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Pathophysiology & methods of pain control PRESENTED BY :BHANU PRIYA MODERATED BY : DR. AKSHAY D SHETTY
Your Logo Here CONTENTS 1. INTRODUCTION 2. CLASSIFICATION OF PAIN 3. PATHOPHYSIOLOGY 4. MANAGEMENT OF PAIN 5. CONCLUSION
Your Logo Here INTRODUCTION • Pain is the most common symptom of any illness. • The alerting function of pain evokes protective responses, and is intended to keep tissue damage to a minimum. • If tissue damage is unavoidable, a cascade of changes occurs in the peripheral and central nervous system (CNS) responsible for the perception of pain
Your Logo Here An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage - INTERNATIONAL ASSOCIATION FOR THE STUDY OF PAIN (IASP)
Your Logo Here CLASSIFICATION OF PAIN Based on duration Acute Chronic based on intensity mild Moderate severe Classification of Chronic Pain Second Edition, IASP Task Force on Taxonomy
Your Logo Here Based on aetiology Nociceptive pain Somatic pain Visceral pain Neuropathic pain Peripheral Central Inflammatory Classification of Chronic Pain Second Edition, IASP Task Force on Taxonomy
Your Logo Here DEFENITIONS Allodynia* Pain due to a stimulus that does not normally provoke pain. Analgesia Absence of pain in response to stimulation which would normally be painful. Anesthesia dolorosa Pain in an area or region which is anesthetic. Dysesthesia An unpleasant abnormal sensation, whether spontaneous or evoked. Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy
Your Logo Here Hyperalgesia* Increased pain from a stimulus that normally provokes pain. Hypoalgesia Diminished pain in response to a normally painful stimulus. Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy
Your Logo Here Nociception The neural process of encoding noxious stimuli. Classification of Chronic Pain Second Edition, IASP Task Force on Taxonomy
Your Logo Here Nociceptive Pain (perception of noxious stimuli) • Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors. • Sensory endings that are activated by such stimuli are known as nociceptors Classification of Chronic Pain Second Edition, IASP Task Force on Taxonomy
Your Logo Here Nociceptors A high-threshold sensory receptor of the peripheral somatosensory nervous system that is capable of transducing and encoding noxious stimuli. Classification of Chronic Pain Second Edition, IASP Task Force on Taxonomy
Your Logo Here • respond only to pain • free nerve endings of primary afferent Aδ and C fibres. • Distributed throughout the body (skin, viscera, muscles, joints, meninges) Classification of Chronic Pain Second Edition, IASP Task Force on Taxonomy
Your Logo Here Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11
Your Logo Here 1. Mechanosensitive nociceptors (of Aδ fibers), which are sensitive to intense mechanical stimulation (such as pinching with pliers) or injury to tissues. 2. Temperature-sensitive (thermosensitive) nociceptors (of Aδ fibers), which are sensitive to intense heat and cold. 3. Polymodal nociceptors (of C fibers), which are sensitive to noxious stimuli that are mechanical, thermal, or chemical in nature. Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11
Your Logo Here Pain pathways – 4 stages Transduction • where an external noxious stimulus is converted into electrophysiological activity. Transmission • this coded information is relayed via the spinal cord to the brainstem and thalamus. modulation • the body alters a pain signal as it is transmitted along the pain pathway Perception • connections between the thalamus and higher cortical centers control and integrate the affective response to pain. Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11
Your Logo Here Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11
Your Logo Here 1. Transduction • Peripheral activation of the nociceptors • This occurs in the peripheral axons where primary afferent neurons are activated by a noxious stimulus. • Receptors found on these axons include vanilloid receptor 1, which responds to heat, capsaicin and protons, and Mas-related G protein– coupled receptors, which are thought to mediate nociceptive behavior to mechanical stimuli Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11
Your Logo Here Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11
Your Logo Here 2.Transmission • pain impulses are transmitted by a 2-fiber system , includes Aδ and C fibers. • Both fibers end in the dorsal horn of the spinal cord • Aδ fibers synapse with neurons in laminas I and V • C fibers synapse in laminas I and II. • There are three major components of the transmission system. Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11
Your Logo Here 1st order neuron The peripheral sensory neurons with their cell bodies residing in the dorsal root ganglia transmit impulses from the site of transduction at their peripheral terminal to the spinal cord where the central terminals synapse with second-order neurons. 2nd order neuron The spinal neurons are the second component in the transmission network. These cells send projections to the thalamus and various brainstem and diencephalic structures. 3rd order neuron Finally, neurons of the brainstem and diencephalon form the third component of the transmission network as they project to various cortical sites. Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11
Your Logo Here Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11
Your Logo Here Dorsal horn of the spinal cord • On entering the spinal cord from dorsal spinal roots, the pain fibers terminate on relay neurons in dorsal horns. • The dorsal horn can be divided histologically into ten layers called Rexed laminae • Laminae I-VI correspond to the dorsal horn. • C and Aδ fibres terminate in laminae I (marginal zone) and laminae II (substantia gelatinosa). • Further, they are carried to the brain by the neospinothalamic tract or the paleo spinothalamic tract.
Your Logo Here • DRG neurons are classically pseudo unipolar. • Sensory neuron cell bodies are located in the dorsal root ganglia (DRG). • one process extends into the peripheral nerve. • other process extends centrally, transmitting information through the dorsal root into the spinal cord.
Your Logo Here A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
Your Logo Here A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
Your Logo Here Lateral spinothalamic tract A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
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Your Logo Here The Neospinothalamic tract • Aδ fibers terminate in the dorsal horns, cross over to the opposite side of the cord and continue upwards to the brain as anterolateral columns. • Most fibers terminate in the ventro basal or posterior nuclei of the thalamus few fibers terminate in the reticular areas. • Signals are also sent to the somatosensory cortex. • Glutamate is the neurotransmitter secreted in the spinal cord at Aδ fibres. A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
Your Logo Here The Palaeospinothalamic tract C fibers terminate in the substantia gelatinosa of dorsal horn. They cross over to the opposite side and continue as anterolateral ascending tracts. terminates in brain stem in one of the following areas: 1. Reticular nuclei of medulla, pons and mesencephalon. 2. Tectal area of mesencephalon deep.10-25% of the fibers pass to the thalamus. 3. Periaqueductal gray region surrounding the aqueduct of Sylvius. A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
Your Logo Here • The signals are relayed into the intra laminal and ventrolateral nuclei of thalamus, hypothalamus and basal regions of brain. • The pain carried by slow chronic pathway is poorly localised. • Substance P is the neurotransmitter concerned with slow pain A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
Your Logo Here A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
Your Logo Here A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
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Your Logo Here 3.MODULATION OF PAIN • body possesses an endogenous mechanism that dissociates and modulates (enhances or diminishes) the transmission of pain. • 3 mechanisms segmental inhibition endogenous opioid system descending inhibitory nerve system A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
Your Logo Here Segmental inhibition / gate theory (Melzack and Wall) • the synapses between (Aδ and C fibers)and neurons in the dorsal horn of the spinal cord can be blocked. • occurs when large myelinated nerve fibers (Aβ) that sense touch stimulate the inhibitory nerve in the spinal cord, which in turn inhibits the transmission of the pain signal by C fiber afferents. • This explains why rubbing an injury reduces the sensation of pain. • The mechanism TENS for pain control is based on this theory. A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
Your Logo Here Endogenous Opioid System • The endogenous opioid system arose when receptors to opium derivatives were found in the central nervous system (PAG, ventral medulla) and spinal cord (lamina I and II). • they include enkephalins, endorphins, and dynorphins. • These bind to the opioid receptors in the pain pathway and modulate the pain signal A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
Your Logo Here Descending Inhibitory Nerve System controls the transmission by using the neurotransmitters serotonin and norepinephrine These work by (1) direct inhibition of the dorsal horn cells transmitting pain. (2) inhibition of excitatory dorsal horn neurons that work to enhance/ exacerbate the transmission of pain. (3) excitation of inhibitor neurons in the dorsal horn. A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
Your Logo Here 4. PERCEPTION OF PAIN A complex network of cortical structures is activated during pain perception. four cortical structures important for the perception of pain . 1.Somatosensory cortex (SI) 2.secondary somatosensory cortex (SII) 3. ACC 4.insular cortex (IC) (SI and SII) -sensory discriminative aspect of pain ACC and IC - affective component of pain. A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
Your Logo Here OROFACIAL PAIN PATHWAY • Pain and temperature information from receptors in the face is carried into the brain on the fifth nerve. • The cell bodies of the first order neurons are in the trigeminal ganglion • the central processes of the cells make synapses in a nucleus in the medulla known as the spinal trigeminal nucleus. • This nucleus is actually continuous with the dorsal horn of the spinal cord. A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
Your Logo Here • Second-order neurons located in the spinal trigeminal nucleus send their axons across the midline to form the ventral trigeminothalamic tract. • travels to the ventral posterior medial(VPM) nucleus of the thalamus • Third-order neurons in the ventral posterior nucleus and in other thalamic nuclei then project to the cortex via the internal capsule. A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
Your Logo Here A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
Your Logo Here Visceral pain A striking characteristic of the brain is that although it receives and processes nociceptive information, the brain itself has no sensation of pain. • During brain surgery, the patient is often awake and has no pain sensation from the brain tissue itself. • The structures that have to be anesthetized during brain surgery are the dura mater, the bones of the skull, and the extracranial soft tissues. Pathophysiology Of Pain , Vikram A Londhey* Supplement To Journal Of The Association Of Physicians Of India
Your Logo Here • The visceral pain in the thorax and abdominal cavity is transmitted through the C fibers. • The visceral pain fibers synapse in the spinal cord on same second order neurons that receive pain signals from the skin fibers. • Hence pain in the remote or deep seated organs is experienced in the skin which have a common embryological dermatomal origin. • This is called as referred pain. Pathophysiology Of Pain , Vikram A Londhey* Supplement To Journal Of The Association Of Physicians Of India
Your Logo Here Methods Of Pain Control
Your Logo Here 1. PHARMACOLOGICAL METHODS A. Paracetamol B. Non-steroidal anti-inflammatory drugs (NSAIDs) C. Opioids D. Antidepressants E. Anticonvulsants F. Antiarrhythmics G. Topical analgesics Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here A. Paracetamol • the first-line analgesic for all pain states • analgesic and antipyretic • mode of action is still uncertain • thought to act centrally near the hypothalamus and possibly through a COX-3 mechanism. • action on serotoninergic systems and a peripheral action on bradykinin-sensitive chemoreceptors. Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here phenazone • antipyretic and anti-inflammatory • COX-3 mechanism in the dorsal horn of the spinal cord. • 500 mg to 1 g orally • poorer safety profile • cause agranulocytosis, anaphylaxis, haemolysis and nephrotoxicity. • rarely used as an oral analgesic and its use is restricted in many countries. Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here B. Non-steroidal anti-inflammatory drugs (NSAIDs) Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here C. OPIOIDS Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here D . Antidepressants Tricyclic antidepressants • TCAs inhibit the reuptake of noradrenaline (NA) and serotonin (5-HT) • Amitriptyline is the prototypic • first choice in the treatment of peripheral and central neuropathic pain • prevention of tension headaches and migraines or as analgesics in LBP and fibromyalgia. Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here Serotonin and noradrenaline reuptake inhibitors • venlafaxine, duloxetine, and milnacipran • should not be used in patients who are severely hypertensive or with a history of cardiac failure, coronary artery disease or ECG abnormalities Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here E. Anticonvulsants Gabapentin/pregabalin • act on presynaptic Ca 2 + channels which causes reduction in neurotransmission in abnormally active sensory neurons. • first choice treatments of all types of peripheral neuropathic Pain • sedation and dizziness. Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here Carbamazepine • blocks voltage gated Na + channels • principal indication- trigeminal neuralgia (TN). • dizziness and sedation, hepatitis, skin toxicity, and hyponatraemia. Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here F. Antiarrhythmics Mexiletine diabetic peripheral neuropathy ,spinal cord injury pain and HIV associated pain. prominent GI and neurological side effects initiated at low dose, gradually titrated up, and patient carefully monitored for side effects. Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here G. Topical analgesics 1. Topical NSAIDs 2. Topical lidocaine patches (5 % )- postherpetic neuralgia 3. Capsaicin - patch (8%, Qutenza)- neuropathic pains Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here Novel and atypical agents Ketamine • intravenous anaesthetic agent • analgesic at subanaesthetic doses • Uses - phantom limb, PHN, and central pain • confusion, hallucinations, delirium Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here Baclofen • GABA B agonist • depress synaptic transmission • trigeminal neuralgia. Clonidine • selective α-2 agonist • Similar analgesic effect to opiates • No respiratory depression and less abuse potential • PHN and diabetic neuropathy Ziconitide • synthetic derivative of a toxin • Binds irreversibly to calcium channels. • severe, intractable pain. Calcitonin • osteoporotic vertebral wedge fractures. Cannabinoids • cancer pain • Central neuropathic pain • multiple sclerosis (MS). Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here 2.INTERVENTIONAL THERAPIES 1. Peripheral nerve blocks 2. Specific nerve blocks Occipital nerve Trigeminal nerve-mental, infraorbital, IANB 3. Plexus blocks brachial, lumbar, and sacral. Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here 4. Neurolytic blocks • placing a toxic chemical in or around a nerve in order to permanently disrupt its function. • phenol, ethyl alcohol and glycerol. • Trigeminal ganglion block Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here Other interventional techniques used in chronic pain 1. Intra-articular injections • LA and steroids • Arthritis • short-term symptomatic relief 2. Botulinum toxin • blocks the release of acetylcholine from the NMJ and reduces spasticity. • Myofacial pain syndrome. Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here 3. Cryoanalgesia • relief of pain by the application of cold • application of a cryoprobe to a nerve in order to produce nerve injury by freezing the nerve (cryoneurolysis). • results in axonal disruption followed by degeneration of the axon distal to lesion with the preservation of the fibrous architecture • Intercostal nerves, spinal nerve roots, the greater occipital nerves, and neuromas. Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here 4. Radiofrequency (RF) lesioning • produces heat within tissues by applying a high frequency current between 2 electrodes • one within the tissue and one on the surface of the body. • results in thermocoagulation • trigeminal neuralgia Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here 3.NEUROMODULATION 1. Transcutaneous electrical nerve stimulation 2. Spinal cord stimulation 3. Deep brain stimulation 4. Motor cortex stimulation Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here 1. Transcutaneous electrical nerve stimulation • TENS units deliver electrical impulses activating sensory nerve afferents, particularly A β fibres, responsible for touch sensation. • gate control theory of Melzac and Wall • A β afferents would obtund incoming pain signals at the spinal segmental level. • Acute pain- acute back pain, orofacial and dental pain, fractured ribs. • Chronic pain- OA and RA, postherpetic neuralgia, TN, peripheral neuropathies • contraindications — pacemakers, implanted defibrillators, epilepsy, and pregnancy Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here 2. Spinal cord stimulation electrodes implanted in the epidural space to deliver electrical impulses which excite fibres and neurons in the spinal cord. produce a pleasant paraesthesia over the painful region. • Failed back surgery syndrome with radicular pain • CRPS • Neuropathic pain secondary to nerve injury • Refractory angina Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here 3. Deep brain stimulation long-term implantation of stimulating electrodes Indications • Post-traumatic brain injury • Poststroke pain • Thalamic syndrome • Cranial nerve pain: • Anaesthesia dolorosa • Dental pain • Postherpetic pain. Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here 4. Motor cortex stimulation involves the stimulation of motor cortex, using an implanted electrode plate Indications Intractable neuropathic pain syndromes. Central • Spinal cord injury • Thalamic stroke/lesion. Peripheral • Trigeminal neuropathic pain • Peripheral nerve injury • Phantom pain or plexus avulsion. Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here 4. SURGICAL TECHNIQUES- Trigeminal Neuralgia 1. Microvascular decompression • gold standard surgical treatment • posterior fossa craniotomy • visualize the whole extent of the nerve from the root entry zone into the pons to Meckel’s cave and identify the possible source of vascular compression. • superior cerebellar artery is the most common culprit • Nerve root decompressed by gentle dissection of vessel from the nerve root • separated by placement of interposing material Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here 2. Partial sensory rhizotomy (PSR) • Partial section of trigeminal sensory root is done • Best for pain in maxillary (V2) and mandibular (V3) divisions. Complications of MVD and PSR • Death • Posterior fossa haematoma/infarction • Ipsilateral deafness • Trigeminal sensory loss/dysesthesia. • Other cranial nerve deficits (IV and VII) Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here 3. Percutaneous Ablative Treatments • involve passage of a needle, under brief GA, through the foramen ovale under X-ray control to target the trigeminal ganglion. • The ganglion is then lesioned using either radiofrequency thermocoagulation (RTC), glycerol rhizotomy (GR), or balloon compression (BC). Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here 4.Stereotactic radiosurgery • single high dose of radiation to a well-defined Target. • Gamma knife • SRS induces demyelination and inflammation of trigeminal nerve and selective damage to less myelinated pain fibres • Advantages • • Non-invasive • • No sedation/anaesthesia required • • Low rates of facial numbness and anaesthesia dolorosa. Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here Physical therapies Physiotherapy • form of treatment which employs physical approaches to promote, maintain, and restore physical, psychological, and social wellbeing. • manual therapy, the application of electrophysical modalities, and therapeutic exercises. Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here Acupuncture treatment modality of piercing the skin with fine needles to elicit a therapeutic effect. Therapeutic effects • Local release of trophic and vasoactive neuropeptides • Segmental modulation • descending inhibitory pathways. • Generally (release of neuropeptides and hormones into the blood and CSF). Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here Psychological therapy • Stress management • Cognitive behavioural therapy • hypnosis Oxford Handbook of Pain Management Edited by Peter Brook
Your Logo Here WHO's cancer pain ladder for adults
Your Logo Here REFERENCES 1. Wall and melzacks textbookof pain , 3rd edition 2. A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner 3. Orofacial Pain Guidelines for Assessment, Diagnosis, and Management, Sixth Edition ,The American Academy of Orofacial Pain 4. Classification Of Chronic Pain, Second Edition, IASP Task Force On Taxonomy 5. Pathophysiology Of Pain , Vikram A Londhey* Supplement To Journal Of The Association Of Physicians Of India 6. Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11 7. Head, Face, And Neck Pain: Science, Evaluation, And Management An Interdisciplinary Approach, Noshir R. Mehta 8. Oxford Handbook of Pain Management Edited by Peter Brook 9. Handbook of Pain Management Editor Michael Serpell
Your Logo Here 10. Practice Guidelines for Acute Pain Management in the Perioperative Setting An Updated Report by the American Society of Anesthesiologists Task Force on Acute Pain Management 11. Theories of pain: from specificity to gate control Massieh Moayedi , Karen D. Davis J Neurophysiol 109: 5–12, 2013 12. ReviewGeneral Pathways of Pain Sensation and the Major Neurotransmitters Involved in Pain Regulation,Mun Fei Yam Int. J. Mol. Sci. 2018, 19, 2164
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pain

  • 1. Pathophysiology & methods of pain control PRESENTED BY :BHANU PRIYA MODERATED BY : DR. AKSHAY D SHETTY
  • 2. Your Logo Here CONTENTS 1. INTRODUCTION 2. CLASSIFICATION OF PAIN 3. PATHOPHYSIOLOGY 4. MANAGEMENT OF PAIN 5. CONCLUSION
  • 3. Your Logo Here INTRODUCTION • Pain is the most common symptom of any illness. • The alerting function of pain evokes protective responses, and is intended to keep tissue damage to a minimum. • If tissue damage is unavoidable, a cascade of changes occurs in the peripheral and central nervous system (CNS) responsible for the perception of pain
  • 4. Your Logo Here An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage - INTERNATIONAL ASSOCIATION FOR THE STUDY OF PAIN (IASP)
  • 5. Your Logo Here CLASSIFICATION OF PAIN Based on duration Acute Chronic based on intensity mild Moderate severe Classification of Chronic Pain Second Edition, IASP Task Force on Taxonomy
  • 6. Your Logo Here Based on aetiology Nociceptive pain Somatic pain Visceral pain Neuropathic pain Peripheral Central Inflammatory Classification of Chronic Pain Second Edition, IASP Task Force on Taxonomy
  • 7. Your Logo Here DEFENITIONS Allodynia* Pain due to a stimulus that does not normally provoke pain. Analgesia Absence of pain in response to stimulation which would normally be painful. Anesthesia dolorosa Pain in an area or region which is anesthetic. Dysesthesia An unpleasant abnormal sensation, whether spontaneous or evoked. Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy
  • 8. Your Logo Here Hyperalgesia* Increased pain from a stimulus that normally provokes pain. Hypoalgesia Diminished pain in response to a normally painful stimulus. Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy
  • 9. Your Logo Here Nociception The neural process of encoding noxious stimuli. Classification of Chronic Pain Second Edition, IASP Task Force on Taxonomy
  • 10. Your Logo Here Nociceptive Pain (perception of noxious stimuli) • Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors. • Sensory endings that are activated by such stimuli are known as nociceptors Classification of Chronic Pain Second Edition, IASP Task Force on Taxonomy
  • 11. Your Logo Here Nociceptors A high-threshold sensory receptor of the peripheral somatosensory nervous system that is capable of transducing and encoding noxious stimuli. Classification of Chronic Pain Second Edition, IASP Task Force on Taxonomy
  • 12.
  • 13. Your Logo Here • respond only to pain • free nerve endings of primary afferent Aδ and C fibres. • Distributed throughout the body (skin, viscera, muscles, joints, meninges) Classification of Chronic Pain Second Edition, IASP Task Force on Taxonomy
  • 14. Your Logo Here Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11
  • 15. Your Logo Here 1. Mechanosensitive nociceptors (of Aδ fibers), which are sensitive to intense mechanical stimulation (such as pinching with pliers) or injury to tissues. 2. Temperature-sensitive (thermosensitive) nociceptors (of Aδ fibers), which are sensitive to intense heat and cold. 3. Polymodal nociceptors (of C fibers), which are sensitive to noxious stimuli that are mechanical, thermal, or chemical in nature. Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11
  • 16. Your Logo Here Pain pathways – 4 stages Transduction • where an external noxious stimulus is converted into electrophysiological activity. Transmission • this coded information is relayed via the spinal cord to the brainstem and thalamus. modulation • the body alters a pain signal as it is transmitted along the pain pathway Perception • connections between the thalamus and higher cortical centers control and integrate the affective response to pain. Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11
  • 17. Your Logo Here Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11
  • 18. Your Logo Here 1. Transduction • Peripheral activation of the nociceptors • This occurs in the peripheral axons where primary afferent neurons are activated by a noxious stimulus. • Receptors found on these axons include vanilloid receptor 1, which responds to heat, capsaicin and protons, and Mas-related G protein– coupled receptors, which are thought to mediate nociceptive behavior to mechanical stimuli Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11
  • 19. Your Logo Here Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11
  • 20. Your Logo Here 2.Transmission • pain impulses are transmitted by a 2-fiber system , includes Aδ and C fibers. • Both fibers end in the dorsal horn of the spinal cord • Aδ fibers synapse with neurons in laminas I and V • C fibers synapse in laminas I and II. • There are three major components of the transmission system. Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11
  • 21. Your Logo Here 1st order neuron The peripheral sensory neurons with their cell bodies residing in the dorsal root ganglia transmit impulses from the site of transduction at their peripheral terminal to the spinal cord where the central terminals synapse with second-order neurons. 2nd order neuron The spinal neurons are the second component in the transmission network. These cells send projections to the thalamus and various brainstem and diencephalic structures. 3rd order neuron Finally, neurons of the brainstem and diencephalon form the third component of the transmission network as they project to various cortical sites. Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11
  • 22. Your Logo Here Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11
  • 23. Your Logo Here Dorsal horn of the spinal cord • On entering the spinal cord from dorsal spinal roots, the pain fibers terminate on relay neurons in dorsal horns. • The dorsal horn can be divided histologically into ten layers called Rexed laminae • Laminae I-VI correspond to the dorsal horn. • C and Aδ fibres terminate in laminae I (marginal zone) and laminae II (substantia gelatinosa). • Further, they are carried to the brain by the neospinothalamic tract or the paleo spinothalamic tract.
  • 24. Your Logo Here • DRG neurons are classically pseudo unipolar. • Sensory neuron cell bodies are located in the dorsal root ganglia (DRG). • one process extends into the peripheral nerve. • other process extends centrally, transmitting information through the dorsal root into the spinal cord.
  • 25. Your Logo Here A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
  • 26. Your Logo Here A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
  • 27. Your Logo Here Lateral spinothalamic tract A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
  • 29. Your Logo Here The Neospinothalamic tract • Aδ fibers terminate in the dorsal horns, cross over to the opposite side of the cord and continue upwards to the brain as anterolateral columns. • Most fibers terminate in the ventro basal or posterior nuclei of the thalamus few fibers terminate in the reticular areas. • Signals are also sent to the somatosensory cortex. • Glutamate is the neurotransmitter secreted in the spinal cord at Aδ fibres. A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
  • 30. Your Logo Here The Palaeospinothalamic tract C fibers terminate in the substantia gelatinosa of dorsal horn. They cross over to the opposite side and continue as anterolateral ascending tracts. terminates in brain stem in one of the following areas: 1. Reticular nuclei of medulla, pons and mesencephalon. 2. Tectal area of mesencephalon deep.10-25% of the fibers pass to the thalamus. 3. Periaqueductal gray region surrounding the aqueduct of Sylvius. A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
  • 31. Your Logo Here • The signals are relayed into the intra laminal and ventrolateral nuclei of thalamus, hypothalamus and basal regions of brain. • The pain carried by slow chronic pathway is poorly localised. • Substance P is the neurotransmitter concerned with slow pain A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
  • 32. A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
  • 33. Your Logo Here A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
  • 34. Your Logo Here A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
  • 36. Your Logo Here 3.MODULATION OF PAIN • body possesses an endogenous mechanism that dissociates and modulates (enhances or diminishes) the transmission of pain. • 3 mechanisms segmental inhibition endogenous opioid system descending inhibitory nerve system A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
  • 37. Your Logo Here Segmental inhibition / gate theory (Melzack and Wall) • the synapses between (Aδ and C fibers)and neurons in the dorsal horn of the spinal cord can be blocked. • occurs when large myelinated nerve fibers (Aβ) that sense touch stimulate the inhibitory nerve in the spinal cord, which in turn inhibits the transmission of the pain signal by C fiber afferents. • This explains why rubbing an injury reduces the sensation of pain. • The mechanism TENS for pain control is based on this theory. A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
  • 38.
  • 39. Your Logo Here Endogenous Opioid System • The endogenous opioid system arose when receptors to opium derivatives were found in the central nervous system (PAG, ventral medulla) and spinal cord (lamina I and II). • they include enkephalins, endorphins, and dynorphins. • These bind to the opioid receptors in the pain pathway and modulate the pain signal A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
  • 40. Your Logo Here Descending Inhibitory Nerve System controls the transmission by using the neurotransmitters serotonin and norepinephrine These work by (1) direct inhibition of the dorsal horn cells transmitting pain. (2) inhibition of excitatory dorsal horn neurons that work to enhance/ exacerbate the transmission of pain. (3) excitation of inhibitor neurons in the dorsal horn. A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
  • 41. Your Logo Here 4. PERCEPTION OF PAIN A complex network of cortical structures is activated during pain perception. four cortical structures important for the perception of pain . 1.Somatosensory cortex (SI) 2.secondary somatosensory cortex (SII) 3. ACC 4.insular cortex (IC) (SI and SII) -sensory discriminative aspect of pain ACC and IC - affective component of pain. A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
  • 42. Your Logo Here OROFACIAL PAIN PATHWAY • Pain and temperature information from receptors in the face is carried into the brain on the fifth nerve. • The cell bodies of the first order neurons are in the trigeminal ganglion • the central processes of the cells make synapses in a nucleus in the medulla known as the spinal trigeminal nucleus. • This nucleus is actually continuous with the dorsal horn of the spinal cord. A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
  • 43. Your Logo Here • Second-order neurons located in the spinal trigeminal nucleus send their axons across the midline to form the ventral trigeminothalamic tract. • travels to the ventral posterior medial(VPM) nucleus of the thalamus • Third-order neurons in the ventral posterior nucleus and in other thalamic nuclei then project to the cortex via the internal capsule. A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
  • 44. Your Logo Here A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner
  • 45. Your Logo Here Visceral pain A striking characteristic of the brain is that although it receives and processes nociceptive information, the brain itself has no sensation of pain. • During brain surgery, the patient is often awake and has no pain sensation from the brain tissue itself. • The structures that have to be anesthetized during brain surgery are the dura mater, the bones of the skull, and the extracranial soft tissues. Pathophysiology Of Pain , Vikram A Londhey* Supplement To Journal Of The Association Of Physicians Of India
  • 46. Your Logo Here • The visceral pain in the thorax and abdominal cavity is transmitted through the C fibers. • The visceral pain fibers synapse in the spinal cord on same second order neurons that receive pain signals from the skin fibers. • Hence pain in the remote or deep seated organs is experienced in the skin which have a common embryological dermatomal origin. • This is called as referred pain. Pathophysiology Of Pain , Vikram A Londhey* Supplement To Journal Of The Association Of Physicians Of India
  • 48. Your Logo Here 1. PHARMACOLOGICAL METHODS A. Paracetamol B. Non-steroidal anti-inflammatory drugs (NSAIDs) C. Opioids D. Antidepressants E. Anticonvulsants F. Antiarrhythmics G. Topical analgesics Oxford Handbook of Pain Management Edited by Peter Brook
  • 49. Your Logo Here A. Paracetamol • the first-line analgesic for all pain states • analgesic and antipyretic • mode of action is still uncertain • thought to act centrally near the hypothalamus and possibly through a COX-3 mechanism. • action on serotoninergic systems and a peripheral action on bradykinin-sensitive chemoreceptors. Oxford Handbook of Pain Management Edited by Peter Brook
  • 50. Your Logo Here phenazone • antipyretic and anti-inflammatory • COX-3 mechanism in the dorsal horn of the spinal cord. • 500 mg to 1 g orally • poorer safety profile • cause agranulocytosis, anaphylaxis, haemolysis and nephrotoxicity. • rarely used as an oral analgesic and its use is restricted in many countries. Oxford Handbook of Pain Management Edited by Peter Brook
  • 51. Your Logo Here B. Non-steroidal anti-inflammatory drugs (NSAIDs) Oxford Handbook of Pain Management Edited by Peter Brook
  • 52. Your Logo Here C. OPIOIDS Oxford Handbook of Pain Management Edited by Peter Brook
  • 53. Your Logo Here D . Antidepressants Tricyclic antidepressants • TCAs inhibit the reuptake of noradrenaline (NA) and serotonin (5-HT) • Amitriptyline is the prototypic • first choice in the treatment of peripheral and central neuropathic pain • prevention of tension headaches and migraines or as analgesics in LBP and fibromyalgia. Oxford Handbook of Pain Management Edited by Peter Brook
  • 54. Your Logo Here Serotonin and noradrenaline reuptake inhibitors • venlafaxine, duloxetine, and milnacipran • should not be used in patients who are severely hypertensive or with a history of cardiac failure, coronary artery disease or ECG abnormalities Oxford Handbook of Pain Management Edited by Peter Brook
  • 55. Your Logo Here E. Anticonvulsants Gabapentin/pregabalin • act on presynaptic Ca 2 + channels which causes reduction in neurotransmission in abnormally active sensory neurons. • first choice treatments of all types of peripheral neuropathic Pain • sedation and dizziness. Oxford Handbook of Pain Management Edited by Peter Brook
  • 56. Your Logo Here Carbamazepine • blocks voltage gated Na + channels • principal indication- trigeminal neuralgia (TN). • dizziness and sedation, hepatitis, skin toxicity, and hyponatraemia. Oxford Handbook of Pain Management Edited by Peter Brook
  • 57. Your Logo Here F. Antiarrhythmics Mexiletine diabetic peripheral neuropathy ,spinal cord injury pain and HIV associated pain. prominent GI and neurological side effects initiated at low dose, gradually titrated up, and patient carefully monitored for side effects. Oxford Handbook of Pain Management Edited by Peter Brook
  • 58. Your Logo Here G. Topical analgesics 1. Topical NSAIDs 2. Topical lidocaine patches (5 % )- postherpetic neuralgia 3. Capsaicin - patch (8%, Qutenza)- neuropathic pains Oxford Handbook of Pain Management Edited by Peter Brook
  • 59. Your Logo Here Novel and atypical agents Ketamine • intravenous anaesthetic agent • analgesic at subanaesthetic doses • Uses - phantom limb, PHN, and central pain • confusion, hallucinations, delirium Oxford Handbook of Pain Management Edited by Peter Brook
  • 60. Your Logo Here Baclofen • GABA B agonist • depress synaptic transmission • trigeminal neuralgia. Clonidine • selective α-2 agonist • Similar analgesic effect to opiates • No respiratory depression and less abuse potential • PHN and diabetic neuropathy Ziconitide • synthetic derivative of a toxin • Binds irreversibly to calcium channels. • severe, intractable pain. Calcitonin • osteoporotic vertebral wedge fractures. Cannabinoids • cancer pain • Central neuropathic pain • multiple sclerosis (MS). Oxford Handbook of Pain Management Edited by Peter Brook
  • 61. Your Logo Here 2.INTERVENTIONAL THERAPIES 1. Peripheral nerve blocks 2. Specific nerve blocks Occipital nerve Trigeminal nerve-mental, infraorbital, IANB 3. Plexus blocks brachial, lumbar, and sacral. Oxford Handbook of Pain Management Edited by Peter Brook
  • 62. Your Logo Here 4. Neurolytic blocks • placing a toxic chemical in or around a nerve in order to permanently disrupt its function. • phenol, ethyl alcohol and glycerol. • Trigeminal ganglion block Oxford Handbook of Pain Management Edited by Peter Brook
  • 63. Your Logo Here Other interventional techniques used in chronic pain 1. Intra-articular injections • LA and steroids • Arthritis • short-term symptomatic relief 2. Botulinum toxin • blocks the release of acetylcholine from the NMJ and reduces spasticity. • Myofacial pain syndrome. Oxford Handbook of Pain Management Edited by Peter Brook
  • 64. Your Logo Here 3. Cryoanalgesia • relief of pain by the application of cold • application of a cryoprobe to a nerve in order to produce nerve injury by freezing the nerve (cryoneurolysis). • results in axonal disruption followed by degeneration of the axon distal to lesion with the preservation of the fibrous architecture • Intercostal nerves, spinal nerve roots, the greater occipital nerves, and neuromas. Oxford Handbook of Pain Management Edited by Peter Brook
  • 65. Your Logo Here 4. Radiofrequency (RF) lesioning • produces heat within tissues by applying a high frequency current between 2 electrodes • one within the tissue and one on the surface of the body. • results in thermocoagulation • trigeminal neuralgia Oxford Handbook of Pain Management Edited by Peter Brook
  • 66. Your Logo Here 3.NEUROMODULATION 1. Transcutaneous electrical nerve stimulation 2. Spinal cord stimulation 3. Deep brain stimulation 4. Motor cortex stimulation Oxford Handbook of Pain Management Edited by Peter Brook
  • 67. Your Logo Here 1. Transcutaneous electrical nerve stimulation • TENS units deliver electrical impulses activating sensory nerve afferents, particularly A β fibres, responsible for touch sensation. • gate control theory of Melzac and Wall • A β afferents would obtund incoming pain signals at the spinal segmental level. • Acute pain- acute back pain, orofacial and dental pain, fractured ribs. • Chronic pain- OA and RA, postherpetic neuralgia, TN, peripheral neuropathies • contraindications — pacemakers, implanted defibrillators, epilepsy, and pregnancy Oxford Handbook of Pain Management Edited by Peter Brook
  • 68. Your Logo Here 2. Spinal cord stimulation electrodes implanted in the epidural space to deliver electrical impulses which excite fibres and neurons in the spinal cord. produce a pleasant paraesthesia over the painful region. • Failed back surgery syndrome with radicular pain • CRPS • Neuropathic pain secondary to nerve injury • Refractory angina Oxford Handbook of Pain Management Edited by Peter Brook
  • 69. Your Logo Here 3. Deep brain stimulation long-term implantation of stimulating electrodes Indications • Post-traumatic brain injury • Poststroke pain • Thalamic syndrome • Cranial nerve pain: • Anaesthesia dolorosa • Dental pain • Postherpetic pain. Oxford Handbook of Pain Management Edited by Peter Brook
  • 70. Your Logo Here 4. Motor cortex stimulation involves the stimulation of motor cortex, using an implanted electrode plate Indications Intractable neuropathic pain syndromes. Central • Spinal cord injury • Thalamic stroke/lesion. Peripheral • Trigeminal neuropathic pain • Peripheral nerve injury • Phantom pain or plexus avulsion. Oxford Handbook of Pain Management Edited by Peter Brook
  • 71. Your Logo Here 4. SURGICAL TECHNIQUES- Trigeminal Neuralgia 1. Microvascular decompression • gold standard surgical treatment • posterior fossa craniotomy • visualize the whole extent of the nerve from the root entry zone into the pons to Meckel’s cave and identify the possible source of vascular compression. • superior cerebellar artery is the most common culprit • Nerve root decompressed by gentle dissection of vessel from the nerve root • separated by placement of interposing material Oxford Handbook of Pain Management Edited by Peter Brook
  • 72. Your Logo Here 2. Partial sensory rhizotomy (PSR) • Partial section of trigeminal sensory root is done • Best for pain in maxillary (V2) and mandibular (V3) divisions. Complications of MVD and PSR • Death • Posterior fossa haematoma/infarction • Ipsilateral deafness • Trigeminal sensory loss/dysesthesia. • Other cranial nerve deficits (IV and VII) Oxford Handbook of Pain Management Edited by Peter Brook
  • 73. Your Logo Here 3. Percutaneous Ablative Treatments • involve passage of a needle, under brief GA, through the foramen ovale under X-ray control to target the trigeminal ganglion. • The ganglion is then lesioned using either radiofrequency thermocoagulation (RTC), glycerol rhizotomy (GR), or balloon compression (BC). Oxford Handbook of Pain Management Edited by Peter Brook
  • 74. Your Logo Here 4.Stereotactic radiosurgery • single high dose of radiation to a well-defined Target. • Gamma knife • SRS induces demyelination and inflammation of trigeminal nerve and selective damage to less myelinated pain fibres • Advantages • • Non-invasive • • No sedation/anaesthesia required • • Low rates of facial numbness and anaesthesia dolorosa. Oxford Handbook of Pain Management Edited by Peter Brook
  • 75. Your Logo Here Physical therapies Physiotherapy • form of treatment which employs physical approaches to promote, maintain, and restore physical, psychological, and social wellbeing. • manual therapy, the application of electrophysical modalities, and therapeutic exercises. Oxford Handbook of Pain Management Edited by Peter Brook
  • 76. Your Logo Here Acupuncture treatment modality of piercing the skin with fine needles to elicit a therapeutic effect. Therapeutic effects • Local release of trophic and vasoactive neuropeptides • Segmental modulation • descending inhibitory pathways. • Generally (release of neuropeptides and hormones into the blood and CSF). Oxford Handbook of Pain Management Edited by Peter Brook
  • 77. Your Logo Here Psychological therapy • Stress management • Cognitive behavioural therapy • hypnosis Oxford Handbook of Pain Management Edited by Peter Brook
  • 79. Your Logo Here REFERENCES 1. Wall and melzacks textbookof pain , 3rd edition 2. A Textbook of Neuroanatomy , Second Edition Maria A. Patestas and Leslie P. Gartner 3. Orofacial Pain Guidelines for Assessment, Diagnosis, and Management, Sixth Edition ,The American Academy of Orofacial Pain 4. Classification Of Chronic Pain, Second Edition, IASP Task Force On Taxonomy 5. Pathophysiology Of Pain , Vikram A Londhey* Supplement To Journal Of The Association Of Physicians Of India 6. Anatomy, Physiology And Pharmacology Of Pain:clare Bridgestock , Colin P Rae, Anaesthesia And Intensive Care Medicine 14:11 7. Head, Face, And Neck Pain: Science, Evaluation, And Management An Interdisciplinary Approach, Noshir R. Mehta 8. Oxford Handbook of Pain Management Edited by Peter Brook 9. Handbook of Pain Management Editor Michael Serpell
  • 80. Your Logo Here 10. Practice Guidelines for Acute Pain Management in the Perioperative Setting An Updated Report by the American Society of Anesthesiologists Task Force on Acute Pain Management 11. Theories of pain: from specificity to gate control Massieh Moayedi , Karen D. Davis J Neurophysiol 109: 5–12, 2013 12. ReviewGeneral Pathways of Pain Sensation and the Major Neurotransmitters Involved in Pain Regulation,Mun Fei Yam Int. J. Mol. Sci. 2018, 19, 2164