Diagnostik und Therapie des sympathisch unterhaltenen Schmerzes

Abstract

The term "sympathetically maintained pain" (SMP) describes a symptom that might accompany a variety of diseases (CRPS, (post-) herpetic and post-injury neuralgia), which might transform into sympathetically independent pain (SIP) after some time. Patients with SMP present a bunch of disorders of the autonomic and sensory system, but the only reliable way to diagnose a pain as SMP is a positive response to an intervention at the sympathetic nervous system. Three ways of influencing the sympathetic system are commonly used: (a) local anesthetic sympathetic blockade (SB), (b) intravenous regional sympathectomy (IVRS) and (c) ganglionic local opioid application (GLOA). A review of current literature shows that SB has certain advantages in diagnostic sensitivity, whereas GLOA might be slightly superior in therapy of some diseases with longstanding pain history. Obviously, the therapeutic benefit of all interventions is complete independent of the accompanying autonomic disorder and of a blockade of efferent fibers. A new heuristic model of the SMP mechanism is presented, including both experimental and clinical data. For reducing the risks of false positive or negative diagnosis of SMP and SIP, a diagnostic algorithm is proposed. This includes optimizing the technique, changes of interventional measures, and adequate monitoring both of analgesia and as well of the extend of efferent sympathetic blockade (e.g. measurement of sympathetic reflexes). The treatment recommendations in patients with SMP vary in dependence of the kind of disease. In SMP, invasive measures play an important, but only limited role within the comprehensive treatment concept. As an example a three-stage, symptom-adapted treatment algorithm is demonstrated for CRPS, including also drug therapy, psychologic and physiotherapeutic approaches.

Causalgia and reflex sympathetic dystrophy: Does the sympathetic nervous system contribute to the generation of pain?

“…As far as possible we tried to distinguish between the initial pain relief (i.e., the percentage of patients that achieve pain reduction immediately after one intervention) and long-term pain relief (i.e., the percent-age of patients that achieve prolonged pain reduction, which involves variable follow-up between studies from 1 to 6 months) after a series of sympatholytic interventions or after sympathectomy. 109 In RSD and causalgia, about 85% of the patients report a positive acute effect of SE, SB, and IVRS, but fewer patients experience long-term relief (60% in SB and 30% in IVRS). In posttraumatic neuralgias the sympatholytic interventions are clearly less effective.…”

“…The summaries in Tables 3 and 4 are not exhaustive, but they represent the overall trend. 109 RSD and causalgia are subsumed in one group, because, in many studies, the data from these two syndromes were pooled. As far as possible we tried to distinguish between the initial pain relief (i.e., the percentage of patients that achieve pain reduction immediately after one intervention) and long-term pain relief (i.e., the percent-age of patients that achieve prolonged pain reduction, which involves variable follow-up between studies from 1 to 6 months) after a series of sympatholytic interventions or after sympathectomy.…”

Blockade des Ganglion cervicale superius des Truncus sympathicus

“…Sie wird bei zahlreichen, oft langwierigen und die Patienten in der Lebensqualität stark beeinträchtigenden Krankheiten wie der Rhinitis atrophicans cum foetore (Ozäna) [10], der Menièr-Krankheit [10], bei vasomotorischen Schwindelanfällen [10], den idiopathischen Gesichtsschmerzsyndromen [8] oder auch beim Vasospasmus der zerebralen Arterien [14] mit Erfolg angewandt. Weitere Indikationen sind die Trigeminusneuralgie [11], die akute Zosterneuralgie [7] und die postzosterische Neuralgie [7].…”

“…7 8 a Horizontalschnitt nach beiderseitiger Gabe von 5 ml Kontrastmittel, rechts im Spatium parapharyngeum (weiter kaudal befindlicher Schnitt), links im Spatium praevertebrale; rechts nach lateral beträchtliche Ausdehnung bis in Fossa retromandibularis, links Ausbreitung nach dorsal bis weit zwischen Nackenmuskulatur, b 3D-Rekonstruktion, Ansicht von vorne, weit nach kaudal und lateral reichende Ausdehnung des Kontrastmittels Abb. 8 ris vor. Dies erklärt die Therapiemöglich-keit der Trigeminusneuralgie [8,11].…”

“…Spacek et al [11] beschrieben bei der Therapie der Trigeminusneuralgie keine Besserung in bis zu 37 der Fälle. Maier u. Gleim [8] berichteten bei der Therapie von akuter Zosterneuralgie 13 therapieresistente Patienten. Pejič [10] beobachtete bei 152 behandelten Patienten unterschiedlicher Indikation 24 ohne sichtbaren Therapieerfolg.…”