Neuropathic Pain

Neuropathic pain is a cause of many types of chronic pain.  It is hard to diagnose and hard to treat.  Examples of neuropathic pain include the following:
  • Postherpetic neuralgia
  • Trigeminal neuralgia
  • Diabetic neuropathy
  • Phantom limb pain
  • Radiculopathy pain
  • Plexopathy pain in cancer patients
Neuropathic pain is defined as a pain that stems from a damaged central or peripheral nervous system.  Pain is usually described as burning or stabbing pain but can be any type of pain.

Some doctors treat neuropathic pain by ablating the nerve but this can make the condition worse because it causes increased damage to the affected nerve.  Medications such as anti-seizure medication and tricyclic antidepressants in low doses have been found to help many people with neuropathic pain.

Neuropathic pain can come from any aspect of the nervous system, from the distal peripheral nerves to the spinal cord to areas of the central nervous syndrome.  This kind of pain can continue following an injury long after the trauma and inflammation have resolved.  It is believed to be related to abnormal sodium channels in the tissue innervated by the nerves.  Calcium channels in the cells are also known to play a role in this type of pain.
 
Treatment of Neuropathic Pain
 
Treatment of neuropathic pain is difficult and can involve pharmacological and nonpharmacological approaches.  Some patients respond to chronic opioid therapy while others benefit from anti-convulsants, tricyclic antidepressants, nerve ablation or TENS unit use.  Spinal cord stimulation helps in some cases along with a technique known as the CraigPENS technique, which uses percutaneous nerve stimulation.

The two types of pain medications include membrane stabilizing agents and medicines that increase the inhibitory mechanisms in the dorsal horn of the spinal cord.  Membrane stabilizing medications include local anesthetics and some anti-convulsants, such as valproic acid, carbamazepine, and phenytoin.  These medications block sodium channels in nerve cells.  Steroids also have the ability to be membrane stabilizers to nerve fibers.  The same is true of tricyclic antidepressant medications.

Anticonvulsant medications are especially good for lancinating pain, such as is seen in trigeminal neuralgia.  In fact, carbamazepine, an anti-seizure medication is indicated in trigeminal neuralgia and is FDA approved for its use.  Carbamazepine is started at 50 mg twice daily and increased to up to 300 mg four times daily.  Phenytoin is useful but isn’t as good as carbamazepine for trigeminal neuralgia.  It is taken in doses of about 100 mg twice daily, checking for therapeutic levels if the dose needs to be increased.  Valproic acid acts on the GABA system and on sodium channels.  It is especially good as a preventative for migraine headaches.  Clonazepam is used for radicular pain and pain that is lancinating. It is a medication that inhibits the GABA system in the dorsal horn of the spinal cord.  It is taken as 0.5 to 1 mg at bedtime, increasing to a maximum of 4 mg at bedtime.

Gabapentin is also popular for pain management.  It has a structural similarity to GABA and is useful in neuropathic pain.  It has few side effects, making it a good first choice for neuropathic pain management. It acts on calcium channels in nerve cells.  It acts on the central nervous system regulating pain, rather than on the peripheral nervous system.  It is especially good for patients with diabetic neuropathy.

Post-herpetic neuralgia is particularly difficult to treat.  Only about half of all patients find relief with tricyclic antidepressants.  Gabapentin helps 65 percent of patients.  Gabapentin is preferred in many cases of neuropathic pain because it is relatively safe and has a low potential for side effects.

Antidepressants, particularly tricyclic antidepressants can help people with neuropathic pain and have the advantage of once nightly dosing.  There can be side effects, including constipation, orthostatic hypotension and sedation.  Doses may run as high as is used for depression but this doesn’t always have to be the case.  Amitriptyline is the most commonly used tricyclic antidepressant for neuropathic pain.  SSRI antidepressants haven’t been found to be as helpful as tricyclic antidepressants for the relief of pain.

Anti-arrhythmics are useful in some cases of neuropathic pain.  They block nerve activity both in the central nervous system and the peripheral nervous system.  These include lidocaine, mexiletine and Dilantin.  They stabilize the sodium channels in nerve cell.

Corticosteroids work well for neuropathic pain.  They also have great anti-inflammatory properties.  They can be used as an epidural for pain caused by discogenic radiculopathy.  They can be effective when given orally as well as parenterally.

Baclofen is used for the treatment of trigeminal neuralgia.  It acts on the spinal cord as a GABA agonist.  It acts similarly to clonazepam when it comes to neuropathic pain.
Capsaicin is a pain cream used for peripheral neuropathic pain.  It gradually reduces the amount of the pain molecule substance P and works after application over several weeks.  The medication causes intense pain when given initially and patients must get past this in order to have the medication ultimately be helpful. 
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