Neuropathic pain: Information for clinicians

Neuropathic pain is a common complication of cancer and may be due to: 

  • vertebral metastases from prostate, lung, bowel and breast cancer causing root or cord compression
  • breast cancer brachial plexopathy 

Other causes of neuropathic pain include:

  • neurological illnesses such as Multiple Sclerosis
  • treatment e.g. chemotherapy-induced peripheral neuropathy
  • other co-morbid conditions e.g. post-herpetic neuralgia or diabetic neuropathy
Red flags

Always consider spinal cord compression in patients with neuropathic pain.

Key symptoms of cord compression include:

  • new intractable, progressive pain, especially thoracic or legs. 
  • New spinal nerve root pain may radiate down the leg (like sciatica), or the arm, or more like a band around the chest or abdomen
  • Coughing, straining or weight bearing may aggravate pain
  • New difficulty walking or climbing stairs; reduced power and heavy legs

Late signs include:

  • Sensory impairment at an abdominal or thoracic level plus altered limb sensation
  • Bowel or bladder disturbance; loss of sphincter control 
Clinical features
  • Patients often describe neuropathic pain as burning, shooting, tingling or stabbing in nature
  • Altered sensation is also a symptom. Sensitivity to light touch may be reduced or increased (allodynia)
  • Pain may follow a dermatomal distribution

When examining always compare both sides of the body.

An initial approach to treatment
  • Tricyclic antidepressants e.g. Amitriptyline 10mgs at night and titrate to 25mg 
  • Anticonvulsant e.g. Pregabalin or Gabapentin. Pregabalin is a BD dosage and easier to titrate than Gabapentin. Remember that Pregabalin and Gabapentin are sedative in combination with opioids 
  • Duloxetine is another alternative and may help mood as well as pain
  • A combination of neuropathic agent, Paracetamol and opioid analgesics may be needed 
  • Bloods to exclude a metabolic cause e.g. B12 deficiency
Specialist care

If the above approaches are not working and sleep in disturbed, then specialist advice is recommended. Options include:

  • Dexamethasone 6mg for 6 days (or 40mg Prednisolone) with PPI cover for urgent control of neuropathic pain. This takes the pressure off the nerve
  • Other anticonvulsants may be tried e.g. Oxcarbazepine 150mg BD
  • Urgent MRI to inform whether further intervention is needed e.g. radiotherapy, surgery or nerve block 

Recommended Resources

Scottish Palliative Care Guidelines - Neuropathic pain

Published 14th April 2022

MHRA Pregabalin (Lyrica): reports of severe respiratory depression

Published 18th February 2021

Share

Related Services

Brent North Community Palliative Care Team - based at St Luke's
Close

Brent North Community Palliative Care Team - based at St Luke's

T. 020 8382 8013

North Brent Community Specialist Palliative Care Nurse team provides advice and visiting to palliative care patients in North Brent. The team is based at St Lukes Hospice.

Areas: Queensbury, Fryent, Welsh Harp, Barnhill, Kenton, Northwick Park, Preston, Sudbury, Wembley Central, Alperton, Tokyngton

The team can be contacted for referrals Monday to Sunday 8.30am to 4.30pm. 

After 4.30pm the Out of Hours Telephone Advice line 020 8382 8000 operates and calls will be taken by a nurse on St Lukes inpatient unit

Referral form for clinician use only.

Community Specialist Palliative Care Referral Form V4 (DOCX)
Brent South Community Palliative Care Team - based at Pembridge Hospice
Close

Brent South Community Palliative Care Team - based at Pembridge Hospice

T. 020 8102 5000

South Brent Community Specialist Palliative Care Nurse Team provides advice and visiting to palliative care patients in South Brent. The team are based at Pembridge Hospice

Areas: Harlesden, Willesden, Kilburn, Neasden (south of north circular Brent, except the St Raphael's Estate) 

The team can be contacted for referrals Monday to Friday 8.30am to 5.00pm. Weekends and Bank Holidays 9.00am to 5.00pm.  

Between Monday to Friday 5.00pm and 8.30am, the Out of Hours Telephone Advice line 020 8102 5000 takes calls. Weekends and Bank Holidays 5.00pm to 9.00am.

All referrals to be made via SPA email address.

For any other email correspondence. clcht.pembridgeunit@nhs.net.

Referral form for clinician use only.

Community Specialist Palliative Care Referral Form V4 (DOCX)

Related Articles

11th September 2023

Spinal cord compression: Information for patients and carers

Feedback