Going Beyond the Usual Neuropathic Pain Conditions

Author: Ignacio Badiola

Dr. Badiola: Odd neuropathic pain disorders are a problem in the United States and across the world. Some of the more common ones that we tend to see are post mastectomy syndrome, post thoracotomy syndrome, and post inguinal hernia repair syndrome. They’re typically considered neuropathic pain states. They’re not the typical neuropathic pain disorders that we think of in pain management and primary care, which tend to be more things like diabetic neuropathy that affects a larger proportion of the population. They are usually postsurgical and their treatment might differ a little bit as well.

Dr. Yi: I’m not sure if odd is necessarily the right word. They’re odd in the sense that not everyone gets them after these certain types of surgeries. It’s only a subset of patients that tend to get long sequelae of pain after these surgeries. So I guess in that way, it’s odd, but they are actually pretty prevalent for people that experience it.

Dr. Badiola: The best treatment options include a multimodal approach using things like anti-neuropathic pain medications, as well as treating any comorbidities that these patients may have - things such as depression, anxiety, and sleep disorders. Some of the more common medications that have the best evidence for them are things like gabapentin and pregabalin. Those are usually considered the first line of therapy for these kind of pain symptoms. Second-line therapy would be things like some antidepressants specifically like duloxetine and venlafaxine, which work in the serotonin and norepinephrine reuptake inhibitor pathway, and that has been shown to be pretty successful in these patients as well. In general, these patients are not good candidates for opioid therapy. Most people consider opioids in these patients more as a second-line, and even third-line. Ideally, you want to try to maximize some of the non-opioid modalities.

Dr. Yi: We try to emphasize a multimodal approach; medical treatment, procedural interventions, psychological interventions like cognitive-behavioral therapy, graded motor imagery. These therapies benefit patients the most when they’re used in conjunction with each another. Some of the non-pharmacological therapies for these neuropathic pain syndromes would be preemptive modalities, meaning targeting pain before a noxious stimuli happens. In a lot of these cases, it will be surgery. So preemptive procedures - like a thoracic epidural or a paravertebral catheter, different types of PEC blocks for mastectomy. Those types of procedures would be alternatives to medications.

Dr. Badiola: I would tell a primary care physician to either consul or refer to pain management specialists if they have questions. Most pain management physicians are more than happy to assist. A lot of times, we that see primary care physicians are able to start patients on some of these medications, and in a lot of patients, they will do fine. They will never need to see a pain management physician. But as soon as any questions come up where it just doesn’t seem right, we’re always just a phone call away.

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