Clinical practice guideline for neuropathic pain

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æ.». 2551ISBN: 978-974-598-056-3




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ISBN: 978-974-598-056-3

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æ.». 2551ISBN: 978-974-598-056-3




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æ.». 2551ISBN: 978-974-598-056-3




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Neuropathic pain “

”

“

”

(general practitioners)

“ ”

. .

ก

1. . .

2. . .

3. . . .

4. . .5. . .6. . .7. .8. . .9. . .10. . .11. .12. .13. . .

14. .

15. .

ข

สารบญ

หนาคำนำ ก

รายนามคณะผจดทำ ขขอแนะนำการใช CPG

วธการสบคนขอมล

ง

ฉ

บทท 1 บทนำ 1

1.1 ลกษณะอาการปวดเหตพยาธสภาพประสาท 1

1.2 ระบาดวทยา 2

บทท 2 การวนจฉย เครองมอ และวธตดตามภาวะปวดเหตพยาธสภาพประสาท 3

บทท 3 การรกษาภาวะปวดเหตพยาธสภาพประสาท 7

3.1 การรกษาโดยการใชยา 7

3.2 การรกษาโดยการผาตด 12

3.3 การรกษาโดยเวชศาสตรฟนฟ การแพทยผสมผสาน และ การแพทยทางเลอก 15

บทท 4 การวนจฉย และรกษาภาวะปวดเหตพยาธสภาพประสาทในโรคทจำเพาะ 20

4.1 Diabetic peripheral neuropathy 20

4.2 Post herpetic neuralgia 22

4.3 Trigeminal neuralgia 23

4.4 Phantom limb pain 24

4.5 Central pain

4.6 อนๆ25

26

บทท 5 เกณฑการสงตอผปวย 27

ภาคผนวก 1 คณภาพหลกฐาน (Quality of evidence) 28

ภาคผนวก 2 หลกการกำหนดนำหนกคำแนะนำ 29

ภาคผนวก 3 แนวทางการใชระดบหลกฐานประกอบการกำหนดนำหนกคำแนะนำ 32

ภาคผนวก 4 ลกษณะของความปวดและการตรวจรางกาย 33

ภาคผนวก 5 เครองมอทใชในการวนจฉยและคดกรอง 35

ภาคผนวก 6 แบบสอบถาม Thai DN4 36

บรรณานกรมและเอกสารแนะนำเพมเตม 37

ค

CPG

CPG CPG CPG

(Strength of Recommendation) ++

(cost effective) “ ” +

“ ” +/-

“”

-“

” - -

“ ”

(Classification of references)Level of evidence A systematic review randomized,

controlled clinical trials randomized, controlled clinical trials

Level of evidence B systematic review controlled clinical study controlled clinical study (nonrandomized, controlled trial, cohort study, case-control study, cross sectional study)

ง

randomized, controlled clinical trials randomized, controlled clinical trials

systematic review randomized, controlled clinical trials randomized, controlled clinical trials

Level of evidence C systematic review descriptive study descriptive study

systematic review controlled clinical study controlled clinical study

controlled clinical trials

Level of evidence D (consensus)

: Level of evidence ( 18 6 . .- . . 2544)

จ

/ Medline, Cochrane library, EMBASE 1966

2008 neuropathic pain, epidemiology, assessment, treatment, diagnosis, guideline, rehabilitation, complementary medicine, alternative medicine, acupuncture, central pain, post herpetic neuralgia, trigeminal neuralgia, diabetic peripheral neuropathy

key articles

ฉ

�

11.1

Neuropathic pain somatosensory system (lancinating) (burning) (tingling)

(pins and needles) (itching) (paresthesia) (stimulus- independent pain spontaneous pain)

(stimulus- dependent pain stimulus-evoked pain) allodynia

hyperalgesiaNeuropathic pain

neuropathic pain HIV

neuropathic pain neuropathic pain

(mixed pain) neuropathic pain

neuropathic pain diabetic neuropathy, multiple sclerosis

neuropathic pain . . 1994 International Association for the Study of Pain neuropathic pain neuropathic pain

“ ”1

somatosensory pathways spino-thalamocortical system

1

�

“ ” neuropathic pain 2

neuropathic pain . . 2007 2nd Congress of Neuropathic Pain

“ somatosensory system” (Pain arising as a direct consequences of disease affecting the somatosensory system)3

(hyperexcitability) (plasticity) neuropathic pain neuropathic pain

4

1.2

neuropathic pain multiple sclerosis

post herpetic neuralgia spinal cord injury post mastectomy syndrome phantom pain amputation low back

pain sciatica neuropathic pain

6.8-8.25, 6 37.8-48 7, 8 369

post herpetic neuralgia 10-1510 16-2611 low back pain 54.712 post stroke pain 813 multiple sclerosis 27.514

13- 38 15, 16, 17 neuropathic pain post mastectomy syndrome 2018

Neuropathic pain 19

20

neuropathic pain21, 22

2

�

2

nociceptive, neuropathic, psychogenic neuropathic pain

(pathognomonic sign)

neuropathic pain(neuroanatomy)

neuropathic pain ( 2.1 2.1)

3

�

2.1 ( 4, 5 6)

( 4) DN4 ( Thai

DN4 6) +

1. ++2. ++

3. ++

4. ,, ,

++

5. +6. +

1 2+ 3-6 1

Neuropathic painneuropathic pain

( ) visual analog scale numerical rating scale ++

+/-+

4

�

NEUROPATHIC PAIN Definite

ProbableDocument of nerve lesion

PossibleDecreased sensibility in painful area

Decreased sensibility in painful area

History of relevant disease or lesion in the nervous system



Pain in neuro-anatomical area



2.1 neuropathic pain1

neuropathic pain

neuropathic pain ( 2.1) Neuropathic Pain Scale (NPS)2, Neuropathic Pain

Questionnaire (NPQ)3, NPQ short form4, Neuropathic Pain Symptom Inventory (NPSI)5, ID Pain6, DN47, PainDetect8 LANSS Pain Scale9 ( 5)

DN410 ( Thai DN4 6)

(quantitative) neuropathic pain (qualitative)

spontaneous ongoing pain, spontaneous paroxysmal pain, dysesthesia paresthesia (evoked pains) allodynia

hyperalgesia1. Visual analogue scale (VAS)

11 VAS 10

5

�

( 2.2 A)2. Numerical rating scale (NRS) 11-point Likert scale (0 = no pain, 10 =

worst possible pain) ( 2.2 B)3. Verbal rating scales (VRS) (

2.2 C)4. Wong-Baker faces pain rating scale

3 numerical rating scale

( 2.2 D)

0 1-3 4-6 7-10

0 1 2 3 4 5 6 7 8 9 10

A

B

C

D

2.2 A: Visual analogue scale (VAS), B: Numerical rating scale (NRS), C: Verbal rating scales (VRS), D: Wong-Baker faces pain rating scale

6

�

( 2.3)

2.3

Quantitative Sensory Testing (QST)

allodynia hyperalgesia

7

�

*

?A

?B

?C

first-line drug

first-line

second-line ( 3.1)

*A Average pain score VAS NRS < 3/10 B Average pain score VAS NRS > 4/10 4-8 C Average pain score VAS NRS 30% 4-8

first-line drug 1

( 1)

first-line drug

9

�0

3.1 neuropathic pain

1. First-line medications

1.1 Tricyclic antidepressants - Amitriptyline + + - -

- Nortriptyline +(

75 ./ )

-

- Imipramine

Enhance descending inhibitorypain pathway

10-75 ./

10-25 .

10-25 .1-2

,,

anticholinergic,

anticholinergic*

- - - 1.2 Calcium channel 2 1 ligands

- Gabapentin Block 2 1

subunit of calciumchannel

300-3600 ./

100-300 .

100-300 .3-7

2-4

, + + +

1.3 Sodium channel blockers - Carbamazepine 200-1200

./+ -

- Oxcarbazepine

Block sodium channel

300-1800 ./

+ -

* anticholinergic

10

��

3.1 neuropathic pain ( )

2. Second-line medications 2.1 Tramadol -Weak

agonist

-Enhance descending inhibitory pain pathway

50-400 ./ -

SSRIs SNRIs

-

+ +/-

SSRIs SNRIs

TCAs

2.2 Oral morphine agonist -

-

+

tramadol

+/-

2.3 Methadone agonist NMDA antagonist

- +

tramadol

morphine

+/-

2.4 Pethidine agonist neuropathic pain - -

2.4 Selective serotonin and norepinephrine reuptake inhibitors (SNRIs) - Venlafaxine 75-150 ./ + +/-

- Duloxetine*

Enhance descending Inhibitory pain pathway

30-60 ./

tramadol

serotoninsyndrome

+ +/-

2.5 Calcium channel 2 1 ligands - Pregabalin Block 2 1

subunit of calciumchannel

75-600 ./ ,,

+ ++

2.6 Paracetamol, NSAIDs, COX-2 inhibitors

chronic neuropathic pain - -

* : Duloxetine 31 2549

11

��

3.2 neuropathic pain neuropathic pain

Burning Lancinating Hyperalgesia Allodynia Paresthesia,dysesthesia

TCA Amitriptyline + + +/- + + + + +SNRI Venlafaxine + +/- + + +/-

Duloxetine + + +/- + + + +/-Sodium channel Carbamazepine +/- + + + + +blockers Oxcarbazepine +/- + + + + +Calcium channel Gabapentin + + +/- + + + + +

2 1 ligands Pregabalin + + +/- + + + + +Opioids Tramadol + +/- + + +

Morphine +/- +/- +/- +/- +/-

3.3 neuropathic pain neuropathic pain

DPN PHN TGN Phantomlimb pain

Central pain

TCA Amitriptyline + + + + +/- + + + SNRI Venlafaxine + + - - +/-

Duloxetine + + + - - +/-Sodium channel Carbamazepine +/- +/- + + + +blockers Oxcarbazepine +/- +/- + + + +Calcium channel Gabapentin + + + + +/- + +

2 1 ligands Pregabalin + + + + +/- + +Opioids Tramadol + + - +/- +/-

Morphine +/- +/- - +/- +/-DPN: diabetic peripheral neuropathy, PHN: post herpetic neuralgia, TGN: trigeminal neuralgia

12

��

3.2

3.4 neuropathic pain

1.

2.

3. vascular loop compression

Microvascular decompression (MVD)

+ + 68-95% 70 – 95%

72 – 73% 5-6

0.1%1 %

Gamma knife +/- 47 – 88 % 1 (75 – 92.9 % 1 )

24 – 74 % 18 3 ( 48 –

90% )10%SRS

persistent paresthesia ( 15.8%

16.3%

Radiofrequency thermoregulation

+ 83 – 97%

49 – 70% 5-7

Trigeminal neuralgia

1.

2.

Motor cortex stimulation +/- 10% ,42% , 35%

, 13%

36%Dorsal root entry zone (DREZ) dressing

+/-

Spinal cord stimulation +/-

Post herpetic neuralgia 1.

2.

Motor cortex stimulation +/-

DREZ spinal cord stimulation (60-70% for DREZ)

13

��

3.4 neuropathic pain ( )

+/-For general

traumatic amputations associated with root avulsion

Dorsal root entry zone (DREZ) lesion

- - Stump pain

phantom stump pain stump pain

Phantom limb pain 1.

2.

Deep brain stimulation (DBS) +/- DBS PVG/PAG grey matter

(79%) PVG/PAG plus sensory thalamus/internal capsule (87%)

sensory thalamus (58%

long-term success) (p < 0.05) DBS nociceptive pain deafferentation pain (63% vs 47% long-term success; p < 0.01)

3. neuroma +

+/-

Deep brain stimulation +/- Trial stimulation 50%

post-stroke pain 58%

Thalamic pain 1.

2.

Motor cortex stimulation +/- 10%, 42%

, 35% , 13% 36%

Causalgia, Sympathetic mediated pain

1.

2.

Sympathectomy +

sympatheticblock

66-96% 94% sympathectomy

14

��

3.3

Neuropathic pain

neuropathic pain 2 1

1.2.

neuropathic pain

RCT

(adjunctive therapy)

15

��

2,3

3.3.1

neuropathic pain 40 5 alternative medicine 36

(acupuncture) 3.5

3.5 /

Patient education ++

TENS (Transcutaneous Electrical Nerve Stimulation)

- Hi-TENS (conventional) Hi frequency, low

intensity

- Lo-TENS (acupuncture-like) Lo frequency, Hi intensity

Chronic neuropathic pain

- cardiac

pacemaker

-

allodynia

TENS 8

- 9 200

-

-Hi-TENS,

Lo-TENS -

-

30 /

- Hi-TENS

Lo-TENS

trial & error

accommodation effects of nerve nerve fiber

4,5,6,7 +(

)

+/-

- - Hi-TENS

cardiac pacemaker

16

��

3.5 ( )/

Relaxation techniques Neuropathic pain: Postherpetic neuralgia

peripheral neuropathy

- - 7,8,17 +

General Exercise improve general condition

-

(immobilizationsyndrome)

-

6,7 ++

Specific exercise +/-

Heat & Cold hot pack, warm bath, ice

Neuropathic pain - burn sensory impaired

- 7 +/-

- -

sensory deficit DM

Desensitization Neuropathic pain - allodynia

- 9 +/-

- - allodynia

()

17

��

3.3.2

(Complementary & Alternative Medicine: CAM) peripheral neuropathy 43 CAM

(mega-vitamins 35) (magnet 30) ( 30) ( 22) chiropractor ( 21)10

27

CAM neuropathic pain 3.6

18

��

3.6/

(Acupuncture)Painful diabetic neuropathy, central neuropathic pain in spinal cord injury (SCI)

--

--

HIV, hepatitis B

-RCT (postherpetic neuralgia)

placebo, sham,- painful diabetic neuropathy, central neuropathic pain in SCI -

-

- 1-3 (10 / ) 4-5

5,8,11

1,6,12,13

10,14

+/-

radiculopathytrigeminal neuralgia

+/- Central NeP

(SCI) painful diabetic neuropathy

- post-herpetic neuralgia

Painful peripheral neuropathy

-neuropathic pain

neuropathic pain - (balanced diet)-

( 1 )-

-

B6 neuropathy

6,10 +Balanced diet

+ +Avoid alcohol

+/-MTV, B complex, 3B

- - B6

100 ./ )

- -Vitamin E > 400

U/day Parkinson’

diseaseAlzheimer’s disease

()

Mild degree neuropathic pain

- peripheral sensitization-

+/-

19

�0

44.1 Diabetic neuropathy

1 2 2

1

13.12

32.33

7-13 4

20-33% 10 4

5

3 1. Distal symmetric diabetic polyneuropathy (DSDP)

/ 2

2. Autonomic neuropathy (autonomic neuropathy)

DSDP

20

��

QT 3. Focal and multifocal neuropathy

truncal radiculoneuropathy, median, radial, ulnar peroneal nerve (entrapment)

,

(hyperglycemia)

(reactive oxygen species)

(advanced glycation endproducts AGEs) polyol pathway protein kinase C

6

2 glucose tolerance test

serum electrophoresis, TSH, BUN, Creatinine

(skin biopsy)

7

Quantitative sensory testing (QST)

21

��

: aldose

reductase inhibitors nerve growth factor 8,9

: (focal or multifocal neuropathy)

(carbamazepine, gabapentin, pregabalin), antidepressant (amitryptyline, nortryptyline, duloxetine)10 opioid tramadol strong opioid

11 topical capsaicin 0.075% neuropathic pain 12

fludrocortisone midodrine

13

4.2 (Post herpetic neuralgia, PHN)

varicella-zoster 2.2-3.4 1,000

20 1

(dermatome)

1-3 (post herpetic neuralgia) PHN

2

acyclovir, valacyclovir famciclovir 72

22

��

PHN1,2

PHN3

amitryptyline 2

PHN PHN 4

gabapentin pregabalin TCAs tramadol

1,5

4.3 (Trigeminal neuralgia or Tic douloureux)

5 5.9 3.4 100,000

5

trigeminal ganglion (sensory function)

2 3 (V2,V3) 1 (V1)(trigger point)

1

arterial venous loop 5

MRI brain demyelination multiple sclerosis meningioma

carbamazepine 100 . 2-3

600-1,200 .

23

��

oxcarbazepine baclofen, phenytoin, gabapentin, lamotrigine 1-3

(2)

alcohol ganglion

micro vascular loop decompression (MVD) Gamma

knife radiosurgery 4

MVD 5

4.4 (Phantom limb pain)

1, 2

phantom sensation acute just post amputation pain

chronic residual limb pain

phantom phenomena

60-80 (phantom pain)

5-10

(stump pain)

(nerve block)

24

��

(randomized control trial) (neuropathic pain)

(non invasive treatment)

(antidepressants) tricyclic sodium channels calcium channels opioids

randomized controlled trials meta analysis

4.5 Central neuropathic pain

8 40

spinothalamic pathway neuronal excitability

central neuropathic pain

randomized controlled trial 1. Central neuropathic pain, post stroke : TCA 2. Spinal cord injury pain: calcium channel 2 1 ligands pregabalin 3. Pain associated with multiple sclerosis: cannabinoids (level B) 4. Central neuropathic pain : pregabalin, TCAs, lamotrigine, gabapentin (level B)

25

��

first second line peripheral neuropathic pain

4.6

(mixed pain) neuropathic pain

neuropathic pain neuropathic pain neuropathic pain

Cancer pain: neuropathic pain

opioids gabapentin, pregabalin, TCAs, SNRIs antiepileptics

Painful polyneuropathy

o HIV neuropathy antiretrovirals CYP450 CYP450

gabapentino Drug-induced neuropathy o Guillain–Barre syndrome gabapentin carbama-

zepine opioids Nerve injury pain radicular pain (include back pain), post-traumatic/post-surgical neuropathic pain complex regional pain syndromes (CRPS)

paracetamol NSAIDs neuropathic pain

neuropathic pain

neuropathic pain

26

27

5 neuropathic pain

(chronic pain) /

1. neuropathic pain 2.

3 50 7/10

3. first-line drugs 2 strong opioids

4. invasive techniques /5. 1 /

(chronic pain syndrome)5.1

5.25.3

5.45.5

5.65.7

27

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1

(Quality of Evidence)

1 1.1 (systematic review) -

(randomize-controlled clinical trials) 1.2 - 1 (a well-designed,

randomize-controlled, clinical trial) 2

2.1 (non-randomized, controlled, clinical trials)

2.2 (well-designed, non-randomized, controlled clinical trial)

2.3 (cohort) (case control analytic studies)

/2.4 (multiple time series)

. .2480

3 3.1 (descriptive studies) 3.2 (fair-designed, controlled clinical trial)

4 4.1 (consensus)

4.2 2

(anecdotal report)

28

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2

“ (strength of recommendation)” (prolonged life)

(decreased morbidity) (improved quality of life)

(

/ ) “ ”

1 “++” “++” 1

( 50 “+/-”)

Papanicolaou “++” 2

CT / MRI brain “++”

(“+/-”) “+/-” :-1.

2.3.4.

29

�0

5.

12

(systematic review and consensus of peer reviewers)

/

“5 ”

(1)

(2)

(3) / ( )

“5 ”(1) (safety) (2) (efficacy) (3) (effectiveness) (4) (benefit of population and entire society) (5) (efficiency)

1. (safety)

(safety monitoring program: SMP) ( NNH: number needed to harm)

2. (efficacy)

/

30

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( NNT: number needed to treat)

3. (effectiveness)

/ /

/

3.1 3.2

3.3 3.4 4. (benefit of population and entire society)

/ (utility)

5. (efficiency) 4

31

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3

:-1. “++”, “--” /

/ ( ) 2 :-

1.1. 1 : - (randomize-controlled, clinical trial) 1

1.2. 2 : (non-randomized, controlled, clinical trial) 2

1.2.1. (cohort)1.2.2. (case-control)1.2.3. (multiple-time series) adrenaline

2. “+”, “-” /

/ ( ) ( ) / /

1 :-2.1. 1 ( 1 1 , 2 2 )

2.2. 3 / 43. “+/-”

( ) :-3.1. ( )

3.1.1.3.1.2.3.1.3. (surrogated end-point) 3.1.4. (safety monitoring program : SMP)3.1.5. .

3.2. ( 1 / 2) 3.3. .3.4. (ultimate end points) 3.5.

32

��

4

Neuropathic pain 2 1. (stimulus-independent spontaneous pain)

(burning) (intermittent shooting), (lancinating sensations), (electric shock-like pain)

(tingling) “paresthesias” “dysesthesias”

2. (stimulus-dependent stimulus-evoked pain)

“Hyperalgesia” (mechanical) (thermal)

(chemical)“Allodynia”

Mechanical allodynia (

1A)Thermal allodynia

40 ( 1B) neuropathic pain

( 2)1.2. (pinprick sense) 3.4. (tuning fork) 128-Hz

33

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1 neuropathic painA

B

2

34

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5

LANS

S for

physi

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7

Identif

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admin

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DN4 f

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10

Discrim

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NeP f

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Non-N

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Physi

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admin

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LANS

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7

Identif

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Patien

tad

ministe

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Pain

DETE

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9

Scree

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compo

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in LB

P

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DN4 f

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7

Scree

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tad

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ID PA

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6

Scree

n NP

Patien

tad

ministe

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NPSI5

7

Identif

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Patien

tad

ministe

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NPQ

Short

Fo

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3

Scree

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Patien

tad

ministe

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NPQ3

12

Discrim

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betwe

en

NeP a

nd

Non-N

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Patien

tad

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NPS2

10

Asses

sdis

tinct

qualit

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Ne

P

Patien

tad

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neuro

pathi

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Quest

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/ pa

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Numb

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Qu

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Type

Inten

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se

NeP =

neuro

pathic

pain

35

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Thai DN4

1. ?

1. 2. 3.

2. ?

3.

4.

4 neuropathic pain

4. 5. 6. 7.

8. 9.

10.

= 1 = 0 _______/10

Chaudakshetrin P, Prateepavanich P, Chira-Adisai W, Tassanawipas W, Leechavengvongs S, Kitisomprayoonkul W. Cross-cultural adaption to the Thai language of the neuropathic pain diagnostic questionnaire (DN4). J Med Assoc Thai 2007; 90:1860-5.

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11. Merskey H, Bogduk N. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. 1.

Seattle, WA: IASP Press, 1994: 209-13. 2. Jensen TS, Gottrup H, Sindrup SH, Bach FW. The clinical picture of neuropathic pain. Eur J Pharmacol. 2001; 429:1-11. 3. Treede R-D, Jensen TS, Campbell JN, Cruccu G, Dostrovsky JO, Griffin JW, Hansson P, Hughes R, Nurmikko T, Serra J.

Neuropathic pain: Redefinition and a grading system for clinical and research purposes. Neurology 2008; 70;1630-1635. 4. Bouhassira D, Lanteri-Minet M, Attal N, Laurent B, Touboul C. Prevalence of chronic pain with neuropathic characteristics in the

general population. 2008;136:380-7. 5. Torrance N, Smith BH, Bennett MI, Lee AJ. The epidemiology of chronic pain of predominantly neuropathic origin. Results from

a general population survey. J Pain 2006; 7:281-9. 6. Hans G, Masquelier E, De Cock P. The diagnosis and management of neuropathic pain in daily practice in Belgium: an

observational study. BMC Public Health 2007; 7:170.7. Chaudakshetrin P. A survey of patients with neuropathic pain at Siriraj pain clinic. J Med Assoc Thai 2006; 89(3):354-61. 8. Grond S, Radbruch L, Meuser T, Sabatowski R, Loick G, Lehmann KA. Assessment and treatment of neuropathic cancer pain

following WHO guidelines. Pain 1999; 79:15-20. 9. Dubinsky RM, Kabbani H, El-Chami Z, Boutwell C, Ali H. Practice parameter: treatment of postherpetic neuralgia: an evidence-

based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2004; 63:959-65. 10. Jensen TS, Backonja MM, Hernandez Jimenez S, Tesfaye S, Valensi P, Ziegler D. New perspectives on the management of

diabetic peripheral neuropathic pain. Diab Vasc Dis Res 2006; 3:108-19. 11. Kaki AM, El-Yaski AZ, Youseif E. Identifying neuropathic pain among patients with chronic low-back pain: use of the Leeds

Assessment of Neuropathic Symptoms and Signs pain scale. Reg Anesth Pain Med 2005; 30:422-8. 12. Andersen G, Vestergaard K, Ingeman-Nielsen M, Jensen TS. Incidence of central post-stroke pain. Pain 1995; 61:187-93. 13. Osterberg A, Boivie J, Thuomas KA. Central pain in multiple sclerosis--prevalence and clinical characteristics. Eur J Pain 2005;

9:531-42.14. Jan FK, Wilson PE. A survey of chronic pain in the pediatric spinal cord injury population. J Spinal Cord Med 2004; 27Suppl

1:S50-3.15. Werhagen L, Budh CN, Hultling C, Molander C. Neuropathic pain after traumatic spinal cord injury--relations to gender, spinal

level, completeness, and age at the time of injury. Spinal Cord 2004; 42:665-73. 16. Stevens PE, Dibble SL, Miaskowski C. Prevalence, characteristics, and impact of postmastectomy pain syndrome: an

investigation of women's experiences. Pain 1995; 61:61-8. 17. Werhagen L, Hutling C, Molander C. The prevalence of neuropatihc pain after non-traumatic spinal cord lesion. Spinal Cord 2007;

45:609-15.18. Jensen MP, Chodroff MJ, Dworkin RH. The impact of neuropathic pain on health-related quality of life: review and implications.

Neurology 2007; 68:1178-82. 19. Meyer–Rosberg K, Kwanstrom A, Kinnman E, Gordh T, Nordfos LO, Kristofferson A. Peripheral neuropathic pain--a

multidimensional burden for patients. Eur J Pain 2001;5:379-389.20. Berger A, Dukes EM, Oster G. Clinical characteristics and economic costs of patients with painful neuropathic disorders. J Pain

2004; 5:143-9. 21. Taylor RS. Epidemiology of refractory neuropathic pain. Pain Pract 2006; 6:22-6.

2 1. Treede R-D, Jensen TS, Campbell JN, Cruccu G, Dostrovsky JO, Griffin JW, Hansson P, Hughes R, Nurmikko T, Serra J.

Neuropathic pain: Redefinition and a grading system for clinical and research purposes. Neurology 2008; 70;1630-1635. 2. Galer BS, Jensen MP. Development and preliminary validation of a pain measure specific to neuropathic pain: the Neuropathic Pain

Scale. Neurology 1997; 48:332-8. 3. Krause SJ, Backonja MM. Development of a neuropathic pain questionnaire. Clin J Pain 2003; 19:306-14. 4. Backonja MM, Krause SJ. Neuropathic pain questionnaire--short form. Clin J Pain 2003; 19:315-6. 5. Bouhassira D, Attal N, Fermanian J, Alchaar H, Gautron M, Masquelier E, et al. Development and validation of the Neuropathic Pain

Symptom Inventory. Pain 2004; 108:248-57. 6. Portenoy R. Development and testing of a neuropathic pain screening questionnaire: ID Pain. Curr Med Res Opin 2006; 22:1555-65.7. Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, et al. Comparison of pain syndromes associated with nervous

or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain 2005; 114:29-36.

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8. Freynhagen R, Baron R, Gockel U, Tölle TR. painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin 2006; 22:1911-20.

9. Bennett M. The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs. Pain 2001; 92:147-57. 10. Chaudakshetrin P, Prateepavanich P, Chira-Adisai W, Tassanawipas W, Leechavengvongs S, Kitisomprayoonkul W. Cross-cultural

adaption to the Thai language of the neuropathic pain diagnostic questionare (DN4). J Med Assoc Thai 2007; 90:1860-5. 11. Huskisson EC. Measurement of pain. Lancet. 1974; 2:1127-31.

3 3.1

1. Attal N, Cruccu G, Haanpää M, Hansson P, Jensen TS, Nurmikko T, Sampaio C, Sindrup S, Wiffen P; EFNS Task Force. EFNS guidelines on pharmacological treatment of neuropathic pain. Eur J Neurol 2006; 13:1153-69.

2. Attal N, Bouhassira D. Translating basic research on sodium channels in human neuropathic pain. J Pain 2006; 7:S31-7. 3. Dworkin RH, Backonja M, Rowbotham MC, Allen RR, Argoff CR, Bennett GJ, Bushnell MC, Farrar JT, Galer BS, Haythornthwaite

JA, Hewitt DJ, Loeser JD, Max MB, Saltarelli M, Schmader KE, Stein C, Thompson D, Turk DC, Wallace MS, Watkins LR, Weinstein SM. Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations. Arch Neurol 2003; 60:1524-34.

4. Dworkin RH, O'Connor AB, Backonja M, Farrar JT, Finnerup NB, Jensen TS, Kalso EA, Loeser JD, Miaskowski C, Nurmikko TJ, Portenoy RK, Rice AS, Stacey BR, Treede RD, Turk DC, Wallace MS. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain 2007; 132:237-51.

5. Eisenberg E, McNicol E, Carr DB. Opioids for neuropathic pain. Cochrane Database Syst Rev 2006; 3:CD006146. 6. Finnerup NB, Otto M, Jensen TS, Sindrup SH. An evidence-based algorithm for the treatment of neuropathic pain. MedGenMed

2007; 9:36. 7. Finnerup NB, Otto M, McQuay HJ, Jensen TS, Sindrup SH. Algorithm for neuropathic pain treatment: An evidence based proposal.

Pain 2005; 18:289-305. 8. Hansson PT, Dickenson AH. Pharmacological treatment of peripheral neuropathic pain conditions based on shared commonalities

despite multiple etiologies. Pain 2005; 113:251-54. 9. Hollingshead J, Dühmke RM, Cornblath DR. Tramadol for neuropathic pain. Cochrane Database Syst Rev. 2006; 3:CD003726. 10. Jensen TS. Anticonvulsant for neuropathic pain. Eur J Pain 2002; 6;S61-8 11. Markman JD, Dworkin RH. Ion channel targets and treatment efficacy in neuropathic pain. J Pain 2006; 7:S38-47. 12. Saarto T, Wiffen PJ. Antidepressants for neuropathic pain. Cochrane Database Syst Rev 2007; 4:CD005454.13. Wiffen P, Collins S, McQuay H, Carroll D, Jadad A, Moore A. Anticonvulsant drugs for acute and chronic pain. Cochrane Database

Syst Rev 2005; 3:CD001133. 14. Wiffen PJ, McQuay HJ, Edwards JE, Moore RA. Gabapentin for acute and chronic pain. Cochrane Database Syst Rev 2005;

3:CD005452.15. Wiffen PJ, McQuay HJ, Moore RA. Carbamazepine for acute and chronic pain. Cochrane Database Syst Rev 2005; 3:CD005451.

3.21. Tyler-Kabara EC, Kassam AB, Horowitz MH, Urgo L, Hadjipanayis C, Levy EI, Chang YF. Predictors of outcome in surgically

managed patients with typical and atypical trigeminal neuralgia: comparison of results following microvascular decompression. JNeurosurg 2002; 96:527-31.

2. Laghmari M, El Ouahabi A, Arkha Y, Derraz S, El Khamlichi A. Are the destructive neurosurgical techniques as effective as microvascular decompression in the management of trigeminal neuralgia? Surg Neurol 2007; 68:505-12.

3. Pamir MN, Peker S. Microvascular decompression for trigeminal neuralgia: a long-term follow-up study. Minim Invasive Neurosurg 2006; 49:342-6.

4. Barker FG 2nd, Jannetta PJ, Bissonette DJ, Larkins MV, Jho HD. The long-term outcome of microvascular decompression for trigeminal neuralgia. N Engl J Med 1996; 334:1077-83.

5. Sheehan J, Pan HC, Stroila M, Steiner L. Gamma knife surgery for trigeminal neuralgia: outcomes and prognostic factors. J Neurosurg 2005; 102:434-41.

6. Brisman R. Microvascular decompression vs. gamma knife radiosurgery for typical trigeminal neuralgia: preliminary findings. Stereotact Funct Neurosurg 2007; 85:94-8.

7. Fountas KN, Smith JR, Lee GP, Jenkins PD, Cantrell RR, Sheils WC. Gamma Knife stereotactic radiosurgical treatment of idiopathic trigeminal neuralgia: long-term outcome and complications. Neurosurg Focus 2007; 23:E8.

8. Oturai AB, Jensen K, Eriksen J, Madsen F. Neurosurgery for trigeminal neuralgia: comparison of alcohol block, neurectomy, and radiofrequency coagulation. Clin J Pain 1996; 12:311-5.

9. Kanpolat Y, Savas A, Bekar A, Berk C. Percutaneous controlled radiofrequency trigeminal rhizotomy for the treatment of idiopathictrigeminal neuralgia: 25-year experience with 1,600 patients. Neurosurgery 2001; 48:524-32.

10. Nuti C, Peyron R, Garcia-Larrea L, Brunon J, Laurent B, Sindou M, Mertens P. Motor cortex stimulation for refractory neuropathic

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pain: four year outcome and predictors of efficacy. Pain 2005; 118:43-52. 11. Koszewski W, Jarosz J, Pernak-De Gast J. The DREZ lesion as an effective treatment for chronic hypothetically post-herpetic

neuropathic pain. Case report and review of literature. Neurol Neurochir Pol 2003; 37:943-53.12. Petersen KL, Rowbotham MC. Relief of post-herpetic neuralgia by surgical removal of painful skin: 5 years later. Pain 2007;

131:214-8.13. Meglio M, Cioni B, Rossi GF. Spinal cord stimulation in management of chronic pain. A 9-year experience. J Neurosurg 1989;

70:519-24.14. Tseng SH. Treatment of chronic pain by spinal cord stimulation. J Formos Med Assoc 2000; 99:267-71. 15. Saris SC, Iacono RP, Nashold BS Jr. Successful treatment of phantom pain with dorsal root entry zone coagulation. Appl

Neurophysiol 1988; 51:188-97. 16. Bittar RG, Kar-Purkayastha I, Owen SL, Bear RE, Green A, Wang S, Aziz TZ. Deep brain stimulation for pain relief: a meta-analysis.

J Clin Neurosci 2005; 12:515-9.17. Owen SL, Green AL, Nandi DD, Bittar RG, Wang S, Aziz TZ. Deep brain stimulation for neuropathic pain. Acta Neurochir Suppl

2007; 97:111-6. 18. Kumar K, Toth C, Nath RK. Deep brain stimulation for intractable pain: a 15-year experience. Neurosurgery 1997; 40:736-46. 19. Hassantash SA, Afrakhteh M, Maier RV. Causalgia: a meta-analysis of the literature. Arch Surg 2003; 138:1226-31.20. Johnson JP, Ahn SS, Choi WC, Masciopinto JE, Kim KD, Filler AG, Desalles AA. Thoracoscopic sympathectomy: techniques and

outcomes. Neurosurg Focus 1998; 4:e4. 21. Mailis A, Furlan A. Sympathectomy for neuropathic pain. Cochrane Database Syst Rev 2003; 2:CD002918.

3.31. Argoff CE, Backonja MM, Belgrade MJ, Bennett GJ, Clark MR, Cole BE, Fishbain DA, Irving GA, McCarberg BH, McLean MJ.

Consensus Guidelines: treatment planning and options. Diabetic peripheral neuropathic pain. Mayo Clin Proc 2006; 81:S12-S25. 2. Moulin DE, Clark AJ, Gilron I, Ware MA, Watson CP, Sessle BJ, et al. Pharmacological management of chronic neuropathic pain-

consensus statement and guidelines from the Canadian Pain Society. Pain Res Manag 2007; 12:13-21. 3. Chen H, Lamer TJ, Rho RH, Marshall KA, Sitzman BT, Ghazi SM, Brewer RP. Contemporary management of neuropathic pain for

the primary care physician. Mayo Clin Proc 2004; 791:1533-1545. 4. Cruccu G, Aziz TZ, Garcia-Larrea L, Hansson P, Jensen TS, Lefaucheur JP, Simpson BA, Taylor RS. EFNS guidelines on

neurostimulation therapy for neuropathic pain. Eur J Neurol 2007; 14:952-70. 5. Corbett CF. Practical management of patients with painful diabetic neuropathy. Diabetes Educ 2005; 31:523-540.6. Wolfe GI, Hotz SE, Barohn RJ. Treatment of painful peripheral neuropathy. J Clin Neuromusc Dis 2002; 4:50-59.7. Kowalske KJ, Agre JC. Neuromuscular rehabilitation and electrodiagnosis: generalized peripheral neuropathy. Arch Phys Med

Rehabil 2000;81:S20-S26. 8. Panlilio LM, Christo PJ, Raja SN. Current management of postherpetic neuralgia. Neurologist 2002; 8:339-50. 9. Watson CPN, Oaklander AL. Postherpetic neuralgia. Pain Pract 2002;2:295-307. 10. Brunelli B, Gorson KC. The use of complementary and alternative medicines by patients with peripheral neuropathy. J Neurol Sci

2004; 218:59-66. 11. Dubinsky RM, Kabbani H, El-Chami Z, Boutwell C, Ali H. Practice parameter: treatment of postherpetic neuralgia; An evidence-

based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2004; 63:959-965.12. Abuaisha BB, Costanzi JB, Boulton AJM. Acupuncture for the treatment of chronic painful peripheral diabetic neuropathy: a long-

term study. Diabetes Res Clin Pract 1998; 39:115-121. 13. Rapson LM, Wells N, Pepper J, Majid N, Boon H. Acupuncture as a promising treatment for below-level central neuropathic pain:

retrospective study. J Spinal Cord Med 2003; 26:21-26. 14. Chong MS, Bajwa ZH. Diagnosis and treatment of neuropathic pain. J Pain Symptom Manage 2003; 25:S4-S11.

4.4.1 Diabetic peripheral neuropathy (DPN)

1. Kulkantrakorn K. Diabetic neuropathy: new insights and treatments. Intern Med J Thai 2005;21:286-91. 2. Tapp RJ, Shaw JE, de Courtenm MP, Dunstan DW, Welborn TA, Zimmet PZ, et al. Foot complications in type 2 diabetes: an

Australian population-based study. Diabet Med 2003; 20:105-13. 3. Fedele D, Comi G, Coscelli C, Cucinotta D, Feldman EL, ChirlandaG, et al. A multicenter study on the prevalence of diabetic

neuropathy in Italy. Diabetes Care 1997; 20:836-43. 4. Partanen J, Niskanen L, Lehtinen J, Mervaala E, Siitonen O, Uusitupa M. Natural history of peripheral neuropathy in patients with

non-insulin-dependent diabetes mellitus. N Engl J Med 1995; 333:89-94. 5. Sriussadaporn S, Mekanandha P, Vannasaeng S, Nitiyanant W, Komoltri C, Ploybutr S, Yamwong P, Peerapatdit T, Vichayanrat A.

Factors associated with diabetic foot ulceration in Thailand: a case-control study. Diabet Med 1997; 14:50-6.

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6. Yagihashi S, Yamagishi S, Wada R. Pathology and pathogenetic mechanisms of diabetic neuropathy: correlation with clinical signsand symptoms. Diabetes Res Clin Pract 2007; 77:S184-89

7. Lauria G, Lombardi R. Skin biopsy: a new tool for diagnosing peripheral neuropathy. BMJ 2007; 334:1159-62. 8. Gabbay KH. Aldose reductase inhibition in the treatment of diabetic neuropathy: Where are we in 2004? Curr Diab Rep 2004; 4:405-

8.9. Pittinger G, Vinik A. Nerve growth factor and diabetic neuropathy. Exp Diabesity Res 2003; 4:271-85. 10. Casellini CM, Vinik AI. Clinical manifestations and current treatment options for diabetic neuropathies. Endocr Pract 2007; 13:550-66.11. Dworkin RH, Backonja M, Rowbotham MC, Allen RR, Argoff CR, Bennett GS, et al. Advances in neuropathic pain: diagnosis,

mechanism and treatment recommendations. Arch Neurol 2003; 100:1524-34. 12. Nolanoa M, Simoneb DA, Wendelschafer-Crabb C , Johnsonc T, Hazenc E, Kennedyc WR. Topical capsaicin in humans: parallel

loss of epidermal nerve fibers and pain sensation. Pain 1999; 81:135–145. 13. Vinik A, Ullal J, Parson HK, Casellini CM. Diabetic neuropathies: clinical manifestations and current treatment options. Nat Clin Pract

Endocrinol Metab 2006; 2:269-81. 4.2 Post herpetic neuralgia (PHN)

1. Pavan-Langston D. Herpes zoster antivirals and pain management. Ophthalmology 2008: 115:S13-S20. 2. Opstelten W, EekohoF J, Neven AK, et al . Treatment of herpes zoster. Can Fam Physician 2008; 54:373-377 3. He L, Zhang D, Zhou M, Zhu C. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev 2008;

1:CD003582.4. Johnson R, McElhaney J, Pedalino B, Levin M. Prevention of herpes zoster and its painful debilitating complications. Int J Infeut Dis

2007; 11:S43-S48. 5. Tyring SK. Management of herpes zoster and posterpetic neuralgia. J Am Acad Dermatol 2007; 57:S136-S142.

4.3 Trigeminal neuralgia (TGN) 1. Cheshire WP. Trigeminal neuralgia : for one nerve a multitude of treatments. Expert Rev Neurother 2007; 7:1565-79. 2. Jorns TP, Zakrzewska JM. Evidence-based approach to the medical management of trigeminal neuralgia. Br J Neurosurg 2007;

21:253-61.3. Hunt K, Patwardhan R. Trigeminal neuralgia: a modern-day review. Int Rev Neurobiol 2007; 76:621-31. 4. Guo S, Chao ST, Reuther AM, Barnett GH, Suh JA. Review of the treatment of trigeminal neuralgia with gamma knife radiosurgery.

Sterotact Funct Neurosurg 2008; 86:135-146. 5. Tatli M, Satici O, Kanpolat Y, Sindou M. Various surgical modalities for trigeminal neuralgia: literature study of respective long term

outcomes. Acta Neurochir (Wien) 2008; 150:243-55. 4.4 Phantom limb pain

1. Nikolajsen L, Jensen TS. Phantom pain. In: McMahon SB, Koltzenburg M, eds. Wall and Melzack’s textbook of pain, 5th ed. China: Elsevier, Churchill Livingstone, 2006:961-72.

2. Sherman RA. Postamputation pain. In: Jensen TS, Wilson PR, Rice ASC, eds. Clinical pain management: Chronic pain, 1st ed. London: Arnold, 2003, 427-36.

3. Woodhouse A. Phantom limb sensation. Clin Exp Pharmacol Physiol 2005; 32:132-4.4. Flor H. Phantom-limb pain: characteristics, causes, and treatment. Lancet Neurol 2002; 1:182-9.

4.5 Central pain 1. Vranken JH , Dijkgraaf MGW., Kruis MK , van der Vegt MH, Hollmann MW, Heesen M. Pregabalin in patients with central

neuropathic pain: A randomized , double – blind , placebo - controlled trial of a flexible - dose regimen . Pain 2008;136:150-157.2. Dworkin RH, O’ Connor AB, Backonja M, et al . Phamacologic management of neuropathic pain: Evidence-based recommend-

dations. Pain 2007; 132:237-51. 3. Finnerup NB, Jensen TS. Spinal cord injury pain : mechanisms and treatment. Eur J Neurol 2004;11:73-82 4. Finnerup NB, Otto M, Jensen TS, Sindrup SH. Algorithm for neuropathic pain treatment : an evidence based proposal. Pain 2005;

118:289-305.

5. Referral criteria 1. Argoff CE, Backonja MM, Belgrade MJ, Bennett GJ, Clark MR, Cole BE, et al. Consensus Guidelines: Treatment Planning and

Options. Mayo Clin Proc 2006;81(Suppl 4):S3-S11.

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Clinical practice guideline for neuropathic pain

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