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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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Presentation Transcript
  • 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 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 picture symptoms and signs
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
Prevalence and time course
  • High prevalence involve surgical procedures in upper trunk
    • Mastectomy, thoracotomy, sternotomy
mechanisms of injury and their clinical implications
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
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.
treatment pharmacology
  • 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
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
  • 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
  • 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
  • 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