Neuropathic Pain. Dr. Christopher A. Jenner Consultant in Pain Medicine and Anaesthesia, SMH 25 th  September 2007
Agenda <ul><li>Definition </li></ul><ul><li>Physiology </li></ul><ul><li>Acute </li></ul><ul><li>Chronic </li></ul><ul><li...
Definitions  <ul><li>Pain.  ‘An unpleasant  sensory  and  emotional  experience which we primarily associate with tissue d...
Definitions (2) <ul><li>Time-course:   </li></ul><ul><li>•  acute  </li></ul><ul><li>•  chronic </li></ul><ul><li>Type:   ...
Pain Physiology <ul><li>(boring) </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
 
Pain Physiology  (funky version)  www.londonpainconsultants.com
 
Prevalence <ul><li>Acute pain </li></ul><ul><li>•  SMH 13,213 operations p.a.  (Nov 03-04, DSU 41%) </li></ul><ul><li>•  S...
The Challenges of Acute Pain <ul><li>•  Primary Care </li></ul><ul><li>• ↑  healthcare utilisation </li></ul><ul><li>•  Se...
Acute Pain Management <ul><li>Non-pharmacological </li></ul><ul><li>•  RICE </li></ul><ul><li>Pharmacological </li></ul><u...
The Challenges of Chronic Pain <ul><li>Bio-psycho-social model </li></ul><ul><li>Individual and societal costs </li></ul><...
Massive Financial Burden <ul><li>NHS/ DWP/ tax-payers </li></ul><ul><li>•  Lower back pain  (CSAG 1994) </li></ul><ul><li>...
Physical and Alternative Treatments
Physical and Alternative Treatments <ul><li>•  Physical-  heat/ cold/ TENS/ hydro/ supports/ US/ IR </li></ul><ul><li>•  M...
Any Vets in the audience? <ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
5. (a)  Veterinary practitioners?
Headache!
Pharmacological Treatment
Pharmacological Treatment <ul><li>•  WHO analgesic ladder  (abridged) </li></ul><ul><li>•  + tramadol </li></ul><ul><li>• ...
Opioid Therapy <ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
 
 
Pharmacological treatment of Neuropathic Pain <ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
Neuropathic Pain Management <ul><li>Antidepressants-  Amitryptilline </li></ul><ul><li>Anticonvulsants-  Gabapentin/ Prega...
<ul><li>NMDA antagonists </li></ul><ul><li>Sympatholytics </li></ul><ul><li>GABA -ergics </li></ul><ul><li>Capsaicin </li>...
Future Agents for Neuropathic Pain <ul><li>Ziconotide  (sea snail, conus magnus) </li></ul><ul><li>P2X3-  (purine) recepto...
Psychologicaly based therapy
Pain Management <ul><li>Psychological </li></ul><ul><li>CBT </li></ul><ul><li>Operant Conditioning </li></ul><ul><li>Psych...
Pain Management Programmes (MDT) <ul><li>●  Medication </li></ul><ul><li>•  Coping </li></ul><ul><li>•  Contingency </li><...
Minimally Invasive Pain Management
Chronic Pain Management <ul><li>•  Nerve block techniques:  </li></ul><ul><li>- Epidurals </li></ul><ul><li>- Facets </li>...
Neuropathic Pain Management <ul><li>Non-pharmacological </li></ul><ul><li>•  Nerve blockade-   lumbar sympathectomy/ stell...
The Kit www.londonpainconsultants.com
 
The Target www.londonpainconsultants.com
 
C-arm
Radiofrequency
Epiduroscopy
IDET
Disc Dekompressor
Vertebroplasty
Exotica www.londonpainconsultants.com
Nerve Stimulation
Nerve Stimulation (2)
Intrathecal Pumps
Intrathecal Pumps (2)
The Future? www.londonpainconsultants.com
The Future? <ul><li>Demographics </li></ul><ul><li>•  Healthcare advances </li></ul><ul><li>• ↑  Patient expectations and ...
Summary <ul><li>Very common (1 in 7 UK) </li></ul><ul><li>Time course- acute n chronic </li></ul><ul><li>Nociceptive and n...
<ul><li>Any Questions </li></ul>
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Neuropathic Pain 25.9.07

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Neuropathic Pain

Causes, Mechanisms and Treatment of Neuropathic Pain

Presented to General Practitioners and Hospital Doctors in London

25th September 2007

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Neuropathic Pain 25.9.07

  1. 1. Neuropathic Pain. Dr. Christopher A. Jenner Consultant in Pain Medicine and Anaesthesia, SMH 25 th September 2007
  2. 2. Agenda <ul><li>Definition </li></ul><ul><li>Physiology </li></ul><ul><li>Acute </li></ul><ul><li>Chronic </li></ul><ul><li>Neuropathic </li></ul><ul><li>Differences </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  3. 3. Definitions <ul><li>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) </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  4. 4. Definitions (2) <ul><li>Time-course: </li></ul><ul><li>• acute </li></ul><ul><li>• chronic </li></ul><ul><li>Type: </li></ul><ul><li>• nociceptive </li></ul><ul><li>• neuropathic </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  5. 5. Pain Physiology <ul><li>(boring) </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  6. 7. Pain Physiology (funky version) www.londonpainconsultants.com
  7. 9. Prevalence <ul><li>Acute pain </li></ul><ul><li>• SMH 13,213 operations p.a. (Nov 03-04, DSU 41%) </li></ul><ul><li>• SMH 484 operations p.m. (Sep 04, Main, 15% PCA/ epi) </li></ul><ul><li>• Chronic pain </li></ul><ul><li>• 7-14% UK population </li></ul><ul><li>• ‘ 1 in 7’ figure </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  8. 10. The Challenges of Acute Pain <ul><li>• Primary Care </li></ul><ul><li>• ↑ healthcare utilisation </li></ul><ul><li>• Secondary Care </li></ul><ul><li>• ↑ length stay/ complications </li></ul><ul><li>• 10-15% post-op chronic pain (Macrae) </li></ul>
  9. 11. Acute Pain Management <ul><li>Non-pharmacological </li></ul><ul><li>• RICE </li></ul><ul><li>Pharmacological </li></ul><ul><li>• WHO ladder (amended from cancer) </li></ul><ul><li>Step 1 paracetamol/ NSAID/ COX 2 </li></ul><ul><li>Step 2 + weak opioids </li></ul><ul><li>Step 3 + strong opioids </li></ul>
  10. 12. The Challenges of Chronic Pain <ul><li>Bio-psycho-social model </li></ul><ul><li>Individual and societal costs </li></ul><ul><li>Biological- pain/ suffering/ disability </li></ul><ul><li>Psychological- anxiety/ depression </li></ul><ul><li>Social- work/ relationship/ family/ benefits </li></ul>
  11. 13. Massive Financial Burden <ul><li>NHS/ DWP/ tax-payers </li></ul><ul><li>• Lower back pain (CSAG 1994) </li></ul><ul><li>• NHS £481 million </li></ul><ul><li>• The Exchequer £1.4 billion </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  12. 14. Physical and Alternative Treatments
  13. 15. Physical and Alternative Treatments <ul><li>• Physical- heat/ cold/ TENS/ hydro/ supports/ US/ IR </li></ul><ul><li>• Manipulation- PxTx/ chiropracter/ osteopathy/ deep tissue massage </li></ul><ul><li>• Alternative- acupuncture </li></ul>
  14. 16. Any Vets in the audience? <ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  15. 17. 5. (a) Veterinary practitioners?
  16. 18. Headache!
  17. 19. Pharmacological Treatment
  18. 20. Pharmacological Treatment <ul><li>• WHO analgesic ladder (abridged) </li></ul><ul><li>• + tramadol </li></ul><ul><li>• + opioids- buprenorphine TDD/ oxycontin/ fentanyl TDD </li></ul><ul><li>• (New: sufentanyl TDD/ product X ) </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  19. 21. Opioid Therapy <ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  20. 24. Pharmacological treatment of Neuropathic Pain <ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  21. 25. Neuropathic Pain Management <ul><li>Antidepressants- Amitryptilline </li></ul><ul><li>Anticonvulsants- Gabapentin/ Pregabalin/ Carbamazepine/ Valproate </li></ul><ul><li>Opioids </li></ul><ul><li>Local Anaesthetics- Lignocaine/ EMLA </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  22. 26. <ul><li>NMDA antagonists </li></ul><ul><li>Sympatholytics </li></ul><ul><li>GABA -ergics </li></ul><ul><li>Capsaicin </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  23. 27. Future Agents for Neuropathic Pain <ul><li>Ziconotide (sea snail, conus magnus) </li></ul><ul><li>P2X3- (purine) receptor antagonists (ATP) (knockout mice) </li></ul><ul><li>Epibatidine (Equadorian poison dart frog) </li></ul><ul><li>Morphine and ketamine </li></ul><ul><li>Regular gabapentin </li></ul><ul><li>Dexmetomidine </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  24. 28. Psychologicaly based therapy
  25. 29. Pain Management <ul><li>Psychological </li></ul><ul><li>CBT </li></ul><ul><li>Operant Conditioning </li></ul><ul><li>Psychoanalysis </li></ul><ul><li>Relaxation </li></ul><ul><li>Biofeedback </li></ul><ul><li>• Psychiatric </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  26. 30. Pain Management Programmes (MDT) <ul><li>● Medication </li></ul><ul><li>• Coping </li></ul><ul><li>• Contingency </li></ul><ul><li>• Pacing </li></ul><ul><li>• Education </li></ul><ul><li>• Goals (SMART- specific/ measured/ agreed/ realistic/ timed) </li></ul><ul><li>• Pain Behaviours </li></ul><ul><li>• Reinforcement </li></ul><ul><ul><li>www.londonpainconsultants.com </li></ul></ul>
  27. 31. Minimally Invasive Pain Management
  28. 32. Chronic Pain Management <ul><li>• Nerve block techniques: </li></ul><ul><li>- Epidurals </li></ul><ul><li>- Facets </li></ul><ul><li>- Tenoperiostial </li></ul><ul><li>- ON </li></ul><ul><li>- SSN </li></ul><ul><li>- Occipital N </li></ul><ul><li>- Ilioinguinal </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  29. 33. Neuropathic Pain Management <ul><li>Non-pharmacological </li></ul><ul><li>• Nerve blockade- lumbar sympathectomy/ stellate/ guanethidine </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  30. 34. The Kit www.londonpainconsultants.com
  31. 36. The Target www.londonpainconsultants.com
  32. 38. C-arm
  33. 39. Radiofrequency
  34. 40. Epiduroscopy
  35. 41. IDET
  36. 42. Disc Dekompressor
  37. 43. Vertebroplasty
  38. 44. Exotica www.londonpainconsultants.com
  39. 45. Nerve Stimulation
  40. 46. Nerve Stimulation (2)
  41. 47. Intrathecal Pumps
  42. 48. Intrathecal Pumps (2)
  43. 49. The Future? www.londonpainconsultants.com
  44. 50. The Future? <ul><li>Demographics </li></ul><ul><li>• Healthcare advances </li></ul><ul><li>• ↑ Patient expectations and involvement </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  45. 51. Summary <ul><li>Very common (1 in 7 UK) </li></ul><ul><li>Time course- acute n chronic </li></ul><ul><li>Nociceptive and neuropathic </li></ul><ul><li>Massive socio-economic impact </li></ul><ul><li>Multiple treatment modalities </li></ul><ul><li>www.londonpainconsultants.com </li></ul>
  46. 52. <ul><li>Any Questions </li></ul>

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