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The use of laboratory studies and imaging studies in the diagnosis of neuropathic pain present clinical challenges and, although medications remain the mainstay of therapy, it is frequently necessary to try multiple different medications and modalities for adequate treatment. There are two types of pain: nociceptive and neuropathic. The former is of a mechanical nature and relates to nerve pain through direct nerve irritation, such as an arthritic joint. The latter implies a specific injury or insult to nerves causing pain and discomfort. Based on my clinical observations in treating patients with neuropathic pain for almost 20 years, it is my belief that neuropathic pain and, in particular, radicular pain has been under-diagnosed and under-treated for a variety of reasons. Partly it’s our reliance on electrodiagnostic testing in making the diagnosis of radicular pain and the difficulty in obtaining an accurate history from the patient, and an absence of other diagnostic testing to make this diagnosis. Also, health care professionals often overlook the neuropathic component of pain and focus on other causes of chronic pain. Further, the difficulty in the treatment of neuropathic pain presents a clinical challenge. Neuropathic pain includes, but is not limited to diabetic neuropathy, all peripheral neuropathies, radiculopathy, complex regional pain syndrome, sympathetically mediated pain, fibromyalgia, and interstitial cystitis. A variety of medical conditions that cause peripheral neuropathy include inherited diseases, alcoholism, nutritional vitamin deficiencies, cancers, autoimmune reactions, medications, kidney and thyroid disease and infections such as Lyme disease, shingles or AIDS. Peripheral neuropathy of idiopathic etiology, diabetic peripheral neuropathy, radiculopathy and mono-neuropathies make up the majority of all the causes of neuropathic pain. Diagnostic Issues Although the diagnosis of a specific type of neuropathic pain can be complicated, distinguishing between neuropathic pain and nociceptive pain is not as complicated. It is important to distinguish pain patterns in making the diagnosis of neuropathic pain. Practitioners should evaluate the patients as to whether the pain involves an extremity and, if so, is it radiating from the spine or is it a separate pain of a joint or a separate part of the extremity. Pain location is important and the patient needs to elaborate specifically where the pain occurs. It is helpful to use a pain diagram to show where their pain is located. The practitioner should then go over the diagram with the patient and complete an examination and have the patient show them physically on their body where the pain occurs. If the pain involves an extremity, is it sock-like pain or is it linear in fashion? Are there neurological changes on examination and does the patient have other neurological symptoms or complaints such as numb-ness or tingling? For the purpose of this article, Noxicare™ Natural Pain Relief examined 30 patients in my clinic with chronic back pain and confirmed compressive pathology in patients who also had extremity pain. Of those 30 patients, only two were able to adequately describe a radicular symptomatology that could be considered as anatomically accurate. Less than half the patients had EMG studies and, of those, about two thirds were reported as negative. In our practice, we have found that the treatment of radicular pain has frequently been denied specifically based on these two issues: that there is a lack of a clear dermatomal pain pattern, and that there is a normal EMG report.
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