DN4 Questionnaire

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The Douleur Neuropathique 4 (DN4) questionnaire is a diagnostic tool used to identify and assess neuropathic pain. Neuropathic pain arises from a lesion or dysfunction in the somatosensory nervous system (e.g., due to diabetes, multiple sclerosis, or postherpetic neuralgia). The questionnaire aims to measure the presence of symptoms and signs commonly associated with neuropathic pain.

It was developed by French neurologist Bouhassira et al. (2005) and the French Neuropathic Pain Group in 2005. This tool was administered to 160 patients who were presenting with pain related to a specific somatic or neurological lesion in a prospective trial. It became apparent that only 10 items were sufficient to distinguish neuropathic pain. The 10 items were grouped under 4 questions.

Since the DN4 is a short, simple screening tool designed to help distinguish neuropathic pain from other types of pain, such as nociceptive pain, the questionnaire is easy and rapid to administer. Both patient’s sensory descriptors and therapist’s examination sensory examination at the bedside are considered in the questionnaire.

The DN4 is specifically designed to detect neuropathic pain. The use of the DN4 questionnaire in the diagnostic pathway for patients with possible neuropathic pain received a strong recommendation by the Joint European Academy of Neurology-European Pain Federation-Neuropathic Pain Special Interest Group of the International Association for the Study of Pain task force group (Truini et al. 2023).

Validity and Reliability

The DN4 has been validated in multiple studies and languages (Van Seventer et al. 2010; Unal-Cevik et al. 2010; Perez et al. 2007). The DN4 has demonstrated good test-retest reliability and inter-rater reliability in various studies. This means that the questionnaire yields consistent results when administered multiple times or by different assessors.

The DN4 questionnaire demonstrated “excellent” diagnostic ability with an area under the ROC curve of 0.89 (95% CI: 0.83-0.95). Based on the optimal cutoff values, the DN4 had the highest sensitivity and lowest specificity in discriminating between neuropathic and nonneuropathic patients (Abolkhair et al. 2021). It has high diagnostic accuracy for identifying neuropathic pain. The tool has shown sensitivity of around 89% and a specificity of around 77%. The PPV was found to be 92% and the NPV lies at 69% (Abolkhair et al. 2021).

Scoring and Interpretation

The questionnaire consists of 10 items, and it covers sensory descriptors and clinical examination findings:

7 items are related to the patient’s description of their pain (such as burning, painful cold, electric shocks, tingling, pins and needles, numbness, itching).
3 items are based on the sensory examination performed by the clinician, focusing on touch and pinprick hypoesthesia and brush-induced allodynia.

The DN4 is scored out of 10 points. Each “yes” answer is scored as 1 point. Each “no” answer is scored as 0 points. A score of 4 or more suggests the presence of neuropathic pain. A score of 3 or below indicates that neuropathic pain is unlikely.

It seems important to evaluate the presence of neuropathic pain characteristics preoperatively, since Misir et al. 2021 showed that a preoperative DN4 score ≥4 was found to be associated with prolonged pain and analgesic use post rotator cuff repair (Misir et al. 2021).