Post surgical neuralgia
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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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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 pain에 비해 PSN 에 대한 연구는 지금까지 많지 않음

  • This review focuses on the characterization, classification, Tx of PSN


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


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


  • 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


Prevalence and time course

  • High prevalence involve surgical procedures in upper trunk

    • Mastectomy, thoracotomy, sternotomy


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


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.


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


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


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


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


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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