Resultados sobre la aplicación cráneo-facial del parche de capsaicina 8 % en una serie de 5 casos / Results of the capsaicin 8% patch in craniofacial application in five clinical cases

Los parches de capsaicina al 8 % son una alternativa de segunda línea para el tratamiento del dolor neuropático periférico. Aunque tiene pocos efectos secundarios, no tiene indicación para el tratamiento cráneo-facial debido a la posible irritación de mucosas por la capsaicina. Sólo hemos encontrado tres publicaciones que refieren la aplicación del parche en estas localizaciones, describiendo 7 casos clínicos. Hemos recogido 4 casos en los que se realizan 5 aplicaciones en total, 3 mujeres (repitiendo aplicación en una de ellas) y 1 hombre, entre 58 y 84 años, con los siguientes diagnósticos: necrosis cáustica en labio inferior tras limpieza dental, neuralgia del trigémino y neuropatía postherpética. Tras comprobar ineficacia de otros tratamientos, se propuso el parche de capsaicina al 8 %, con firma previa de los consentimientos informados de la aplicación de parche en régimen de hospital de día y de tratamiento fuera de ficha técnica. Previamente a la aplicación del parche en la zona cutánea dolorosa, se procedió a realizar protección ocular de ambos ojos con parche oftálmico quirúrgico, y de mucosas oral y nasal con mascarilla facial quirúrgica sellada. La protección se mantuvo durante toda la aplicación del parche y se quitó una vez retirado éste y limpiada la zona de aplicación. Únicamente se reportaron 3 efectos secundarios leves del total de las 5 aplicaciones: un paciente presentó piel eritematosa que cedió espontáneamente, otra paciente refirió sensación de quemazón y dolor que cedió con analgesia endovenosa, y otra paciente explicó dolor leve bien tolerado, que cedió de manera espontánea. En ninguno de los casos se apreciaron efectos secundarios a nivel de mucosas. En cuanto a resultados, dos pacientes notaron mejoría durante uno y dos meses, colocando nuevamente el parche en una de ellas, sin lograr esta segunda vez alivio. Las otras dos pacientes no notaron ningún cambio. El tratamiento con parches de capsaicina 8 % en superficies cráneo-faciales parece tener similar eficacia a su aplicación en otras áreas de la piel. Los efectos secundarios en su aplicación en estas superficies son escasos, al igual que en otras aplicaciones corporales. Creemos que con las medidas de precaución adecuadas en las regiones cráneo-faciales, la utilidad clínica observada del parche de capsaicina 8 % lo sitúa como otra opción de tratamiento para dolor neuropático, sin complicaciones añadidas. No obstante, estudios clínicos con mayor número de pacientes deberían llevarse a cabo para confirmar estos hallazgos (AU)

The capsaicin 8 % patch is a secondary line alternative to neuropathic peripheral pain treatment. Although it has few secondary effects, is not indicated in head and facial treatment due to the possibility of the irritation of mucosa. We have only found three publications related with the patch application in those locations, describing 7 clinical cases. We have analyzed 4 cases in which we have applied 5 patches in total. There were 3 women (repeating the application in one of them) and 1 man, between 58 and 84 years old, with the following diagnosis: caustic necrosis in the inferior lip after dental cleaning, trigeminal neuralgia and post-herpetic neuropathy. Inefficacy of other treatments was confirmed, and after that, the capsaicin 8 % patch was proposed. Informed consent of the application of the patch at day clinic and treatment out of technical data sheet were previously signed. Before the patch was applied to the painful cutaneous area, we proceed with ocular protection of both eyes with surgical ophthalmic patch and oral and nasal mucosa protection with surgical mask hermetically seal. That protection was maintained during the whole application of the patch, and was removed once the capsaicin patch was taken off and the application area was cleaned. There were only 3 mild secondary effects of the total 5 applications: one patient showed erythematic skin that was resolved spontaneously, another patient related burn and pain sensation which was solved with endovenous analgesia. Finally, another patient explained mild pain well tolerated, that was resolved also spontaneously. In no cases there were secondary effects in mucosa. Related with the results, 2 patients felt improvement between one and two months, applying again the patch in one of them, not reaching this time relief in the pain. The other 2 patients did not notice any change. The capsaicin 8 % patch treatment in head and facial areas seems to have similar efficacy as the application in other skin areas. Secondary effects in these surfaces are very low, the same as in other corporal locations. We believe that with the adequate preventive measures in head and facial areas, clinical utility observed with capsaicin 8 % patch places it as another treatment option for neuropathic pain, with no complications added. However, clinical studies with a higher number of patients should carry on to confirm these findings (AU)

Dolor nocioceptivo, dolor neuropático y memoria de dolor / Nocioceptive pain, neuropathic pain and pain memory

Introducción. El dolor es una evaluación cognitiva y su traducción en las nuevas técnicas de imagen funcional ha despertado un gran interés. El dolor nocioceptivo, habitualmente agudo o persistente, tiene como función alejar al animal del daño. Desarrollo. El dolor crónico constituye una enfermedad por sí mismo y es debido a fenómenos de sensibilización y de memoria de dolor con una marcada relación en los aspectos emocionales. El dolor neuropático es un síntoma neurológico debido a una disfunción en el sistema somatosensorial en el que intervienen fenómenos de generación ectópica de impulsos, hiperexcitabilidad axonal y sináptica y secundariamente instauración de fenómenos de sensibilización central y memoria. Conclusión. El tratamiento del dolor debe ser orientado a partir de su fisiopatología. Las unidades de dolor, entrenadas en el tratamiento analgésico y en técnicas relativamente invasivas, son habitualmente muy eficaces en el tratamiento del dolor agudo nocioceptivo. El dolor neuropático debe tener un enfoque principalmente neurológico, tanto en el diagnóstico como en el tratamiento. El dolor crónico por memoria de dolor debe interesar a los neurólogos cada vez más a medida que se conozcan mejor los mecanismos cerebrales de la cognición. de los ensayos terapéuticos (AU)

Introduction. Pain is a cognitive evaluation. Its appearance in the new functional image systems is promising. Nocioceptive pain, usually acute or persistent, is useful to prevent animals from getting injured. Discussion. Chronic pain is disease per se: It is due to a sensitisation phenomena and pain memory with an important relationship with emotions. Neuropathic pain is a neurological symptom due to a somatosensorial system dysfunction. In this case, axonal ectopic generation of impulses and synaptic hyperexcitability occurs. In persistent cases, sensitisation phenomenon and memory of pain appear together with neuropathic pain. Conclusions. Pain treatment should be physiopathologicaly orientated. Pain units, specialized in analgesic treatment and some invasive techniques, are usually competent in the treatment of nocioceptive pain. Neuropathic pain should have a neurologic diagnosis and treatment. But neurologist need to be more and more interested in the chronic pain related with memory and sensitisation: better knowledge of the cerebral mechanisms in this phenomenon can add to this pathology in our field (AU)

[Treatment of neuropathic pain in neurology units. The PREVADOL study]. / Tratamiento del dolor neuropático en las consultas de neurología. Estudio PREVADOL.

INTRODUCTION: Neuropathic pain (NPP) is defined as a pain started or caused by an injury to or dysfunction of the nervous system. Its treatment is different to that of nociceptive pain since it does not respond to conventional analgesics or non-steroidal antiinflammatory drugs. AIM: To describe the treatment being received by patients with NPP in the daily clinical practice of the specialist in neurology. PATIENTS AND METHODS: An observational, epidemiological, cross-sectional study was conducted in 36 neurology units (24 extra-hospital and 12 belonging to hospitals). We collected the clinical data and the treatment administered to the first 20 patients with NPP to visit the neurology units over a period of 20 consecutive working days. RESULTS: Data were collected for a total of 451 patients with NPP. The pharmacological groups most frequently used in patients with NPP attended in neurology units are antiepileptics (71%) and antidepressants (15%). Of these patients, 60% were being treated with a single drug (an antiepileptic agent in 84.5% of cases; antidepressants in 10.3%). Two pharmacological treatments were being received by 23.7%, and 2.3% of patients were given treatment involving three or more pharmacological agents. A total of 30% received non-pharmacological treatments, especially physiotherapy (50.4%). CONCLUSIONS: Most patients with NPP attended in neurology units follow first-order pharmacological treatments (antiepileptics or antidepressants). Over half the patients are controlled with monotherapy, usually with an antiepileptic agent. Non-pharmacological treatments (especially physiotherapy) are used in a third of the patients.

[Epidemiological study of prevalence, incidence and neuropathic pain characterization in neurology units. PREVADOL study]. / Estudio de prevalencia, incidencia y caracterización del dolor neuropático en consultas de neurología. Estudio PREVADOL.

INTRODUCTION: Neuropathic pain is defined as a pain initiated or caused by a lesion or dysfunction in the nervous system. The objectives of the study were to estimate the prevalence and incidence of neuropathic pain in hospital neurology units and primary care centres, to characterize the clinical profile of the patient with neuropathic pain and to know the most frequent treatments in the pharmacological management of this type of pain. METHODS: Observational, cross-sectional epidemiological survey carried out in 36 Neurology Units of the national territory (24 primary care centres and 12 hospitals). During 20 consecutive days neurologists collected the diagnoses of all the attended patients by any reason, up to 30 patients/day. In parallel the 20 first consecutive patients with neuropathic pain were chosen for their characterization in depth by means of a specific questionnaire. RESULTS: A total of 12,688 patients were attended and a total of 13,555 diagnoses were collected through 713 consultation days. The most frequent diagnosis was migraine/cephalea, with a prevalence of 23.40% (95% CI: 22.66%-24.14%). Neuropathic pain represented the eighth more frequent diagnosis, with a prevalence in neurology units of 3.88% (95% CI: 3.54%- 4.22%). The prevalence of neuropathic pain was 2.92% in primary care centres and 6.09% in hospital units (p < 0.01). The daily incidence of new neuropathic pain cases was 1.24% (95% CI: 1.05%-1.53%); 1.14% in primary care neurology centres and 1.45% in hospital units. CONCLUSIONS: The data obtained indicate that neuropathic pain is the eighth more frequent diagnosis in the neurology units. Medical assistance request by neuropathic pain is higher in the hospital units.

Estudio de prevalencia, incidencia y caracterización del dolor neuropático en consultas de neurología. Estudio PREVADOL / Epidemiological study of prevalence, incidence and neuropathic pain characterization in neurology units. PREVADOL study

Introducción. El dolor neuropático (DNP) se define como un dolor iniciado o causado por una lesión o disfunción del sistema nervioso. Los objetivos del estudio fueron estimar la prevalencia e incidencia de DNP en consultas de neurología hospitalarias y extrahospitalarias, caracterizar el perfil del paciente con DNP y conocer los tratamientos más utilizados en el manejo farmacológico de este tipo de dolor. Métodos. Se realizó un estudio observacional, epidemiológico y transversal, en 36 consultas de neurología del territorio nacional (24 extrahospitalarias y 12 hospitalarias). Durante 20 días consecutivos se recogieron los diagnósticos de los pacientes que acudieron a consulta por cualquier motivo, hasta un máximo de 30 pacientes/día. Paralelamente se eligieron los primeros 20 pacientes consecutivos que presentaban DNP, para su caracterización en profundidad mediante un cuestionario específico. Resultados. Se recogieron 13.555 diagnósticos de un total de 12.688 pacientes atendidos en 713 días de consulta. El diagnóstico más frecuente fue migrañas/cefaleas, con una prevalencia del 23,40% (IC 95%: 22,66-24,14%). El DNP representó el octavo diagnóstico más frecuente, con una prevalencia en consultas de neurología del 3,88 % (lC 95 %: 3,544,22%). La prevalencia de DNP fue del 2,92 % en consultas extrahospitalarias y del 6,09 % en consultas hospitalarias (p < 0,01). La incidencia diaria de casos nuevos de DNP se situó en el 1,24% (lC 95%: 1,05-1,53 %); 1,14% en consultas de neurología extrahospitalarias y 1,45% en consultas hospitalarias. Conclusiones. Los datos obtenidos indican que el DNP es el octavo diagnóstico más frecuente en las consultas de neurología. La demanda asistencial por DNP es más elevada en las consultas hospitalarias

Introduction. Neuropathic pain is defined as a pain initiated or caused by a lesion or dysfunction in the nervous system. The objectives of the study were to estimate the prevalence and incidence of neuropathic pain in hospital neurology units and primary care centres, to characterize the clinical profile of the patient with neuropathic pain and to know the most frequent treatments in the pharmacological management of this type of pain. Methods. Observational, cross-sectional epidemiological survey carried out in 36 Neurology Units of the national territory (24 primary care centres and 12 hospitals). During 20 consecutive days neurologists collected the diagnoses of all the attended patients by any reason, up to 30 patients/day. In parallel the 20 first consecutive patients with neuropathic pain were chosen for their characterization in depth by means of a specific questionnaire. Results. A total of 12,688 patients were attended and a total of 13,555 diagnoses were collected through 713 consultation days. The most frequent diagnosis was migraine/cephalea, with a prevalence of 23.40 % (95 % Cl: 22.66 %-24.14 %). Neuropathic pain represented the eighth more frequent diagnosis, with a prevalence in neurology units of 3.88 O/o (95 % CI: 3.540/04.22 %). The prevalence of neuropathic pain was 2.92 % in primary care centres and 6.09 % in hospital units (p < 0.01). The daily incidence of new neuropathic pain cases was 1.24 % (95 % CI: 1.05 %-1.53 %); 1.14 % in primary care neurology centres and 1.45 % in hospital units. Conclusions. The data obtained indicate that neuropathic pain is the eighth more frequent diagnosis in the neurology units. Medical assistance request by neuropathic pain is higher in the hospital units

[Sphincter function disorders. physiopathology and neurophysiological study]. / Trastornos de la funcion esfinteriana. Fisiopatología y estudio neurofisiológico.

Miction and defecation disturbances are very frequent in the general population and far more so among neurological patients. It is essential to know the physiopathology of these disorders in clinical practice. The neurological control of these functions is carried out by automatisms that are regulated in the nuclei of the brain stem through somatic and vegetative peripheral structures that act simultaneously. The cortical, hypothalamic and reticular levels play a part in the activation or inhibition of the pontine nuclei. Continence depends on the integrity of the anatomical structures and the sensory, pressure and mechanical systems that enable the automatisms to develop. Neurological examination must be combined with studies conducted by other specialists on patients in which no neurological illness is known, but who have this kind of dysfunction. Adding a neurophysiological examination allows us to complete the clinical study and to check objectively for the existence of external anal sphincter denervation or disorders involving the exteroceptive reflexes of the sacrum. The recent appearance of techniques for treating incontinence that make use of the repeated and continuous stimulation of the sacral roots has revolutionised the way these patients are treated and calls for greater involvement of neurologists in dealing with these problems.

[Congenital neuromyotonia. Retrospective study of 4 cases]. / Neuromiotonía congénita. Estudio retrospectivo de cuatro casos.

BACKGROUND: Fasciculation, double discharge, myokymia and neuromyotonia are different kinds of involuntary muscular activity that originate in ectopic discharges of the motor axons. Electrophysiological studies are needed in all cases for the diagnosis. Non rigorous electrophysiological studies in some cases is the cause of the historically unclear nosological delimitation of the neuromyotonic syndromes. OBJECTIVE: To report the clinical picture and electrophysiological findings in patients with congenital neuromyotonia. PATIENTS AND METHODS: Four patients with congenital neuromyotonia were studied. Electrophysiological exam included nerve conduction measurements, study of the after-discharges and conventional EMG. Spontaneous discharges were displayed after applying a low pass filter, signal trigger and delay line. RESULTS: In one case positive motor features predominate (continuous muscle fiber activity). On the contrary, two cases, showed neuropathic deficitary signs with a Charcot-Marie-Tooth type II disease phenotype; neuromyotonia was, in both cases, an electrophysiological feature. In the last patient, motor signs were limited to the facial muscles but electrophysiological study discovered generalized neuromyotonia. Treatment with carbamazepine or oxcarbazepine was useful in the four cases. CONCLUSION: Congenital neuromyotonia is a clinically heterogeneous syndrome with uniform electrophysiological features that permit its qualification.

[Treatment of Guillain-barre syndrome: immunoglobulins or plasmapheresis?]. / Tratamiento del síndrome de Guillain-Barré: inmunoglobulinas o plasmaféresis?

The aim of this study was to compare the efficacy of IgIV versus plasmapheresis in the treatment of Guillain-Barré syndrome. Twenty-four Guillain-Barré patients were treated either with IgIV (n = 17), or plasmapheresis (n = 7). Evolution during the first year after onset were assessed using the motor functional scale of Hughes and nerve conduction studies. IgIV treated patients had better functional recovery than the plasmapheresis group (p < 0.05) and shorter hospital stays (p < 0.05). These differences were significant from day 30 after treatment. Complications occurred in 14 patients: 9 (58%) in the IgIV group, and 5 (71%) in the patients treated with plasmapheresis. IgIV treated patients had better functional recovery scores and shorter hospital stays. There were no differences in the complication rates. Therefore we believe that IgIV is the treatment of choice for Guillain-Barré syndrome in our clinical setting.

[Electroneurographic parameters in cubital neuropathy of the elbow]. / Diferentes parámetros electroneurográficos en la neuropatía cubital en el codo. Interés de la conducción sensitiva antidrómica.

Using conventional techniques with cutaneous electrodes, 14 parameters of antidromic, motor and mixed segmentary sensory conduction of the cubital nerve were assessed in the first 45 patients presenting to us with some form of electroneurographic abnormality. Changes suggestive of axonal degeneration due to a decrease in amplitude or conduction velocity of the distal segment were found in 17. The remaining 28 patients showed only signs of change in conduction velocity at the elbow and could be classified according to electroneurographic degrees of progressive abnormality. Changes in antidromic sensory conduction are early and constant, constituting the parameter of choice for detection of slight compressive neuropathy.