Neuropathic Pain 25.9.07
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Neuropathic Pain 25.9.07

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Neuropathic Pain

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 Neuropathic Pain 25.9.07 Presentation Transcript

  • Neuropathic Pain. Dr. Christopher A. Jenner Consultant in Pain Medicine and Anaesthesia, SMH 25 th September 2007
  • Agenda
    • Definition
    • Physiology
    • Acute
    • Chronic
    • Neuropathic
    • Differences
      • www.londonpainconsultants.com
  • 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)
      • www.londonpainconsultants.com
  • Definitions (2)
    • Time-course:
    • • acute
    • • chronic
    • Type:
    • • nociceptive
    • • neuropathic
    • www.londonpainconsultants.com
  • Pain Physiology
    • (boring)
      • www.londonpainconsultants.com
  •  
  • Pain Physiology (funky version) www.londonpainconsultants.com
  •  
  • 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
      • www.londonpainconsultants.com
  • 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
    • www.londonpainconsultants.com
  • 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?
      • www.londonpainconsultants.com
  • 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 )
      • www.londonpainconsultants.com
  • Opioid Therapy
      • www.londonpainconsultants.com
  •  
  •  
  • Pharmacological treatment of Neuropathic Pain
      • www.londonpainconsultants.com
  • Neuropathic Pain Management
    • Antidepressants- Amitryptilline
    • Anticonvulsants- Gabapentin/ Pregabalin/ Carbamazepine/ Valproate
    • Opioids
    • Local Anaesthetics- Lignocaine/ EMLA
      • www.londonpainconsultants.com
    • NMDA antagonists
    • Sympatholytics
    • GABA -ergics
    • Capsaicin
      • www.londonpainconsultants.com
  • 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
    • www.londonpainconsultants.com
  • Psychologicaly based therapy
  • Pain Management
    • Psychological
    • CBT
    • Operant Conditioning
    • Psychoanalysis
    • Relaxation
    • Biofeedback
    • • Psychiatric
      • www.londonpainconsultants.com
  • Pain Management Programmes (MDT)
    • ● Medication
    • • Coping
    • • Contingency
    • • Pacing
    • • Education
    • • Goals (SMART- specific/ measured/ agreed/ realistic/ timed)
    • • Pain Behaviours
    • • Reinforcement
      • www.londonpainconsultants.com
  • Minimally Invasive Pain Management
  • Chronic Pain Management
    • • Nerve block techniques:
    • - Epidurals
    • - Facets
    • - Tenoperiostial
    • - ON
    • - SSN
    • - Occipital N
    • - Ilioinguinal
    • www.londonpainconsultants.com
  • Neuropathic Pain Management
    • Non-pharmacological
    • • Nerve blockade- lumbar sympathectomy/ stellate/ guanethidine
    • www.londonpainconsultants.com
  • 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?
    • Demographics
    • • Healthcare advances
    • • ↑ Patient expectations and involvement
    • www.londonpainconsultants.com
  • Summary
    • Very common (1 in 7 UK)
    • Time course- acute n chronic
    • Nociceptive and neuropathic
    • Massive socio-economic impact
    • Multiple treatment modalities
    • www.londonpainconsultants.com
    • Any Questions