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From Acute to Chronic Pain Chronic Post Surgical Pain Prevention or Treatment

From Acute to Chronic Pain Chronic Post Surgical Pain Prevention or Treatment. Xavier Capdevila M.D.,Ph.D. Head of Department Department of Anesthesiology and Critical Care Medicine Lapeyronie University Hospital and Montpellier School of Medicine Montpellier , France.

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From Acute to Chronic Pain Chronic Post Surgical Pain Prevention or Treatment

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  1. From Acute to Chronic Pain Chronic Post Surgical Pain Prevention or Treatment Xavier Capdevila M.D.,Ph.D. Head of Department Department of Anesthesiology and Critical Care Medicine Lapeyronie University Hospital and Montpellier School of Medicine Montpellier , France

  2. Pain physiopathology: are wetoosimplistics???

  3. SII Insula (emotivity) Nucleus accumbens (awakeness) Cerebellum (motivation) Thalamus SI Pain physiopathology: complexsystems!!!

  4. Pain physiopathology: are wetoosimplistics??? No Brain No Pain

  5. Transition … from acute to chronic pain ASA 2008, d’après J.Eisenach, RCL 123

  6. Transition … from acute to chronic pain FonctionalImagery Manyhemisphericregions are activatedduringpainful stimulation, and particularlyat the controlaterallevel (orange areas). http://www.hopkins-arthritis.som.jmhi.edu/rheumatoid

  7. Pain Imagery…for pain and other goals!!!

  8. Genes, Pain, Analgesia Zubieta, Science 2003 ; Rakvåg et al, Pain 2005 Génotype COMT et fréquence des allèles chez 207 patients cancéreux Val158Met polymorphism of humangenom for catechol-O-methyltransferase (COMT) influences morphine consumption in painfull patients Pharmacologic results for genotypics groups Val158Met (mean ± DS ; a : p = 0,025 ; b : p = 0,03 Val/Val vs Met/Met)

  9. All patients had a continuous popliteal block with 20 ml 0.5% ropivacaine before surgery

  10. Chronic P.O. pain

  11. Post-operative pain chronicisation CRPS 1 after orthopedic surgeries Gooschalk & Raja Anesthesiology 2004

  12. Pain physiopathology : the peripheral inflammation!

  13. Pain physiopathology: central inflammation and sensitization Neuropathic pain = neuro-immune disorder ? ASA 2008, d’après J.Eisenach, RCL 123

  14. Pain Physiopathology: central inflammation ………from acute to chronic pain Neuropathic pain (pain without stimulus) implies a lowerthresholds and involves the samepathway as Schwann cells, cellsfrom dorsal rootganglia, theimmune system, microglia and spinal astrocytes. Glial cells are the inflammatorycells of the central nervous system abatacept , etanercept…infliximab, tanezumab, natazulimab… http://www.hopkins-arthritis.som.jmhi.edu/rheumatoid

  15. From acute pain to chronic pain: TNF antibodies

  16. Acute pain/ Chronic pain: Atb anti-NGF NGF (nerve growth factor) : acute/chronic pain tanezumab --> monoclonal Antibody anti-NGF Useful in Rheumatology (knee), ½ life: 21 days No fixation of NGF on TrkA receptor (tropomyosin kinase A) Plantar incision model Intraperitonea/IV injection 16h before incision Significantdecrease of pain scores Lessefficacy if intraoperative administration ASA 2008, d’après Shelton et al, A-1539

  17. Pain physiopathology: non-NMDA receptors

  18. TNF in the DRG Transport of TNF

  19. TNF Expression along the saphenous nerve

  20. Paw circumference TNF alpha at the surgical site

  21. Postoperative pain and chronic pain related? Eisenach Reg Anesth Pain Med 2006

  22. Colectomies : midline xyphopubic incision • i.v. ketamine : antihyperalgesic dose • then i.v. sufentanil-lidocaïne-clonidine • or EA sufentanil-bupivacaïne-clonidine• G1 : i.v.-i.v. • G2 : i.v.-EA• G3 : EA-EA • G4 : EA-i.v. • VAS / cough, hyperalgesia (von Frey hairs) • Analgesic consumption • Follow up 2 weeks, 6 months, 1 year M De Kock et al , Pain 2001 P Lavand’homme et al, Anesthesiology 2005

  23. Chronic postsurgical pain… The effect of three different analgesia techniques on long-term post-thoracotomy painSentürk et al. Anesth Analg 2001;94:11-5 * * * P < 0.05 vs. IV PCA

  24. Anesth Analg 2005;101:1427-32. * Treatment: gabapentin + EMLA cream + ropi in the brachial plexus and in the third to the fifth intercostal nerves * Gabapentin: 400 mg started the evening before surgery and for 8 days (400 mg x 4). EMLA cream for 3 days. * P < 0.05 vs. control

  25. All patients received a continuous brachial plexus block with ropivacaine 0;375% PP: phantom pain SP: stump pain

  26. Research of the optimal local analgesia: capsaïcin and TRPv1 receptors

  27. CRPS 1 and orthopedic surgeries Does a PNB modifie the evolution? • Dupuytren Surgery •  4,4% to 40% of postoperative CRPS 1 • Sennwald J Hand Surg 1990 • Prosser J Hand Ther 1996 •  Interest of PNBs • ReubenAnesth Analg 2006 • 300 patients, Dupuytren surgery • GA  n : 100 Axillary block  n : 96 • IVRA lido  n : 48 IVRA lido + clo  n : 50 GA  24% Axillary block  5% IVRA lido  25 % IVRA lido + clo  6% p<0,01 % CRPS 1 + for Axillary block : tourniquet tolerance and postoperative analgesia

  28. Pain evaluation after PNB

  29. Iliac crest graft for orthopaedic surgery Pain chronicisation: 8% at 3 months The TAP block Chiono J, Capdevila X et al RAPM 2010

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