Pain

surgical point of view

 Sri Maliawan .

16-5-2012
The IASP defines pain as “an unpleasant
sensory and emotional experience
associated with actual or potential tissue
damage, or described in term of such
damage”.
 Difference of Pain concept

Disease pain
disease
Pain

Doctor Patient
NYERI

PELINDUNG PASIEN DARI ANCAMAN ATAU

DAPAT JUGA DIKATAKAN SEBAGAI SIKSAAN
DARI PENYAKIT YANG DIDERITA

Nyeri merupakan siksaan (cruciatum),kutukan

(curse)
Images of Pain
“Relief pain should be a
human right”
Fundamental Considerations

Millions of patients worldwide undergo surgery.

The perioperative period is stressful
Patients vulnerable to several potential adverse events.
Postoperative pain can contribute human suffering and
postoperative morbidity.
Improvement in surgical outcome require integration of
surgical, anesthetic, pain management interventions
 Global day Against Pain Promote
 Pain whatever the cause is should be
considered as a basic human right.

 Pain is the fifth vital sign should be written in

patient chart.

 Pain should be taught at medical school and

nurse education .

 Pain specialist should be established as one of

specialist in medical profession.
 Perception

Pain

Medulation
Descending
modulation Dorsal Horn

Ascending
input
Dorsal root
ganglion
transmission

Spinothalamic
Peripheral
tract
nerve

Trauma
Peripheral
nociceptors

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg. 1993;77:1049.
 Pain Pathways:
 Tissue damage>>>Algesic substanses
release>>>Noxious stimuli>>>A delta and
C fibers>>>to theNeuraxis>>>Many
toAnt.andAnterolat.Horns>>>Segmenal
reflex responses , and others via the
Spinothalamic and Spinoreticular
tracts>>>Suprasegmental and cortical
responses.
 KENDALA PENANGGULANGAN NYERI

 PIHAK DOKTER
 PENGETAHUAN KURANG
 “PHOBIA” THD MORFIN
 KHAWATIR THD KETERGANTUNGAN
 PIHAK PASIEN
 KURANG TERUS TERANG (TERBUKA)
 “PHOBIA” THD MORFIN  “MORFINIS”
 PIHAK PELAYANAN MEDIS
 SISTEM GANTI PEMBIAYAAN MEMBERATKAN PASIEN
 PERATURAN TERLALU KETAT THD OBAT GOL II DAN III
TRANSDUKSI

ADALAH PROSES Pressure

PERUBAHAN
RANGSANG NYERI
(NOXIOUS STIMULI) Heat
MENJADI SUATU
AKTIFITAS LISTRIK
PADA UJUNG- Chemical
UJUNG SARAF
SENSORIS.
TRANSMISI

ADALAH PROSES
PERAMBATAN SUATU
IMPULS NYERI
MELALUI SERABUT A
& C MENYUSUL
PROSES TRANSDUKSI.
MODULASI

MERUPAKAN INTERAKSI
ANTARA SISTEM ANALGESIK
ENDOGEN (ENDORFIN, NA, 5HT)
DENGAN INPUT NYERI YANG
MASUK KE KORNU POSTERIOR.
MERUPAKAN INTERAKSI
ANTARA SERABUT EKSITASI
DAN INHIBISI
Persepsi
ADALAH HASIL AKHIR DARI
PROSES INTERAKSI YANG
Pain
KOMPLEKS DAN UNIK Brain
Perception
YANG DIMULAI DARI
TRANSDUKSI, TRANSMISI
& MODULASI YANG
MENGHASILKAN PERSEPSI
NYERI YANG AMAT
SUBYEKTIF PADA PUSAT
NYERI (DI KORTEKS SEREBRI
= AREA 3,2,1)
Goals of pain treatment
Effective pain management is now an integral part of :
1. Modern surgical practice.
2. Postoperative pain management

not only minimises patient suffering but also can reduce

morbidity and facilitate rapid recovery and early discharge
from hospital which can reduce hospital costs.

Produced in consultation with the

European Society of Regional Anaesthesia
and Pain Therapy
 Multimodal Analgesia
OPIOID
- Systemic
PERCEPTION - Epidural
- Subarach
Pain Tramadol

LOCAL ANESTHETIC
- Epidural
Descending
modulation Dorsal Horn - Subarachnoid
Ascending Dorsal root
input ganglion

TRANSMISSION LA
COX-1
COX-2
Spinothalamic
Peripheral
tract TRANSDUCTION
nerve

Trauma
Peripheral
nociceptors

No single drug can produce optimal analgesia without adverse effect 21

Adapted from Gottschalk A et al. Am Fam Physician. 2001;63:1981, and Kehlet H et al. Anesth Analg.
1993;77:1049.
 PERCEPTION:
Tramadol, opioid

MODULATION:
Tramadol,opioids,
antidepressants

TRANSMISSION:
Paracetamol, tramadol,
opioids

TRANSDUCTION:
NSAIDs,
COX-2 inhibitors,
local anesthetics
Multi Modal Mechanism
Tramadol+
APAP
 Konsep pembedahan

Memutuskan impul nyeri agar tidak

sampai ke thalamus atau cortex cerebri
 Nyeri yang memerlukan
pertimbangan operatif.

Penderita dg nyeri kronis akibat

malignansi atau penyakit terminal.
Penderita dg nyeri oleh karena sindroma
khusus.
 Tindakan pembedahan
1. Non ablatif prosedur.

Dekompresi ekternal ( external neurolysis)

Entrapment syndrome, canal stenosis,HNP,
carval tunnel syndrome, microvascular
decompression nervus V. dll.
Dekompresi interna ( internal neurolysis)
misalnya neurofibroma.
 Tindakan pembedahan
2. Ablatif prosedur.
– Neurektomi
– Ganglionektomy
– Simpatektomi
– Posterior rizotomi
– Drezs lesion
– Mielotomi
– Chordotomy
– Lissauer tractotomi
– Trigeminal tractotomy
– Talamotomy ( open surgery, Stereotictic thalamotomy, gamma knife
radiosurgery thalamotomy)
– Medullary tractotomy
– Mesencephalic tractotomy
– Hipofisektomi
– Prefrontal lobotomy
– Girektomy
 Non ablatif prosedur
Trigeminal neuralgia (micro vascular
decompression)
Carpal tunnel syndrome
HNP
DLL
 Trigeminal neuralgia

Is the most painful hemifacial pain

syndrome “ painful to extent of
driving some sufferers to the point
of suicide”

Turel, Keki E., 2002

Hyper disfunction syndrome

Etiology
Vascular compression
Neoplasm
AVM
Skull base anomalies
Multiple sclerosis.

Desease of the elderly

Historical Evolution of Surgical Therapies
for Trigeminal Neuralgia

Peripheral neurectomy

Classic Frazier operation

Radiofrequency gangliotomy
Glycerol Injection
Balloon decompression

Microvascular decompression

Gamma knife radiosurgery

Carpal Tunnel Syndrome (CTS)
merupakan entrapment neuropathy
 Pendahuluan
Pada Tulisan ini akan dibahas:
– Surgical Anatomy
– Patofisiologi dan Etiologi,
– Diagnosis
– Penatalaksanaan
 Surgical Anatomy
N. Medianus
Carpal Tunnel
 Synonim
Entrapment neuropathy,
Neuropathic compression
syndrome.
Peripheral nerve compression
syndrome
caused by chronic compression of
peripheral nerve
 Nerve Entrapment
Pathophysiology
– Ischemia/Mechanical Factors
Earliest manifestation
– Reduced epineurial blood flow
– 20-30 mmHg compression
Interference in venular flow
– 40-50 mmHg
Impairment of arteriolar and interfascicular
capillary flow
– 60-80 mmHg
Complete blockage of nerve perfusion
WRIST SPLINTS
 LOCAL INJECTION
A mixture of 10 to 20 mg of lidocaine
(Xylocaine) without epinephrine and 20 to
40 mg of methylprednisolone acetate
(Depo-Medrol) or similar corticosteroid
preparation is injected with a 25-gauge
needle at the distal wrist crease (or 1 cm
proximal to it).
Ablatif procedur
METODA PENGHILANG NYERI
 KESIMPULAN

1. Aspek opertif perlu dipertimbangkan

untuk nyeri kronis atau nyeri yang
membandel saja.

2. Saraf yang sakit ( iritasi). Saraf yang

mati tidak nyeri.

3. Tidak ada nyeri yang tidak bisa

diatasi, sehingga yang perlu
dipertimbangkan adalah komplikasi
dari prosedur yang dipilih.
WHAT IS THE MESSAGES ?

Pain is a real perception

Unlike other diseases such as blind, Parkison,

or Alzheimer , etc where people may easily
observed, but …..
Pain can not be seen

What you have to do is to listen to the patient

Pain is whatever patients say!!