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Grading system
G Di Stefano A Truini
Dipartimento di Neurologia e Psichiatria, Università “Sapienza” di Roma
IASP 2004: pain initiated or caused by a primary lesion or dysfunctionof the nervous system
NeuPSIG 2008: pain arising as a direct consequence of a lesion ordisease affecting the somatosensory system
Definition of neuropathic pain
(Treede et al., Neurology 2007)
Grading system
Criteria to be evaluated for each patient
1.Pain with a distinct neuroanatomically plausible distribution
2.A history suggestive of a relevant lesion or disease affecting the peripheral or
central somatosensory system
3.Demonstration of the distinct neuroanatomically plausible distribution by at
least one confirmatory test
4.Demonstration of the relevant lesion or disease by at least one confirmatory
test
Grading system for neuropathic pain
(Treede et al., Neurology 2007)
Grading system
Brown Sequard Syndrome
Fibromyalgia
Clinical criteria
Careful assessment of the patient’s history and
clinical symptoms is an important prerequisite for the
diagnostic workup of neuropathic pain.
Geber et al., Am J Med 2009
Cruccu and Truini, PLoS Med 2009
Screening tools
Brown Sequard Syndrome
Fibromyalgia
Neurological examination
Geber et al., Am J Med 2009Hanpaa et al., Am J Med 2009
Quantitative sensory testing
NCS
SEP
Right side Left side
R1 R2
SP1 SP2
A
B
Trigeminal reflex A fibre
C fibre
A fibre
Neurophysiological tests
A-LEPs
Ducreux et al., Brain 2006
fMRI
Skin Biopsy
Advanced techniques
Case 1: Trigeminal Neuropathic Pain
Trigeminal Reflexes•48-year old woman;
•Diagnosis of Multiple Myeloma in 2008;
•Pain localized at the right second trigeminal division;
•Neurological examination: tactile hypoesthesia and hypoalgesia in the same trigeminal division;
•Trigeminal reflexes: absence of SP1 component following infraorbital nerve stimulation.
V2 DxV2 Dx V2 SxV2 Sx
SP1
Case 1: Trigeminal Neuropathic Pain
Case 2: Ehlers-Danlos syndrome (EDS)
Castori et al, 2009
Case 2: Ehlers-Danlos syndrome (EDS)
Laser Evoked Potentials
Right Hand
Left Foot
N2
P2
N1
N2
P2
N1
Skin Biopsy
Case 3: Carpal Tunnel Syndrome
Patients with CTS may complain pain outside the typical median nerve distribution.
Case 4: Idiopathic Trigeminal Neuralgia
Geber et al., Am J Med 2009
Trigeminal reflex
Right side Left side
Case 4: Idiopathic Trigeminal Neuralgia
Case 4: Idiopathic Trigeminal Neuralgia
Patient ID Age DN4 Score Pain Site1 71 4 V3dx2 72 2 V1V2sn3 70 2 V1V2sn4 63 3 V2dx5 57 6 V1V2V3dx6 74 2 V1V2V3dx7 63 3 V1V2V3dx8 67 3 V2V3sn9 64 4 V2V3dx
10 69 1 V1dx11 74 2 V1V2V3dx12 62 3 V1V2V3dx13 61 2 V1V2dx14 74 1 V1V2V3dx Average DN4 Score: 2.515 63 2 V3dx16 75 1 V3dx17 80 1 V3 dx18 69 3 V2sx19 79 5 V2dx20 49 1 V1V2V3dx21 67 2 V2sn22 65 2 V3 dx
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