Q&A: UCSF Neurosurgeon Line Jacques, MD on Neuropathic Pain

What is neuropathic pain?

Neuropathic pain is a condition related to nerve damage. It can be caused by injury, infection, and a number of diseases. In the United States, an estimated 1 in 10 people are affected by neuropathic pain. 

When should patients with chronic pain be seen for surgical evaluation?

After two years of chronic pain, it begins to have an impact on quality of life that is very difficult to treat and at ten years it is often irreversible. So the best time to be evaluated for surgery is six months to two years after the onset of chronic refractory pain.

Is that because chronic pain rewires neurological pathways in the brain?

I think that could be true, but it is not very well understood and a lot more research needs to be done in this area.

If it gets more difficult to treat the pain over time, why do many patients not see pain specialists earlier?

Sometimes neuropathic pain can be very difficult to diagnose and sometimes it’s a lack of knowledge about the therapies that are currently available. In other cases, a patient may slowly get better with medication, but not enough, and then you get into a vicious cycle in which the patient keeps getting higher doses of narcotics over a period of years without frequent enough reassessments, preventing them from moving to the next therapeutic modality. But there is more and more awareness about decreasing narcotics and using neuropathic drugs instead because narcotics are not useful for nerve pain. If patients don’t respond to neuropathic drugs within six months to a year, they might be surgical candidates. In particular, referrals for brachial plexus injury stretch avulsion can be much delayed, but surgery needs to be done quickly to provide better functional recovery. New studies also suggest that patients with complex regional pain syndrome need to be assessed and treated in the first 6 months of nerve injury if there is any hope of reversing or halting progression of their condition.

What is your approach to treating neuropathic pain with surgery?

You have to consider how the patient’s life will be changed by your surgery, and that means not just looking at motor recovery, but also considering the pain component. We could do a perfect nerve reconstruction, but if the patient can’t return to work or does not have a reasonable quality of life because they are still in pain, the surgery cannot be considered a success. If you look at your patient’s condition in its entirety, you will be able to provide a better outcome. I am very interested in functional outcomes, and using validated tools like questionnaires, which can often help us determine whether the patient can be managed with nonsurgical therapies, or if neuromodulation fits into their treatment. Most of these patients have been in chronic pain for a significant length of time before they navigate their way to our clinical program, which has a significant impact on their quality of life. Being able to manage their pain and return their quality of life is very rewarding for our team.

What lead you to specialize in pain and peripheral nerve surgery?

For me the nervous system has always been an interesting puzzle. Early in my career I pursued a master’s degree in neurophysiology and found that I loved doing surgeries in the lab. I knew I always wanted to be a physician, so combining medicine with surgery and my fascination with the human nervous system made neurosurgery a perfect fit. When I pursued my neurosurgical training, peripheral nerve surgery was perhaps the least developed area of neurosurgery leaving boundless opportunities. 

In the last decade, what have been major advances for peripheral nerve surgery, as it relates to treating chronic neuropathic pain?

Neuroimaging and nerve conduit technology have been the biggest developments in treating nerve injuries. In the future, I think we will see a lot of improvements with nerve transfers and the enhancement of nerve regeneration, which will come with a better understanding of the electrophysiology and the molecular biology.

Learn more about surgical treatment for pain disorders at UCSF.