Neuropathic pain is
caused by an injury to a peripheral nerve.
This can be caused by trauma,
or it can be caused by disease. And we most
commonly see it in people with chronic,
often Type 2 Diabetes, but it can happen in Type 1
Diabetes as well, and it usually occurs
in the legs, although it can occur in the upper
limbs as well. And in this situation, if we look
at the nerves microscopically, we can see
there's actually deterioration of the nerve.
And in those areas where there's been nerve injury caused
by trauma, we can actually see regeneration of the nerve
and kind of a shower of nervelets
coming off the injured end of the nerve.
And this can form a little nodule or nidus
that's exquisitely sensitive. The pain that these
folks have is flitting, it's shock-like, it happens
completely unexpectedly, so they can't prepare for it.
So we've already noted that neuropathic
pain can occur in the presence
of diseases such as diabetes, and can occur
after nerve damage and when the nerves
are examined microscopically they do appear
to be damaged. But it can occur with absolutely no
underlying disease. And it can occur without
any diagnosis whatsoever other than
neuropathic pain. My wife, who is
a completely healthy woman, has
neuropathic pain in her legs and in her feet.
For the last 3 years, she's been largely incapacitated
by this pain. There have been periods where she's had
to crawl up the stairs in our house, because
the pain was so severe she couldn't stand.
The good news is, she's starting to respond
to therapy. The bad news is, I suspect she's going
to have neuropathic pain for the rest of her life,
and all we can hope for is the treatment will make
her more comfortable. Very, very difficult
to treat. And it requires more than any
single discipline to treat it. It needs
physicians, and nurses, and all that whole pain
team I mentioned to you earlier. Neuromodulation
is one of the treatments. It's a late treatment. It's
extremely costly. It costs between $30,000 and
$50,000 to place neuromodulation
systems in the spinal cord.
This is a spinal cord stimulator. Very expensive
and it doesn't always work. When it works,
it's a dream. But it doesn't always work, and frequently
doesn't work. So, when it comes to chronic pain,
a lot of the management of the pain
is not to treat it or cure it, but
to teach the patient how to live with it. But,
as I mentioned, neuropathic pain can occur with
diabetics, but it can occur with no apparent
cause at all. And the focus has to be on,
“This is what you have to live with. We're not going
to get rid of it. You have to learn to live with it.”
It's a discouraging statement to give to a person.
So, in summary, in this lecture we've discussed
the complexity of pain, the various definitions of pain
and the different types of pain. Acute,
Chronic and my Transitional. We've talked about some
of the treatment modalities for pain and how
we approach patients with pain, and how
important it is to have a multidisciplinary
approach to pain management. And how we try
to assist patients in learning to live with pain.
We're going to have a second lecture on Pain
Management that will go into more detail on the various
drugs that are used in management of pain. And then
we'll have some case summaries to discuss.
And we'll follow that up with a discussion
of Treatment And Management Of Obstetrical Pain.