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Cordotomias: indicações e resultados
Luiz Cláudio Modesto Pereira (DF)
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Dor oncológica Aspectos especiais:
• Prevalência
• Sobrevida
• Sofrimento e QV
• Complicações
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Dores Nociceptiva MISTA e Neuropática
Exemplos
•Cervicobraquialgia e Lombociatalgia •Radiculopatia cervical, torácica e lombar
•Dor Oncológica •Neuropatia Compressiva (ex. Síndrome do túnel do carpo)
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Domínios da dor crônica
Social Consequences
• Marital/family relations
• Intimacy/sexual activity
• Social isolation
Socioeconomic
Consequences
• Healthcare costs
• Disability
• Lost workdays
Quality of Life Physical functioning Ability to perform activities
of daily living Work Recreation
Psychological Morbidity Depression Anxiety, anger Sleep disturbances Loss of self-esteem
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Conceitos inadequados:
Ultrapassado x Antigo x Aprimorado
Alto risco X Consistente
Sequelante X benéfico e de impacto
Evitável X importante e necessario
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Histórico
I. Observações clínicas
II. Conceitos anatômicos
III. Resultados iniciais
I. Método aberto
IV. Evolução de técnicas
I. Método percutâneo
II. CT
III. Monitorização
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-40
-20
0
20
40
60
80
100
120
140
160
1 2 3 4 5 6 7 8
Número de publicações por década
N publicações Revisão PUBMED 2010 cordotomia
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Revisão PUBMED 2010 – cordotomia
• Importância da patologia • Consistência dos resultados • Larga experiência - número de procedimentos
0
1
2
3
4
5
6
7
8
9
10
1998. 1999. 2000. 2001. 2002. 2003. 2004. 2005. 2006. 2007. 2008. 2009. 2010.
Artigos publicados por ano N artigos
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Epidemiology of Cancer Pain
Pain in cancer population:
1- 66% of all patients
2- 90% of advanced disease
3- 25% of pt.with active ttt. Have significant Pain
70-90% of pt. Got adequate pain control with stabilized guideline
The rest 10-30% of pt. Need More invasive procedures
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Esquema clássico da OMS Uso de opiáceos – “papaver somniferum”- em dor cônica de origem maligna
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Curtis LH et al, Health Serv Res, 41:837-855; 2006
Geographic variation in opioid prescription claims in 2000
Curtis LH et al. Health Serv Res 2006;41:837-55
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Topical vs Transdermal Drug Delivery Systems
Systemic activity
Applied away from painful site
Serum levels necessary
Systemic side effects
Peripheral tissue activity
Applied directly over painful site
Insignificant serum levels
Systemic side effects unlikely
Topical
(lidocaine patch 5%) Transdermal
(fentanyl patch)
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Infusão intraespinhal de morfina
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•Remoção das causas
•Melhora do sofrimento: físico / mental
•Melhora da qualidade de vida: física / mental / social
•Profilaxia de complicações:
Tratamento da Dor Oncológica
Escala Modificada da Dor Oncológica *Suporte Saúde Mental
Opióides Fortes AINES Adjuvantes, Reabilitação Psiquiatria/Psicologia *
Opióides fracos AINEs Adjuvantes, Reabilitação Psiquiatria/Psicologia * AINEs
Adjuvantes Reabilitação Psiquiatria/Psicologia*
Procedimentos Neurocirúrgicos Funcionais
Ablação x modulação Opióides, AINEs Adjuvantes, Reabilitação Psiquiatria/Psicologia * Bloqueios Anestésicos (s/n)
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Anatomo-fisiologia
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Anatomia relevante
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Alvos possíveis
Dr. Elie D. Al-Chaer
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Cordotomia percutânea
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Técnica
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Técnica :
resposta clinica e impedância
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Localização e efeitos de estimulo
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Resultado inadequado
Bom resultado
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Outras técnicas: • Outros níveis • Outras vias de entrada
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Outras técnicas * CIRÚRGICAS
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MIELOTOMIA MEDIANA
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Tracotomia espinotalamica bulbar/pontina
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Tracotomia espinotalamica ponto-mesencefálica
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RESULTADOS REVISÃO MEDILINE - PUBMED
• Meta-analysis - 0
• Randomized trials - 0
• Guidelines - 0
• Trials - 0
• Review - 2
• MAIOR CASUÍSTICA RECENTE:
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RESULTADOS
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RESULTADOS
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RESULTADOS
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COMPLICAÇÕES
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COMPLICAÇÕES
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CONCLUSÕES