DN4 Outperforms In Diagnosis of Cancer Neuropathy

Douleur Neuropathique in 4 Questions (DN4) proved more sensitive to neuropathic pain in cancer than the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) – 87.5% for DN4 versus 68.1% for LANSS in sensitivity. However LANSS had slightly better specificity – 93.4% for LANSS versus 88.4% for DN4 – not that much difference though. I have always like the LANSS but this suggest the DN4 might be a better tool.

Eur J Pain. 2015 Jul;19(6):752-61. doi: 10.1002/ejp.598.
Prevalence of pain and relative diagnostic performance of screening tools for
neuropathic pain in cancer patients: A cross-sectional study.
Pérez C(1), Sánchez-Martínez N, Ballesteros A, Blanco T, Collazo A, González F,
Villoria J

  • 285 cases
  • About   1/3 of cancer victims had no pain

Of those in pain almost 2/3 were nociceptive with:

  • 20%  neuropathic and 17.5% mixed – a little over 1/3 having some neuropathic features

Reliability ratings:

  • sensitivity – 87.5% for DN4 versus 68.1% for LANSS .
  • specificity – 93.4% for LANSS versus 88.4% for DN4.

The DN4 is available easily on the web. Here is one version I saw:

Diagnosing Neuropathic Pain – DN4 Questionnaire

Please complete this questionnaire by ticking one answer for each item in the 4 questions below.

Question 1: Does the pain have one or more of the following characteristics?

1: Burning Yes No
2: Painful Cold Yes No
3: Electric Shocks Yes No

Question 2: Is the pain associated with one or more of the following symptoms in the same area?

4: Tingling Yes No
5: Pins and Needles Yes No
6: Numbness Yes No
7: Itching Yes No

Examination Of The Patient

Question 3: Is the pain located in an area where the physical examination may reveal one or more of the following characteristics?

8: Hypoesthesia to touch Yes No
9: Hypoesthesia to prick Yes No

Question 4: In the painful area, can the pain be caused or increased by:

10: Brushing ? Yes No


  • Score 1 to each YES answer
  • Score 0 to each NO answer
  • If the score is 4 or higher then the pain is likely to be neuropathic pain.
  • If the score is less than 4 then the pain is unlikely to be neuropathic pain

It relies heavily on

  • neuropathic pain (burning, painful cold)
  • neuralgic pain (shooting)
  • nerve loss(tingling, pins and needles and finding of numb patches on touching or pricking)
  • Hyperpathia –  a form or hypersensitivity that is painful – a painful sensation to brushing

Another recent study got similar results:
Comparing the DN4 tool with the IASP grading system for chronic neuropathic pain screening after breast tumor resection with and without paravertebral blocks: a prospective 6-month validation study
Faraj W. Abdallah et al
Pain 156(4) (2015) 740–74

  •  DN4  estimated at 90% sensitivity and 60% specificity


Comment – I have always been a bit uncomfortable requiring numbness in cases in which pain is severe but it is my number one scale now. However not all cases are going to be neuropathic sac michael kors soldes sac michael kors soldes

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