Pierre Sprumont

Who has never suffered from pain? It does not matter if this pain was physical or emotional. Oh God, and how difficult it is to describe it! Many times the people around us do not seem to understand the extent of our pain. And this is legitimate. Each one interprets his/her pain according to his/her own threshold of pain, but also, in relation to previous experiences of pain. These experiences are either from situations we have lived ourselves or from the observation of the suffering of others.

La troisième édition de l’Atlas des territoires cutanés pour le diagnostic des douleurs neuropathiques vient de paraître chez Sauramps Médical. Les deux premières avaient été préfacées par Bernard Moxham (Cardiff, Royaume-Uni) et par Stephen Carmichael (Rochester, États-Unis), celle-ci l’a été par John Fraher (Cork, Irlande). À partir de 2519 patients et des données de 97 ouvrages d’anatomie consultés, les auteurs définissent les territoires cutanés des nerfs spinaux et de leurs branches principales en précisant les bornes limitrophes de leur territoire maximal de distribution, et leur territoire autonome, qu’elles ne partagent avec aucun autre nerf.

Clinicians and researchers work hand in hand to investigate and understand functions und dysfunctions of pain. So could we dream of a life without pain ? Certainly not, when it comes to its function as a necessary protection mechanisms that accompanies us through our development. But when it comes to pain that becomes a conqueror who invades our bodies we dare to dream of a life without it.

Comme première conclusion, les mécanismes de sensibilisation dans la corne postérieure de la moelle épinière (Kohama et al., 2000 ; Sukhotinsky et al., 2004 ; Todd & Koerber, 2006) sont qualifiés parfois de périphériques (Woolf & Salter, 2000 ; Chiu et al., 2012 ; Devor, 2013) et plus fréquemment de centraux (Schweinhardt, 2006 ; Bennett, 2012). Les deux points de vue ne sont pas faux, mais reflètent chacun des concepts différents – de leur dénotation à leur univers de sens. Nonobstant, le lecteur peut s’y perdre, c’est pourquoi nous proposons - pour éviter tout malentendu – de spécifier la région anatomique de la sensibilisation : mécanismes de sensibilisation spinale, supra-spinale et/ou corticale.

Comme deuxième conclusion, la théorie de la porte abandonne la notion de douleur purement sensorielle et véhiculée directement au cerveau. Bien qu’elle ne rende pas compte de certains mécanismes cérébraux de la douleur, elle présente une conception dynamique de celle-ci : elle intègre d’autres dimensions de la personne, bien au-delà du dualisme corps-esprit (Le Breton, 2017). C’est seulement ainsi que nous pouvons tracer un chemin qui tente d’appréhender le phénomène de la douleur UNIQUE de chaque patient, qu’elle persiste ou non dans ses dimensions biologique, psychologique, sociale et interpersonnelle.

For the Ancient Greeks, anatomy was the study of the body through dissection. The word itself derives from its Greek origin: ἀνὰ (ana) for <upon> and τέμνειν (temnein) for <to cut> gave in Greek ἀνατομὶα (anatomia) for anatomy and ἀνατομὴ (anatomê) for dissection. But anatomical terms were older.

Taking the analogy of human development, anatomical terminologies have taken 4,000 years to reach puberty. By the time of the advent of the Renaissance, they were just about ready to adapt to the accelerating pace of discovery for both descriptive and functional anatomy. When one considers the relatively long time taken for their evolution, one realises that it was the result of the activity of many types of professional persons, not only within medicine and surgery, but within philosophy and linguistics as well. Furthermore, priests, cooks and butchers, warriors, and even magicians should be included in this list of players.

The first people to use anatomical terms were the embalmers who dared to touch human bodies, the priests who claimed to be able to read the future in the entrails of animals and the magicians who prepared amulets and healing charms from various human, animal or plant components. Anatomy was thus spoken with the numerous dialects formed from archaic beliefs and religions. Early Egyptians and Mesopotamians were among those who began to give more specific names to parts of the body, yet it remained difficult to always understand them as they considered that each part or organ of the body was inhabited by a specific god. Were they perhaps naming the god or the organ? At the very least, they then were writing down what they spoke and thus we in our time can, more or less, read them.

A new language meanwhile unfolded in the South East corner of Europe as the Ancient Greeks began to understand each other's dialects and to write a literature that was to inspire mankind ever after. During the 8th century BCE, a great writer, Homer, wrote some epic poems that still exert their charm and included aspects of anatomy.  From this point, the development of anatomical terminology accelerated. Amongst many others, Hippocrates and his medical students in the 5th century BCE and later Aristotle in the 4th century BCE belonged to those who inspired the creation of the Library and School of Alexandria at the end at the 4th century BCE. Greek physicians were famous all over the Hellenic world, which included Asia Minor. Medicine, and thus anatomy, spoke Greek.

An important milestone in anatomy was planted by Herophilos and Erasistratos who independently at the beginning of the 3rd century BCE were the first physicians to perform human dissections. In addition, 350 years later, in the early 2nd century CE, the Greek physician Rufos completed writing a book that is widely understood to be the first systematic compendium of anatomical terms.

Greek at that time was still the language of medicine but Latin had superseded it in terms of political and linguistic influence. This meant that pure translators, such as Celsus who was a literary polymath, began to play a major role during the first years of the Christian era. Nevertheless, it was still through the medium of Greek that Galen captivated the world byproducing an immense medical literature in which anatomy was prominent. However, because Galen dissected animals he unfortunately stamped in the minds of his successors errors that would last from his death (probably in 216 CE) until the Renaissance in the 15th century.

Even as the world of Latin imploded, the language maintained its influence. In the West, Christianity spread, installing churches and monasteries that, while preserving Greek and Latin manuscripts, left clinical and anatomical practice and research stagnating. Fortunately, in the East, numerous manuscripts had survived, mainly in Greek. With the advent of Islam in 622 CE, the brilliant Abassid civilisation was born. A "House of Wisdom" was created in Baghdad at the beginning of the 9th century CE, modelled on the Library of Alexandria. Under the leadership of a famous translator, Hunayn ibn Ishak, a large team of experts undertook to translate into Syriac or Arabic all the manuscripts that the armies of the Caliph could collect in the territories that were conquered. Thanks to the “House of Wisdom”, Greek science, medicine and literature were studied throughout the Islamic world during the early Middle Ages. Avicenna, a Persian medical doctor from Bukhara, wrote a monumental literary work on philosophy and medicine. The most famous medical opus was the "Canon of Medicine", which influenced medicine, and anatomy, until well beyond the 16th century. Notably, he translated, commented upon, and amended the books of Herophilos and Galen that he had discovered.

On the Western side of the former Roman Empire, however, only the organisation of medical practice had changed. It was firmly linked to the abbeys, cathedrals and churches where healing monks and lay people (men and women) were instructed and charged with helping "the sick and the poor ones". Nevertheless, a medical school of a kind emerged in Salerno (Italy) and flourished there until the end of the 9th century. Essentially independent from the Church, midwives and medical healers were trained at this establishment and practised their trades throughout Europe.

During the 11th century, Arabic manuscripts found their way to Salerno and to the most influential abbey at that time, Monte Cassino. Their translation into Latin permitted the Occidental World to re-access the ancient literatures. At the same time, the School of Toledo was founded by the King of Castile after he had conquered the city from the Muslims. There he discovered numerous libraries containing Arabic books, many of them being translations from ancient Greek authors.

Anatomy re-emerged in Italy during the 12th and 13rd centuries, thanks to the existence of two institutions: the School of Salerno and the universities that were gradually founded from 1088, Bologna being the first. Whereas barber-surgeons, surgeons and master-surgeons often came from Salerno, medical doctors came from such Universities as Padua, Bologna and Siena, Oxford, Paris or Salamanca. Nevertheless, trained surgeons did not disdain attending Universities to deepen their knowledge. Their presence amongst "traditional" medical students certainly would have modified attitudes; the passive presence of surgical practitioners in anatomical lectures where a Professor read out loud extracts from books by Galen or Avicenna surely must not have always been silently received!

In 1315, Mondino de' Liuzzi, Professor of Anatomy at the University of Bologna, inaugurated the teaching of human anatomy based upon the dissection of human cadavers. The doors now opened to the re-discovery of anatomy, and especially of the internal organs. But Mondino still stuck to the doctrines of the “infallible” masters, although he had written (still in Latin) a book on dissection that remained a classic for two centuries. Some surgeons who had benefited from both an apprenticeship and a Humanist education wrote books in which  they finally dared to contradict the old masters. The time was ripe for the arrival of Vesalius.

Background Thoracic neuropathic pain may be related to an area of altered skin sensation over the territory of cutaneous thoracic branches. The somatosensory rehabilitation method (SRM), a non-pharmacological treatment, focuses on the detection, classification and treatment of this condition. The aim of this prospective observational case series of 66 thoracic neuropathic pain patients (tNPP) was to evaluate a management algorithm of two different types of neuropathic pain: spontaneous ongoing neuropathic pain (type A) and touch-evoked neuropathic pain (type B). Material and methods The authors precisely explain the assessment and treatment algorithm for findings of tactile hypoaesthesia versus static mechanical allodynia (SMA). 66 chronic tNPP referred in a single centre were assessed by two mapping techniques of the skin A) aesthesiography (in case of tactile hypoaesthesia) or B) allodynography (in case of SMA) and pre/post treatment evaluations with the McGill pain questionnaire (MPQ). In clinical practice, hypoaesthetic territories were treated by basic somatosensory rehabilitation. Allodynic territories were treated initially by distant vibratory counter-stimulation (DVCS), then by basic somatosensory rehabilitation once the allodynia disappeared. Results All tNPP presented somatosensory abnormality on at least one damaged cutaneous thoracic branch: 52 hypoaesthetic and 47 allodynic. At a mean of 76 days, 34 of these 47 were converted by DVCS into hypoaesthetic territory, which finally is amenable to treatment by basic somatosensory rehabilitation. 61 % of the tNPP treated with SRM had a pain reduction of at least 50% on the MPQ. Conclusion These observations illustrate a management algorithm for assessing and treating A) hypoaesthesia and B) SMA.

La névralgie crurale est une affection clinique assez fréquente et handicapante. Il existe de nombreuses formes cliniques en raison des variations anatomiques des différentes branches cutanées des nerfs saphène et fémoral. La neuroplasticité du système somesthésique est aujourd’hui démontrée et permet de mieux comprendre les modalités de la rééducation sensitive. Les différentes étapes de la prise en charge des patients souffrant de cruralgie sont expliquées avec précision. Les différentes stratégies du traitement de la rééducation sensitive sont mentionnées. Les traitements médicamenteux des douleurs neuropathiques périphériques sont brièvement rappelés. Enfin, le résultat de la rééducation sensitive d’une cruralgie (NNT = 1,8) est documenté sur la base d’un travail prospectif comprenant le suivi de 59 patients.

... Cependant, l&amp;#x27;origine de la mère de Néfertiti reste inconnue et peut-être est-ce là l&amp;#x27;élément qui pourrait expliquer la présence éventuelle d&amp;#x27;une pratique étrangère à la tradition égyptienne. ... TOUTANKHAMON ET SMENKHKARÉ. ...

ABSTRACT La publication en 1998 de « Terminologia. Anatomica » représentait une étape relativement importante dans l’adoption d’un langage anatomique universellement compréhensible. Un peu plus de 7 000 termes anatomiques ont été compulsés en latin par un comité élu à cet effet et approuvés par une soixantaine de sociétés anatomiques dans le monde. La liste de ces termes était accompagnée d’une liste de noms équivalents en anglais. Elle a déjà servi de base à la rédaction de listes officielles en plusieurs langues vernaculaires. Une terminologie française officielle est d’ailleurs en cours de réalisation. Cependant, si l’existence de termes officiels communs satisfait les anatomistes et les enseignants, il n’en va généralement pas de même pour les cliniciens. Il arrive même souvent que chaque spécialité utilise un vocabulaire clinique qui lui est propre. De plus, un des objectifs de l’Organisation Mondiale de la Santé (OMS) est de promouvoir la transparence des dossiers médicaux au moyen d’outils informatiques indépendants des contingences linguistiques. Or il apparaît très vite, dès qu’on s’attaque à une tâche pareille, que ce sont les termes anatomiques prennent une place importante à la base de tels outils. Une équipe de chercheurs menée par Cornelius Rosse à Seattle a donc développé, au cours des 10 dernières années, un modèle descriptif, le Foundational Model of Anatomy (FMA), qui détaille les entités constituant le corps humain en fonction de leurs rapports topographiques. Ce modèle comporte actuellement 70 000 concepts, qui peuvent être explorés de manière automatique à partir de leurs interrelations. Un projet se dessine maintenant visant à rendre compatibles avec le FMA une version future de la Terminologie Anatomique (et Histologique). Il s’agit d’accorder les termes formels utilisés dans l’enseignement académique de la médecine avec les dénominations variées employées dans les nombreux jargons de l’usage clinique, et cela, quelle que soit la langue des utilisateurs.

Does technology such as virtual reality have
a role in the treatment of pain?

The literature around VR and pain is growing daily. However, much of it is limited to small
sample sizes, lack of control groups, poor outcome measurement and lack of appropriate follow
up. Opportunities abound to harness this multisensory world, in critically thought out trials, to
address the various neurophysiological changes found in persistent and complex pain
conditions. Exploring the technology first will allow clinicians to truly see the diverse array of
possibilities rather then apply it solely to achieve an upscale version of an old treatment. It is
likely that the greatest success will be found in program+ms that allow adjustments in VR
programs to individuals’ neurophysiological contexts rather than a one size fits all model.
However, this will bring large challenges in proving efficacy in trials.

Abstract: Patients and Methods
Prepared by Tara Packham, OTReg(Ont), CSTP®, PhD

The point of view offered by this atlas is unique among its peers: while most start with a central focus and move towards the periphery, this atlas dares to do the opposite.  It starts in the periphery at the origins of the sensation of touch, and maps this afferent transmission from the skin to the higher centres of somatosensory perception in the brain. 
The second, but no less unique, feature of this atlas is its origin in the clinical data derived from the assessment of 2519 persons with Neuropathic Pain (NeP), and 97 references based on clinical anatomy. Further, this is presented reflecting the diversity of the clinical realities, documenting the perimeter points of the largest known territory for the cutaneous distribution of any individual nerve branch.  However, this information is anchored by designating the autonomous territory for each branch. Thus each diagram contains five key topographical elements :
1. The autonomous or unique territory of each cutaneous distribution, and
2. the most distal point ;
3. the most proximal point ;
4. the most medial point, and
5. the most lateral point forming the largest territory of cutaneous distribution of each nerve branch the borders.
The combined visual representation of these clinically derived parameters can now be used by clinicians in medicine, surgery and rehabilitation as a valid reference for the most common clinical presentation: the axonal lesion (axonotmesis) resulting in NeP accompanied by a partial loss of sensation (hypoesthesia).  Unlike the profound and more defined sensory loss seen with complete axonal transsections (neurotmesis), these partial losses reflect the individual variability of the degree and location of the dysfunction, resulting in less confidence for formulating the anatomically plausible hypothesis required for confirming a diagnosis of neuropathic pain.1 Further, the precise details for 240 branches covering the surface of the entire body are clearly organized for easy reference. 
1 Haanpää M, Attal N, Backonja M et al. (2011). NeuPSIG guidelines on neuropathic pain assessment. PAIN®, 152(1), 14–27. Available from: http://dx.doi.org/10.1016/j.pain.2010.07.031.