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| NI FEATURE: THE EDITORIAL DEBATE II-- PROS AND CONS |
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| Year : 2019 | Volume
: 67
| Issue : 7 | Page : 25-26 |
Neuropathic pain: Searching for the magic bullet
Lukas Rasulic1, Vikram Singh2, MS Gopalakrishnan3, K V L N Rao2
1 Department of Neurosurgery, University of Belgrade, Serbia
2 Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
3 Department of Neurosurgery, Jawaharlal Institute of Post-graduate Medical Education and Research, Pondicherry, India
| Date of Web Publication | 23-Jan-2019 |
Correspondence Address:
Dr. M S Gopalakrishnan
Department of Neurosurgery, Jawaharlal Institute of Post-graduate Medical Education and Research, Pondicherry
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.250713
How to cite this article:
Rasulic L, Singh V, Gopalakrishnan M S, Rao K V. Neuropathic pain: Searching for the magic bullet. Neurol India 2019;67, Suppl S1:25-6 |
Socolovsky et al.;, have provided a comprehensive review detailing the pathophysiological mechanisms and management strategies for neuropathic pain.[1]
Brachial plexus and peripheral nerve injuries are most prevalent in the young working population, forming a significant cause of disability and decreasing the quality of life.[2] The early initiation of physiotherapy following injury plays a large role in recovery, relief from pain and prevention of complications such as formation of contractures and autonomic dysfunction.[3] Furthermore, physiotherapy might have a role in reducing the extent of cortical reorganization in the deafferented motor area by maintaining some degree of afferent input, thus relieving phantom limb pain.[4] The authors could have stressed on the importance of physiotherapy as a first line measure in pain management.
The surgical management of brachial plexus injuries has also seen considerable technological advancements over the last decade.[5] While the selection of treatment strategy is based on the nature and severity of injury, a direct nerve repair is preferred wherever possible. Autografts play an important role when the nerve ends are separated by greater than 30 mm (because decellularized allografts remain unproven in such cases). Smaller nerve gaps may be managed with tubulisation techniques or allografts. Nerve transfers have now become the standard for proximal injuries owing to their capacity to reduce the regeneration time, thereby improving the speed of end-organ re-innervation and outcomes.[6],[7] The use of epineurial repair and fibrin glue for achieving better coaptation has also led to better results. In the cases resistant to other treatment measures, the dorsal route entry zone (DREZ) lesioning has provided a good alternative.[8] Accelerated peripheral nerve repair using stem cells is also under research.[9] A detailed discussion on the surgical options and techniques would have brought these issues to the fore.
With the relative plateauing of surgical results, research on central mechanisms and neuromodulation has gained momentum. The authors provide a good overview of the experience with spinal cord and cortical stimulation. Recent research suggests that a major component of pain can be attributed to the ingrowth of sensory representation into the deafferented motor area as a result of plasticity.[10] Resting state functional magnetic resonance imaging fMRI studies have shown widespread disturbances in neural networks following brachial plexus injuries. These changes involve not just the sensorimotor network, but higher networks such as the default mode network as well.[11] With increasing evidence and elucidation of these mechanisms, the role of neuromodulation in pain relief can only be expected to increase.
To conclude, the cause of pain following nerve injuries is multifactorial. The authors have, therefore, rightfully stressed on the role of multidisciplinary management. We congratulate them for providing a holistic overview of a frequently neglected, but increasingly common health issue.
| » References | |  |
| 1. | Lovaglio AC, Socolovsky M, Di Masi G, Bonilla G. Treatment of neuropathic pain after peripheral nerve and brachial plexus traumatic injury. Neurol India 2019;67:S32-7.  |
| 2. | Midha R. Epidemiology of brachial plexus injuries in a multitrauma population. Neurosurgery. 1997;40:1182-9. |
| 3. | Baruah S, Deepika A, Shukla D, Devi BI, Preethish-Kumar V, Sathyaprabha TN. Demonstration of autonomic dysfunction in traumatic brachial plexus injury using quantitative sudomotor axon reflex test: Preliminary results. Neurol India 2017;65:1317-21. [ PUBMED] [Full text] |
| 4. | Lotze M, Grodd W, Birbaumer N, Erb M, Huse E, Flor H. Does use of a myoelectric prosthesis prevent cortical reorganization and phantom limb pain? Nat Neurosci 1999;2:501-2. |
| 5. | Khuong HT, Midha R. Advances in nerve repair. Curr Neurol Neurosci Rep 2013;13:322. |
| 6. | Moiyadi AV, Devi BI, Nair KP. Brachial plexus injuries: Outcome following neurotization with intercostal nerve. J Neurosurg 2007;107:308-13. |
| 7. | Sinha S, Khani M, Mansoori N, Midha R. Adult brachial plexus injuries: Surgical strategies and approaches. Neurol India 2016;64:289-96. [ PUBMED] [Full text] |
| 8. | Baruah S, Devi BI, Bhat DI, Shukla D. Drezotomy in the management of post brachial plexus injury neuropathic pain: Preliminary results. Indian J Neurotrauma 2014;11;27-9. |
| 9. | Grochmal J, Midha R. Recent advances in stem cell-mediated peripheral nerve repair. Cells Tissues Organs 2014;200:13-22. |
| 10. | Mohanty CB, Bhat D, Indira Devi B. Role of central plasticity in the outcome of peripheral nerve regeneration. Neurosurgery 2015;77:418-23. |
| 11. | Bhat DI, Indira Devi B, Bharti K, Panda R. Cortical plasticity after brachial plexus injury and repair: A resting-state functional MRI study. Neurosurg Focus 2017;42:E14. |
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