Conditions Accompanied by Neuropathic Pain

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There is a diverse group of conditions in which pain is described as neuropathic. These are central disorders, such as post-stroke pain, spinal cord damage or disease; more peripheral conditions, such as nerve trauma, phantom limb pain, post-herpetic neuralgia; and even conditions with no known neural insult, such as Sudecks atrophy. The principles of management are broadly the same for all.

Some of these disorders have been gathered together under two categories, known as Complex Regional Pain Syndrome I and II (CRPS I, II). Both types show spontaneous pain, hyperalgesia and/or allodynia in the territory of, and frequently spreading beyond the territory of, a single peripheral nerve. They show or give a history of blood flow changes and trophic changes to skin, nails and/or hair. There may be, or have been, edema. CRPS II (causalgia) follows nerve injury; CRPS I (reflex sympathetic dystrophy) follows any noxious event.

There is, however, no agreement on the cause of each syndrome or the best treatment. Both syndromes consist of neuropathic pain. Following an initiating event, it seems that changes take place in both the somatic and sympathetic nervous systems, consisting of structural changes both peripherally and centrally, alteration in the chemical contents of afferent nerve cells and the development of adrenergic sensitivity.

The pain associated with these syndromes is neuropathic in nature and out of proportion to any injury. It is described as burning in nature and has features of dysesthesia, paraesthesia, mechanical allodynia and hyperalgesia to cold stimuli. The clinical course is divided into three stages.

Stage 1 consists of pain, the affected extremity being either warm or cold, along with accelerated nail and hair growth. The symptoms come on at any time, from hours to weeks after the original injury. Stage 2 (the dystrophic phase) consists of continuing pain in the affected limb, which is cold and cyanotic. Nails become rigid and brittle and osteoporosis develops. Finally, lack of use of the affected limb leads to

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