Overview of Neuropathic Pain

Dr Tay Kwang Hui

Dept of Anaesthesia, NUHS
8 Jan 2011

Research
Clinical Care
Education

Contents
Determining presence of neuropathic pain.
Common mechanisms of neuropathic pain.
Treatment of neuropathic pain.

Pain

Somatic
Visceral
Neuropathic
Combinations

Neuropathic pain: Classification

Peripheral

Spinal

Brain

post surgery

spinal injury

stroke

nerve injury

MS

MS

plexus avulsions

tumor

tumor

amputation

arachnoiditis

compression syndr.

syrinx

herpes zoster
Trig. Neuralgia
Neuropathies

pain arising as a direct consequence

of a lesion or disease affecting the
somatosensory system..
IASP NeuroSIG

Part
2.
Divider
1
Introducing presence
Determining
new topic of
Neuropathic pain

Example CGL
21 Year Old NS man
C/O :left groin, scrotum and thigh pain for 6
months following varicocele surgery.
Not improving with rest or medication.

 Diagnostic Clue:
Pain + Abnormal Sensory Perception*.
Abnormal Sensory Perception:
Negative: Hypoalgesia or
Hypoaesthesia.
Spontaneous: Paraesthesia,
Paroxysmal or Superficial.
Evoked: Hyperalgesia or Allodynia.

If neuropathic pain is likely, then:

1.Where is the lesion?

2.What type of lesion?

We evaluate the patients on 4 criteria to

establish likelihood:
1. Is pain in a distinct neuroanatomically plausible
distribution?
2. Is the history suggestive of a relevant lesion or
disease affecting the peripheral or central
somatosensory system?
3. Can we demonstrate a distinct
neuroanatomically plausible distribution by at
least one confirmatory test?
4. Can we demonstrate the relevant lesion or
disease by at least one confirmatory test

Part
3.
Divider
2: Explaining the cause
Introducing new
Mechanisms
of Neuropathic
topic
pain.

Descending
Modulatory
System
2nd Order WDR
Neurone
GABAergic
Interneurone

Glial Cell

Peripheral changes leading to peripheral sensitization.

Primary afferent neurons 1 and 3 injured.

Spontaneous activity in C-nociceptors induces secondary

changes in central sensory processing, leading to spinal
cord hyperexcitability.

Part
4.
Divider
3
Introducing
Treatment
of new
Neuropathic
topic
Pain

Treatment of Neuropathic pain A Challenge.

Heterogenous Neuropathic Pain
Mechanisms.
Coexisting Psychosocial and Emotional
Components of Chronic Pain.
Poor compliance with medications due to
adverse effects.

Treatment of Neuropathic pain Diagnosis and

Treatment.
Thorough Diagnosis.
Aim to treat:
Underlying cause Diabetes or Nerve root
compression etc.
Symptomatic Treatment
Address associated psychosocial issues.

Neuropathic pain Diagnosis and Treatment.

Education is important for compliance:
Information of Neuropathic Pain.
Treatment Plan
Adverse effects
Address associated depression or anxiety.
Mood disorders may need medication or
psychological counseling.

Treatment of Neuropathic pain Setting

expectations of outcomes/ Goals of Tx.
30% improvement of pain clinically
meaningful outcome.
Health related Quality of Life improvements:
Improved Sleep.
Social and Emotional function.

Neuropathic pain Modalities of Tx.

1. Pharmacological Treatment.
2. Interventional and Invasive Procedures.
3. Psychological including Pain Management
Programs
4. Physical Therapy PT or OT

Neuropathic pain Primary Prevention.

Limited
Vaccination against Varicella Zoster Virus.
Aggressive Treatment of Acute Pain.

Neuropathic pain Pharmacological Tx

Challenges.
Difficult to predict who will respond!
At best NNT 2-3:1
Recommended Treatments for some
conditions not all.
Lack of robust data for all neuropathic
conditions.
Balance with adverse effects stepwise
titrations needed to get balance of outcome
with acceptable adverse effects.

Pharmacological Tx - Classifications.
1. Antidepressants: Serotonin and
Noradrenaline Reuptake inhibitors:
Tricyclics Antidepressants, SNRIs.
2. Anticonvulsants (Na Channel Blockers)
Carbamazepine, Na Valproate, Lamotrigine,
Topiramate.
3. Anticonvulsants (Ca Channel Blockers)
Gabapentin and Pregabalin.
4. Opioids (including Tramadol).
5. Topical Agents
Lidocaine 5% Patch, Capsaicin.

Pharmacological Tx Practical Aspects.

Combination therapy may be needed.
Elderly patients with neuropathic pain:
Adverse effects may be severe:
Confusion, Sedation, Unsteady gait and falls.
Drug interactions due to polypharmacy/
comorbidities.
Topical agents if available advantageous.

Interventional Tx
Not first line treatment for neuropathic pain.
Offered if poor response to Tx or
unacceptable adversed effects.
Mixture of treatment for:
underlying cause or
symptomatic treatment.

Interventional Tx - Examples
Underlying Cause:
Epidural steroids for nerve root pain, PHN.
Sympathetic blocks for sympatheticallymediated pain CRPS, PHN.
Symptomatic Tx:
Spinal cord or Peripheral Nerve Stimulator for
Failed Back Surgery syndrome, CRPS, Postsurgical Pain syndromes.
Motor Cortex Stimulation for Central poststroke pain.
Intrathecal analgesia for PHN, PNP, SCI,
CRPS etc

Physical Therapy
Limited efficacy but minimal adverse effects.
Complementary to medications.
Examples:
Transcutaneous Electrical Stimulation (TENS)
Acupuncture
Physiotherapy to improve physical strength
and endurance.
Occupational Therapy to improve physical
function.

Psychological Therapy and Pain Management

Programs
Eg: Cognitive Behavioral Therapy, Mirror
therapy (OT).
Symptomatic Management:
Emotional: Anxiety and Depression.
Sleep and Fatigue.
Lifestyle modification to improve overall
function.
Improve motivation as a complement to
physical and medication therapy.

Summary
2.
Divider
Introducing pain
Neuropathic
new topic

Summary
Cause/Mechanism of development of
neuropathic pain unclear in many patients.
Clinical Suspicion and Thorough Diagnosis
needed for treatment of neuropathic pain.
Address Underlying Cause + Symptoms.
Treatment modality primarily
pharmacological.
Outcome may not be ideal needs a careful
titration to balance of acceptable adverse
effects to outcome.
Physical modalities may help in certain
patients.

Reference
Treede et al. Neuropathic pain: Redefinition and a
grading system for clinical and research purposes.
Neurology 2008;70:16301635.
Baron R et al. Neuropathic pain: diagnosis,
pathophysiological mechanisms, and treatment. Lancet
Neurology 2010; 9: 80719.

Thank you
for your attention
Research
Clinical Care
Education