lunes, 12 de febrero de 2018

Síndrome de dolor regional complejo / Complex regional pain syndrome,

Febrero 7, 2018. No. 2987

Síndrome de dolor regional complejo. Actualización
Complex regional pain syndrome-up-to-date.
Pain Rep. 2017 Oct 5;2(6):e624. doi: 10.1097/PR9.0000000000000624. eCollection 2017 Nov.
Abstract
Complex regional pain syndrome (CRPS) was described for the first time in the 19th century by Silas Weir Mitchell. After the exclusion of other causes, CRPS is characterised by a typical clinical constellation of pain, sensory, autonomic, motor, or trophic symptoms which can no longer be explained by the initial trauma. These symptoms spread distally and are not limited to innervation territories. If CRPS is not improved in the acute phase and becomes chronic, the visible symptoms change throughout because of the changing pathophysiology; the pain, however, remains. The diagnosis is primarily clinical, although in complex cases further technical examination mainly for exclusion of alternative diagnoses is warranted. In the initial phase, the pathophysiology is dominated by a posttraumatic inflammatory reaction by the activation of the innate and adaptive immune system. In particular, without adequate treatment, central nociceptive sensitization, reorganisation, and implicit learning processes develop, whereas the inflammation moderates. The main symptoms then include movement disorders, alternating skin temperature, sensory loss, hyperalgesia, and body perception disturbances. Psychological factors such as posttraumatic stress or pain-related fear may impact the course and the treatability of CRPS. The treatment should be ideally adjusted to the pathophysiology. Pharmacological treatment maybe particularly effective in acute stages and includes steroids, bisphosphonates, and dimethylsulfoxide cream. Common anti-neuropathic pain drugs can be recommended empirically. Intravenous long-term ketamine administration has shown efficacy in randomised controlled trials, but its repeated application is demanding and has side effects. Important components of the treatment include physio- and occupational therapy including behavioural therapy (eg, graded exposure in vivo and graded motor imaging). If psychosocial comorbidities exist, patients should be appropriately treated and supported. Invasive methods should only be used in specialised centres and in carefully evaluated cases. Considering these fundamentals, CRPS often remains a chronic paindisorder but the devastating cases should become rare.
KEYWORDS: Central reorganisation; Complex regional pain syndrome; Neuroplasticity; Posttraumatic inflammation; Treatment
Interacciones aberrantes de medidas periféricas y neurometabolitos con lípidos en el síndrome de dolor regional complejo mediante espectroscopía de resonancia magnética: un estudio piloto.
Aberrant interactions of peripheral measures and neurometabolites with lipids in complex regional pain syndrome using magnetic resonance spectroscopy: A pilot study.
Mol Pain. 2018 Jan-Dec;14:1744806917751323. doi: 10.1177/1744806917751323.
Abstract
Background The aim of this study was to assess peripheral measures and central metabolites associated with lipids using magnetic resonance spectroscopy. Results Twelve patients with complex regional pain syndrome (CRPS) and 11 healthy controls participated. Using magnetic resonance spectroscopy, we measured the levels of lipid 13a (Lip13a) and lipid 09 (Lip09) relative to total creatine (tCr) levels in the right and left thalamus. We found negative correlations of Lip13a/tCr in the right thalamus with red blood cells or neutrophils, but a positive correlation between Lip13a/tCr and lymphocytes in the controls. We found negative correlations between Lip09/tCr and peripheral pH or platelets in the controls. There were positive correlations between Lip09a/tCr and myo-inositol/tCr, between Lip13a/tCr and N-acetylaspartate (NAA)/tCr, and between Lip09/tCr and NAA/tCr in healthy controls. On the other hand, there were positive correlations between Lip13a/tCr and Lip09/tCr and urine pH in CRPS patients. There were significant correlations between Lip13a/tCr or Lip09/tCr and different peripheral measures depending on the side of the thalamus (right or left) in CRPS patients. Conclusion This is the first report indicating that abnormal interactions of Lip13a and Lip09 in the thalamus with peripheral measures and central metabolites may mediate the complexpathophysiological mechanisms underlying CRPS.
KEYWORDS: Complex regional pain syndrome; lipid 09; lipid 13a; pH; thalamus
Síndrome doloroso regional complejo: revisión
Berenice Carolina Hernández-Porras , Ricardo Plancarte-Sánchez, Silvia Alarcón-Barrios y Marcela Sámano-García
Cirugía y Cirujanos. 2017;85(4):366---374
Resumen
Antecedentes: El síndrome doloroso regional complejo se caracteriza por dolor espontáneo o inducido, desproporcionado con relación al evento inicial y que se acompana˜ de una gran variedad de alteraciones autonómicas y motoras, dando lugar a una gran variedad de presentaciones clínicas. Con frecuencia se asocia a cirugías y a traumatismos menores. Fisiopatología: Se postulan 3 mecanismos: cambios por inflamación postraumática, disfunción vasomotora periférica y cambios funcionales y estructurales del sistema nervioso central secundarios a una mala adaptación. Diagnóstico: Se realiza tomando como base los criterios de Budapest. El paciente debe presentar un síntoma de cada criterio al momento del diagnóstico: dolor continuo, desproporcionado en relación con cualquier evento desencadenante. Un signo y un síntoma: sensorial, vasomotor, edema y cambio motor / trófico. Por último, estos no se explican por otro diagnóstico o causa. Tratamiento: Se sugiere que sea multimodal. No existe un estándar de oro. En fase temprana se pueden utilizar AINE o esteroides. Se han indicado fármacos utilizados para tratamiento de dolor neuropático, pero ninguno de estos posee suficiente evidencia. Hay baja evidencia de la efectividad de que los bifosfonatos, la calcitonina, la ketamina y la terapia en espejo sean efectivos comparados con placebo. El tratamiento intervencionista debe ser escalonado de bloqueo peridural, neuroestimulación, bomba intratecal hasta las terapias experimentales en caso de dolor refractario a tratamiento. Discusión: A pesar de que el síndrome doloroso regional complejo es una entidad reconocida desde hace más de 100 anos, ˜ todavía no existe evidencia clara en las primeras elecciones terapéuticas, aunque hay nuevas tecnologías aplicables en su tratamiento.
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