Scleroza multipla si durerea

2 Septembrie, 2010 - 23:00

de Marilyn Kassirer,
Boston University School of Medicine, Neurology Department, Boston

Comunitatea medicala a subestimat adesea atat proportia durerii la persoanele afectate de SM cat si impactul asupra vietii lor. In timp ce dizabilitatea fizica rezultata din boala este de obicei preocuparea primara in tratament, durerea cauzeaza serioase probleme in buna stare a pacientului.

Pacientii cu SM prezinta o varietate de sindromuri dureroase, de la stari acute (nevralgia trigeminala si sindromul Lhermitte), pana la simptomul cronic care apare secundar (spasticitate).

Aproximativ 65% dintre pacientii cu scleroza multipla (SM) au experienta sindromului durerii acute si subacute. in starile acute (nevralgia trigeminala si sindromul Lhermitte), durerea severa se poate inrautati o data cu varsta si progresia bolii.

Durerea cronica (ex.: artralgia) este de asemenea o componenta a sclerozei multiple. Sindromul dureros, include nevrita optica si alte sindromuri mai putin cunoscute, putand raspunde farmacologic, chirurgical sau la alte interventii alternative.

Pacientii cu SM pot, de asemenea, avea experienta durerii din cauza iatrogenica. Cateva tratamente medicamentoase, care pot fi
folosite in combinatie sau singure, includ anticonvulsive, antidepresive triciclice, metilprednisolon si narcotice. Interventiile chirurgicale si ablatia cu radiofrecventa sunt alte optiuni viabile pentru cateva dintre sindromurile dureroase jogos casino online.

Acestea pot dura o luna sau mai mult, unele dintre ele intensificandu-se o data cu varsta pacientilor si progresia bolii. Sindromurile dureroase comune sunt rezultatul bolii insasi (nevrita optica, crampele si nevralgiile), iar altele, cum ar fi sindromul dureros complex regional (complex regional pain syndrome - CRPS) apar mai putin frecvent Bonus Fara Depunere

Stabilirea numarului de pacienti suferinzi constant de durere ca sindrom sever al SM, dezvoltarea unor strategii de tratament eficace pentru diferitele sindromuri dureroase este o preocupare importanta pentru pacienti si medici.

Nevralgia trigeminala

Nevralgia trigeminala (tic douloureux) afecteaza prima, a doua sau a treia distributie ale celui de-al cincilea nerv cranian. Ea este mai des intalnita in cea de-a doua sau a treia distributie (diviziunile mandibulei si maxilarului) si poate fi declansata de stimuli senzoriali cum ar fi spalatul pe dinti.

Este mai des intalnita la femei decat la barbati, 56 fiind varsta medie la care apare, dar debutul poate avea loc mai devreme la pacientii cu scleroza multipla, 1,9% dintre ei dezvoltand nevralgie trigeminala.

La un procent mic de pacienti, nevralgia trigeminala este primul semn al sclerozei multiple. Pentru ca punctele trigger se pot afla oriunde pe fata sau cap, inclusiv scalpul, ele pot ingreuna viata pacientilor. In stadiile de inceput ale nevralgiei trigeminale, tratamentul se bazeaza pe carbamazepin.

Totusi, cand episoadele nevralgice se intensifica, acest agent poate deveni mai putin eficient si ca medicament alternativ poate fi adaugat, de exemplu: baclofen, gabapentin, lamotrigin sau misoprostol. Frecvent, datele in ceea ce priveste uzul gabapentinului provin din triale necontrolate. Alte doua optiuni de tratament traditional sunt injectiile cu alcool sau glicerina.

Daca terapia medicala nu reuseste, tratamentul chirurgical poate fi necesar. Decompresiunea microvasculara este una dintre cele doua proceduri chirurgicale de tratament pentru acest sindrom. O alta tehnica chirurgicala foloseste compresiune percutana cu balon, iar ablatia cu radiovrecventa este folosita uneori la pacientii care nu tolereaza medicatia.

Sindromul Lhermitte

O alta cauza pentru durerea severa este sindromul lui Lhermitte, un fenomen binecunoscut in scleroza multipla, fiind o cauza obisnuita pentru leziunile maduvei spinarii la nivelul segmentului cervical.

Este o senzatie severa si brusca asemanatoare unui soc electric puternic
care afecteaza corpul atunci cand pacientul ridica capul; ea este asociata cu leziuni active. Cel putin 25% dintre pacientii cu SM sufera de acest sindrom.

Nevrita optica

Nevrita optica, o inflamatie a nervului optic, este adesea un prim semn al sclerozei multiple. Mai mult de 42% dintre oamenii care au avut un atac initial de nevrita optica, au dezvoltat SM in mai putin de zece ani.

De obicei, nevrita optica are un debut subacut si se soldeaza cu
pierderi de vedere. La pacientii suferinzi de aceasta afectiune si de SM, pierderile de vedere sunt unilaterale, cu toate ca vederea este de obicei restabilita.

Pentru ca mai multe alte conditii pot imita nevrita optica, inclusiv retinitele, stabilirea diagnosticului cu acuratete este importanta, iar o examinare a fluidului spinal poate ajuta la identificarea pacientilor care au cele mai mari sanse de a dezvolta SM in urmatorii ani.

Au aparut controverse in jurul tratamentului nevritei optice, cu diferende intre oftalmologi si neurologi. In ciuda efectelor secundare ale glucocorticoizilor, un recent studiu japonez a aratat ca IV metilprednisolon asigura restabilirea rapida a acuitatii vizuale.

O alta sugestie de tratament pentru nevrita optica este imunoglobulina (IVIg). Cu toate acestea, studii curente nu i-au demonstrat eficacitatea si au aratat inrautatirea functiunii vizuale pe durata bolii.

Spasticitatea

Aproximativ 40%-50% dintre pacientii cu SM au intr-un grad oarecare spasticitate care poate fi extrem de dureroasa. Spasticitatea este o tulburare motorie insotita de cateva sau chiar toate simptomele: rigiditate, contractii si violente spasme musculare.

Asupra noilor agenti farmacologici care au constituit tratamentul spasticitatii in ultimii ani, planeza o dilema, considerandu-se ca agentii cu actiune scurta furnizeaza solutii partiale. Acestia nu pot fi folositi pentru tratarea spasmelor dureroase nocturne care apar in timpul somnului si care sunt urmate de rigiditate la trezire.

Baclofenul administrat oral poate fi folosit cu succes timp de mai multi ani. Mult mai recenta, tiazidina s-a aratat eficace in tratarea acestei afectiuni. Ambii agenti fac parte din tratamentul de prima linie. Exista multe alte medicamente pentru spasticitate, inclusiv diazepamul, clonazepamul, dantrolenul si toxina botulinica.

Pacientii cu SM sufera si de alte simptome dureroase ca spasmele, crampele, simptomele senzoriale. Spasmul muscular sau contractia apar brusc si sunt suficient de puternice pentru a arunca un pacient din scaunul cu rotile. Aceste spasme sunt de obicei unilaterale si sunt considerate a fi rezultatul leziunilor limbului posterior al capsulei interne.

Tratamentul partial include opioide administrate in spatiile epidurale sau intratecale, dar anticonvulsivele sunt adesea o buna terapie de prima linie. Fenitoina se dovedeste a fi eficienta la multi dintre pacienti, desi carbamezepinul si gabapentinul, la fel de bine si baclofenul, pot fi folosite, de asemenea.

Inaintea recomandarii pacientilor pentru operatie, clinicianul ar trebui sa ia in considerare si prescrierea acetazolamidei (un inhibitor al anhidrazei carbonice, administrat in tratamentul unui numar de afectiuni, inclusiv epilepsia).

Durerea neuropatica care afecteaza multi pacienti cu scleroza multipla poate fi foarte severa si este adesea amplificata de progresul bolii. Mai mult, sindromul durerii atipice in cazurile de SM include si nevralgia esentiala glosofaringiala, care este marcata prin durerea paroxistica a
gatului, faringelui, radacinii limbii.

Cu toate acestea, el este relativ rar - doar patru din 8.000 de pacienti sunt afectati - durerea fiind extrema si cauzand pacientilor suferinzi anxietate.

Tratamentul efectiv a acestei nevralgii a fost realizat cu carbamazepin.
Unii practicieni folosesc ACTH si ciclofosfamide, dar din cauza numarul foarte mic de pacienti, studiile definitive asupra acestei terapii nu au fost inca definitivate.

Desi este intalnit rar la pacientii cu SM, CRPS (Complex Regional Pain Syndrome) cauzeaza durere groaznica care poate fi acuta si brusca, avand tendinta de a aparea mai mult in timpul noptii.

CRPS a fost identificat la pacientii cu scleroza multipla de origine asiatica, care aveau distructie tisulala la nivelul maduvei spinarii si care dezvoltau siringomielie in aria in care era activ procesul de demielinizare.

Dintre toate sindroamele dureroase, CRPS este poate cel mai greu de tratat. De aceea, multe masuri terapeutice trebuie sa fie incercate, inclusiv terapia fizica, antiinflamatoarele nesteroidiene, narcoticele.

Desi, ele sunt eficace la unii, aceasta terapie nu se poate aplica la
toti pacientii, medicul avand posibilitatea de a prescrie medicamente din clasa antidepresivelor triciclice sau anticonvulsivelor.

Durere cu etiologie iatrogenica

Multe terapii impotriva SM pot exacerba durerea pacientilor. Tratamentul de lunga durata cu steroizi poate induce osteoporoza, pregatind astfel terenul
pentru posibile fracturi vertebrale.

La pacientii supusi unei astfel de terapii va fi masurata densitatea osoasa si deficienta tratata cu suplimente de calciu. Cea mai importanta masura
care poate fi luata in aceasta situatie este preventia.

Alte medicamente, de pilda beta-interferonul, care este in mod obisnuit folosit in tratamentul MS, poate cauza durere. Pacientii care iau beta-interferon pot experimenta migrene care pot fi intalnite si la multi pacienti care primesc IVIg, iar tratamentul profilactic al migrenei este
recomandat imediat acestora.

Conluzii

Desi sindromurile dureroase care insotesc SM sunt foarte obisnuite, terapii medicamentoase, chirurgicale sau cele alternative pot furniza alinare. Prima optiune de tratament ramane insa farmacoterapia.

Tratamentul poate sa nu aiba succes cu primele medicamente selectate, dar
combinatiile de medicamente sau de monoterapii alternative pot calma durerea. Tratamentul secundar este interventia chirurgicala, care are succes doar pentru tratarea unora dintre aceste sindroame.

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Sunteti de acord cu modificarea examenului de rezidentiat propusa de ministrul Sanatatii?
Da
40%
Nu
60%
Total voturi: 5