The prevalence and management of benign and malignant neuropathic chronic pain  in a Greek Tertiary Hospital Pain Clinic. An Observational Study

Authors: Koraki E^1a*, Sifaki F^1a, Apostologlou V^2b, Gkiouliava A^1c, Arnaoutoglou E^1d

 

¹MD, MSc, PhD, Anesthesiology
²MD, MSc, Anesthesiology

^aDepartment of Anesthesiology, General Hospital “Papageorgiou”, Thessaloniki, Greece
^bDepartment of Anesthesiology, General Hospital of Thessaloniki “G Papanikolaou”, Thessaloniki, Greece
^cClinic of Anesthesiology and Intensive Care, School of Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
^dAnesthesiology Department, Larissa University Hospital, Faculty of Medicine, University of Thessaly, Larissa, Greece

*Correspondance: General Hospital of Thessaloniki “Papageorgiou”, Municipality of Pavlos Melas, N. Efkarpia, 56403, Thessaloniki, Greece, email: , tel.: 0030 6977350844

 

ABSTRACT

Neuropathic pain is a complex condition which encompasses both benign (e.g. trigeminal / post – herpetic neuralgia) and malignant etiologies. The effective management of both types of neuropathic pain often requires a multimodal approach to be relieved. Understanding the prevalence, characteristics and treatment options and outcomes of neuropathic pain is crucial, for optimizing patient care and enhancing their quality of life. In this study, we aim to investigate the prevalence and management of benign and malignant neuropathic chronic pain in a Greek Tertiary Hospital Pain Clinic. In this retrospective observational study, patients who visited the pain clinic of “G. Papanikolaou” General Hospital of Thessaloniki, between 2017 and 2022 were included. Data regarding demographics, pain etiology and neuropathic pain characteristics were collected. The presence of neuropathic pain was assessed using the DN4 questionnaire. The treatment options for the effective management of patient’s neuropathic pain were also documented.

A total of 278 patients visited the pain clinic. 39.6% of the patients presented with cancer pain. Regarding benign pain, back pain was the most common cause. Burning pain, electric shock-like sensations, and constant pain were the characteristics of pain which were frequently reported by the patients. According to the DN4 questionnaire, 66.5% of the patients exhibited neuropathic pain. The treatment by the multidisciplinary team of the pain clinic primarily involved the use of antidepressants, anticonvulsants, as well as invasive techniques, which demonstrated efficacy in reducing pain levels. The findings of this study indicate that a large proportion of patients who visited the pain clinic, suffered from neuropathic pain. Most of these patients experienced relief following treatment interventions by the multidisciplinary team of the pain clinic. This study highlights the importance of assessment and individualized management strategies for patients presenting with neuropathic pain.

 

 

INTRODUCTION

According to the International Association for the Study of Pain (IASP), pain is “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”¹. Chronic pain may be present as nociceptive, neuropathic or nociplastic, it describes the pain that still occurs after 3 months and can affect as much as 20% of the general population². A significant percentage of patients experience a combination of these types of chronic pain. Neuropathic pain, affecting approximately 10% of the general population, arises from damage or dysfunction of the somatosensory nervous system, either peripherally or centrally³. Initially it presents with inflammatory features and can progress to chronicity in 20-30% of cases, thus it constitutes a significant clinical challenge⁴.

Neuropathic pain is characterized by clinical signs and symptoms which can be either spontaneous (eg burning sensation, paraesthesias) or stimulous – evoked (eg allodynia, hyperalgesia). Neuropathic pain can be persistent or intermittent; it is often resistant to conventional and opioid analgesics and significantly impairs quality of life, as it often causes sleep disturbances, anxiety and depression to patients⁵. The diagnosis of neuropathic pain, along with the detailed medical history and clinical examination of the patient, often relies on validated questionnaires such as the Douleur Neuropathique 4 Questionnaire (DN4) and Pain DETECT questionnaire, which facilitate the assessment of symptoms and signs indicating neuropathic origin. Complementary tools like the Leeds Scale, further contribute to characterizing the manifestations of neuropathic pain^6,7.

Many pharmacological approaches have been tested (including medications such as gabapentinoids, opioids, and antidepressants) with limited effectiveness for the management of neuropathic pain⁸.

Interventional treatments such as peripheral nerve blocks, targeted drug administration, neuromodulation, spinal cord and peripheral nerve stimulation have also been tested⁹.

Effective management of neuropathic pain is challenging, as it has a multifactorial pathogenesis, necessitating an individualized treatment approach. However, the scarcity of trained pain specialists, exacerbated by the socioeconomic crisis in Greece, has led to inadequate access to pain clinics for many patients. Consequently, individuals often endure prolonged suffering and seek assistance from various medical specialties before eventually accessing specialized pain care.

The aim of this study was to address the prevalence and the clinical features of neuropathic pain in patients presenting with malignant or benign pain conditions, who visited a Greek Tertiary Hospital Pain Clinic.

By investigating the efficacy of current management strategies, this study aims to contribute to the optimization of neuropathic pain management and enhance patient outcomes and quality of life.

Material and Methods

Access to the registry of patients, who visited the pain clinic at “G. Papanikolaou” General Hospital of Thessaloniki, was granted after approval by the Institutional Review Board. The medical records of adult patients, who visited the pain clinic, from January of 2017 until December of 2022 were retrieved.

Inclusion criteria included a primary consultation for chronic pain, with a VAS score equal to or exceeding 5. A baseline DN4 score equal to or exceeding 4 during the initial interview was defined as “neuropathic pain”. Exclusion criteria encompassed individuals with significant cognitive impairments, mental incapacities, or psychiatric disorders.

Data acquisition included the documentation of patients’ demographic details, concurrent medical conditions, and ongoing medication regimens. Additional data collected for the purposes of this study included VAS – assessed pain levels, detailed pain characteristics (e.g. burning, numbness, electric shock – like sensations, acute, dull, constant, intermittent pain, cold, tingling, throbbing and sharp pain) and pain management strategies.

A descriptive analysis was conducted for each variable. For continuous variables (such as age and VAS), depending on their distribution, either non-parametric methods (median and interquartile range) or parametric methods (mean and standard deviation) were applied.

For categorical variables (such as medication use), relative frequencies and corresponding percentages were calculated.

Comparisons between quantitative variables were performed using the t-test or the Mann-Whitney U test, depending on the distribution, while comparisons of qualitative variables were conducted using the chi-square (χ²) test.

The level of statistical significance was set at 95% (p < 0.05). Logistic regression analysis was performed to identify independent predictors of neuropathic pain.

Results

A total of 278 patients were examined at the pain clinic of “G. Papanikolaou” General Hospital of Thessaloniki, from January of 2017 until December of 2022.

All patients’ examinations were performed by the same multidisciplinary medical team, consisting of an anesthesiologist specialized in pain management and a trained nurse.

The median age of the patients was 68 years and 58.6% (n= 163) were women (Table 1).

 

Variable	Median Values	Interquartile Range (IQR)
Age (yrs)	68	20
DN4 Score	4	3
VAS at Initial Assessment	8	4
VAS at Last Visit	3	3

Table 1. Patients Age, DN4 Questionnaire Scores and Pain Scale Scores.

 

Among all patients, 60.4% (n= 168) suffered from chronic benign pain, with the most frequent cause being lower back pain. The most frequently reported pain characteristics among patients were burning (n=137, 49.3%), electrical shock – like pain (n=134, 48.2%), and continuous pain (n=118, 42.4%) (Table 2).

According to the DN4 questionnaire, 185 patients (66.5%) were identified as patients

with neuropathic pain. The frequency of each pharmacological or interventional treatment is presented in Table 3.

Based on the Wilcoxon signed-rank test for paired samples, pain scores were significantly reduced at the follow-up visit (p<0.001). No statistically significant association was found between cancer-related pain and the presence of neuropathic pain (p=0.9).

 

Pain characteristics	Number of patients	Percentage of patients
Sharp	108	38.8%
Electric Shock like	134	48.2%
Burning	137	49.3%
Numbness	112	40.3%
Constant	118	42.4%
Dull	50	18%
Acute	119	42.8%
Tingling	7	2.5%
Intermittent	60	21.6%
Painful cold	2	0.7%
Hypesthesia	2	0.7%

Table 2. Pain Characteristics

Medical treatment	Number of patients	Percentage of patients
Benzodiazepines	62	22.3%
Hypnotics	4	1.4%
Antidepressants	14	5%
Antiepileptics	205	73.7%
Non-opioids	212	76.3%
Weak opioids	193	69.4%
Potent opioids	109	39.2%
Regional Anaesthesia Topical Infiltration or Other Interventional Technique	45	16.2%

Table 3. Medical Treatment

 

Regarding patients with neuropathic pain, there was no evidence of an increased likelihood of receiving a specific interventional technique or medication. However, treatment patterns differed significantly based on the presence of cancer-related pain. Specifically, cancer pain was associated with a higher likelihood of benzodiazepine use (p<0.001, 95% CI 2.5–8.3), strong opioids (p<0.001, 95% CI 4.5–13.4), and weak opioids (p=0.005, 95% CI 1.2–3.8). Conversely, non-cancer pain was more likely to be treated with an interventional technique (p=0.03, 95% CI 0.2–0.9).

A logistic regression model assessing the presence of neuropathic pain using potential independent predictors yielded statistically significant results (p<0.001). Burning pain (p=0.03, 95% CI 1.073–3.86) and paraesthesias (p<0.001, 95% CI 1.8–7.4) were identified as independent predictors of neuropathic pain. In contrast, dull (p=0.011, 95% CI 0.13–0.7) and acute pain (p=0.019, 95% CI 0.21–0.87) were associated with a lower likelihood of neuropathic pain. The final model was statistically significant for prediction (p<0.001).

Figure 1 displays the ROC curve derived from the predicted probabilities, with an area under the curve (AUC) of 0.739.

 

DISCUSSION

Neuropathic pain is widely recognized as one of the most challenging pain syndromes to manage. Despite advances in therapeutic approaches, treatment outcomes often remain suboptimal. A significant etiology for this issue is the limited awareness among frontline healthcare providers regarding the existence, recognition, and management strategies for neuropathic pain^10,11.

Epidemiological research in this field faces considerable challenges, largely due to multifactorial reasons. These include the absence of universally accepted, precise definitions of neuropathic pain that accurately reflect the clinical condition; heterogeneity and variable quality among existing studies; the use of disparate pain assessment tools; and the inclusion of patient populations where pain is not the primary complaint¹².Consequently, existing prevalence estimates of neuropathic pain within the general population exhibit substantial variability. It is likely that a significant proportion of individuals experiencing pain possess unrecognized and, therefore, untreated neuropathic components. Accurate estimation of the population-based prevalence of neuropathic pain is crucial for informing resource allocation—both financial and educational—and for guiding treatment and prevention strategies^13,14.

The development of validated screening tools for the identification of neuropathic pain has led to a surge in questionnaire-based epidemiological studies. An expanding body of literature now explores the epidemiology, symptomatology, and societal impact of neuropathic pain. In the present study, we employed the Greek version of the DN4 questionnaire, which has been linguistically validated by Sykioti et al.¹⁵.The DN4 is a concise, patient-friendly instrument that combines descriptive sensory adjectives with straightforward administration and scoring. Its cross-cultural validity has been confirmed in numerous languages.

In our study, based on the DN4 questionnaire, 66.5% of patients were identified as suffering from neuropathic pain. Prior studies utilizing the DN4, such as those by Bouhassira et al., De Moraes Vieira et al. and Toth et al., have estimated the prevalence of neuropathic characteristics in pain at rates between 6.6% and 7.2% ^16-18. The prevalence rates in the first two studies were comparable; however, Toth et al. reported a significantly higher prevalence¹⁸. Chronic pain affected 35.0% of the 1,207 patients studied, and neuropathic pain accounted for 17.9% of cases. It is important to note that these figures primarily reflect patients seen in primary care settings. Our substantially higher prevalence likely reflects the tertiary nature of our pain clinic population, consisting of referrals from other specialties, often without specific expertise in neuropathic pain management¹⁸.

Burning and electric shock-like sensations were the most frequently reported pain characteristics in our study, consistent with previous findings by Vadalouca et al.¹⁹. Pain was predominantly continuous in nature, emphasizing the critical need for specialized care in dedicated pain clinics staffed by trained professionals.

Among our patients, those with cancer-related pain exhibited a higher likelihood of receiving benzodiazepines, strong opioids, and weak opioids. Cancer-related neuropathic pain presents a unique management challenge, as outlined by Mishra and de Andrade, where antidepressants (such as SNRIs, duloxetine, and venlafaxine), antiepileptics (pregabalin and gabapentin), opioid combination therapy, and interventional techniques are considered first-line treatment options. Adjuvant analgesics remain a cornerstone for cancer-related neuropathic pain, not only addressing pain but also alleviating associated psychological symptoms such as insomnia, anxiety, and depression^20,21.

Conversely, in cases of non-cancer pain, interventional techniques are more commonly employed. Low back pain, frequently cited as a primary cause of benign chronic pain in our clinic, was often managed with epidural administration of local anesthetics and corticosteroids—a practice with modest but immediate analgesic benefits, albeit limited in duration.

Our study population encompassed both sexes across a broad age range (18–85 years), included patients with moderate to severe pain (VAS ≥ 5), and represented a diverse diagnostic spectrum, reflective of the typical tertiary pain clinic population.

However, interpretation of our findings must be interpreted with several limitations. First, the relatively small sample size limits generalizability. While our cohort included a broad range of pain diagnoses, it notably excluded patients with central neuropathic pain (e.g. following a cerebrovascular event). Furthermore, our focus on patients with moderate to severe pain intensity may limit the applicability of the Greek DN4 to individuals with milder symptoms. The inclusion of additional validated neuropathic pain scales, such as the PAINDETECT questionnaire, could have enriched our assessment.

Conclusion

This study demonstrates that neuropathic pain is highly prevalent among patients referred to tertiary pain clinics, affecting both cancer and non-cancer populations. Implementation of guideline-directed therapy, including antiepileptics, antidepressants, and interventional techniques, appears effective in mitigating symptoms. In cancer patients, adjunctive use of benzodiazepines and opioids further enhances pain control.

In conclusion, specialized pain clinic management offers substantial relief to patients suffering from neuropathic pain, underscoring the necessity of accurate diagnosis and multidisciplinary, evidence-based intervention strategies.

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Addittional materials: No

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Acknowledgements: Not applicable

Authors’ contributions: Conceptualization: KE, AE; Methodology: KE, AE, GkA; Software: GkA; Validation: KE, AE, SF; Formal analysis: KE, GkA; Investigation: KE, AE; Data Curation: KE, AE, GkA, SF; Writing—Original Draft Preparation: SF, AV, KE, AE; Writing—Review and Editing: SF; KE, AE; Visualization: KE, AE; Supervision:Arnaoutoglou Eleni; Project Administration: KE, AE. All authors read and approved the final manuscript.

Funding: Not applicable

Availability of supporting data: Not applicable.

Consent for publication: Patient’s consent was obtained

Ethical approval and consent to participate:

No IRB approval required.

Competing interests: The authors declare that they have no competing interests.

Received: April 2025, Accepted: April 202, Published: May 2025.

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Citation: Koraki E, Sifaki F, Apostologlou V, Gkiouliava A, Arnaoutoglou E. The prevalence and management of benign and malignant neuropathic chronic pain in a Greek Tertiary Hospital Pain Clinic. An Observational Study. Greek e j Perioper Med. 2025;24(a):3-13.

 

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