Neuroplastizität und Schmerzchronifizierung*

Zusammenfassung.

In Tierstudien der siebziger und achtziger Jahren wurden schmerzhemmende spinale Mechanismen entdeckt, die neue Methoden der Schmerztherapie, z. B. durch Verwendung spinaler Opioide, ermöglichten. Weitere Untersuchungen im folgenden Jahrzehnt fanden eine Sensibilisierung von Rückenmarkszellen durch massive, lang anhaltende Schmerzen, den wind-up. Diese Hyperalgesie hat gleichzeitig genetische Veränderungen der Rückenmarkszellen zur Folge, die möglicherweise als „Schmerzgedächnis der Zelle” zur Chronifizierung von Schmerzen beitragen. Obwohl die klinischen Konsequenzen dieser Entdeckung nicht völlig klar sind, ist es möglich, dass durch sie in der nächsten Zeit einige unserer Standards der Narkoseführung bzw. der Behandlung akuter postoperativer, traumatischer oder krankheitsbedingter Schmerzen verändert werden müssen. Der zuverlässigste Weg zur Verhinderung der spinalen Sensibilisierung ist offenbar eine kontinuierliche und konsequente rückenmarksnahe Blockade. Alternativ kann auch versucht werden durch spezifische Transmitter oder verwandte Substanzen die Entstehung der plastischen Veränderungen zu blockieren oder zu antagonisieren. Alle über spinale Mechanismen wirkenden Maßnahmen sollten rechtzeitig zum Einsatz kommen, da im weiteren Verlauf supraspinale plastische Veränderungen in den Vordergrund rücken, zu denen auch die typischen psychischen Veränderungen der chronischen Schmerzkrankheit gehören.

Neuroplasticity and Chronification of Pain.

In the seventies and eighties spinal mechanisms inhibiting pain processing were discovered in animal studies leading to new therapeutic regimens such the use of spinal opioids. During the last decade additional studies revealed an increased sensibility of the spinal cord upon severe, long lasting pain perception, a mechanism called wind-up. Hyperalgesia is accompanied by persiting genetic changes of spinal cord cells, which may contribute to the chronification of pain. The severity and duration of acute pain apparently contributes to the possibility of chronic pain development. Although not all the consequences of these findings are clear, they may influence our way of performing anaesthesia and treating postoperative or acute pain situations, e. g. pain during herpes zoster or pain after trauma and amputation. In general, analgetic measures should be potent enough to prevent spinal sensiblisation, which can be best achieved with spinal blockade by local anesthetics. Another way of counteracting pain-induced spinal plasticity is by blocking or antagonizing its pathways with specific transmitters or their aquivalents. All these spinally mediated regimens should be performed prior to later predominating mechanisms of supraspinal plasticity involving psychic changes due to persisting pain, which seem to evolve with delay to spinal processes.

Schlüsselwörter:

Neuroplastizität - - Spinale Sensibilisierung - - Chronifizierung - - Präventive Analgesie - - Postoperativer Schmerz

Key words:

Neuroplasticity - - Wind-up - - Chronification - - Pre-emptive analgesia - - Postoperative pain

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