What is the best treatment for a patient with neuropathic pain from a stab wound on the left chest?

Treatment of Neuropathic Pain from Chest Stab Wound

Start with pregabalin 75 mg twice daily (150 mg/day), increasing to 150 mg twice daily (300 mg/day) within one week, as this provides the fastest and most effective relief for traumatic neuropathic pain. 1

First-Line Pharmacological Treatment

Gabapentinoids are the preferred initial therapy for post-traumatic neuropathic pain like yours:

• Pregabalin offers superior pharmacokinetics with linear absorption, meaning more predictable pain relief compared to gabapentin 1

  • Start: 75 mg twice daily for 1 week 1
  • Target dose: 150 mg twice daily (300 mg/day) 1, 2
  • Maximum if needed: 300 mg twice daily (600 mg/day) after 2-4 weeks at target dose 1, 2
  • Pain relief may begin within the first week 2

• Gabapentin is an effective alternative if pregabalin is unavailable or not tolerated 1

  • Day 1: 300 mg once daily 3
  • Day 2: 300 mg twice daily (600 mg/day) 3
  • Day 3: 300 mg three times daily (900 mg/day) 3
  • Target dose: 1800 mg/day in 2-3 divided doses 1, 3
  • Maximum: 3600 mg/day if needed 3, 4
  • Requires dose adjustment if you have kidney problems 1

Adding Topical Treatment for Localized Pain

For the specific area of chest pain, add a 5% lidocaine patch applied directly over the painful site:

• Apply one patch daily to the stab wound area 5, 1
• Minimal systemic absorption makes this extremely safe 5
• Particularly effective for localized neuropathic pain with burning or hypersensitivity 5, 1
• Can be used simultaneously with oral medications 5

If Partial Response After 2-4 Weeks

Add an antidepressant if pregabalin/gabapentin alone provides less than 50% pain relief 1:

• Duloxetine (preferred for fewer side effects) 1

  • Week 1: 30 mg once daily to minimize nausea 1
  • Week 2 onward: 60 mg once daily 1
  • Maximum: 120 mg/day if needed 1
  • No cardiac monitoring required 1

• Nortriptyline (alternative) 1

  • Start: 10-25 mg at bedtime 5, 1
  • Titrate slowly over 2-4 weeks to 75-150 mg/day 5, 1
  • Requires ECG screening if you're over 40 years old 1
  • Avoid if you have heart disease, recent heart attack, or arrhythmias 1

The combination of gabapentinoid plus antidepressant provides superior pain relief compared to either alone by targeting different pain mechanisms 1

Critical Treatment Timeline

• Allow at least 2-4 weeks at therapeutic dose before declaring treatment failure 1, 6
• Some patients experience relief within the first week, but full effect requires adequate time 2, 4
• Do not abandon medications prematurely—ensure you've reached target doses 1

Second-Line Option for Refractory Pain

Tramadol only if first-line treatments fail after adequate trials 1:

• Start: 50 mg once or twice daily 1
• Maximum: 400 mg/day 1
• Has dual mechanism (weak opioid + blocks pain neurotransmitter reuptake) 1
• Caution: Can cause serotonin syndrome if combined with duloxetine—use lower doses and monitor closely 1

What to Avoid

• Do NOT use strong opioids for long-term management of your neuropathic pain—they are ineffective for nerve pain, cause dependence, and worsen pain over time 1, 6
• Do NOT use NSAIDs or acetaminophen alone—they are ineffective for neuropathic pain 6
• Do NOT stop medications too quickly—neuropathic pain requires sustained treatment at adequate doses 1

Adjunctive Non-Pharmacological Measures

• Physical therapy and gentle chest wall exercises can reduce pain through anti-inflammatory effects and improved pain pathway modulation 1
• Consider elastic compression garment over the chest area to provide constant mechanical stimulation that may reduce neuropathic pain 1

When to Seek Specialist Referral

If pain remains uncontrolled after trials of pregabalin/gabapentin plus antidepressant, request referral to pain management for consideration of:

• Intercostal nerve blocks 5
• Transcutaneous electrical nerve stimulation (TENS) 5
• Advanced interventional procedures 5

Special Considerations for Your Chest Location

Post-traumatic intercostal neuralgia (nerve pain between ribs from stab wound) responds well to the combination of oral gabapentinoids plus topical lidocaine patches 5. The localized nature of your pain makes topical treatment particularly valuable as an adjunct 1.