Multidisciplinary strategies to treat painful mononeuropathies in the upper extremity: from lab to bedside

Abstract

Neuropathic pain in the upper extremity is a serious problem, commonly involving relatively young patients. The pain causes loss of function and productivity, changes a patient's lifestyle and can progress into a chronic pain syndrome with secondary psychosocial co-morbidities. Treating patients with a painful mononeuropathy remains challenging, with a monodisciplinary approach often having limited treatment efficacy. This narrative review discusses how to deal with this challenge in the treatment of patients with peripheral nerve injury pain, addressing the four important pillars: (1) diagnosing a painful mononeuropathy; (2) clinical pain phenotyping; (3) personalized pain treatment; and (4) using a multidisciplinary team approach.

Keywords: Multidisciplinary; mononeuropathy; pain; phenotyping.

Figure 1.

Peripheral nerve injury and neuroma formation. (a) Healthy myelinated peripheral nerve innervating the skin. (b) Peripheral inflammatory process damaging myelin and the nerve endings. (c) Partial nerve laceration or severe crush injury resulting in a neuroma-in-continuity and (d) severed nerve left in discontinuity resulting in an end-bulb neuroma comprised of a disorganized tangle of regenerating nerve fibres.

Figure 2.

Left: palmar view of the hand, showing three surgical options for a painful neuroma at the level of the fingers: nerve reconstruction; nerve end burying in bone; and RPNI. Right: dorsal view of the hand and wrist showing surgical options for the radial sensory nerve: reconstruction; implanting in muscle; and TMR. Options for painful neuromas at level of the hand are also shown. RPNI: regenerative peripheral nerve interface; TMR: targeted muscle reinnervation.

Figure 3.

Proposed triage for a patient with suspected painful mononeuropathy involves referral to healthcare providers, such as a pain specialist, psychologist, physiotherapist and nerve surgeon, enabling a comprehensive assessment and appropriate redirection to other team members as needed. This collaborative approach ensures a thorough understanding of the patient’s condition and tailors interventions accordingly.