Pain practice : the official journal of World Institute of Pain
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Optimal management of patients with chronic neuropathic pain requires a multidisciplinary approach that may include surgery. Yet despite the fact that lumbosacral spinal surgery, for example, is performed in thousands of patients every year, there is very little controlled clinical data to support its use or that of other surgical techniques in the treatment of chronic nonmalignant pain, especially neuropathic pain. ⋯ However, before considering a surgical procedure, a nonsurgical approach should have been tried and the suitability of the patient must be carefully assessed. To fully establish the role of surgery in the treatment of chronic neuropathic pain, further well-designed, prospective, controlled trials are essential.
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Intrathecal drug delivery (IDD) is a proven and effective treatment alternative in carefully selected patients with chronic pain that cannot be controlled by a well-tailored drug regime and/or spinal cord stimulation (SCS), and may be specifically trialed in patients who fail to respond to SCS. While the lack of randomized controlled trials is often perceived as a limitation of IDD, many studies attest to the efficacy of this therapy, and a number are large-scale and with follow-up periods of up to five years. Good to excellent pain relief is achieved in many patients who have failed more conservative therapies, and there is often a reduced need for analgesia. ⋯ Some patients are able to return to work. The benefits of IDD (including a potent analgesic response with a more stable therapeutic drug level, decreased latency, increased duration of action, and decreased pharmacological complications) mean that side effects such as nausea, vomiting, sedation, and constipation are reduced. In addition, IDD demonstrates long-term cost-effectiveness when compared to conventional pain therapies, addressing a concern that affects many physicians in clinical practice today.
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Although neuropathic pain can be acute in nature, in most patients the pain is persistent (or "refractory"). Patients with chronic neuropathic pain are seen most often in clinical practice. It consists of a number of different disease-specific indications, each of which can have differing diagnostic definitions and cutoffs. ⋯ The burden of neuropathic pain on patients and healthcare systems appears to be potentially large, with an estimated prevalence of 1.5%. Patients with neuropathic pain experience a poor health-related quality of life and consume a high level of healthcare resources, and costs. The future prioritization by healthcare policy makers for neuropathic pain treatment funding requires further data to clarify its epidemiology, the burden on the health of patients, and the demand on healthcare budgets.
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Refractory neuropathic pain can be devastating to a patient's quality of life. Ideally, the primary goal of therapy would be to prevent the pain, yet even the most appropriate treatment strategy may be only able to reduce the pain to a more tolerable level. ⋯ Even so, effective pain relief is achieved in less than half of patients with chronic neuropathic pain. In refractory patients, combination therapy using two agents with synergistic mechanisms of action may offer greater pain relief without compromising the side-effect profile of each agent.