Kuliah Neuropathic Pain-1

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
contd
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
contd
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
contd
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-evoked pain
Stimulus-independent pain
Continous
non-noxious
stimulus
Paroxysmal
Mechanical
Allodinia
Dynamic
Static
Therma
Allodinia
Noxious
stimulus
Mechanical
Hyperalgesia
Dynamic
Thermal
Hyperalgesia
Static
Hyperalgesia >< Allodynia

Non noxious
stimulus
Noxious stimulus
Hyperalgesia
Respons
Allodinia
Stimulus Intensity
Martin, 1998.
Normal
Alodinia
Nerve injury triggers central reorganization on dorsal horn
of spinal cord
normal
A
C
Ganglion radiks dorsalis

deep
after injury
Woolf, 1994.
Midline
Superficial
Hyperalgesia
Mechanism : peripheral sensitization
Vasodilatasi
Hiperalgesia
6
5
Edema
4
3
2
1
Hyperalgesia
Continuous
noxious stimuli
Fields, 1987; Willis, 1992.
CLINICAL FEATURE
contd
THE RANGE OF SEVERITY OF PAIN IS WIDE IT

MAY BE SO EXTREME AS TO TOTALLY CONSUME a
PATIENTS LIFE
NeP must be differentiated from NOCICEPTIVE PAIN
(NoP)
DD is IMPORTANT because NoP and NeP respond to
different treatment modalities
CLINICAL FEATURE
contd
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
is :
NeP
PAIN
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
> metabolic derangement

> injury
> 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 patients life
Hence, the management of Ne P :

Involves a multidisciplinary approach
TREATMENT of Ne P
contd
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
contd
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
contd
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
desenden
Lesi
Otak
TCA
Th/
NE/5HT
Reseptor
opioid
Medulla
Spinalis
Sensitisasi perifer/ ion Na
Th/
GABAPENTIN
Karbamazepin
Okskarbazepin
FENITOIN
Meksiletin
Lidokain, dll
Beydoun, 2002; modifikasi penulis
Tramadol
Opioid
dll
Sensitisasi
sentral
(NMDA,
Calcium)
Th/
GABAPENTIN
Okskarbazepin
Lamotrigin
Ketamin
Dextromethorphan
Mechanism of action of Tricyclic anti depressant

NO
BRAIN
PAIN
PAIN
PAIN
Inhibisi
Descenden
Th/
NE/SHT
Reseptor
Opoid
Sensitisasi perifer ion Na
TCA
Tramadol
Opioid
DLL
Medula
Spinalis
Beydoun, 2002
Modifikasi Meliala, 2003
Mechanism of action of anti convulsant (1)

NO
NO
BRAIN
PAIN
PAIN
PAIN
PAIN
Inhibisi
Descenden
NE/SHT
Reseptor
Opoid
Sensitisasi perifer ion Na
Medula
Spinalis
GABAPENTIN
KARBAMAZEPIN
OKSKARBAZEPIN
Th/
FENITOIN
MEKSILETIN
LIDOKAIN
DLL
Beydoun, 2002
Mechanism of action of anti convulsant (2)

NO
BRAIN
PAIN
PAIN
Inhibisi
descenden
NE/SHT
Reseptor
Opoid
Medula
Spinalis
Sensitisasi perifer
ion Na
Beydoun, 2002
Sensitisasi
Sentral
(NMDA,
Calcium)
Th/
GABAPENTIN
Okskarbazepin
Lamotrigin
Ketamin
Dextrometorphan
Metorphan
DLL
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)

contd :
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
contd
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
Most invasive
Less invasive
Psychologic/physical therapy
Topical therapy
Oral therapy
Injection therapy
Interventional therapy

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NEUROPATHIC PAIN

Sub Division of Pain

PAIN ASSOCIATED WITH A FUNCTIONAL

CHARACTERISTICALLY : The pain persists

ABSENCE OF ONGOING NOR

THERE IS NO ABSOLUTE TEMPORAL

NOXIOUS STIMULI MAY PRODUCE GREATER

Hyperalgesia >< Allodynia

Ganglion radiks dorsalis

Fields, 1987; Willis, 1992.

THE RANGE OF SEVERITY OF PAIN IS WIDE IT

Examples of NoP : post operative pain, arthritis

a primary lesion or dysfunction

> metabolic derangement

(Woolf and Mannion, 1999)

The pathophysiology of Ne P is COMPLEX

Hence, the management of Ne P :

The ideal team should comprise :

The tools that a pain team implements include use

There are several categories of

Guidelines for drug treatment of neuropathic pain

Adjuvan Therapy for Neuropathic Pain

Beydoun, 2002; modifikasi penulis

Mechanism of action of Tricyclic anti depressant

Sensitisasi perifer ion Na

Mechanism of action of anti convulsant (1)

Sensitisasi perifer ion Na

Mechanism of action of anti convulsant (2)

Severe side effect of carbamazepine

Steven Johnson Syndrome

Numeric Pain Rating Scale (NPRS)

Faces Pain Rating Scale (for children)

Teng and Mekhail (2003)

3. Combination therapy is frequently necessary

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