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Post-surgical Neuralgia

Post-surgical Neuralgia. 정준영. Introduction. Post-surgical neuralgia(PSN) Traumatic nerve injury(TNI) during surgery Often result in persistent pain diabetic neuropathy, post herpetic neuralgia, phantom limb pain 과 같은 neuropathic pain 에 비해 PSN 에 대한 연구는 지금까지 많지 않음

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Post-surgical Neuralgia

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  1. Post-surgical Neuralgia 정준영

  2. Introduction • Post-surgical neuralgia(PSN) • Traumatic nerve injury(TNI) during surgery • Often result in persistent pain • diabetic neuropathy, post herpetic neuralgia, phantom limb pain 과 같은 neuropathic pain에 비해 PSN 에 대한 연구는 지금까지 많지 않음 • This review focuses on the characterization, classification, Tx of PSN

  3. Animal models of TNI and their relevance to PSN in humans • Animal model에서 nerve transection, chronic constrictive injury, partial ligation 등으로 spontaneous or stilumus-evoked pain like behabior 유발시킴 • The mechanism of injury in human with PSN are far less ‘clean’ • TNI 있는 animal 대부분에서 chronic pain-like behavior보이지만 human 에서 surgery 후 PSN은 흔히 생기지는 않는다

  4. Clinical pictureSymptoms and signs • Negative phenomena • Loss of pain or touch sensations • Positive phenomena • Tingling(paresthesia), burning, shooting, aching pain • Continuous or paroxysmal • Evoked by thermal and mechanical stimuli • Hyperalgesia, allodynia, wind up like pain, hyperpathia • Evoked by percussion on the injured n. • Tinel sign, pain, paresthesia

  5. Only diagnosed when spontaneous and/or positive painful sensations are detected • Some of TNIs have typical characteristics • Intercostal n. injury • Spontaneous pain along with mechanical hyperalgesia • inf.alveolar or lingual n. injury • Spontaneous paresthesia and sensory loss

  6. Prevalence and time course • High prevalence involve surgical procedures in upper trunk • Mastectomy, thoracotomy, sternotomy

  7. Mechanisms of injury and their clinical implications • Common mechanisms • Crush, traction, constriction, partial and complete transection, inflammation • Little is known about the correlations between mechanisms of injury and clinical symptoms • Post-CABG pain • Intercostal n. injury from direct n. trauma during surgery • Tension or compression of n. from chest wall retraction or n. ischemia from harvesting internal mammary artery • Kalso et al.(2001) • Prevalence 28% • Points to tension or avulsion of the intercostal n. during the retraction of the firm rib cage as the putative mechanism

  8. Risk factor • Young and high BMI following mastectomy (Smith et al., 1999), CABG surgery, saphenectomy (Bruce, 2003), inguinal hernia repair (Poobalan et al., 2001) • Female gender and pain 1 day after surgery(Gotoda et al., 2001) • Mirovsky and Neuwirth(2000) • No significant difference between length of surgery, gender, height or weight between pts with and without injuries of lat. Femoral curaneous n. during spine op.

  9. Treatmentpharmacology • PSN에 대한 연구가 적기 때문에 다른 neuropathic pain 치료로부터 추정 • Kalso et al.,1996 • Amitriptyline in relieving post-mastectomy pain : 50% reduction in pain (8 in 15 subjects) • Ellison et al.,1997 • 0.075% capsaicin cream in post-mastectomy pain : 53% pain reduction as compared to 17% in placebo group • Anticonvulsant : Gabapentin, Lamotrigine • NMDA receptor antagonist and opioid • Reduce spontaneous pain and area & magnitude of tactile allodynia • Alfentanil can inc. threshold for cold allodynia

  10. Peripheral nerve stimulation and spinal cord stimulation • Most studies reported long term good relief of pain in majority of the pts. Nerve blocks • Pph. n. blocks using local anesthetics, lytic agent, thermal stimuli are commonly used • Defalque and Bromley (1989) • Succesful Tx in 89% of 54 pts with sternotomy-induced neuralgia • Permanent relief in 58% with repeated bupivacaine block • 22% after phenol block • 9 % subsequent alcohol block

  11. Surgery • Neurolysis, nerve and neuroma transection, venous rapping, nerve-to-nerve anastomosis • Surgical procedures can be considered in pts with chronic intractable PSN that fail to respond other Tx

  12. Prevention • Administration of local anesthetics, anti-inflammatory drugs, opioids, NMDA receptor antagonists, and other anents can prevent the development of long-term hyperalgesia and pain-like behavior in animals • Tiippana et al., 2003 • Thoracic epidural analgesia reduce the prevalence of chronic post-thoracotomy pain

  13. Conclusion • PSN is not rare form of chronic pain and it can be expected to occur in a high percentage of pts undergoing certain types of surgeries • There is clear need to classification of the currently known syndromes into subcategories • Due to the potential intractability, prevent its development

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