Recommendations for the Management of Neuropathic Pain Associated With Peripheral Nerve Entrapment.
Peripheral nerve entrapment is often associated with neuropathic pain symptoms. These recommendations – an update of the recommendations first published in 20051—describe the management of some of the more common causes of neuropathic pain due to peripheral nerve entrapment. The recommendations are structured by nerve level as follows:
- Root level
– Cervical radiculopathy
– Lumbar radiculopathy
Less common causes
– Brachial plexus injury
– Thoracic outlet syndrome
- Peripheral nerve level
– Carpal tunnel syndrome
– Cubital tunnel syndrome
– Other sites
Less common cause
– Radial tunnel syndrome.
Treatment of neuropathic pain associated with peripheral nerve entrapment differs from other neuropathic pain conditions, such as post-herpetic neuralgia, painful diabetic neuropathy and trigeminal neuralgia, in that surgical decompression is often a first-line treatment option, rather than pharmacological treatment. Nerve repair may be required in cases of nerve injury; these procedures are beyond the scope of this paper. In the presence of a definite mechanical compression, the primary goal is surgical decompression of the nerve. However, conservative treatment and pharmacotherapy tend to be more effective when neuroimaging shows no significant compression on the affected nerve root. Neuropathic pain sometimes persists following surgical decompression or repair of compressed or damaged nerves. In these cases, pharmacotherapy is an appropriate treatment option.
Conservative treatment: This may include short-term use of a cervical collar during the acute phase (a soft collar will in most cases be sufficient for conservative treatment), oral nonsteroidal anti-inflammatory drugs (NSAIDs), neck care exercises, postural training and activity modification, and intermittent cervical traction. While many cases of cervical spondylosis respond to conservative treatment, patients with cervical radiculopathy may require surgical decompression of the nerve root.
Patients with painful cervical radiculopathy and neuropathic pain symptoms may improve with pharmacotherapy, such as antidepressant or anticonvulsant agents. A recently published observational, prospective study in the treatment of painful cervical or lumbosacral radiculopathy in a primary care setting revealed that pregabalin monotherapy or add-on therapy, versus non-pregabalin pharmacotherapy, for 12 weeks resulted in improvements in pain, anxiety symptoms, depression, sleep disturbance, general health and level of disability; improvements were significantly greater in the pregabalin groups.4
There is some evidence for a role for epidural corticosteroids in the management of cervical radiculopathy.5,6 One systematic review concluded that there is moderate evidence for cervical interlaminar and transforaminal epidural steroid injections in providing long-term relief.6 However, care must be taken with these procedures, with some evidence for rare, but severe, neurologic complications reported for transforaminal cervical epidural steroid injection.7 A review of complications of interlaminar cervical epidural steroid injections revealed that it is a relatively safe procedure, with most adverse reactions being minor and transient, but serious complications may also result.8 Hence, patients should be referred to experienced physicians for epidural corticosteroid injection.
Surgical interventions: Surgery is indicated when other treatments have failed. The main aim of surgery in patients with cervical myelopathy and radiculopathy is decompression of the spinal cord or nerve root. However, surgical interventions are associated with complications (1% to 8% of patients), including death (0% to 1.8%).9 Complications resulting from damage to the spinal cord include tetraplegia, and those resulting from damage to the nerve root include muscle weakness. Patients with pain only are the most difficult group to treat; surgery tends to be more beneficial in patients with severe neurological deficits.
Surgical decompression of the nerve root is often achieved via an anterior approach (with removal of the intervertebral disc and osteophyte), or a posterior approach (with laminectomy). A 2002 Cochrane review on the role of surgery in cervical spondylotic radiculomyelopathy identified two controlled trials involving 130 patients.9 The most common surgical interventions were via an anterior cervical approach with spinal fusion. Patients receiving surgery via a posterior approach underwent laminectomy. Control interventions included physiotherapy, hard or soft cervical collar, anti-inflammatory drugs, intermittent bed rest and prevention of vigorous activities. Surgery patients had greater improvements in pain, weakness and sensory loss in the short term than control patients. However, after 1 to 2 years’ follow-up, there were no significant differences observed between groups. The authors concluded that there was inadequate data with which to determine whether surgical interventions were superior to more conservative therapy.
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