Pain practice : the official journal of World Institute of Pain
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Neural blockade is widely used in clinical practice to alleviate acute or chronic pain, including neuropathic pain. However, to date there is little controlled evidence to confirm the efficacy of nerve blocks in neuropathic pain. ⋯ Sympathectomy is recommended for the treatment of neuropathic pain only after careful consideration of its usefulness, effectiveness, and risk of adverse effects. Current evidence and clinical experience suggest that neural blockade could be a useful adjunct in the management of refractory neuropathic pain, but further well-controlled studies would be of great benefit to support this type of therapy.
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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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Postherpetic neuralgia (PHN) is defined as pain that persists 1 to 3 months following the rash of herpes zoster (HZ). PHN affects about 50% of patients over 60 years of age and 15% of all HZ patients. Patients with PHN may experience two types of pain: a steady, aching, boring pain and a paroxysmal lancinating pain, usually exacerbated by contact with the involved skin. ⋯ Although antiviral agents are appropriate for acute HZ, and the use of neural blockade and sympathetic blockade may be helpful in reducing pain in selected patients with HZ, there is little evidence that these interventions will reduce the likelihood of developing PHN. Postherpetic neuralgia remains a difficult pain problem. This review describes the epidemiology and pathophysiology of PHN and discusses proposed mechanisms of pain generation with emphasis on the various pharmacological treatments and invasive modalities currently available.