Neuropathic Pain 25.9.07
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Transcript of Neuropathic Pain 25.9.07
Neuropathic Pain.
Dr. Christopher A. JennerConsultant in Pain Medicine and Anaesthesia, SMH
25th September 2007
Agenda
• Definition
• Physiology
• Acute
• Chronic
• Neuropathic
• Differences
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Definitions
• Pain. ‘An unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of tissue damage, or both.’ (IASP 2001)
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Definitions (2)
• Time-course:
• acute
• chronic
• Type:
• nociceptive
• neuropathic www.londonpainconsultants.com
Pain Physiology
(boring)
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Pain Physiology
(funky version)
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Prevalence
• Acute pain • SMH 13,213 operations p.a. (Nov 03-04, DSU 41%)
• SMH 484 operations p.m. (Sep 04, Main, 15% PCA/ epi)
• Chronic pain • 7-14% UK population • ‘1 in 7’ figure
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The Challenges of Acute Pain
• Primary Care
• ↑ healthcare utilisation
• Secondary Care
• ↑ length stay/ complications • 10-15% post-op chronic pain (Macrae)
Acute Pain Management
• Non-pharmacological • RICE
• Pharmacological • WHO ladder (amended from cancer)
Step 1 paracetamol/ NSAID/ COX 2
Step 2 + weak opioids
Step 3 + strong opioids
The Challenges of Chronic Pain
• Bio-psycho-social model
• Individual and societal costs
• Biological- pain/ suffering/ disability
• Psychological- anxiety/ depression
• Social- work/ relationship/ family/ benefits
Massive Financial Burden
• NHS/ DWP/ tax-payers
• Lower back pain (CSAG 1994)
• NHS £481 million
• The Exchequer £1.4 billion
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Physical and Alternative Treatments
Physical and Alternative Treatments
• Physical- heat/ cold/ TENS/ hydro/ supports/ US/ IR
• Manipulation- PxTx/ chiropracter/ osteopathy/ deep tissue massage
• Alternative- acupuncture
Any Vets in the audience?
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5. (a) Veterinary practitioners?
Headache!
Pharmacological Treatment
Pharmacological Treatment
• WHO analgesic ladder (abridged)
• + tramadol • + opioids- buprenorphine TDD/ oxycontin/ fentanyl TDD
• (New: sufentanyl TDD/ product X)
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Opioid Therapy
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Pharmacological treatment of Neuropathic Pain
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Neuropathic Pain Management
• Antidepressants- Amitryptilline
• Anticonvulsants- Gabapentin/ Pregabalin/ Carbamazepine/ Valproate
• Opioids• Local Anaesthetics- Lignocaine/ EMLA
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• NMDA antagonists
• Sympatholytics
• GABA -ergics
• Capsaicin
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Future Agents for Neuropathic Pain
• Ziconotide (sea snail, conus magnus)
• P2X3- (purine) receptor antagonists (ATP) (knockout mice)
• Epibatidine (Equadorian poison dart frog)
• Morphine and ketamine
• Regular gabapentin
• Dexmetomidine
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Psychologicaly based therapy
Pain Management
• Psychological
CBT
Operant Conditioning
Psychoanalysis
Relaxation
Biofeedback
• Psychiatricwww.londonpainconsultants.com
Pain Management Programmes (MDT)
● Medication
• Coping
• Contingency
• Pacing
• Education • Goals (SMART- specific/ measured/ agreed/ realistic/ timed)
• Pain Behaviours
• Reinforcementwww.londonpainconsultants.com
Minimally Invasive Pain Management
Chronic Pain Management
• Nerve block techniques: - Epidurals - Facets - Tenoperiostial - ON - SSN - Occipital N - Ilioinguinal
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Neuropathic Pain Management
• Non-pharmacological • Nerve blockade- lumbar
sympathectomy/ stellate/ guanethidine
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The Kit
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The Target
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C-arm
Radiofrequency
Epiduroscopy
IDET
Disc Dekompressor
Vertebroplasty
Exotica
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Nerve Stimulation
Nerve Stimulation (2)
Intrathecal Pumps
Intrathecal Pumps (2)
The Future?
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The Future?
• Demographics
• Healthcare advances
• ↑ Patient expectations and involvement
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Summary
• Very common (1 in 7 UK)
• Time course- acute n chronic
• Nociceptive and neuropathic
• Massive socio-economic impact
• Multiple treatment modalities
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Any Questions