Dor neuropática após trauma com agulha de peridural

Gilson Cassem Ramos; Eduardo Custódio de O. Gomes

doi:10.1590/S0034-70942008000400007

Clinical Information

Dor neuropática após trauma com agulha de peridural

Neuropathic pain after epidural needle trauma

Gilson Cassem Ramos; Eduardo Custódio de O. Gomes

http://dx.doi.org/10.1590/S0034-70942008000400007 Braz J Anesthesiol, vol.58, n4, p.380-386, 2008

PDF

Downloads: 1

Resumo

JUSTIFICATIVA E OBJETIVOS: Complicações neurológicas decorrentes de anestesia peridural são incomuns. O trauma mecânico direto em raízes nervosas pode provocar dor neuropática que costuma evoluir de maneira favorável; contudo, trata-se de complicação potencialmente grave que, em certas circunstâncias, pode progredir para quadro crônico. O objetivo foi discorrer o tema dor neuropática aguda e traumática, abordando, sobretudo, sobre o seu tratamento. RELATO DO CASO: Paciente do sexo masculino, admitido para tratamento cirúrgico de refluxo gastroesofágico, pela técnica laparoscópica e com alta hospitalar prevista para o primeiro pós-operatório (PO). Submeteu-se a bloqueio anestésico peridural associado à anestesia geral. Durante a localização do espaço peridural, o paciente referiu dor muito intensa e parestesia em membro inferior esquerdo. A agulha foi reposicionada e o espaço peridural localizado. O paciente evoluiu no PO com alodinia e hiperestesia. Foi firmado o diagnóstico de dor neuropática. O tratamento instituído constou de antidepressivo, anticonvulsivante, corticóide, tramadol e complexo vitamínico B. No 28º PO o paciente apresentava-se assintomático e com exame físico normal, quando recebeu alta médica. CONCLUSÕES: A evolução do quadro com o tratamento proposto foi favorável. O diagnóstico e tratamento precoces podem evitar lesões irreversíveis, mudar o prognóstico dos pacientes e evitar desdobramentos de caráter social e médico-legal.

Palavras-chave

COMPLICAÇÕES, DOR, TÉCNICAS ANESTÉSICAS, Regional

Abstract

BACKGROUND AND OBJECTIVES: Neurologic complications secondary to epidural block are uncommon. Direct mechanical trauma to nerve roots may cause neuropathic pain that, usually, has a favorable evolution; however, it is a potentially severe complication that can evolve into a chronic disorder. The objective of this study was to discuss acute traumatic neuropathic pain and, especially, its treatment. CASE REPORT: A male patient was admitted for surgical treatment of gastroesophageal reflux via laparoscopy and scheduled to be discharged on the first postoperative (PO) day. He underwent epidural block associated with general anesthesia. During the localization of the epidural space, the patient complained of severe pain in the left lower limb. The needle was repositioned and the epidural space was located. In the PO, the patient developed allodynia and hyperesthesia. Neuropathic pain was diagnosed. Treatment included antidepressant, anticonvulsant, corticosteroids, tramadol, and vitamin B complex. On the 28th PO the patient was asymptomatic and presented a normal physical exam, being discharged from the hospital. CONCLUSIONS: The patient presented a favorable evolution with the treatment instituted. Early diagnosis and treatment can avoid irreversible lesions, change the prognosis, and avoid social and medical-legal consequences.

Keywords

ANESTHETIC TECHNIQUES, Regional, COMPLICATIONS, PAIN

Referencias

Albazaz R, Wong YT, Homer-Vanniasinkam S. Complex regional pain syndrome: a review. Ann Vasc Surg. 2008;22:297-306.

Aromaa U, Lahdensuu M, Cozanitis DA. Severe complications associated with epidural and spinal anaesthesias in Finland 1987-1993: A study based on patient insurance claims. Acta Anaesthesiol Scand. 1997;41:445-452.

Auroy Y, Narchi P, Messiah A. Serious complications related to regional anesthesia. Anesthesiology. 1997;87:479-486.

Dahegren N, Törnebrandt K. Neurological complications after anaesthesia: A follow-up of 18.000 spinal and epidural anaesthetics performed over three years. Acta Anaesthesiol Scand. 1995;39:872-880.

Gardner E. Coxa e Joelho. Anatomia. 1985:213.

Rowbotham MC. Síndromes Dolorosas Específicas. Tratado de Medicina Interna. 2005:2599-2601.

Loeser JD, Melzack R. Pain: an overview. Lancet. 1999;353:1607-1609.

Watkins LR, Maier SF, Goehler LE. Immune activation: the role of pro-inflammatory cytokines in inflammation, illness responses and pathological pain states. Pain. 1995;63:289-302.

Amano N, Hu JW, Sessle BJ. Responses of neurons in feline trigeminal subnucleus caudalis (medullary dorsal horn) to cutaneous, intraoral, and muscle afferent stimuli. J Neurophysiol. 1986;55:227-243.

LaMotte C. Distribution of the tract of Lissauer and the dorsal root fibers in the primate spinal cord. J Comp Neurol. 1977;172:529-561.

Basbaum AI, Fields HL. Endogenous pain control systems: brainstem spinal pathways and endorphin circuity. Annu Rev Neurosci. 1984;7:309-338.

Besson JM. Chaouch - A Peripheral and spinal mechanisms of nociception. Physiol Rev. 1987;67:67-186.

Finnerup NB, Otto M, Jensen TS. An evidence-based algorithm for the treatment of neuropathic pain. MedGenMed. 2007;9:36.

Finnerup NB, Otto M, McQuay HJ. Algorithm for neuropathic pain treatment: an evidence based proposal. Pain. 2005;118:289-305.

Rosenblatt RM, Reich J, Dehring D. Tricyclic antidepressants in treatment of depression and chronic pain: analysis of the supporting evidence. Anesth Analg. 1984;63:1025-1032.

Hays H, Woodroffe MA. Using gabapentin to treat neuropathic pain. Can Fam Physician. 1999;45:2109-2112.

McQuay H, Carroll D, Jadad AR. Anticonvulsant drugs for management of pain: a systematic review. BMJ. 1995;311:1047-1052.

Gilron I, Bailey JM, Tu D. Morphine, gabapentin, or their combination for neuropathic pain. N Engl J Med. 2005;352:1324-334.

Budd K. Chronic pain-challenge and response. Drugs. 1994;47(^s1):33-38.

Parrillo JE, Fauci AS. Mechanisms of glucocorticoid action on immune processes. Annu Rev Pharmacol Toxicol. 1979;19:179-201.

Caram-Salas NL, Reyes-García G, Medina-Santillán R. Thiamine and cyanocobalamin relieve neuropathic pain in rats: synergy with dexamethasone. Pharmacology. 2006;77:53-62.

Wang S, Lim G, Zeng Q. Expression of central glucocorticoid receptors after peripheral nerve injury contributes to neuropathic pain behaviors in rats. J Neurosci. 2004;24:8595-8605.

Zoorob RJ, Cender D. A different look at corticosteroids. Am Fam Physician. 1998;58:443-450.

Metz AS. Anti-inflammatory agents as inhibitors of prostaglandin synthesis in man. Med Clin North Am. 1981;65:713-757.

Herrero JF, Romero-Sandoval EA, Gaitan G. Antinociception and the new COX inhibitors: research approaches and clinical perspectives. CNS Drug Rev. 2003;9:227-252.

Sacramento EF, Silva BB. Vitaminas e Minerais. Farmacologia. 2002:979-984.

Thielke SM, Fan MY, Sullivan M. Pain limits the effectiveness of collaborative care for depression. Am J Geriatr Psychiatry. 2007;15:699-707.

Oliveira JT. Aspectos comportamentais das síndromes de dor crônica. Arq Neuropsiquiatr. 2000;58:360-365.

Dor neuropática após trauma com agulha de peridural

Neuropathic pain after epidural needle trauma

Gilson Cassem Ramos; Eduardo Custódio de O. Gomes

Resumo

Palavras-chave

Abstract

Keywords

Referencias

Links

compartir

Braz J Anesthesiol