What is the best approach to manage a patient with neuralgia (nerve pain) on multiple sites accompanied by back pain?

Management of Multisite Neuropathic Pain with Back Pain

For patients with neuropathic pain affecting multiple sites accompanied by back pain, implement a multimodal treatment strategy combining neuropathic pain medications (anticonvulsants and tricyclic antidepressants/SNRIs), physical therapy, and psychological interventions, with early specialist referral (within 2-3 months) for severe or refractory cases. 1

Initial Pharmacological Management

First-Line Neuropathic Pain Medications

• Anticonvulsants (α-2-delta calcium-channel antagonists like gabapentin/pregabalin, or sodium-channel antagonists) should be initiated as the foundation of multimodal therapy for neuropathic pain. 1
• Tricyclic antidepressants (amitriptyline, nortriptyline, desipramine) or SNRIs (duloxetine, venlafaxine) should be added as part of the multimodal strategy. 1
• These medications specifically target neuropathic mechanisms that simple analgesics fail to address 1

Adjunctive Pharmacotherapy

• For peripheral neuropathic pain components, topical agents (capsaicin, lidocaine patches, or ketamine) may be added to the regimen. 1
• Extended-release oral opioids should be reserved for neuropathic or back pain only when other treatments fail, using the lowest dose for the shortest duration with close monitoring of efficacy and side effects. 1
• NSAIDs may be considered specifically for the back pain component 1
• Establish a monitoring strategy for side effects, adverse effects, and compliance before prescribing any long-term pharmacologic therapy. 1

Non-Pharmacological Interventions

Physical and Restorative Therapy

• Physical or restorative therapy (physiotherapy, fitness classes, exercise therapy) should be implemented as part of the multimodal strategy, particularly for the back pain component. 1
• Evidence demonstrates effective low back pain relief for assessment periods ranging from 2 to 18 months 1

Psychological Treatment

• Cognitive behavioral therapy, biofeedback, or relaxation training should be incorporated for both back pain and other chronic pain conditions. 1
• These interventions provide relief for assessment periods ranging from 4 weeks to 2 years 1
• Supportive psychotherapy, group therapy, or counseling may be considered as additional support 1

Risk Stratification and Timing of Specialist Referral

Early Assessment (2 Weeks from Onset)

• Use the STarT Back tool at 2 weeks to stratify patients into low, medium, or high risk for developing persistent disabling pain. 1
• Low-risk patients: encourage self-management 1
• Medium-risk patients: refer to physiotherapy with patient-centered management plan 1
• High-risk patients: refer to physiotherapy with biopsychosocial assessment capabilities 1

Specialist Referral Timeline

• For severe radicular pain (disabling, intrusive, preventing normal activities) or patients with neurological deficits, refer to specialist services within 2 weeks of presentation. 1
• For less severe radicular pain not responding to initial management, refer to specialist pain services no later than 3 months (earlier if pain is severe). 1
• The minimum time from presentation to specialist referral should be 14 weeks for non-severe cases 1

Advanced Interventional Options (Specialist Level)

For Radicular Pain Component

• Epidural steroid injections with or without local anesthetics may be used as part of multimodal treatment for radicular pain or radiculopathy. 1
• Transforaminal epidural injections must be performed with appropriate image guidance (fluoroscopy) to confirm correct needle position and contrast spread before injecting therapeutic substances. 1
• Image guidance may be considered for interlaminar epidural injections 1

For Persistent Multisite Neuropathic Pain

• Spinal cord stimulation should be considered for persistent radicular pain, postherpetic neuralgia, peripheral neuropathic pain, and CRPS. 1
• A spinal cord stimulation trial must be performed before permanent implantation 1
• This is particularly relevant for patients with failed back surgery syndrome or persistent pain after surgery 1

TENS Therapy

• TENS should be used as part of multimodal pain management for chronic back pain and may be used for other pain conditions (neck and phantom limb pain). 1

Critical Pitfalls to Avoid

Medication Management Errors

• Never use opioids as first-line therapy; they lack long-term benefit evidence and carry significant harm potential. 1, 2
• Avoid benzodiazepines—evidence is equivocal and expert consensus does not support their use 1
• Do not rely on paracetamol or NSAIDs alone for neuropathic components—they are unlikely to provide meaningful relief 3

Imaging and Diagnostic Errors

• Do not order MRI at primary care level for spinal pain—it is too sensitive and not specific enough for cost-effective screening. 1
• Only clinicians capable of interpreting images should order MRI for radicular symptoms to avoid diagnostic errors 1, 2
• Never perform spinal injections without image guidance—this is essential for both safety and efficacy. 1, 2

Management Delays

• Do not delay specialist referral for patients with progressive neurological deficits—this is associated with worse outcomes. 2
• Avoid multiple unsatisfactory assessment cycles in primary care; refer appropriately within recommended timeframes 1

Biopsychosocial Assessment at Specialist Level

When patients reach specialist care, conduct comprehensive biopsychosocial assessment including:

• Evaluation of psychosocial factors contributing to disability 1
• Development of individualized stepped management plan within multidisciplinary team framework 1
• Consideration of high-intensity cognitive behavioral therapy for complex cases 1
• Assessment for vocational rehabilitation and return-to-work planning 1

Recognition of Neuropathic Components

Approximately 20-35% of patients with back pain have a neuropathic pain component, making this a common mixed pain syndrome. 4

• Neuropathic pain in back pain may arise from: degenerated disc nociceptive sprouts (local neuropathic), mechanical nerve root compression, or inflammatory mediators from degenerative discs 4
• The neuropathic component is often under-recognized and undertreated, requiring specific targeted therapy 3