PAIN

Prof Dr H Suharko Kasran SpS SpKJ

RECEPTOR OF PAIN FREE NERVE ENDING , SKIN OR
OTHER ORGAN AXON DISTAL NEURON SENSORIK .
UNMYELINATED OR THIN MYELINATED , SMALL DIAMETER

TYPE STIMULUS TO ACTIVATE FREE NERVE ENDING :

1. IN MUSCLE ISCHAEMIA
2. IN ABDOMEN VISCERA DISTENTION
3 BRADYKININS , PROSTAGLANDIN , HISTAMINE ,
RELEASED BY DAMAGED TISSUES. STIMULATE
NERVE ENDING

NEUROPATHIC : PAIN WITH UNCLEAR CAUSE . PRIMARY NERVE

LESION OR NEUROLOGICAL SYSTEM (MERSKEY 1994).
DYSFUNCTION (ALODYNIA :BURNING , SEVERE PAIN , THOUGH
WITH A VERY LIGHT TOUCH , ) SERING MERUPAKAN KOMPONEN
DARI NYERI NOCICEPTIF

NOCICEPTIVE : PAIN DUE TO CLEAR CAUSE , INJURY, TRAUMA.

TUMOR, VASKULAR DISEASES
THE TYPE TO STIMULUS FREE ENDING : IN MUSCLE -> ISCAHEMIA . IN
ABD VISCERA _> DISTENTION

SUBSTANCES : BRADYKINESIS , PROSTAGLANDIN, HISTAMINE ,

STIMULATE FREE NERVE ENDING
THESE SUBSTANCES ARE RELEASED IN DAMAGED TISSUE
CONTROL SENSORY (PAIN) INPUT

THE GATE CONTROL THEORY :

RELAY SYSTEM IN THE CORNU POTERIOR MODIFIES PAIN
INPUT INTERNEURAL CONNECTIONS WITHIN THE
SUBSTANTIA GELATINOSA
AFFERENT IMPULS ARRIVES AT THE CORNU POSTERIOR
, THICK MYELINATED FIBRES INHIBITORY EFFECT IN
THE REGION SUBSTANTIA GELATINOSA .
AFFERENT IMPULS ARIVING IN THIN MYELINATED, /
UNMYELINATED FIBRES EXITATION EFFECT IN THE
REGION OF SUBSTANTIA GELATINOSA .
OVERALL INTERACTION OF INHIBITORY AND EXITATION
EFFECT DETERMINES THE ACTIVITY OF SECOND
ORDER, NEURONS OF THE SPINO THALAMIC PATHWAY
REDUCTION OF ACTIVITY OF LARGE SENSORIC FIBRES
OPENS THE GATE . (OR) STIMULATION OF LARGE
SENSORY FIBRES , CLOSES THE GATE
NEURO TRANSMITTER

ENDOGENOUS SYTEM WITHIN THE CENTRAL

NERVOUS SYSTEM CAN INDUCE A DEGREE OF
ANALGESIA
ELECTRICAL STIMULATION AT CERTAIN SITES :
PAERIAQQUADUCTAL AREA CAN INHIBIT PAIN
PERCEPTION
RECEPTOR SITES FOR ENDOGENOUS OPIATES HAVE
BEEN FOUND IN THE CORNU POSTERIOR AND
THALAMUS . THE ENDOGENOUS SUBSTANCES
WHICH BINDS TO THESE SITES : ENCEPHALIN OR
ENDORPHIN
SUBSTANCE P (POLYPEPTIDE) PREDOMINANTLY
AROUND FREE NERVE ENDING RECEPTORS
AND IN THE SPINAL CORD CORNU POSTERIORES
IS THE PRIMARY TRANSMITTER OF PAIN
DRUG TREATMENT

SITES OF DRUG ACTION

BLOCK RECEPTORS BLOCK TRANSMISION BLOCK TRANSMISION CENTRAL
AT PERIPHEY
ASPIRIN OPIATES / NARCOTICS
NON STEROID , ANTI
INFLAMMATORY

DRUG SELECTION (SEVERITY , CAUSE, DURATION)

A. ACUTE PAIN : < 2 WEEKS DURATION , POST OP, POST TRAUMATIC, RENAL COLIC.
B. CHRONIC PAIN : BENIGN ORIGIN : POST HERPETIC , PHANTOM LIMB, CHRONIC
BACK PAIN
C. MALIGNANT :

1. IN ACUTE PAIN , MILD ANALGESICS: ASPIRIN, PARACETAMOL, NARCOTIC,

MORPHINE , HEROIN, TRANQUILISERS.
2. IN CHRONIC PAIN , BENIGNE: AVOID NARCOTICS, SEDATIVES. GIVE
ANTIDEPRESSANT. ANTICONVULSIVE CARBAMAZEPINE ,MODE OF ACTION
UNKNOWN
3. IN CHRONIC PAIN: TERMINAL MALIGNANCY : STRONG NARCOTICS, MORPHINE,
HEROINE,
CENTRAL TECHNICS PAIN TREATMENT

A. STEREOTACTIC THALAMOTOMY
THE SPINO RETICULAR SYSTEM IS RESPONSIBLE FOR THE UNPLEASANT
FEELING OF PAIN SENSATION, STEREOTACTIC OBLITERATION OF THE
SPINORETCULAR RELAY IN THE THALAMUS . RELIEVE MALIGNANCY
PAIN , (HEAD, NECK, BRACHIUM

B. DEEP BRAIN STIMULATION

STIMULATION OF IMPLANTED ELECTRODES IN THE PERIVENTRICULAR
GREY MATTER , SENSORY RELAY NUCLEUS OF THE THALAMUS . OR
CAPSULA INTERNA

C. HYPOPHYSECTOMY
TRANS SPHENPOIDAL EXCISSION (YTTRIUM) AGAINST METASTATIC
PAIN DEPOSITS, TUMOUR REGRESSION

D MEDULLARY TRACTOTOMY
A RADIO FREQUWNCY HEAT LESION , WITH A STEREOTACTIC ALLY
IMPLANTED ELECRODE INSERTED INTO NUCLEUS DESNEDENCE n v
FACIAL , ORAL ANALGESIA
 A
D

G
F

H
E. DORSAL ROOT ENTRY ZONE LESIONS
MULTIPLE RADIOFREQUENCY HEAT ELECTRODE . DE
AFFERENTIATION OF PAIN , PLEXUS BRACHIALIS AVULSION ,
POST HERPETIC NEURALGIA , (BUT IPSILATERAL LEG
WEAKNESS AS COMPLICATIOAN .

F. PERCUTANEUS ANTEROLATERAL CORDOTOMY

PERCUTANEUS RADIOFREQUENCY HEAT LESION OF THE
SPINOTHALAMIC TRACTREPLACES OPEN CORDOTOMY . PAIN
RELIEF 90% OF PATIENTS IN THE CONTRALATERAL LIMB .
AGAINST MALIGNANCY. RISKA OF IPSILATERAL, & RESPIRATORY
DIFFICULTIES ARE SMALL.

G. MYELOTOMY
EXPOSURE OF THE CORD AND DIVISION OF THE DECUSSATING
PAIN FIBRES . AGAINST MALIGNANCY PAIN

H. DORSAL COLLUMN STIMULATON

STIMULATION OF INSERTED ELECTRODES PERCUTANEOUSLY
INTO THE EPIDURAL SPACE -> AGAINST CHRONIC PAIN
PERIPHERAL TECNIQUES

A. NERVE BLOCKS
INJECTIONS INTO PERIPHERAL NERVES OR ROOT , RELIEF PAIN OF THE
APPROPRIATE DERMATOME ; LOST OF SYMPATHIC AND MOTOR
FUNCTION
LOCAL ANAESTHETICS PRODUCE TEMPORARY EFFECT : NEUROLOGIC
AGENTS : PHENOL , ALCOHOL, GIVE PERMANENT RESULTS
1. INTRASPINAL : PHENOL/ HYPERTONIC SALINE ; AGAINST TERMINAL
MALIGNANCY
2.. SYMPATHETIC GANGLION OR TRUNK : LOCAL ANAESTHETIC
AGAINST
CAUSALGIA
3. PARAVERTEBRAL / PERIPHERAL NERVE : LOCAL ANASTHETIC ,
TEMPORARY
BENEFIT : AGAINST FRACTURED RIB ,
B. DORSAL RHIZOTOMY VERY HIGH RISK , SELDOM USED .
C. DENERVATION OF THE FACET JOINTS
D. ACUPUNCTURE
E. TRANS CUTANEOUS ELECTRICAL NERVES STIMULATION
PAIN SYNDROMES

BASIC FUNCTION :
1. PAIN IS NOT A PRIMARY PATHOLOGICAL PHENOMENON , BUT A PROTECTIVE
FUNTION .
2. LOSS OF PAIN PERCEPTION RESULT IN FREQUENT INJURIES , BURNS, MUTILATION
(SYRINGOMYELIA, NEUROPATHY , CONGENITAL INSENSITIVITY TO PAIN ).
3. PATHOLOGICAL CONDITION , CAUSE PAIN ( CANCER, INJURY)

I CAUSALGIA :

1 INCOMPLETE PERIPHERAL INJURY ( INTENSE, CONTINUOUS , BURNING PAIN )

2 TOUCHING AGGRAVATES THE PAIN , RESENTS MOBILISATION
3 SKIN RED , WARM, SWOLLEN
4 MECHANISM :
A. AT THE SITE OF DAMAGE : EFFERENT SYMPATHIC FIBRE LINK UP TO AFFERENT
SOMATIC FIBRE PRODUCE SHORT CIRCUIT
B MIXED PERIPHERAL NERVE : MOTOR, SENSORIK, AUTONOMIC
C. EFFERENT SYMP LINK UP TO AFFERENT SOMATIC.
D PERIPHERAL NERVE DAMAGE , CONTAINING LARGE NUMBER OF SYMPATHETIC
FIBRES , RESPONDS TO SYMPATHETIC BLOCKADE (PHARMACOLOGICAL /
SURGICAL )
II . POST HERPETIC NEURALGIA

1. FOLLOWING ACTIVATION OF A LATENT INFECTION WITH HERPES ZOSTER VIRUS

(LYING DORMANT IN THE DORSAL ROOT , GANGLION GASSERI
2. BURNING, , CONSTANT PAIN , SEVERE, SHARP, PAROXYSMAL , OVER TRHE AREA
SUPPLIED BY THE AFFECTED AFFERENT SENSOR8IC NEURON .
3. TOUCH EXACERBATES THE PAIN
4. THICK MYELINATED FIBRES PREFERENTIALLY DAMAGED (OPENING THE GATE )
5. TREATMENT : NEURALGIA CARBAMEZEPINE, ETHYL CHLORIDE SPRAY,
TEMPOARRY RELIEVE . . VIRAL --. ZOVIRAX
6. SURGICAL TREATMENT : PERCUTANEOUS CORDOTOMY .

III THALAMIC PAIN

1. THALAMIC STIMULATION MAY PRODUCE OR ABOLISH PAIN DEPENDING ON THE

ELECTRODE SITE
2. VASKULAR LESION MAY INVOLVES INHIBITORY PORTION OF THE THALAMUS MAY
RESULT IN PAIN THALAMIC SYNDROME
3. CLINICAL : HEMIANESTHESIA AT ONSET, PRECESDES THE DEVELO[PMENT OF PAIN
CONTRALATERAL : BURNING , DIFFUSE, EXACERBATED BY TOUCH OF CLOTHING
4. TREATMENT : DRUG NEGATIF . STEREOTACTIC MAY HELP, BUT BEWARE OF
COMPLICATION , MOVEMENT DISORDER.
IV PHANTOM PAIN

1. FOLLOWING LIMB AMPUTATION . 10 % DEVELOP PAIN

2. BURING , CONTINUOUS , PERSISTENT , CAUSED BY NEUROMA FORMATION IN THE
STUMP
3. FEELS THE PAIN ARISING FROM SOME POINT IN THE MISSING LIMB
4. TREATMENT : AS FOR HERPES . NO SPECIFIC TREATMENT .

V. VISCERAL AND REFERRED PAIN

1. DEEP VISCERAL PAIN : DULL AND BORING . DUE TO DISTENTION OR TRACTION OF

FREE NERVE ENDING
2. REFERRED PAIN OF A DULL QUALITYRELATES TO SPECIFIC AREA OF THE BODY
SURFACE HYPERSENSITIVE TO TOUCH .
3. THE BASIS OF REFERRED PAIN :
a. THE VISCERAL AFFERENT CONVERGE UPON THE SAME CELLS IN THE CORNU
POSTERIOR AS THE SOMATIC EFFERENT
b . THE PATIENT PROJECT PAIN FROM THE VISCERA TO THE AREA SUPPLIED BY
CORESPONDING SOMATIC AFFERENT FIBRES
SITES OF REFERRED PAIN FROM SPECIFIC ORGAN

1. ASCENDING AORTA T2 T3
2. HEART T1 - T3.
3. GALL BLADDER T7- T8
4. PANCREAS T7 - T8
5. APPENDIX T11 - T12
6. KIDNEY T10 L1
7. TESTIS T10 T11
8. URETER T10 - L1
9. COLON T11 L1
10. OVARY T10 T11
11. PROSTATE S2 - S4
12. CERVIX / VAGINA S2 - S4
LIMB PAIN
CHARACTERISTIC :
PAIN MAY ARISE FROM ANY ANATOMICALSTRUCTURE WITHIN THE LIMB , EACH
PRODUCES CHARATERISTIC SYNDOMES / FEATURES :
1. BONE : DIFFUSE , ACHING PAIN , PALPABLE MASS
2. JOINTS : PAIN LOCALISED TO AFFECTED JOINT, TENDERNESS ON PALPATION
,
MOVEMENT RESTRICTED AND PAIN , WASTINOF SURROUNDING
MUSCLE
3. MUSCLES: PAIN LOCALISED SPECIFIC, WASTING AND WEAKNESS, PALPABLE
MASS
4. TENDONS: PAIN AND SWOLLEN IN LOCALISED , TENDER TENDON SHEATH
5. BLOOD VESSELS : PAIN BROUGHT BY EXCERCISES (CLAUDICATION ) RELIEVED
BY
REST : PAIN AT REST PALE, PULSELESS (OCCLUSION). PAIN
ASSOCIATED
WITH PARESTHESIA AND DIGITAL PALLOR (RAYNAUDS SINDROME)
6. NERVE ROOT : PAIN INCREASED BY COUPHING , SNEEZING , MOVEMENT ,
PRESSURE
DEFAECATION , ASSOCIATED WITH NEUROLOGICAL DEFICIT
7. PLEXUS OR PERIPHERAL NERVE : BURNING , SWEATING , CYANOSIS, OEDEMA
OF THE
EXTREMITY, ASSOCIATED WITH NEUROLOGICAL DEFICIT
CAUSES OF UPPER LIMB PAIN :

A. BRACHIAL PLEXUS : D NERVE ROOT

1. CERVICAL RIB
2. APICAL BRONCHIAL CA
3. BRACHIAL NEURITIS
MENINGIOMA
4 POST IRRADIATION
5 NEUROFIBROMA E. REFERRED PAIN
B MUSCLE
1. POLYMYOSITIS
2. POLYMYALGIA RHEUMATICA
3. TUMOR : RHABDOMYOMA
SARCOMA , DESMOID
4. MYOSITIS OSSIFICANS
RHEUMATOID
C BONE
1. OSTEOMALACIA
2 TUMOR : BENIGNE OSTEOMA/
CHONDROMA .
MALIGNE : SARCOMA,
MYELOMA , METASTASE
1. SPONDYLOSIS
2. MALIGNE EXTRADURAL
3 NEUROFIBROMA,
1. PLEURA
2 HEART/ LEFT ARM
F JOINTS
1 CARPO TUNNEL SYNDROME
2 TENDINITIS CALCFIC
3. ROTATOR CUFF TEAR
4. BURSITIS , OSTEOARTHR,
ARTHR, INFECTIVE ARTHR.
5 TENNIS ELBOW (PERIARTICULAR)
G BLOOD VESSEL;
CAUSES OF UPPER LIMB PAIN (LANJUTAN )

G BLOOD VESSELS :
1. THORACIC OUTLET SYNDROME
2. COLLAGEN VASCULAR DISEASE
3. PARA PROTEINEMIA

H TENDON :
1. ACUTE CHRONIC TENOSYNOVITIS

I. PERIPHERAL NERVE :
1. PARTIAL NERVE INJURY
2. PERIPHERAL NEUROPATHY
3. CARPAL TUNNEL SYNDROME
4. ULNAR NERVE ENTRAPMENT
MUSCLE PAIN :

METABOLIC BONE DISEASE :

1. OSTEOMALACIA , IMMIGRANTS WITH VIT D DEFICIENCY DIETARY DISEASE
2 MUSCLE WEAKNESS, DIFFUSE MUSCLE PAIN , WADDLING GAIT
3 EMG , MUSCLE ENZYME NORMAL .
4 MUSCLE BIOPSY = POLYMYALGIA RHEUMATICA
5 CONFIRMATION OF SERUM VIT D. OSTEOMALACIA. MALABSORPTIOON
SYNDROME , HYPER PARA THYRIODISM , CHRONIC ANTI CONVUKLSAN
THERAPY .
DIAGNOSIS :
A. ANTECEDENT CIRCUMSTANCES . DRUGS, ALCOHOL , VIRAL ILLNESS,
GENERAL ANESTHETIC (MALIGNANT HYPERPYREXIA) . EXERCISE (IDIO-
PATHIC PAROXYSMAL MYOGLOBINURIA)
B PERIODICITY : METABOLIC BONE DISEASE . POLYMYALGIA
RHEUMATICA.
C. INTERMITTENT :
1. WITH EXERCISE : DISORDERS OF MUSCLE METABOLISM. IDIOPATHIC
PAROXYSMAL MYOGLOBINURIA . BENIGNE MYALGIC ENCEPHALO
MYELITIS
2. WITHOUT EXERCISE : IDIOPATHIC PAROXYSMAL MYOGLOBINURIA.