Invasive treatment to control neuropathic pain / Tratamento invasivo para o controle da dor neuropática

ABSTRACT BACKGROUND AND OBJECTIVES: Distress, allied to neuropathic pain persistence and its refractory nature, often leads patients to accept invasive procedures. Neuropathic pain control is a major medical challenge requiring approaches and decisions especially based on effectiveness, risks and costs. This study aimed at reviewing these aspects related to major invasive procedures. CONTENTS: Major invasive procedures to control neuropathic pain are presented. Initially, classically reversible anesthetic blocks; then invasive neuromodulation techniques using electric current application and the magnetic field generated by it becomes a target to be stimulated, inhibited or modified in the nervous system (central, peripheral or autonomic); and, finally, ablative procedures including anesthetic methods administering neurolytic agents rather than anesthetics and neurosurgeries using different methods to injure the nervous system to control painful neuropathic discomfort. CONCLUSION: Patients eligible to invasive procedures to control neuropathic pain have, in addition to pain itself, a mixed distress including the collection of repeated delusions at every treatment failure. They have reserved prognosis with regard to total cure and, unfortunately, relieve obtained with invasive treatment in general does not reach persistent and high rates. In such adverse situation, these partial results of decreasing original pain intensity may be interpreted as acceptable, provided the impact on final quality of life is positive. Maybe, the rare exceptions are good results obtained with typical idiopathic/cryptogenic neuralgias ironically excluded from the stricter interpretation of the new pathophysiologic classification of neuropathic pains.

RESUMO JUSTFICATIVA E OBJETIVOS: O sofrimento aliado à persistência e refratariedade da dor neuropática frequentemente leva seu portador a aceitar tratamentos invasivos. O controle da dor neuropática representa um desafio médico importante necessitando adoção de condutas e decisões baseadas, principalmente, em efetividade, riscos e custos. O escopo deste estudo foi a revisão desses aspectos relacionados aos principais procedimentos invasivos CONTEÚDO: São apresentados os principais procedimentos invasivos utilizados para o controle da dor neuropática. Inicialmente, os bloqueios anestésicos, classicamente reversíveis; depois as técnicas de neuromodulação invasiva que utilizam a aplicação de corrente elétrica e o campo magnético por ela gerado em alvos a serem estimulados, inibidos ou modificados, no sistema nervoso (central, periférico ou autônomo); e, finalmente, os procedimentos ablativos que incluem os métodos anestésicos que administram agentes neurolíticos ao invés de anestésicos, e, as neurocirurgias que utilizam métodos diversos de produção de lesões no sistema nervoso para o controle do desconforto doloroso neuropático. CONCLUSÃO: Os pacientes que se apresentam como candidatos a receberem indicações de procedimentos invasivos para controle de dores neuropáticas, possuem além do inerente à própria dor, sofrimento misto, que inclui a coleção de desilusões reiteradas a cada insucesso de tratamento. Possuem prognóstico reservado no que tange a plena cura, e, infelizmente, o alívio obtido com o tratamento invasivo, em geral, não atinge taxas persistentes e elevadas. Nessa situação tão adversa esses resultados parciais de redução da intensidade da dor original possam ser interpretados como aceitáveis desde que o impacto na qualidade de vida final seja positivo. Talvez, as raras exceções, recaiam sobre os bons resultados obtidos com as neuralgias típicas, idiopáticas/criptogenéticas, ironicamente, excluídas da interpretação mais rígida da nova classificação fisiopatológica das dores neuropáticas.

Microsurgical DREZotomy for treatment of intractable central pain in patient with spinal cord injury / 영남의대학술지

The central pain in patient with spinal cord injury is a common and disabling sequelae. The microsurgical DREZ(Dorsal Root Entry Zone)otomy is a surgical procedure effective in the treatment of intractable pain and spasticity in spinal cord injured patients. It consists of a microsurgical lesions performed in the ventrolateral region of the dorsal root entry zone at the selected levels. This report presents one case with incomplete paraplegia patient, who had chronic central neuropathic pain ineffective to many conservative treatments in bilateral T10 and right T11 segments and both lower extremities, is relieved from the pain after microsurgical DREZotomy. In conclusion, microsurgical DREZotomy is one method of effective treatments for spinal cord injured patients with intractable central neuropathic pain.

Microsurgical DREZotomy for treatment of intractable central pain in patient with spinal cord injury / 영남의대학술지

The central pain in patient with spinal cord injury is a common and disabling sequelae. The microsurgical DREZ(Dorsal Root Entry Zone)otomy is a surgical procedure effective in the treatment of intractable pain and spasticity in spinal cord injured patients. It consists of a microsurgical lesions performed in the ventrolateral region of the dorsal root entry zone at the selected levels. This report presents one case with incomplete paraplegia patient, who had chronic central neuropathic pain ineffective to many conservative treatments in bilateral T10 and right T11 segments and both lower extremities, is relieved from the pain after microsurgical DREZotomy. In conclusion, microsurgical DREZotomy is one method of effective treatments for spinal cord injured patients with intractable central neuropathic pain.

The Efficacy of Doral Root Entry Zone(DREZ) Lesions Making for Intractable Pain and DREZ-otomy for Inractable Spasticity

The dorsal root entry zone(DREZ) lesions making by focal destruction of the substantia gelatinosa controls intractable pain, and the DREZ-otomy by the selective destroying mainly the laterally located nociceptive and centrally located myotactic afferent fibers within the posterior root relieves the spasticity of the limbs. The authors analysed the results of 12 patients, treated by the DREZ lesions making for intractable pain, and 6 patients, treated by the DREZ-otomy for intractable spasticity of lower extremities, who were admitted to department of neurosurgery of Soonchunhyung University from 1983 to 1993. The obtained results were as follows. 1) Among the 12 patients suffered from intractable pain, three were brachial plexus avulsion, three were spinal cord injury, two were causalgia, and the others were paraneoplastic syndrome, metastatic carcinoma, postoperative spinal cord tumor, and atypical facial pain respectively. There were six patients intractable spasticity of that major cause was diffuse axonal injury(67%), and of that major posture was decorticate rigidity(83%). 2) The rate of immediate relief of intractable pain and spasticity was 82% in each after DREZ lesions making or DREZ-otomy. 3) The result of pain relief by the DREZ lesions making was excellent(100%) in brachial plexus avulsion, and poor(almost no relief) in paraplegic pain of spinal cord injury. 4) After DREZ-otomy on bilateral conus medullaris sparing S(2-4) segment, the degree of spasticity of lower extremitries reduced gradually to mean Ashworth scale 2.1 from mean 5. 5) Five of six patients of the bedridden state due to harmful spasticity was able to do comfortably wheel chair ambulation immediately after operation.