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LA SAPIENZA UNIVERSITY

LA SAPIENZA UNIVERSITY. Clinical Neurophysiology of Pain G. CRUCCU, G.D. IANNETTI, A. TRUINI EFNS Panel Neuropathic Pain, Vienna Dept. Neurological Sciences, Rome. EFNS Guidelines on Pain Assessment (2004). 1. Scales and Questionnaires. 2. Clinical Examination.

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LA SAPIENZA UNIVERSITY

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  1. LA SAPIENZA UNIVERSITY Clinical Neurophysiology of Pain G. CRUCCU, G.D. IANNETTI, A. TRUINI EFNS Panel Neuropathic Pain, Vienna Dept. Neurological Sciences, Rome

  2. EFNS Guidelines on Pain Assessment (2004) 1. Scales and Questionnaires 2. Clinical Examination 3. QST (quantitative sensory testing) 4. Neurophysiological Methods 5. Functional Neuroimaging 6. Biopsy

  3. Standard electrodiagnostics SEP  NCS  • Standard neurophysiological tests (NCS, SEP) • are useful to demonstrate, quantify and localise a lesion along the sensory pathways • cannot assess small-fibre funcion

  4. Microneurography Torebjoerk & Ochoa l990 Serra Marchettini Ochoa 1998 Although it has provided important pathophysiological information, microneurography is time consuming and difficult, requiring both an expert investigator and a collaborative patient; hence it is unsuitable for clinical applications (Good Practice Point)

  5. Blink Reflex: Aβ Masseter Inhibitory Reflex: Aβ Trigeminal Reflexes (Cruccu et al, Neurology 2006) the R1 Blink Reflex and the SP1 Masseter Inhibitory Reflex, although non-nociceptive, have great diagnostic value in differentiating Classical from Symptomatic Trigeminal Neuralgia (level A evidence).

  6. Trigeminal Reflexes in Pain associated to Multiple Sclerosis (Cruccu et al, Pain 2009)

  7. Differential diagnosis between CTN and STN(from the AAN-EFNS guidelines on trigeminal neuralgia 2008) Response to treatment and involvement of first trigeminal division are similar in the two populations. Onset age is lower in CTN than STN (P <0.0001). Bilateral neuralgia and sensory deficits only occur in STN (P <0.001). Trigeminal reflexes (TR) are abnormal in STN (87%) and normal in CTN (94%) (P <0.0001). Data from 10 trials (Class I-III) in 628 patients.

  8. Cutaneous Silent Period CSP LEP (Truini et al Muscle Nerve 2008)

  9. Nociceptive Reflexes Lower limb RIII flexion reflex  (Garcia-Larrea et al, Arch Med Res 2000) Nociceptive reflexes, such as the RIII flexion reflex, the cutanous silent period and the corneal reflex, have little diagnostic value(grade C statement). But the RIII flexion reflexappears to be the most reliable tool in assessing treatment effects (grade B recommendation).

  10. Laser Evoked Potentials (LEPs) Laser stimulators raise very quickly the temperature in the superficial layers of the skin, selectively excite free nerve endings (mostly A and C nociceptors) and provide a synchronous afferent volley that is easily recorded from the scalp (over 200 studies have been published, including several top Class)

  11. Signals and generators Garcia-Larrea et al 2003 Truini et al 2003

  12. LEPs in central neuropathic pain and nonorganic pain Garcia-Larrea et al Brain 2002 In central neuropathic pain (spinal, brainstem, thalamo-cortical) LEPs are suppressed after stimulation of the painful territory, even if the laser pulses evoke hyperalgesia, and may distinguish neuropathic from non-organic pain

  13. Spinal pathway conduction of A and C inputs (Iannetti et al J Neurophysiol. 2003)

  14. Trigeminal C-LEPs highest density of C receptors Because of the short conduction distance and a high receptor density, the trigeminal territory is even more advantageous for eliciting (with low-intensity large-spot pulses) “ultralate” LEPs (N2 latency about 280 ms), mediated by unmyelinated C afferents (conduction velocity 1.2 m/s). (Cruccu et al, Brain 2003)

  15. Trigeminal C LEPs Patients with trigeminal neuropathy: (Cruccu et al, Brain 2003)

  16. C-LEPs in patients: Trigeminal Laser evoked potentials in Wallenberg syndrome (Cruccu et al Brain 2003)

  17. General results of LEP studies in peripheral neuropathic pain Truini et al NSL 2004

  18. Specificity/Sensitivity of LEPs vs. SEPs Data from 28 studies in 441 patients (Garcia-Larrea and Cruccu, in preparation)

  19. Pain in Carpal Tunnel Syndrome (Truini et al, Pain 2009)

  20. PHNCorrel. Pain vs. R1 A-LEP C-LEPresponsesSignificantat least P<0.01 (Truini et al Pain 2008)

  21. LEPs assessing response to treatment (Truini et al, Eur J Pain 2009)

  22. 0 1 2 3 4 sec CHEPs vs. LEPs (Iannetti et al, J Physiol, 2007)

  23. Myelinated-fibre Neuropathy (Truini et al, Pain 2007)

  24. Evidence Table LEPs

  25. Andrea Truini Giorgio Cruccu Giandomenico Iannetti

  26. THANKS FOR YOUR ATTENTION

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