Neuropathic Pains

Neuropathic pains are stimulant pains that usually occur as a result of a lesion or dysfunction in regions involving the central nervous system and peripheral nervous system. As a result of damage to neurons, also called nerve cells, uncontrolled electrical discharges occur. This occurs together with neuropathic pain, which gives different findings in patients. These findings are described as burning, tingling, stabbing, stinging and electric shock. Diabetes mellitus is the most common cause of neuropathic pain, seen in 1-2% of the population.

*What are the Causes of Neuropathic Pain?

*Central Nervous System Originated Neuropathic Pain

Neuropathic pain is inevitable in diseases such as paralysis, spinal cord injury, multiple sclerosis and spinal cord infections, which are closely related to the central nervous system.

*Peripheral Nervous System Originated Neuropathic Pain

It is especially common in people with metabolic diseases and inflammatory problems. In addition, nutritional disorders, toxins, shingles infections, cancers, hereditary diseases and diseases of unknown origin can also cause neuropathic pain originating from the peripheral nervous system.

* Neuropathic Pain Findings and Diagnosis

Experiencing stinging, burning, tingling, freezing or electric shock-like pain in the legs, hands and other areas directs physicians to neuropathic pain. In addition to these, the onset time of the disease, its severity, how it progresses at night and how often it is seen are also very important for diagnosis.

Primarily, it is aimed to reduce the complaints of a patient experiencing neuropathic pain. For example; In a diabetic patient, high blood sugar will create negative effects on the nerves, leading to neuropathic pain. The main purpose of treatment here is; to regulate blood sugar. Classical analgesics do not respond to pain relief because the cause of pain is nerve cell origin. Epileptic drugs, rhythm disorder drugs, local anesthetics, muscle relaxants and morphine derivative drugs, which are frequently used in treatment, are beneficial. In advanced cases, nerve blockade is performed with interventional methods.

*Trigeminal Neuralgia

By definition, it is the experience of lightning-like pain that hits the face and lasts for a short time. In trigeminal neuralgia, which occurs as a result of various pressures on the nerve trigeminus, which is the 5th of the 12 nerves coming out of the brain stem, pain can be controlled for a short time with painkillers. Over time, as a result of getting used to the drug and various side effects, the pain threshold will increase again and different treatment methods will be started. However, pain relievers can be considered as the first treatment steps in trigeminal neuralgia.

Nervus trigeminus has 3 branches that spread to the face. The first branch, the nervus ophthalmicus, receives the pain, temperature and motor sensations of the lower region of the face, the eye region of the face, the second branch of the nervus maxillaris maxilla region, and the third branch, the nervus mandibularis. In partial or complete defects of these nerve branches, the patient will have loss of pain and temperature sensations and deterioration in motor functions. In addition, varicella zoster infection can cause ophthalmic shingles by compressing the nerve. Although pain is experienced, rash lesions can be seen on the forehead and cornea.

Any lesion in the branches of the trigeminal border causes severe trigeminal neuralgia, and patients experience loss of sensation that cannot be relieved by drugs.

*Trigeminal Neuralgia Treatment

In patients with trigeminal neuralgia, the pain threshold will increase as they get used to analgesic drugs over time. In addition, other treatment methods can be used. Trigeminal radiofrequency rhizotomy, microvascular decompression, trigeminal glycerol rhizolysis and gamma-knife applications are among the alternative treatment methods when there is no response to painkillers. The sole purpose of these treatment methods is to block the fibers that transmit pain in the nerve or to relieve the pressure on the brain stem.

* Shingles and Postherpetic Neuralgia

It is a type of pain caused by varicella zoster virus type, which is caused by a rash with chickenpox. Chickenpox usually occurs in childhood and viruses remain in the nerve root. Later, this disease recurs for various reasons and causes rash lesions in various parts of the body. Shingles usually gets better within 2 weeks. However, the presence of pain even after 3 months after the rash makes the diagnosis of postherpetic neuralgia.

In postherpetic neuralgia, people may feel pain even when wearing clothes. Nerves that become extremely sensitive can give signs of pain even with a small touch.

*How Does the Varicella Zoster Virus Reactivate?

Viral infections will increase when the body’s immune system weakens.Rheumatic diseases, cancer and various malignancies or some drugs that damage the immune system trigger shingles and then lead to postherpetic neuralgia.

Patients may experience general malaise, loss of appetite, weight loss and psychological problems.

*Pain Due to Diabetes (Diabetic Neuropathy)

Diabetic neuropathy, which can be counted among the chronic complications of diabetes mellitus, is a life-threatening and very important condition. It may not cause any symptoms in patients, or it may cause symptoms such as numbness, pins and needles, tingling and pain in the hands and feet. Loss of sensation can also be experienced in the chronic period.

Most of the listed clinical or subclinical symptoms are among the chronic complications of diabetes, and as a result, a picture called diabetic neuropathy occurs. Many events play a role in the pathogenesis of this disease. Genetic predisposition, oxygen deprivation of nerve cells or immune mechanisms can be counted. High blood sugar levels for a long time will cause disruption of many metabolic pathways. In this case, the energy mechanism will be disrupted and since sufficient energy cannot be produced in the body, conduction defects will occur in the nerve cells. As a result, damage to peripheral, autonomic or local nerves occurs. This picture may occur before or after diabetes develops. The patient is unaware of diabetes and may only apply to the hospital with diabetic neuropathy complaints. With or without diabetes, blood sugar regulation must be well balanced in order to avoid end-organ damage and complications.

*Effects of Diabetic Neuropathy on the Autonomic Nervous System

As diabetes affects many systems, it can also affect the gastrointestinal system. Especially the intestines under the control of the enteric nervous system are damaged, and constipation and diarrhea, which are among the various digestive problems, are experienced. Bloating, gastroesophageal reflux, feeling full despite eating less are other gastrointestinal system findings. To avoid these, you can eat small but frequent meals.

In addition, it can cause vascular diseases by keeping the cardiovascular system. Hypotension may occur. When blood sugar drops in patients with diabetic neuropathy, complaints such as fatigue and darkening appear. As a precaution, you can check blood sugar regularly and ensure its regulation.

Diabetic neuropathy can also negatively affect sexual life, leading to dryness during sexual intercourse in women and erectile dysfunction in men. Lubricating gels or creams can also be used as a solution.

The most common complaint of diabetic patients is frequent urination at night. The solution to this problem, which is caused by the inability to empty the bladder completely, may be to use drugs or a catheter. Some patients may also experience urinary incontinence.

*Regional Nerve Damage Caused by Diabetic Neuropathy

Regional damages of diabetes usually occur suddenly and affect the nerves that go to structures such as arms, legs, head and trunk.

By affecting the face, health problems such as diplopia (double vision), paralysis on half the face, unilateral and bilateral pain in the waist or legs, feeling of pressure in the chest and cholecystitis are experienced.

Regional nerves are often painful and greatly reduce the patient’s standard of living. Since it occurs suddenly, it can be relatively easy to treat. It may heal on its own.

*Effect of Diabetic Neuropathy on Near Central Nerves

Generally, unilateral (one-sided) pain is experienced in the hip. It may cause loss of sensation by causing difficulty in walking. In advanced cases, amputation can be achieved without the possibility of treatment.

Diabetes sometimes also causes entrapment syndromes. Trap syndromes that occur with the picture of nerve compression are most commonly seen in the wrist. If a situation similar to Carpal Tunnel syndrome is experienced and the treatment is not sufficient, it may go as far as the surgical method.

*Phantom (Ghost) Pain

Phantom pain is when a limb that is amputated as a result of various conditions gives signs of contraction and stinging as if it is standing still. The pain felt in the stump area of ​​the amputation area is also called stump pain.

In the phantom pain type, patients usually begin to feel chronic pain at variable intervals after a certain period of time after losing their limbs. Some of the patients do not feel these pains, while others state that the typical amputated limb aches as if it is standing still. This wide range has caused physicians to accept this type of pain and to determine treatment methods. The description of pain felt in foot and arm losses is similar to the type of pain experienced after the loss of organs such as tongue, nose, breast, finger, and teeth. Approximately 22-63% of patients describe phantom pain after breast removal surgery.The main manifestation of phantom pain is chronic pain before the amputation of the amputated limb. Patients can continue to experience this pain they have experienced before, even after their limbs are amputated.

The sensation of pain can be perceived as the shortening or distorted feeling of the limb, which we call the telescope sign. If the patient is experiencing severe pain before the limb is removed, the probability of experiencing phantom pain increases after amputation is achieved.

The treatment of phantom pain is provided by physicians and nerve blockade, epidural steroid injection or spinal cord stimulation are performed. Although there is no specific treatment available, if a drug works well for one patient for phantom pain, it may not work for another patient. TENS (transcutaneous electrical nerve stimulation) should be performed before attempting sympathetic nerve blockade. If no benefit is achieved, nerve blockade should be performed.

If the patient does not respond to any treatment, then he can receive various psychotherapy support to cope with the phantom pain. The standard of living will be increased.

*Complex Regional Pain Syndrome

It is chronic pain caused by dysfunction in the central or peripheral nervous system. Pain, redness, tenderness and swelling in the affected area draw attention. Reklex sympathetic dystrophy syndrome, or causalgia as it was called during the civil war, people feel burning pain even after their wounds have achieved complete remission.

The most prominent symptom is pain, which increases in intensity over time. It often involves the extremities (hands, arms and legs). So what symptoms do these patients present with?

• Severe burning pain

• Increased sensitivity and redness of the skin

• Color and texture changes in the skin

• Disproportionate growth in keratin-containing structures

• Motor dysfunction

Even if the pain has started to occur in a regional place as a result of the first trauma, it progresses gradually over time. Pain felt unilaterally may acquire a bilateral character over time. At first, muscle spasms may accompany the pain. Intense pain felt afterwards can lead to joint stiffness or skin changes. In the chronic process, the pain will be felt intensely in atrophic areas, irreversibly.

Although the pathogenesis is not fully explained, it is thought that pain receptors are accustomed to noradrenaline, which is one of the catecholamines of the sympathetic nervous system. Inflammation findings such as redness, warmth and tenderness are seen in the area where the syndrome occurs.

*Treatment

Although there is no known form of treatment, the basic principle should be to reduce pain symptoms. Functional losses of patients can be regained with physiotherapy. Pain should be reduced a little with analgesic drugs. If adequate pain relief cannot be achieved, sympathetic nerve block, sympathectomy, spinal cord stimulation (TENS) applications can be tried.