Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Neuropathic pain with neurological compromise
New burning or radicular pain with weakness, gait change, saddle sensory loss, sphincter dysfunction, cranial neuropathy or rapidly ascending deficit may indicate cord, cauda equina, plexus or brain compression.
Action: Perform urgent structured neurological examination, protect an unstable spine when relevant and activate the appropriate MRI, acute oncology, spinal or neurological pathway. Start emergency disease-specific treatment when indicated while providing analgesia; do not wait for an adjuvant trial to declare failure.
Synopsis
Diagnose pain caused by a somatosensory lesion, identify urgent compressive and treatment-related causes, combine cause-directed care with a cautious adjuvant trial, and judge success by function and tolerability rather than complete symptom abolition.
Diagnose neuropathic pain only when characteristic symptoms and sensory signs fit a plausible lesion or disease of the somatosensory system.
First-line examination maps light touch, pinprick, temperature, allodynia, reflexes, power and gait and checks urgently for cord, root or plexus compromise.
Treat the cause when possible: decompression, radiotherapy, diabetes control, vitamin replacement, antiviral treatment or modification of a neurotoxic medicine may preserve function.
Key red flags
Back or radicular pain with new motor, sensory, gait or bladder or bowel change requires emergency MSCC or cauda-equina assessment.
Compressive emergency
Pain with new weakness, gait decline, saddle loss or sphincter dysfunction requires urgent structural imaging and specialist care.
Investigation priorities
01
First-line neurological pain historyFirst stepFirst line
Map distribution, positive and negative symptoms, onset, progression, triggers, functional loss and temporal relation to cancer or treatment.
Management branches
Initial treatmentChoose one adjuvant by patient risk
Non-trigeminal neuropathic pain is diagnosed and no neurological emergency requires immediate intervention.
Identify and treat the cause, define a sleep or function goal and review renal, hepatic, cardiac, falls, mood, interaction and misuse risks.
Choose amitriptyline, duloxetine, gabapentin or pregabalin, start at a tolerable dose and provide titration, driving and withdrawal information.
Key medicines
Amitriptyline for neuropathic painStart 10 mg orally at night, or 10 to 25 mg in a younger robust adult, and titrate slowly every one to two weeks according to response and the BNF, usually not exceeding 75 mg nightly for pain.
Duloxetine for neuropathic painA common regimen is 60 mg orally once daily, with 30 mg once daily initially when tolerability is a concern before increasing under the BNF and local pathway.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.