Zentraler Deafferenzierungsschmerz: Klinisches Bild und Therapie

Zusammenfassung

Zentraler Deafferenzierungsschmerz kann grundsätzlich nach jeder Läsion im Verlauf der zentralen Schmerzbahn entstehen. Leitsymptom ist ein konstanter oder intermittierender Schmerz mit sensiblen Auffälligkeiten im schmerzhaften Körperteil. Eine Allodynie ist pathognomonisch für alle Arten des neuropathischen Schmerzes; sie ist in mehr als der Hälfte der Fälle von zentralem Deafferenzierungsschmerz vorhanden. Realistisches Therapieziel ist eine Linderung der Schmerzen, Schmerzfreiheit hingegen ist selten erreichbar. Es gibt nur wenige kontrollierte Studien an relativ kleinen Patientenkollektiven. Die Wirksamkeit von Amitriptylin und Lamotrigin in der Behandlung zentraler Deafferenzierungsschmerzen wurde in plazebokontrollierten Studien nachgewiesen. Diese Substanzen sind daher Mittel der ersten Wahl. Für Gabapentin zeigte eine offene Studie eine Wirksamkeit, ebenso für Mexiletin als Add-on-Therapie zusammen mit Antidepressiva. Häufig ist eine Kombinationstherapie notwendig. Sie sollte immer begleitet sein von Rehabilitationsmaßnahmen, insbesondere Bewegungstherapie, und der Beseitigung zusätzlicher nozizeptiver Schmerzquellen. Nach Ausschöpfen aller medikamentösen Behandlungsoptionen verbleiben invasive Therapiemaßnahmen als Ultima Ratio, z. B. Thalamusstimulation, Motokortexstimulation, Rückenmarkstimulation. Ihre Erfolge sind jedoch häufig zeitlich limitiert.

Abstract

Central pain can occur following lesions anywhere in the spinothalamic pathway and its corticopetal projections. It is characterized by constant or intermitted pain in association with sensory abnormalities in the painful part of the body. Allodynia is a classic hallmark that is present in more than 50 % of patients with central pain. Pain reduction rather than pain relief is the goal of the treatment. Randomized controlled trials are rare and include only small numbers of patients. Amitriptyline and lamotrigine have proven to be effective in placebo-controlled randomised trials and are the drugs of first choice. Gabapentin has demonstrated promising effects in an open study, as well as Mexiletine added-on to antidepressants. Combination therapy is often needed and should always be accompanied by a comprehensive rehabilitation program and an accurate search for and treatment of accompanying sources of nociceptive pain. If drug treatment fails, surgical interventions like deep brain stimulation, cortical stimulation, or spinal cord stimulation can be the ultima ratio. Unfortunately, with these later therapies, recurrence of pain after months or years is common.

Key words

Central pain - neuropathic pain - mechanisms - therapy

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