NYERI NEUROPATIK DAN

TRIGEMINAL NEUROPATIK
Yann Penduff - 0906620474
Nova Yundiarto - 1206207413
DEFINISI
Pain is an unpleasant sensory and emotional experience associated
with actual or potential tissue damage or described in terms of such
damage IASP
KLASIFIKASI NYERI
AKUT

WAKTU
KRONIK

Nosiseptif

JENIS Neuropatik

Campuran
NYERI NEUROPATIK
Nyeri yang dicetuskan oleh lesi primer atau disfungsi pada sistem
saraf perifer maupun sentral.
PATOFISIOLOGI
Nyeri Neuropatik
Mekanisme Perifer
Aktivitas ektopik spontan
Sensitisasi nosiseptor
Sprouting kolateral neuron aferen
primer
Ephaotic conduction
Perubahan pada ekspresi saluran ion
Sprouting neuron simpatetik ke dalam
ganglion radiks dorsalis
Sensitivitas terhadap katekolamin
Rangsangan pada nervi nervorum
Mekanisme Sentral
Sensitisasi sentral
Reorganisasi spinal
Reorganisasi kortikal
Hilangnya kontrol inhibisi
Peningkatan jumlah reseptor
(contoh: alfa2delta presinaptik
medula spinalis)
Physical Examination, DDX,
Treatment and Prognosis
 Diagnosing Neuropathic Pain
Innumerable possible diseases
VITAMIN D
The lesion must involve a nociceptive pathway

Goals
Elimination/control of the primary responsible underlying pathology
Proper Diagnosis
Management
Restore Quality of Life
Minimise drug intake
 Neuropathic Pain: Not Nociceptive Pain
Differentiate Nociceptive and Neuropathic Pain
Nociceptive Pain is physiological
Nociceptive Pain arises from peripheral sensory nerves
Defined location
External : skin, cornea, mucosa
Internal: muscle, joint, bladder, gut, digestive tract
Arises from mechanical, chemical or thermal irritation
Pain is usually described as sharp, and is localized
Allodynia / Hyperalgesia

Mindruta I. et al. Overview of Neuropathic Pain Diagnosis & Assessment An Approach Based on Mechanisms. Univ Emer Hosp of Bucharest. Mar 2012
 Neuropathic Pain: Diagnosis
Quality of the pain
Duration
Pattern
Intensity (VAS)
Context / Triggers
Relieving /
enhancing factors
Topographic
distribution of pain
Other neurological
symptoms
Impact on daily life

Table from: Goucke CR. The Management of Persistent Pain. Med J Aust 2003. 178 (9): 444-447
Mindruta I. et al. Overview of Neuropathic Pain Diagnosis & Assessment An Approach Based on Mechanisms. Univ Emer Hosp of Bucharest. Mar 2012
Physical Exam

Table from: Mindruta I. et al. Overview of Neuropathic Pain

Diagnosis & Assessment An Approach Based on
Mechanisms. Univ Emer Hosp of Bucharest. Mar 2012
Physical Exam

Table from: Mindruta I. et al. Overview of Neuropathic Pain

Diagnosis & Assessment An Approach Based on
Mechanisms. Univ Emer Hosp of Bucharest. Mar 2012
Supporting Examinations

EEG Imaging

Laboratory
 Principles of Treatment
Controlling/curing the underlying disease
(e.g corticosteroids for neuropathies caused by an auto-immune disease)
Treating Troublesome Symptoms
Pain
Depression
Sleep Problems

Hui TK. Overview of Neuropathic Pain. NUHS. Jan 2011.

 Painful Polyneuropathies
Tricyclic Antidepressants
Amitriptyline (150 mg/d)
Tricyclic Antidepressant
SE: Dry mouth, postural hypotension, arrhythmias, cognitive impairment, constipation, urinary retention

Antiepileptics
Pregabalin (150-600mg/d) / Gabapentin (1200-3600mg/d)
GABA Analogue, inhibits the release of excitatory neurotransmitters
SE: Dizziness, somnolence, peripheral edema, headache, weight gain

Topical Lidocaine
useful for the elderly, esp. if concerns about oral intake
Opioids (2nd / 3rd line)
Oxycodone / Tramadol

Attal N, Cruccu G et al. EFNS Guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur Jour of Neurology, 2010. 17: 1113-1123
 Diabetic Neuropathy
Treatment is symptomatic
With the exception of glucose control
Difficult to manage pain: Clinical Trials generally accept 50% of pain intensity as successful,
associated with improvements in quality of life (sleep, fatigue, depression)

3 drugs having regulatory approval in the USA for DNP

Pregabalin (150-600mg/d) / Gabapentin (1200-3600mg/d)
GABA Analogue, inhibits the release of excitatory neurotransmitters
SE: Dizziness, somnolence, peripheral edema, headache, weight gain

Duloxetine (60-120mg/d) / Venlafaxine (150-225mg/d)

SNRI
SE: Nausea, somnolence, dizziness

Amitriptyline (150 mg/d)

Tricyclic Antidepressant
SE: Dry mouth, postural hypotension, arrhythmias, cognitive impairment, constipation, urinary retention

Schreiber AK, Nones CF, Reis RC, Chichorro JG, Cunha JM. Diabetic neuropathic pain: Physiopathology and treatment. World Journal of Diabetes. 2015;6(3):432-444. doi:10.4239/wjd.v6.i3.432.
Huizinga MM, Peltier A. Painful Diabetic Neuropathy: A Management-Centered Review. Clinical Diabetes. 2007;25:615.
 Central Neuropathic Pain
Pregabalin (150-600mg/d) / Gabapentin (1200-3600mg/d)
GABA Analogue, inhibits the release of excitatory neurotransmitters
SE: Dizziness, somnolence, peripheral edema, headache, weight gain

Opioids (2nd Line)

Tramadol (200-400 mg/d)

Attal N, Cruccu G et al. EFNS Guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur Jour of Neurology, 2010. 17: 1113-1123
 Other Neuropathies

Table modified from: Attal N, Cruccu G et al. EFNS Guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur Jour of Neurology, 2010. 17: 1113-1123
 Examples of neuropathies

Image from: Gouvas H. Wikimedia Commons. Sep 2010

 Management of CTS
Avoid Repetition
Not use vibratory tools (drills, jackhammer, etc)
Ergonomic Measures
Improved wrist positioning
Wrist Splint
Pharmacological
Oral / Injection Corticosteroids
Surgery

Viera AJ. Management of Carpal Tunnel Syndrome. Am Fam Physician. 2003 Jul 15;68(2):265-72.
Trigerminal Neuralgia
TRIGEMINAL NEURALGIA
Trigeminal Neuralgia (Tic Douloureux)
Nyeri yang hebat
tiba-tiba
Unilateral
paroksismal/singkat
berulang dan episodik
pada distribusi saraf sensorik N. trigeminal

Primer

Etiologi
Sekunder
Epidemiologi
Awitan diatas usia 40 tahun
Wanita > laki-laki (3:1)
Insidens keseluruhan 4,3 per 100.000 penduduk per tahunnya
Rata-rata usia awitan 52-58 tahun untuk NTI dan 35 tahun untuk NTS
 Diagnosis of TN

Table from: Croccu G et al. Trigerminal Neuralgia: New classification and diagnostic grading for practice and research. AAN. Jun 2016.
 Diagnosis of Possible
Trigerminal Neuralgia
: Anamnesis
Minimum Requirement: Pain Distribution
with the facial or intraoral territory of the
Trigerminal Nerve
If the pain involves 2 divisions, they
should be contiguous
Affected Division and side of the face may
change over the course of the disease.
Paroxysmal Character to the pain
Notions of brief, sudden, stabbing, electrick
shock-like, severe.
A few seconds - < 2minutes.
Frequency: 1 50 / day
Virtually always unilateral

Complete remission in 63% of patients.

Cruccu G et al. Trigerminal Neuralgia: New classification and diagnostic grading for practice and research. AAN. Jun 2016.
Sandell T, Eide PK. Effect of microvascular decompression in trigeminal neuralgia patients with or without constant pain. Neurosurgery 2008;63:9399
 Diagnosis of Clinically Established TN
Evoked pain: 99% of the patients
triggered pain qualifies as a criteria to
the diagnosis of Clinically Established TN.
Can be as light as a shaving, face washing, or
even wind.
Movement can also be a trigger (smiling /
talking)
Location of trigger and resulting pain may be
different.
Trigger Zones
Most often in the central portion of the
face
Allodynia
with a refractory period ( refractory
period specific to TN)

Cruccu G et al. Trigerminal Neuralgia: New classification and diagnostic grading for practice and research. AAN. Jun 2016.
Bowsher D. Dynamic mechanical allodynia in neuropathic pain. Pain 2005;116:164165
Image from: Trigerminal Neuralgia. Distribution of Trigger Zones. Perkin 2002.
 Diagnosis of Etiologically
Established TN
Classical TN :
MRI demonstrates vascular
compression with morphologic changes
of the trigerminal nerve root.
Contact alone : Highly sensitive (89%), but not
specific (36%).
Nerve dislocation or atrophy : 97% Specificity
Compression of the trigerminal root: 100%
specificity
Most common form of TN

Image from: Cruccu G et al. Trigerminal Neuralgia: New classification and diagnostic grading for practice and research. AAN. Jun 2016.
Bowsher D. Dynamic mechanical allodynia in neuropathic pain. Pain 2005;116:164165
 Diagnosis of Etiologically
Established TN
Secondary TN:
Diagnosis relies on evidence of a
major neurologic disease which
causes neuralgia.
Tumor at the cerebellopontine angle
MS (2-5 of MS patients have TN. 2-14% of
TN patients have MS).

Image from: Cruccu G et al. Trigerminal Neuralgia: New classification and diagnostic grading for practice and research. AAN. Jun 2016.
Bowsher D. Dynamic mechanical allodynia in neuropathic pain. Pain 2005;116:164165
 Differential Diagnosis for TN

Ropper A, Brown R. Adams and Victors Principles of Neurology. 8th Edition. USA: The McGraw-Hill Companies 2005
 Differential Diagnosis for TN

Ropper A, Brown R. Adams and Victors Principles of Neurology. 8th Edition. USA: The McGraw-Hill Companies 2005
Neuropathic Pain Guideline. GMMMG/NHS. Nov 2013
Prognosis of NP Management
Prognosis depends on the underlying cause
75% pain relief after decompression surgery
Clinical Summary
Cause / mechanism of development of neuropathic pain can be
unclear in many patients
Clinical Suspicion and Complete Diagnosis is needed for the treatment
of neuropathic pain
Primarily address the underlying cause + symptoms
As a primary physician, your treatment modality is primarily
pharmacological (with some exceptions)
The final outcome may not be ideal you must explain this to your
patient and manage his expectations

Hui TK. Overview of Neuropathic Pain. NUHS. Jan 2011.

PERTANYAAN
Tami : Pada GP bagaimana suspek TN? Kapan keputusan ambil
operasi?
Yuda : Kapan kita lakukan pemeriksaan penunjang? Pada proses
diagnosis ada jenis pasien? Saraf yang rusak berarti semua neuropatik
pain?
Kiwah : Kenapa trigeminal neuralgia banyak terjadi di macxillaries dan
mandibullaries? Mungkin terjadi adaptasi? Apakah semua nyeri
kronik pasti neuropatik? Kapan nentuin pasien operasi atau tidak?
Nisa : Trigeminal neuralgia apakah diagnosis klinis? Apakah ada alur
diagnosisnya ada? Apakah ada gold standar pemeriksaaan
penunjnagnya? Edukasi apa yang kita berikan pada pasien TN?
 IHS
Sefalgia primer : Migrain, TTH, TNI (SUNCT, Cluster, TNI)
Jika tidak ditemukan defisit neurologi primer
MRI menjadi gold standar dengan sekuens CISS. Bisa dilakukan NCV atau EMJ.
3 Bulan terjadi reorganisasi saraf di sentral