Photoclinic

Neuropathic Pain: Case Report and Considerations in Children and Adolescents

Alexandra Fonseca, MS-IV, and Sutapa Khatua, MD

Authors: 
Alexandra Fonseca, MS-IV, and Sutapa Khatua, MD

Citation: 
Fonseca A, Khatua S. Neuropathic pain: case report and considerations in children and adolescents [published online October 5, 2017]. Consultant360.

 

A 16-year-old boy presented to the emergency department (ED) with left groin pain, which had begun 16 months after a left orchiectomy secondary to torsion. The patient described intermittent, sharp, needlelike pain, with radiation to his left lower abdomen and left upper thigh. The pain worsened significantly with movement and forced him to refrain from all activity and to miss school when it occurred. In addition to the orchiectomy, the patient’s medical history was significant for obesity, anxiety, and depression. His family history was remarkable for anxiety in his mother, and depression, stroke, and for diabetes in his maternal grandparents.

At his initial presentation, he was evaluated by a urologist, who found no abnormalities. The patient was discharged home.

Eight months later, the patient returned to the ED with worsening of the same pain, at which time he was admitted to the hospital for further evaluation and care. His workup included blood tests, urinalysis, urine culture testing, abdominal/pelvic computed tomography, and ultrasonography, as well as further evaluation by a urologist; all findings were within normal limits. He was also evaluated by a pain specialist before being discharged on a regimen of ketorolac and gabapentin.

Two weeks later, the boy again returned to the ED with acute abdominal pain and received a diagnosis of gastritis secondary to ketorolac use.

At present, the patient’s pain remains poorly controlled and leaves him bedbound for a significant portion of the day. Because his pain is interfering with his ability to attend school and other activities, he has been scheduled for follow-up with a pediatric pain specialist and a psychiatrist to optimize his pain management. The boy’s mother is also investigating alternative therapies such as meditation to supplement his medical care and to build coping skills for his comorbid depression and anxiety.

Discussion

The International Association for the Study of Pain recently redefined neuropathic pain as that “arising as a direct consequence of a lesion or disease affecting the somatosensory system.”1,2 Symptoms of neuropathic pain consist of a burning, throbbing, or needlelike sensation that is disproportionate to physical examination findings and often is present consistently.3 However, the signs and symptoms and the causes are highly variable, making a clinical diagnosis challenging, especially in young patients.1 As such, neuropathic pain in the pediatric population is not well documented or researched.4

Current evidence shows that the incidence of and prognosis of neuropathic pain differ in children compared with adults.4 The prevalence is significantly lower in childhood, and the causes do not reflect the conditions that are typically associated with neuropathic pain in the adult population.4 While the most common causes of neuropathic pain in adults are conditions such as diabetic neuropathy and postherpetic neuralgia, these are either rare in children or less frequently result in significant pain.3,4 In children, the causes of neuropathic pain are more commonly trauma, nerve lesion or injury, neurologic and neuromuscular disease, metabolic disease, chronic infection, cancer, and genetic syndromes.4

Some neuropathic conditions are becoming increasingly recognized in children and adolescents, including complex regional pain syndrome (primarily type 1), phantom limb pain, spinal cord injury, trauma and postoperative neuropathic pain, autoimmune and degenerative neuropathies (eg, Guillain-Barré syndrome, Charcot-Marie-Tooth disease), and the effects of different cancers and their treatment. Also, some rare neuropathic pain syndromes are relatively unique to the pediatric population, including toxic and metabolic neuropathies (eg, lead, mercury, alcohol, infection), hereditary neurodegenerative disorders (eg, Fabry disease), mitochondrial disorders, and primary erythromelalgia.5

Treatment Options

In the adult and pediatric populations, treatment of neuropathic pain remains a challenge, since patients often respond poorly to standard pharmacotherapy or remain undertreated.6 The mainstay of treatment includes an initial choice of amitriptyline, duloxetine, gabapentin, or pregabalin, with ketorolac available as a rescue therapy if initial management fails.7 Despite these interventions, less than 50% of patients with neuropathic pain report adequate pain relief, and medication adverse effects are commonly experienced.8 For example, although clinical trials have demonstrated efficacy of gabapentin in reducing neuropathic pain, the adverse effects of dizziness, ataxia, convulsions, headache, nausea, and somnolence limit its use in many patients.7 As such, recent research has focused on alternative approaches to the treatment of neuropathic pain in an effort to enhance relief and quality of life in patients with it.

One such approach is the use of topical agents, which been investigated as an alternative first-line therapy for localized cutaneous neuropathic pain.7 Topical agents have the advantage of acting locally on the peripheral nerves, with minimal systemic exposure, limiting the unwanted adverse effects associated with systemic drug use.7 Other adjunct therapies include mindfulness-based and acceptance-based interventions, including mindfulness-based stress reduction and acceptance and commitment therapy, which aim to improve functioning and reduce suffering by managing the psychological components of pain.9

Alexandra Fonseca, MS-IV, is a medical student at the McGovern School of Medicine at the University of Texas Health Science Center at Houston.

Sutapa Khatua, MD, is an assistant professor in the Department of Pediatrics at the University of Texas Health Science Center at Houston.

References:

  1. Jensen TS, Baron R, Haanpää M, et al. A new definition of neuropathic pain. Pain. 2011;152(10):2204-2205.
  2. Treede R-D, Jensen TS, Campbell JN, et al. Neuropathic pain: redefinition and a grading system for clinical and research purposes. Neurology. 2008;70(18):1630-1635.
  3. Ingelmo PM, Fumagalli R. Neuropathic pain in children. Minerva Anestesiol. 2004;70(5):393-398.
  4. Howard RF, Wiener S, Walker SM. Neuropathic pain in children. Arch Dis Child. 2014;99(1):84-89.
  5. Walco GA, Dworkin RH, Krane EJ, LeBel AA, Treede R-D. Neuropathic pain in children: special considerations. Mayo Clin Proc. 2010; 85(3 suppl):S33-S41.
  6. Smith BH, Torrance N. Epidemiology of neuropathic pain and its impact on quality of life. Curr Pain Headache Rep. 2012;16(3):191-198.
  7. Shahid M, Subhan F, Ahmad N, et al. Topical gabapentin gel alleviates allodynia and hyperalgesia in the chronic sciatic nerve constriction injury neuropathic pain model. Eur J Pain. 2017;21(4):668-680.
  8. O’Connor AB, Dworkin RH. Treatment of neuropathic pain: an overview of recent guidelines. Am J Med. 2009;122(10 suppl):S22-S32.
  9. Reiner K, Tibi L, Lipsitz JD. Do mindfulness-based interventions reduce pain intensity? A critical review of the literature. Pain Med. 2013;14(2):230-242.