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Interventional management of neuropathic pain: NeuPSIG recommendations

Dworkin, Robert H.a,b,*; O’Connor, Alec B.c; Kent, Joelc; Mackey, Sean C.d; Raja, Srinivasa N.e; Stacey, Brett R.f; Levy, Robert M.g; Backonja, Miroslavh; Baron, Ralfi; Harke, Henningj; Loeser, John D.k; Treede, Rolf-Detlefl; Turk, Dennis C.k; Wells, Christopher D.m

doi: 10.1016/j.pain.2013.06.004
Comprehensive review
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Neuropathic pain (NP) is often refractory to pharmacologic and noninterventional treatment. On behalf of the International Association for the Study of Pain Neuropathic Pain Special Interest Group, the authors evaluated systematic reviews, clinical trials, and existing guidelines for the interventional management of NP. Evidence is summarized and presented for neural blockade, spinal cord stimulation (SCS), intrathecal medication, and neurosurgical interventions in patients with the following peripheral and central NP conditions: herpes zoster and postherpetic neuralgia (PHN); painful diabetic and other peripheral neuropathies; spinal cord injury NP; central poststroke pain; radiculopathy and failed back surgery syndrome (FBSS); complex regional pain syndrome (CRPS); and trigeminal neuralgia and neuropathy. Due to the paucity of high-quality clinical trials, no strong recommendations can be made. Four weak recommendations based on the amount and consistency of evidence, including degree of efficacy and safety, are: 1) epidural injections for herpes zoster; 2) steroid injections for radiculopathy; 3) SCS for FBSS; and 4) SCS for CRPS type 1. Based on the available data, we recommend not to use sympathetic blocks for PHN nor radiofrequency lesions for radiculopathy. No other conclusive recommendations can be made due to the poor quality of available data. Whenever possible, these interventions should either be part of randomized clinical trials or documented in pain registries. Priorities for future research include randomized clinical trials, long-term studies, and head-to-head comparisons among different interventional and noninterventional treatments.

aDepartment of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA

bDepartment of Neurology, Center for Human Experimental Therapeutics, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA

cUniversity of Rochester, Rochester, NY, USA

dStanford University, Palo Alto, CA, USA

eJohns Hopkins University, Baltimore, MD, USA

fOregon Health and Science University, Portland, OR, USA

gNorthwestern University, Chicago, IL, USA

hUniversity of Wisconsin, Madison, WI, USA

iUniversity of Kiel, Kiel, Germany

jSchmerzfachpraxis, Krefeld, Germany

kUniversity of Washington, Seattle, WA, USA

lUniversität Heidelberg, Mannheim, Germany

mPain Matters, Liverpool, UK

*Corresponding author. Address: Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 604, Rochester, NY 14642, USA. Tel.: +1 585 275 8214; fax: +1 585 244 7271.

E-mail: robert_dworkin@urmc.rochester.edu

Submitted December 18, 2012; revised May 24, 2013; accepted June 3, 2013.

© 2013 Lippincott Williams & Wilkins, Inc.
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