Nerve injuries can be associated with excruciating pain.
Treatment of pain is vital to the overall treatment of the patient. A patient in pain will not have a meaningful functional recovery no matter what fancy treatment is done, even if motor function recovers. Pain trumps all!
First, recognize and acknowledge the pain. Track it over time using the pain diagram and questionnaire.
Local anesthetic blocks may help in diagnosis (e.g., successful injection of a discrete neuroma might make subsequent surgical treatment an option), and provide (temporary) alleviation of specific nerve branch pain.
Numerous other treatments are available, and referral to a specialist in pain management is often quite helpful as well.
Medications — a variety have been used; all have side-effects and risk-benefit ratio should be carefully discussed along with planned duration of treatment (some patients may require years of treatment):
- Sympatholytics such as clonidine
- Anti-inflammatory agents
- Antiepileptics such as gabapentin (300 mg po tid to start, up to 1200 mg po tid; must wean off slowly) and pregabalin (50 mg po tid or 75 mg po bid to start, up to 300 mg total daily; must wean off slowly)
- Antidepressants such as amitriptyline (25 mg po qhs; must wean off slowly)
- Our preferred agents are pregabalin and amitriptyline.
Other adjunct maneuvers:
- Sympathetic blocks
- Nerve stimulators
- Spinal cord stimulators — note that cervical-level dorsal column stimulators are tricky to place because of the movement in the cervical spine, and you will need to search a bit to find someone with success with this.
Physical therapy is a vital component of treatment:
- Desensitization is important.
- Stress loading is helpful in incipient/established chronic regional pain syndrome.
- Range of motion exercises can help prevent painful contracture