Neuromuscular pain Clinical Assessment and Therapeutic Management. Dr Jean-Jacques LABAT Dr Jérôme RIGAUD

Transcription

1 Neuromuscular pain Clinical Assessment and Therapeutic Management Dr Jean-Jacques LABAT Dr Jérôme RIGAUD

2 Chronic Post-operative operative pelvi-perineal Pain Eliminate Infection Haematoma Mesh erosion Normal standard imagery Chronic Pain > 6 months

3 Neuropathic Pain Per-operative Traumatism Direct (section ± total) Indirect (retractor, haematoma) Progressive nerve lesion Nevroma Nerve Entrapment by fibrosis

4 Somatic Neuropathic Pain Arguments Localization Troncular (or radicular) systematization Type of Pain Burning, shooting, numbness, stabbing or aching pain Superficial Hypoesthesia Allodynia Anatomo-clinic correlation +++ Which surgery for which nerve? Which nerve for which surgery? Operative report +++

5 Ilio inguinal Génito-fémoral Obturateur Cluneal inf Pudendal

6 Mechanism Operative traumatism Immediate neurological troubles Favourable progressive evolution Fibrosis and chronic compression Progressive installation and aggravation Nevroma Paroxysmal pain Trigger point, Tinel

7 Chronology +++++

8 High-Risk Surgery Oncological surgery Abdominal wall surgery All abdominal scares (transversal or lateral) Prosthesis Mesh Incontinence surgery Sub-urethral sling Prolapse surgery Prosthesis Mesh (abdominal or vaginal approach)

9 Clinical Assessment Therapeutic Management

10 Parietal Nerves

11 Ilio-hypogastrique Ilio-inguinal Cutané latéral de la cuisse Génito-fémoral

12 Parietal Nerves High-risk Surgery Hernia repair (Aasvang et al ) 5-10% at 1 year (EVA > 5 in 2-4%) Neuropathic pain Decrease of threshold of painand cold perception Increase of threshold of tactile and warm perception Dysejaculation 2.5 % No interest of imagery (MRI)

13 Parietal Nerves High-risk Surgery All lateral abdominal incisions Open surgery Laparoscopic surgery Transversal incision 10 % caesarian Excepted Median incision

14 Parietal Nerves Clinical Assessment Exam of scares Trigger point Relative interest of EMG Infiltration loco-dolenti ++ Diagnosis Anaesthetic Therapeutic Corticoids Improvement 70% (Palumbo et al 2007)

15 Treatment Parietal Nerves Exploration of the scares with neurolysis If trigger point (Nevroma) Improvement 75% Pulsed Radiofrequency Improvement 4/5 (1-9 months) (Rozen et al2006) Improvement 1 case (Mitra et al 2007)

16 Treatment Ilio-inguinal Neurectomy Ligatured and cauterization (Zacest et al 2009) Improvement in 70 % Severe Pain, follow-up 1.5 years (loos et al2009) 50% pain free or almost pain free 25% moderate improvement 25% no benefit Selective Neurectomy + Mesh removal (Aasvang et al 2009) VAS score Parietal Nerves 27 before vs 13 after Follow-up 6 months Worsening pain in 15%

17 Pudendal Nerve

18 Ilio inguinal Génito-fémoral Obturateur Cluneal inf Pudendal

19 Pudendal Neuralgia High-Risk Surgery Not exposed Proximal lesion Prolapse surgery (Richter) Pain in 4,5% (1/3 pudendal) Distal lesion Urinary incontinence surgery Prolapse vaginal surgery (Mesh) Impotence surgery

20 Per-operative Pudendal Per-operative Pudendal neuralgia Neuralgia Pain Localization (cf anat) Subjective and objective sensory deficiency Hypoesthesia Numbness Decrease the sensation of urination and defecation Motor deficiency Urinary and anal continence troubles Sexual deficiency Erectile dysfunction Decrease sexual sensation

21 Pudendal neuralgia by entrapment Secondary symptomatology Apparition of real pudendal neuralgia by pudendal nerve entrapment? Diagnostic criteria (Critères de Nantes) (Labat JJ et al 2007) Pain in the anatomical territory of the pudendal nerve From the anus to the penis or clitoris Worsened by sitting The patient is not woken at night by the pain No objective sensory loss on clinical examination Positive anaesthetic pudendal nerve block

22 Post-operative operative Pudendal Neuralgia neuralgia Pre-existing asymptomatic pudendal nerve entrapment appear (decompensated) after all pelvic surgery Treatment of the entrapment Clinical Assessment MRI Compression (tumor, haematoma, ) Infiltration Nerve block (CT-Scan guidance) if entrapment Not necessary if deficiency Proximal lesion near the sacral plexus by stitch or clip, Negative diagnosis nerve block at ischial spine Positive Radicular block at S3

23 Post-operative operative Pudendal neuralgia Neurolysis According to the initial surgery Prolapse surgery (Richter) Transgluteal approach Laparoscopic approach (Possover et al 2007) Distal lesion Vaginal or perineal approach Good results, several months Interest of laparoscopic exploration (Possover et al 2009) 109 cases of pudendal pain ( ) Exploration of sacral plexus, dissection of pudendal nerve Endometriose Entrapment 43 cases 13 case Post-op lesion (fibrosis) 53 cases Improvement 62% at mean follow-up of 17 months

24 Obturator Nerve

25 Ilio inguinal Génito-fémoral Obturateur Cluneal inf Pudendal

26 Obturator Neuralgia High-risk Surgery Oncological pelvic surgery Urinary incontinence surgery Hernia repair surgery (mesh)

27 Obturator Neuralgia Pain of anterior-internal surface of the thigh Descending to the inside of the knee No pain in the lower leg Neuropathic pain Burning, paresthesia or allodynia Alleviated in the sitting or lying down position Exacerbated on walking Exacerbated by weight bearing on one leg Limping with a sidestepping gait No sensory or motor deficiency Positive infiltration test

28 Obturator Neuralgia Clinical Assessment Imagery Organic compression EMG Haematoma, tumor Discuss Denervation of adductor muscles Infiltration test ++ Posterior approach CT-Scan guidance

29 Anterior Obturator nerve block

30 Posterior Obturator nerve block

31 Posterior Approach Obturator Nerve Obturator Neuralgia Infiltration block Obturator Nerve Anterior approach Posterior Approach Anterior Approach

32 Obturator Neuralgia Treatment Per-operative section Suture Radiofrequency or cryoanalgesia Laparoscopic Neuolysis (J Rigaud et al 2008) Iatrogenic obturator neuralgia Release of the nerve + section of the scarring fibrosis or prosthetic mesh in contact TOT (3 cases), TVT (3 cases), hernia mesh (2 cases), haematoma (1 case) Idiopathic obturator neuralgia Release of the nerve + incision of 2 to 3 cm in the internal obturator muscle (obturator foramen)

33 Normal Obturator Nerve

34 Iatrogenic Obturator Neuralgia (TVT)

35 Idiopathic Obturator Neuralgia

36 Our Experience (Rigaud J et al ) 2009) Total (n = 13) Iatrogenic (n = 9) Idiopathic (n = 4) Mean VAS score before surgery 7.3 ± ± ± 0 Mean VAS score after surgery 2.4 ± ± ± 2.3 VAS = 0 Decrease of VAS score > 50% Failure 54 % (n=7) 23 % (n=3) 23 % (n=3) 55 % (n=5) 11 % (n=1) 33 % (n=3) 50 % (n=2) 50 % (n=2) 0 % (n=0) Follow-up (months) % Improvement

37 Muscular Pain

38 Myo-fascial Pain Diffuse pain at palpation Endopelvic side, Buttock Fibromyalgia Muscular tension Obturator internus muscle Levator ani muscle Syndrome of the Obturator internus muscleor piriformis muscle Global pain in several nervous area

39 Example: Pain localised at perineal, perineal, buttock, buttock, inside of inside the of the knee knee and and sciatic sciatic after after a transobturator a transobturatrice tape Myofascial Syndrome of the Obturator internus muscle and piriformis muscle Buttock portion linked with sciatic nerve and posterior cutaneous nerve of the thigh Pelvic portion linked with pudendal nerve and obturator nerve Buttock and pelvic Trigger points

40 5 cms Piriformis Muscle Syndrome Obturator Internus Muscle Syndrome

41 High-Risk surgery Trans-obturator route TOT Vaginal Mesh Trans-levatori route TVT Myorrhaphy

42 TVT TOT

43 Pain after TVT/TOT Post-operative pain 15% Persistant pain 1% (> 5% -30%) Meta-analysis (Latthe et al 2007) 11 randomized, controlled studies 1261 cases: 630 TVT 631 TOT Incidence of Pain TVT 1.3% TOT 12 % (OR of 9.34)

44 Pain after TVT/TOT Treatment Cystoscopy and Imagery (MRI) Tape into the bladder (Frenkl et al 2008) Section or ablation by an endoscopic approach Tape Infiltration (Duckett et al 2005) 4/6 Improvement (not durable) Surgical Removal Few series with few patients 15 patients (Misrai et al2009)

45 TVT

46 TVT

47 TVT

48 Our Experience From November 2004 to August patients with pelvic pain after TVT/TOT 2 groups: TVT (n=17) and TOT (n=15) Delay tape placement - tape removal 37 months Associated Neuropathic Pain Pudendal: TVT (41%) vs TOT (20%) (Rigaud J et al 2010) p=0,1972 Obturator: TVT (18%) vs TOT (47%) p=0,0772

49 Tape removal Our Experience TVT group (retropubic tape) (n=17) Transperitoneal laparoscopy approach in every cases Tape in the levator ani muscle 70% (n=12) Tape in the bladder wall 23% (n=4) TOT group (transobturator tape) (n=15) Transvaginal approach (Rigaud J et al 2010) Possibly associated with a unilateral or bilateral incision in the proximal part of the thigh (8 cases)

50 TVT into the levator ani muscle

51 TVT into the bladder wall

52 Total TVT TOT n VAS Before VAS After % of Improvement 56% 55% 56% Rate of Improvement Our Experience (Rigaud J et al 2010) 0% 25% 23% 27% < 50% 6% 6% 7% > 50% 53% 59% 47% 69% 100% 16% 12% 20% Urinary Incontinence 22% 24% 20% Follow-up (months)

53 Pelvic Neural Pain Laparoscopic exploration (Possover et al 2009) 120 cases of pelvic neural pain secondary to pelvic surgery Exploration Superior hypogastric plexus Nerve decompression Sacral plexus Improvement in 65%

54 Complex Pelvic Pain

55 Post-operative Pain not systematized Myo-fascial Pain Neuropathic Pain Complex Regional Pain Syndrome Emotional context Medico-legal context Hypersensitization type fibromyalgia Visceral Hypersensitization : urinary, digestive, genital Predisposing factors Surgery = Matchstick Consequence = Blaze

56 Conclusions Post-operative Pain Direct or Indirect Neurological lesion Myofascial Pain Chronology of facts +++ (Operative report) Listen the patients Medico-legal consideration Treatment Infiltration Surgery: Neurolysis, mesh removal