In The Name of GOD Central Pain Syndrome

In The Name of GOD Central Pain Syndrome HR Saeidi MD Associate Professor of NeurosurgeryKUMS Central Pain Syndrome Pain associated with lesions of the CNS

The clinical picture is similar regardless if the pts suffered a massive injury/stroke or a minor one The common feature is a steady, constant, burning, dysesthetic, or achy pain

Content outline Cord central pain Brain central pain Post stroke Thalamic Spinal Stenosis MS, Parkinsons, Misc Theories of pathogenesis

Spinothalamic injury Pathways that carry pain & temperature sensations Most accepted theory Lemniscal injury & release of the spinothalamic system Less recognized Neurologic abnormalities

Numbness incomplete Sensory abnormalities variable Abnormality of superficial touch, temperature & pain Decreased sensory position sense Spontaneous & evoked pain Abnormalities in gait (sensory ataxia) Cord Central Pain Essentially a young mans disease Reported incidence is 6% to 94% Etiology and level or completeness of lesions did not

correlate with presence, severity, or quality of pain Cord Central Pain Etiology Trauma number one cause Cord infarction AVM Neoplasm Iatrogenic Inflammatory

Congenital Cord Central Pain Onset of symptoms may be delayed after the causative event The longer the delay in pain onset, the more likely that a syrinx is present Syrinx must be identified & treated to prevent ND

Cord Central Pain Spontaneous steady pain Spontaneous neuralgic pain 1/2 of patients have severe pain Steady & neuralgic components predominate Brain Central pain Results from HI Stroke: most common AVMs

Neoplasm MS Syringobulbia Abscesses Brain Central Pain Brainstem lesions Most common vascular cause of pain is Wallenbergs synd (lateral medullary synd) Brain lesions

Dejerine-Roussy synd(thalamic pain synd) Brain Central Pain Steady & evoked pain predominate HI & craniotomy rarely result in central pain Onset may be immediate or delayed Medical treatment

Antispasmodics: Baclofen, tizanidine Anticonvulsants TCAs NSAIDs Opioids? Intrathecal

Opioids Baclofen Clonidine Surgical Treatment Rhizotomy Cordotomy / Cordectomy Useful for lancinating and evoked pain Dorsal root entry zone (DREZ) lesions Helps with radicular pain

Central Pain Syndrome Treatment Neuromodulation SCS Deep brain stimulation Spinal Stenosis

Technically categorized as central pain Probably has ischemic etiology in classic case Classic description Neurogenic claudication

Not necessary to walk to have pain Stenotic canal (< 10 mm) causes root Ischemia producing leg cramps Dont Forget Cervical Spinal Stenosis May involve single root or cord

Cervical myelopathy Muscles affected with weakness Weakness, atrophy & fasciculations) Cervical injections may be risky Spinal Stenosis

Compression syndromes of cauda equina & cord Single root or cauda equina Abnormally narrow spinal canal Acquired Spondylosis & HDL Arthritic proliferation Ligamentous hypetrophy

Congenital (short pedicles) Remember Differential Diagnoses Root and cord problems may be confused with: Supraspinatus tendinitis Acromoclavicular pain Cervical ribs

Must exclude neoplasms Epidemiology of MS 42-65% of patients with MS have pain

Trigeminal neuralgia often cited Not all pain is central 20 % have nociceptive musculoskeletal pain Paresis Spasticity

Peripheral neuropathy Psychogenic pain is rare Pain not related to depression or disability Most Common MS Pain

Nonparoxysmal extremity pain Dysesthesias Burning Aching pain Pricking Stabbing Squeezing

Pain Characteristics Lhermitte sign Classical of MS Produced by bending neck forward Paresthesias or dysesthesias Radiate down back to extremities Bilateral Can be painful

Types of Central Pain in MS TN 5% Brain stem demyelination Usual TN is peripheral

Paroxysmal Pain (lancinating) 6% Pain Quality Burning Toothache Like Pricking/Stabbing MS Pain continued Painful tonic seizures - 2% of patients Spreading paresthesias

Affected spinal segments Evoked by light touch or movement Occur with exacerbation of cord symptom Non-sensory Symptoms of MS 50% of patients Paresis Ataxia Bladder dysfunction

Parkinsons Disease Movement disorder Rigidity Bradykinesias Tremors Off periods Defective postural control Cognitive problems

Depression Pain and PD 43% have sensory symptoms Pain Tingling Numbness

Pain is common complaint - 29% Poorly localized cramping Aching sensation Burning - 11% Muscle spasms 12% Epilepsy 3% have pain

Unilateral pain in face, arm, leg, trunk Head pain

Abdominal pain Brain Tumors Rarely produce central pain Thalamic tumors generally dont cause pain

Remember: Brain tumors can produce headache Metastatic lesions can produce pain Thanks for your Attention

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