Elemente introductive de

terapia durerii
Elena Copaciu
Asociatia Romina pentru Studiul Durerii
UMF Carol Davila
 Durerea este principalul simptom care
aduce pacientul la medic
Analgeticele nu sunt medicamente
esentiale pentru supravietuire
Esentiale pentru ameliorarea calitatii vietii
BALANTA RISC BENEFICIU- mai
importanta decit pentru orice alta clasa de
medicamente
Importanta capitala pentru medic si pacient
Precautii de prescriere- medic
Automedicatie responsabila- pacient
 Analgeticele
medicaie pentru ameliorarea calitii vieii/ reaciile lor
adverse- decisive pentru selecia terapeutic

PRIMUM NON
NOCERE!
 intrebari>:
Ce recomandam ca analgetic la un
bolnav cu dureri severe si:
Ciroza hepatica?
Insuficienta renala?
Insuficienta cardiac congestive NYHA III
si sechele de AVC?
Ulcer duodenal?
Polineuropatie diabetic dureroasa
Cancer de san socs din evidenta
oncologica si parestezii/disestezii MI?
Ce este durerea ?
Religii primitive triburi africane : durerea
lucrtura demonilor
Biblia Iov toi oamenii sunt vinovai:
penitena trupului pentru salvarea sufletului
Oh ! De ar fi cu putin s mi se cntreasc
durerea i s mi pun toate nenorocirile n
cumpn, ar fi mai grele dect nisipul mrii:
de aceea mi merg cuvintele pn la nebunie

Pain poena (lat) (a

plti - penalty sau
payment )
6
 ISTORIE
De milenii, de la ieirea din peteri omul a
fost marcat de existena durerii.
La origini, durerea a fost suportat ca un
dat al zeilor/ divinitii sau ca o pedeaps,
nu numai divin.
Condiie nedorit, supliciu, durerea a
afectat aciunile, sentimentele i mai trziu
gndirea, n grade diferite n funcie de
intensitatea i durata ei.
n mitologie i diversele religii ale lumii
experiena de suferin prin durere a fost
elementul central al legendelor, miturilor i
parabolelor. (ex.- Titanul Prometeu) 7
Tablite mesopotamiene 5000 ien-
folosirea opiului pentru controlul
durerii
 ISTORIE (II)
Hipocrate (sec IV BC) i medici dedicai
lui Aesculapius au ncercat s:
Defineasc fenomenul durerii
Investigheze raional durerea
Elimine cauzele durerii
nlture durerea nenecesar ( tuto, cito et jucunde)

Galen (130-200 AC)

Descrie SN i relaia cu creierul
Contribuie la nelegerea durerii
Descrie opiul, util ca pain-killer

Avicena ( sec XI AC)

Descrie 15 tipuri de durere ( i inflamaie)
Precizeaz zon de percepie a durerii n ventricolul anterior

9
 HOMER- ODISEEA
Folosirea opiului
pentru controlul
durerii dar si in
scop recreational
 HOMER - ODISEEA
TELEMACH-
foloseste opiu
pentru alinarea
durerilor date de
rani
HIPOCRATE
AVICENNA
 ART

Din cele mai vechi timpuri artitii au

ncercat s figureze puterea distructiv
i pericolul durerii.

Sfinii doctori Cosma i Damian

1490- pictur de altar gotic la Ditzingen

14
MAREA ART

15
 ART
Din sec. XVII
artitii
reuesc s
portretizeze
durerea n
dimensiunea
ei real

1750-litografie: Operaie la Spitalul St Thomas din Londra

16
 Combaterea durerii
ncercri arhaice: extracte de plante
(mtrgun, cucut, dud, mselari, mac)
Buretele soporific Nicolaus din Salerno

Ritualuri amanice

Hipnoz

Aplicarea de rece

Somnambulism provocat

Pn la jumtatea sec XIX efectuarea unui

act chirurgical echivala cu o condamnare la

tortur
Obs.: a evita durerea n operaii este o
himer. 1839 Alfred Armand Velpeau 19
20
Pain relief should
be a Human Right
Sloganul Sptmnii Europene
de combatere a durerii
Octombrie 2004, Geneva
24
 Durerea cronica scara OMS

3 Severa

2 Moderata Morfina
Hidromorfon

Codeina Metadona
1 Usoara
Dihidrocodeina Fentanil

Oxicodon Oxicodon
Metamizol
Tramadol Adjuvante
Paracetamol
Adjuvante
AINS
Adjuvante
 Managementul durerii
neuropate
Ghid EFNS 2006
Ghid APS 2003 cu updates ulterioare
Ghid Canadian Pain Clinicians 2007
Recomandari NICE UK 2009
 Managementul farmacologic al
durerii neuropate
ANTIDEPRESIVE ANTICONVULSIVANTE
AMITRIPTILINA PREGABALIN
Nortriptilina GABAPENTIN
Imipramina Carbamazepina in
DULOXETINE nevralgia de trigemen
Nu inhibitori selectivi Nu topiramat,
ai serotoninei valproat, lamotrigina,
fenitoin
 Managementul durerii
neuropate
Tratament nefarmacologic
Echipa multidisciplinara: terapia durerii,
neurolog, neurochirurgie, recuperare, psiholog,
psihiatru, consilier vocational, acupunctura,
medicina alternativa.
Blocuri diagnostice si terapeutice
Blocuri simpatice
Corticoizi transforaminal, epiduroliza
Terapii ablative neurochirurgicale- 0,4%
Terapii intradiscale
Pompe implantabile: subcutane, intratecale,
epidurale, ventriculare

 Rolul anestezistului in
managementul durerii cronice
Management perioperator al bolnavului cu durere
cronica/ terapie cronica opioida/ antidepresive/
anticonvulsivante/ remedii naturiste- vezi
www.asahq.org si www.arsd.ro
Proceduri interventionale diagnostice si
terapeutice
Ca parte a unei abordari multidisciplinare, in echipa
Blocuri
Discografie provocativa
Managementul miniinvaziv al coloanei dureroase
Vezi Practice guidelines for chronic pain management
Anesthesiology, 2010; 112:1-1
 Durerea neoplazica
Scala OMS pentru durere nociceptiva
Identificarea componentei neuropate si
tratate conform ghidurilor
Managementul pacientului cu tratament
cronic cu opioide ( vezi recomandari ARSD-
www.atitimisoara.2008)
Managementul miniinvaziv al sindroamelor
dureroase refractare- revista ARSD 2007-
www.arsd.ro
Durerea cronica postoperatorie- capitol
SRITATI2009
 Diagnosticul corect al TUTUROR
sindroamelor dureroase ale pacientului
Anamneza, ex clinic
Evaluare- scala vizuala analoga
Identificarea componentei neuropate
Identificarea patologiei comorbide asociate
durerii cronice- insomnie, anxietate,
depresie
Comorbiditati, interactiuni medicamentoase
 Durere nociceptive severa=
opioide
Morfina si opioidele de potenta superioara
la morfina- regim de prescriptive de
stupefiante, retete cu regim special
Tramadol, DHC- prescriptive controlata
Opioid retard pentru platou de analgezie
Forme cu eliberare rapida pentru control
rapid al paroxismelor dureroase
 AINS o lunga istorie de analgezie si toxicitate

Mecanism de actiune aspirina

400 I.C.
Medicul grec 1899 1938 1950 1970 1982 1992 1998
Hippocrate

Descoperire AINS
neselective Sinteza
Extract salcie pt Prima dovada Descoperire primului
dureri endoscopica de inhibitori COX-2
musculoschelet Sinteza
ale aspirinei lezare mucoasa COX-2 selectiv
digestiva .

Lancet 1938;ii:12225
 SOLUTII
EXISTA INTOTDEAUNA!!
 METAMIZOL-
restricii de prescripie
Belgia 1987-
numai cu prescripie medical/ nu > 5
prescripii/ 6 luni!!
pstrat n farmacie la seciunea otrvuri,
etichete cap de mort!
Germania- 1987- interzis combinaii cu
metamizol
Spania 1989- retras combinaii/ indicaie
pentru analgezie posttrauma,
postoperator i febra care nu rspunde la
alte antipiretice
 Recomandari ARSD
Administrare pe perioada cea mai scurta
de timp
Nu se recomanda administrarea mai mult
de 7 zile consecutiv
Nu ca antipiretic de prima linie
Atentie la injectarea iv- lent, cca 15
minute
Adm rapida- hipotensiune arteriala, greata
incoercibila
Sa nu uitam ca si forma injectabila si cea
per os se elibereaza cu prescriptie!....
 Paracetamol analgetic cu
eficacitate dovedit
n prima utilizare- antipiretic- in 1894 (Hinsberg
and Treupel)1

n efect analgetic demostrat n 1948(Flinn and Brodie)1

n Recomandat ca terapie analgetic de prim linie n:

- tratamentul osteoartritei din 20002,3
- durere musculoscheltal la vrstnici- 20024
- bolnavi cu boli renale- 19965

1. Prescott LF. Am J Therapeut 2000;7(2):143-7.

2. EULAR recommendations. Pendleton A et al. Ann Rheum Dis 2000;59(12):936-44.
3. American College of Rheumatology Subcommittee on osteoarthritis guidelines.
Arthritis Rheum 2000;43(9):1905-15.
4. AGS Panel on Persistent Pain in Older Persons. JAGS 2002;50:S205-24.
5. Henrich WL et al. Am J Kidney Dis 1996;27(1):162-5.
 Paracetamol iv
Profil de siguran n DPO
n fr efecte adverse mediate la nivel central1
(e.g. sedare, constipaie, grea, vom, depresie respiratorie)
n fr efecte pe agregarea plachetar, sngerare sau excreia acidului uric2
n fr efecte adverse gastrointestinale
3

n profil de siguran la nivel renal i hepatic - bune

4 5

n puine contraindicaii i interaciuni medicamentoase

n poate fi folosit la femeia gravid i n cursul lactaiei,
la copii, vrstnici i bolnavi cu insuficien renal

1. Lechat P et al. Thrapie 1989;44:337-54.

2. Insel PA. Analgesic-antipyretic and antiinflammatory agents and drugs employed in the treatment of gout. In: Goodman & Gilman eds.
The pharmacological basis of therapeutics. McGraw Hill, 9th edition, 1996:617-57.
3. Singh G. Am J Therapeut 2000;7(2):115-21.
4. Whelton A. Am J Therapeut 2000;7(2):63-74.
5. Whitcomb DC et al. JAMA 1994;272(23):1845-50.
 AINS SELECTIVE SI
NESELECTIVE

RISC GASTROINTESTINAL
RISC CARDIOVASCULAR
Efecte adverse GI ale AINS

Dispepsia
Esofagita
Stricturi esofagiene
Petesii gastrice si duodenale
Eroziuni, ulceratii, singerare,
perforatii
Gastrita tip C
Ulceratii, singerare, perforatii-
intestin subtire si gros
Exacerbari colita
LEZIUNI GI AINS DG
ENDOSCOPIC
 Incidenta leziunilor GI induse de AINS

Leziune / efect advers Frecventa relevanta clinica

Eroziuni > 50% redusa

Ulcere endoscopice 10-30%

Dispepsia >30%

Ulcere simptomatice 2-4%

Complicatii tract difgestiv sup 1-1.5%
Complcaitii tract digestiv inf 0.8%
mare

Lanas A, Hunt R, Ann Meds 2006.

Risc relativ (RR) de singerare digestiva superiora pt
fiecare AINS
Cazuri(n = 2777) si control (n = 5532)

AINS Risc relativ (95% CI) Redus

Neutilizare Reference
Celecoxib 1.0 (0.4-2.1)
Aceclofenac 2.6 (1.5-4.6)
Diclofenac 3.1 (2.3-4.2)
Ibuprofen 4.1 (3.1-5.3)
Naproxen 7.3 (4.7-11.4)
Lomoxicam 7.7 (2.4-24.4)
Ketoprofen 8.6 (2.5-29.2)
Indomethacin 9.0 (3.9-20.7)
Mare
Meloxicam 9.8 (4.0-23.8)
Piroxicam 12.6 (7.8-20.3)

Lanas A et al. Gut (2006)

 Cum identificam bolnavii cu risc
GI?
Istoric de boala ulceroasa
Istoric de infectie H.Pilori
Virsta
Terapie concomitenta anticoagulanta,
antiagreganta, steroidiana
Asociere de alte AINS, inclusiv
minidoze de Aspirina
Boli cronice debilitante, in sp CV
 Bolnavi cu patologie GI
semnificativa
Boala ulceroasa, hernie hiatala
Paracetamol
Inhibitori pompa de protoni asociati
la AINS acolo unde este tolerata
combinatia
Inhibitori selectivi COX2 daca nu
exista contraindicatii CV
 De ce IPP in gastroprotectie?
MISOPROSTOL
Doza mica eficienta similara IPP
Doze mari- superior la IPP- dar reactii adverse GI- nu
este tolerat de bolnavi
Femeile care doresc a ramina gravide( Am J Phys, 2009)
IPP- eficienta dovedita statistic
ANTAGONISTI REC H2
La doze mari- pot conferi gastroprotectie
Nu este superioara la IPP
Inhibitori COX2
Reactii adv gastrice minime
Asocierea cu minidoza aspirina anuleaza acest avantaj
 Bolnavii cu ciroza hepatica
Nu AINS
Nu paracetamol
Prudenta metamizol
Coxibi daca nu au contraindicatii CV
Doza cea mai mica eficienta
Cea mai scurta durata de timp posibila
 PIROXICAM
AVERTIZARE ANM-
IULIE 2007
INDICAIILE TERAPEUTICE AU FOST LIMITATE DUP
CUM URMEAZ:
Piroxicam nu mai este indicat n afeciuni acute, precum:
atac acut de gut, dismenoree primar, durere post-operatorie,
tratament stomatologic sau n cursul unei infecii dentare, febr i
durere asociat cu inflamaia de tract respirator superior,
patologie musculoscheletic acut (ex: bursit, tendinit),
patologie acut posttraumatic, radiculalgie.
Indicaiile restricionate sunt:
Reducerea simptomatologiei din osteoartrit, artrit
reumatoid sau spondilit anchilozant.
Reducerea simptomatologiei din poliartrita reumatoid
juvenil.
Piroxicam nu reprezint prima opiune de tratament dac se
poate recomanda un alt AINS.
Decizia de recomandarea piroxicamului trebuie s se bazeze
pe evaluarea complet a riscurilor i beneficiilor individuale pe
care le prezint pacientul.
 Diclofenac si fc hepatica
Terapia cronica- poate induce cresterea
AST, ALT- tranzitorie
 Reaciile adverse GI ale AINS au loc cu
precdere la nivelul tractului GI superior

Desi strategiile curente par sa aib eficacitate similar n

reducerea riscului la nivelul tractului GI superior, exist
dovezi importante care sugereaz c evenimentele adverse
clinice GI poteniale nu sunt limitate la nivelul tractului GI
superior
Studiile sugereaz c pacienii care iau AINS au un risc crescut de
evenimente clinice la nivelul tractului GI inferior* 1-5

*GI inferior nseamn distal de

ligamentul Treitz sau al patrulea
segment al duodenului.
1Allison
et al. N Engl J Med. 1992;327:749-754; 2Lanas and Sopena. Gastroenterol Clin N Am.
2009;38:333-353; 3Fujimori et al. Gastro Endoscopy. 2009;69:1339-1346; 4Laine et al.
Gastroenterology 2003;124:288-292; 5Chan et al. N Engl J Med. 2002;347:2104-2110.

55
 ENTEROPATIA INDUSA DE

AINS
Ulceratii multiple
test hemoragii oculte

Ulceratii circulare-
stricturi

Subocluzie cronica
Ocluzie intestinala

Perforatii cu
peritonita
 ENTEROPATIA INDUSA DE
AINS
Atentie la aspirina tamponata( enteric coated)
Posibil eliberare in intestinul proximal la
concentratii ridicate
Efect iritant topic, aditionat celul prin
prostaglandine( CoX1, CoX2)
Leziunile tubului digestiv inferior mai putin
induse de hiperaciditate( practic inexistenta la
acest nivel)
Dependente de inflamatie- PG + accentuata de
flora intestinului subtire si/sau cea colonica
- enteropatie de cauza inflamatorie
- hipoalbuminemie importanta
ENTEROPATIA AINS CLINICA
Simptomatologia clinica pusa de
multe ori pe seama bolii de baza
Dispepsia care nu raspunde la IPP
Durere abdominala vaga ce nu poate
fi obiectivata prin schemele clasice
de diagnostic si tratament dar
ameliorata de oprirea adm AINS.
anemie feripriva
 ENTEROPATIA INFLAMATORIE
INDUSA DE AINS
Pierderea de proteine si activ inflamatorie se
coreleaza cu niv pierderilor sanguine in tubul
digestiv si imaginea endoscopica
Stricturi intestinale-cca 1%- HP/ fibroza/
vizualizate prin enteroscopie cu capsula
Asp endoscopic derutant- enteropatie AINS vs b.
Crohn
Dg diferential
Test inflamatie- calcoprotectina fecala
Biopsie asp inflamator/ peretele vascular putin
afectat/fara granuloame
Atentie la pacientul asimptomatic cu scadere de Hb
> 2 g/dl- necesita investigatii aprofundate
 Sd anemic indus de AINS
Ulceratii si
hemoragie la
nivelul intestinului
subtire
AINS SI FC RENALA
 AINS si functia renala
Pt preventia insuficientei renale acute- AINS de
evitat la boln cu afectare renala, insuf cardiaca
congestiva, ciroza (Am J Phys 2009, level of evidence, C,
based on a literature review and a summary of consensus
guidelines).

Pt pacientii cu risc de insuficienta renala, cei cu

tratament cu inhibitori enzima de conversie,
blocanti receptori angiotensina- se recomanda
monitorizarea nivelului creatininei serice dupa
debutul terapiei cu AINS (Am J Phys, 2009, level of
evidence, C, based on a summary of consensus guidelines).
 Bolnavi cu risc cardio si
cerebrovascular(AHA 2007)
Infarct miocardic, AVC, AIT, hipertensiuena
arteriala, sindrom metabolic, TEV, embolie
pulmonara- contraindicatii absolute- coxibi
AINS neselectivi+ IPP
Asociere IPP recomandata intotdeauna daca
minidoze de aspirina
Atentie la asocierea cu ibuprofen
paracetamol
AINS i COXIBII continu s fie n atenia
EMEA i FDA

Toate AINS au risc CV, cu excepia aspirinei 80-

100mg
Etoricoxib- averitzare suplimentara- risc HTA!

Nu exist date de siguran CV pe termen lung

pentru AINS neselective sau selective
Pfizer conduce un studiu pe termen lung avnd
ca obiectiv sigurana Celebrex vs. ibuprofen i
alte AINS clasice
PRECISION (Prospective Randomized Evaluation of
Celecoxib Integrated Safety vs Ibuprofen Or
Naproxen) September 2006- approx. 2010
 RISCUL
CARDIOVASCULAR AL
ANTIINFLAMATORIILOR
NESTERIOIDIENE
SELECTIVE SI
NESELECTIVE
 Bolnavi cu risc cardio si
cerebrovascular(AHA 2007)

Infarct miocardic, AVC, AIT, hipertensiuena

arteriala, sindrom metabolic, TEV, embolie
pulmonara- contraindicatii absolute- coxibi
AINS neselectivi+ IPP
Asociere IPP recomandata intotdeauna daca
minidoze de aspirina
Atentie la asocierea cu ibuprofen
paracetamol
Infarct miocardic
 AINS i COXIBII continu s fie n atenia
EMEA i FDA

Toate AINS au risc CV, cu excepia aspirinei 80-

100mg
Etoricoxib- averitzare suplimentara- risc HTA!

Nu exist date de siguran CV pe termen lung

pentru AINS neselective sau selective
Pfizer conduce un studiu pe termen lung avnd
ca obiectiv sigurana Celebrex vs. ibuprofen i
alte AINS clasice
PRECISION (Prospective Randomized Evaluation of
Celecoxib Integrated Safety vs Ibuprofen Or
Naproxen) September 2006- approx. 2010
 Reducerea riscurilor la utilizatorii de
AINS

Evaluare pentru prezenta factorilor de risc inalt pentru efectele adverse induse de
AINS . La nevoie se va mentine doza cea mai redusa posibil
Analiza comorbiditatilor (ie boala hepatica si renala) inainte de instituire
Prescriere cu prudenta la bolnavii cu factori de risc pt boli GI sau CV
Atentie la interactiunile medicamentoase ale AINS si coxibilor
Pacienti cu anamneza de reactii alergice cronice/cutanate
Se prefera un AINS neselectiv
Prudenta pt coxibi
Majoritatea cazurilor apar in prima luna de tratament
Soluia
- individualizarea terapiei
- evaluare risc / beneficiu
- interventie intit, energic i scurt
- risc GI: mai bine coxibi (Celecoxib)
- risc CV:
- coxibi conform recomandrilor (EMEA)
- pruden la AINS neselective;
- Aspirina naintea AINS neselectiv
- Celecoxib +Aspirin (nu conteaza ordinea)
 Pain Treatment
Continuum

8/3/2006
Invasive and noninvasive
neuromodulation in pain
management
National Spinal Cord Stimulation Programme
Elena Copaciu
Ovidiu Palea
University Hospital of Bucharest
NeuroPain Multidisciplinary Pain Clinic, Bucharest
 Neuromodulation
Variable definition in both its entity and
activity
Includes treatments that involve
stimulation of the various nerves of the
central, peripheral and autonomic nervous
system/ deep brain nuclei
That lead to ~modulation~ of its activity
Main target- reversible neural
modulation as opposed to ablative or
resective procedures.
Treatments are reversible and can be
turned off in most situations.
 Neuromodulation
Neural stimulators
Drug delivery devices
 Neuromodulation- stimulators

Spinal cord stimulation- delivers therapeutic doses of electrical

current to the spinal cord for the management of the neuropathic
pain- postlaminectomy syndrome, CRPS, ischemic limb pain,
angina
At least 50% pain relief in 50- 60% of implanted patients
Deep brain stimulation- movement disorders Parkinsons disease,
dystonia, tremor
Cortical stimulation: poststroke, neuropathic pain syndromes,
movement disorders, depression, stroke, epilepsy
Peripheral nerve stimulation- vagal nerve stimulation- epilepsy,
occipital nerve stimulation- headaches
Cochlear implants- deafness
Retinal stimulation- blindness
 Drug delivery devices
Surgically implanted pumps in the area of
interestand deliver the medication directly
to the desired target
Enables lower dosages
Decreases/eliminates the systemic
medication side effects
Intrathecal implants- pain management-
syndromes associated with nerve injury or
cancer/ treatment of spasticity
Intraventricular implants- medication
directly to CSF or CNS- epilepsy or pain
Scrambler therapy
Transcutaneous electrical
modulation pain reprocessing
 Lumbar and cervical spinal
fusion, bilateral shoulder

surgery after
57 yrs old US patient
car crash
Lumbar pain- 9/10
Current medication: 160 mg oxicontin+
naloxone, 900 mg gabapentin, Tylenol
Lumbar therapy- 0/10 VAS during treatment,
4/10 after 22 hrs
10 therapies- stable 2/10 VAS, also treatment at
cervical and shoulder level
Atends gulf session during the wkd, very good
QoL
Oxicontin 60 mg/morning, renounced at the
evening dose
 Clinical case 2- trigeminal

neuralgia
62 yrs old pt, excrutiating pain
Right trigeminal neuralgia,
carbamazepine side effects
12 kg body weight lost in 4 weeks
because of impossible swallowing.
difficult speech
Severe hyperalgesia and allodynia
10 scrambler therapies significantly
improved pain, one single painful
point on the tragus- significant
hyperalgesia
Succesfully treated with RF ablation
Pain free after 4 months
 CLINICAL CASE 3

76 old female, severe trigeminal

neuralgia- high dose pregabalin +
carbamazepine, not willing to rescue
anticonvulsants
RF ablation with partial relief for one week
Severe trigeminal neuralgia- severe
muscle contractures- masseters, cervical,
impossible swallowing, burning mouth
syndrome
Only after 3 ST therapies- eating became
possible
 Orofacial pain syndrome-
ST as rescue therapy
54 yrs old woman- Severe pain mimicking
trigeminal neuralgia
Noise in the ipsilateral middle ear- tympanotomy
Bruxism
Ipsilateral temporomandibular joint disorder
Cerebral MRI- invasive tumour of the nasopharynx
64 years old male patient, with 6 teeth
extractions on left maxillary bone for phantom
tooth syndrome- for 3 years
After pain relief- dental implant, excrutiating pain
Dental care practitioner implant not involved in pain
symptoms
Dental Rx- apical cavity- reffered for specialized cure
 Orofacial pain syndromes
when ST was not applied
Severe migraine attacks- reffered to
neurologists- EEG paroxysmal
discharges during painful attack-
lamotrigine and neurological follow
up
 Clinical case 1- failed back surgery
- 46 yrs old woman
- 10 lumbar surgeries for radicular pain. Nr 8 for
osteodiscittis
- 9/10 VAS pain score for lumbar pain, 6/10- L5
left, severe functional impairment, severe
alteration in daily living
- Currently on Oxicontin 80 mg and Lyrica 300 mg
- From the first treatment- lumbar VAS 2/10- 3
treatment at lumbar level with 3 channels
- Irradiating pain treated simultaneously
thereafter
- Reduced opioid dose
- Increased daily walking distance
- VAS stable under 3/10 after treatment..but
- She had a fall on a slippery surface and lumbar
nociceptive pain issued again
Postherpetic neuralgia
Anterior cutaneous entrapment
syndrome- T9
 Devils grip syndrome-
Bornholm disease
Rare Coxsackie B virus disease of intestinal origin
Intercostal muscles inflammation, severe chest pain,
lasting for a month
60 yrs old woman, sudden onset 5 yrs ago
Severe pain, had surgery for hiatal hernia
Pain become excrutiating, severe hyperalgesia, severe
anxiety, significant alteration in QoL
Started therapy with vertical placement for the
postoperative scar and continued with the intercostal
area
Pain free at 4 monthsbut still a rope makes a knot
inside the body from time to timerefuses
psychological counselling
 Clinical case
68 years old woman
Pain in the left lower limb, pelvis, IBS,
intersititial cystitis( urodynamic tests)
Cerebral MRI- multilacunarism with
multiple demyelinating lesions
Peripheral nerve function- normal
Dislipidemia
Under investigation for cerebral amyloid
angiopathy with peripheral component
 Cancer pain patients
Spinal/ osseous metastasis: cervix cancer,
colorectal cancer, humerus osteosarcoma with
pulmonary and thoracal vertebrae metastasis,
prostate cancer with sacral metastasis
Postchemotherapy pain
Pain due to postiradiation pelvic fibrosis-
cervical cancer
 Painful syndromes requiring
multidisciplinary approach
Failed back surgery with radicular pain and
residual extraforaminal inflammation
Atypical facial pain- odontogenic origin
aggravated
Trigeminal neuralgia
3 STs- with significant improvement, previous
TMJ pathology- neglected
Sudden aggravation- right otitis media,
tympanotomy
Psychollogic counselling, ENT, maxillofacial
surgery refferal
 Spinal cord stimulation
The first year the National Healthcare
Insurance House accepted to finance a
National Programme on Spinal Cord
Stimulation at the:
Anesthesia, ICU and Pain Medicine Department
University Hospital of Bucharest
Programme Director- Assoc Prof Elena Copaciu
Medical Director- dr Ovidiu Palea
Executive Director- dr Elena Ursache
 intrebari:
Ce recomandam ca analgetic la un
bolnav cu dureri severe si:
Ciroza hepatica?
Insuficienta renala?
Insuficienta cardiac congestive NYHA III
si sechele de AVC?
Ulcer duodenal?
Polineuropatie diabetic dureroasa
Cancer de san socs din evidenta
oncologica si parestezii/disestezii MI?