Neurogenic Pain Syndromes Research Articles

Etiopathogenetic substantiation of surgical treatment of neurogenic pain syndromes

The purpose of the study was to improve classification of neurogenic (neuropathic) pain syndromes. This will make it possible to define the indications for appropriate analgesic surgery for each type of drug-resistant neurogenic pain syndrome. Incorrect management of neurogenic pain syndromes is usually associated with underestimation of pathogenetic prerequisites for its occurrence. Differentiation of compression, deafferentation and mixed neurogenic pain syndromes makes it possible to determine appropriate surgery and avoid tactical errors. Moreover, this approach allows you to save patients from unreasonable long-standing suffering. Patients with chronic pain syndromes often become disabled, sometimes in the prime of life, and isolated from society and family. Therefore, treatment of chronic pain is currently an urgent problem.

Historical aspects of the problem of treatment of trigeminal neuralgia and the role of neurosurgical methods in its solution (literature review)

The trigeminal nerve is a mixed fifth cranial nerve, consisting of motor and sensory components. The sensitive component receives somesthetic information from the skin and mucous membranes of the face into the central nervous system, and the motor component is responsible for the innervation of chewing muscles. One of the manifestations of the pathology of the trigeminal nerve is pain syndrome. Trigeminal neuralgia occupies the main place among neurogenic pain syndrome in the face, is characterized by а severe course and the absence of sufficiently effective methods of treatment. According to the World Health Organization (WHO), the prevalence of trigeminal neuralgia in different countries is 2–5 cases per 100 thousand people per year. Trigeminal neuralgia is classified into 3 etiologic categories. Idiopathic trigeminal neuralgia occurs without apparent cause. Classical trigeminal neuralgia is caused by vascular compression of the trigeminal nerve root. Secondary trigeminal neuralgia is the consequence of a major neurologic disease, e. g., a tumor of the cеrеbеllоpоntine angle or multiple sclerosis. Today, there are many different options for the surgical treatment of trigeminal neuralgia. microvascular decompression of the root, radiosurgical destruction of the Gasser’s node, radiofrequency destruction, glycerol rhizotomy, balloon microcompression are considered the main effective and proven surgical methods for treating trigeminal neuralgia. But the questions of diagnosing the cause of the disease and choosing an adequate surgical method for treating therapeutically resistant trigeminal neuralgia for a particular patient remain open. The development of surgical methods begins from ancient times to the present day. The main stages in the development of neurosurgical treatment methods are presented. The following surgical techniques are described: open method – microvascular decompression, and closed percutaneous destructive methods – radiofrequency destruction, glycerol rhizotomy, balloon compression, radiosurgery, cryodestruction, laser destruction, botulinum toxin injections.

Anorectal and perineal pain

Anorectal and perineal pain Abstract. Anorectal pain is a common clinical challenge in the outpatient office. Anal fissures, anal venous thrombosis, proctitis or neoplasms are frequent etiologies for proctalgia. After exclusion of somatic disorders by diagnostic imaging and endoscopy, functional anorectal pain or pathologies like interstitial cystitits, chronic prostatitis, coccycodynia or pudendal neuralgia should be considered. The Rome IV criteria distinguish proctalgia fugax, a sharp paroxysmal pain lasting for maximum 30minutes, and the levator ani syndrom. Latter is characterized by a tender puborectal muscle on digital rectal examination and pain lasting for more than 30minutes. Treatment consists in reassurance, sitz bathes, topical vasodilators and anal massage. Biofeedback is a further option for levator ani syndrome. Painful palpation of the ox coccygis leads to the diagnosis of coccycodynia, a non-functional disorder. Therapy consists in anti-inflammatory medications, os coccygis mobilisation and infiltration therapy. Urologic chronic pelvic pain (chronic prostatitis and interstitial cystitis) as well as pudendal neuralgia, both neurogenic pelvic pain syndromes, can cause pain radiating into the after and perineum. The diagnosis and discrimination from functional rectal pain is difficult. Patients with neurogenic anorectal pain are best treated with anti-inflammatory medications, pain modulating antidepressives, anticonvulsives or local infiltration therapy. Interdisciplinary management of complex pain patients is mandatory.

Alkalinized lidocaine solution as a first-line local anesthesia protocol for intradetrusor injection of onabotulinum toxin A: Results from a double-blinded randomized controlled trial.

Local anesthesia protocols for intradetrusor onabotulinum toxin A (BoNTA) injection lack standardization. We aimed to determine if an alkalinized lidocaine solution is more effective than lidocaine only. Patients of both genders aged 18 or above enlisted for intradetrusor BoNTA injection (idiopathic, neurogenic, and bladder pain syndrome) were included in a double-blinded randomized controlled trial after obtaining their informed consent. All participants filled a bladder diary and a urine culture was performed. Subjects were randomized 1:1 to Protocol A (20 ml 2% lidocaine + 10 ml 8.4% sodium bicarbonate) or Protocol B (20 ml 2% lidocaine + 10 ml 0.9% saline solution). A Numeric Rating Scale (0-10) was used to assess the level of pain immediately after the procedure (primary endpoint). Secondary endpoints included pain after 1 h, urinary tract infection, acute urinary retention, and hematuria related to the procedure. A total of 116 patients were randomized. Baseline characteristics (age, sex, indication, and bladder diary parameters) of patients in Group A and B were similar. Pain scores at the end of the procedure were significantly lower with the alkalinized solution (Protocol A and B, respectively, 2.37 ± 0.31 vs. 4.44 ± 0.36, p < .01). No differences were observed 1 h after treatment (Protocol A and B, respectively, 0.54 ± 0.17 vs. 0.69 ± 0.19, p = .487). The only adverse event reported was mild-to-moderate self-limited hematuria in 15.4% of patients. The use of an alkalinized lidocaine solution has proven to be significantly superior to lidocaine only as local anesthesia before intradetrusor BoNTA injection, suggesting that this may be considered a first-line option.

ANTINOCYCEPTIVE EFFECT OF A SYSTEMIC ADMINISTRATION OF PALMITOYLETHANOLAMIDE, STEAROYLETHANOLAMIDE AND DYNCLOFENAC IN RATS WITH EXPERIMENTAL NEUROGENIC PAIN SYNDROME

The antinociceptive effect of palmitoylethanolamide (PEA), stearoyl- ethanolamide (SEA) and sodium diclofenac in experimental peripheral neuropathy in rats was studied. Intraperitoneal administration of PEA one hour prior to stimulation on the 7th and 14th day significantly weakened CCI-induced mechanical hyperalgesia by increasing PNR by 23.1 and 31.8 %, respectively. SEA under similar conditions increased PNR by 27.9 and 30.3 %, while diclofenac – by 29.0 and 26.2 %. New data were obtained and pointed that stearoylethanolamide effectively weakens mechanical hyperalgesia caused by neuropathy. The antinociceptive effects of these fatty acid derivatives in the modeling of neurogenic pain syndrome are comparable to those of sodium diclofenac. It seems advisable to consider PEA and SEA as a basis for drugs, whose addition to treatment regimens of neuropathic pain will increase its effectiveness.

Application of spinal cord stimulation in the treatment of persistent pain in failed back surgery syndrome

The study objectiveis to demonstrate our experience of the spinal cord stimulation in the treatment of drug-resistant pain in patients with the failed back surgery syndrome (FBSS) and to evaluate its effectiveness and complications.Materials and methods.Systems for chronic spinal cord stimulation were implanted in 78 patients suffering from FBSS in Federal Neurosurgical Center (Novosibirsk) during 2013–2015. All patients had a drug-resistant neurogenic pain syndrome character and were undergone surgical intervention on the spine. Evaluating of the treatment effectiveness was carried out by visual analogue scale (VAS) and a scale Douleur Neuropathique en 4 Questions (DN4). Catamnesis ranged from 6 to 18 months.Results.The median preoperative VAS score evaluation was 6.7, at hospital discharge – 3.1, after 6 months – 3.2, after 12 months – 3.5, after 18 months – 3.4. Evaluation on a scale DN4 before surgery was 5.3, at hospital discharge – 2.1, after 6 months – 2.4, after 12 months – 2.5, after 18 months – 2.4. Complications in the form of migration, fracture of the electrodes and development of hemorrhage or inflammation at the site of implantation of the system were observed in 12 (15.3 %) cases and required revision surgery.Conclusion.Spinal stimulation is an effective and safe method of treatment of pain in FBSS, but it has specific complications associated with implantable systems.

Neuron-astrocyte interactions in spinal cord dorsal horn in neuropathic pain development and docosahexaenoic acid therapy

The analgesic activity of docosahexaenoic acid (DHA, 22:6 n−3) was studied using a chronic constriction injury (CCI) rat model. Animals were subcutaneously injected with DHA emulsion at a dose of 4.5mg/kg (125mМ/kg) daily during 2weeks after surgery. We characterized the dynamics of GFAP-positive astrocyte, substance P (SP) and nNOS-positive neurons activity in the spinal cord dorsal horn (SCDH) superficial lamina. We found that DHA treatment decrease the intensity and duration of neurogenic pain syndrome, results in earlier stabilization of weight distribution, prevents the cold allodynia and dystrophic changings in denervated limb tissue. DHA treatment reduced the reactive astrocyte number, decrease SP-immunopositive fibers and nNOS-positive neurons number in the SCDH in neuropathic pain.

Spinal cord stimulation in the treatment of chronic pain syndromes

The study objective was to estimate the efficacy of chronic epidural spinal cord stimulation in the treatment of patients with neuropathic pain syndrome. A system for chronic spinal cord stimulation (St. Jude) was implanted to 75 patients with neuropathic pain syndrome. Fifty three (70.7%) patients were diagnosed with failed back surgery syndrome (FBSS); 9 (12.0%) patients had complex regional pain syndrome type II; 4 (5.3%) patients had diabetic polyneuropathy of the lower limbs; 3 (4.0%) patients had idiopathic pelvic-perineal pain; 2 (2.7%) patients had spinal stroke pain; 2 (2.7%) patients had postherpetic intercostal neuralgia; 1 (1.3%) patient had stump pain; 1 (1.3%) patient had spinal cord injury pain. The treatment efficacy was evaluated using the visual analog scale (VAS) and DN4 questionnaire. The follow-up period ranged from 6 to 18 months. 136 patients underwent test stimulation at the Center in 2014. A significant reduction in pain was observed in 75 (55.1%) patients. These patients underwent the second stage of surgery that included implantation of permanent electrodes and a generator. The mean VAS score was 6.5 (maximum: 10; minimum: 5) before surgery, 3.2 at discharge, and 3.1 after 3 and 6 months. The VAS score amounted to 3.6 after 12 months. Complications in the form of pain at the generator implantation site and the need for removal of the system occurred in 2 patients (2.6%), electrode migration was observed in 4 (5.3%) cases. Chronic epidural spinal cord stimulation is an effective and safe technique for the treatment of drug-resistant chronic neurogenic pain syndromes.

Results of motor cortex stimulation in the treatment of chronic pain syndromes

The article is aimed to demonstrate our experience in motor cortex stimulation (MCS) in patients with chronic neuropathic pain syndromes, assess the clinical efficacy of the technique in short-term and long-term follow-up, and analyze potential predictors of the MCS efficacy. Twenty patients were implanted with MCS electrodes at the Burdenko Neurosurgical Institute in the period between 2004 and 2014. The mean age of patients was 52 years (26 to 74 years). The patients suffered from neuropathic pain syndromes of different genesis (post-stroke, multiple sclerosis, atypical facial pain, phantom limb pain, brachial plexus injury, spinal cord injury, complex regional pain syndrome I). All patients underwent neurological examination with verification of neuropathic pain (DN4, Pain Detect, LANSS). The pain intensity and its effect on quality of life were assessed before operation and during follow-up according to 10-point visual-analog scales (modified Brief Pain Inventory). Before surgery, all patients underwent several repetitive transcranial magnetic stimulation (rTMS) sessions. After implantation of epidural electrodes, test MCS was performed. Test stimulation was positive in 19 (95%) patients. All these patients were implanted with a chronic MCS system. The mean follow-up was 49.3 months (from 3 to 96 months). In short-term follow-up (fist 6 months), a positive result of MCS was observed in 17 patients, and a reduction in the pain intensity ranged from 37.5% to 90%. In long-term follow up (from 12 to 96 months), 14 patients had positive MCS RESULTS: and a reduction in the pain intensity amounted to 25% to 60%. All patients with positive MCS results received significantly decreased doses of opioids and tramadol. Two patients developed infectious complications, but there was no neurological deficit. Analysis of the factors affecting the efficacy of motor cortex stimulation did not reveal a statistically significant effect of rTMS and the presence and intensity of motor deficit. Chronic epidural MCS is an effective and safety method for the treatment of some chronic neurogenic medically-refractory pain syndromes. Further research is necessary to specify the patient selection criteria and the MCS efficacy predictors.

Management of CRPS Type-I: Combination of stellate ganglion block and continuous brachial plexus block (ultrasound-guided): Case report

The complex regional pain syndrome (CRPS) I is a neurogenic pain syndrome that is characterized by pain, vasomotor and dystrophic changes and often motor impairments. The etiology of the condition resides in multiple theories, and diagnosis can be difficult and therapy focuses on pain management and restoration of physical function. The conservative treatment includes both non-pharmacological and pharmacological methods, and invasive therapy is centered on sympathetic and somatic blocks. We report a case of CRPS type-I in a 15-year-old young boy following repeated trauma to right elbow, which was successfully managed by a stellate ganglion block and continuous interscalene brachial plexus block and function restored to its full extent.

Botulinum toxin therapy: its use for neurological disorders of the autonomic nervous system

Botulinum toxin (BoNT) has gained widespread use for the treatment of overactive muscles, overactive exocrine glands and, most recently, non-muscular pain conditions. Autonomic conditions treated with BoNT include achalasia, gastroparesis, sphincter of Oddi spasms, and unspecific esophageal spasms in gastroenterology and prostate disorders in urology. BoNT's use for autonomic conditions related to neurology includes various forms of bladder dysfunction (detrusor sphincter dyssynergia, idiopathic detrusor overactivity, neurogenic detrusor overactivity, urinary retention and bladder pain syndrome), pelvic floor disorders (pelvic floor spasms and anal fissures), hyperhidrosis (axillary, palmar, and plantar hyperhidrosis, diffuse sweating, Frey's syndrome) and hypersalivation (hypersalivation in Parkinsonian syndromes, motor neuron disease, neuroleptic use, and cerebral palsy). Hyperhidrosis, hypersalivation, some forms of bladder dysfunction and pelvic floor disorders can easily be treated by neurologists. Most bladder dysfunctions require cooperation with urology departments.

Characterization of upper lamina propria interstitial cells in bladders from patients with neurogenic detrusor overactivity and bladder pain syndrome

The upper lamina propria (ULP) area of interstitial cells (IC) in bladder has been studied for more than a decade in several species including human beings. Nevertheless there is still lack of uniformity in terminology of this cell layer. The aim of the present study was to add new data to the morphological and immunohistochemical phenotype of these cells and to find out whether this phenotype is changed in bladders from patients with neurogenic detrusor overactivity (NDO) and bladder pain syndrome (BPS). Bladder tissue was obtained from a control group and from patients with NDO and BPS. Samples were processed for morphology, electron microscopy and immunohistochemistry. A morphological and immunohistochemical phenotype for the ULP IC was assessed and changes in this phenotype were looked for in samples from patients with NDO and BPS. The ULP IC were characterized ultrastructurally by the presence of actin filaments with densifications, many caveolae and abundant rough endoplasmic reticulum (RER); on immunohistochemistry ULP IC were immunoreactive for α-sma, vimentin, CD10 and podoplanin and categorized as interstitial Cajal-like cells (ICLC). In NDO and BPS bladders we found a phenotypical shift towards a fibroblastic phenotype which was even more pronounced in the NDO group. In both groups there was also an increased presence in ULP lymphocytes. The ULP area in the human bladder contains a population of ICLC with distinct ultrastructural morphology and immunohistochemical phenotype. Their unique α-sma+/desmin–/CD34– phenotype allows studying this population in various bladder disorders. In bladders form patients with BPS and NDO, we observed these ULP ICLC to shift towards a fibroblast phenotype.

Experimental Model of Combined Pain and Depression Status in Rats

Combined pain and depression status in rats was created by inducing experimental depressive syndrome (by subchronic injection of MPTP proneurotoxin) in animals with manifest and developing neurogenic pain syndrome induced by preliminary crossing of the sciatic nerve in the hind limb. The neurogenic pain syndrome augmented by some parameters the depressive symptoms and provoked manifestation of signs of depressive behavior in animals treated with saline.

Conference of neurosurgeons of Ukraine «Neurosurgical aspects of neurogenic pain syndromes diagnosis and treatment». Koktebel, AR of Crimea, 17–18 September 2009. Abstracts

Conference of neurosurgeons of Ukraine «Neurosurgical aspects of neurogenic pain syndromes diagnosis and treatment». Koktebel, AR of Crimea, 17–18 September 2009. Abstracts

Changes in spectral measures of brain electrical activity in rats after transection of the sciatic nerve

Electrophysiological measures of brain electrical activity were studied in rats during the development of neurogenic pain syndrome induced by transection of the sciatic nerve. At the peak of development of pain syndrome, three weeks after deafferentation, rearrangements in the spectra of electrical activity were seen in the limbic structures of the brain (hippocampus, amygdala, nucleus accumbens), in the frontal areas of the neocortex, and in the caudate-putamen complex: changes consisted of increases in the relative power of the delta and alpha ranges as compared with controls, along with a decrease in relative power in the beta-2 range. Changes in spectral measures of electrical activity in the limbic structures of the brain occurred independently of the clinical manifestations of neurogenic pain syndrome (autotomy). The increase in relative power in the alpha range of the spectrum of electrical activity in all the structures studied suggests that the reticular nucleus of the thalamus is involved in the pathogenetic mechanisms of neurogenic pain syndrome.

Neurovascular Interrelations and Tissue Microcirculation in Posttraumatic Reflex Sympathetic Dystrophy

Thirty eight patients with posttraumatic reflex sympathetic dystrophy (RSD) of upper extremities and 28 healthy individuals of the same age (control group) were examined using computer laser doppler flowmetry (LDF) and wavelet-analysis of amplitude-frequency spectrum of fluctuations of microvascular circulation. RDS prevailed in patients with primary warm forms, increase ofportion of shunt circulation, decrease of sympathetic activity and its breakdown at activation. Patients with primary cold forms were characterized by inconstant increase of neurogenic tonus of microvessels at rest. Prolong activation of peptidergenic function of sensory fibres supporting neurogenic inflammation, edema and pain syndrome were typical. One could not exclude that sympathetic vasomotor function and sympathetic support of pain may innervated by different groups of sympathetic neurons. Objective assessment of perivascular innervation and tissue microcirculation is of great clinical importance for individual RSD treatment protocol. Use of LDF is reasonable for early diagnosis of RSD, determination the role of sympathetic and peptidergenic mechanisms in RSD pathogenesis and indications for sympathetic blockades and capsaicin.

Peripheral Nerve Biomechanics: Application To Neuromobilization Approaches

Neuromobilization is a therapeutic technique that has received favorable acceptance as a management approach for neurogenic pain syndromes. As reported in the literature, anatomy of peripheral nerve and its connective tissue structure profoundly influence both spinal and extremity movement. The physical therapist needs to develop a clear understanding of peripheral nerve anatomy and mechanics in order to better understand nerve physiology. Anatomical and biomechanical review of peripheral nerve includes: nerve mobility and stress/strain characteristics in both the upper and lower extremities; and mechanisms and consequences of trauma on nerve microcirculation as well as influence on axoplasmic and lymphatic flow within peripheral nerve. Physical therapy management of peripheral nerve dysfunction as reported by Elvey and Butler is reviewed. Guidelines for appropriate principles of clinical examination and treatment are outlined as well as possible areas for future clinical research.

Effectiveness of manipulative physiotherapy for the treatment of a neurogenic cervicobrachial pain syndrome: a single case study – experimental design

A single case study ABC design was used to evaluate the effectiveness of manipulative physiotherapy in a 44-year-old woman with an 8-month history of neurogenic cervicobrachial pain. Clinical examination demonstrated significant signs of upper quadrant neural tissue mechanosensitivity indicating that neural tissue was the dominant tissue of origin for the subject's complaint of pain. Magnetic resonance imaging revealed correlating discal pathology at the C5/6 intersegmental level. The study involved a 4-week pre-assessment phase, a 4-week treatment phase and a 2-week home exercise phase. Functional disability was measured using the Northwick Park Neck Pain Questionnaire and pain was assessed using the McGill Short Form Pain Questionnaire. Cervical motion was measured by a cervical range of motion device (CROM) and the range of shoulder abduction with a mediclino inclinometer. Manipulative physiotherapy treatment involved a cervical lateral glide mobilization technique. Following treatment, visual analysis revealed beneficial effects on pain, functional disability as well as cervical and shoulder mobility. These improvements were maintained over the home exercise phase and at 1-month follow-up. The single case limits generalization of the findings, but the results support previous studies in this area and gives further impetus to controlled clinical trials.

Interstitial cystitis: A complex visceral pain syndrome

Case reports of patients with painful idiopathic bladder ulceration and symptoms of dysuria and frequency first appeared in the late 19th century. The term interstitial cystitis (IC) was coined soon after, yet for nearly a century this disorder has been underrecognized or dismissed as a psychosomatic symptom complex seen mostly in women. Since the mid-1980s, patient self-advocacy has won federal and other support to develop consensus approaches to the clinical diagnosis and evaluation of IC, and to investigate its pathophysiology. Diverse etiologies, many supported by credible preclinical models, have been advanced for this disorder or group of disorders. Treatments remain heterogeneous and empirical. Recent insights into visceral pain and hyperalgesia, together with clinical and basic research on IC, suggest that self-sustaining peripheral and central nociceptive sensitization after any of several inciting events is the final common pathway that leads to IC. IC shares many features in common with other debilitating, self-sustaining neurogenic pain syndromes recognized in other visceral organs or somatic sites. One may advance the term complex visceral pain syndrome to encourage a holistic and mechanistic rather than organ-specific, empiric approach to the diagnosis, treatment, and taxonomy of chronic neurogenic pain evoked by a spectrum of insults to distinct visceral organs.

Effect of lamotrigin on the development of neurogenic pain syndrome in rats

Analgesic activity of a new anticonvulsive agent lamotrigin was studied on the model of neurogenic pain syndrome produced in rats by penicillin applied to the dorsal surface of the spinal cord and by dissection of the sciatic nerve. Lamotrigin was shown to have a profound analgesic activity. It can be used as an efficient prophylactic agent for prevention of chronic pain syndromes by suppression of the generators of pathologically enhanced excitation in the nociceptive structures which are the pathophysiological basis of the chronic pain syndromes.