Kauzalgiya — the intensive burning pain which is followed by local vasomotorial, trophic, motive frustration. Arises at damage of peripheral nerves of various etiology. Proceeds with touch violations: giperesteziya, giperpatiya, allodynia. It is diagnosed on compliance to clinical criteria at identification of defeat of a nervous trunk by results of ENMG and an exception of other possible reasons of pain. Treatment of a kauzalgiya complex, includes pharmacotherapy, medical blockade, physiotherapeutic techniques, psychotherapy, LFK, a gidrokinezioterapiya.
Kauzalgiya was for the first time described in 1855 by N. I. Pirogov under the name "traumatic giperesteziya". The term "kauzalgiya" was published in 1864 in the book of the American doctor V. Mitchell and group of the coauthors studying during the civil war in the USA a pain syndrome at gunshot wounds of extremities. In 1900 the German surgeon Paúl Zudec described secondary post-traumatic trophic violations in an extremity. Similarity of a clinical picture of a kauzalgiya and Zudec's syndrome is revealed in the middle of the 20th century. In 1988 it was offered to replace with the International association of pain the term "kauzalgiya" with more accurate information – the complex regional pain syndrome (CRPS). According to the European researches, prevalence of KRBS makes 26 cases on 100 thousand of the population, women suffer 3,5 times more often than men.
In 80-85% of cases of KRBS it is caused by traumatizing an extremity, including during surgeries. Act as additional etiofaktor: wrong repozition of a change, insufficient anesthesia, excessively long immobilization, hard imposing of plaster. Carry KRBS options arising owing to direct defeat of a peripheral nervous trunk (KRBS of the 2nd type) to a kauzalgiya. Are associated with development of a kauzalgiya by triggers:
- Injury of a nerve: contusion, compression, concussion, full or partial interruption. Injuries of peripheral nerves are noted at fractures of extremities, dislocations, wounds, operations. Kauzalgiya arises owing to irritation of a nerve, violation of its trophic function. In case of full interruption of a nervous trunk the pain syndrome has the central mechanism similar to phantom pain.
- Tunnel syndromes: the tunnel neuropathy of a beam nerve, a syndrome of a carpal tunnel, a tunnel neuropathy of a low-tibial nerve, etc. Kauzalgiya is caused by a compression of a nervous trunk in the narrow anatomic tunnel formed by bones, ligaments, muscles. At an arrangement of a vascular bunch near a nervous trunk defeat of tissues of nerve has an ischemic component.
- Radiation therapy. Local radiation is carried out concerning tumors of bones, new growths of soft fabrics, rheumatic diseases. Nervous tissue is very sensitive to the radioactive radiation therefore the radiotheraphy has the damaging effect on peripheral nerves.
- Vascular disorders. Vein thromboses at varicose veins, occlusion of peripheral arteries at the obliterating atherosclerosis, the obliterating endarteriit, a vaskulita lead to disorder of blood supply of a nervous trunk. Owing to chronic insufficiency of blood circulation ischemic neuropathy develops.
- Infections. The brucellosis, herpes, HIV, diphtheria often proceed with involvement of nervous trunks, textures, spinal backs. Kauzalgiya is caused by the inflammatory changes arising at damage of nerves by infectious agents.
The mechanism of development of a kauzalgichesky syndrome is definitely not defined. The paramount role of the irritating influence of an etiofaktor and involvement in pathological process of vegetative fibers is supposed. The neurogenetic aseptic inflammation which is result of release in a zone of damage of biologically active agents (a histamine, prostaglandins, tsitokin) acts as the integral component of the mechanism of developing of pain.
The afferent impulsation comes to a spinal cord, then to a thalamus and cerebral bark. The Notsitseptivny giperimpulsation causes formation in bark of focus of the increased excitement which supports further synchronization of a pain syndrome. The theory of participation of the central structures in the mechanism of emergence of pain is confirmed by the fact that the kauzalgiya is possible at full interruption of diameter of a nerve. The trophic frustration accompanying a pain syndrome are caused by dysfunction of the affected nerve, its vegetative fibers. In the sharp period they lead to vasomotorial violations, in the subsequent — to dystrophic and atrophic changes of the innervated fabrics.
According to clinical options the kauzalgiya is classified on disteel (Zudek's syndrome), proximal (cervicobrachial) and widespread — the covering all extremity (a syndrome "shoulder brush"). Development of KRBS takes place several phases which understanding is necessary for the correct choice of medical tactics. During a disease allocate three main stages:
- Sharp (2-6 weeks). The constant kauzalgiya against the background of the expressed vasomotorial frustration is noted. It is observed swelled, hyperaemia.
- Dystrophic (from 6 weeks to 6 months). It is characterized by reduction of a pain syndrome, emergence and increase of a rigidnost of joints up to formation of contractures. The hypertrophy, the lowered elasticity, skin comes to light.
- Atrophic (more than 6 months). The progressing atrophy of fabrics, dryness, pallor of skin, an ankiloza of joints is found. The pain syndrome usually is absent.
The clinical picture consists of painful, vasomotorial, trophic, motive components. In the sharp period the burning, baking pain which duration does not correspond to etiologichesky influence is noted. Pain is provoked by any irritants (a touch, the movement), often arises without the previous trigger. Intensity of a pain syndrome average or expressed. Patients point to decrease in pain when moistening of the affected extremity. The gigromaniya symptom is typical – patients keep an extremity in water, apply wet bandages.
Touch frustration are characteristic: a giperpatiya — emergence of discomfort at harmless influences (for example, stroking), allodynia — perception of any influences as painful, a giperalgeziya — hypersensibility to painful irritations. Vasomotorial dysfunction is followed by puffiness of fabrics. Swelled covers disteel departments of an extremity, causes a smoothness of the skin drawing. A hypostasis consistence pasty, in the subsequent – more dense.
The vegetative and trophic component is presented by two options. The first is shown by hyperaemia, increase in local temperature, gipergidrozy, the accelerated growth of hair, nails, the second — tsianotichesky pallor, a hypothermia, angidrozy, the slowed-down growth of appendages of skin. Kauzalgiya duration before half a year is characterized by the first type of trophic violations, over half a year — the second. Motive frustration at the initial stages of a disease are connected with a pain syndrome, damage of motive nervous fibers. In process of progressing of symptomatology dystrophy of muscular tissue, a contracture of joints begins to play the leading role in restriction of movements. Peripheral sluggish paresis of the muscles innervated by the affected nerve is noted. Existence of a tremor, convulsive twitchings, feelings of constraint of movements is possible.
Kauzalgiya sharply reduces working ability of patients, in lack of treatment leads to a resistant invalidization. The expressed pain syndrome in some cases is complicated by pathological changes of character. Patients become gloomy, closed, inclined to a depression or, on the contrary, excited, irritable up to affective states. Possible anorexia, lack of good nutrition are followed by a kakheksiya, hypovitaminosis. Formation of articulate contractures and ankiloz leads to the full irreversible restriction of movements permanent to the compelled position of an extremity.
The instruction on a trauma in the anamnesis, compliance of symptomatology to clinical criteria, confirmation of damage of a nerve and an exception of other reasons of a pain syndrome is of great importance. As the international standard the clinical criteria of 2004 developed in Budapest are accepted, their sensitivity makes 85%, specificity — 69%. The main stages of diagnostics are:
- Objective survey. It is carried out by the traumatologist, the therapist, the neurologist. Confirms swelled, hypersensibility, various coloring and skin temperature of the struck area and symmetric site of the healthy party. Restriction of movements is defined.
- Consultation of the neurologist. Diagnoses local disorders of sensitivity (a giperalgeziya, a giperpatiya, allodynia), decrease in a tone and force of muscles, oppression of tendinous reflexes. Degree of paresis depends on weight of injury of a nerve, prescription of a disease.
- Elektroneyromiografiya. Reveals change of speed and amplitude of potentials of action. Allows to exclude primary muscular disease, to establish the fact and the level of injury of a nerve, to estimate its weight.
- Joint X-ray analysis. Detection of the large centers of osteoporosis is possible. In need of specification of the diagnosis joint KT is carried out. Determination of density of a bone tissue is carried out by means of densitometry.
- Biochemical blood test. Definition of calcium, a paratgormon, blood calcitonin is made for studying of a condition of mineral exchange. At normal indicators the dismetabolichesky, endocrine nature of pathology is excluded.
Kauzalgiya is diagnosed at compliance of clinical symptomatology to the minimum diagnostic criteria, confirmation of damage of a nerve according to ENMG. Differential diagnostics is necessary for detection of nature of causal pathology. The post-traumatic kauzalgiya is differentiated from a tumor of a nerve, infectious and inflammatory, radiation, dismetabolichesky, ischemic injury.
Treatment of a kauzalgiya
The combined therapy including drug treatment, physical therapy, a kinezioterapiya, psychotherapy is shown. Appointments are selected according to an etiology, a stage of a current of KRBS, the prevailing symptoms. Treatment in the sharp period is presented by the following components:
- Anti-inflammatory therapy. It is carried out in the presence of inflammatory changes. It is carried out by nonsteroid resolvents, in hard cases — glucocorticosteroids.
- Knocking over of pain. Usual anesthetics can be effective at average expressiveness of pain. Perhaps temporary purpose of narcotic analgetics, carrying out medical blockade with local anesthetics. At the expressed giperalgeziya antikonvulsant give good effect.
- Treatment of osteoporosis. Radiological the confirmed osteoporosis is the indication to application of a calcitonin, the biofosfanat inhibiting a bone resorption. In addition use calcium medicines, vitamin D.
- Psychotropic therapy. Antidepressants, anksiolitik remove alarm, reduce irritability and concern, exponentiate analgetic effect, reducing activity of opioid endotelialny system. The pharmacotherapy is supplemented with psychotherapeutic occupations with the psychologist, the psychotherapist.
- Physical therapy. Apply an electrophoresis with analgetics to elimination of a pain syndrome, , an elektroanalgeziya, an electrodream, reflexotherapy. The positive effect is rendered by UVCh, an amplipulsterapiya.
- Kinezioterapiya. The early beginning of LFK is recommended. In the sharp period of exercise are carried out by a counterlateral extremity. Further at the expressed paresis the passive gymnastics for joints is shown. The gidrokinezoterapiya gives good effect.
In the dystrophic period complex therapy includes pharmacotherapy, reflexotherapy, a gidrokinezioterapiya. In an atrophic stage infiltration therapy by proteolytic enzymes, mud cure, radonic bathtubs is carried out. From methods of surgical treatment the simpatektomiya is effective. Nerve operations (, , a neyrotomiya) are capable to provoke strengthening of pain.
Forecast and prevention
Kauzalgiya can have the favorable forecast at the early beginning and the complex nature of therapy. In 75% of cases at local changes the tendency to expansion of a zone of defeat is noted. Without treatment the disease progresses to an atrophic stage, contractures and ankiloza of joints lead to an obezdvizhennost of an extremity, disability of the patient. Preventive actions are directed to the prevention of the damaging impacts on peripheral nervous trunks. Important preventive value has observance of the technology of surgical interventions, correct treatment of changes and reposition of dislocations.