Neuropathy
If you are experiencing a persistent burning, itching or numbness, a sensation of pins and needles, or a phantom pain that seems difficult to classify or localize, you might be experiencing symptoms that fall under the broad umbrella of Neuropathy, or nerve damage. First and foremost, your doctor must identify the underlying cause before he/she can tailor the correct course of treatment. This is crucial because the sooner treatment is initiated, the less likely the nerve damage will become permanent.
What is Neuropathy?
Simply put, Neuropathy means nerve damage. Although it can affect 
the Central Nervous System (CNS), the Peripheral Nervous System (SNS), or both, we most commonly are talking about peripheral Neuropathy, i.e. damage to the nerves of the peripheral nervous system.
Two examples of Neuropathy you might be already familiar with are:
-Carpal tunnel syndrome (CTS)
-Diabetic peripheral polyneuropathy (DPPN)
Numbness, burning, tingling and weakness are all reported with Neuropathic conditions.
Neuropathy can be caused by a variety of things, ranging from physical injury and infection to inherited genetic disorders and systemic disease.
Neuropathy is usually diagnosed by patient history and a standard neurological examination alone. If you believe you are suffering from these symptoms, the Ainsworth Institute of Pain Management can offer unique treatment options unavailable anywhere else in New York City.
Symptoms of a body area affected by Neuropathy include:
Neuropathy 101
Broadly speaking, Neuropathy is a disturbance of function or pathologic change in a nerve.[3] Neuropathic pain is pain arising as a direct consequence of a lesion or disease affecting the somatosensory system.[4]
Types
There are three types of Neuropathy depending on how the damage to the nerve affects the patient.
Sensory Neuropathy
Damage to a nerve affects sensation only. The patient will typically experience numbness to touch and vibration, reduced position sense, poor coordination, reduced or increased sensitivity to temperature, spontaneous tingling or burning pain.
Motor Neuropathy
Damage to a nerve affects muscle movement only. The patient will typically experience weakness, impaired balance and/or coordination.
Autonomic Neuropathy (Dysautonomia)
Damage affects the autonomic nervous system only (i.e. subconscious pathways that coordinate digestion, blood flow, perspiration, etc) The patient can experience diverse symptoms depending on the glands or organs affected; excessing fatigue, excessive thirst, lightheadedness, abnormal heart rate or blood pressure, shortness of breath, incontinence, abdominal distention, gastroparesis, excessive sweating or lack of sweating, temperature intolerance.
Classification
The three types of Neuropathy are further broken down into three classifications depending on the number of nerves affected. It is important the doctor classifies the Neuropathy correctly in order to tailor the appropriate treatment plan for the patient. Many neuropathies have very similar presentations – this is due in part to the similarities in how each disease process affects the nervous system. Below is a list of conditions associated with the three classifications:
| Etiology | Terminology | Peripheral vs. Central Nervous System Etiology |
|---|---|---|
| Physical Injury/Trauma | ||
| Complex regional pain syndrome (CRPS), Type I (reflex sympathetic dystrophy or RSD) | Mixed? | |
| Complex regional pain syndrome (CRPS), Type II (causalgia) | Mixed? | |
| Radiculopathy | Peripheral > central | |
| Stroke (cerebrovascular accident) | Central | |
| Spinal cord injury | Central | |
| Inherited/Genetic | ||
| Charcot-Marie-Tooth | Mixed | |
| Fabry’s disease | ||
| Infections/Autoimmune | ||
| Human immunodeficiency virus | Peripheral | |
| Herpes simplex virus | Peripheral > central | |
| Acute inflammatory demyelinating polyneuropathy (AIDP) | Mixed | |
| Chronic inflammatory demyelinating polyneuropathy (CIDP) | Peripheral | |
| Systemic Disease | ||
| Diabetes mellitus | Peripheral | |
| Kidney disorders/renal failure | Peripheral > central | |
| Vitamin deficiencies (beriberi, alcoholic pellagra, vitamin B12 deficiency) | Mixed | |
| Vascular disorders | Peripheral > central | |
| Chemical toxins (isoniazid, chemotherapy agents) (platinum, vinca alkaloids, taxanes), arsenic, thallium | Mixed | |
| Hypothyroidism | Peripheral | |
| Amyloidosis | Mixed | |
| Multiple myeloma | Mixed |
The Pain Caused by Neuropathy
Neuropathic pain can often be difficult for a patient to describe. Some patients have problems pinpointing where the pain is even located. This is because neuropathic pain is perceived differently than nociceptive pain (pain that is sharp, aching or throbbing) and typically consists of strange or abnormal sensations. There are six classifications of pain associated with Neuropathy:
Paresthesias: Abnormal, non-painful sensations typically described as tingling, or pins-and-needles sensation; can be spontaneous or evoked.[5]
Dysesthesias: Unpleasant or even painful tingling; can be spontaneous or evoked.
Hyperpathia: Normally painful stimulus is abnormally painful; an exaggerated painful response.
Allodynia: A painful response to a normally non-painful stimulus (e.g., light touch is perceived as burning pain).
Hyperalgesia: An exaggerated painful response to a normally noxious stimulus.
Spontaneous Pain: Painful sensation with no apparent external stimulation.
So drawing together all this information (including “read more” above), we can fully diagnose any given Neuropathic condition. For example, the above mentioned diabetic peripheral polyneuropathy (DPPN).
This patient would suffer from:
1. Sensory Neuropathy
2. Polyneuropathy
3. Paresthesias
What causes Neuropathy?
Neuropathy can be caused by a seemingly endless group of factors. Genetics, injury, disease and environmental agents can all potentially contribute.
Am I Suffering from Neuropathy?
If any of these neuropathic symptoms seem familiar to you, it is important you schedule an appointment with the Ainsworth Institute. Your doctor will generally be able to diagnose neuropathy with your medical history and a standard neurologic examination alone.
While it is true there is a great deal of overlap between many of the different types of neuropathy, identifying the area of the body you are experiencing pain, in conjunction with the particular signs and symptoms a patient presents with can be very suggestive of not only what type of neuropathy is present, but the underlying pathological process as well.
As part of your neurologic evaluation, your physician will evaluate:
Light touch
Pinprick
Temperature
Reflex
Balance
Muscle Strength
Coordination
Proprioception (position sense)
In addition to a thorough physical exam, your physician may elect to order some blood work as well as imaging (i.e. x-ray, CT scan, or MRI). In some cases, when patients do not respond as well to treatment, further examination may be necessary.
Further and more in depth testing may be required to accurately diagnose a patient’s type of Neuropathy. Some examples are:
Electromyography (EMG): Typically implemented in conjunction with an NCV as part of an electrodiagnostic work up. Placing small acupuncture-sized needles into specific muscles, your physician will be able to “listen” to the those particular muscles and evaluate if there is any irregular activity present in them that might be suggestive of a particular neuropathy.
Nerve Conduction Velocity (NCV) Study: Typically performed in conjunction with an EMG as part of an electrodiagnostic work up. Your physician will send a small electrical impulse into individual nerves and then measure how long it takes for that impulse to travel different lengths along the nerve. This will allow your physician to measure the speed of transmission of these nerves in order to evaluate their health.
Skin Biopsy: Your physician will take a small sample of your skin from an affected area to evaluate the density and morphology of the nerve fibers. This test is of particular importance when evaluating for small fiber neuropathy
The most important aspect of treating neuropathy is identifying the underlying cause or toxic agent, and attempting to treat or rectify that first.
(For example, in the case of Diabetic Peripheral Polyneuropathy or carpal tunnel syndrome, better management of blood sugars or relief of pressure on the median nerve can improve the symptoms and prevent progression of the neuropathy.)
Once the underlying cause is established, the doctor can then initiate a treatment plan. The sooner treatment is initiated, the less likely the symptoms and nerve damage will become permanent.
At the Ainsworth Institute of Pain Management, our physicians can offer treatments for Neuropathy that are not available anywhere else in New York City. Some of these include:
Sympathetic Nerve Blocks – These injections have been utilized as both a diagnostic and therapeutic tool. Your physician will insert a thin needle under radiographic guidance, through the skin, targeting the Sympathetic Nervous System (SNS). The nerves of the SNS are then “blocked” with small amount of local anesthetic. The pain relief from these injections can dramatic. Procedures that focus on facial and upper extremity neuropathy include the Stellate Ganglion Block. Lumbar Sympathetic Blocks are typically performed for lower extremity neuropathic pain.
IV Infusion Therapy – A simple procedure commonly performed in the office. Your doctor will place a small IV catheter and then infuse special medications intravenously in an attempt to halt the pain process. Depending on the type of neuropathy, a number of different medications are available for infusion – in the case of small fiber neuropathy, Intravenous Immunoglobulin (IVIG) has become the medication of choice.
Spinal Cord Stimulation (SCS) – This is a commonly performed procedure utilizing technology similar to that of cardiac pacemakers. This method involves placing small electrodes into the epidural space near the spinal cord. These electrodes produce a small electrical current over the spinal cord that your brain will interpret as a gentle massage or a “champagne bubble” feeling. This will inhibit pain transmission and provide relief to areas affected by neuropathy. In the case of DPPN, Spinal Cord Stimulation can help restore healthy blood flow as well as relieving pain.
DRG Stimulation – DRG Stimulation (aka Dorsal Root Ganglion Stimulation) is THE most cutting-edge treatment for pain available in the United States. The clinical trial (ACCURATE Study) recorded unprecedented improvements in pain and overall successes that have never before been seen. The procedure is almost identical to traditional Spinal Cord Stimulation, except a special system called Axium™ (available exclusively through St. Jude Medical™) provides isolated stimulation to only the DRG. Even if you have failed traditional Spinal Cord Stimulation in the past, statistics suggest DRG Stimulation will still work!
Peripheral Nerve Stimulation – This is very similar to spinal cord stimulation, except the electrodes are placed adjacent to the affected nerves in the extremity.
Medication Management – One of the most studied classes of medication for neuropathy are antidepressants – more specifically, tricyclic antidepressants (TCAs), serotonin-norepinephrine reuptake inhibitors (SNRIs) and selective serotonin reuptake inhibitors (SSRIs).[7] Anticonvulsants, like gabapentin and Lyrica, are considered by most to be the “first-line” medications in treating neuropathic pain.
The Ainsworth Institute is Here to Help
The doctors at the Ainsworth Institute of Pain Management specialize in treating neuropathic pain. Dramatic improvements in pain and quality of life are a single phone call away. Schedule an appointment today with one of our board certified pain management experts to discuss what options for treatment may best suit your needs.
References
[1] Hall GC, Carroll D, Parry D, et al.: Epidemiology and treatment of neuropathic pain. the UK primary care perspective Pain. 2006; 122:156-162.
[2] Turk DC: Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. Clin J Pain. 2002; 18:355-365.
[3] Benzon, Honorio. Essentials of Pain Medicine. Philadelphia: Saunders Elsevier, 2011. Print
[4] Treede R-D, Jensen TS, Campbell JN, et al.: Neuropathic pain. Redefinition and a grading system for clinical and research purposes Neurology. 2008; 70:1630-1635.
[5] Task Force on Taxonomy: International Association for the Study of Pain. Merskey H Bogduk N Classification of chronic pain. descriptions of chronic pain syndromes and definitions of pain terms 1994 IASP Press Seattle, WA.
[6] Elliott KJ: Taxonomy and mechanisms of neuropathic pain. Semin Neurol. 1994; 14:195-205.
[7] Sindrup SH, Otto M, Finnerup NB, et al.: Antidepressants in the treatment of neuropathic pain. Basic Clin Pharmacol Toxicol. 2005; 96:399-409.
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