Disriflessia autonomica in corso di mielopatia: fisiopatologia

Incontro Nazionale Neurofisiologia:
Nuove Strategie
“Controversie sulla diagnosi e terapia del dolore
neuropatico”
Palermo, 29-30 novembre 2012
Gli Strumenti di Screening devono essere
applicati nella diagnosi di DN?
Si  Nadine Attal
No  Sandrini
Discussant
Brigida Fierro, Angelo Quartarone
Premesse: Il Topic
Brigida Fierro
Dipartimento BioNec
Università degli studi di Palermo
Palermo, 29-30 novembre 2012
Neuropathic Pain: definition
Neurology. 2008 Apr 29;70(18):1630-5. Epub 2007 Nov 14.
Neuropathic pain: redefinition and a grading system for clinical and research purposes.
Treede RD, Jensen TS, Campbell JN, Cruccu G, Dostrovsky JO, Griffin JW, Hansson P, Hughes R, Nurmikko T, Serra J.
The International Association for the Study of Pain (IASP 1994) introduced the
term neuropathic pain, defined as "pain initiated or caused by a primary lesion or
dysfunction in the nervous system." While this definition has been useful in
distinguishing some characteristics of neuropathic and nociceptive types of pain, it lacks
defined boundaries.
The Neurophatic pain Special interest group (NeuPSIG 2008) present a more
precise definition : pain arising as a direct consequence of a lesion or disease
affecting the somatosensory system.
so including a wide range of neuropathic pain conditions ranging from painful
neuropathy to central poststroke pain.
Palermo, 29-30 novembre 2012
Palermo, 29-30 novembre 2012
Neuropathic Pain
The challenge is:
 to differentiate neuropathic pain from other
types of pain
and then
 to diagnose the lesion or disease causing the
pain.
Palermo, 29-30 novembre 2012
Methods of assessing nerve function
(1) bedside examination, which relies on the physician's experience and
the patient's ability and willingness to collaborate;
(2) quantitative sensory testing, a measure that despite using
quantitative, graded stimuli also relies on the patient's evaluation;
(3) laboratory tests use quantitative tools and measure an objective
responses.
Neuropathic Pain
The challenge is:
first step
 to differentiate neuropathic pain from other
types of pain
and then
 to diagnose the lesion or disease causing the
pain.
Palermo, 29-30 novembre 2012
Grading system of neuropathic pain
(NeuPSIG 2008)
Treede et al Neurology 2008
Palermo, 29-30 novembre 2012
Neuropathic vs. nociceptive Pain
Pain is a subjective condition that cannot be objectively
measured; for this reason, self patient-perspective is
crucial to evaluate:
character (quality, intensity,temporal aspects,
stimulus-dependent or not etc.)
distribution of pain (confined to innervation
territory of the affected nervous structure)
Presence of positive or negative symptoms or signs.
Screening tools
Based on pain descriptors
recently, several screening tools have been
developed essentially to discriminate between
nociceptive and neuropathic pain
Modern Screening tools
Palermo, 29-30 novembre 2012
Le Douleur Neuropathique 4 DN4: Italian Version
Interview
Subjective measures
Physician
Examination
se il punteggio del paziente è uguale o maggiore di 4/10, il test è
positivo (sensibilità=82,9%; specificità=89,9%)
Bouhassira et., 2005; versione italiana a cura di Caraceni, Zecca e Martini)
Screening tools
Pearls
• identify patients with
possible neuropathic
pain.
• are easy to use
• provide immediately
available informations
• are useful for research
pourposes
Pitfalls
• fail to identify abot 1020% of patients with
clinical diagnosed
neuropahic pain
so
• cannot replace clinical
judgment
Screening Tools
The questions are:
 are they useful in the real life or only for clinical
trials?
 do they identify subtypes of neuropathic pain?
 can they be used to assess the effects of treatment?
 should also be used to predict treatment outcome
and better define responder profiles to treatment?