POSITION PAPER
Neuropathic pain needs systematic classification
Accepted for publication
17 December 2012
doi:10.1002/j.1532-2149.2012.00282.x
Disease classification is of paramount importance in
medicine, because it shapes the way patients are
treated. Health statistics and health care policies,
insurance plans and the reimbursement of health care
providers for their services depend on an accurate and
unambiguous designation of diseases and clinical syn-
dromes. Neuropathic pain is a major epidemiological
problem and a therapeutic challenge; commonly per-
sisting for months or years, it requires chronic and, in
some patients, lifelong treatment (Baron et al., 2010).
Yet, despite its clinical significance and the costs asso-
ciated with neuropathic pain management, there is, to
date, no systematic classification of neuropathic pain,
and conditions associated with neuropathic pain are
under-represented in the International Classification
of Diseases (ICD) by the World Health Organization
(WHO), the most widely used source for disease codes
and classification (WHO, 2010).
Neuropathic pain is responsible for chronic pain
in up to 8% of the general population (Smith and
Torrance, 2012). Disorders commonly associated with
peripheral neuropathic pain include, e.g., diabetic
polyneuropathy, radicular back pain and post-herpetic
neuralgia; frequent causes of central pain are multiple
sclerosis, stroke and spinal cord injury (Baron et al.,
2010). The true prevalence of neuropathic pain is dif-
ficult to estimate, because neuropathic forms of cancer
pain, post-operative pain and even back pain are gen-
erally classified based on aetiology, without character-
izing them as pain caused by neural damage.
Neuropathic pain is, however, one of the most fre-
quent disorders for which patients are referred to
qualified specialists in pain management, pain clinics
or multidisciplinary centres for advanced diagnostic
evaluation and therapy. Establishing the neuropathic
nature of chronic pain may involve specific tests, e.g.,
nerve conduction studies to confirm the diagnosis of
polyneuropathy, or magnetic resonance imaging of
the brainstem to elucidate the cause of symptomatic
trigeminal neuralgia. Developing a treatment plan for
an individual patient with neuropathic pain can be a
protracted process. It is currently not possible to
predict the response to any particular analgesic so that
Eur J Pain 17 (2013) 953–956 © 2013 European Federation of International Association for the Study of Pain Chapters
each drug or combination of drugs, even if recom-
mended as first-line medication, has to be titrated and
tested over weeks. In the majority of patients, analge-
sic treatment provides only partial relief, reducing
quality of life and work productivity (Doth et al.,
2010; Finnerup et al., 2010; Attal et al., 2011;
Poliakov and Toth, 2011; Smith and Torrance, 2012).
The economic burden on health care systems and
society that results from the necessity of costly long-
term management and the loss of workforce produc-
tivity is substantial (Gore et al., 2006; Dworkin et al.,
2010). These distinct diagnostic and therapeutic
requirements should warrant adequate representation
of neuropathic pain in disease classifications, to
support documentation, enable the tracking of health
care expenses and facilitate epidemiological and clini-
cal research.
Considering the complex pathophysiology of
chronic pain, the often incomplete response to anal-
gesic treatment and its disabling consequences, the
European Federation of Chapters in the International
Association for the Study of Pain (IASP) and the Insti-
tute of Medicine of the National Academies in the
United States suggest recognizing chronic pain as a
disease in its own right (Niv and Devor, 2007; Institute
of Medicine, 2011). However, current classifications
assign diagnostic codes primarily based on aetiology,
not to clinical syndromes such as chronic pain, even
though the suffering from persistent pain may well
surpass the burden of other health effects. This risks
underdiagnosis and, as a consequence, underreporting
of conditions that manifest predominantly with pain-
related symptoms and signs.
The IASP has recently adopted a revised definition of
neuropathic pain as pain caused by a lesion or disease of
somatosensory system (Jensen et al., 2011). Guidelines
for grading the diagnostic certainty have been formu-
lated based on the neuroanatomical distribution of
symptoms, patient history and tests confirming the
underlying nervous system lesion or disease (Treede
et al., 2008). Recognizing a timely opportunity to
reflect on the classification of neuropathic pain, the
Special Interest Group on Neuropathic Pain (NeuPSIG)
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Neuropathic pain classification
Table 1 ICD-10 codes related to neuropathic pain (bold font) and examples of disorders for which neuropathic pain is not specified.
Chapter
Diseases of the nervous system
Diseases of the circulatory system
Symptoms, signs and abnormal clinical and laboratory findings,
not elsewhere classified
ICD, International Classification of Diseases.
a
Extracranial manifestations of post-zoster neuralgia are not classified.
of the IASP convened this group of pain specialists and
researchers to review currently used classifications of
diseases and comment on potential problems associ-
ated with the categorization of neuropathic pain.
The ICD, now in its 10th edition, sets the standard
for classifications of medical conditions (WHO, 2010).
The original intention behind the ICD was to create a
reference catalogue of diseases to facilitate the inter-
national comparison of mortality statistics, but the
classification soon became a defining list of all dis-
eases, including nonfatal disorders. ICD codes are
widely employed in epidemiology and support mul-
tiple aspects of health care management. The ICD
organizes diseases based on aetiology and the affected
organ or body region. Clinical entities and syndromes,
i.e., constellations of symptoms and signs, are orga-
nized in chapters and assigned alphanumerical codes.
Neurological conditions that primarily manifest as
neuropathic pain are rarely acknowledged as distinct
entities, e.g., trigeminal neuralgia (G50.0), post-
herpetic neuralgia with a cranial distribution (G53.0)
or phantom limb syndrome with pain (G54.6)
(Table 1). Instead, neuropathic pain has to be assigned
an unspecific code for pain together with the code of
the underlying disease, e.g., polyneuropathy (G60-64)
(Table 1). A separate chapter for Symptoms, signs and
abnormal clinical and laboratory findings, not elsewhere
classified contains generic codes for acute (R52.0) and
chronic (R52.1, R52.2) pain but no codes for neuro-
pathic pain.
ICD codes do not reflect the epidemiology of neu-
ropathic pain. Post-herpetic neuralgia is recognized as
a diagnosis only if cranial nerves are affected (G53.0),
although thoracic nerve roots are much more com-
monly involved. Pain may not be mentioned at all,
even if it is the most prominent symptom of a disease.
954 Eur J Pain 17 (2013) 953–956 © 2013 European Federation of International Association for the Study of Pain Chapters
N.B. Finnerup et al.
Disease/Symptom ICD-10 code
Trigeminal neuralgia G50.0
Disorders of cranial nerves G51-G53
Post-zoster neuralgiaa G53.0
Nerve root and plexus disorders/compressions G54-55
Phantom limb syndrome with pain G54.6
Polyneuropathies G60-64
Other specified peripheral vascular diseases
Erythromelalgia I73.8
Hyperesthesia R20.0
Chronic intractable pain R52.1
Other chronic pain R52.2
Pain, unspecified R52.9
The diagnosis of brachial plexus lesions (G54.0) or
sequelae of spinal cord injury (T91.3) does not allow
for the specification of pain, a major disabling compli-
cation of these disorders that requires long-term phar-
macological and physical treatment and special
attention during rehabilitation. Erythromelalgia is
classified as a peripheral vascular disorder (I73.8)
because it presents with episodes of erythema
(Table 1), but a hereditary variant of the disease is a
neuropathy caused by mutations of the SCN9A gene,
which encodes the voltage-gated sodium channel
subunit Nav1.7 (Dib-Hajj et al., 2010). This disease
variant, in which intense pain, not reddening, is the
leading symptom, is not specified. Other genetically
defined entities of neuropathic pain are also missing,
e.g., paroxysmal extreme pain disorder, channelopa-
thies associated with small-fibre neuropathy or famil-
ial episodic pain syndrome.
A comprehensive list of neurological diseases and
syndromes is provided in the neurological adaptation
(NA) of the ICD (van Drimmelen-Krabbe et al.,
1998), yet extensions to the original codes were
amended as fifth, sixth and seventh digits, e.g.,
G43.820 for abdominal migraine, preventing the cor-
rection of superseding misclassifications in the ICD.
The last edition of the ICD-NA was issued in 1997 and
is available in print only, severely compromising its
use.
The IASP has published an independent classifica-
tion of chronic pain, which differentiates between
peripheral and central neuropathic pain and catego-
rizes clinical entities by aetiology, affected body region,
organ, temporal characteristics, intensity and time
since onset (Merskey and Bogduk, 1994). Despite its
systematic approach, this classification has never been
widely employed, even by pain specialists.
N.B. Finnerup et al.
A successful example for an independent classifica-
tion of pain is the International Classification of Head-
ache Disorders (ICHD), which was quickly adopted by
the WHO and integrated into the ICD upon its 10th
revision (Headache Classification Subcommittee of the
International Headache Society, 2012). Here, a hierar-
chical structure that is easy to navigate organizes clini-
cal entities that are succinctly characterized by history
and clinical phenotype. Without explicitly labelling
them as neuropathic pain, the ICHD comprises disor-
ders such as trigeminal, glossopharyngeal or post-
herpetic neuralgia. Distinct diagnostic criteria ensure
unambiguous identification, although the criteria are
not consistent across the different neuropathic pain
conditions. Diagnostic utility and therapeutic rel-
evance have led to wide acceptance of the classifica-
tion among clinicians and researchers.
A similar comprehensive classification system for
disorders associated with neuropathic pain is needed
in order to provide specific and accurate diagnostic
codes for conditions that affect millions of patients.
Existing ICD codes should be amended in the upcom-
ing 11th revision of the WHO’s disease classification to
include disorders associated with neuropathic pain
that are currently missing, and correct inaccurate des-
ignations. We suggest introducing a separate code for
neuropathic pain, because it would allow accounting
for both primary neuropathic pain conditions and
neuropathic pain as a manifestation of diseases classi-
fied elsewhere, e.g., painful diabetic polyneuropathy.
The recent improvements of diagnostic criteria and the
availability of evidence-based guidelines for assess-
ment and treatment (Dworkin et al., 2007; Treede
et al., 2008; Haanpää et al., 2011) also provide a solid
foundation for developing a new, systematic classifi-
cation of neuropathic pain. Classification criteria
would have to follow aetiological categories, but
should integrate genetic factors and major phenotypi-
cal characteristics that are likely to reflect underlying
pain mechanisms (Dib-Hajj et al., 2010; Kremeyer
et al., 2010; Baron et al., 2012; Von Hehn et al., 2012).
Additional information may include a description of
specific investigations that are capable of increasing
diagnostic certainty, and expanded classification crite-
ria for research purposes. An independent classifica-
tion of neuropathic pain with utility for clinical
practice and research beyond diagnostic codes would
be likely to find broad support among clinicians, epi-
demiologists and pain researchers. Disease categories
should be designed compatible with the ICD to allow
for future integration.
Neuropathic pain is a major epidemiological problem
and an enormous therapeutic challenge that deserves
Eur J Pain 17 (2013) 953–956 © 2013 European Federation of International Association for the Study of Pain Chapters
Neuropathic pain classification
specific coding in disease classifications. Adequate rep-
resentation of the conditions associated with neuro-
pathic pain is necessary to ensure targeted allocation of
health care resources and further the implementation
of evidence-based treatment guidelines in primary and
specialist care. We encourage the pain community to
discuss the development of a systematic classification of
neuropathic pain and recognize its utility beyond a
catalogue of disease codes. We see an opportunity for
the IASP, as an institution committed to bringing
together scientists, clinicians and health care providers,
and an organization that represents national chapters
as well as regional and specialist organizations in the
pain field, to lead an effort to improve the coding of
neuropathic pain in existing disease classifications and
establish a new systematic classification for neuro-
pathic pain.
Acknowledgements
This work was initiated by the NeuPSIG of the IASP. N.B.F.,
N.A., R.B., M.H., S.N.R., A.S.C.R., D.M.S. and R.-D.T. are
members of the NeuPSIG Management Committee.
N.B. Finnerup1, J. Scholz2, N. Attal3, R. Baron4,
M. Haanpää5, P. Hansson6, S.N. Raja7, A.S.C. Rice8,
W. Rief9, M.C. Rowbotham10, D.M. Simpson11,
R.-D. Treede12
1 Danish Pain Research Center, Aarhus University,
Denmark
2 Departments of Anesthesiology and Pharmacology,
Columbia University College of Physicians and
Surgeons, New York, USA
3 Centre d’Evaluation et de Traitement de la
Douleur, Institut National de la Santé et de la
Recherche Médicale (Inserm) U-987, Hôpital
Ambroise Paré, Boulogne-Billancourt and Université
Versailles Saint-Quentin en Yvelines, Paris, France
4 Division of Neurological Pain Research and
Therapy, and Department of Neurology,
Universitätsklinikum Schleswig-Holstein,
Kiel, Germany
5 Department of Neurosurgery, Helsinki University
Central Hospital, Finland
6 Department of Molecular Medicine and Surgery,
Karolinska Institute, and Pain Center, Department of
Anesthesiology and Intensive Care, Karolinska
University Hospital, Stockholm, Sweden
7 Division of Pain Medicine, and Department of
Anesthesiology and Critical Care Medicine,
Johns Hopkins University School of Medicine,
Baltimore, USA
955
Neuropathic pain classification
8 Section of Anaesthetics, Pain Medicine and
Intensive Care, Faculty of Medicine, Imperial College
London, UK
9 Klinische Psychologie und Psychotherapie,
Philipps-Universität Marburg, Germany
10 California Pacific Medical Center Research
Institute, and Pain Clinical Research Center,
University of California San Francisco, USA
11 Department of Neurology, Mount Sinai School of
Medicine, New York, USA
12 Center for Biomedicine and Medical Technology
Mannheim and Medical Faculty, Heidelberg
University, Mannheim, Germany
Correspondence
Nanna Brix Finnerup
E-mail: finnerup@ki.au.dk
Conflicts of interest
The authors declare no conflicts of interest regarding
the topic of this commentary.
Author contributions
N.B.F. and J.S. contributed equally to the manuscript. All
authors contributed to the manuscript and provided
comments during the editing process.
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