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Zentrale Schmerzverarbeitung bei funktionellen somatischen Syndromen

CNS processing of pain in functional somatic syndromes

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Zusammenfassung

Funktionelle Schmerzsyndrome sind in der Regel gekennzeichnet durch eine erhöhte lokale oder generalisierte Schmerzempfindlichkeit, spontane Schmerzen und eine Vielzahl variabler begleitender Symptome. Die Einteilung oder Zuordnung der Syndrome bezieht sich meist auf den Ort der Hauptbeschwerden oder das Hauptsymptom, eine Überlappung der Symptomatik findet sich jedoch häufig. Weitere Hinweise für eine mögliche Beteiligung des zentralen Nervensystems (ZNS) sind häufige komorbide affektive Störungen, Beeinträchtigungen der Kognition, Veränderungen der neuroendokrinen Funktion und eine Dysregulation des autonomen Nervensystems, wobei diese Störungen immer nur bei einem Teil der Betroffenen vorliegen. Ergebnisse der funktionellen Bildgebung liefern weitestgehend plausible Korrelate für die geklagten subjektiven Beschwerden und weisen auf eine zentrale Augmentation in der Schmerzverarbeitung und anderen sensorischen Systemen einschließlich des postulierten Systems der interozeptiven Regulation hin. In der pathophysiologischen Zuordnung dieser Augmentation gibt es keinen einheitlichen Befund, die Bedeutung peripherer Faktoren bleibt unklar, ebenso wie die genaue Rolle spinaler und supraspinaler Mechanismen. Kognitive und affektive Faktoren beeinflussen die Schmerzverarbeitung, erklären aber die beschriebene Augmentation nicht. Beim Fibromyalgiesyndrom (FMS), beim chronischen Rückenschmerz und dem Reizdarmsyndrom gibt es Hinweise auf eine Dysfunktion der deszendierenden Hemmung. Longitudinale Studien sind notwendig, um die Kausalität der beschriebenen Zusammenhänge und eine primäre Störung im ZNS zu sichern. Aktuelle Methoden (VBM, H-MRS) haben strukturelle und lokale metabolische Veränderungen des ZNS bei vielen der Syndrome nachgewiesen, die Konsequenz und klinische Relevanz bleiben derzeit noch offen. Neue theoretische Konzepte bieten einen Rahmen, um interdisziplinäre, prospektive und hypothesengetriebene Forschungsansätze zu entwickeln, um das ganze Potenzial der Methoden der funktionellen Bildgebung zu nutzen.

Abstract

Functional pain syndromes usually are characterized by a local or generalized increase in pain sensitivity, spontaneous ongoing pain, and a variety of other common symptoms. Classification or definition of a syndrome is usually somewhat arbitrarily based on the predominantly affected body region or a main symptom, resulting in significant overlap between conditions. Support for the involvement of the central nervous system (CNS) comes from the frequent comorbidity of affective disorders and symptomatology, disturbances in cognitive function, changes in neuroendocrine function, and dysregulation of the autonomic nervous system, although only subgroups of patients are affected. Findings of neuroimaging studies in functional pain syndromes typically reveal plausible correlates for the patients’ subjective complaints and indicate a central augmentation in pain processing but also in other sensory systems including a postulated interoceptive system. The pathophysiology of this augmentation is not clear, and the importance of peripheral input remains unresolved, as well as the contribution of spinal and supraspinal mechanisms. Affective and cognitive factors clearly influence pain processing in these syndromes, but do not fully explain the observed augmentation. For FMS, chronic low back pain, and irritable bowel syndrome a dysfunction of the descending inhibitory systems is supported by these findings. However, longitudinal studies are needed to confirm the causality of the reported associations and to establish a primary role of the CNS in these syndromes. Current techniques like VBM and H-MRS have revealed potential yet highly variable structural abnormalities of the CNS in several of the syndromes, but clinical relevance and conclusions from these studies remain far from clear. New theoretical concepts should drive prospective and interdisciplinary research based on well-defined hypotheses to use the full potential of the current neuroimaging techniques.

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  1. Schmerzzentrum, Klinik für Anästhesiologie und Operative Intensivmedizin, Uniklinik Köln, Lindenthal, 50924, Köln, Deutschland

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Petzke, F. Zentrale Schmerzverarbeitung bei funktionellen somatischen Syndromen. Schmerz 24, 146–155 (2010). https://doi.org/10.1007/s00482-010-0903-5

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