Role of the Qst-Testing for the Determination of the Nervus Intermedius Neuralgia Phenotype – Case Report
International Journal of Anesthesia and Clinical Medicine
Volume 7, Issue 1, June 2019, Pages: 7-12
Received: Nov. 24, 2018; Accepted: Dec. 26, 2018; Published: Feb. 28, 2019
Views 237      Downloads 49
Authors
Bruno Vítor Martins Santiago, Department of Anesthesiology, Medical Sciences College at Pedro Ernesto University Hospital, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil ; Anesthesiology Clinic, Marcílio Dias Naval Hospital, Brazilian Navy, Rio de Janeiro, Brazil
Carlos Darcy Alves Bersot, Department of Anesthesiology, Medical Sciences College at Pedro Ernesto University Hospital, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
Fernando Cardoso de Lemos Souza, Department of Anesthesiology, Medical Sciences College at Pedro Ernesto University Hospital, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
Odilea Rangel Gonçalves, Department of Anesthesiology, Medical Sciences College at Pedro Ernesto University Hospital, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
Nivaldo Ribeiro Villela, Department of Anesthesiology, Medical Sciences College at Pedro Ernesto University Hospital, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
Article Tools
Follow on us
Abstract
Background and Objectives: Nervus Intermedius neuralgia is a rare and difficult to suspect entity. This study aims to present the case of intermedius neuralgia, discusses the implications of the phenotype in the patient approach, as well as the role of quantitative susceptibility testing (QST), as an important tool in the diagnosis and therapeutic management. Case report: 40-year-old female patient, smoker, accompanied by neurology (generalized tonic-clonic seizures), in use of carbamazepine. During one of the seizures, she said fall from height, resulting in fracture of the left temporal bone and ipsilateral facial paralysis. After to optimal the therapy, she had no more seizures, but evolved with paroxysmal pain, shock-like, located in the groove between the ear and scalp at high intensity, with shooting area in the wall of the external auditory channel. Reports that had more crisis with the arrival of winter. The examination revealed mechanical hyperalgesia and "wind-up" phenomenon on the affected side. CT mastoid with evidence of temporal fracture to the left crossing the mast cells. Electroneuromyography corroborating with peripheral facial paralysis. Other tests without changes. It was submitted to the QST-test, evidencing hyperalgesia to cold in the region corresponding to the pain complaint. Lamotrigine was associated with the treatment regimen with 90% improvement of symptoms. Conclusion: This is a rare etiology and difficult diagnosis. The QST-test was extremely important, as well as aid in the diagnosis also allows us to identify the great variability of phenotypic profile within each etiology, which may reflect distinct pathophysiological mechanisms, with different therapeutic responses. There is evidence that lamotrigine assist in the treatment of neuropathic pain associated hyperalgesia to cold.
Keywords
QST, Nervus Intermedius, Neuropathic Pain, Lamotrigine, Phenotype
To cite this article
Bruno Vítor Martins Santiago, Carlos Darcy Alves Bersot, Fernando Cardoso de Lemos Souza, Odilea Rangel Gonçalves, Nivaldo Ribeiro Villela, Role of the Qst-Testing for the Determination of the Nervus Intermedius Neuralgia Phenotype – Case Report, International Journal of Anesthesia and Clinical Medicine. Vol. 7, No. 1, 2019, pp. 7-12. doi: 10.11648/j.ijacm.20190701.12
Copyright
Copyright © 2019 Authors retain the copyright of this article.
This article is an open access article distributed under the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
[1]
Alfieri A, Strauss C, Prell J, Peschke E. History of the nervus intermedius of Wrisberg. Annals of Anatomy-Anatomischer Anzeiger. 2010 May 20;192(3):139-144.
[2]
Gadient PM, Smith JH. The neuralgias: diagnosis and management. Current neurology and neuroscience reports. 2014 Jul 1;14(7):459.
[3]
Loeser JD. Cranial neuralgias. In: Bonica JJ, editor. The Management of Pain. Philadelphia, PA: Lea & Febiger, 1990:676-686.
[4]
Tubbs RS, Steck DT, Mortazavi MM, Cohen-Gadol AA. The nervus intermedius: a review of its anatomy, function, pathology, and role in neurosurgery. World Neurosurgery. 2013 May 1;79(5-6):763-7.
[5]
Calvin WH, Loeser JD, Howe JF. A neurophysiological theory for the pain mechanism of tic douloureux. Pain. 1977 Apr 1;3(2):147-54.
[6]
Fromm GH, Chattha AS, Terrence CF, Glass JD. Role of inhibitory mechanisms in trigeminal neuralgia. Neurology. 1981 Jun 1;31(6):683
[7]
Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, (beta version). Cephalalgia. 2013 Jul;33(9):629-808.
[8]
Schestatsky P. Definição, diagnóstico e tratamento da dor neuropática. Revista HCPA. Porto Alegre. Vol. 28, n. 3,(2008), p. 177-187. 2008.
[9]
Bouhassira D, Lantéri-Minet M, Attal N, Laurent B, Touboul C. Prevalence of chronic pain with neuropathic characteristics in the general population. Pain. 2008 Jun 15;136(3):380-7.
[10]
Woolf CJ, Bennett GJ, Doherty M, Dubner R, Kidd B, Koltzenburg M, Lipton R, Loeser JD, Payne R, Torebjork E. Towards a mechanism-based classification of pain? Pain. 1998 Sep; 77(3):227–229.
[11]
Ross E. Moving towards rational pharmacological management of pain with an improved classification system of pain. Expert Opin Pharmacother. 2001 Oct; 2(10):1529–1530.
[12]
Baron R. Mechanisms of disease: neuropathic pain--a clinical perspective. Nat Clin Pract Neurol. 2006 Feb; 2(2):95–106.
[13]
Finnerup NB, Jensen TS. Mechanisms of disease: mechanism-based classification of neuropathic pain-a critical analysis. Nat Clin Pract Neurol. 2006 Feb; 2(2):107–115.
[14]
Gracely RH. Pain measurement. Acta Anaesthesiol Scand. 1999 Oct; 43(9):897–908.
[15]
Haanpää ML, Laippala PA, Nurmikko TJ. Thermal and tactile perception thresholds in acute herpes zoster. Eur J Pain. 1999 Dec; 3(4):375–386.
[16]
Greenspan JD. Quantitative assessment of neuropathic pain. Curr Pain Headache Rep. 2001 Apr; 5(2):107–113.
[17]
Rolke R, Magerl W, Campbell KA, Schalber C, Caspari S, Birklein F, Treede RD. Quantitative sensory testing: a comprehensive protocol for clinical trials. Eur J Pain. 2006 Jan; 10(1):77–88.
[18]
Rolke R, Baron R, Maier C, Tölle TR, Treede RD, Beyer A, Binder A, Birbaumer N, Birklein F, Bötefür IC, Braune S, Flor H, Huge V, Klug R, Landwehrmeyer GB, Magerl W, Maihöfner C, Rolko C, Schaub C, Scherens A, Sprenger T, Valet M, Wasserka B. Quantitative sensory testing in the German Research Network on Neuropathic Pain (DFNS): standardized protocol and reference values. Pain. 2006 Aug; 123(3):231–243. Epub 2006 May 11.
[19]
Yenisel Cruz-Almeida and Roger B. Fillingim, Pain Med. 2014 January; 15(1): 61–72.
[20]
Kasch H, Qerama E, Bach FW, Jensen TS. Reduced cold pressor pain tolerance in non-recovered whiplash patients: a 1-year prospective study. Eur J Pain. 2005 Oct; 9(5):561–569.
[21]
Weissman-Fogel I, Granovsky Y, Crispel Y, Ben-Nun A, Best LA, Yarnitsky D, Granot M. Enhanced presurgical pain temporal summation response predicts postthoracotomy pain intensity during the acute postoperative phase. J Pain. 2009 Jun; 10(6):628–636.
[22]
Goodin, B., et al. "Temporal summation of mechanical pain predicts reports of clinical pain severity in everyday life: a prospective analysis of patients with symptomatic knee osteoarthritis." The Journal of Pain 14.4 (2013): S45.
[23]
Cruz-Almeida Y, Fillingim RB. Can quantitative sensory testing move us closer to mechanism-based pain management?. Pain medicine. 2014 Jan 1;15(1):61-72.
[24]
Krumova EK, Geber C, Westermann A, Maier C. Neuropathic pain: is quantitative sensory testing helpful?. Current diabetes reports. 2012 Aug 1;12(4):393-402.
[25]
Pedro Schestatsky; Luciana Cadore Stefani; Paulo Roberto Sanches; Danton Pereira da Silva Júnior; Iraci Lucena Silva Torres; Letizzia Dall-Agnol et al. Validação de um aparelho brasileiro de teste de quantificação sensitiva brasileiro para o diagnóstico de neuropatia de fibras finas. Arq. Neuro-Psiquiatr. vol. 69 no. 6 São Paulo Dec. 2011.
[26]
Finnerup NB, Haroutounian S, Kamerman P, Baron R, Bennett DL, Bouhassira D, Cruccu G, Freeman R, Hansson P, Nurmikko T, Raja SN, Rice AS, Serra J, Smith BH, Treede RD, Jensen TS. Neuropathic pain: an updated grading system for research and clinical practice. PAIN 2016;157:1599–1606.
[27]
Finnerup NB, Attal N, Haroutounian S, McNicol E, Baron R, Dworkin RH, Gilron I, Haanpaa M, Hansson P, Jensen TS, Kamerman PR, Lund K, Moore A, Raja SN, Rice AS, Rowbotham M, Sena E, Siddall P, Smith BH, Wallace M. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol 2015;14: 162–73.
[28]
Roy Freemana, Ralf Baronb, Didier Bouhassirac, d, Javier Cabrerae, Birol Emirf. Sensory profiles of patients with neuropathic pain based on the neuropathic pain symptoms and signs. PAIN: 155 (2014) 367-376.
[29]
Bouhassira D, Attal N. Translational neuropathic pain research: a clinical perspective. Neuroscience 2016;338:27–35.
[30]
R. Baron et al. Peripheral neuropathic pain: a mechanism-related organizing principle based on sensory profiles. PAIN:158 (2017) 261–272
[31]
Demant DT, Lund K, Vollert J, Maier C, Segerdahl M, Finnerup NB, Jensen TS, Sindrup SH. The effect of oxcarbazepine in peripheral neuropathic pain depends on pain phenotype: a randomised, doubleblind, placebo-controlled phenotype-stratified study. PAIN 2014;155: 2263–73.
[32]
Attal N, deAndrade DC, Adam F, Ranoux D, Teixeira MJ, Galhardoni R, Raicher I, Uceyler N, Sommer C, Bouhassira D. Safety and efficacy of repeated injections of botulinum toxin A in peripheral neuropathic pain (BOTNEP): a randomised, double-blind, placebo-controlled trial. Lancet Neurol 2016;15:555–65.
[33]
Mainka T, Malewicz NM, Baron R, Enax-Krumova EK, Treede RD, Maier C. Presence of hyperalgesia predicts analgesic efficacy of topically applied capsaicin 8% in patients with peripheral neuropathic pain. Eur J Pain 2016;20:116–29.
[34]
Wasner G, Kleinert A, Binder A, Schattschneider J, Baron R. Postherpetic neuralgia: topical lidocaine is effective in nociceptordeprived skin. J Neurol 2005;252:677–86.
[35]
Edwards RR, Haythornthwaite JA, Tella P, Max MB, Raja S. Basal heat pain thresholds predict opioid analgesia in patients with postherpetic neuralgia. Anesthesiology 2006;104:1243–8.
[36]
Demant DT, Lund K, Vollert J, Maier C, Segerdahl M, Finnerup NB, Jensen TS, Sindrup SH. The effect of oxcarbazepine in peripheral neuropathic pain depends on pain phenotype: a randomised, doubleblind, placebo-controlled phenotype-stratified study. PAIN 2014;155: 2263–73.
[37]
Simpson DM, Schifitto G, Clifford DB, Murphy TK, Durso-De Cruz E, Glue P, Whalen E, Emir B, Scott GN, Freeman R; Group HIVNS. Pregabalin for painful HIV neuropathy: a randomized, double-blind, placebo-controlled trial. Neurology 2010;74:413–20.
[38]
Wasner G, Kleinert A, Binder A, Schattschneider J, Baron R. Postherpetic neuralgia: topical lidocaine is effective in nociceptordeprived skin. J Neurol 2005;252:677–86.
[39]
Finnerup NB, Sindrup SH, Bach FW, Johannesen IL, Jensen TS. Lamotrigine in spinal cord injury pain: a randomized controlled trial. Pain. 2002 Apr 1;96(3):375-83.
[40]
Attal N, Rouaud J, Brasseur L, Chauvin M, Bouhassira D. Systemic lidocaine in pain due to peripheral nerve injury and predictors of response. Neurology 2004;62:218–25.
[41]
Zimmermann K, Deuis JR, Inserra MC, Collins LS, Namer B, Cabot PJ, Reeh PW, Lewis RJ, Vetter I. Analgesic treatment of ciguatoxin-induced cold allodynia. PAIN®. 2013 Oct 1;154(10):1999-2006.
[42]
SAKATA, Rioko Kimiko; ISSY, Adriana Machado; VLAINICH, Roberto;CAVALCANTI, IL, MADDALENA, M. L. Dor neuropática. Rio de Janeiro: Sociedade de Anestesiologia do Estado do Rio de Janeiro, 2003. p 167 - 207.
[43]
Gaspar AT, Antunes F. Dor crónica após acidente vascular cerebral. Índice geral. 2010 Nov:38.
[44]
Alves, Túlio César Azevedo, Giselli Santos Azevedo, and Emannuela Santiago de Carvalho. "Pharmacological treatment of trigeminal neuralgia: systematic review and metanalysis." Revista brasileira de anestesiologia. 54.6 (2004): 836-849.
[45]
Backonja MM. Use of anticonvulsants for treatment of neuropathic pain. Neurology. 2002 Sep 10;59(5 suppl 2):S14-7.
[46]
N. B. Finnerup, M. Otto, H. J. McQuay, T. S. Jensen, S. H. Sindrup. Algorithm for neuropathic pain treatment: An evidence based proposal. Pain., 5 December 2005, Pages 289-305.
[47]
Robert H. Dworkin,; Miroslav Backonja; Michael C. Rowbotham; Robert R. Allen; Charles R. Argoff; Gary J. Bennett et al. Advances in Neuropathic Pain Diagnosis, Mechanisms, and Treatment Recommendations. Arch Neurol. 2003;60(11):1524-1534.
ADDRESS
Science Publishing Group
1 Rockefeller Plaza,
10th and 11th Floors,
New York, NY 10020
U.S.A.
Tel: (001)347-983-5186