Treating

Neuropathy
Pain
Anwar Wardy W
Neurology FK UMJJ
2011

anwar wardy fk.umj 2011

 Neuropathy primer
Neuropathy: Non-inflammatory
functional disturbance or pathologic
changes in central/peripheral nerve system
(sensory/motor/autonomic)

Neuritis: Same as neuropathy except that it is

inflammatory in nature

anwar wardy fk.umj 2011

 Categories
Mononeuropathy: focal
involvement of single nerve

Polyneuropathy: generalized or
homogeneous involvement of many
peripheral nerves (distal nerves
being affected most)

Mononeuropathy multiplex:
simultaneous or sequential
involvement of non-contiguous
nerves
anwar wardy fk.umj 2011
 Define patient complaint
Careful neuro history / physical
Sensory (paresthesia, dysesthesia, anesthesia)
Motor (weakness)
Reflexes
Cerebellar (gait, balance, proprioception)
Usual PMHx, Meds, ROS, Exposure hx,
FHx

anwar wardy fk.umj 2011

 Diagnosing the neuropathy
The diagnostic workup of neuropathy can
be challenging
Broad differential
Sometimes difficult or non-specific
history and/or exam

*Remember that piece of watermelon

anwar wardy fk.umj 2011

 A very broad differential
Peripheral: Central:
Metabolic/nutritional Ischemic (CVA, TIA)
(DM, thyroid, b12, etoh)
Tumor
Entrapment
Infectious (encephalitis)
Connective tissue disorders
(vasculitis, RA) Inflammatory (vaculitis)
Toxins (Meds, heavy metals, Degenerative (MS)
chemo)
Infectious (HIV, Lyme)
Malignancy (myeloma, lymphoma)
Other (Hereditory conditions,
sarcoid, idiopathic)
anwar wardy fk.umj 2011
 Testing
Labs: Special testing
CBC EMG
Chem panel NCS
B12 Nerve/skin
ESR biopsy
SPEP/UPEP
ANA
RPR/HIV
History & Physical
Radiology
Hepatitis findings to focus MRI
panel
ddx and testing (spine, brain)
And lots
more
anwar wardy fk.umj 2011
 Focus back to treatment
Based on common
clinical neuropathy
scenarios or conditions

before we get too

much under water

anwar wardy fk.umj 2011

 Treatment concepts

1.Treat the underlying condition

2.Alleviate symptoms
related to neuropathy

anwar wardy fk.umj 2011

 Scenario #1
Burning & tingling in hands
or feet
Insidious type onset
Progressive over extended
time period
Occasional stabbing, shock ,
shooting pains
No motor symptoms

anwar wardy fk.umj 2011

 Peripheral Chronic
Sensory Neuropathy
DIABETES
Chronic Alcohol overuse
Nutritional deficiency (B vitamins)
Drug/medication toxicity
The Rest
Thyroid, anemia, myeloma/gammopathy,
vasculitis, infection (HIV, syphilis), sarcoid,
heavy metal toxicity, uremia, amyloid,
IDIOPATHIC
anwar wardy fk.umj 2011
 Treatment
Address underlying causes
Glucose control
Etoh cessation
B vitamin supplementation
Eliminate potential causative medications
Thyroid replacement
Other disease specific
Pharmacotherapy

anwar wardy fk.umj 2011

 Medication Therapy
Antidepressants
TCAs
SSRI/NERI
Anticonvulsants
Old agents
New agents
Opiates
Antioxidants
Anesthetic/analgesic
anwar wardy fk.umj 2011
 Diabetic Neuropathy
First Tier Second Tier
more than 2 RCTs evidence from 1 RCT
demonstrating positive effect demonstrating positive effect
(Level I) (Level II)

Duloxetine Venlafaxine
Pregabalin Tramadol
Oxycodone CR Carbamazepine /
TCAs Lamotrigine

Veves A, et al. Painful Diabetic Neuropathy: Epidemiology, Natural History, Early Diagnosis, and
Treatment Options. Pain Medicine, Vol 9, No 6. 2006.
anwar wardy fk.umj 2011
 Diabetic Neuropathy
Additional Therapies
Topicals :
- Capsaicin, lidocaine 5% patch

Acupuncture
NMDA receptor antagonists
- detromethrophan

Antioxidants: alpha-lipoic
acid (ALA)
Antiarrhythmics
- mexilitine
anwar wardy fk.umj 2011
 Diabetic Neuropathy

Duloxetine & Pregabalin

Only meds FDA approved for diabetic
peripheral neuropathy

- Tight Glucose control

- Adequate treatment of symptoms may

require dual agent/modality therapy

anwar wardy fk.umj 2011

 Peripheral Chronic
Sensory Neuropathy
Consider applicability of treatment options
for diabetic neuropathy to other chronic
sensory peripheral neuropathies
Determine and treat underlying cause first
Balance risks/side effects of meds with
potential benefit when treating pain

anwar wardy fk.umj 2011

 Scenario #2
Stinging, shooting,
numbness sensation in
localized area
Occurring over several
weeks to months
May wax / wane
depending on activity
+/- motor involvement
anwar wardy fk.umj 2011
Sensory (motor) Mononeuropathy
Entrapment or compression of nerve
Nerve vs. nerve root

Local inflammation / infection

Trauma
Including post surgical

Idiopathic

anwar wardy fk.umj 2011

 Treatments
Physical Therapy
Steroid injections
Surgical
decompression
Nerve ablation
Medications

anwar wardy fk.umj 2011

 Nerve Root Compression
(radiculopathy)

Surgery

Epidural

Rest, meds, PT Step-up treatment

anwar wardy fk.umj 2011

 Trigeminal Neuralgia
Unilateral or bilateral
(mono vs. multifocal neuropathy)
Blends mono / poly
neuropathy treatment strategies
Distinguish classic form (CTN)
from symptomatic form (STN)
Eval & Treatment varies
between CTN & STN

anwar wardy fk.umj 2011

 Trigeminal Neuralgia
Classic TN Symptomatic TN
No clinically evident
neurologic deficit
Without established
etiology
Neuroimaging (SOR C)
Non-vascular structural
lesion affecting TN
(MS plaque, skull base
abnormality, tumor)
Sensory deficits and bil
involvement (SOR B)
Electrophysiologic studies
(SOR B)
Neuroimaging (SOR C)

anwar wardy fk.umj 2011

 Questions?

anwar wardy fk.umj 2011