Kompleks Bölgesel Ağrı Sendromunun Yönetiminde Girişimsel Tedaviler
Özet
Kompleks Bölgesel Ağrı Sendromu (KBAS), başlatıcı bir olayla orantısız ağrı, allodini, hiperaljezi, vazomotor, sudomotor ve motor disfonksiyonlarla karakterize klinik bir tanı olup majör sinir hasarı varlığına göre Tip 1 ve Tip 2 olarak sınıflandırılmaktadır. Tanıda Budapeşte kriterleri, klinik takibinde ise semptom ve bulguları değerlendiren CRPS Şiddet Skoru kullanılmaktadır. KBAS yönetiminde fizik tedavi, farmakoterapi ve psikoterapinin yanı sıra girişimsel ağrı tedavileri kritik bir rol oynamaktadır. Erken evrede üst ekstremite ve yüz tutulumunda Stellate ganglion bloğu uygulanırken, Kuntz sinir anatomik varyasyonlarında torakal sempatik blok, alt ekstremite tutulumlarında ise lomber sempatik blok tercih edilmektedir. Sempatik bloklara botulinum toksini ilavesi veya radyofrekans nöroliz uygulamaları klinik etkinlik süresini belirgin şekilde uzatmaktadır. Nörostimülasyon seçenekleri arasında Dorsal Root Ganglion (DRG) stimülasyonu, klasik Spinal Kord Stimülasyonuna (SKS) kıyasla ağrının rahatlatılmasında ve yaşam kalitesinin artırılmasında daha yüksek başarı oranlarına sahiptir. Tek bir majör sinirle ilişkili belirtilerde Periferik Sinir Stimülasyonu (PSS), KBAS'a bağlı distoni varlığında ise intratekal baklofen infüzyonları kullanılabilmektedir. Erişkinlerin aksine pediatrik hasta popülasyonunda sempatik blokların kanıt düzeyi düşük olduğundan erken dönemde 10-14 günlük epidural infüzyonlar önerilmekte, dirençli vakalarda SKS sonuçları umut verici bulunmaktadır. Özetle, erişkinlerde erken evre sempatik bloklar ve yanıtsız olgularda nörostimülasyon uygulamaları temel girişimsel adımları oluşturmaktadır.
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