Neuropathic pain

The Peripheral Neuropathy Solution

Peripheral Neuropathy Solution By Dr. Randall Labrum

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Nociceptive pain results from real or potential tissue damage. Neuropathic pain is caused by damage to the peripheral or central nervous system. A simple definition is "pain in an area of abnormal sensation." Pain may be described as aching, burning, shooting, or stabbing and may be associated with abnormal sensation; normal touch is perceived as painful (allodynia). It may be caused by tumour invasion or compression but also by surgery, radiotherapy, and chemotherapy. Many patients have neuropathic pain that responds to opioids, and so initial management should include a trial of opioids. Patients who remain in pain will require additional measures.

The early addition of adjuvant analgesics, such as a tricyclic antidepressant or an anticonvulsant, should be considered. The number needed to treat is 3 for both categories. There is no evidence for a specific adjuvant for specific descriptors of neuropathic pain.

Computed tomography scan showing advanced pelvic disease from colorectal tumour resulting in severe pain

Classical changes associated with a brachial plexopathy due to a right Pancoast tumour: oedema, trophic changes, muscle wasting

Patients may be overwhelmed by their situation and the central nervous system can express this as physical pain, though social, psychological, or spiritual factors may be major components

About 10% of patients will have pain that responds poorly to opioids and is uncontrolled even with a dose of morphine sufficient to give them intolerable side effects

Classical changes associated with a brachial plexopathy due to a right Pancoast tumour: oedema, trophic changes, muscle wasting

In addition, there is no evidence for combining adjuvants. In clinical practice, an adjuvant is chosen for an individual patient after all symptoms and potential side effects are considered. Doses should be titrated to balance analgesia with adverse effects. If titration has reached a limit and pain has only partially responded then a second adjuvant may be added in some cases. This usually means a reduction in the dose of the first. A common example of combining adjuvants is gabapentin, which at maximum tolerated dose can sometimes be reduced to allow the addition of amitriptyline.

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