Jianguo Cheng, M.D., Ph.D.

Neuropathic pain can be difficult and expensive to manage, but new guidelines and strategies based on evidence-based decision-making are leading to improved outcomes. Those new approaches are explained in a Self-Study course available for CME during the ANESTHESIOLOGY 2016 annual meeting.

Kiosks to complete Self-Study courses are available outside Room 190, on level 1 of McCormack Place. The courses also will be available online after the meeting, but users cannot earn CME.

“The greatest challenge in pain medicine is neuropathic pain, defined by a lesion or disease of the somatosensory nervous system. It will require not only education but also research to have a better understanding to overcome the difficulties in pain management in general and neuropathic pain in particular,” said Jianguo Cheng, M.D., Ph.D., developer of the presentation.

“State-of-the-Art of Neuropathic Pain Management” defines neuropathic pain, explains its mechanisms and outlines management strategies, said Dr. Cheng, Professor of Anesthesiology and Director of the Pain Medicine Fellowship Program, Cleveland Clinic. He also is Vice President for Scientific Affairs of the American Academy of Pain Medicine.

“The course describes peripheral and central sensitization as common mechanisms of neuropathic pain and describes broad classifications of neuropathic pain,” he said. “The big take-home is information on the new guidelines for pharmacological treatment and interventional treatment.”

Neuropathic pain is distinct from nociceptive pain and is linked to a lesion or disease of the somatosensory system. It is characterized by spontaneous ongoing or shooting pain and evoked amplified pain responses after noxious or non-noxious stimuli.

Common mechanisms of neuropathic pain are peripheral and central sensitizations. Peripheral sensitization is described as plasticity in the peripheral nervous system involving inflammatory responses to insults. Central sensitization is described as plasticity in the spinal cord and brain involving activation of glial cells and immune cells, and increased neuronal excitability.

Non-pharmacological, pharmacological and interventional treatments are linked to etiology-based classifications of neuropathic pain and practice guidelines.

Non-pharmacological treatments can complement or serve as stand-alone treatments. They provide better outcomes in combination with a comprehensive multimodal pain management plan that also includes pharmacologic agents and interventional modalities. They can include exercise, physiotherapy treatments, mirror therapy, psychological approaches, tai chi, yoga, acupuncture, transcutaneous electrical nerve stimulation and repetitive transcranial magnet stimulation.

Pharmacological management features first-line, second-line and third-line treatments. First-line treatment includes tricyclic antidepressants, serotonin-noradrenaline reuptake inhibitors, pregabalin and gabapentin. Second-line treatments include lidocaine patches, capsaicin high-concentration patches and tramadol. Third-line treatments include strong opioids and botulinum toxin A.

The International Association for the Study of Pain’s Neuropathic Pain Special Interest Group has made four recommendations for interventional therapies, but significant progress has been made since the recommendations were released, Dr. Cheng said. Those therapies include botulinum toxin injections, steroid injections, chemical neurolysis, radiofrequency therapy, spinal cord stimulation, peripheral nerve stimulation, cortical or deep brain stimulation and intrathecal therapy.

Another treatment option is surgery, such as neuroma excision, release of entrapment, decompression of spinal stenosis, microvascular decompression and partial sensory rhizotomy.