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Neuropathic Pain

Nerve cell

Nerve cell

Introduction

Neuropathic pain is pain caused by injury or disease of the peripheral or central nervous system. Sometimes colloquially called “nerve irritation pain”. It is one of the major causes of chronic pain.

It is thought to affect between 1-8% of the population.

Management firstly should involve treatment of the underlying condition, but in many cases, neuropathic pain becomes chronic. In these cases, management involves a variety of drugs, usually from the various classes of antidepressants, which are thought to also affect peripheral nerve signal transmission, in addition to their antidepressant effects.

Epidemiology

Aetiology

There are many possible causes of neuropathic pain. These include:

Presentation

Pain is typically described as “burning”, “aching” or “shooting”. Can be continuous or intermittent, generally is continuous with some day to day variation, and specific actions that may cause worsening of the pain. Other features include:

Management

Management is very similar to others causes of chronic pain.

If possible, treat the underlying disorder, or at the very lest, attempt to limit its progression (e.g. in diabetes).

Analgeisa

Analgesic therapy typically would involve the analgesic ladder:

The role of opiates remains somewhat controversial. Most studies conclude that they are of very limited use in chronic pain and their use should be discouraged.

Many agents have been proven effective for neuropathic pain. These include:

Which agent to use?

Guidelines vary on which agents to use (which seems to suggest the evidence fOr the efficacy of one agent over another is poor [author’s opinion]).

UK NICE guidelines ??

Australian eTG guidelines ??

In general, the use of opioids should be avoided and discouraged, although in reality, as all chronic pain starts out as acute pain, many patients you meet maybe on long term opioids. (Seems to be more of a problem in Australia than in the UK in the author’s experience).

In a specialist (pain clinic) setting, some of the other agents may be tried:

Non-pharmacological treatments

Cognitive behavioural therapy

PENS

Other measures

There is no proven evidence for the benefit of any of the following:

Trigeminal neuralgia is a special case and considered separately.

References

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