation pain, with rTMS finding utility in identifying MCS responders. Future advances in electrode arrays, neuro-navigation, and high-definition tDCS hold promise in providing pain relief to growing numbers of patients. Deafferentation pain is severe, disabling, and remains a challenge for patients and providers alike. Over the last several years, the MCS literature has been revitalized with studies and meta-analyses demonstrating MCS effectiveness and providing guidance in identifying responders. At the same time, rTMS and tDCS, two time-honored non-invasive stimulation techniques, are finding new utility in managing deafferentation pain and identifying good MCS candidates. As the number of potential therapies grow, the clinician's role is shifting to personalizing treatment to the unique pain of each patient. With new treatment modalities, this form of personalized medicine is more possible than ever before.


Assuntos
Causalgia/diagnóstico por imagem , Causalgia/terapia , Córtex Motor/diagnóstico por imagem , Manejo da Dor/métodos , Estimulação Transcraniana por Corrente Contínua/métodos , Estimulação Magnética Transcraniana/métodos , Animais , Humanos , Córtex Motor/fisiologia , Manejo da Dor/tendências , Estimulação Transcraniana por Corrente Contínua/tendências , Estimulação Magnética Transcraniana/tendências
19.
Kaohsiung J Med Sci ; 34(4): 231-237, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29655412

RESUMO

In the last few decades, neurobiological and human brain imaging research have greatly advanced our understanding of brain mechanisms that support perception and memory, as well as their function in daily activities. Knowledge of the neurobiological mechanisms behind the deafferentation of stomatognathic systems has also expanded greatly in recent decades. In particular, current studies reveal that the peripheral deafferentations of stomatognathic systems may be projected globally into the central nervous system (CNS) and become an associated critical factor in triggering and aggravating neurodegenerative diseases. This review explores basic neurobiological mechanisms associated with the deafferentation of stomatognathic systems. Further included is a discussion on tooth loss and other dental deafferentation (DD) mechanisms, with a focus on dental and masticatory apparatuses associated with brain functions and which may underlie the changes observed in the aging brain. A new hypothesis is presented where DD and changes in the functionality of teeth and the masticatory apparatus may cause brain damage as a result of altered cerebral circulation and dysfunctional homeostasis. Furthermore, multiple recurrent reorganizations of the brain may be a triggering or contributing risk factor in the onset and progression of neurodegenerative conditions such as Alzheimer's disease (AD). A growing understanding of the association between DD and brain aging may lead to solutions in treating and preventing cognitive decline and neurodegenerative diseases.


Assuntos
Envelhecimento/patologia , Doença de Alzheimer/fisiopatologia , Causalgia/fisiopatologia , Disfunção Cognitiva/fisiopatologia , Perda Auditiva/fisiopatologia , Sistema Estomatognático/patologia , Perda de Dente/fisiopatologia , Doença de Alzheimer/patologia , Encéfalo/patologia , Encéfalo/fisiopatologia , Causalgia/patologia , Circulação Cerebrovascular , Disfunção Cognitiva/patologia , Dentição Permanente , Perda Auditiva/patologia , Humanos , Mastigação , Fatores de Risco , Sistema Estomatognático/inervação , Perda de Dente/patologia
20.
J Nippon Med Sch ; 84(4): 183-185, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28978899

RESUMO

Deafferentation pain induced by subarachnoid block (SAB) is rare, but it can appear in the form of recurrent phantom lower limb pain, new acute-onset stump pain in amputees, lower limb pain in patients with tabes dorsalis, and neuropathic pain. We have previously reported that thiopental is an effective treatment for deafferentation pain induced by therapeutic SAB applied to treat neuropathic pain of central origin. Here, we report the case of an amputee who developed new stump pain in his lower limb immediately after subarachnoid tetracaine was administered prior to appendectomy. A 51-year-old man who had previously undergone right below-knee amputation for acute arterial thrombosis, and who had not previously experienced chronic phantom limb or stump pain, was scheduled for emergency open appendectomy. For anesthesia, we induced SAB with a hyperbaric tetracaine solution. No paresthesia occurred during administration. However, the patient immediately complained of severe, lightning-bolt pain in the right lower limb stump after the SAB was established. He was given intravenous pentazocine, which promptly resolved the pain. Appendectomy was then performed under sedation using intravenous midazolam. The patient did not experience further deafferentation pain during his hospital stay and has reported no stump pain since discharge from the hospital. This case report suggests that SAB induces deafferentation pain in some patients and that this unusual pain can be treated with pentazocine.


Assuntos
Raquianestesia/efeitos adversos , Causalgia/tratamento farmacológico , Causalgia/etiologia , Pentazocina/uso terapêutico , Espaço Subaracnóideo , Tetracaína/administração & dosagem , Tetracaína/efeitos adversos , Amputados , Raquianestesia/métodos , Apendicectomia , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Pentazocina/administração & dosagem , Membro Fantasma/tratamento farmacológico , Membro Fantasma/etiologia , Resultado do Tratamento
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