New insight into RNA biomarkers in neuropathic pain: a clinician-neuroscientist roadmap to translational testing and treatment monitoring a clinical review.

Neuropathic pain affects an estimated 7%-10% of the global population and imposes an annual economic burden exceeding $600 billion in the United States alone. It lacks robust objective biomarkers; current diagnosis relies heavily on subjective reporting and heterogeneous phenotypes. Currently utilized pain assessment tools include the brief pain inventory (BPI), numerical rating scales (0-10 pain scores), and the visual analog score (VAS), which depend on patient-reported outcomes and are influenced by social, psychological and contextual factors. This subjectivity contributes to heterogeneous phenotyping and variability (>30%) towards the treatment response. Emerging transcriptomic and epitranscriptomic evidence suggests that RNA-based biomarkers may offer a biologically sound and objective approach to understanding and managing pain by capturing underlying molecular mechanisms. Therefore, the present clinical review focused on RNA biomarker classes (mRNA, miRNA, lncRNA, RNA editing, RNA modifications) and proposes a clinically deployable testing system for diagnosis, stratification, and treatment monitoring, since there are no FDA-approved RNA-based biomarkers for pain. Therefore, this review synthesizes evidence from immune-cell transcriptomic meta-analysis (TCL1A/ERAP2), dorsal root ganglion (DRG) and central nervous system gene expression patterns (EFNB2, GABBR1, NCAM1, SCN11A)/brain genetic architecture via single-cell omics integration, and atlas-driven frameworks, like iPain single-cell atlas of pain chronification and nociceptor senescence. Additional sources include studies on RNA editing mediator adenosine deaminase acting on RNA2 (ADAR2), clinical and translational evidence supporting miRNA biomarkers, and lncRNA axes (NEAT1/miR-183-5p; H19/miR-141) as tissue-specific regulatory nodes. Additionally, m6A epitranscriptomic modifications regulated by the METTL3/METTL14 writer complex and FTO/ALKBH5 erasers, with site-specific methylation of GRIN2B mRNA shown to upregulate GluN2B in dorsal horn neurons and augment central sensitization. These biomarkers also demonstrate potential utility as pharmacodynamic readouts in drug and neuro-modulation trials. Additionally, an emerging RNA workflow technology pathway leveraging rapid low-input RNA based assays was also explained. All evidence supports the idea that these biomarkers can provide complementary insight into the mechanisms underlying pain. Although current evidence supports the feasibility of RNA-based biomarkers as indicators of key biological processes, however, the current pain biology score remains at the theoretical model stage and has not been validated through