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dr. Ken Wirastuti, MKes, Sp.SBagian Ilmu Penyakit Saraf
Fakultas Kedokteran-Universitas Islam Sultan Agung
Classification of Neuropathic Pain Duration
– Acute neuropathic pain (< 3 months)– Chronic neuropathic pain(>3 months)
Location Peripheral neuropathic pain Central neuropathic pain Sympathetically maintained pain
Describe Non-painful stimuli are now painful Can be episodic or continuous Example: trigeminal neuralgia (light touch)
Nonsympathetically mediated pain=Peripheral Neuropathic Pain is due to damage to a peripheral nerve without autonomic change (eg, post-herpetic neuralgia, neuroma formation).
Central Neuropathic Pain arises from abnormal central nervous system (CNS) activity (eg, phantom limb pain, pain from spinal cord injuries, and post-stroke pain).
Sympathetically mediated pain from peripheral nerve lesion and associated with autonomic changes (eg, complex regional pain syndrome I and II [reflex sympathetic dystrophy and causalgia]).
What is Neuropathic Pain? Nyeri biasanya bertahan lebih lama dan merupakan proses
input sensorik yang abnormal oleh sistem saraf perifer atau Seringkali tidak diketahui penyebabnya dan respon
terhadap terapi standart buruk lebih sulit diobati Dapat berakhir indefinitely dan bahkan meningkat dari
waktu ke waktu Mengakibatkan disabilitas berat
Wall PD. Textbook of Pain. 4th ed. 1999; Dworkin RH, et al. Arch of Neuro. 2003;60:1524-1534; Belgrade MJ. Postgraduate Medicine.1999;106(6):127-140.
Neuropathic Orofacial Pain Perubahan menetap pada daerah dimana saraf
pertamakali mengalami injuri Perubahan tersebut dapat mengakibatkan nyeri yang
berlangsung terus meski telah sembuh Sistem saraf dapat mengalami perubahan baik di
perifer muapun di sentral Nyeri bisa diprovokasi oleh sentuhan ringan, panas,
dingin (Allodynia, Hyperalgesia) Nyeri paroxysmal, nyeri umum, tumpul sampai
tajam, seperti ditusuk, seperti disetrum Nyeri kronis yang berasal dari otak, saraf kranialis,
wajah dan leher. Dapat diterapi secara efektif jika diagnosa sudah
ditegakkan.
How Neuropathic Pain Happens
When nerves become damaged or injured, they stop working properly May send the wrong signal to the brain Injured nerves might tell the brain that your
foot is experiencing burning pain even when you aren’t stepping on something hot
Nerves can be injured or damaged in a number of ways, including a spinal cord injury or a medical condition such as diabetes, shingles or a stroke
Price SA. Pathophysiology: Clinical Concepts of Disease Processes. 5th ed; 1997
Pain MediatorsCell Damage
Brain
Spinal cord
Aa K+ BK
PG
Nociceptor
Peptides, eg, SUBSTANCE P
HISTAMINE
SEROTONIN
Mast Cell
PlateletAa = arachidonic acid; BK = bradykinin; PG = prostaglandin
Role of Neurotransmitters
Excitatory Glutamate, aspartate, ATP Mediate afferent synaptic transmission
Inhibitory GABA, glycine, norepinephrine, 5-HT, adenosine,
Ach Analgesia at spinal and higher levels Altered function hyperalgesia, neuropathic or
chronic pain
GABA = -aminobutyric acid; 5-HT = 5-hydroxytryptamine (serotonin); Ach = acetylcholineDougherty PM, Raja SN. In: Benzon HT, et al, eds. Essentials of Pain Medicine and Regional Anesthesia; 1999:7–9.
Role of NeuropeptidesRole of NeuropeptidesExcitatory Substance P, neurokinin A Ca2+, induce sensitization, hyperalgesia Transsynaptic transmitters
Inhibitory Somatostatin, enkephalins, endorphins,
dynorphins Modulate intracellular cAMP, K+
Act at , , opioid receptorscAMP = cyclic adenosine monophosphateDougherty PM, Raja SN. In: Benzon HT, et al, eds. Essentials of Pain Medicine and Regional Anesthesia; 1999:7–9.
(Peripheral Afferent Nerves)
Central SensitizationPeripheral
Sensitization Tissue Injury
C-fiber output Hyperalgesia (1, 2)
Allodynia Activation of NMDA
receptors
Spinal cord
Sensitization
Gottschalk A et al. Am Fam Physician. 2001;63:1979-84.
InjuryInjury
Pai
n I
nte
nsi
ty
10
8
6
4
2
0
Stimulus Intensity
NormalPain
Response
Allodynia
Hyperalgesia
Hyperalgesia—heightened sense of pain to noxious stimuli
Allodynia—pain resulting from normally painless stimuli
HyperalgesiaPrimary Sensitization of primary neurons threshold to noxious
stimuli within site of injury May include response to innocuous stimuli pain from suprathreshold stimuli Spontaneous pain
Secondary Sensitization of primary neurons in surrounding uninjured areas May involve:
– Peripheral sensitization– Central sensitization
Raja SN, et al. In: Wall PB, Melzack R, eds. Textbook of Pain. 4th ed; 1999:11–57.
Allodynia
Pain evoked by innocuous stimuli Central sensitization pain produced
by A fibers1
Possibly mediated by spinal NMDA receptors2
1. Woolf CJ. Drugs. 1994;47(suppl 5):1–9.2. Dolan S, Nolan AM. Neuroreport. 1999;10(3):449–452.
Possible Descriptions of Neuropathic Pain
Sensations numbness tingling burning paresthetic paroxysmal lancinating electriclike raw skin shooting deep, dull, bonelike ache
Signs/Symptoms allodynia: pain from a
stimulus that does not normally evoke pain
thermal mechanical
hyperalgesia: exaggerated response to a normally painful stimulus
Neuropathic Pain is Different from Muscle/skeletal Pain
Neuropathic Pain Muscle/skeletal Pain
Chronic pain (months/years) Acute pain (hours or days)
Caused by injury or disease to nerves
Caused by injury or inflammation that affects both the muscles and
joints
Mild to excruciating pain that can last indefinitely
Moderate to severe pain that disappears when the injury heals
Causes extreme sensitivity to touch –simply wearing light
clothing is painful
Causes sore, achy muscles
Sufferers can become depressed or socially withdrawn because they see no relief in sight and
may experience sleep problems
Sufferers can become anxious and distressed but optimistic
about relief from pain
Wall PD. Textbook of Pain. 4th ed; 1999; Jude EB. Clin in Pod Med and Surg.1999;16:81-97; Price SA. Pathophysiology: Clinical Concepts of Disease Processes. 5th ed; 1997: Goldman L. Cecil Textbook of Medicine. 21st ed; 2000
Emotional and Social Impact of Neuropathic PainPeople with neuropathic pain report: Difficulty sleeping A lack of energy Drowsiness Difficulty concentrating Strained relationships with family and friends An inability to work, walk, or even wear
clothes as the contact with their skin can cause an unbearable burning pain
Meyer-Rosberg K. Euro J of Pain. 2001;5:379-389; Berger A.. Pain. 2004;5(3):143-9
The most common neuropathicpain syndromes in the orofacial traumatic neuropathy; trigeminal neuroma; postherpetic neuralgia; diabetic neuropathy; cancer-related neuropathy; neuropathy induced by acquired
immunodeficiency syndrome, or AIDS;