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NEUROPATHIC PAIN
Neuropathic pain is the sensation of pain due to abnormal discharges of impaired or injured neural structures in the peripheral &/or central nervous system.
It is characterized by hyperesthesia, hyperalgesia and allodynia.
Common neuropathic pain syndromes are central neuropathic pain, painful diabetic peripheral neuropathy, postherpetic neuralgia, trigeminal neuralgia, postsurgical neuropathic pain, HIV-related neuropathy, lumbosacral radiculopathy and complex regional pain syndrome.

Surgical Intervention

Trigeminal Neuralgia (TN)

  • For patients with trigeminal neuralgia refractory to medical therapy, early surgical therapy may be considered
  • Prior to considering surgery, eligible patients should have an MRI to eliminate other causes of compression of the trigeminal nerve
  • Peripheral Techniques
    • Involve blocking or destruction of portions of the trigeminal nerve distal to the Gasserian ganglion
    • Low morbidity but 50% have pain recurrence after 1 year
  • Percutaneous Procedures on Gasserian Ganglion
    • Preferred for elderly patients, those with multiple sclerosis (MS), with impaired contralateral hearing, and those with recurrent pain after microvascular decompression
    • Eg radiofrequency thermocoagulation, balloon compression rhizotomy, percutaneous retro-Gasserian glycerol rhizotomy
    • After percutaneous trigeminal radiofrequency, initial pain relief can be achieved in 98% of patients & 15-20%of patients may experience recurrence in 12 months
  • Microvascular Decompression
    • Preferred procedure for young patients with typical trigeminal neuralgia
    • Major neurosurgical procedure involving craniotomy to reach the trigeminal nerve in the posterior fossa
    • Vessels compressing the nerve are identified and moved out of contact
    • Provides longest duration of pain relief while preserving facial sensation
    • Complications include aseptic meningitis, hearing loss, cerebrospinal fluid (CSF) leaks, infarcts, hematomas, transient diplopia and sensory loss
    • Associated with 0.5% mortality rate and 3-29% facial numbness rates
  • Gamma Knife Stereotactic Radiosurgery
    • Least invasive procedure for trigeminal neuralgia
    • Treatment option for patients with comorbidities, high-risk medical illness or pain refractory to prior surgical procedures
    • Aims a focused beam of radiation at the trigeminal root in the posterior fossa
    • In a study, it showed that adequate pain relief were 75%, 60% & 58% at 1, 3, & 5 years, respectively
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For the first time, a randomized controlled trial has found the serotonin-norepinephrine reuptake inhibitor (SNRI) duloxetine to be effective against chronic neuropathic pain associated with taxane- or platinum-based chemotherapy. [ASCO 2012; abstract CRA 9013]

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