Joint European Academy of Neurology–European Pain Federation–Neuropathic Pain Special Interest Group of the International Association for the Study of Pain guidelines on neuropathic pain assessment

Abstract

Background and Purpose: In these guidelines, we aimed to develop evidence-based recommendations for the use of screening questionnaires and diagnostic tests in patients with neuropathic pain (NeP). Methods:We systematically reviewed studies providing information on the sensitivity and specificity of screening questionnaires, and quantitative sensory testing, neurophysiology, skin biopsy, and corneal confocal microscopy. We also analysed how functional neuroimaging, peripheral nerve blocks, and genetic testing might provide useful information in diagnosing NeP. Results: Of the screening questionnaires, Douleur Neuropathique en 4 Questions (DN4), I-DN4 (self-administered DN4), and Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) received a strong recommendation, and S-LANSS (self-administered LANSS) and PainDETECT weak recommendations for their use in the diagnostic pathway for patients with possible NeP. We devised a strong recommendation for the use of skin biopsy and a weak recommendation for quantitative sensory testing and nociceptive evoked potentials in the NeP diagnosis. Trigeminal reflex testing received a strong recommendation in diagnosing secondary trigeminal neuralgia. Although many studies support the usefulness of corneal confocal microscopy in diagnosing peripheral neuropathy, no study specifically investigated the diagnostic accuracy of this technique in patients with NeP. Functional neuroimaging and peripheral nerve blocks are helpful in disclosing pathophysiology and/or predicting outcomes, but current literature does not support their use for diagnosing NeP. Genetic testing may be considered at specialist centres, in selected cases. Conclusions: These recommendations provide evidence-based clinical practice guidelines for NeP diagnosis. Due to the poor-to-moderate quality of evidence identified by this review, future large-scale, well-designed, multicentre studies assessing the accuracy of diagnostic tests for NeP are needed.

Earlier diagnosis of peripheral neuropathy in primary care: A call to action

“…Genetic testing targeting peripheral ion channel and transient receptor potential (TRP) genes has recently shown promise in the evaluation of painful neuropathies, 33–35 but is not widely available. There are limited rapid and objective measures of early neurodegeneration 36,37 and DPN may be undiagnosed in 35%–99.8% of patients in Saudi Arabia, 18,22 Qatar, 18,19,38 Kuwait, 18 Germany, 39 United Kingdom, 40 USA, 41,42 Japan, 43 Malaysia, 44 Hong Kong, Philippines, Taiwan and Thailand 45 (Figure 1).…”

Small and large fiber neuropathy in adults with myotonic dystrophy type 1

“…Another limitation is that we did not use standardized questionnaires for neuropathic pain. A recently published guideline on assessment of neuropathic pain using the GRADE system showed that only three of the many questionnaires in use are highly recommended, while IENFD is the only diagnostic method that reaches the same level ( 10 ). Other possible symptoms and findings of small fiber neuropathy such as change of swelling, orthostatism and other autonomic signs were not explored in this study.…”

“…These fibers may be tested by the semi-objective method of quantitative sensory testing (QST), while the gold standard is skin biopsy for quantification of intraepidermal nerve fiber density (IENFD) ( 9 ). Indeed, a recent review on diagnosis of neuropathic pain using the GRADE system found that skin biopsy is so far the only investigation to confirm peripheral neuropathic pain ( 10 ). To our knowledge, this has not previously been performed in patients with DM1.…”

The Impact of Relapses on Pain and Quality of Life in Patients with Multiple Sclerosis Treated with Corticosteroids

“…In the original trial from which these prospective data were taken, pain was not the major study endpoint and the 6-week duration of follow-up was limited. It was also not possible to differentiate between nociceptive and neuropathic pain, chronic versus acute relapse pain, or to identify pain syndromes that occur commonly in MS [ 6 , 27 , 28 ]. The patients were asked to estimate their pain over the preceding 4 weeks at each study visit, introducing the possibility of recall bias.…”