1. Grading system G Di Stefano A Truini
Dipartimento di Neurologia e Psichiatria, Università “Sapienza” di Roma

2. Definition of neuropathic pain
IASP 2004: pain initiated or caused by a primary lesion or dysfunction
of the nervous system
NeuPSIG 2008: pain arising as a direct consequence of a lesion or
disease affecting the somatosensory system

3. Grading system
(Treede et al., Neurology 2007)

4. Grading system for neuropathic pain
Criteria to be evaluated for each patient
Pain with a distinct neuroanatomically plausible distribution
A history suggestive of a relevant lesion or disease affecting the peripheral or central somatosensory system
Demonstration of the distinct neuroanatomically plausible distribution by at least one confirmatory test
Demonstration of the relevant lesion or disease by at least one confirmatory test

5. Grading system
(Treede et al., Neurology 2007)

6. Brown Sequard Syndrome
Clinical criteria
Brown Sequard Syndrome
Fibromyalgia
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

7. Screening tools
Cruccu and Truini, PLoS Med 2009

8. Neurological examination
Brown Sequard Syndrome
Fibromyalgia
Hanpaa et al., Am J Med 2009
Geber et al., Am J Med 2009

9. Quantitative sensory testing9

10. Neurophysiological tests
A fibre
C fibre
A fibre
Trigeminal reflex
Right side Left side R2 R1 A
SP1
SP2 B
NCS
 SEP

11. Advanced techniques fMRI A-LEPs Skin Biopsy
Ducreux et al., Brain 2006
Skin Biopsy

12. Case 1: Trigeminal Neuropathic Pain
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.
Trigeminal Reflexes
SP1
V2 Dx
V2 Sx

13. Case 1: Trigeminal Neuropathic Pain

14. Case 2: Ehlers-Danlos syndrome (EDS)
Castori et al, 2009 14

15. Laser Evoked Potentials
Case 2: Ehlers-Danlos syndrome (EDS)
Skin Biopsy
Laser Evoked Potentials
Right Hand N2 P2 N1
Left Foot N2 P2 N1

16. Case 3: Carpal Tunnel Syndrome
Patients with CTS may complain pain outside the typical median nerve distribution.

17. Case 4: Idiopathic Trigeminal Neuralgia
Trigeminal reflex
Right side
Left side
Geber et al., Am J Med 2009

18. Case 4: Idiopathic Trigeminal Neuralgia

19. Case 4: Idiopathic Trigeminal Neuralgia

20. THANK YOU!