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From the Departments of Anesthesiology and of Pharmacology & Toxicology (Gilron, Cahill), Queen's University and Kingston General Hospital, Kingston, Ont.; the Department of Medicine (Watson), University of Toronto, Toronto, Ont.; Pain and Symptom Management (Moulin), London Regional Cancer Program and Departments of Clinical Neurological Sciences and Oncology, University of Western Ontario, London, Ont.
Correspondence to: Dr. Ian Gilron, Director of Clinical Pain Research, Department of Anesthesiology, Kingston General Hospital, Victory 2 Pavilion, 76 Stuart St., Kingston ON K7L 2V7; fax 613 548-1375; gilroni{at}post.queensu.ca
Abstract
Neuropathic pain, caused by various central and peripheral nerve disorders, is especially problematic because of its severity, chronicity and resistance to simple analgesics. The condition affects 2%–3% of the population, is costly to the health care system and is personally devastating to the people who experience it. The diagnosis of neuropathic pain is based primarily on history (e.g., underlying disorder and distinct pain qualities) and the findings on physical examination (e.g., pattern of sensory disturbance); however, several tests may sometimes be helpful. Important pathophysiologic mechanisms include sodium-and calcium-channel upregulation, spinal hyperexcitability, descending facilitation and aberrant sympathetic–somatic nervous system interactions. Treatments are generally palliative and include conservative nonpharmacologic therapies, drugs and more invasive interventions (e.g., spinal cord stimulation). Individualizing treatment requires consideration of the functional impact of the neuropathic pain (e.g., depression, disability) as well as ongoing evaluation, patient education, reassurance and specialty referral. We propose a primary care algorithm for treatments with the most favourable risk–benefit profile, including topical lidocaine, gabapentin, pregabalin, tricyclic antidepressants, mixed serotonin–norepinephrine reuptake inhibitors, tramadol and opioids. The field of neuropathic pain research and treatment is in the early stages of development, with many unmet goals. In coming years, several advances are expected in the basic and clinical sciences of neuropathic pain, which will provide new and improved therapies for patients who continue to experience this disabling condition.
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