Neuropathic Pain. Dr. Christopher A. Jenner Consultant in Pain Medicine and Anaesthesia, SMH 25 th September 2007
Dec 25, 2014
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