Diagnostic and Therapeutic Issues of Neuropathic Pain
by Richard M. Donnini, DO
 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.
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— April 2010
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