neuropathy n : any pathology of the peripheral nerves
Neuropathy is usually short for peripheral neuropathy. Peripheral neuropathy is defined as deranged function and structure of peripheral motor, sensory, and autonomic neurons, involving either the entire neuron or selected levels.
ClassificationThe four cardinal patterns of peripheral neuropathy are polyneuropathy, mononeuropathy, mononeuritis multiplex and autonomic neuropathy. The most common form is (symmetrical) peripheral polyneuropathy, which mainly affects the feet and legs.
A radiculopathy involves spinal nerve roots, but if peripheral nerves are also involved the term radiculoneuropathy is used.
The form of neuropathy may be further broken down by cause, or the size of predominant fiber involvement, i.e. large fiber or small fiber peripheral neuropathy. Frequently the cause of a neuropathy cannot be identified and it is designated idiopathic.
Neuropathy may be associated with varying combinations of weakness, autonomic changes and sensory changes. Loss of muscle bulk or fasciculations, a particular fine twitching of muscle may be seen. Sensory symptoms encompass loss of sensation and "positive" phenomena including pain. This wikipedia entry will focus on the painful aspects of neurological conditions. Readers interested in a more detailed discussion of peripheral neuropathy should follow the links to the main entry.
Neuropathic painseealso Neuralgia According to the most widely accepted definition, neuropathic pain is "initiated or caused by a primary lesion or dysfunction in the nervous system." As much as 3% of the population is affected.
Neuropathic pain may result from disorders of the peripheral nervous system or the central nervous system (brain and spinal cord). Thus, neuropathic pain may be divided into peripheral neuropathic pain, central neuropathic pain or mixed (peripheral and central) neuropathic pain.
Central neuropathic pain is found in spinal cord injury, multiple sclerosis, and some strokes. Fibromyalgia, a disorder of chronic widespread pain, is potentially a central pain disorder and is responsive to medications effective for neuropathic pain.
Aside from diabetes (see Diabetic neuropathy) and other metabolic conditions, the common causes of painful peripheral neuropathies are herpes zoster infection, HIV-related neuropathies, nutritional deficiencies, toxins, remote manifestations of malignancies, genetic and immune mediated disorders.
Neuropathic pain is common in cancer as a direct result of cancer on peripheral nerves (e.g., compression by a tumor), as a side effect of some chemotherapy drugs, and as a result of radiation injury.
SymptomsNeuropathy often results in numbness, abnormal sensations called dysesthesias and allodynias that occur either spontaneously or in reaction to external stimuli, and a characteristic form of pain, called neuropathic pain or neuralgia, that is qualitatively different from the ordinary nociceptive pain one might experience from stubbing a toe.
Neuropathic pain may have continuous and/or episodic (paroxysmal) components. The latter are likened to an electric shock. Common qualities of the pain include burning or coldness, "pins and needles" sensations, numbness and itching. "Ordinary" pain results from exclusive stimulation of pain fibers, while neuropathic pain often results from the firing of both pain and non-pain (touch, warm, cool) sensory nerve fibers serving the same area. The result is signals that the spinal cord and brain do not normally receive.
Treatments for neuropathic painNeuropathic pain can be very difficult to treat with only some 40-60% of patients achieving partial relief.
Deciding on the best treatment for individual patients challenges both the art and science of medicine. Attempts to synthesize scientific studies into best practices are limited by such factors as differences in reference populations and a lack of head-to-head studies. Furthermore, there are few studies evaluating treatment combinations or the special needs of children.
It is common practice in medicine to designate classes of medication according to their most common or familiar use e.g. as "antidepressants" and "anti-epileptic drugs" (AED's). These drugs have alternate uses to treat pain because the human nervous system employs common mechanisms for different functions, for example ion channels for impulse generation and neurotransmitters for cell-to-cell signaling.
In addition to the work of Dworkin, O'Connor and Backonja et al., cited above, there have been several recent attempts to derive guidelines for pharmacological therapy. These have combined evidence from randomized controlled trials with expert opinion.
Favored treatments are certain antidepressants e.g tricyclics and selective serotonin-norepinephrine re-uptake inhibitors (SNRI's), anticonvulsants, especially pregabalin (Lyrica) and gabapentin (Neurontin), and topical lidocaine. Opioid analgesics and tramadol are recognized as useful agents but are not recommended as first line treatments.
Many of the pharmacologic treatments for chronic neuropathic pain decrease the sensitivity of nociceptive receptors, or desensitize C fibers such that they transmit fewer signals.
AntidepressantsAntidepressants function differently in neuropathic pain than in depression. Activation of descending norepinephrinergic and serotonergic pathways to the spinal cord limit pain signals ascending to the brain. Antidepressants will relieve neuropathic pain in non-depressed persons.
In animal models of neuropathic pain it has been found that compounds which only block serotonin reuptake do not improve neuropathic pain. Similarly, compounds that only block norepinephrine reuptake also do not improve neuropathic pain. Compounds such as duloxetine, venlafaxine, and milnacipran that block both serotonin reuptake and norepinephrine reuptake do improve neuropathic pain.
Tricyclic antidepressants may also work on sodium channels in peripheral nerves.
AnticonvulsantsPregabalin (Lyrica) and gabapentin (Neurontin) work by blocking specific calcium channels on neurons. The actions of the anticonvulsants carbamazepine (Tegretol) and oxcarbazepine (Trileptal), especially effective on trigeminal neuralgia, are principally on sodium channels.
Lamotrigine may have a special role in treating two conditions for which there are few alternatives, namely post stroke pain and HIV/AIDS-related neuropathy in that subgroup on antiretroviral therapy.
OpioidsOpioids, also known as narcotics, are increasingly recognized as important treatment options for chronic pain. They are not considered first line treatments in neuropathic pain but remain the most consistently effective class of drugs for this condition. Opioids must be used only in appropriate individuals and under close medical supervision.
Several opioids, particularly methadone have NMDA antagonist activity in addition to their µ-opioid agonist properties.
Methadone and ketobemidone possess NMDA antagonsism. Methadone does so because it is a racemic mixture; only the l-isomer is a potent µ-opioid agonist.
There is little evidence to indicate that one strong opioid is more effective than another. Expert opinion leans toward the use of methadone for neuropathic pain, in part because of NMDA antagonism. It is reasonable to base the choice of opioid on other factors.
Topical agentsIn some forms of neuropathy, especially post-herpes neuralgia, the topical application of local anesthetics such as lidocaine can provide relief. A transdermal patch containing Lidocaine is available commercially in some countries.
Repeated topical applications of capsaicin, are followed by a prolonged period of reduced skin sensibility referred to as desensitization, or nociceptor inactivation. Capsaicin not only deplete substance P but also results in a reversible degeneration of epidermal nerve fibers. Nevertheless, benefits appear to be modest.
Marijuana and cannabinoidsCannabinoids are modestly effective in reducing chronic pain. Nabilone is a synthetic cannabinoid which is significantly more potent than delta-9-tetrahydrocannabinol (THC). Nabilone produces less relief of chronic neuropathic pain and had more side effects than a weak opioid.
The predominant adverse effects are CNS depression and cardiovascular effects which are mild and well tolerated but, psychoactive side effects limit their use. A complicating issue may be a narrow therapeutic window; lower doses decrease pain but higher doses have the opposite effect.
Sativex, a fixed dose combination of delta-9-tetrahydrocannabinol (THC) and cannabidiol, is sold as an oromucosal spray. It has some limited effect on multiple sclerosis pain. There are high rates of adverse effects (92%), especially dizziness and nausea and intoxication. About half the users will stop the drug after one year.
Nabilone has some positive effects on the pain and other symptoms of fibromyalgia, at least in the short term. Long-term studies are need to assess the probability of weight gain and other adverse effects.
A recent study showed smoked marijuana is beneficial in treating symptoms of HIV-associated peripheral neuropathy.
NMDA antagonismThe N-methyl-D-aspartate (NMDA) receptor seems to play a major role in neuropathic pain and in the development of opioid tolerance.
Dextromethorphan is an NMDA antagonist at high doses.
Experiments in both animals and humans have established that NMDA antagonists such as ketamine and dextromethorphan can alleviate neuropathic pain and reverse opioid tolerance. Unfortunately, only a few NMDA antagonists are clinically available and their use is limited by unacceptable side effects.
Reducing sympathetic nervous stimulationIn some neuropathic pain syndromes, "crosstalk" occurs between descending sympathetic nerves and ascending sensory nerves. Increases in sympathetic nervous system activity result in an increase of pain; this is known as sympathetically-mediated pain.
Lesioning operations on the sympathetic branch of the autonomic nervous system are sometimes carried out.
Dietary supplementsThere are two dietary supplements that have clinical evidence showing them to be effective treatments of diabetic neuropathy; alpha lipoic acid and benfotiamine.
A 2007 review of studies found that injected (parenteral) administration of alpha lipoic acid (ALA) was found to reduce the various symptoms of peripheral diabetic neuropathy. While some studies on orally administered ALA had suggested a reduction in both the positive symptoms of diabetic neuropathy (including stabbing and burning pain) as well as neuropathic deficits (paresthesia), the metanalysis showed "more conflicting data whether it improves sensory symptoms or just neuropathic deficits alone".
Benfotiamine is a lipid soluble form of thiamine that has several placebo controlled double blind trials proving efficacy in treating neuropathy and various other diabetic comorbidities.
Other ModalitiesIn addition to pharmacological treatment several other modalities are commonly recommended. While lacking adequate double blind trials, these have shown to reduce pain and improve patient quality of life for chronic neuropathic pain: chiropractic, massage, meditation, cognitive therapy, and prescribed exercise. Some pain management specialists will try acupuncture, with variable results.
Transcutaneous electrical nerve stimulation (TENS) may be worth considering in chronic neurogenic pain. TENS, with certain electrical waveforms, appears to have an acupuncture-like function.
Infrared photo therapy has been used to treat neuropathic symptoms. However, recent work has cast doubt on the value of this approach.
Neuromodulation is a field of science, medicine and bioengineering that encompasses both implantable and non-implantable technologies (electrical and chemical) for treatment purposes.
Implanted devices are expensive and carry the risk of complications. Available studies have focused on conditions having a different prevalence than neuropathic pain patients in general. More research is needed to define the range of conditions for which they might be beneficial.
Spinal Cord Stimulators And Implanted Spinal Pumps
Spinal cord stimulators, use electrodes placed adjacent to, but outside the spinal cord. The overall complication rate is one-third, most commonly due to lead migration or breakage. Lack of pain relief sometimes prompts device removal.
Infusion pumps delivery medication directly to the fluid filled (subarachnoid) space surrounding the spinal cord. Opioids alone or opioids with adjunctive medication (either a local anesthetic or clonidine) or more recently ziconotide are infused. Complications such as, serious infection (meningitis), urinary retention, hormonal disturbance and intrathecal granuloma formation have been noted.
There are no randomized studies of infusion pumps. For selected patients 50% or greater pain relief, is achieved in 38% to 56% at six months but declines with the passage of time. These results must be viewed skeptically since placebo effects cannot be evaluated.
Motor Cortex Stimulation
Stimulation of the primary motor cortex through electrodes placed within the skull but outside the thick meningeal membrane (dura) has been used to treat pain. The level of stimulation is below that for motor stimulation. As compared with spinal stimulation, which requires a noticeable tingling (paresthesia) for benefit, the only palpable effect is pain relief.
Deep Brain Stimulation
The best long-term results with deep brain stimulation have been reported with targets in the periventricular/periaqueductal grey matter (79%), or the periventricular/periaqueductal grey matter plus thalamus and/or internal capsule (87%). There is a significant complication rate which increase over time.
Neuropathy related organizations
- Nep Know More Provides Additional Help and Information on Neuropathic Pain
- A neuropathic series of articles from a neurologist who researches neuropathic pain
- Up to 16% of Patients with Small Fiber Neuropathy May Have Celiac Disease
- National Diabetes Information Clearinghouse
- Information about Neurology Article on marijuana's effect on neuropathic pain
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