Neuropathic Pain

Neuropathic pains are excitatory pains that usually occur as a result of a lesion or dysfunction in the regions involving the central nervous system and peripheral nervous system. As a result of damage to neurons, also called nerve cells, uncontrolled electrical discharges occur. This occurs along with neuropathic pain that causes different symptoms in patients. These symptoms are described as burning, tingling, stabbing, stinging and electric shock. The most common cause of neuropathic pain, which occurs in 1-2% of the population, is diabetes.

Neuropathic Pain Originating from the Central Nervous System

Neuropathic pain is inevitable in diseases such as stroke, spinal cord injury, multiple sclerosis and spinal cord infections, which are closely related to the central nervous system.

Neuropathic Pain Originating from the Peripheral Nervous System

It is especially common in people with metabolic diseases and inflammatory-related problems. In addition, nutritional disorders, toxins, shingles infections, cancers, hereditary diseases and disorders of unknown cause can also cause neuropathic pain originating from the peripheral nervous system.

Neuropathic Pain Findings and Diagnosis

Experiencing stinging, burning, tingling, freezing or electric shock-like pain in the legs, hands and other acral areas directs physicians to neuropathic pain. In addition, the time of onset of the disease, its severity, how it progresses at night and how frequently it occurs are also very important for diagnosis.

It is primarily aimed to reduce the complaints of a patient experiencing neuropathic pain. For example; High blood sugar in a diabetic patient will have negative effects on the nerves, causing neuropathic pain. The main aim of the treatment here is; is to ensure blood sugar regulation. Since the cause of pain is nerve cell origin, classical analgesics do not respond to pain relief. Epileptic drugs, arrhythmia drugs, local anesthetics, muscle relaxants and morphine-derived drugs, which are frequently used in treatment, are useful. In advanced cases, nerve blockade is performed with interventional methods.

Trigeminal Neuralgia

By definition, it is a lightning-like pain that strikes the face and lasts for a short time. In trigeminal neuralgia, which occurs as a result of various pressures on the trigeminus nerve, which is the 5th of the 12 nerves originating from the brain stem, the pain can be controlled with painkillers for a short time. Over time, as a result of getting used to the medication and various side effects, the pain threshold will increase again and different treatment methods will be used. However, painkillers can be considered the first step of treatment in trigeminal neuralgia.

Nervus trigeminus has 3 branches that spread over the face. The first branch, the nervus ophthalmicus, receives the eye region of the face, the second branch, the nervus maxillaris, receives the maxilla region, and the third branch, the nervus mandibularis, receives the pain, temperature and motor sensations of the lower region of the face. In partial or complete defects of these nerve branches, the patient will experience loss of pain, temperature sensations and impairment of motor functions. In addition, varicella zoster infection can cause ophthalmic shingles by pressing on the nerve. Although pain is experienced, rash lesions may be seen on the forehead and cornea.

Any lesion occurring in the branches of the trigeminal border causes severe trigeminal neuralgia and patients experience loss of sensation that cannot be relieved by medication.

Trigeminal Neuralgia Treatment

Pain threshold will increase in trigeminal neuralgia patients as they will get used to analgesic medications over time. In addition, other treatment methods can be started. Trigeminal radiofrequency rhizotomy, microvascular decompression, trigeminal glycerol rhizolysis and gamma-knife applications are among the alternative treatment methods when there is no response to painkillers. The sole purpose of these treatment methods is to block the fibers that transmit pain in the nerve or to eliminate the pressure on the brain stem.

Shingles And Postherpetic Neuralgia

It is the type of pain that occurs as a result of the rash disease that comes with chickenpox, caused by the varicella zoster virus type. Chickenpox is usually acquired in childhood and the viruses remain in the nerve root. Later, for various reasons, this disease relapses and causes rash lesions in various parts of the body. Shingles usually heals within 2 weeks. However, pain even 3 months after the rash is diagnosed as postherpetic neuralgia.

People with postherpetic neuralgia may feel pain even when wearing clothes. Nerves that become extremely sensitive may cause pain even with a slight touch.

How Does Varicella Zoster Virus Become Active Again?

Viral infections will increase when the body’s immune system is weakened. Rheumatic diseases, cancer and various malignancies or some medications that damage the immune system trigger shingles, which subsequently leads to postherpetic neuralgia.

Patients may experience general malaise, loss of appetite, weight loss and psychological problems.

Postherpetic Neuralgia Treatment

Although there is no general treatment principle for this disease, relieving the pain caused by the nerve is among the first steps to be taken. Although antiepileptic and antidepressant drugs are commonly used, preparations containing local anesthetics can also be used as a direct treatment method. Other treatment methods include cold application and various nerve blocks, depending on the affected sensory area.

Unfortunately, despite all these treatments, postherpetic neuralgia may not heal completely. However, simple measures that can be taken in time can prevent this pain. Vaccination in childhood against the varicella zoster virus, which causes chickenpox, will provide protection from future shingles infection and will reduce the incidence of postherpetic neuralgia.

Taking antiviral treatment within 3 days of the onset of shingles will significantly prevent post-trigeminal neuralgia that may occur in the future.

Pain Due to Diabetes (Diabetic Neuropathy)

Diabetic neuropathy, which can be considered among the chronic complications of diabetes mellitus, is a life-threatening and very important condition. It may not cause any symptoms in patients, or it may cause symptoms such as numbness, prickling, tingling and pain in the hands and feet. Loss of sensation may also occur in the chronic period.

Most of the clinical or subclinical symptoms listed are among the chronic complications of diabetes, resulting in a condition called diabetic neuropathy. Many events are involved in the pathogenesis of this disease. These may include genetic predisposition, oxygen deprivation of nerve cells, or immune mechanisms. Keeping blood sugar at high levels for a long time will cause many metabolic pathways to be disrupted. In this case, the energy mechanism will be disrupted and since sufficient energy cannot be produced in the body, conduction defects will occur in the nerve cells. As a result, damage to peripheral, autonomic or local nerves occurs. This picture may occur before or after the development of diabetes. The patient is not aware of diabetes and may only apply to the hospital with complaints of diabetic neuropathy. Whether you have diabetes or not, it is necessary to balance blood sugar regulation well to prevent end organ damage and complications. Even after developing diabetes, none of these complications will be seen if it is well balanced.

Effects of Diabetic Neuropathy on the Skin

If you have diabetes, check your feet and hands for nerve damage. If your skin is dry, moisturize it. Pay attention to your hand and foot health and consult a doctor if you feel any abnormality.

Effects of Diabetic Neuropathy on the Autonomic Nervous System

Diabetes affects many systems and can also affect the gastrointestinal system. Especially the intestines, which are under the control of the enteric nervous system, are damaged and various digestive problems such as constipation and diarrhea occur. Bloating, gastroesophageal reflux, and feeling full despite eating less are other gastrointestinal system symptoms. To prevent these, you can eat small but frequent meals.

In addition, it can affect the cardiovascular system and cause vascular diseases. Hypotension problem may occur. When blood sugar drops in patients with diabetic neuropathy, complaints such as fatigue and darkening appear. As a precaution, you can check and regulate your blood sugar at regular intervals.

Diabetic neuropathy can also negatively affect sexual life, causing dryness during sexual intercourse in women and erectile dysfunction in men. Lubricating gels or creams can be used as a solution.

The most common complaint of diabetic patients is frequent urination at night. The solution to this problem, which arises from the inability to empty the bladder completely, may be medication or the use of a catheter. Some patients may also experience urinary incontinence.

Regional Nerve Damage Caused by Diabetic Neuropathy

Regional damage of diabetes usually occurs suddenly and affects the nerves going to structures such as arms, legs, head and trunk.

By affecting the face, health problems such as diplopia (double vision), paralysis of the half face, unilateral and bilateral pain in the waist or legs, feeling of pressure in the chest and cholecystitis are experienced.

Regional nerves are generally painful and greatly reduce the patient’s standard of living. Since it occurs suddenly, it may be relatively easier to treat. It may heal spontaneously.

Effect of Diabetic Neuropathy on Nerves Near the Center

Generally, unilateral (one-sided) pain is experienced in the hip. It may cause loss of sensation, causing difficulty in walking. In advanced cases, treatment is not possible and amputation may be required.

Diabetes sometimes causes trap syndromes. Entrapment syndromes, which occur due to nerve compression, are most commonly seen in the wrist. A situation similar to Carpal Tunnel syndrome occurs and if the treatment is not sufficient, it may lead to surgery.

The general treatment of diabetic neuropathy varies depending on the region where the complication occurs. Pain treatments are provided with physiotherapy and various analgesics. Further treatments are decided by the physician.

Phantom Pain

Phantom pain is when a limb that has been amputated as a result of various circumstances gives symptoms such as contraction and stinging as if it were still in place. The pain felt in the stump area of the amputated area is called stump pain.

In the phantom pain type, patients usually begin to feel chronic pain at variable intervals after a certain period of time after losing their limbs. Some patients do not feel these pains, while others say that the amputated limb hurts as if it were still in place. This wide range has caused physicians to accept this type of pain and determine treatment methods. The description of the pain felt in the loss of feet and arms is similar to the type of pain experienced after the loss of organs such as tongue, nose, breast, fingers and teeth. Approximately 22-63% of patients describe phantom pain after breast removal surgery.

The main manifestation of phantom pain is the pain that occurs before the amputation of the amputated limb and becomes chronic. Patients can continue to experience the pain they previously experienced after their limbs are amputated.

The feeling of pain may be perceived as a feeling of shortening or deformation of the limb, which we call the telescope symptom. If the patient experiences severe pain before the limb is removed, the likelihood of experiencing phantom pain increases after the amputation is achieved.

Treatment of phantom pain is provided by physicians and includes nerve blockade, epidural steroid injection or spinal cord stimulation. Although it is not possible to specifically treat it, if a medication works well for phantom pain in one patient, it may not work in another patient. TENS (transcutaneous electrical nerve stimulation) should be performed before sympathetic nerve blockade is attempted. If no benefit is achieved, nerve blockade should be performed.

If the patient does not respond to any treatment, he/she can receive various psychotherapy support to cope with phantom pain. There will be an increase in the standard of living.

Complex Regional Pain Syndrome

They are chronic pains that occur as a result of dysfunction in the central or peripheral nervous system. Pain, redness, tenderness and swelling in the affected area are noted. In reflex sympathetic dystrophy syndrome, or collagia, as it was called during the civil war, people feel burning pain even after their wounds have achieved complete remission.

The most obvious symptom is pain that increases in intensity over time. It often affects the extremities (hands, arms and legs). So what symptoms do these patients present with?

Severe burning pain
Increased sensitivity and redness of the skin
Color and texture changes in the skin
Disproportionate growth of keratin-containing structures
motor dysfunction

Even if the pain begins to occur in a local area as a result of the initial trauma, it gradually progresses over time. Pain felt unilaterally may acquire a bilateral character over time. At first, muscle spasms may accompany the pain. The intense pain felt afterwards may lead to joint stiffness or skin changes. In the chronic process, pain will be felt intensely in irreversibly atrophic areas.

Although the pathogenesis cannot be fully explained, it is thought that pain receptors become accustomed to noradrenaline, one of the sympathetic nervous system catecholamines. Inflammation symptoms such as redness, increased temperature and tenderness are seen in the area where the syndrome occurs.

Although the prognosis varies from person to person, spontaneous recovery may occur. Some authors are sensitive about early diagnosis and believe that it shapes the treatment.

Treatment

Although there is no known form of treatment, the basic principle is to try to reduce pain symptoms. Functional losses of patients can be regained with physiotherapy. Pain should be reduced somewhat with analgesic medications. If adequate pain relief cannot be achieved, sympathetic nerve block, sympathectomy, and spinal cord stimulation (TENS) applications can be tried.