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“I sustained burns to my right thigh three years ago and experienced occasional searing pain after the wound healed. Now I can feel a burning sensation all the time and it is extremely distressing”

“Living with diabetes has been challenging enough; the start of constant pain in my feet has made walking a nightmare. There is no relief with pain-killers or rest, this pain is driving me crazy!”

“I had a successful hernia repair six months ago and the scar has healed well. I now have a constant dragging pain in my groin; my doctor says all my tests are normal; why do I have the pain?”

Why is nerve damage pain different?

This might be your own story or one of your loved ones. When there is no ongoing tissue damage and the pain fails to respond to routine painkillers, it is difficult to make sense of why it should be thus. These pains are usually associated with sleep disturbance and depression, and many of our patients confess that it affects various facets of their life adversely. Pain in response to ongoing tissue injury is a protective mechanism we all need to survive. What is difficult to understand is that why it should last beyond the point of tissue healing. Experts and researchers have now teased out the changes that happen in your nerves, spinal cord and brain following injury that could lead to a vicious cycle of pain, suffering and disability. Neuropathic pain, as it is known, when left untreated becomes a disease in itself.

What causes nerve pain?

As the name suggests, neuropathic pain is a form of nerve pain. Let us imagine you holding your hand over a candle for a few seconds. Under normal circumstances a harmful stimulus such as intense heat triggers the nerve endings in the skin of the hand. This information is relayed to your spinal cord and then to your brain through complex pathways and your brain in turn sends down signal through the nerves asking for withdrawal of the limb from the intense heat. Obviously this protective mechanism is responsible for saving you a lot of pain and tissue damage.

On occasions, the ongoing presence of tissue injury leads to a continuous volley of signals from your nerve fibres, which sets up a vicious cycle of stimuli within the nervous system. Nerve injury such as following hernia repair; nerve entrapment conditions such as carpal tunnel syndrome; or intrinsic damage as in diabetes, could all lead to continuous firing of signals.

Mechanism of nerve pain

This constant barrage of signals sensitizes your nerves, spinal cord and brain. This means that your nerves might fire spontaneously without stimuli (ectopic firing) and they also talk to each other in a way they are not supposed to (ephaptic talk). In addition, a soup of chemicals is poured out to sustain this sensitisation. Misinterpretation of signals happens due to this, so that light touch may be felt as pain. Imagine your body as a sound system where the amplifier is turned to maximum and you would not be far off in fathoming the changes to your nervous system. In fact the diagnosis of neuropathic pain is based on increased sensitivity to pressure or light touch in an area corresponding to a nerve distribution. You might also suffer with burning sensation, pins and needles, reduced sensation, and other unpleasant sensations.

Diagnosis of nerve damage pain

You would now have recognised that the culprit is no longer the original injury, but the way by which our nervous system responds to the original insult. Sometimes an obvious triggering factor such as nerve injury secondary to trauma, surgery or herpes zoster may be present. Many times no single precipitating cause can be determined as the cause for your unrelenting pain. Routine lab tests and imaging may not show anything abnormal and you might have visited numerous clinics/specialists seeking a diagnosis and cure. Often you might have faced non-supportive medical care where your symptoms were viewed as “all in the head.”

What do we do at Atlas Pain Care, Coimbatore?

Careful and empathetic elicitation of your pain history and clinical examination with documentation of all relevant findings is important, as treatment response can be judged during subsequent visits. Appropriate investigations may be requested to rule out underlying disease. A complete sensory and motor examination with mapping of the affected area is essential. Often the history may indicate the initial insult however this may not always be the case. Apart from pain related history and examination often bio-psychosocial issues need to be carefully looked into.

Medicines to treat nerve damage pain

The medication based interventions decrease the abnormal sensory input at the peripheral and central level. Moreover modulation of the pain signals at various stages is an important strategy. Antidepressants, anti- seizure medications and local anaesthetics use their inherent property of changing ionic balance in nervous tissue to combat this type of pain. Gabapentin and Pregabalin have shown promising results in most cases. Often addition of Amitriptyline and/or other medications may help you. Traditional painkillers such as paracetamol or opioids such as morphine may be of limited use. The chronic nature of this pain makes it unsuitable for anti-inflammatory therapy, moreover there may not be any ongoing tissue inflammation associated with this pain.

Other treatments for nerve pain

Surgery may be needed to manage trigeminal neuralgia if unresponsive to medical management. Electrical stimulation therapy has been used in refractory cases and works on the basis of blocking off the damaging sensory input from the peripheral to the central nervous system. Apart from these measures psychological interventions such as relaxation therapy and biofeedback are useful for coping and managing pain on a long- term basis.

Neuropathic pain is a unique challenge and responds best to a multidisciplinary approach that integrates pharmacological and non-pharmacological measures.