Peripheral neuropathy is damage or dysfunction of the nerves outside the brain and spinal cord. It commonly affects the feet and hands, causing numbness, tingling, burning or shooting pain, and sometimes weakness and balance problems. Diabetes is the most common cause in the UK, but there are many others. When neuropathy is painful, treatment has two parts: finding and managing the underlying cause, and controlling the pain itself. Where standard medicines have not given enough relief, some people may be considered for nerve-based treatments such as spinal cord stimulation.
What is peripheral neuropathy?
The peripheral nerves carry signals between the brain, spinal cord and the rest of the body. When these nerves are damaged, the signals can be lost or distorted. Neuropathy can affect sensory nerves (numbness, tingling, pain), motor nerves (weakness) or autonomic nerves (dizziness, digestive or bladder problems). Small fibre neuropathy involves the thinnest nerves and often causes burning pain with normal-looking nerve tests.
Typical symptoms start in the toes and feet and slowly spread upwards, then may affect the hands, often called a stocking-and-glove pattern. The pain is often worse at night. Some people find even light touch, such as bedsheets, painful, which is called allodynia.
Common causes
- Diabetes. Long-standing high glucose damages nerves, and up to a third of people with diabetes may develop painful neuropathy.
- Vitamin B12 deficiency. Can be caused by diet, some medicines such as metformin, or absorption problems, and is treatable.
- Alcohol. Long-term heavy use damages nerves directly and through poor nutrition.
- Chemotherapy. Some cancer drugs cause chemotherapy-induced peripheral neuropathy that can persist after treatment.
- Other medical conditions. Underactive thyroid, kidney disease, autoimmune conditions and infections such as shingles or HIV.
- Inherited neuropathies. For example, Charcot-Marie-Tooth disease.
- Unknown cause. A significant number of people have no identifiable cause after tests.
How we assess neuropathic pain
Dr Poply takes a detailed history, examines sensation, reflexes, strength and balance, and reviews earlier tests such as blood results and nerve conduction studies. Blood tests commonly include glucose or HbA1c, vitamin B12, thyroid function and kidney function, and your GP or neurologist may already have arranged them. If a cause has not been thoroughly looked for, we will suggest further investigation or a neurology opinion. We also ask how pain affects sleep, mood and daily life, and we review all your current medicines, including any that may contribute.
Treatment options
Treating the cause
For diabetic neuropathy, stable glucose control and regular foot care are the foundation. For B12 deficiency, replacement can prevent further damage. Reducing alcohol and reviewing medicines that can affect nerves also matter. Where the cause cannot be reversed, treatment focuses on symptoms and safety.
Medicines for nerve pain
NICE recommends amitriptyline, duloxetine, gabapentin or pregabalin as initial options for neuropathic pain, and duloxetine as the first choice for painful diabetic neuropathy, with amitriptyline if duloxetine cannot be used. These medicines help some people and not others, and side effects such as drowsiness, dizziness and weight gain are common. A structured trial at an adequate dose, with a review of benefit, is better than staying on a medicine that is not helping.
Skin-applied treatments
For pain confined to a small area, treatments applied to the skin, such as capsaicin, are sometimes used and are an option for people who cannot tolerate tablets.
Nerve blocks and other interventional treatments
Local nerve blocks can help when a specific nerve is involved, for example after an injury or surgery, and can be diagnostic as well as therapeutic.
Spinal cord stimulation and peripheral nerve stimulation
Spinal cord stimulation delivers mild electrical pulses to the spinal cord to change how pain signals reach the brain. In the SENZA-PDN trial, 216 people with painful diabetic neuropathy that had not responded to at least two medicine classes were randomised to 10 kHz spinal cord stimulation plus medical management or to medical management alone, and those with stimulation were followed for 24 months. The study was open-label, meaning patients and doctors knew who had the device, and it was funded by the manufacturer. Participants also needed reasonably controlled diabetes (HbA1c up to 10%) and to be suitable for surgery, and people with large foot ulcers were excluded.
NICE recommends spinal cord stimulation for adults with chronic neuropathic pain that has lasted at least 6 months despite conventional management, following multidisciplinary assessment and a successful trial. Dr Poply offers spinal cord stimulation for diabetic neuropathy and peripheral nerve stimulation for targeted nerve pain, and she discusses expected benefits and risks candidly, including infection, lead movement and the possibility of further procedures.
Living well with neuropathy
- Check your feet every day if you have numbness, and see a podiatrist promptly for any sore or blister.
- Wear well-fitting shoes and avoid walking barefoot.
- Stay as active as your balance allows. Gentle exercise helps circulation and mood.
- Speak to your GP about falls if your balance is affected.
- Sleep, low mood and worry often make nerve pain feel worse, and treating them is part of managing pain.
About your specialist
Dr Kavita Poply is a Consultant in Pain Medicine and Neuromodulation at St Bartholomew’s Hospital, London, and a Reader at Queen Mary University of London. Her clinical interests include diabetic and other peripheral neuropathy, and her practice includes spinal cord stimulation and peripheral nerve stimulation for refractory neuropathic pain.
Frequently asked questions
Q.1 What is the most common cause of peripheral neuropathy?
Ans. In the UK, diabetes is the most common cause, followed by alcohol, vitamin B12 deficiency, chemotherapy and other medical conditions. In a significant number of people no cause is found. Because some causes such as B12 deficiency are treatable, it is worth having the standard blood tests and a proper assessment.
Q.2 Can peripheral neuropathy be cured?
Ans. It depends on the cause. If the cause can be corrected early, for example B12 deficiency, nerves can sometimes recover. In diabetes, good glucose control helps slow further damage, though existing damage may not fully reverse. Even when the nerve damage is permanent, the pain can often be reduced with the right combination of treatments.
Q.3 What is the best medicine for neuropathic pain?
Ans. There is no single best medicine. NICE lists amitriptyline, duloxetine, gabapentin and pregabalin as initial options, and duloxetine is first choice for painful diabetic neuropathy. Each helps some people and not others, and side effects are common, so a structured trial with a clear review of benefit is important.
Q.4 Can spinal cord stimulation help painful diabetic neuropathy?
Ans. It may help selected people whose pain has not improved with medicines. The SENZA-PDN trial tested 10 kHz stimulation in 216 people with painful diabetic neuropathy. It was open-label and funded by the manufacturer, so results should be interpreted carefully. A trial with temporary leads lets you test the effect before a permanent device is fitted.
Q.5 When should I see a specialist for nerve pain?
Ans. See your GP first to look for treatable causes. A pain specialist referral is sensible when pain continues despite appropriate medicines, when side effects limit treatment, or when pain is affecting sleep, mood and daily life. Seek urgent help for rapidly spreading weakness or numbness, or for any foot ulcer if you have diabetes.