Contemporary Management of Neuropathic Pain for the Primary Care Physician

Abstract

Neuropathic pain (NP), caused by a primary lesion or dysfunction in the nervous system, affects approximately 4 million people in the United States each year. It is associated with many diseases, including diabetic peripheral neuropathy, postherpetic neuralgia, human immunodeficiency virus-related disorders, and chronic radiculopathy. Major pathophysiological mechanisms include peripheral sensitization, sympathetic activation, disinhibition, and central sensitization. Unlike most acute pain conditions, NP is extremely difficult to treat successfully with conventional analgesics. This article introduces a contemporary management approach, that is, one that incorporates nonpharmacological, pharmacological, and interventional strategies. Some nonpharmacological management strategies include patient education, physical rehabilitation, psychological techniques, and complementary medicine. Pharmacological strategies include the use of first-line agents that have been supported by randomized controlled trials. Finally, referral to a pain specialist may be indicated for additional assessment, interventional techniques, and rehabilitation. Integrating a comprehensive approach to NP gives the primary care physician and patient the greatest chance for success.

Interventional management of intractable sympathetically mediated pain by computed tomography‐guided catheter implantation for block and neuroablation of the thoracic sympathetic chain: technical approach and review of 322 procedures

“…thoracoscopic sympathectomy, spinal cord stimulation etc), but with the suspicion that the time needed to treat sympathetically maintained pain may exceed the duration of effect brought about by a single exposure (injection) to local anaesthetics. Our interventional pain management techniques are primarily considered in patients with pain which is refractory to conventional treatment [7][8][9]. The aim of modern pain management is to move from empiric therapies to a mechanism-based approach [10].…”

Neuropathic pain—Current concepts

“…9 The diagnosis of pain of predominantly neuropathic origin (POPNO) may be simplified with the use of various recently developed screening tools. [9][10][11][12][13] Neuropathic pain may also be classified as peripheral or central, depending on where the nerve lesion is anatomically located 2,14,15 (see Table I). Diabetic polyneuropathy is one of the most common complications of diabetes, with a prevalence of 30-50%.…”

“…clinical evaluation and these patients should be examined carefully and comprehensively. 14,28,29 In two research studies in cohorts of patients with low back pain where different screening tools were used, 37% and 54,7% of patients had scores that suggested pain of predominantly neuropathic origin. 28,29 Complex regional pain syndrome (CRPS) is indeed a complex disorder characterised by the development of NP after tissue trauma, e.g.…”

“…Symptoms include skin colour changes, sweating asymmetry and trophic changes in the nails and skin in the presence of the features of NP. 14,30 The health and quality of life of patients with NP has been shown to be severely impaired. The Health Related Quality of Life (SF-36) questionnaire was used in a population based sample of patients with chronic pain and results demonstrated poor health in all dimensions (physical, psychological and social) in chronic pain patients, in particular in individuals with NP.…”

“…Other forms of NP in HIV-infected patients may include postherpetic neuralgia, mononeuropathy multiplex and progressive polyradiculopathy. 14,23 Iatrogenic neuropathic pain is probably the most important cause of chronic postsurgical pain. 25 If nerves are injured during surgery NP may develop early and persist long-term in the absence of ongoing peripheral stimuli.…”