Diagnosis and treatment of painful peripheral neuropathy

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The guide to the diagnosis and treatment of painful peripheral neuropathyPainful peripheral neuropathy (painful peripheral neuropathy) on ne

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The guide to the diagnosis and treatment of painful peripheral neuropathy

Painful peripheral neuropathy (painful peripheral neuropathy) on neuropathic pain (neuropathic pain) for the outstanding performance of the peripheral neuropathy, usually refers to the pain of sensory peripheral neuropathy (painful sensory peripheral neuropathies) or painful sensorimotor peripheral nerve disease (painful sensory and motor peripheral neuropathies). In this article, we refer to painful peripheral neuropathy as well as a generalization of peripheral neuropathy associated with pain symptoms, including a mixture of motor and sensory. Painful peripheral neuropathy can be a single disease, but also a manifestation of systemic disease. The lesions mainly involved small or unmyelinated nerve fibers (C fibers), with or without large fibrous lesions.

Etiology and classification

There are many kinds of causes of painful peripheral neuropathy, which can be divided into two categories: congenital and acquired. Congenital hereditary painful peripheral neuropathy mainly includes: hereditary sensory and autonomic neuropathy, familial amyloid polyneuropathy, Fabry disease, neuropathy, Tangier disease, etc.. Acquired peripheral neuropathy pain according to cause of disease mainly include: (1) the metabolic and nutritional disorders: the most common cause for abnormal glucose metabolism such as diabetes and abnormal glucose tolerance related peripheral neuropathy, peripheral uremic polyneuropathy, thyroid disease associated peripheral neuropathy, vitamin deficiency or excess caused by peripheral neuropathy; (2) trauma and oppression: entrapment neuropathy, acute and chronic injury of peripheral neuropathy; (3) immune-mediated: Guillain Barre syndrome, amyloid polyneuropathy, around in psychosis, associate protein vasculitic neuropathy polyneuropathy, sarcoidosis, etc.; (4) human immunodeficiency virus infection: correlation of peripheral neuropathy, Lyme disease, peripheral neuropathy, peripheral neuropathy and leprosy; (5) the drug or other physical and chemical factors of poisoning : furazolidone, lamivudine and other drugs or alcohol, arsenic, thallium; (6) tumor associated peripheral neuropathy: direct invasion or distant effect; (7) cryptgenic, also known as idiopathic pain sensory neuropathy.

Causes of painful peripheral neuropathy according to the onset frequency were: diabetes, impaired glucose tolerance, idiopathic, familial, vitamin deficiency or excess (B12, B1, B6), thyroid disease, inflammatory or autoimmune (Sjogren syndrome, systemic lupus erythematosus, rheumatoid arthritis, paraneoplastic) sex, drugs (amiodarone, chloroquine, colchicine and dapsone, disulfiram, isoniazid, metronidazole, phenytoin, naphthalene sulfonyl benzoyl urea, vincristine), toxic or heavy metals (aminoacyl, arsenic, thallium, ethylene oxide).

Two, clinical manifestation

Painful peripheral neuropathy is characterized by pain and other sensory abnormalities that may be associated with other manifestations of peripheral neuropathy, including motor nerve symptoms and signs. Chronic pain can be associated with anxiety, depression and sleep disorders.

(I) symptoms

1 Characteristics of pain: pain, including spontaneous and non spontaneous pain (induced pain). (1) spontaneous pain: refers to the continuous or intermittent pain, the pain, tingling, pain, shock, pain, spasm of sharp biting pain, burning pain, pain, pain and tenderness, oppression tearing pain, hoop like fatigue, the patients have nausea, fear or cruel tortured sense [see brief Mcgill pain questionnaire (SF-MPQ). (2) non spontaneous pain (induced pain): including paresthesia (hyperesthesia), paresthesia (dysesthesia), sensory overload (hyperpathia), paresthesia.

2 the nature of pain: (1) local pain: localized pain in the lesion of the system, such as the local pain of nerve root lesions. (2) radiation pain: pain may be localized to the affected area of the sensory nerve. In neural stem or a neuropathy, such as sciatica. (3) diffuse pain: the pain of a branch of the nerve may spread to another area, such as the distal end of the finger, and the pain can spread to the upper limb. (4): when the referred pain of visceral disease pain impulses through sympathetic nerve and dorsal root to the spinal cord, spread to the spinal cord segments innervate the surface and pain, such as cholecystitis caused by pain in the right shoulder, left shoulder and arm pain caused by angina pectoris. (5) burning neuralgia: as a burning pain, it is common in the peripheral nerve incomplete injury, such as median nerve injury.

(two) signs

1 sensory disorders: (1) shallow sensory disorder: including positive signs and negative signs. Positive signs include: paresthesia and pain, hyperalgesia, and (or) excessive feeling; negative signs include: anesthesia (hypesthesia), hypoaesthesia (sensory), and sensory loss. (2) deep sensory disorder: can be associated with or without deep sensory disturbance, the degree of involvement is different. For painful peripheral neuropathy, superficial sensory disturbance is more important and prominent.

2 motor dysfunction: dysfunction of peripheral neuropathy is divided into irritative symptoms (including fasciculations, cramps and other symptoms) and inhibitory or paralysis symptoms (including muscle weakness and muscle atrophy).

3 tendon reflex abnormalities: peripheral neuropathy will appear to reduce or eliminate tendon reflexes. Only in the small fiber neuropathy pain of nociceptive and autonomic nervous function was abnormal, and the tendon reflex is relatively preserved.

4 autonomic dysfunction: no sweat and orthostatic hypotension are the most common clinical manifestations of autonomic dysfunction. Other abnormal autonomic nervous function also includes non reactive pupils, sweat, tears and reduce the secretion of saliva, sexual dysfunction, rectum and bladder sphincter dysfunction leading to urinary disorders, gastrointestinal expansion etc..

(three) pain score

1 visual analogue scale: with a straight line of up to 10cm, the intensity of pain increased, and both ends of the line were "no pain" and "the most severe pain". Please describe the past subjects to a certain period of time or at the moment pain position to draw a straight line on the diagonal, drawn by the staff after the measurement of its value, is the pain score.

2 present pain intensity index: painless for 0 minutes, mild pain for the 1 points, discomfort for the score of 2 points, the pain for a score of 3, fear of a score of 4 points, very painful for.

3 SF-MPQ: to determine the extent of each of the following items on the nature of pain: pain, pain, pain, shock sharp pain, spasm like pain, bite like pain, burning pain, pain, pain and tenderness, oppression tearing pain, tight like nausea, fatigue, fear, be cruel sense of torture. Inaction 0 points, mild for the score of 1, moderate for the score of 2, severe for the 3 points, and then add the total score, the range of 0-45.

4 clinical manifestations: preliminary assessment can determine whether the neuropathic pain. (1) neuropathic pain checklist: "to the following 6 questions is" or "no" judgment: if you have pain? Do you have the same feeling as fire or burning? You are tingling? Do you feel the pain like an electric shock? If you encounter in bed or clothes when the pain? Your pain is only in the joints? The first 5 questions each answer 1 "is" 1 "," no "is the answer for 0 points, the sixth question is -1, answer" no "is 0 points. Finally add the total score. The range of -1-5, the higher the score, the greater the likelihood of neuropathic pain. (2) Leeds neuropathic pain symptoms and signs: "evaluation form to the following 7 questions is" or "no" judgment: the pain is unusual discomfort? Such as acupuncture, crawling, tingling and pain feeling? The area of skin and normal skin feel feel like? Red or swollen? The pain skin area whether to touch more sensitive as the pain hyperalgesia? Whether can suddenly erupt without external lightning?? the pain does not change with the temperature? Non painful stimuli such as feather touch pain skin, pain or hyperalgesia zone in? Feel the pain area of pinprick and non pain is different? Every 1 times to answer "yes" is 5 points, answer "no" is 0. Finally, the sum score, the highest score is 35 points, 12 points for > neuropathic pain. (3) DN4 (4 Douleur Neuropathique questions): on the following 9 questions for "yes" or "no" judgment: if the pain was burning? The pain is as cold pain? The pain is the pain shock like? Is accompanied by tingling and pain? Whether with acupuncture kind of feeling? The pain is accompanied by numbness and pain is part of a physical examination? Hypopselaphesia? The medical pain is part of a pinprick to decrease? Pain is due to touch every increase? Answer 1 times "is" 1 points, answer "no" is 0. Finally add the score. The total score should be 0-9, > 4 points high considering the diagnosis of neuropathic pain.

Three, auxiliary examination

(a) electrophysiological detection

1 nerve conduction: including sensory nerve conduction and motor nerve conduction (including F wave) determination is routine method for the diagnosis of peripheral neuropathy, can determine axonal damage and demyelination, helps to peripheral neuropathy, mononeuropathy and multiple block diagnosis of peripheral neuropathy, nerve compression and nerve root plexus lesion. Not a specific means of diagnosing painful peripheral neuropathy.

2 concentric needle electromyography: motor function of the peripheral nerve. If the diagnosis of painful peripheral neuropathy is clear, generally do not need to check the concentric needle emg.

3 skin sympathetic response (skin sympathic response, SSR): the human body is stimulated by the stimulation of the sweat gland after the occurrence of synchronous activity of the skin reflex potential, is sympathetic efferent fibers caused by the impulse. The electrophysiological characteristics of small fibers, especially C type unmyelinated fibers, are mainly used to objectively evaluate the function of autonomic nervous system. The factors influencing the determination of SSR were skin temperature, age, stimulus intensity and adaptability.

4 quantitative sensory testing (quantitive sensory, testing, QST): (1) different frequency stimulation method: using different frequency stimulation to detect the different functions of nerve fibers, A-B, A-d, C evaluation function fiber. (2) quantitative temperature perception test: evaluating the function of A-d and C fibers by sensitive judgment of cold, heat, cold pain and heat pain.

(two) special detection of autonomic nerve

With the obvious autonomic nervous system symptoms and signs of painful peripheral neuropathy, can be selected according to the actual situation of the following tests (Table 1).

The guide to the diagnosis and treatment of painful peripheral neuropathy

Painful peripheral neuropathy (painful peripheral neuropathy) on neuropathic pain (neuropathic pain) for the outstanding performance of the peripheral neuropathy, usually refers to the pain of sensory peripheral neuropathy (painful sensory peripheral neuropathies) or painful sensorimotor peripheral nerve disease (painful sensory and motor peripheral neuropathies). In this article, we refer to painful peripheral neuropathy as well as a generalization of peripheral neuropathy associated with pain symptoms, including a mixture of motor and sensory. Painful peripheral neuropathy can be a single disease, but also a manifestation of systemic disease. The lesions mainly involved small or unmyelinated nerve fibers (C fibers), with or without large fibrous lesions.

Etiology and classification

There are many kinds of causes of painful peripheral neuropathy, which can be divided into two categories: congenital and acquired. Congenital hereditary painful peripheral neuropathy mainly includes: hereditary sensory and autonomic neuropathy, familial amyloid polyneuropathy, Fabry disease, neuropathy, Tangier disease, etc.. Acquired peripheral neuropathy pain according to cause of disease mainly include: (1) the metabolic and nutritional disorders: the most common cause for abnormal glucose metabolism such as diabetes and abnormal glucose tolerance related peripheral neuropathy, peripheral uremic polyneuropathy, thyroid disease associated peripheral neuropathy, vitamin deficiency or excess caused by peripheral neuropathy; (2) trauma and oppression: entrapment neuropathy, acute and chronic injury of peripheral neuropathy; (3) immune-mediated: Guillain Barre syndrome, amyloid polyneuropathy, around in psychosis, associate protein vasculitic neuropathy polyneuropathy, sarcoidosis, etc.; (4) human immunodeficiency virus infection: correlation of peripheral neuropathy, Lyme disease, peripheral neuropathy, peripheral neuropathy and leprosy; (5) the drug or other physical and chemical factors of poisoning : furazolidone, lamivudine and other drugs or alcohol, arsenic, thallium; (6) tumor associated peripheral neuropathy: direct invasion or distant effect; (7) cryptgenic, also known as idiopathic pain sensory neuropathy.

Causes of painful peripheral neuropathy according to the onset frequency were: diabetes, impaired glucose tolerance, idiopathic, familial, vitamin deficiency or excess (B12, B1, B6), thyroid disease, inflammatory or autoimmune (Sjogren syndrome, systemic lupus erythematosus, rheumatoid arthritis, paraneoplastic) sex, drugs (amiodarone, chloroquine, colchicine and dapsone, disulfiram, isoniazid, metronidazole, phenytoin, naphthalene sulfonyl benzoyl urea, vincristine), toxic or heavy metals (aminoacyl, arsenic, thallium, ethylene oxide).

Two, clinical manifestation

Painful peripheral neuropathy is characterized by pain and other sensory abnormalities that may be associated with other manifestations of peripheral neuropathy, including motor nerve symptoms and signs. Chronic pain can be associated with anxiety, depression and sleep disorders.

(I) symptoms

1 Characteristics of pain: pain, including spontaneous and non spontaneous pain (induced pain). (1) spontaneous pain: refers to the continuous or intermittent pain, the pain, tingling, pain, shock, pain, spasm of sharp biting pain, burning pain, pain, pain and tenderness, oppression tearing pain, hoop like fatigue, the patients have nausea, fear or cruel tortured sense [see brief Mcgill pain questionnaire (SF-MPQ). (2) non spontaneous pain (induced pain): including paresthesia (hyperesthesia), paresthesia (dysesthesia), sensory overload (hyperpathia), paresthesia.

2 the nature of pain: (1) local pain: localized pain in the lesion of the system, such as the local pain of nerve root lesions. (2) radiation pain: pain may be localized to the affected area of the sensory nerve. In neural stem or a neuropathy, such as sciatica. (3) diffuse pain: the pain of a branch of the nerve may spread to another area, such as the distal end of the finger, and the pain can spread to the upper limb. (4): when the referred pain of visceral disease pain impulses through sympathetic nerve and dorsal root to the spinal cord, spread to the spinal cord segments innervate the surface and pain, such as cholecystitis caused by pain in the right shoulder, left shoulder and arm pain caused by angina pectoris. (5) burning neuralgia: as a burning pain, it is common in the peripheral nerve incomplete injury, such as median nerve injury.

(two) signs

1 sensory disorders: (1) shallow sensory disorder: including positive signs and negative signs. Positive signs include: paresthesia and pain, hyperalgesia, and (or) excessive feeling; negative signs include: anesthesia (hypesthesia), hypoaesthesia (sensory), and sensory loss. (2) deep sensory disorder: can be associated with or without deep sensory disturbance, the degree of involvement is different. For painful peripheral neuropathy, superficial sensory disturbance is more important and prominent.

2 motor dysfunction: dysfunction of peripheral neuropathy is divided into irritative symptoms (including fasciculations, cramps and other symptoms) and inhibitory or paralysis symptoms (including muscle weakness and muscle atrophy).

3 tendon reflex abnormalities: peripheral neuropathy will appear to reduce or eliminate tendon reflexes. Only in the small fiber neuropathy pain of nociceptive and autonomic nervous function was abnormal, and the tendon reflex is relatively preserved.

4 autonomic dysfunction: no sweat and orthostatic hypotension are the most common clinical manifestations of autonomic dysfunction. Other abnormal autonomic nervous function also includes non reactive pupils, sweat, tears and reduce the secretion of saliva, sexual dysfunction, rectum and bladder sphincter dysfunction leading to urinary disorders, gastrointestinal expansion etc..

(three) pain score

1 visual analogue scale: with a straight line of up to 10cm, the intensity of pain increased, and both ends of the line were "no pain" and "the most severe pain". Please describe the past subjects to a certain period of time or at the moment pain position to draw a straight line on the diagonal, drawn by the staff after the measurement of its value, is the pain score.

2 present pain intensity index: painless for 0 minutes, mild pain for the 1 points, discomfort for the score of 2 points, the pain for a score of 3, fear of a score of 4 points, very painful for.

3 SF-MPQ: to determine the extent of each of the following items on the nature of pain: pain, pain, pain, shock sharp pain, spasm like pain, bite like pain, burning pain, pain, pain and tenderness, oppression tearing pain, tight like nausea, fatigue, fear, be cruel sense of torture. Inaction 0 points, mild for the score of 1, moderate for the score of 2, severe for the 3 points, and then add the total score, the range of 0-45.

4 clinical manifestations: preliminary assessment can determine whether the neuropathic pain. (1) neuropathic pain checklist: "to the following 6 questions is" or "no" judgment: if you have pain? Do you have the same feeling as fire or burning? You are tingling? Do you feel the pain like an electric shock? If you encounter in bed or clothes when the pain? Your pain is only in the joints? The first 5 questions each answer 1 "is" 1 "," no "is the answer for 0 points, the sixth question is -1, answer" no "is 0 points. Finally add the total score. The range of -1-5, the higher the score, the greater the likelihood of neuropathic pain. (2) Leeds neuropathic pain symptoms and signs: "evaluation form to the following 7 questions is" or "no" judgment: the pain is unusual discomfort? Such as acupuncture, crawling, tingling and pain feeling? The area of skin and normal skin feel feel like? Red or swollen? The pain skin area whether to touch more sensitive as the pain hyperalgesia? Whether can suddenly erupt without external lightning?? the pain does not change with the temperature? Non painful stimuli such as feather touch pain skin, pain or hyperalgesia zone in? Feel the pain area of pinprick and non pain is different? Every 1 times to answer "yes" is 5 points, answer "no" is 0. Finally, the sum score, the highest score is 35 points, 12 points for > neuropathic pain. (3) DN4 (4 Douleur Neuropathique questions): on the following 9 questions for "yes" or "no" judgment: if the pain was burning? The pain is as cold pain? The pain is the pain shock like? Is accompanied by tingling and pain? Whether with acupuncture kind of feeling? The pain is accompanied by numbness and pain is part of a physical examination? Hypopselaphesia? The medical pain is part of a pinprick to decrease? Pain is due to touch every increase? Answer 1 times "is" 1 points, answer "no" is 0. Finally add the score. The total score should be 0-9, > 4 points high considering the diagnosis of neuropathic pain.

Three, auxiliary examination

(a) electrophysiological detection

1 nerve conduction: including sensory nerve conduction and motor nerve conduction (including F wave) determination is routine method for the diagnosis of peripheral neuropathy, can determine axonal damage and demyelination, helps to peripheral neuropathy, mononeuropathy and multiple block diagnosis of peripheral neuropathy, nerve compression and nerve root plexus lesion. Not a specific means of diagnosing painful peripheral neuropathy.

2 concentric needle electromyography: motor function of the peripheral nerve. If the diagnosis of painful peripheral neuropathy is clear, generally do not need to check the concentric needle emg.

3 skin sympathetic response (skin sympathic response, SSR): the human body is stimulated by the stimulation of the sweat gland after the occurrence of synchronous activity of the skin reflex potential, is sympathetic efferent fibers caused by the impulse. The electrophysiological characteristics of small fibers, especially C type unmyelinated fibers, are mainly used to objectively evaluate the function of autonomic nervous system. The factors influencing the determination of SSR were skin temperature, age, stimulus intensity and adaptability.

4 quantitative sensory testing (quantitive sensory, testing, QST): (1) different frequency stimulation method: using different frequency stimulation to detect the different functions of nerve fibers, A-B, A-d, C evaluation function fiber. (2) quantitative temperature perception test: evaluating the function of A-d and C fibers by sensitive judgment of cold, heat, cold pain and heat pain.

(two) special detection of autonomic nerve

With the obvious autonomic nervous system symptoms and signs of painful peripheral neuropathy, can be selected according to the actual situation of the following tests (Table 1).

(three) nerve and skin biopsy

1 sural nerve biopsy: to determine the peripheral neuropathy by focusing on observation of inflammatory cell infiltration of myelinated and unmyelinated nerve fiber loss, vascular and vascular lesions and interstitial space, especially the feeling of the severity of peripheral neuropathy and the possible etiology. The peroneal muscular atrophy (CMT), Dejerine-Pick disease, neuropathy type -1 CMT neuropathy type -4B and X linkage of autosomal dominant CMT neuropathy, peripheral chronic inflammatory demyelinating neuropathy has confirmed the diagnosis significance of lesions.

2 skin biopsy: Observation of skin dominant superficial skin feeling and sweat glands, blood vessels, nerve fibers, muscle, change the epidermal layer of nerve fiber density and morphological quantitative analysis, diagnostic significance in diagnosis of small fiber disease.

(four) imaging examination

Ultrasonography is helpful in the diagnosis of peripheral nerve entrapment and trauma. MRI is of great significance for some hypertrophic neuropathy, nerve root compression or peripheral nerve tumors.

(five) biochemical detection of blood and cerebrospinal fluid

1 blood test: the etiological diagnosis of painful peripheral neuropathy. Blood glucose and electrolytes are of significance to the systemic disease complicated with peripheral neuropathy. The diagnosis of toxic peripheral neuropathy can be confirmed by hematological toxicity screening. Infectious diseases can be detected by the corresponding antibody. Detection of immunoglobulin in blood can be used as a marker for monoclonal globulin disease or hypoproteinemia. Detection of blood vitamin may indicate nutritional disorders. Determination of specific antibodies in serum can be used to assist in the diagnosis of peripheral neuropathy. Limited by space, there is no longer a list.

2 cerebrospinal fluid examination: cerebrospinal fluid examination for the diagnosis of immune mediated peripheral neuropathy. Cerebrospinal fluid examination of some infectious peripheral neuropathy is helpful to understand the inflammatory reaction of the nervous system and can be used in the diagnosis and differential diagnosis. The determination of serum and cerebrospinal fluid associated antibodies is associated with some immune-mediated peripheral nerve injury. The related antibody in serum and cerebrospinal fluid appeared paraneoplastic can contribute to tumor examination.

Four, diagnostic procedures and scoring

(1) diagnosis of pain

1 to determine the pain caused by peripheral neuropathy, and can fully explain the source of pain.

2 for peripheral neuropathy after treatment, pain relief or disappear.

(three) pain score

Refer to the "pain score" section.

Five, treatment

Treatment of painful peripheral neuropathy including etiological treatment and symptomatic treatment. Etiology and treatment should be carried out corresponding treatment according to the primary disease, such as diabetic peripheral neuropathy should pay attention to the control of blood glucose, alcoholic peripheral neuropathy should stop drinking and supplement of vitamin B on immune related peripheral neuropathy should be immunosuppressive treatment etc.. This part of the content involved more, not discussed in this article, this article discusses the general treatment.

1 diet and lifestyle guidance: abstinence, vitamin supplements, etc..

2 drug treatment: should follow the principle of individualization, efficacy varies from person to person, the pain can only be partially alleviated. Doctors and patients should reach consensus to seek effective treatment and tolerable adverse reactions. Currently the pain medication is based on expert experience. Generally, the baseline of pain was assessed every 6 months after the onset of pain control and effective treatment of the primary disease. (1) monotherapy: starting from the minimum dose, every 3-7 days increased 1 dosage units, gradually increase the dose to the satisfactory effect, judgment index: 1. Significant pain relief (CR > 50%); the adverse reactions can endure (according to the patient's judgment and non physician judgment; 3) the patient's activity and social function. (2) the combination of drugs: when the single drug control is not good, increase the dose and appear to be unable to tolerate adverse reactions, can be considered dressing or combination, and the use of different mechanisms of drugs. Adequate treatment time should be at least 4-6 weeks before dressing change or combination therapy. Drug or non drug treatment can be used as an alternative. (3) drug selection: current clinical trials for the treatment of painful peripheral neuropathy are based on diabetic neuropathic pain.

Commonly used drugs are: anticonvulsants: gabapentin, pregabalin, C Masi Bing, oxcarbazepine, lamotrigine, topiramate, valproate; II antidepressants: tricyclic antidepressants (amitriptyline), 5- serotonin and norepinephrine reuptake inhibitors (duloxetine and Vin Rafa Sin); the Opium sedative: tramadol, oxycodone, morphine; 4: topical use of topical capsaicin, local lidocaine.

Recommendations for the use of the European Society of Neurology for the treatment of different painful peripheral neuropathy (Table 2).

3 other treatments: (1) physical therapy: thermotherapy, cold therapy, hydrotherapy, phototherapy and so on; (2) transcutaneous electrical nerve stimulation, spinal cord stimulation; (3) interventional therapy: nerve block, minimally invasive treatment including acupuncture therapy, radiofrequency therapy, spinal cord stimulation, epiduroscopy; (4) surgery treatment: pain route destruction, pain inhibition stimulation system, microvascular decompression, Gamato; (5) psychotherapy: biofeedback and behavior therapy; (6) Chinese medicine and acupuncture therapy.

(three) nerve and skin biopsy

1 sural nerve biopsy: to determine the peripheral neuropathy by focusing on observation of inflammatory cell infiltration of myelinated and unmyelinated nerve fiber loss, vascular and vascular lesions and interstitial space, especially the feeling of the severity of peripheral neuropathy and the possible etiology. The peroneal muscular atrophy (CMT), Dejerine-Pick disease, neuropathy type -1 CMT neuropathy type -4B and X linkage of autosomal dominant CMT neuropathy, peripheral chronic inflammatory demyelinating neuropathy has confirmed the diagnosis significance of lesions.

2 skin biopsy: Observation of skin dominant superficial skin feeling and sweat glands, blood vessels, nerve fibers, muscle, change the epidermal layer of nerve fiber density and morphological quantitative analysis, diagnostic significance in diagnosis of small fiber disease.

(four) imaging examination

Ultrasonography is helpful in the diagnosis of peripheral nerve entrapment and trauma. MRI is of great significance for some hypertrophic neuropathy, nerve root compression or peripheral nerve tumors.

(five) biochemical detection of blood and cerebrospinal fluid

1 blood test: the etiological diagnosis of painful peripheral neuropathy. Blood glucose and electrolytes are of significance to the systemic disease complicated with peripheral neuropathy. The diagnosis of toxic peripheral neuropathy can be confirmed by hematological toxicity screening. Infectious diseases can be detected by the corresponding antibody. Detection of immunoglobulin in blood can be used as a marker for monoclonal globulin disease or hypoproteinemia. Detection of blood vitamin may indicate nutritional disorders. Determination of specific antibodies in serum can be used to assist in the diagnosis of peripheral neuropathy. Limited by space, there is no longer a list.

2 cerebrospinal fluid examination: cerebrospinal fluid examination for the diagnosis of immune mediated peripheral neuropathy. Cerebrospinal fluid examination of some infectious peripheral neuropathy is helpful to understand the inflammatory reaction of the nervous system and can be used in the diagnosis and differential diagnosis. The determination of serum and cerebrospinal fluid associated antibodies is associated with some immune-mediated peripheral nerve injury. The related antibody in serum and cerebrospinal fluid appeared paraneoplastic can contribute to tumor examination.

Four, diagnostic procedures and scoring

(1) diagnosis of pain

1 to determine the pain caused by peripheral neuropathy, and can fully explain the source of pain.

2 for peripheral neuropathy after treatment, pain relief or disappear.

(three) pain score

Refer to the "pain score" section.

Five, treatment

Treatment of painful peripheral neuropathy including etiological treatment and symptomatic treatment. Etiology and treatment should be carried out corresponding treatment according to the primary disease, such as diabetic peripheral neuropathy should pay attention to the control of blood glucose, alcoholic peripheral neuropathy should stop drinking and supplement of vitamin B on immune related peripheral neuropathy should be immunosuppressive treatment etc.. This part of the content involved more, not discussed in this article, this article discusses the general treatment.

1 diet and lifestyle guidance: abstinence, vitamin supplements, etc..

2 drug treatment: should follow the principle of individualization, efficacy varies from person to person, the pain can only be partially alleviated. Doctors and patients should reach consensus to seek effective treatment and tolerable adverse reactions. Currently the pain medication is based on expert experience. Generally, the baseline of pain was assessed every 6 months after the onset of pain control and effective treatment of the primary disease. (1) monotherapy: starting from the minimum dose, every 3-7 days increased 1 dosage units, gradually increase the dose to the satisfactory effect, judgment index: 1. Significant pain relief (CR > 50%); the adverse reactions can endure (according to the patient's judgment and non physician judgment; 3) the patient's activity and social function. (2) the combination of drugs: when the single drug control is not good, increase the dose and appear to be unable to tolerate adverse reactions, can be considered dressing or combination, and the use of different mechanisms of drugs. Adequate treatment time should be at least 4-6 weeks before dressing change or combination therapy. Drug or non drug treatment can be used as an alternative. (3) drug selection: current clinical trials for the treatment of painful peripheral neuropathy are based on diabetic neuropathic pain.

Commonly used drugs are: anticonvulsants: gabapentin, pregabalin, C Masi Bing, oxcarbazepine, lamotrigine, topiramate, valproate; II antidepressants: tricyclic antidepressants (amitriptyline), 5- serotonin and norepinephrine reuptake inhibitors (duloxetine and Vin Rafa Sin); the Opium sedative: tramadol, oxycodone, morphine; 4: topical use of topical capsaicin, local lidocaine.

Recommendations for the use of the European Society of Neurology for the treatment of different painful peripheral neuropathy (Table 2).

3 other treatments: (1) physical therapy: thermotherapy, cold therapy, hydrotherapy, phototherapy and so on; (2) transcutaneous electrical nerve stimulation, spinal cord stimulation; (3) interventional therapy: nerve block, minimally invasive treatment including acupuncture therapy, radiofrequency therapy, spinal cord stimulation, epiduroscopy; (4) surgery treatment: pain route destruction, pain inhibition stimulation system, microvascular decompression, Gamato; (5) psychotherapy: biofeedback and behavior therapy; (6) Chinese medicine and acupuncture therapy.

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