Paolo Marchettini MD

Pain Medicine Center Scientific Institute San Raffaele - Turro

Milan-Italy

Pain Pathophysiology and Therapy

University School of Italian Switzerland

Lugano-CH

Douleur Aigue

Lombalgie

pidmiologie Prvalence pendent la vie dun pisode de

lombalgie: 70-90%

Prvalence dpisodes durant > 2 semaines: 13,8%

Prvalence de sciatique pendent la vie : 1,2-43%

Prvalence annuaires de sciatique dans la

population gnrale: 9,9-25%

35% des patient avec hernie dveloppe une

sciatique

Peripheral and Central Effect

NSAIDS, COXIBS

IL DOLORE LOMBARE HA ORIGINI SVARIATE

LA DIAGNOSI -NON SEMPRE FACILE-

E INDISPENSABILE PER AVVIARE UNA CORRETTA

___________TERAPIA__________

DOLORE DA FLOGOSI LOCALE

DOLORE DA CONTRATTURA MUSCOLARE

DOLORE DA SPONDILOLISTESI

DOLORE DA ERNIA DEL DISCO

DOLORE DA FRATTURA

DOLORE DA OSTEOPOROSI

DOLORE DA DISTURBI VISCERALI

Median hernia

Posterior-lateral hernia

Intraforaminal

hernia

Perimetral protrusion

Perimetral protrusion with

posterior focal component

The epidural space: its contribution to pain generation

NeP from hypoxia of the compressed roots; Venous supply often poorly considered

Recognizing the neuropathic component of the pain in radiculopathy

Positive DIAGNOSTIC criteria

Pain distribution

Muscle bulk & strength

Sensory disorder

Reflexes

Lasgue sign

Sympathetic signs

Rule out the nociceptive component:

Disk, ligament,

facet and sacroiliac joint pain

Relationship between disk and root

Nociceptive Afferent Fibers

QUALSIASI CARICO ESERCITATO SUL CORPO VERTEBRALE SI

DISTRIBUISCE SOLO PARZIALMENTE ALLA VERTEBRA

SOTTOSTANTE COME FORZA DI COMPRESSIONE PERCHE IN

PARTE SI TRASFORAM IN FORZA DI TRAZIONE E QUINDI DI

CONTENZIONE

-LAZIONE DEI LEGAMENTI INSIEME A QUELLA DEI MUSCOLI PARAVERTEBRALI E

ADDOMINALI E FONDAMENTALE PER LEQUILIBRIO STATICO E DINAMICO DELLA

COLONNA

LA ROTTURA DI QUESTO EQUILIBRIO CONSEGUENTE A UNA MALFORMAZIONE VERTEBRALE A UN TRAUMA O A UN

ATTEGGIAMENTO SCORRETTO -TIPICO DELLA VITA SEDENTARIA- E CAUSA DI SOVRACCARICHI E PROCESSI DEGENERATIVI

ABOLIRE IL DOLORE E LA FLOGOSI INTERROMPE

IL CIRCOLO VIZIOSO E CONSENTE DI AGIRE SULLA PATOLOGIA DI BASE

FLOGOSI

DOLORE

PATOLOGIA DI

BASE

SOVRACCARICO

CONTRATTURA

CONCLUDING RECOMMENDATIONS In patients with mild-to-moderate levels of acute pain, the recommendation is to

initiate treatment with a maximum dose of 4 g/day paracetamol, with a minimum 4 h interval between each 1 g dose (step 1).

Patients who do not achieve sufficient analgesia within 1 2 days should switch to a selective COX-2 inhibitor or, if gastrointestinal safety and risk of bleeding are not an issue, a NSAID (step 2).

If analgesia continues to be inadequate, the recommendation is to add tramadol, or combination therapy with acetaminophen plus either codeine or tramadol (step 3).

Patients reporting severe pain should be referred to a pain clinic or specialist for treatment with an opioid analgesic. (step 4).

Treatment with an oral selective COX-2 inhibitor or topical ns-NSAID gel or cream, or a combination of oral and topical treatments was recommended for patients with acute pain from musculoskeletal injury due to sport or other trauma.

They also stressed the importance of early and aggressive treatment of acute pain in order to reduce the risk of pain becoming chronic or neuropathic in nature.

Nonsteroidal anti-inflammatory drugs Nonsteroidal anti-inflammatory drugs are recommended as second-line analgesics in the Dutch guidelines [1,2], and as first-

line treatment in the ACP/APS guidelines [3,4]. Previous systematic reviews have found no evidence to support the use of NSAIDs in the treatment of sciatica [2,1517], but in a more recent Cochrane review, NSAIDs were slightly but significantly more effective than placebo in producing short-term (3 weeks) reductions in pain intensity (mean treatment difference 8.39, 95% confidence interval [CI] 12.68, 4.10) and the proportion of patients with acute low back pain experiencing global improvement (risk ratio [RR] 1.19, 95% CI 1.07, 1.33). They were also significantly more effective than placebo in reducing chronic low back pain (mean treatment difference 12.40, 95% CI 15.53, 9.26) [18]. There were no significant differences in efficacy, in terms of pain reductions or global improvements, between NSAIDs and paracetamol, or between NSAIDs and other drugs, including narcotic analgesics and muscle relaxants [18]. Treatment with NSAIDs was associated with a significantly higher incidence of adverse events, compared with placebo (acute back pain: RR 1.35, 95% CI 1.09, 1.68; chronic back pain: RR 1.24, 95% CI 1.07, 1.43) or paracetamol (RR 1.76, 95% CI 1.12, 2.76). Cyclooxygenase-2 (COX-2)-specific inhibitors were comparable in analgesic efficacy to nonselective NSAIDs in patients with acute low back pain (mean treatment difference -1.17, 95% CI -4.67, 2.33), but were associated with a lower risk of adverse events (RR 0.83, 95% CI 0.70, 0.99) [18]. There was no evidence that any nonselective NSAID was superior in efficacy to the others.

Nonsteroidal anti-inflammatory drugs are associated with a number of well-documented adverse events (Table 8.1), including gastrointestinal disturbances such as dyspepsia or nausea, and alterations in renal function. Such adverse events are usually mild or moderate in severity [18], although serious gastrointestinal complications such as bleeding or ulceration can occur [19]. Selective COX-2 inhibitors are associated with a lower risk of gastrointestinal adverse events than nonselective agents [20]; however, some of these agents are associated with an increased risk of cardiovascular adverse events [21,22], although it is unclear whether this is a significant concern during the short treatment periods recommended for sciatica [18].

Lignes directrices de lAustralian and

New Zealand College of Anaesthetists

Les coxibs se sont montrs aussi efficaces que

les anti-inflammatoires non strodiens non

slectifs (AINSns) dans le traitement de la

douleur postopratoire (Romsing & Moiniche, 2004 Niveau I).

Les nombres traiter sont comparables ceux

obtenus avec les AINSns dans le traitement

de la douleur aigu dintensit modre leve.

Macintyre PE et al. 2010. Acute Pain Management: Scientific Evidence .3rd edition. Melbourne:

ANZCA & FPM,; South African Society of Anaesthesiologists SAJAA 2009;15:1-120.

Dietrich I et al. Ann Rheum Dis 2006; 65(Suppl II):238.

Lombalgie aigu

(n = 244) Clcoxib 200 mg 2 f.p.j. (+ 200 mg) (n = 123)

Clcoxib 200 mg 2 f.p.j.

valuations de lefficacit

Jour 1

X

Jour 3

X

Jour 7

X

Diclofnac 75 mg 2 f.p.j. (n = 121)

Clcoxib contre diclofnac : lombalgie aigu

Variation du score sur lEVA par rapport au dbut de ltude

Variation par rapport au dbut de ltude

ch

elle v

isu

elle a

nalo

giq

ue

(EV

A)

(mm

)

Dietrich I et al. Ann Rheum Dis 2006; 65(Suppl II):238.

-40,0

-58,8

-42,6

-60,7 -70

-60

-50

-40

-30

-20

-10

0 Jour 3 Jour 7

Clcoxib 200 mg 2 f.p.j. (n = 123) Diclofnac 75 mg 2 f.p.j. (n = 121)

Clcoxib contre diclofnac : lombalgie aigu

p = NS

p = NS

* Les patients taient aussi autoriss prendre un ou deux comprims de bitartrate dhydrocodone 5 mg ou dactaminophne

500 mg toutes les 4-6 heures au besoin titre de mdicament de secours pour soulager leur douleur.

Ekman EF et al. Arthroscopy 2006; 22:635-42.

Patients ayant subi une chirurgie du genou par arthroscopie

Clcoxib 400 mg* (n = 99)

Clcoxib 200 mg 1 f.p.j. au besoin*

(n = 200) Placebo* (n = 101)

Placebo*

valuations de lefficacit

1 heure avant

la chirurgie

X X X X X X X X

Heures

Chirurgie 1 2 6 8 10 12 24 36

Lefficacit du clcoxib dans le traitement de la douleur postopratoire : chirurgie du genou par

arthroscopie Mthodologie de ltude

26,8 32,9

Score

moyen d

inte

nsit

de la d

oule

ur

(mm

)

Dure de lvaluation (heures)

*

*p = 0,026 c. placebo p = 0,011 c. placebo p = 0,002 c. placebo

Doule

ur

moin

s in

tense

36,1 42,4

47,2

31,3

0

10

20

30

40

50

8 10 12

Placebo + opiodes (n = 101)

Clcoxib 400 mg + opiodes (n = 99)

Dans les 24 heures suivant la chirurgie, la consommation totale danalgsiques opiodes a t significativement rduite dans le

groupe trait par Celebrex comparativement au groupe placebo (p = 0,009). Celebrex a t associ des rductions significatives

de la consommation danalgsiques opiodes comparativement au groupe placebo de 10 12 heures (p = 0,005) et de 12 24

heures aprs la chirurgie (p = 0,012). Le pourcentage de patients du groupe placebo (41 %) qui ont requis des analgsiques

opiodes a t significativement plu