Diagnostik und Therapie neuropathischer Schmerzen

ZUSAMMENFASSUNG

Die Ätiologie neuropathischer Schmerzen gründet auf einer Schädigung des somatosensorischen Systems. Sie unterscheiden sich von nozizeptiven Schmerzen, bei welchen das somatosensorische System intakt ist, nicht nur in ihrer Schmerzqualität, sondern auch in ihrer Therapie. Periphere neuropathische Schmerzen, beispielsweise aufgrund einer Polyneuropathie, werden von zentralen neuropathischen Schmerzen, beispielsweise als Folge eines Schlaganfalls abgegrenzt. Bei der Diagnostik neuropathischer Schmerzen, wird zwischen „sicheren“, „wahrscheinlichen“, „möglichen“ und „unwahrscheinlichen“ neuropathischen Schmerzen unterschieden. Eine gründliche Anamnese, welche durch Fragebögen ergänzt werden kann, und körperliche Untersuchung sind bei der Diagnostik erforderlich. Zum Erkennen der „Positiv“- und „Negativsymptome“, welche für neuropathische Schmerzen charakteristisch sind, kann man sich einfacher „Bedside-Tools“ bedienen. Für die Sicherung der Diagnose können die Quantitative Sensorische Testung (QST), Methoden der Bildgebung und der klassischen Elektrophysiologie sowie die Hautbiopsie und weitere spezialisierte Methoden eingesetzt werden. Das Ansprechen neuropathischer Schmerzen auf klassische Analgetika ist in der Regel schlecht. Daher werden als Medikamente erster Wahl Antikonvulsiva und Antidepressiva eingesetzt. Auch topisch applizierte Substanzen wie Capsaicin oder Lidocain und niedrigpotente Opioide finden in der Therapie neuropathischer Schmerzen häufig ihre Anwendung. Oft ist eine Kombination mehrerer Substanzen erforderlich. Die Trigeminusneuralgie sowie der zentrale Schmerz nach Schlaganfall oder bei Multipler Sklerose weisen Besonderheiten in ihrer Diagnostik und Therapie auf, welchen in Exkursen Aufmerksamkeit gewidmet werden soll.

ABSTRACT

The etiology of neuropathic pain lies in damage to the somatosensory system. It differs from nociceptive pain, in which the somatosensory system is intact, not only in its pain quality but also in its management. Peripheral neuropathic pain, for example due to polyneuropathy, is distinguished from central neuropathic pain, for example as a consequence of stroke. In the diagnosis of neuropathic pain, a distinction is made between “certain”, “probable”, “possible” and “improbable” neuropathic pain. A thorough history, which can be supplemented by questionnaires, and physical examination are required in the diagnostic process. Simple “bedside tools” can be used to identify the so-called “positive” and “negative symptoms” that are characteristic for neuropathic pain. Quantitative sensory testing (QST), methods of imaging and classical electrophysiology, as well as skin biopsy and other specialized methods can be used to confirm the diagnosis. The response of neuropathic pain to classical analgesics is usually poor. Therefore, anticonvulsants and antidepressants are used as first-line therapy. Topically applied substances such as capsaicin or lidocaine and low-potency opioids are also frequently used in the treatment of neuropathic pain. A combination of several substances is often required. Trigeminal neuralgia, as well as central pain after stroke or in multiple sclerosis have special features in their diagnosis and therapy, to which attention will be paid in excursions.

Schlüsselwörter

Neuropathischer Schmerz - Trigeminusneuralgie - zentraler Schmerz - mixed pain - Fragebögen - Bedside-Test - Quantitative Sensorische Testung - Antikonvulsiva - Antidepressiva - Opioide - topische Therapien

Key words

Neuropathic pain - trigeminal neuralgia - central pain - mixed pain - questionnaires - bedside test - quantitative sensory testing - anticonvulsants - antidepressants - opioids - topical therapies

Publication History

Article published online:
09 March 2021

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