What is the best way to relieve nerve pain after myelitis when prompt steroid treatment was not administered?

Management of Neuropathic Pain After Myelitis Without Prompt Steroid Treatment

For neuropathic pain following myelitis without prompt steroid treatment, first-line therapy should be gabapentin, which provides good pain relief with 3-4 out of 10 patients achieving at least 50% pain reduction. 1

First-Line Pharmacological Options

Gabapentinoids

• Gabapentin: Start at low dose (100-300mg daily) and titrate gradually to effective dose (1800-3600mg daily in divided doses)
• Pregabalin: Alternative to gabapentin with potentially fewer cognitive side effects; start at 25-50mg daily and titrate slowly 1

Other First-Line Options

• Duloxetine: Consider as next therapeutic option if gabapentinoids are ineffective; start at 30mg daily for one week, then increase to 60mg daily if tolerated 1
• Topical lidocaine: 5% patches applied to painful areas for up to 12 hours daily for localized pain 1

Second-Line Pharmacological Options

• Amitriptyline: Start at low dose (10mg at bedtime) if duloxetine is ineffective; use with caution in elderly due to anticholinergic effects 1
• Compounded amitriptyline-ketamine mixture: Amitriptyline 1-2% and ketamine 0.5-5% applied up to 3 times daily for localized pain 1

Advanced Interventions for Refractory Pain

Spinal Cord Stimulation

• Consider for intractable neuropathic pain unresponsive to medical treatment
• Has shown improvement in pain scores, medication usage, and daily function in patients with myelitis-related neuropathic pain 2, 3

Immunomodulatory Therapy

• For patients with ongoing inflammatory component:
  • Intravenous immunoglobulin (IVIG): 0.4 g/kg/day for five days has shown prompt improvements in some demyelinating neuropathies 4
  • Plasma exchange: Consider in severe cases refractory to other treatments 5

Non-Pharmacological Interventions

• Physical therapy: Strengthening exercises, range of motion exercises, proper body mechanics, and postural training 1
• Cognitive behavioral therapy: Helps develop adaptive coping strategies for chronic pain 1
• Heat/cold therapy: Limited ice application (10 minutes, 4 times daily) may provide relief 1
• Transcutaneous electrical nerve stimulation (TENS): May provide modest adjunctive benefit 1

Treatment Algorithm

1. Start with gabapentin as first-line therapy
2. If inadequate response after 4-6 weeks of optimal dosing:
   • Add or switch to duloxetine
3. If still inadequate response:
   • Consider amitriptyline or topical agents
4. For refractory cases:
   • Consider referral for spinal cord stimulation evaluation
   • Consider immunomodulatory therapy if ongoing inflammatory component suspected

Important Considerations

• Avoid corticosteroids in purely motor demyelinating neuropathy as they may worsen symptoms 4
• Regular assessment of treatment efficacy and side effects is crucial 1
• Adjust dosages based on renal function, age, and comorbidities 1
• Refer to neurology if symptoms persist or worsen despite intervention 1

Cautions

• Steroid treatment should be used with caution in purely motor forms of acquired demyelinating polyneuropathy, as it may unexpectedly increase weakness 4
• NSAIDs should be avoided in patients with renal impairment due to risk of worsening renal function 1
• Long-term opioid therapy for chronic pain should be avoided when possible 1

By following this structured approach to managing neuropathic pain after myelitis, patients can achieve better pain control and improved quality of life.