L’ELETTROMIOGRAFIA NEL DOLORE NEUROPATICO

Michelangelo Buonocore

Fondazione Maugeri – Istituto Scientifico di Pavia Servizio di Neurofisiopatologia

Laboratorio di Biopsia Cutanea Neurodiagnostica

Electromyography (EMG) is a diagnostic procedure to assess the health of muscles and the nerve cells that control them (motor neurons). A nerve conduction study, another part of an EMG, uses electrodes taped to the skin (surface electrodes) to measure the speed and strength of signals traveling between two or more points.

http://www.mayoclinic.org

DEFINIZIONE DI ELETTROMIOGRAFIA

Electromyography (EMG) Strictly defined, the recording and study of insertion, spontaneous, and voluntary activity of muscle with a recording electrode (either a needle electrode for invasive EMG or a surface electrode for kinesiologic studies). The term is also commonly used to refer to an electrodiagnostic medicine consultation, but its use in this context is discouraged.

https://www.aanem.org

DEFINIZIONE DI ELETTROMIOGRAFIA

Electroneurography (ENG) The recording and study of the action potentials of peripheral nerve. Synonymous with nerve conduction studies.

https://www.aanem.org

DEFINIZIONE DI ELETTRONEUROGRAFIA

Electroneuromyography (ENMG) The combined studies of electromyography and electroneurography. Synonymous with clinical electromyography. See preferred term electrodiagnostic medicine consultation.

https://www.aanem.org

DEFINIZIONE DI ELETTRONEUROMIOGRAFIA

NEUROPATHIC PAIN

Pain arising as a direct consequence of a lesion or disease affecting the somatosensory system

DEFINIZIONE DI DOLORE NEUROPATICO

Treede et al. 2008

Cruccu et al. 2008

SISTEMA SOMATO-SENSORIALE

Pain usually arises as a consequence of activation of primary nociceptive afferents by actually or potentially tissue-damaging stimuli and processing of this activity within the nociceptive system. This type of pain is physiologic. Pain, however, may also arise by activity generated within the nociceptive system (?) without adequate stimulation of its peripheral sensory endings. For these clinical conditions, the term neuropathic pain has been introduced.

Treede et al 2008

DOLORE NEUROPATICO – NO RECETTORI ATTIVATI

Buonocore 2007

GENESI ECTOPICA DI IMPULSI

Buonocore

DOLORI NOCICETTIVO E NEUROPATICO

Because of the lack of a specific diagnostic tool

for neuropathic pain,

a grading system of definite, probable, and possible

neuropathic pain is proposed

Treede et al. Neurology 2008

NO STRUMENTI DIAGNOSTICI SPECIFICI PER NP

Treede et al 2008

NP E INDAGINI STRUMENTALI

… it is essential to demonstrate

in the individual patient that this disorder

does affect the somatosensory system (evidence for neural damage).

Treede et al. Neurology 2008

The neurologic diagnosis depends on the answers to two questions:

“Where is the lesion?”

(anatomy)

“What type of lesion?” (pathology, including pathophysiology)

These principles also apply to neuropathic pain

…

Treede et al. Neurology 2008

L’Elettromiografia (EMG + ENG)

studia solo fibre di grande calibro, siano esse motorie o sensitive (sistema lemniscale). non studia le piccole fibre del sistema nocicettivo/spino-talamico

EMG E DOLORE NEUROPATICO

L’EMG propriamente detto può essere utile per la diagnosi di dolore

neuropatico dimostrando la presenza di:

Lesioni radicolari

Lesioni di nervi misti

Lesioni di nervi motori

nucleusinc.com

SISTEMA LEMNISCALE ED ENG SENSITIVA

ElettroNeuroGrafia (ENG)

Spehlmann 1985

SISTEMA LEMNISCALE E PESS

Potenziali Evocati Somato-Sensitivi

(PESS)

It needs to be stressed that patients with somatosensory deficits

do not necessarily have pain

Treede et al. Neurology 2008

DIAGNOSI STRUMENTALE

Dick et al. 1998

Nessuna diagnosi algologica andrebbe mai fatta sulla base di un

risultato anormale ottenuto nel corso di una valutazione strumentale

DIAGNOSI ALGOLOGICA

NEUROFISIOLOGIA NEUROIMMAGINI

CLINICA

NEUROPATOLOGIA (ES. BIOPSIA CUTANEA)

PSICOFISIOLOGIA (ES. QST)

Percorso diagnostico

Buonocore e Bonezzi

INTERVISTA DEL PAZIENTE

ESAME OBIETTIVO

IPOTESI DI MECCANISMO FISIOPATOLOGICO

IMPOSTAZIONE DELLA TERAPIA CONFERMA STRUMENTALE