![TYPES DE DOULEURS 2 GRANDES CATEGORIES Douleur neuropathique (périphérique ou centrale) Douleur nociceptive (excès de nociception) Consécutives à des lésions du système nerveux en l’absence de stimulation sur les récepteurs périphériques ,[object Object],[object Object],[object Object],[object Object],[object Object],Traduit, sur un système nerveux entièrement normal, un excès d’influx nociceptif](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
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CHU Fort-de-France Neurostimulation médullaire Dr MANZO
- 1. Évaluation et prise en charge des douleurs neuropathiques PLACE DE LA NEUROSTIMULATION MEDULLAIRE Dr MANZO Norbert. Neurochirurgie. CHU Fort de France. Janvier 2010
- 3. Douleur par excès de nociception Grosses Fibres A , A Douleur Petites Fibres Nociceptives C, A Tact Système Excitateur > Système Inhibiteur
- 4. Douleur Neuropathique Grosses Fibres A , A Douleur Petites Fibres Nociceptives C, A Tact Système Excitateur > Système Inhibiteur Lésion Nerveuse
- 11. Bruit de Fond Somesthésique Stimulation médullaire - Principe Petites Fibres Nociceptives Tact Grosses Fibres SM Lésion Nerveuse Douleur
- 13. Stimulation médullaire - Critères de sélection - Douleurs neuropathiques depuis > 6 mois - Douleurs pharmaco-résistantes sévères et invalidantes Échec du traitement médical bien conduit - Évaluation Multidisciplinaire dans une consultation douleur : . Évaluation quantitative et qualitative des troubles sensitifs . Bilan Neurophysiologique : EMG-PES-PEN . Bilan psycho-social - Intégrité des voies lemniscales = P.E.S. = Faisabilité - Test percutané positif
- 18. PISCES-Quad 3890 PLUS 3892 COMPACT 3891 Matériel : électrodes percutanées
- 19. Matériel : électrodes chirurgicales
- 22. Matériel : le système Restore Programmateur médecin N’Vision™ Neurostimulateur implantable Restore™ Télécommande patient Restore™ Chargeur Restore™
- 23. Quel stimulateur pour quel type de douleur ?
- 29. Montrant des améliorations significatives dans le soulagement de la douleur, la consommation d’antalgiques, la reprise du travail et la satisfaction des patients Median follow-up: 18 months * Implanted patients Nb d’études Nb de cas / taille de l’échantillon Résultats Soulagement ≥ 50 % * 65 1992/3313 62 % Pas d’antalgique 16 324/681 53 % Reprise du travail 15 405/1133 40 % Satisfaction du patient 6 147/220 70 %
- 31. Lazorthes, 1995 : Résultats / indication Résultats = % de succès (nombre de patients) Lazorthes Y et al. Neurochirurgie, 1995, 41, n°2, 73-88 De meilleurs résultats pour les lésions périphériques Radiculalgies 56 - 60 % (n=304) Lésions périphériques 90% (n=132) Lésions médullaires 34% (n=101)
Notes de l'éditeur
- FBSS defines a clinical situation in which patients continue to suffer from CBLP, even after technically, anatomically successful lumbosacral spine surgery 1 The terms FBSS and CBLP are often used interchangeably The syndrome is a complex pain problem with mixed neuropathic and nociceptive elements frequently involving the sympathetic nervous system Treatment of FBSS is a challenge, as conservative therapies (e.g. opioids, anti-epileptic drugs such as gabapentin, local anesthetics) and re-operation are often unsuccessful in providing adequate pain relief The difficulty is even greater in patients who have already undergone multiple spinal surgeries – results of subsequent surgical intervention in such patients are typically worse than for initial surgery 2 Leveque JC et at al. Neuromodulation 2001; 4(1): 1-19 Ohnmeiss DD, Rashbaum RF. Spine J 2001; 1: 358-63
- Conservative treatment is the standard of care for most patients with low back pain Rehabilitation therapy is used to treat the symptoms and to improve physical condition (i.e. to re-educate the muscles of the back and the abdomen and promote good postural practice) NSAIDs are widely prescribed for low back pain, along with other non-opioid analgesics, but they are usually only effective for a limited period of time Despite concern over the use of opioid analgesics in neuropathic pain, studies have shown that they can improve pain and function in patients with persistent low back pain, with a low incidence of abuse and addiction and manageable pharmacological effects 1 Some anticonvulsant and anesthetic (e.g. lidocaine) compounds have also been shown to be effective in neuropathic pain 2-4 Behavioral therapy (e.g. psychotherapy) is often an essential part of the management strategy Anderson VC, Israel Z. Curr Rev Pain 2000; 4: 105–11 Backonja MM, Serra J. Pain Medicine 2004; 5(S1): S48-S59 Sindrup SH, Jensen TS. Prog Pain Res Manage 2001; 21: 169–83 Jensen TS. Eur J Pain 2002; 6(Suppl A): 61-8
- Interventional procedures are increasingly becoming the method of choice over traditional surgery as they typically result in: Less pain Less scarring A quicker recovery time for patients A reduction in health care costs A multidisciplinary approach including conservative treatment and timely application of interventional procedures is essential for optimal management of CBLP
- Early intervention with SCS results in significantly greater pain relief in patients with FBSS 1 The success rate dropped from 93% (at 5.2 years follow-up) for those with <3-year delay between surgery and implantation to 9% (at 5.7 years follow-up) for those with greater than a 12-year waiting period A successful response to SCS was seen in more patients who had not received surgery (68%) than in those who had one or more previous surgeries (53%) However, the number of previous surgeries did not affect the response to SCS The shorter the duration of time between the first surgery and SCS, the better the response to SCS This suggests that pain becomes firmly established over time, leading to difficult in modification via SCS FBSS responded most favorably to SCS, followed by CRPS, peripheral vascular disease and multiple sclerosis Kumar K et al. Surg Neurol 1998; 50: 110–21
- Single-lead SCS may be inadequate to produce paresthesia coverage and corresponding pain relief in the lower back, as well as the leg Therefore, dual-lead stimulation systems (e.g. with two Octad leads) may enable better coverage and improve long-term treatment outcomes Two leads may be used to steer paresthesias, to correct for differences between the anatomical and physiological midline and to obtain better paresthesia coverage Dual-lead stimulation systems provide the potential to manage conditions with prominent low back pain or multiple pain foci Thus, the choice of leads is important to the success of SCS: Those with a predominant neuropathic leg pain component of FBSS respond best to single lead SCS, while greater success is seen with dual leads in patients who are more difficult to treat, such as those with complex, multilateral pain (e.g. severe FBSS) 1 Study has shown that 90% of patients with predominant axial low back pain initially treated with a single-lead system later required a second lead 2 The addition of a second lead resulted in 60% of patients considering themselves improved from their pre-operative condition The authors concluded that these technological advancements have broadened the potential indications for this mode of therapy Aló KM, Holsheimer J. Neurosurgery 2002; 50: 690–704 Ohnmeiss DD, Rashbaum RF. Spine J 2001; 1: 358-63
- Pharmacological management is the mainstay of treatment for neuropathic pain, yet only 50% of patients achieve adequate pain relief 1 The gold standard criterion of 50% or greater pain relief is a stringent measure and the fact that the majority of FBSS patients (62%) 2 achieve this highlights the efficacy of SCS Even a 30% reduction in pain represents a clinically important difference 3 Eisenberg E . JAMA 2005; 293(24): 3043–52 Taylor R et al. Spine 2005; 30(1): 152-60 Cruccu G et al. Eur J Neurol 2004, 11: 153-62
- SCS has been used successfully in FBSS for many years and has resulted in sustained pain relief in 68% of patients 1 Distressing pain was reduced by 12.6% and horrible pain was reduced by 43.5% This allows concomitant pain medication to be reduced (from 3-4 intakes per week before SCS to 1-2 intakes per day after SCS, corresponding to an improvement of more than 50%) Opioid consumption also decreased Pain relief is sustained over time, with 59% of patients treated with SCS continuing to receive successful pain relief 2 Of these, 43% had excellent (75%) pain relief and 57% had good (50-70%) pain relief Sustained pain relief was also seen in patients treated with SCS for low back pain and radicular pain after multiple failed back surgeries 3 75% continued to report at least 50% pain relief after 34 months follow up Van Buyten J-P et al. Eur J Pain 2001; 5: 299-307 Kumar K et al. Surg Neurol 1998; 50: 110-21 Leveque JC et al. Neuromodulation 2001; 4(1): 1-9
- The improvement in quality of life with SCS is more than double that seen with conventional pain therapies in patients with FBSS 1 Difficulties in sleeping and waking during the night as a result of pain also diminished markedly after SCS The duration of sleep was significantly increased from 4.5 h per night before SCS to 6.2 h after SCS Kumar K et al. Neurosurgery 2002; 51: 106-16
- Significant technological advances in stimulator design have broadened the indications for SCS to include axial low back pain, a group that is generally difficult to treat 1 88% of patients with unspecified FBSS were satisfied with treatment 2 , as were 70% of patients with predominantly axial low back pain 1 The majority of patients would have SCS, knowing what their outcome would be, and 78.8% would recommend SCS to others in a similar situation 1 Ohnmeiss DD, Rashbaum RF. Spine J 2001; 358-63 Kumar K et al. Neurosurgery 2002; 51: 106-16
- The table shows a meta-analysis of pooled outcomes with SCS for refractory neuropathic back and leg pain/FBSS case series (median follow-up 18 months) In some studies, ‘good or excellent’ pain relief was taken as the equivalent to the 50% or more cutoff Analysis showed that patient indication, study setting and duration of follow-up review were all significant predictors of pain relief Other clinical results that were also reported: A significant improvement in pooled functional capacity was seen across the three case series that reported this measure A pooled improvement in total Sickness Impact Profile (a quality of life measure) was seen across the two trials that assessed this criterion In the case series, 43% of patients with CBLP/FBSS experienced one or more complications with SCS The majority of these were due to electrode or lead problems (27%) Infections (6%), generator problems (6%), extension cable problems (10%), or other issues such as cerebrospinal fluid leaks (7%), accounted for the remainder No neurologic-related complications were reported Many complications may be reduced by following guidelines designed to improve the implantation technique 1 Kumar K et al. Spinal cord stimulation: practical guidelines to help avoid complications from an expert pan-European panel. Manuscript in preparation, 2005
- Intérêt = grand nombre de patients, et variété des indications
- Résultats par indication : montrent clairement que plus la lésion est distale (lésion périphérique), plus l ’effet de la stimulation est important Au contraire, les lésions médullaires, provoquant une dégénerescence des cordons postérieurs de la moelle, ne permettent pas d ’obtenir de résultats significatifs