Topical Lidocaine)
Capsaicin high-concentration patches (8%)- Dosage: 1 to 4 patches to cover the painful area, repeat every 3 months; 30 minutes application to feet, 60 minutes application to remainder of body; avoid use on face
- Precautions: caution in progressive neuropathy
- Common side effects: pain, erythema, itching, rare hypertension (initial increase in pain)
Tramadol (2)[A]- Dosage: 50 mg once or twice daily/400 mg daily as long-acting drug. Increase by 50 to 100 mg every 3 to 7 days
- Precautions: history of substance abuse, suicide risk
- Geriatric considerations: use of antidepressant in elderly patients.
- Common side effects: nausea, vomiting, constipation, dizziness, somnolence
Third Line
- Opioids (2)[A]
- Morphine, oxycodone
- Dosage: 10 to 15 mg morphine every 4 hours or as needed (equianalgesic doses for other opioids)/up to 300 mg morphine has been used
- Precautions: history of substance abuse, suicide risk, risk of misuse on long-term use
- Botulinum toxin type A
- Dosage: 50 to 300 units subcutaneously to the painful area; repeat every 3 months
- Precautions: infection of area
- Common side effects: pain at injection site
ISSUES FOR REFERRAL
Referral to pain clinic if refractory to initial treatment or additional therapies below are warranted. ‚
ADDITIONAL THERAPIES
- Cannabinoids (dronabinol and nabilone): The appropriateness of medical marijuana for a patient should be comprehensive assessments that revolve around risk " “benefit discussion (8,10).
- Neural stimulation (11)
- Spinal cord stimulation (SCS): Pain that is continuous and unchanging responds best. The most common indication is failed back surgery syndrome with leg pain. Less common indications are peripheral nerve injury, CRPS, and painful peripheral neuropathy (11).
- Dorsal root ganglion stimulation to treat challenging pain syndromes that do not respond to conventional SCS (11).
- Peripheral nerve stimulation (PNS): indications include pain in the distribution of an accessible peripheral nerve. The most common nerves treated are the supraorbital, infraorbital, greater occipital, ulnar, median, suprascapular, intercostal, ilioinguinal, iliohypogastric, genitofemoral, lateral femoral cutaneous, saphenous, sciatic, posterior tibial, superficial peroneal, and sural nerves (12).
- Intrathecal drug delivery considered invasive and labor intensive, may be used when other conservative therapies fail (11).
- Transcutaneous electrical nerve stimulation is widely used, evidence is poor in supporting the efficacy (11).
- Osteopathic manipulative treatment should be offered to all patients. Myofascial trigger point release can be an effective primary technique. Indirect or passive myofascial techniques may be used to address all regions of tissue texture change (12).
- Hypnosis can reduce pain and anxiety related to the pain.
- Acupuncture
SURGERY/OTHER PROCEDURES
Nerve destructive procedures haven 't shown effectiveness and may cause additional insult/injury (an exception is treatment of terminal cancer) (11). ‚
- Sympathectomy dorsal root entry zone lesion (dorsal rhizotomy)
- Lateral cordotomy
- Trigeminal nerve ganglion ablation (13)[A]
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Multidisciplinary team
- Periodic evaluation to rule out other treatable conditions (2)
Patient Monitoring
- Pain management requires ongoing evaluation, patient education, and reassurance
- Patient compliance and adequacy of analgesic drug titrations should be continually evaluated and documented.
PROGNOSIS
Chronic course of pain symptoms often requires management with numerous medications and adjunctive therapies. ‚
COMPLICATIONS
Long-term disability and drug addiction are possible. ‚
REFERENCES
11 Haanp ƒ ¤ ƒ ¤ ‚ M. Clinical Examination of a Patient with Possible Neuropathic Pain. International Association for the Study of Pain, 2014 Refresher Courses: 15th World Congress on Pain.22 Gilron ‚ I, Baron ‚ R, Jensen ‚ T. Neuropathic pain: principles of diagnosis and treatment. Mayo Clin Proc. 2015;90(4):532 " “545.33 van Hecke ‚ O, Austin ‚ SK, Khan ‚ RA, et al. Neuropathic pain in the general population: a systematic review of epidemiological studies. Pain. 2014;155(4):654 " “662.44 Finnerup ‚ NB, Sindrup ‚ SH, Jensen ‚ TS. The evidence for pharmacological treatment of neuropathic pain. Pain. 2010;150(3):573 " “581.55 Gilron ‚ I, Watson ‚ CP, Cahill ‚ CM, et al. Neuropathic pain: a practical guide for the clinician. CMAJ. 2006;175(3):265 " “275.66 Kerstman ‚ E, Ahn ‚ S, Battu ‚ S, et al. Neuropathic pain. Handb Clin Neurol. 2013;110:175 " “187.77 Finnerup ‚ NB, Attal ‚ N, Haroutounian ‚ S, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015;14(2):162 " “173.88 Attal ‚ N, Bouhassira ‚ D. Pharmacotherapy of neuropathic pain: which drugs, which treatment algorithms? Pain. 2015;156(Suppl 1):S104 " “S114.99 Zhou ‚ M, Chen ‚ N, He ‚ L, et al. Oxcarbazepine for neuropathic pain. Cochrane Database Syst Rev. 2013;(3):CD007963.1010 Hill ‚ KP. Medical marijuana for treatment of chronic pain and other medical and psychiatric problems: a clinical review. JAMA 2015;313(24):2474 " “2483.1111 Wallace ‚ M. Interventional and Nonpharmacological Therapies for Neuropathic Pain. International Association for the Study of Pain, 2014 Refresher Courses: 15th World Congress on Pain.1212 Galluzzi ‚ KE. Managing neuropathic pain. J Am Osteopath Assoc. 2007;107(10)(Suppl 6):ES39 " “ES48.1313 Straube ‚ S, Derry ‚ S, Moore ‚ RA, et al. Cervico-thoracic or lumbar sympathectomy for neuropathic pain and complex regional pain syndrome. Cochrane Database Syst Rev. 2013;(9):CD002918.
CODES
ICD10
- M79.2 Neuralgia and neuritis, unspecified
- E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unsp
- E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unsp
- G54.6 Phantom limb syndrome with pain
- E08.42 Diabetes due to underlying condition w diabetic polyneurop
- M54.10 Radiculopathy, site unspecified
- G90.50 Complex regional pain syndrome I, unspecified
- G62.9 Polyneuropathy, unspecified
- E08.44 Diabetes due to underlying condition w diabetic amyotrophy
- E08.41 Diabetes due to undrl condition w diabetic mononeuropathy
- E08.40 Diabetes due to underlying condition w diabetic neurop, unsp
- E08.43 Diab due to undrl cond w diabetic autonm (poly)neuropathy
ICD9
- 729.2 Neuralgia, neuritis, and radiculitis, unspecified
- 250.61 Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled
- 250.60 Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled
- 353.6 Phantom limb (syndrome)
- 356.9 Unspecified hereditary and idiopathic peripheral neuropathy
- 349.9 Unspecified disorders of nervous system
- 357.2 Polyneuropathy in diabetes
SNOMED
- 247398009 neuropathic pain (finding)
- 230574001 Diabetic acute painful polyneuropathy (disorder)
- 1511000119107 Diabetic peripheral neuropathy associated with type II diabetes mellitus (disorder)
- 5771000119106 Phantom limb syndrome with pain (disorder)
- 72274001 nerve root disorder (disorder)
- 25416002 Peripheral neuralgia
- 128200000 complex regional pain syndrome (disorder)
- 42345000 Polyneuropathy (disorder)
CLINICAL PEARLS
- Neuropathic pain is a chronic pain syndrome, affecting between 2% and 8% of people with a major impact on quality of life.
- The ongoing challenge for clinicians (and patients) is being able to determine which treatment is most likely to work for any one individual.
- The first line of treatment is pharmacologic and may be more beneficial with additional therapies.
- Generally resistant to acetaminophen or NSAIDs