A Comprehensive Algorithm for Management of Neuropathic Pain

Abstract

Background The objective of this review was to merge current treatment guidelines and best practice recommendations for management of neuropathic pain into a comprehensive algorithm for primary physicians. The algorithm covers assessment, multidisciplinary conservative care, nonopioid pharmacological management, interventional therapies, neurostimulation, low-dose opioid treatment, and targeted drug delivery therapy. Methods Available literature was identified through a search of the US National Library of Medicine’s Medline database, PubMed.gov. References from identified published articles also were reviewed for relevant citations. Results The algorithm provides a comprehensive treatment pathway from assessment to the provision of first- through sixth-line therapies for primary care physicians. Clear indicators for progression of therapy from firstline to sixth-line are provided. Multidisciplinary conservative care and nonopioid medications (tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, gabapentanoids, topicals, and transdermal substances) are recommended as firstline therapy; combination therapy (firstline medications) and tramadol and tapentadol are recommended as secondline; serotonin-specific reuptake inhibitors/anticonvulsants/NMDA antagonists and interventional therapies as third-line; neurostimulation as a fourth-line treatment; low-dose opioids (no greater than 90 morphine equivalent units) are fifth-line; and finally, targeted drug delivery is the last-line therapy for patients with refractory pain. Conclusions The presented treatment algorithm provides clear-cut tools for the assessment and treatment of neuropathic pain based on international guidelines, published data, and best practice recommendations. It defines the benefits and limitations of the current treatments at our disposal. Additionally, it provides an easy-to-follow visual guide of the recommended steps in the algorithm for primary care and family practitioners to utilize.

Repetitive transcranial magnetic stimulation of the primary motor cortex in management of chronic neuropathic pain: a systematic review

“…Clinical conditions with chronic neuropathic pain (NP) pose a major treatment challenge [1][2][3]. Symptomatic first line therapies consist of different drug strategies which can be combined with conservative non-pharmacological treatments [4,5]. Interventional neuromodulation techniques, using modern implantable technology to deliver long-term electric stimulation to the nervous system, can be considered when drug therapies fail due to insufficient effect or intolerable side effects [6,7].…”

Differentiating Psychosomatic, Somatopsychic, Multisystem Illnesses and Medical Uncertainty

“…In these cases, it is important to clarify the psychodynamics and the pathophysiological processes that result in the perception of pain. However, it is important not to confuse psychogenic pain with undiagnosed medical conditions and radiculopathy, neuropathy, neuropathic pain, hyperalgesia and allodynia, all of which have a neurological and/or immune basis [98][99][100][101][102].…”

A review of the bioelectronic implications of stimulation of the peripheral nervous system for chronic pain conditions

“…Imaging, such as MRI or ultrasound along with diagnostic tests, such as electromyelogram or nerve conduction studies are often used to aid in diagnosis (Rangavajla et al, 2014;Aminoff, 2004). The interventional pain physician may also do diagnostic peripheral nerve blocks using local anesthetic(s) to aid in diagnosis (Bates et al, 2019).…”

“…Treatment options for peripheral nerve injury include: physical therapy, oral medications, ablative therapies (e.g. thermal or chemical) and neurostimulation (Bates et al, 2019). If patients do not significantly improve with conservative therapies, PNS is a viable nerve treatment option to treat pain secondary to peripheral nerve injury (Van Buyten et al, 2015;Nagel et al, 2014;Pereira & Aziz, 2014).…”