The Diagnosis and Treatment of Neuropathic Pain

The reported prevalence of neuropathic pain in the general population in Germany is from 6.9% to 10%. There are both medical and surgical treatment options.

This review is based on pertinent publications retrieved by a selective search in PubMed, with consideration of clinical trials, meta-analyses, and guidelines.

Neuropathic pain is diagnosed when pain of the appropriate character is accompanied by further features such as hypesthesia/anesthesia, allodynia, or hyperalgesia. It is generally treated initially with drugs (antidepressant drugs, anticonvulsant drugs, opioids, topical agents, and others); the number needed to treat (NNT) is between 7 and 8 for gabapentin and 3.6 for amitryptiline, as estimated in meta-analyses. For nerve compression and entrapment syndromes, surgical decompression is a treatment directed against the cause of the problem, which can therefore be curative. Microvascular decompression (MVD) is often used to treat supposed compression syndromes of cranial nerves, above all classic trigeminal neuralgia; according to a meta-analysis, MVD brings about a pain-free state in 92.9% [89.1; 96.8] of patients after 5 months to 5 years of follow-up. Ablative surgical procedures are used for symptom control in patients with refractory and/or cancer-related pain. Further symptomdirected treatment options for medically intractable neuropathic pain include neuromodulatory techniques, which involve minimally invasive electrical stimulation of neural structures, and the chronic intrathecal application of drugs such as opioids and ziconotide.

The treatment of neuropathic pain can be either cause-directed or symptom-directed, depending on its origin. Multidisciplinary collaboration can facilitate both the diagnostic evaluation and the selection of the optional modality and timing of treatment.