Neuropathic Pain Overview

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Neuropathic Pain Overview

Contents 


OVERVIEW

NEUROPATHIC PAIN
  • Pain arising as a consequence of a lesion or disease of the peripheral &/or central nervous system affecting the somatosensory system
  • Characterized by burning, stabbing & electrical pain which may be constant, aching or paroxysmal, pins & needles
  • Nerve conduction blockage causes nerve dysfunction, leading to numbness, weakness & loss of deep tendon reflexes in the area of involved nerve
  • Neuropathic conditions (eg brain infarction, spinal cord trauma, ischemic neuropathies) also cause aberrant symptoms of spontaneous & provoked pain

Below is the overview of disease management of Neuropathic Pain:

Overview of management of neuropathic pain

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Clinical History

  • History & clinical examination are required to confirm the presence of a neuropathic pain syndrome & also an important step in reaching an etiologic diagnosis for neuropathic pain
  • Rapid & correct diagnosis of neuropathic pain (NP) should be done so that appropriate treatment can be started earlier

Refer to Symptoms for more information

Common Neuropathic Pain Syndromes

Central Neuropathic Pain

  • Pain may be burning, shooting, aching, or pricking & is often associated with dysesthesia, hyperalgesia or allodynia to brush or cold
  • Seen among post-stroke, spinal cord injury & multiple sclerosis patients

Painful Diabetic Peripheral Neuropathy (DPN)

  • Symmetrical sensory loss & burning, shooting, stabbing or severe deep aching pain of both lower extremities among patients w/ diabetes mellitus (DM)
  • Affects about 50% of DM patients
  • Pain may be accompanied by allodynia & hyperalgesia
  • Symptoms may worsen at night

Postherpetic Neuralgia (PHN)

  • Pain persisting for >3 mth after herpes zoster skin lesions have healed
  • Risk factors for developing PHN:
    • All patients >50 yr w/ herpes zoster virus (HZV) infection
    • Patients w/ a greater degree of skin surface area involved & more severe pain at presentation of HZV infection
    • Patients w/ HZV ophthalmicus
    • Patients who experience sensory dysfunction on the affected dermatome
    • Painful prodrome prior to rash
  • Patients at greatest risk for developing PHN should be offered antiviral treatment
  • Diagnostic clinical features of PHN:
    • Pain localized to the dermatome affected by the herpes zoster rash
    • Pain may be described as burning, throbbing, sharp or shooting
    • Allodynia
    • Pain accompanying movement
    • Areas of scarring of hypopigmentation caused by herpes zoster rash
    • Presence of psychosocial stress

Trigeminal Neuralgia (TN)

  • Characterized by intermittent unilateral facial pain following the unilateral sensory distribution of the trigeminal nerve, typically radiating to the maxillary or mandibular area
    • Ophthalmic division pain alone occurs in <5% of patients
  • Pain is quite severe, stabbing electric shock-like sensation
  • Pain may be brief & paroxysmal but may occur in multiple attacks several times a day, w/ no pain between episodes
  • Typically w/ normal PE findings, although mild light touch or pin perception loss has been described in the central area of the face
  • Average age of pain onset in idiopathic TN is usually the 6th decade of life, but may occur at any age
  • Symptomatic or secondary TN tends to occur in younger patients
  • Common triggers precipitating pain attack include light touch or vibration & activities such as shaving, face washing or chewing

Postsurgical Neuropathic Pain

  • Peri-incisional sensory loss, pain & allodynia for >3 mth after surgery; phantom pain following amputation or mastectomy

HIV-Related Neuropathy

  • Symmetrical painful paresthesias, most prominent in the toes & soles of the feet among HIV patients

Lumbosacral Radiculopathy (Herniated Intervertebral Disc)

  • Lancinating pain radiating into the anterior thigh (L2/3) or lower leg (L4-S1) w/ motor weakness or sensory loss

Complex Regional Pain Syndrome

  • Regional (eg limb) pain together w/ edema, cutaneous blood flow & sweating abnormalities

Below is the overview of disease management of common neuropathic pain syndromes:

Overview of management of common neuropathic pain syndromes

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Overview of management of common neuropathic pain syndromes 2

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Version: 30 Sep 2015

Guideline References:

  1. American Society of Pain Educators. Diabetic peripheral neuropathic pain consensus guidelines for treatment. Supplement to The Journal of Family Practice. The Journal of Family Practice. http://www.jfponline.com/home/article/diabetic-peripheral-neuropathic-pain/142bfa8d9c5e06565462f6647bfe6418.html. Jun 2006. Accessed 21 Mar 2011
  2. Attal N, Cruccu G, Baron R, et al. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur J Neurol. 2010 Sep;17(9):1113-1123. doi: 10.1111/j.1468-1331.2010.02999.x. PMID: 20402746
  3. Azhary H, Farooq MU, Bhanushali M, et al. Peripheral neuropathy: differential diagnosis and management. Am Fam Physician. 2010 Apr;81(7):887-892. PMID: 20353146
  4. Baron R, Binder A, Wasner G. Neuropathic pain: diagnosis, pathophysiological mechanisms and treatment. Lancet Neurol. 2010 Aug;9(8):807-819. doi: 10.1016/S1474-4422(10)70143-5. Accessed 3 Mar 2014. PMID: 20650402
  5. Bennett MI, Attal N, Backonjan MM, et al. Using screening tools to identify neuropathic pain. Pain. 2007;127(3):199-203. Accessed 3 Mar 2014. PMID: 17182186
  6. Beydoun A, Backonjia MM. Mechanistic stratification of antineuralgic agents. J Pain Symptom Manage. 2003 May;25(Suppl 5):S18-S30. PMID: 12694989
  7. Chan A, Wong S, Chen PP, et al. Validation study of the Chinese Identification Pain Questionnaire for neuropathic pain. Hong Kong Med J. 2011 Aug;17(4):297-300. PMID: 21813898
  8. Chong MS, Bajwa ZH. Diagnosis and treatment of neuropathic pain. J Pain Symptom Manage. 2003 May;25(Suppl 5):S4-S11. PMID: 12694987
  9. Cruccu G, Sommer C, Anand P, et al. EFNS guidelines on neuropathic pain assessment: revised 2009. Eur J Neurol. 2010 Aug;17(8):1010-1018. PMID: 20298428
  10. Dubinsky RM, Kabbani H, El-Chami Z, et al. Practice parameter: treatment of postherpetic neuralgia: an evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2004 Sep;63(6):959-965. PMID: 15452284
  11. Frykberg RG, Armstrong DG, Giurini J, et al. Diabetic foot disorders: a clinical practice guideline. American College of Foot and Ankle Surgeons. J Foot Ankle Surg. 2000;39(Suppl 5):S1-S60. PMID: 11280471
  12. Galluzzi K. Managing herpes zoster and postherpetic neuralgia. J Am Osteopath Assoc. 2009 Jun;109(6)(Suppl 2):S7-S12. PMID: 19553635
  13. Galluzzi KE. Management of neuropathic pain. J Am Osteopath Assoc. 2006 Sep(Suppl 4):S12-S18. PMID: 16273720
  14. Gilron I, Watson CP, Cahill CM, et al. Neuropathic pain: a practical guide for the clinician. CMAJ. 2006 Aug;175(3):265-275. PMID: 16880448
  15. Great Manchester Medicines Management Group. Neuropathic pain guideline. GMMMG website. http://gmmmg.nhs.uk/docs/guidance/GMMMG%20Neuropathic%20Pain%20Guidance%20March%202014.pdf. Mar 2014. Accessed 10 Jul 2015.
  16. Gronseth G, Alksne J, Argoff C, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology. 2008 Oct;71(15):1183-1190. PMID: 18716236
  17. Irving GA. Contemporary assessment and management of neuropathic pain. Neurology. 2005 Jun;64(12)(Suppl 3):S21-S27. PMID: 15999405
  18. Jefferies K. Treatment of neuropathic pain. Semin Neurol. 2010 Sep;30(4):425-432. PMID: 20941675
  19. Johnson RW, McElhaney J. Postherpetic neuralgia in the elderly. Int J Clin Pract. 2009 Sep;63(9):1386-1391. PMID: 19691624
  20. Jovin Z, Cvijanovic M, Ilin M, et al. Assessment of neuropathic pain and clinical evaluation of patients with suspected neuropathic pain. Curr Top Neurol Psychiatr Relat Discip. 2010 Jun;18(2):30-37
  21. Lunsford L, Niranjan A, Young R, et al. International Radiosurgery Association: stereotactic radiosurgery for patients with intractable typical trigeminal neuralgia who have failed medical management. Radiosurgery Practice Guideline Report. 2009 Jan:001-03. http://www.irsa.org/tn%20guideline-updatedjan2009.pdf
  22. May S, Serpell M. Diagnosis and assessment of neuropathic pain. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2948337/. Oct 2009. Accessed 21 Mar 2011
  23. Moulin DE, Clark AJ, Gilron I, et al. Pharmacological management of chronic neuropathic pain - consensus statement and guidelines from the Canadian Pain Society. Pain Res Manag. 2007;12(1):13-21. PMID: 17372630
  24. Ping CP, Ip JW, Lam J, et al. Multidisciplinary Panel on Neuropathic Pain: recommendations for the management of postherpetic neuralgia. Medical Progress. 2006;33(10):475-482. http://www.neuropainhk.org/Portals/0/mpnp-recommendations-postherpetic-neuralgia-update-oct-2006.pdf
  25. Rains C, Bryson HM. Topical capsaicin. A review of its pharmacological properties and therapeutic potential in post-herpetic neuralgia, diabetic neuropathy and osteoarthritis. Drugs Aging. 1995 Oct;7(4):317-328. http://www.ncbi.nlm.nih.gov/pubmed/8535059. Accessed 15 Jul 2015. PMID: 8535059
  26. Taliyan R, Sharma PL. Diabetic neuropathic pain: an update and novel pharmacological strategies for relief of pain. J Med Sci. 2010;10(4):93-109
  27. U.S. Food and Drug Administration. Information for healthcare professionals: dangerous or even fatal skin reactions - carbamazapine. http://www.fda.gov/Drugs/DrugSafety/PostmarketdrugsafetyinformationforPatientsandProviders/ucm124718.htm. Accessed 07 Jun 2013
  28. Unger J. Pathogenesis, diagnosis and treatment of painful diabetic peripheral neuropathy. Applied Neurology. 2007 Feb(Suppl 1):006-15
  29. Várkonyi T, Putz Z, Keresztes K, et al. Current options and perspectives in the treatment of diabetic neuropathy. Curr Pharm Des. 2013;19(27):4981-5007. PMID: 23278494
  30. Vijayan R, Jin GK, Cardosa MS, et al. Malaysian guidelines on management of neuropathic pain. 2nd edition. Malaysian Association for the Study of Pain. www.masp.org.my. 2012. Accessed 26 Jun 2015.
  31. Ziegler D. Current Concepts in the management of diabetic polyneuropathy. Curr Diabetes Rev. 2011 May;7(3):208-220. PMID: 21534920