Nos Ãltimos anos, a prevalÃncia da hansenÃase no Brasil vem sendo reduzida, entretanto, o nÃmero de pessoas com incapacidades resultantes de neurite crÃnica continua alto. O tratamento padrÃo da neurite hansÃnica se constitui de corticoterapia oral. Em casos resistentes à corticoterapia, pode ser realizada intervenÃÃo cirÃrgica descompressiva, denominada neurolise. Dados sobre a efetividade da neurolise sÃo escassos na literatura. Com o objetivo de avaliar o dÃficit sensitivo-motor antes e apÃs neurolise, realizou-se um estudo retrospectivo. Foram incluÃdos portadores de hansenÃase submetidos à neurolise na referÃncia estadual de RondÃnia, nos anos de 2000 a 2003. Dados sÃcio-demogrÃficos e clÃnicos foram coletados do livro de registro de cirurgias do hospital, dos prontuÃrios e da base de dados do Sistema Nacional de Agravos de NotificaÃÃo. Para avaliar o grau de comprometimento sensitivo e motor, foram criados escores ordinais baseadas nas avaliaÃÃes clÃnicas . Dos 118 indivÃduos incluÃdos, que foram submetidos a 297 neurolises, 74 (62,7%) eram do sexo masculino, noventa e seis (81,4%) foram classificados como portadores da forma clÃnica dimorfa. Somente (53,4%) estavam em tratamento com poliquimioterapia no momento da cirurgia. A mediana do tempo entre o primeiro episÃdio de neurite e a neurolise foi de um ano (mÃximo = 12,3 anos). A mediana do escore semi-quantitativo sensitivo diminuiu de 5 para 3 (nervo ulnar), de 3 para 2 (nervo mediano), e de 9,5 para 7,5 (nervo tibial posterior; todos p<0,001). Noventa por cento dos pacientes com dÃficit sensitivo grave do nervo ulnar antes da cirurgia apresentaram um escore melhor apÃs a cirurgia. Na anÃlise, um escore sensitivo alto do nervo ulnar (OR ajustada = 1,9; IC 95%: 1,37 â 2,65; p<0,001) e do nervo tibial posterior antes da cirurgia (OR ajustada = 1,2; IC 95%: 1,02 â 1,39; p = 0,02), aumentaram a chance da melhora. O tempo entre o primeiro perÃodo de neurite e a cirurgia nÃo modificou o resultado clÃnico de forma significativa. Similar à avaliaÃÃo sensitiva, o escore motor dos nervos ulnar e fibular melhorou significativamente (ulnar: p = 0,03; fibular: p<0,001). Quase 60% dos pacientes submetidos à neurolise no nervo fibular apresentaram maior forÃa muscular apÃs a cirurgia. Os dados do estudo indicam que a neurolise à benÃfica em casos de neurite hansÃnica, mesmo apÃs um perÃodo prolongado de neurite. Faz-se necessÃrio elaborar estratÃgias para aperfeiÃoar a terapia da neurite hansÃnica com Ãnfase no monitoramento da funÃÃo neural. / In Brazil, the prevalence of leprosy has been reduced in the last years. However, there are still many people living with disabilities, resulting from chronic leprosy neuritis. Oral corticosteroid therapy is the standard treatment of neuritis. In case of unsuccessful treatment, a surgery, the so-called neurolysis, or external decompression, may be indicated. Data about the effectiveness of neurolysis are scanty. To assess the degree of sensory and motor loss before and after neurolysis, we performed a retrospective study. Leprosy patients were included, that had received neurolysis of peripheral nerve trunks in the reference hospital of RondÃnia State (North Brazil), between 2000 and 2003. Socio-demographic and clinical data were collected from the hospitalâs registry of surgeries, from patientsâ charts and from the Notifiable Diseases Database (âSistema Nacional de InformaÃÃo de Agravos de NotificaÃÃoâ). To assess the degree of sensory and motor deficiencies, we created an ordinal score based on the clinical evaluations. Of the 118 individuals included (in total 297 neurolyses), 74 (62,7%) were males. Ninety-six (81,4%) patients were classified clinically with borderline leprosy. Only (53,4%) of the patients were under multi-drug therapy at the moment of neurolysis. The median time between the first episode of neuritis and the surgery was one year (maximum = 12,3 years). The median of the score reduced from 5 to 3 (ulnar nerve), from 3 to 2 (median nerve) and from 9,5 to 7,5 (posterior tibial nerve; all p<0,001). Ninety % of patients with severe sensory deficiency before surgery presented with an improved score after neurolysis. In the multivariate analysis, only the sensitive score of the ulnar nerve (adjusted OR = 1,9; 95% CI: 1,38 â 2,65; p<0,001) and the sensitive score of the posterior tibial nerve (adjusted OR = 1,2; 95% CI: 1,02 â 1,39; p = 0,02) before surgery were factors increasing the chance of improvement. The clinical classification and the period between the first episode of neuritis and surgery did not modify the clinical result significantly. Similar to the sensory evaluation, the motor score of the ulnar and common peroneal nerves improved significantly after surgical intervention (ulnar nerve: p = 0,03; comnor peroneal nerve: p<0,001). Almost 60% of the patients operated on the common peroneal nerve presented more muscle strength. The data of the present study indicate that neurolysis is of important benefit in leprosy neuritis, even after a prolonged period of neuritis. Strategies need to be elaborated to improve the therapeutic options in the treatment of leprosy neuritis.

Au cours des 20 dernières années, l'utilisation de méthode de guidage par imagerie s'est progressivemen imposé comme gold standar dans nombre d'indications Interventionel antidouleur. Les modalités de guidage els plus utilisés sont la fluoroscopie et l'échographie. Le Scanner est relativement sous-utilisé dans le domaine de la prise en charge interventionnelle de la douleur, principalement en raison des difficultés d'accès et de Disponibilités pour les praticiens de la douleur. Au travers de cette thèse, nous avons montré l'intérêt du guidage scanner dans plusieurs indications avec de bons résultats, grâce à des techniques innovantes* L'Évaluation de l'alcoolisation percutanée du ganglion sphéno-palatin dans la prise en charge de ladouleur cranio-faciale réfractaire, chez 42 patients avec taux d'efficacité globale d'alcoolisation du GSP de67,2% et une durée moyenne de soulagement de la douleur de 10,3 mois. L'analyse a montré un tauxd'efficacité élevé chez les patients avec des algies vasculaires de la face (76,5%) et des syndromesdouloureux faciaux persistent (85,7%)* L' Évaluation de l'efficacité d'un méthode simplifiée d'infiltration sous scanner du nerf grandoccipital (NGO) chez 33 patients souffrant d'une névralgie occipitale avec taux de succès clinique de 86%.En cas de succès clinique, la durée moyenne de soulagement de la douleur suivant la procédure était de9,16 mois.*La comparaison deu block vs. neurolyse par radiofréqence du ganglion stellaire sous guidage scannographique dans la prise en charge du Syndrome Douloureux Régional Complexe de Type 1 du membre supérieur chez 67 patients: on retrouve une efficacité supérieure dans le groupe RFN (67,6%, 23/34) par rapport au groupe de block (21,2%, 7/33) avec un OR de 7,76.* L'Évaluation de la neurolysepar RF des nerfs ilio-inguinal et ilio hypogastrique chez les patients souffrant de douleurs ilio-inguinal et à l'aine réfractaire.• pouvait conduire à une amélioration des résultats. Dans tous les cas, le guidage par Scanner est une valeur ajoutée dans certaines indications, car elle permet en toute sécurité, le placement précis, millimétrique, de l'aiguille. Une autre solution possible afin de réduire les risques liés à certains gestes serait le développement d'une L'Étude préliminaire sur 16 patients traités par RFN a montré une réduction significative dela douleur après RFN pendant 11,8 mois.• Une deuxième étude a été menée permettant de comparer l'efficacité de la RFN et à cellede l'infiltration dans la même indication chez 42 patients: La durée moyenne de soulagementde la douleur était statistiquement supérieure (P = 0,005) dans le groupe RF (12,5 mois)comparé au groupe d'infiltration (1,6 mois).Au cours de ces études publiées, nous avons montré que l'application d'une technique existante (neurolyse, infiltration) à une nouvelle indication, ou la modification d'une technique existante après des considérations anatomiques sonde de radiofréquence unidirectionnel, capable de créer une zone d'ablation en demi sphère dont l'orientation serait contrôlable, ce qui permettrait de réduire les risques d'ablation non désirée.Enfin, il est important de rappeler, que la prise en charge interventionnelle de la douleur d'un patient s'intègre dans une prise en charge globale, centrée autour du patient. Ainsi, la prise en charge d'un patient douloureux ne pourra se faire de manière efficace qu'en prenant en compte l'ensemble des aspects de la douleur exprimé par le patient, bien au delà des seules considérations techniques d'un geste interventionnel. / Over the past 20 years, the use of imaging guidance has progressively but very rapidly evolved to become a standard practice to date, with fluoroscopy and Ultrasound being the most popular imaging guiding tools. However, CT guidance is relatively underused in the field of Interventional pain management, mainly due to acces and availabilty issues for pain physicians. Therefore, the objective of this thesis are mulitple :* to evaluate the usefulness of CT scan guidance, in applying existing neurolytic techniques(block.infiltration and neurolysis) to innovative indications, allowed by the use of such an imagingguiding tool.* to evaluate the clinical effectiveness of these novel indications* Finally, to emphasize on the importance of the clinical aspects of Interventional pain managementAfter after having reminded the definitions of the different existing techniques (neural blocks, infiltration, neurolysis) and detailed existing materials (Local anesthestics, Steroids, Chemical Neurolysis, Physical Neurolysis), a brief description of existing indication of Interventional Pain will be made. Emphasis will then be made on the assessment of innovative interventional CT Guided pain techniques in various refractory pain syndromes :- Evaluation of Alcohol percutaneous neurolysis of the sphenopalatine ganglion in the management of refractory cranio facial pain , in 42 patients : overall efficacy rate of alcohol SPN was 67.2% with a mean pain relief duration of 10,3 months. Analysis showed a higher efficacy rate in patients with Cluster Headaches (76.5%) andPersisting Facial Idiopathic Pain (85.7%)- Evaluation of the efficacy of a simplified CT guided greater occipital nerve (GON) infiltration approach inthe management of occipital neuralgia (ON) in 33 patients : Clinical success rate was 86%. In case of clinicalsuccess, mean pain relief duration following procedure was 9.16 months.- Evaluation of CT-guided Stellate Ganglion Blockade vs. Radiofrequency Neurolysis in the Managementof Refractory type I Complex Régional Pain Syndrome of the Upper Limb in 67 patients : analysis performed onthe blockade and RFN groups showed a significantly (P<0.0001) higher success rate in the RFN group (67.6%,23/34) compared with thé blockade group (21.2%, 7/33) with an OR of 7.76.- Evaluation of CT Guided ilio inguinal (II) and ilio hypogastric Radiofrequency Neurolysis (RFN) inpatients with refractory ilio-inguinal and groin pain.* Preliminary Study on 16 patients treated with II RFN showed significant pain reductionafter RFN with a mean pain relief of 11,8 months.* A second study was conducted to compared the effectiveness of RFN and Infiltration in thesame indication in 42 patients : Mean duration of pain relief was statistically significant (P = .005)in the RF group (12.5 months) compared to the infiltration group (1.6 months).Throughout these published studies, we hâve shown that the application of an existing neurolytic technique in a new indication, or modifying an existing technique after anatomical considerations may lead to either higher efficacy rates, longer pain reliefs, or safer procedures. In ail cases, CT guidance is an added value to any procédures as it allows safe, précise accurate and effective needle placement in most procedures. Another possible solution to reduce procedure related risks discussed in this thesis, is the development of a unidirectional radiofrequency probe, capable of producing tissue destruction only on one half on the probe thereby creating a half mooned shaped thermal zone, which would reduce the risk of surrounding unwanted tissue damage. This topic merits further studies and development as possible everyday implications are numerous .

Background It is possible that interruption of nociceptive input from intervertebral discs can be modulated through bilateral L1 and L2 dorsal root ganglia (DRG) blockade. In order to test this hypothesis, we prospectively collected data from patients with low-lumbar pain, accurately diagnosed as discogenic using provocation discography. Methods Twelve patients were recruited with a mean (SD) symptom duration of 13.7 (8.2) years. Bilateral DRG blocks of L1 and L2 were performed using methylprednisolone 80 mg, clonidine 75 µg and 0.5% bupivacaine 4 ml in each patient. Results Analysis of Brief Pain Inventories showed no significant change in pain scores. Conclusion We conclude that blocks of this nociceptive pathway in humans using bilateral DRG blocks has no therapeutic value.