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There may be signs of sympathetic dysfunction, and occasionally dystrophic changes. Pain is often of mixed nociceptive and neuropathic types, for example, mechanical spinal pain with radiculopathy or myelopathy. It is not generally recognized that nociceptive spinal pain can radiate widely, mimicking a root distribution.

It can be difficult to identify the dominant pain type and treat appropriately. Such patients require careful examination, imaging and neurophysiological investigation. The pathophysiological properties that are responsible for NP can be broadly categorised into five groups: ectopic impulse generation in damaged primary afferent fibres, fibre interactions, central sensitisation, disinhibition failure or reduction of normal inhibitory mechanisms , and plasticity degenerative and regenerative changes associated with altered connectivity.

Screening questionnaires are suitable for identifying potential patients with neuropathic pain, but further validation of them is needed for epidemiological purposes. Clinical examination, including accurate sensory examination, is the basis of neuropathic pain diagnosis. For more accurate sensory profiling, quantitative sensory testing is recommended for selected cases in clinic, including the diagnosis of small fiber neuropathies and for research purposes.

Step 1. A clinical history of disease or lesion of the somatosensory system suggests a possible diagnosis of neuropathic pain.

Diabetes, Nerve Pain, and Medication

Step 2. Confirmation by either clinically reproducible signs or investigations would suggest a probable diagnosis of neuropathic pain. Step 3.

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If the history, clinical examination and investigations are positive, this would support a definite diagnosis of neuropathic pain [10]. Sensory examination - light touch, temperature, painful stimulus, vibration and proprioception. Motor testing tone, strength, reflexes and coordination. Look for autonomic changes in colour, temperature, sweating and swelling.

Examination of a Patient with Peripheral Neuropathic Pain shows a real patient with multiple mononeuropathy due to isolated peripheral nervous system vasculitis. He is suffering from neuropathic pain in his left hand and both legs.

Neuropathic pain -

Functional assessment and sensory and motor examination of both upper and lower limbs is demonstrated. DN4 questionnaire assists with neuropathic pain assessment.

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Use when neuropathic pain is suspected [11]. Unfortunately, neuropathic pain often responds poorly to standard pain treatments and occasionally may get worse instead of better over time. For some people, it can lead to serious disability. A multidisciplinary approach that combines therapies, however, can be a very effective way to provide relief from neuropathic pain.

Anticonvulsant and antidepressant drugs for example, pregabalin, gabapentin and amitriptyline may work to reduce symptoms in most cases. Central pain syndromes potentially caused by virtually any lesion at any level of the nervous system. Postsurgical pain syndromes eg, postmastectomy syndrome, postthoracotomy syndrome, phantom limb pain. Complex regional pain syndrome reflex sympathetic dystrophy and causalgia. Mononeuropathies eg, carpal tunnel syndrome , radiculopathy. Plexopathies typically caused by nerve compression, as by a neuroma, tumor, or herniated disk.

Neuropathic Pain

Polyneuropathies typically caused by various metabolic neuropathies—see tables Causes of Peripheral Nervous System Disorders. Mechanisms presumably vary and may involve an increased number of sodium channels on regenerating nerves. Central neuropathic pain syndromes appear to involve reorganization of central somatosensory processing; the main categories are deafferentation pain and sympathetically maintained pain.

Both are complex and, although presumably related, differ substantially. Deafferentation pain is due to partial or complete interruption of peripheral or central afferent neural activity. Examples are. Phantom limb pain pain felt in the region of an amputated body part. Mechanisms are unknown but may involve sensitization of central neurons, with lower activation thresholds and expansion of receptive fields.

Sympathetically maintained pain depends on efferent sympathetic activity. Complex regional pain syndrome sometimes involves sympathetically maintained pain. Other types of neuropathic pain may have a sympathetically maintained component. Mechanisms probably involve abnormal sympathetic-somatic nerve connections ephapses , local inflammatory changes, and changes in the spinal cord.

Dysesthesias spontaneous or evoked burning pain, often with a superimposed lancinating component are typical, but pain may also be deep and aching. Other sensations—eg, hyperesthesia, hyperalgesia, allodynia pain due to a nonnoxious stimulus , and hyperpathia particularly unpleasant, exaggerated pain response —may also occur. Symptoms are long-lasting, typically persisting after resolution of the primary cause if one was present because the CNS has been sensitized and remodeled. Neuropathic pain is suggested by its typical symptoms when nerve injury is known or suspected.

The cause eg, amputation, diabetes may be readily apparent. If not, the diagnosis often can be assumed based on the description. Pain that is ameliorated by sympathetic nerve block is sympathetically maintained pain. Multimodal therapy eg, psychologic treatments, physical methods, antidepressants or anticonvulsants, sometimes surgery. Without concern for diagnosis, rehabilitation, and psychosocial issues, treatment of neuropathic pain has a limited chance of success.

For peripheral nerve lesions, mobilization is needed to prevent trophic changes, disuse atrophy, and joint ankylosis. Surgery may be needed to alleviate compression.

Psychologic factors must be constantly considered from the start of treatment. Anxiety and depression must be treated appropriately. When dysfunction is entrenched, patients may benefit from the comprehensive approach provided by a pain clinic. Several classes of drugs are moderately effective see table Drugs for Neuropathic Pain , but complete or near-complete relief is unlikely. Antidepressants and anticonvulsants are most commonly used.

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Evidence of efficacy is strong for several antidepressants and anticonvulsants 1. Neuropathic Pain Lindsay A. Article as PDF. Article Tools. Article as EPUB. Print This Article. Add to My Favorites. Export to Citation Manager. Alert Me When Cited. Request Permissions. Share on Facebook. Share on Twitter. Share on LinkedIn. Article Level Metrics. Abstract Purpose of Review: Neuropathic pain is a frequently encountered condition that is often resistant to treatment and is associated with poor patient satisfaction of their treatment.

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