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5. Q. When Does Neuropathic Pain Begin and How Does It Progress?
"Illness is the doctor to whom we pay most heed: to kindness, to knowledge we make promises only:
pain we obey." -- Marcel Proust
Typically, insults to the nerve roots begin in the teens and 20's, but because the nerves possess a reservoir of excessive functional capacity, they are able to compensate for these early insults and there are no symptoms. Following repeated and cumulative traumas, the nerve 'spends' its excess capacity for compensation and the first symptoms appear, although they are usually self-limited and of brief duration. These are usually experienced as muscle strain or spasm. Rest, massage, and/or exercise provide the necessary energy input needed to restore the nerve function to a point where symptoms resolve.
Another useful picture analogy to help understand the deceptive nature of type 3 neuropathic pain is that of an iceberg floating in the sea. When you first glimpse it from your stateroom on the Titanic, it appears to be only an ice floe on the surface that you might even scoop up some ice cubes from to add to your evening cocktail at the Captain's Reception. But alas, it is not an ice floe, but just the visible portion of a much larger underwater iceberg that could sink your boat. This 'invisible' underwater iceberg is analogous to the accumulated wear-and-tear that your nerves have sustained, but previously compensated for, protecting you from symptoms. Eventually the wear-and-tear exceeds the nerves ability to compensate, and symptoms ('ice floe') poke through the surface.
Now because the symptoms appear suddenly, their underlying cause is mistakenly assumed to be of an acute and therefore injurious nature (type 2 pain). The more sinister yet subtle pre-existing nerve deterioration that produced them lurks below the surface and is not readily appreciated (invisible underwater iceberg). The First Mate invites the passengers on deck to enjoy the sighting of the ice floe and proposes a toast, as surely no one anticipates danger.
Initially, simple measures like rest, ice and massage suffice to 're-submerge' the symptoms, but with continued attrition to the nerves, these become inadequate. Symptoms become more intense, longer-lasting, and frequent. This phase typically occurs in the 30' and 40's, and common diagnoses include disc disease, tendonitis, bursitis, fasciitis, repetitive strain, sciatica or even early arthritis. Previous treatments provide less dramatic and consistent benefit. The Captain now begins to realize that there is more than just an ice floe floating off starboard and announces, "All passengers to their muster stations immediately!"
It is also common at this point to have structural diagnoses made based on X-ray and MRI imaging studies, such as rotator cuff disease, meniscus/cartilage knee damage, or cervical/lumbar spondylosis/disc degeneration. Physical therapy, chiropractic, and acupuncture may provide increasingly shorter term relief. The Captain now urgently orders "Man the life boats, women and children first!"
If these rescue measures are unsuccessful, various (pain) medications and/or surgical consultation is sought. Epidural steroid, nerve root, facet joint and/or discogram injections may be tried. These, if unsuccessful, prompt the Captain to send an S.O.S. to psychiatrists and 'Pain Clinics', as he desperately cries out, "All hope is lost, abandon ship!". More medication, spinal cord stimulators/pumps and sometimes more surgery may be offered. Some 'survive', but many drown. Sadly, it is estimated that suicide is 20x more common in the inadequately treated chronic pain population.
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DrGoodman@NorthwestIMS.com