Neuropathic Pain: How to Assess and Treat a Maladaptive Pain Response

Abstract

Neuropathic pain is associated with primary lesion or dysfunction of the peripheral and central nerve systems, affecting up to 10% of the general population. Although both nociceptive pain and neuropathic pain utilize the same nervous system pathways, physiologic differences exist in the pathologic mechanism, clinical presentation, and treatments. Ectopic activity in primary afferent fibers, excitatory and inhibitory somatosensory signaling, nociceptive neuron alterations, and central pain modulation have been implicated in neuropathic pain. These neuropathic mechanisms are associated with the complexity of symptoms, difficult treatment decisions, and challenging poor outcomes. Treatment options include pharmacologic (e.g., anticonvulsants, antidepressants, lidocaine, N-methyl-D-aspartate antagonist, opioids), physical, psychological (e.g., cognitive behavioral therapy), or interventional management (e.g., peripheral or neuro-axial nerve blockade, spinal cord stimulators, intrathecal medications). Medication selection should be individualized, considering patients’ symptoms and potential beneficial or deleterious effects (side effects) on comorbidities. The interventional management of chronic neuropathic pain should be considered for patients who have not responded to pharmacologic and non-interventional treatments, as an integral component of a more comprehensive approach. This article presents an overview of physiological mechanisms, clinical presentation, and assessment of neuropathic pain, and discusses treatment options for neuropathic pain.