Management of Neuropathic Pain
The management of neuropathic pain secondary to TMJ surgery is likely to be challenging due to the poor prognosis. Appropriate diagnosis of the primary etiology and potential comorbid diseases is essential. Due to the poor prognosis, medical and adjunctive therapy should be the first line of treatment.
There are few high-quality studies specifically addressing the medical treatment of postsurgical peripheral dysesthesia; however, there is excellent data on the medical treatment of neuropathic pain in general. While it is currently unknown to what extent a study evaluating treatment in one neuropathic pain syndrome applies to another unstudied condition, a pattern of effective first-line medications has emerged. Additionally, because of the unpredictable individual variation in treatment response that emerges in the management of chronic neuropathic pain, many patients will require multiple trials of first-line medications regardless. Presented are the most recent International Association for the Study of Pain (IASP) recommendations for the treatment of neuropathic pain [46] and the 2010 update [47] (Tables 7.3 and 7.4).
Table 7.3 Stepwise pharmacologic management of neuropathic pain
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Stepwise pharmacologic management of neuropathic pain (NP) |
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Step 1 |
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Assess pain and establish the diagnosis of NP [20, 25]; if uncertain about the diagnosis, refer to a pain specialist or neurologist |
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Establish and treat the cause of NP; if uncertain about availability of treatments addressing NP etiology, refer to appropriate specialist |
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Identify relevant comorbidities (e.g., cardiac, renal, or hepatic disease, depression, gait instability) that might be relieved or exacerbated by NP treatment or that might require dosage adjustment or additional monitoring of therapy |
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Explain the diagnosis and treatment plan to the patient and establish realistic expectations |
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Step 2 |
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Initiate therapy of the disease causing NP, if applicable Initiate symptom treatment with one or more of the following: |
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A secondary amine TCA (nortriptyline, desipramine) or an SSNRI (duloxetine, venlafaxine) |
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A calcium channel a2-5 ligand, either gabapentin or pregabalin |
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For patients with localized peripheral NP, topical lidocaine used alone or in combination with one of the other first-line therapies |
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For patient with acute neuropathic cancer pain, or episode exacerbations of severe pain, and when prompt pain relief during titration of a first-line medication to an efficacious dosage is required; opioid analgesics or tramadol may be used alone or in combination with one of the first-fine therapies |
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Evaluate patient for non-pharmacologic treatments and initiate if appropriate |
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Step 3 |
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Reassess pain and health-related quality of life frequently |
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If substantial pain relief (e.g., average pain reduced to <3/10) and tolerable side effects, continue treatment |
(continued)
Table 7.3 (continued)
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If partial pain relief (e.g., average pain remains >4/10) after an adequate trial (see Table 7.3), add one of the other first-line medications |
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If no or inadequate pain relief (e.g., <30% reduction) at target dosage after an adequate trial (see Table 7.3), switch to an alternative first-line medication |
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Step 4 |
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If trials of first-line medications alone and in combination fail, consider second- and third-line medications or referral to a pain specialist or multidisciplinary pain center |
Adapted from Dworkin et al. [46]
TCA tricyclic antidepressant, SSNRI selective serotonin and norepinephrine reuptake inhibitor
Table 7.4 Stepwise pharmacologic management of neuropathic pain [48]
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Step 1 |
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Assess pain and establish the diagnosis of NP; if uncertain about the diagnosis, refer to a pain specialist or neurologist Establish and treat the cause of NP; if uncertain about availability of treatments for cause of NP, refer to appropriate specialist Identify relevant comorbidities (eg, cardiac, renal, or hepatic disease, depression, gait instability) that might be relieved or exacerbated by NP treatment or that might require dosage adjustment or additional monitoring of therapy Explain the diagnosis and treatment plan to the patient and establish realistic expectations |
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Step 2 |
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Initiate therapy for the disease causing NP, if applicable Initiate symptom treatment with one or more of the following: |
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A secondary amine TCA (nortriptyline, desipramine) or an SSNRI (duloxetine, venlafaxine) A calcium channel a2-6 ligand, either gabapentin or pregabalin For patients with localized peripheral NP, topical lidocaine used alone or in combination with one of the other first-line therapies For patients with acute NP, neuropathic cancer pain, or episodic exacerbations of severe pain and when prompt pain relief during titration of a first-line medication to an efficacious dosage is required, opioid analgesics or tramadol may be used alone or in combination with 1 of the first-line therapies Evaluate patient for nonpharmacological treatments and initiate if appropriate |
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Step 3 |
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Reassess pain and health-related quality of life frequently If substantial pain relief (e.g., average pain reduced to <3/10) and tolerable adverse effects, continue treatment |
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If partial pain relief (e.g., average pain remains >4/10 after an adequate trial, add one of the other four first-line medications) If no or inadequate pain relief (e.g., <30% reduction) at target dosage after an adequate trial, switch to an alternative first-line medication |
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Step 4 |
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If trials of first-line medications alone and in combination fail, consider second- and third-line medications or referral to a pain specialist or multidisciplinary pain center |
Adapted from Dworkin et al. [47]
NP neuropathic pain, SSNRI selective serotonin norepinephrine reuptake inhibitor, TCA tricyclic antidepressant
From Pain [12], with permission of the International Association for the Study of Pain® (IASP®). This table cannot be reproduced for any other purpose without permission
Additionally, it is worthwhile to consider alternative therapies in these patients, such as cognitive behavioral therapy and sensory retraining [48, 49].
