Pain Medicine 2014; *: **–** Pain Medicine 2015; Wiley Periodicals, Inc.16: 374–382 Wiley Periodicals, Inc.

NEUROPATHIC PAIN SECTION Postbariatric Surgery Neuropathic Pain (PBSNP): Case Report, Literature Review, and Review Article Treatment Options Postbariatric Surgery Neuropathic Pain (PBSNP): Case Report, Literature Review, and Treatment Options Vasanth Kattalai Kailasam, MD,* Claricio DeCastro, MD,† Claude Macaluso, MD,‡ and Anne Kleiman, DO§ Departments of *Psychiatry, †Anesthesiology/Pain Service, ‡Internal Medicine/Neurology Service, Harlem Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York; § Department of Internal Medicine/Neurology Service, Harlem Hospital Center, New York, New York, USA Reprint requests to: Vasanth Kattalai Kailasam, MD, Harlem Hospital Center, 16 West 137th Street, WP 539, New York, NY 10037, USA. Tel: (201) 687-6039; Fax: 212-939-2175; E-mail: [email protected]. Disclosure: The study abstract was presented as a poster at the 30th Annual Scientific Meeting of the American Academy of Pain Medicine, Phoenix, AZ, March 2014. Each author certifies that neither he or she, nor a member of his or her immediate family, has a commercial association (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements) that might pose a conflict of interest in connection with this manuscript.

Results. The epidemiology of PBSNP has not been well established, and current therapeutic options are not evidence based. Available data indicate up to 33% incidence of pain in patients with neuropathy after bariatric surgery, resulting in significant decreases in quality of life and increases in health care costs. Pathophysiologic mechanisms underlying PBSNP are unclear, and the natural course is variable, with some patients experiencing spontaneous improvement when nutritional deficiency is identified and corrected. Early identification of nutritional deficiency along with glycemic and lipid control may prevent or partially reverse postsurgical neuropathy and modulate PBSNP. Conclusions. A better understanding of the peripheral and central mechanisms resulting in PBSNP is likely to promote the development of targeted and effective treatments. Key Words. Pain; Neuralgia; Bariatric Surgery Neuropathy; Pharmacokinetics

Introduction Abstract Objective. This study is aimed at facilitating clinician understanding of factors associated with postbariatric surgery neuropathic pain (PBSNP) and discussing the evidence base for management options. Design. A case report and systematic literature review. Methods. A search was conducted of PubMed, MEDLINE, Google Scholar, EMBASE, Psych Info, and Cochrane Database of Reviews for articles published between 1985 and 2013 on neuropathy, pain, and pharmacokinetics associated with postbariatric surgery.

374

Obesity is a major health problem in the United States, with a prevalence that grew from 19.4% in 1997 to 28.9% in 2012 [1]. Bariatric surgery, a term derived from the Greek word bari, meaning weight, has grown in popularity, particularly since the 1990s, to the point where a substantial proportion of the population is living postbariatric surgery (PBS). In 2011 alone, an estimated 340,768 adults globally had bariatric surgery [2]. Gastric bypass has been associated with decreased mortality: A review in the New England Journal of Medicine found that patients who had undergone gastric bypass surgery compared with a severely obese control group had a 40% decrease in adjusted long-term mortality from any cause during a mean follow-up of 7.1 years [3]. However, despite being widely regarded as safe, bariatric procedures exploit malabsorption and restricted volume intake, 1

Postbariatric Surgery Neuropathic Pain

Kattalai Kailasam et al. which can result in acute, subacute, and chronic complications. New onset neuropathy is one of several neurological complications reported in PBS patients [4–14]. However, the epidemiology of PBS neuropathic pain (PBSNP) has not been extensively studied. Only limited data are available regarding the processes leading to cellular damage in the nervous system as a result of bariatric surgery, and the mechanisms specific to pain in PBSNP have not been identified. Furthermore, neurophysiologic and pathologic parameters do not differentiate between painful and painless neuropathy. Additionally, the cause for mononeuropathy and radiculoplexopathy, with and without pain PBS, has not been successfully elucidated thus far. Once diagnosed, PBSNP poses a unique challenge for management and could have debilitating consequences that significantly impact quality of life. To demonstrate these issues, we present a case report of a patient with PBSNP, myelopathy, and associated copper deficiency diagnosed 1 year after gastroplasty. Case Report A 59-year-old woman underwent bariatric surgery in February 2013, with a preoperative body mass index (BMI) of 52.2 kg/m2. Her medical and psychiatric histories were significant for HIV without highly active antiretroviral therapy, hypertension, persistent Helicobacter pylori, and mood disorder. Four months after the surgery, she developed difficulty in feeding herself due to stomach pain, intolerance to solid foods, and episodes of nausea and vomiting. The patient had a lap mesh repair of hiatal hernia and cholecystectomy in July 2013. Approximately 8

months after the bariatric surgery, she developed pain, numbness, tingling, weakness, and subsequent compromise of the lower limbs, which worsened progressively so that she needed support to walk. Her postoperative course was complicated with multiple hospitalizations for nausea, vomiting, and hypokalemia. The patient was fairly consistent in following the bariatric clinic and nutrition supplement regimen after surgery. On January 2014, during her sixth hospitalization, she presented with refractory nausea and vomiting with weakness and pain of both lower limbs. Her neurological examination was significant for upper extremities with reduced strength bilateral (4/5), proximal > distal; lower extremities weakness distal > proximal; and generalized mild hyperreflexia. Her sensation was intact, and her vibration sense was diminished for both feet. An impression of myelopathy was made. The patient complained of severe pain in her right lower extremity and moderate-to-severe pain in the right knee that radiated to the medial aspect of the distal 1/3 of the right thigh and was associated with allodynia. Initial blood laboratory values at hospital admission revealed normocytic, hypochromic anemia, markedly low serum copper:

Postbariatric surgery neuropathic pain (PBSNP): case report, literature review, and treatment options.

This study is aimed at facilitating clinician understanding of factors associated with postbariatric surgery neuropathic pain (PBSNP) and discussing t...
136KB Sizes 0 Downloads 4 Views