Approccio Interventistico Dolore Cranio Faciale

REGIONE SICILIA
Azienda ospedaliera
REGIONE SICILIA
Ospedali Azienda
Riuniti Villaospedaliera
Sofia Cervello
Palermo
Ospedali Riuniti Villa Sofia
Cervello
Palermo
UO di Anestesia Rianimazione
e Terapia del Dolore
direttore Dr. Maria Lucia
NUOVE STRATEGIE IN NEUROFISIOLOGIA
CLINICA
UPDATE SUL DOLORE NEUROPATICO E
CRANIO-FACIALE
Palermo - Palazzo Sclafani 2010
L’aproccio interventistico
al dolore cranio-faciale
Trigeminal neuralgia
Idiopathic Neuralgia
Secondary Neuralgia :
neurovascular compression
neoplastic n.
multiple sclerosis
postraumatic n.
postherpetic n.
Trattamenti
Farmaci: NSAID, anticonvulsivanti,antidepressivi,oppioidi
medicazioni con anestetico locale e corticosteroidi e
tossina botulinica
Lesioni : rizotomia alcoolica Hartell 1912
rizotomia con RF
Sweet e Wepsic1965
compressione con palloncino Mullan e Lichtor 1968 -1983
rizotomia con glicerolo
Hakanson 1981
rizotomia con PRF (la sua effecacia è discussa)
radiochirurgia Gamma knife or Linac 1950
Procedure chirurgiche : decompressione microvascolare
Neuromodulazione : SCS, DBS, MCS, PNS e PSS
Solo il 30-40% dei pazienti con dolore
neuropatico cronico presenta un pain relief >
50% con terapia farmacologica sistemica.
medicazioni con anaestetico locale e
corticosteroidi su n. sovraorbitario ,
n. mascellare ,
n.mandibolare,.
Ganglio di Gasser
Iniezioni di tossina botulinica
Tossina botulinica A
Usata per strabismo ( FDA 1079) ,
blefarospasmo (FDA 1989)
Si evidenzia l’efficacia su emicrania,
cefalea tensiva, cefalea cronica quotidiana,
nevralgia del trigemino.
Viene iniettata su fronte, muscoli
epicranici, massetere, muscoli nucali etc
Può determinare riduzione della intensità e
della frequenza degli attacchi per 4-6 mesi.
E’ ripetibile
Neuromodulazione farmacologica
Emergenze epicraniche
N. sovraorbitario , n. mascellare ,
n.mandibolare, NGO, NPO .
Ganglio di Gasser
Lesioni: rizotomia alcoolica Hartell 1912
rizotomia con RF
Sweet e Wepsic1965
compressione con palloncino
Mullan e Lichtor 1968 -1983
rizotomia con glicerolo
Hakanson 1981
rizotomia con PRF (la sua effecacia è discussa)
radiochirurgia Gamma knife or Linac 1950
ALCOOL ETILICO meccanismo d’azione
Rumbsy, Finean 1966
Dwyer, Gibb 1980
De Leon, Cerasola, Ditonto 2000
Jain, Gupta 2001
precipitazione di lipoproteine e mucoproteine con
sclerosi delle fibre nervose e
danno mielinico > degenerazione walleriana
+rigenerazione assonale
nel ganglio: distruzione cellulare senza rigenerazione
FENOLO
Usato inizialmente come colorante dei vasi e
vasodilatatore , poi come anestetico locale e quindi
come neurolitico per il controllo del dolore sul ganglio
di Gasser, ed altro.
La concentrazione del 5% produce blocco selettivo
delle piccole fibre e denaturazione delle proteine.
Concentrazioni del 5–6% producono coagulazione
delle proteine, demielinizzazione e degenerazione
walleriana con distruzione delle fibre nocicettive
Ha effetto neurotossico diretto
Ed anche effetto secondario a distruzione vascolare
Heavner 1989
GLICEROLO
Usato prevalentemente per la neurolisi del ganglio
di Gasser
Provoca edema delle cellule di Schwann , axolisi e
degenerazione walleriana
Danneggia le piccole fibre mieliniche e le fibre
amieliniche
La sensibilità faciale è conservata
Rischio di neuropatia e di spread nello spazio
subaracnoideo
Feldstein 1988
L’uso di agenti neurolitici chimici nel
trattamento del dolore cronico comporta
degli effetti collaterali indesiderati per cui
é necessario che venga eseguito da
esperti, sotto guida fluoroscopica, e che il
paziente sia accuratamente selezionato ed
informato.
Microcompressione con palloncino
RADIOFREQUENZA
Classica: 75°C
85”
500.000 HZ
Pulsata : 2 cicli attivi di 20 msec con pausa di 480 msec
42° C
140”
45 volts
impedenza inferiore a 400 Ohm
STORIA della RF
Tecniche elettrochirurgiche 1920
Lesioni SNC 1950
Mullan et al. Percutaneous intermedullary cordotomy
utilizing the unipolar anodal electrolytic lesion J. Neurosurg
1965
Rosomof et al. Percutaneous RF cervical cordotomy
tecnic J. Neurosurg 1965
Sweet, Wepsic Controlled termocoagulation of
trigeminal ganglion and rootlets for differential destruction
of pain fibers.
J. Neurosurg 1974
STORIA della RF
Shealy Percutaneous RF denervation of the lumbar facets
1975
Uematsu Percutaneous electrothermocoagulation of
spinal nerve trunk, ganglion end rootlets. 1977
Slujter, Metha 1980 elettrodi di piccolo diametro
Cosman et al. 1984 : calore o elettricità
Slappendel et al :….no difference between 40° C and 67° C
treatment Pain 1997
PNS
Generatore
corrente elettrica
elettrodo
punta
campo elettromagnetico
movimento molecolare
calore
T° > 45° C = lesione
T° > 90° C = ebollizione
- la corrente penetra nel corpo dalla punta attiva e ne esce
attraverso la piastra
- la forma dell’elettrodo condiziona la diffusione della corrente
effetto elettrico : concentrico a pennello davanti alla punta
effetto termico : a pera
RF rischio delle procedure
Procedure selettive
: rischio generico
emorragico e/o settico
danno neurologico
anestesia dolorosa
Latenza ?
Durata ?
Fasi di risposta alla PRF secondo
Sluijter
Stunning phase: immediato sollievo dal dolore
Post procedure disconfort : fino a 3 settimane
Fase di effetti clinici positivi : variabile
Fase di ritorno del dolore : dopo 4-24 mesi di
risoluzione
Altri trattamenti di RF o PRF
per algie craniofaciali
Radiofrequenza su ganglio sfenopalatino
PRF su GRD della radice dorsale di C2
Paziente supino con collo esteso
proiezione LL in fluoroscopia .
rotazione sagittale per evidenziare al meglio i forami
intervert.
approccio laterale
tecnica tunnel mirata al centro del margine posteriore del
forame
PRF su GRD C3
La radiofrequenza nelle due modalità termica e
pulsata , costituisce per la terapia del dolore,
uno strumento di lavoro prezioso che
- con buona selettività
- con minima invasività della procedura
- con minima o nulla lesività
- con minimo rischio
usata appropriatamente , determina un buon
controllo del dolore che si prolunga per mesi o
per anni.
Nel momento in cui il dolore si ripresenti si
può rivalutare la possibilità di ripetere la
procedura.
Neuroloesione
neuromodulazione
Target of neurostimulation for T N
Ganglion stimulation with percoutaneous or open
approach shows high rate of electrode migration: 50%
at 1 year.
DBS is used to treat anesthesia dolorosa and
deafferentation pain with 25-50% success.
MCS is used to treat anesthesia dolorosa and
deafferentation pain.
SCS with electrodes implanted at the C1C2 level is
good for treating pain in the 3th branch Barolat 1988
Peripheral Nerve Stimulation is used in neuropathic
pain that origins from the area of one or more
periferic nerves
Consensus Statement of Eu Fed of IASP 1998
Advantages of PNS and PSS
Low invasiveness
Testability
Reversibility of effect
Adjustability of setting
Some working of action of PNS and PSS
Stimulation of the fibres Ab
Selective block of the small fibres
Effect mediated by the opioid system
partly naloxon –
reversible
Reduction of the stimulant
neurotransmitters
Modulation of GABA neurons
Activation of the Immediate Early Genes
Prolonged peripheral nerve stimulation
induces persistent changes in
excitability of human motor cortex.
Charlton et al. J Neurol Sci. 2003; 208(1-2):79-85
because can induce plastic changes in
the motor cortex’s organization
PNS in Trigeminal Neuralgia
Shelden 1966 (lead wrapped around the mandibular nerve)
Wall and Sweet 1967 (lead into infraorbital foramen )
White and Sweet 1969 (lead applied to temporal area, to
stimulate the branches of mandibular nerve)
Weiner and Reed 1999 ( percutaneous lead insertion in the
vicinity of the occipital nerves)
Slavin and Burchiel 1999 (occipital and trigeminal implants)
Slavin and Burchiel 2000 (occipital and trigeminal implants)
Lou 2000
Hammer et al. 2001
Norenberg et al. 2001
Weiner et al. 2001
Alo’ et al. 2002
Dunteman 2002
Popeney et Alo’ 2003
Weiner 2003
Oh et al. 2004
Johnson and Burchiel 2004
Matharu et al. 2004
Slavin et al. 2005
Slavin and Wess 2005
Kapural et al.2005
Rodrigo-Royo et al. 2005
Slavin et al. 2006
Parameters of stimulation of PNS
frequency 10 - 20 HZ
P w : various
Intensity 0,5- 2 V
Polarity : from + to – proximal
Modality : cyclic ( because gives less tolerance )
Parameters of subcoutaneus stimulation
frequency various
P w : 180-400 msec ( high pw gets better recruitment of
fibres in SCS and perhaps in PNS
also)
Intensity :various
Polarity : from + to - : the + is antalgic
Modality : cyclic , because gives less tolerance
European Federation of Neurological Societies
studies when a patient with neuropathic pain
should try a neurostimulation procedure.
EFNS guidelines on stimulation therapy for
neuropathic pain European Journal of Neurology 2007
40
Recent studies with non-invasive brain stimulation—eg, repetitive
transcranial magnetic stimulation (rTMS) and transcranial direct current
stimulation (tDCS)—using new parameters of stimulation have shown
encouraging results. These studies explored new parameters of
stimulation, such as repeated sessions of tDCS with 2 mA for the
treatment of chronic central pain.
Several questions still need to be addressed before any firm conclusion
about this
therapy is made. Other parameters of stimulation need to be further
explored.
The duration of the therapeutic effects is another important issue to be
considered, especially because the current devices for brain stimulation
do not allow patients to receive this therapy in their homes; therefore,
maintenance therapy regimens, as well as the development of portable
stimulators, need to be investigated.
Further trials must determine the optimum parameters of stimulation.
After that, confirmatory, larger studies
41 are mandatory.
Transcranial magnetic stimulation (TMS) and transcranial
direct current stimulation (tDCS) are two
noninvasive brain stimulation techniques that can
modulate activity in specific regions of the cortex.
At this point, their use in brain stimulation is primarily
investigational; however, there is clear evidence that
these tools can reduce pain and modify neurophysiologic
correlates of the pain experience. TMS has also been used
to predict response to surgically implanted stimulation for
the treatment of chronic pain.
42
43
44
Recommandations EFNS 2007
DBS : positive evidence in peripheral
neuropathic pain including pain after
amputation and facial pain.
It is equivocal in CPSP ( central post stroke
pain )
MCS : level C evidence that MCS is useful in
50-60% of patients with CPSP and
central or peripheral facial neuropathic
pain
Recommandations EFNS 2007
PNS and NRS conclusion not found
TENS high frequency is possibly better than
placebo ( level C ) but probably worse
than low frequency stimulation (level B
)
rTMS induces significant pain relief in CPSP
and several other neuropathic pain
conditions ( level B ) but is short acting
“ The absence of evidence is not evidence
of absence of effect.”
EFNS
some procedures are relatively new and it is
necessary to increase the experiences, using
adequate comparators, estabilished outcome
measures, and to evaluate the harms and the
side-effects.
Peripheral stimulation for treatment of trigeminal postherpetic
neuralgia and trigeminal posttraumatic neuropathic pain: a pilot
study
Johnson and Burchiel. Neurosurgery 2004
10 patients with trigeminal neuropathic pain
after facial trauma (6 p.) or herpes zoster
infection (4 p.), received implant for PNS of
supraorbital or infraorbital branches.
Follow up at 22-31 months
70% has > 50% pain relief
70% declines medication use
2 failures in postherpetic group (50%)
complications with reoperation in 30%
Trigeminal branch stimulation for intractable neuropathic
pain: technical note.
Slavin and Wess. Neuromodulation 2005
8 patients with TNP by surgery-3, trauma-2,
infection-3 : 1 p. had bilateral SON PNS, 2 p.
had occipital+ION or SON electrodes, 1 p. had
SON and ION electrodes on same side
Follow up at 13-50 months
7/8 had > 50% pain relief during the trial
6 p. at latest follow up
1 p. presents skin erosion over SO electrode
1 p. removes the system 26 months after
Trigeminal and occipital peripheral nerve stimulation for
craniofacial pain: a single-institution experience and review of
the literature
Slavin et al. Neurosurg. Focus
2006
30 p. 22 female , 8 male
3 p. had ION PNS, 4 p. had SON PNS, 13 p. had
occipital PNS, 1 p. had ION+ occipital and 1 p. had
SON+occipital PNS. 12 p. had bilateral stimulation:
10 p. had occipital and 2 p. had SON
22 p. (73%) > 50% pain relief at the trial
1 p. revision for cable of the connection
1 p. revision after 2 weeks for electrode migration
Follow up at 1-77 months
14 p. had > 50% pain relief; 3 p. had < 50% p.r.
5 remotions: 2 for improvement in pain intensity,2 for
fall of benefit,1 for infection in the pocket 2 y. after.
3 p. repeat operation for skin erosion,infection of the
connection, migration of electrode
41 p. with TNP
30 p. had a trial stimulation
22 p. had PNS devices implanted
16 p. had >50% pain relief ( 2 p: without
stim.)
3 p. had <50% pain relief
16/41= 39% patients evaluated had pain relief
>50% 16/30= 53% patients enrolled had pain relief
>50%
Our experience
7 patients with craniofacial neuropathic pain:
5 males 2 females
Location of pain : occipital
1 p.
2th rt. branch
1 p.
2th, 3th lt. branches 4 p.
3th lt. branch
1 p.
Causative factors : 1 cronic daily headache
1 multiple sclerosis
4 idiopathic
1 neoplastic
Z.V. 23/03/1922 , f.
PSS suboccipital 2003
M.T.
M. ,
RF 2004 (4 e 5) 2006 – PSS 2nd branch 2007 - PRF DRG C2
2008
DB. A. , 02/01/1969 , f.
RF 2005 – PRF 2007 - RF 2007 –PSS 2nd and 3th lt. Branches
2008
B. S. 01/09/1952 , m. ( M.S.)
PRF 2-2007 , 9-2007 - RF 10-2007 , 01-2008, PSS 2nd and
3th lt. Left branches 2009 right branches 2010
C. D. 15/02/1970 , m.
PRF 2007 , 7/ 2008 , 10/ 2008 , PSS 3th lt. branch 2009
LG G ……….. M PSS 1th and 2nd lt. Branches 2008
DB E….m PSS 2nd and 3th lt. Branches 2008
c2
Diapositiva 54
c2
consip; 11/06/2009
Results
Follow up at 2- 36 months :
VAS , drugs use ,daily living activities social relations.
2 p. had a trial unsatisfactory
5 p. received the implant
1 p. 5 months after the implant has no pain
relief even if he feels paresthesias in the
painful area.
3 p. have > 50% of pain relief
2 p. of these decline the medication use
3 p. improve quality of life and social relations
Complications
Migration - one lead tunnelled before the ear,
slipped behind the ear, but it keeps his
efficacy to relieve the pain around the
ear.
Skin erosion over the anchor : one case in the trial
period
Altre sedi di applicazione degli
elettrocateteri consentono di trattare altre
forme di cefalea quali la emicrania , la
cefalea a grappolo, la cefalea cronica
quotidiana.
Sono in corso delle esperienze sul
trattamento delle algie craniofaciali con
Ziconotide intratecale.
GRAZIE
PER
L’ATTENZIONE