Neuropathic pain
Neuropathic pain is defined as pain caused by a lesion or disease of the somatosensory nervous system. Neuropathic pain manifests with multiple symptoms that vary across individuals, but there are some common characteristics.
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Definition
The International Association for the Study of Pain (2021) defines neuropathic pain as ‘pain caused by a lesion or disease of the somatosensory nervous system’.
The somatosensory nervous system includes components of the central nervous system, such as the spinal cord and brain, and the peripheral nervous system. It is responsible for processing information from the body surface and internal tissues. The somatosensory nervous system allows and detects the perception of pain (nociception), temperature, head and body position and movement (proprioception), as well as pressure (touch) (Daly et al, 2012; Donato, 2024).
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Symptoms
Neuropathic pain manifests with multiple symptoms that vary across individuals, but there are some common characteristics. As a result of the damage to the nerves and the abnormal neuron activity, patients with neuropathic pain may describe the pain as:
- electric shock
- shooting
- stabbing
- squeezing
- pressing
- burning
- tingling (Finnerup et al, 2021)
Altered skin sensations, such as allodynia and hyperalgesia, are also commonly reported.
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Aetiology
The exact mechanism of the development of neuropathic pain is complex and not fully understood. A nerve lesion is the result of a nerve injury caused by an accident, disease or a surgical procedure. Nerve injuries range from compression or stretching of the nerve to complete nerve damage (full transection). There are also common conditions that are known to cause nerve damage and potentially neuropathic pain.
Causes of neuropathic pain by aetiology include:
- viral – eg postherpetic neuralgia, human immunodeficiency virus-associated neuropathy
- bacterial – eg Lyme disease, tuberculosis
- aseptic inflammation – a non-infectious cause of inflammation may occur in acute conditions such as ischemia reperfusion injury, atherosclerosis, lung disease caused by asbestos, aseptic bursitis
- pressure from neoplasm or other structural lesions
- degenerative – eg Parkinson’s disease
- ischaemia – eg peripheral vascular disease, diabetic neuropathy, central post stroke pain
- autoimmune – eg rheumatoid arthritis
- toxic – exposure to industrial chemicals such
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Diagnosis
Neuropathic pain is a clinical description, not a diagnosis. The first step towards confirming neuropathic pain in clinical practice is based on the patient’s history, self-reported symptoms, sensory examination to evaluate involvement of the nervous system and diagnostic tests to confirm a lesion or disease (Finnerup et al, 2016). A simple and inexpensive way to predict the likelihood of neuropathic pain is to use specifically designed questionnaires. These questionnaires rely on the presence of different sensory symptoms, sensory deficit and the extent of the painful area.
There are several validated questionnaires that are completed by patients and nurses when assessing for neuropathic pain:
Leeds Assessment of Neuropathic Symptoms and Signs (LANSS)
The LANNS questionnaire is completed by the patient, producing a total score that is calculated to confirm a presence or absence of neuropathic pain (Bennett, 2001). If the score is above or equal to 12, neuropathic
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Management
Management of the underlying disease is the primary goal when treating patients with neuropathic pain. Despite the different causes of neuropathic pain, treatment is often the same and based on a multidisciplinary approach.
Pharmacological management of neuropathic pain includes tricyclic antidepressants, anticonvulsants and serotonin noradrenaline reuptake inhibitors (Kankowski et al, 2021). The National Institute for Health and Care Excellence (2024) suggests either amitriptyline, gabapentin, pregabalin or duloxetine as the first-line treatment (except for trigeminal neuralgia). If the treatment is not effective or the patient experiences side effects, the remaining three options can be trialed, one at a time, until a suitable treatment is found. If the pain is localised, and the patient cannot or does not want to take oral medication, capsaicin cream 0.075% can be considered (National Institute for Health and Care Excellence, 2024).
For the management of peripheral neuropathic pain or post-surgical scar pain, capsaicin patch 179 mg
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NMC proficiencies
Nursing and Midwifery Council: standards of proficiency for registered nurses
Part 1: Procedures for assessing people’s needs for person-centred care
1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages
Part 2: Procedures for the planning, provision and management of person-centred nursing care
3.5 take appropriate action to reduce or minimise pain or discomfort
11. Procedural competencies required for best practice, evidence-based medicines administration and optimisation
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Resources
Baranidharan G, Das S, Bhaskar A. A review of the high-concentration capsaicin patch and experience in its use in the management of neuropathic pain. Ther Adv Neurol Disord. 2013;6(5):287-97. https://doi.org/10.1177/1756285613496862
Barney CC, Andersen RD, Defrin R, Genik LM, McGuire BE, Symons FJ. Challenges in pain assessment and management among individuals with intellectual and developmental disabilities. Pain Rep. 2020;5(4):e821. https://doi.org/10.1097/PR9.0000000000000822
Bennett GJ. What is spontaneous pain and who has it? The Journal of Pain. 2012;13(10): 921-929. https://doi.org/10.1016/j.jpain.2012.05.008
Bennett M. The LANSS pain scale: the leeds assessment of neuropathic symptoms and signs. Pain. 2001;92 (1–2):147-157. https://doi.org/10.1016/S0304-3959(00)00482-6
Bernetti A, Agostini F, de Sire A et al. Neuropathic pain and rehabilitation: a systematic review of international guidelines. Diagnostics. 2021;11(1):74. https://doi.org/10.3390/diagnostics11010074
Bouhassira D, Attal N, Alchaar H et al. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain. 2005;114(1-2):29-36. https://doi.org/10.1016/j.pain.2004.12.010
British Pain Society. Lidocaine 5% medicated plasters for localised neuropathic pain: a position statement from The British Pain Society. 2018.
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