Traumatic Peripheral Nerve Lesions Medication
- Author: Neil Holland, MBBS, FAAN; Chief Editor: Nicholas Lorenzo, MD more...
Medication Summary
As outlined in the text, a wide variety of analgesic medications may be effective in the treatment of neuralgic pain. These include both narcotic and nonnarcotic medications.
Narcotic analgesics
Class Summary
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.
Fentanyl transdermal patch (Duragesic, Sublimaze)
Potent narcotic analgesic with much shorter half-life than morphine sulfate. DOC for conscious sedation analgesia. Ideal for analgesic action of short duration during anesthesia and immediate postoperative period.
Excellent choice for pain management and sedation with short duration (30-60 min) and easy to titrate.
Easily and quickly reversed by naloxone.
After initial dose, subsequent doses should not be titrated more frequently than q3h or q6h thereafter.
When using transdermal dosage form, pain in majority of patients controlled with 72-h dosing intervals; however, some patients require dosing intervals of 48 h.
Oxycodone (OxyContin)
Relieves moderately severe to severe pain.
Morphine sulfate (MS Contin, Duramorph, Astramorph)
DOC for analgesia because of reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses used; commonly titrated until desired effect attained.
Methadone (Dolophine)
Used in management of severe pain; inhibits ascending pain pathways, diminishing perception of and response to pain.
Oral analgesics
Class Summary
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.
Tramadol (Ultram)
Inhibits ascending pain pathways, altering perception of and response to pain; also inhibits reuptake of norepinephrine and serotonin.
Tricyclic antidepressants
Class Summary
These agents are a complex group of drugs that have central and peripheral anticholinergic effects as well as sedative effects. They have central effects on pain transmission and block the active re-uptake of norepinephrine and serotonin.
Amitriptyline (Elavil)
By inhibiting re-uptake of serotonin and/or norepinephrine by presynaptic neuronal membrane, may increase synaptic concentration in CNS.
Useful as analgesic for certain chronic and neuropathic pain.
Nortriptyline (Pamelor, Aventyl HCl)
Has demonstrated effectiveness in treatment of chronic pain.
By inhibiting reuptake of serotonin and/or norepinephrine by presynaptic neuronal membrane, may increase synaptic concentration in CNS.
Pharmacodynamic effects, such as desensitization of adenyl cyclase and down-regulation of beta-adrenergic receptors and serotonin receptors, also appear to play role in its mechanisms of action.
Anticonvulsants
Class Summary
These agents are used to manage severe muscle spasms and provide sedation in neuralgia. They have central effects on pain modulation.
Gabapentin (Neurontin)
Has properties common to other anticonvulsants and has antineuralgic effects. Exact mechanism of action not known. Structurally related to GABA but does not interact with GABA receptors.
Lamotrigine (Lamictal)
Triazine derivative used in neuralgia. Inhibits release of glutamate and inhibits voltage-sensitive sodium channels, leading to stabilization of neuronal membrane.
Follow manufacturer's recommendation for dose adjustments.
Pregabalin (Lyrica)
Structural derivative of GABA. Mechanism of action unknown. Binds with high affinity to alpha2-delta site (a calcium channel subunit). In vitro, reduces calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia and as adjunctive therapy in partial-onset seizures.
Anesthetics
Class Summary
These agents stabilize the neuronal membrane so the neuron is less permeable to ions. This prevents the initiation and transmission of nerve impulses, thereby producing the local anesthetic action.
Lidocaine anesthetic (Anestacon, DermaFlex gel, Dilocaine)
Several recent studies have advocated topical administration of lidocaine as treatment of PHN.
Lidocaine gel (5%) in a placebo-controlled study showed significant relief in 23 patients studied. Lidocaine tape also decreased severity of pain.
Stewart JD. Focal Peripheral Neuropathies. New York: Raven Press;1993.
Cudlip SA, Howe FA, Clifton A, Schwartz MS, Bell BA. Magnetic resonance neurography studies of the median nerve before and after carpal tunnel decompression. J Neurosurg. Jun 2002;96(6):1046-51. [Medline].
Filler AG, Maravilla KR, Tsuruda JS. MR neurography and muscle MR imaging for image diagnosis of disorders affecting the peripheral nerves and musculature. Neurol Clin. Aug 2004;22(3):643-82, vi-vii. [Medline].
Elkwood AI, Holland NR, Arbes SM, Rose MI, Kaufman MR, Ashinoff RL, et al. Nerve allograft transplantation for functional restoration of the upper extremity: case series. J Spinal Cord Med. 2011;34:241-247. [Medline].
Brown WF, Veitch J. AAEM minimonograph #42: intraoperative monitoring of peripheral and cranial nerves. Muscle Nerve. Apr 1994;17(4):371-7. [Medline].
Kliot M, Slimp J. Techniques for assessment of peripheral nerve function at surgery. In: Loftus CM, Traynelis VC, eds. Intraoperative Monitoring Techniques in Neurosurgery. New York: McGraw-Hill Inc;. 1994:275-85.
Tiel RL, Happel LT Jr, Kline DG. Nerve action potential recording method and equipment. Neurosurgery. Jul 1996;39(1):103-8; discussion 108-9. [Medline].
Kandenwein JA, Kretschmer T, Englhardt M, Richter HP, Antoniadis G. Surgical interventions for traumatic lesions of the brachial plexus: a retrospective study of 134 cases. J Neurosurg. 2005;103:614-621. [Medline].
Kline DG, Hudson AR. Nerve Injuries: Operative Results for Major Nerve Injuries. Philadelphia, Pa: WB;1995.
Landi A, Copeland SA, Parry CB, Jones SJ. The role of somatosensory evoked potentials and nerve conduction studies in the surgical management of brachial plexus injuries. J Bone Joint Surg [Br]. Nov 1980;62-B(4):492-6. [Medline].
Terzis JK, Kokkalis ZT, Kostopoulos E. Contralateral C7 transfer in adult plexopathies. Hand Clin. 2008;24:389-400. [Medline].
Holland NR, Belzberg AJ. Intraoperative electrodiagnostic testing during cross-chest C7 nerve root transfer. Muscle Nerve. 1997;20:903-905. [Medline].
Byrne P, Hilinski J, Hilger P. Facial Nerve Repair. eMedicine Journal [serial online]. 2009. Available at: http://emedicine.medscape.com/article/846448-overview. [Full Text].
Chaput C, Probe R. Brachial Plexus Injuries, Traumatic. eMedicine Journal [serial online]. 2008. Available at: http://emedicine.medscape.com/article/1268993-overview. [Full Text].
Chaudhry V, Cornblath DR. Wallerian degeneration in human nerves: serial electrophysiological studies. Muscle Nerve. Jun 1992;15(6):687-93. [Medline].
Wilbourn AJ. Assessment of the brachial plexus and the phrenic nerve. In: Johnson EW, Pease WS, eds. Practical Electromyography. Baltimore: Williams & Wilkins;1997:273-310.
Print
