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Neuropathic Pain
Neuropathic pain, or NeP, is pain that results from disease, damage or dysfunction of the peripheral or central nervous system.
The International Association for the Study of Pain (IASP) 1994 definition of neuropathic pain has been updated by the Neuropathic Pain Working Group 2006 as:
‘Pain arising as a direct consequence of a lesion or disease affecting the somatosensory system’.
Etiology and Pathophysiology
Peripheral nerve injury or dysfunction can result in neuropathic pain. Forms of Neuropathic pain include, amongst others; Painful Diabetic Neuropathy, Post Herpetic Neuralgia, HIV Associated Neuropathy and Neuropathic Scar Pain.
Symptoms
Dysaesthesias are typical, but pain may also be deep and aching. Other sensations such as hyperaesthesia, hyperalgesia and allodynia, may also occur.
Neuropathic pain is often described as pins and needles, pricking or tingling, abnormally sensitive skin, itching, tight/stretch/squeezing sensations, pain jumps, shock-like, shooting or stabbing pain and lack of sensation. Neuropathic pain also is associated with high levels of emotional distress, particularly depression, anxiety, impaired quality of life, activities of daily living and performance at work.
Diagnosis
Whilst diagnostic tests for neuropathic pain tend to exclude rather than confirm diagnosis, assessment should aim to rule out treatable conditions, confirm diagnosis and identify clinical features that might help to individualise treatment. Neurophysiological responses to nerve conduction studies (NCS) somatosensory evoked potientials (SEPs) and Quantative Sensory Testing (QTS) may be employed during neurologic examination.
Pharmacological Treatment
Treatment of neuropathic pain is focussed on restoration of patient function and as such requires a flexible, patient focussed and interdisciplinary approach to treatment. Several classes of drugs are utilised, including tricyclic antidepressants (e.g. amitriptyline, nortriptyline), anticonvulsants (e.g. gabapentin, pregabalin), SSNRI (e.g. duloxetine) and topicals, such as capsaicin or lidocaine plasters. Data suggests however that clinical management of Neuropathic pain is often inadequate and side effects, including inability to tolerate treatment, are common.
A new Neuropathic Pain Knowledge Centre will launch in June 2010
References:
1. ACNR Volume 3 Number 2 May/June 2003 JW Scadding
2. Cecil textbook of Medicine 22nd Edition
3. http:/anti-infectives/Paris-Event/Live-Webcast.cfmwww.lmsg.nhs.uk/Guidelines/pdfdocs/NeuropathicPainGuideline200711.pdf
4. Merck Manual - review/revision February 2007 by Russell K. Portenoy, MD
5. Gilron I, Watson PN, Cahill CM, et al. Neuropathic pain: a practical guide for the clinician. Can Med Assoc J 2006; 175:265–75.
6. Cruccu G, Truini A. Tools for assessing neuropathic pain. PLoS Med 2009; 6:e1000045.
7. Harden & Cohen (2003) Journal of Pain and Symptom Management, 25; 5S, ppS12-S17
8. O’connor & Dworkin (2009) American Journal of Medicine 122, S22-S32
