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- 1. Évaluation et prise en charge Place de la stimulation médullaire 12/08/11
- 2. 1- PHYSIOPATHOLOGIE DE LA DOULEUR 2- DIAGNOSTIC ET EVALUATION 3- PRISE EN CHARGE 4- TECHNIQUES DE STIMULATION 5- MATERIEL DE STIMULATION MEDULLAIRE 6- RESULTATS DE LA STIMULATION MEDULLAIRE
- 9. Etat Basal : Absence de Douleur 12/08/11 Grosses Fibres A , A Douleur = 0 Petites Fibres NociceptivesC, A Tact Système Excitateur < Système Inhibiteur
- 10. Douleur par excès de nociception 12/08/11 Grosses Fibres A , A Douleur Petites Fibres Nociceptives C, A Tact Système Excitateur > Système Inhibiteur
- 11. Douleur Neuropathique 12/08/11 Grosses Fibres A , A Douleur Petites Fibres Nociceptives C, A Tact Système Excitateur > Système Inhibiteur Lésion Nerveuse
- 18. 12/08/11 Échelles d’évaluation Auto-évaluation quantitative (intensité) Échelle Visuelle Analogique 0 10 Absence de douleur Douleur maximum imaginable Échelle Numérique 0 1 2 3 4 5 6 7 8 9 10 Absence de douleur Douleur maximum imaginable
- 19. Questionnaire DN4 : Un outil simple pour rechercher les douleurs neuropathiques 12/08/11
- 22. TENS 12/08/11 1 / TENS : indications / principes - Douleurs de topographie limitée et fixe, - Trouble sensitif partiel (permettant la sensation des paresthésies), - Pas d’allodynie. Exemples : douleurs d’amputation, post-zostériennes, lombosciatique par fibro-arachnoïdite - Électrode = 4 cm², stimulation 1h toutes les 2-4h, post-effet = 1h (80Hz, 100 à 500 µsec)
- 23. 12/08/11 Pas de Plainte TENS EFFICACITE Partielle / Suffisante Inefficacité TOLERANCE CONFORT Allergie / Allodynie Correcte Plainte qualité de vie Insertion professionnelle Évaluation multidisciplinaire TEST S.M . TENS + - + - + - TENS
- 26. 12/08/11 Stimulation médullaire Principe
- 27. 12/08/11 Petites Fibres Nociceptives Tact Grosses Fibres SM Bruit de Fond Somesthésique Lésion Nerveuse Douleur Stimulation médullaire Principe
- 29. 12/08/11 1. Renforcement des systèmes inhibiteurs spinaux et supra-spinaux AU NIVEAU SEGMENTAIRE : - Inhibition directe des Neurones Convergents de la corne dorsale de la moelle épinière - Activation des Interneurones Inhibiteurs AU NIVEAU SUPRA-SEGMENTAIRE : - Activation d'un Système Inhibiteur Descendant (Mécanisme plus puissant et plus prolongé) Stimulation médullaire Mécanismes d’action
- 31. 12/08/11 3. Effet sympatholytique - Augmentation du débit sanguin dans la microcirculation périphérique - Suppression transitoire de l'activité Vaso-Constrictive Sympathique Stimulation médullaire Mécanismes d’action
- 33. 12/08/11 Stimulation médullaire Critères de sélection - Douleurs neuropathiques chroniques depuis plus de 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 - Absence de contre-indication - Intégrité des voies lemniscales = P.E.S. = Faisabilité - Test percutané positif
- 34. Quand doit-on prescrire la SME ? 12/08/11
- 40. 12/08/11 PISCES-Quad 3890 PLUS 3892 COMPACT 3891 Stimulation médullaire Matériel : électrodes percutanées
- 41. 12/08/11 3890 Stimulation médullaire Matériel : électrodes percutanées Contacts électriques = Platine/Iridium Diamètre de l’électrode = 1,3 mm Isolant externe Polyuréthane 3 mm 6 mm PISCES-Quad COMPACT 3891 Espacement de 4 mm entre les plots PISCES-Quad PLUS 3892 Plots de 6 mm / Espacement de 12 mm
- 42. 12/08/11 Octad 3777 Plots de 3 mm / Espacement de 6 mm Octad Compact 3778 Plots de 3 mm / Espacement de 4 mm Octad SubCompact 3776 Plots de 3 mm / Espacement de 1,5 mm Stimulation médullaire Matériel : électrodes percutanées
- 44. 12/08/11 Stimulation médullaire Matériel : électrodes percutanées 0 mm 10 mm 20 mm 30 mm 40 mm 50 mm 60 mm 70 mm Std Plus Std Compact Compact SC 1x4 Quad 1x8 Octad 2,5 corps vertébraux couverts (66mm)
- 45. 12/08/11 Stimulation médullaire Matériel : électrodes chirurgicales
- 47. 12/08/11 Stimulation médullaire Matériel : électrodes chirurgicales
- 49. 12/08/11 Extensions 7489 Longueur 10, 25, 40, 51 ou 66 cm Isolant externe Silicone revêtu de siloxane Stimulation médullaire Matériel : extensions
- 51. 12/08/11 Stimulation médullaire Matériel : Stimulateurs Test SingleScreener TM 3625 Mono canal Quadripolaire
- 52. 12/08/11 DualScreener TM 3628 Double canal Quadripolaire Stimulation médullaire Matériel : Stimulateurs Test
- 53. 12/08/11 Stimulation médullaire Matériel : Stimulateurs Test ENS 37021 Double canal Octopolaire + Cable Test 3550-31 + N’Vision 8840 +Télécommande 37742
- 54. 12/08/11 Stimulation double-canal Stimulation médullaire Matériel : Stimulateurs Mono - Canal = ITREL 3 (7425 ou 7425KIT) Double - Canal = SYNERGY (7427 ou 7729 = KIT) Mono - Double -
- 57. 12/08/11 Stimulation médullaire Matériel : le système Restore Programmateur médecin N’Vision™ Neurostimulateur implantable Restore™ Télécommande patient Restore™ Chargeur Restore™
- 59. 12/08/11 Quel stimulateur pour quel type de douleur ?
- 60. 12/08/11 Matériel : programmateur N’Vision 8840
- 66. 12/08/11 Van Buyten J-P et al. Eur J Pain 2001; 5: 299–307
- 73. Lazorthes, 1995 : Résultats / indication 12/08/11 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)
Notas do Editor
- Millions of adults in Europe suffer from long-term chronic pain that often results in depression, helplessness and an inability to think or function normallys References Pain in Europe Survey www.painineurope.com Breivik H et al. Eur J Pain 2005, accepted for publication
- Many patients do not receive adequate pain relief and only 2% receive the help of pain management specialist
- 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
- Thymie = humeur / état d ’esprit Paroxystique = spontané, sans stimulus (pics douloureux survenant n ’importe quand et sans raison)
- Thymie = humeur / état d ’esprit Paroxystique = spontané, sans stimulus (pics douloureux survenant n ’importe quand et sans raison)
- 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
- Le TENS est particulièrement bien adapté pour les douleurs de topographie LIMITEE (un ou deux troncs nerveux), SANS ALLODYNIE (intolérance des électrodes cutanées), et avec un trouble sensitif PARTIEL (il faut que le temps de conduction PERIPHERIQUE soit normal ou peu altéré pour que la stimulation du nerf périphérique et donc les paresthésies parviennent jusqu ’à la moelle puis au cerveau)
- L ’intérêt de cette diapo est de montrer que les indications de Stimulation Transcutanée peuvent aboutir à une indication de stimulation médullaire (généralement, les patients que l ’on implante ont tous eu un TENS à un moment donné de leur cursus thérapeutique). Les raisons pour passer du TENS à la stimulation médullaire ne sont pas forcément limitées aux échecs du TENS, car même avec une efficacité partielle ou suffisante, des problèmes secondaires (de tolérance, ou de confort) peuvent amener l ’équipe médicale à considérer un test de stimulation médullaire Préciser aussi qu ’en cas d ’échec du TENS, la stimulation médullaire peut marcher
- Although the mode of action of SCS is still not fully understood, the procedure was originally based on the gate-control theory of pain by Melzack and Wall 1 This proposed that painful ‘nociceptive’ information in the periphery is transmitted to the spinal cord in small diameter C fibers and A-delta fibers, which terminate in the dorsal horn – the gate – of the spinal cord Other sensory information, such as touch or vibration, is carried in large A-beta fibers that pass through this gate As they do, they give off small branches that terminate in the dorsal horn, where they have an inhibitory effect on the nociceptive conduction The basic premise of the gate-control theory was that stimulation of large, low threshold fibers would close the gate to the reception of small-fiber information The clinical result of gate closure was postulated to be analgesia However, if direct inhibition of pain transmission in the dorsal horn of the spinal cord was the principal mode of action, then SCS would control nociceptive pain and this is generally not the case. In a recent review of the mechanisms of action of SCS, it was concluded that a multiplicity of different mechanisms are activated by SCS, some essential for the desired effect but many irrelevant to it 2 Other theories include 2 : Inhibition of pain at supraspinal level Inhibition of the sympathetic nervous system Release of neuromodulators and neurotransmitters Melzack R, Wall PD. Pain mechanisms 1965; 150: 971–9 Linderoth B, Meyerson BA. In: Surgical Management of Pain. Thieme, New York, 2002; 505–26
- At present, SCS is considered a ‘last resort’ in the treatment of refractory neuropathic pain However, evidence suggests that early intervention with SCS results in significantly greater efficacy 1,2 SCS may be delivered in parallel with other therapies and thus should be used as part of an overall rehabilitation strategy 3 In the case of FBSS, it is recommended that for patients with persistent radicular pain after lumbosacral spine surgery, clinicians should offer SCS as an alternative to repeated operation before exhausting all surgical alternatives 3,4 Kumar K et al. Surg Neurol 1998; 50: 110-21 Stanton-Hicks et al. Pain Practice 2002; 2(1): 116 De Andr é s J, Van Buyten J-P. Neuromodulation by neurostimulation. Pain Practice 2006, in publication North RB et al. Neurosurgery 2005; 56: 98-107
- 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
- Octad contains eight 3mm electrodes spaced 6mm apart
- 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