The approach to the management of the patient with neuropathic pain

Neuropathic pain occurs in about 6-7% of the general population and in 15-20% of people with diabetes. It is defined as a disease or disorder of the sensorimotor system and must be distinguished from nociceptive pain, which is a consequence of trauma, injury, or inflammation. A host of other conditions can masquerade as neuropathy including entrapments, fasciitis, and claudication. Pain can derive from damage to unmyelinated C-fibers, Aδ fibers in the periphery, or from mechanisms within the spinal cord, brainstem, and cerebral cortex. A variety of excitatory and inhibitory neurotransmitters are involved and form the basis for targeted drug therapy. More important, however, is the pathogenesis of damage to the pain mechanism, which is multifactorial and includes metabolic disturbances such as hyperglycemia, even impaired glucose tolerance, dyslipidemia, oxidative and nitrosative stress, growth factor deficiencies, microvascular insufficiency, and autoimmune damage to nerve fibers. The approach to managing the patient with neuropathic pain is first to understand and recognize the cause of pain in a particular patient and to use monotherapies or drug combinations directed at the different types and sources of pain. Ultimately, therapy directed at the underlying pathogenesis of neuropathy is needed. The case presented in this report illustrates the complexity of resolution of pain in an individual and the need for a holistic approach to medicine, employing empathy, compassion, and understanding in the relationship between the doctor and the patient to succeed in alleviating pain.