Clinical Review

Diagnosis and management of neuropathic pain

BMJ 2009; 339 doi: http://dx.doi.org/10.1136/bmj.b3002 (Published 12 August 2009) Cite this as: BMJ 2009;339:b3002
  1. R Freynhagen, associate professor1,
  2. M I Bennett, professor2
  1. 1Department of Anaesthesiology, Critical Care Medicine, Pain Therapy & Palliative Care, Pain Center Lake Starnberg, Benedictus Krankenhaus Tutzing, 82327 Tutzing, Germany
  2. 2International Observatory on End of Life Care, School of Health and Medicine, Lancaster University, Lancaster LA1 4YT
  1. Correspondence to: R Freynhagen r.freynhagen{at}krankenhaus-tutzing.de

    Summary points

    • Neuropathic pain commonly presents in primary care and is often unrecognised

    • Diagnosis is based on characteristic symptoms, altered sensation, and a clinical history that matches a neuroanatomical or dermatomal pattern

    • Less than half of patients achieve significant benefit with any single drug

    • Management includes making pain tolerable and maintaining emotional and physical functioning

    • Non-pharmacological approaches can be effective, but referral for specialist help is indicated if pain persists or remains uncontrolled

    Neuropathic pain arises from damage, or pathological change, in the peripheral or central nervous system. It is usually a chronic condition that can be difficult to treat because standard treatment with conventional analgesics does not typically provide effective relief of pain. Patients with neuropathic pain commonly present to primary care professionals, but making a diagnosis may be difficult. Neuropathic pain is usually associated with substantially greater impairment of quality of life compared with other types of chronic pain, and the disorder is a large cost burden on healthcare services. In this review, we provide an overview of published evidence to help clinicians recognise and manage patients with neuropathic pain.

    What is neuropathic pain and who gets it?

    A group of specialists of the International Association for the Study of Pain defines neuropathic pain as “pain arising as a direct consequence of a lesion or disease affecting the somatosensory system.”1 In contrast to inflammatory or nociceptive pain, which is caused by actual tissue damage or potentially tissue damaging stimuli, neuropathic pain is produced either by damage to, or pathological change in, the peripheral or central nervous system, the system that normally signals pain. As such, the term neuropathic pain represents a varying set of symptoms rather than a single diagnosis.

    Damage to the somatosensory system can provoke a range of responses; an absence of sensation and pain is probably a more common response than new onset of …

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