We explore the clinical characterstics, typical lesions (mostly spinothalamic, rarely lemniscal, capsular or cortical), diagnostics and treatment.
- a 2009 article from the Lancet Neurology
- Boivie’s wonderful chapter 48 in the Handbook of Clinical Neurology (vol 81 Pain)
- As an addition this original current article in Pain 2011 shows that – contrary to what I expected (and practice) – Pregabalin helps not a bit.
- My favorite orphans can come into play but as usual without much evidence: Ketamine, Disoprivan and THC. At least the former is widely practiced in pain clinics, so one can try the recommendations of this article.
Here are my take home message (or rather more fittingly, my take-to-work messages):
- It happens more often than we think.
- There is no way to avoid it
- It is best treated by a specialist drawing on both medical on non-medical tools
- As for drugs: standard is Amitryptiline and either LTG or CBZ. Probably other NASRIs (or however they are abbreviated nowadays) should be able to substitute Amitryptiline (here we often use Mirtazapin, Duloxetine or Venlafaxine) and other anticonvulsants might help just as well as LTG, but hey, these two have at least scant evidence. Lyrica doesn’t seem to work
- TMS is easy and cheap (well, the device is not, talk about regulations) and effective, in contrast to many drugs
- DBS is difficult and expensive, probably effective
- TENS has some theory behind it, but there is no proof of effectiveness
- Think about other non-standard stuff: hypnosis, accupuncture, Yoga (there, I said the 3 bad words), Ketamine and THC