Articles: neuralgia.
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Seminars in neurology · Jun 2005
ReviewEvaluation and treatment of painful peripheral polyneuropathy.
Pain is a common component of sensory peripheral polyneuropathy and occurs primarily as a consequence of injury to small, unmyelinated C-fiber nerve axons. This class of fibers is particularly vulnerable to metabolic injury, and the neuropathy manifests in a length-dependent pattern. ⋯ Treatment of painful neuropathy should be directed at removing the offending metabolic injury, if possible. Antiepileptic drugs, tricyclic antidepressants, opiates, and other treatments have shown efficacy in clinical trials for symptomatic relief of neuropathic pain.
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Pharmacologic therapy for neuropathic pain is based on an evolving understanding of its underlying mechanisms, and often requires a patient,methodical sequence of trials that include the "four As": analgesics,antidepressants, anticonvulsants, and antiarrhythmics. Critical for success is a willingness to stay engaged with the patient to evolve a mutually acceptable plan and goals of care with realistic outcomes that emphasize symptom control and maximization of function. Such management is within the capabilities of surgeons for most patients, whereas the use of consultation and interdisciplinary supportive interventions from comprehensive pain management centers, if available, is helpful in more difficult cases.
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Neuropathic pain and fibromyalgia are prevalent diseases which have major consequences on healthcare resources and the individual. From the clinical point of view neuropathic pains represent a heterogeneous group of aetiologically different diseases ranging from cancer to diabetes. Patients with fibromyalgia also display clinical features common in neuropathic pain suggesting that there might be some overlap. ⋯ Treatment of fibromyalgia, which has many features in common with depressive symptoms, became the focus of interest. New promising studies with dual serotonin-norepinephrine reuptake inhibitors (duloxetine and milnacipram) and a newer antiepileptic drug (pregabalin) are in progress. Future research will have to apply new approaches (e.g., using a mechanism-based classification of neuropathic pain and carrying out studies in populations with the same symptom but not necessarily the same disease) in order to find effective treatments for these common and often debilitating diseases.
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Neuropathic pain results from a variety of medical conditions encountered in physiatric practice, including infection, trauma, metabolic abnormalities, and nerve compression. Unlike pain resulting from nociceptive or inflammatory processes, neuropathic pain is associated with primary lesion or dysfunction of the nervous system itself and is often difficult to treat. Existing treatment options include drug therapy (e.g., anticonvulsants, the lidocaine patch 5%, antidepressants, opioids, tramadol) or interventional treatments (e.g., peripheral or neuraxial nerve blockade, implanted spinal cord stimulators, implanted intrathecal catheters). The following article presents an overview of the cellular mechanisms associated with neuropathic pain, summarizes the results of randomized, controlled trials with the major classes of available drugs, and discusses treatment options that provide a rational basis for pharmacotherapy.