Practice points
Classification of spinal cord injury pain
The International Spinal Cord Injury Pain classification provides a standardized system to classify different types of spinal cord injury (SCI) pain. Common types of SCI pain are musculoskeletal, visceral or neuropathic (at-level or below-level).
SCI pain mechanisms
Nociceptive pain in SCI commonly occurs with musculoskeletal overuse during daily activities, mechanical strain associated with spinal deformity, abnormal postures or spasticity. Visceral pain arises from pathology in the thorax, abdomen or pelvis. The mechanisms of neuropathic SCI pain overlap and include structural and functional changes in the spinal cord close to the site of injury, as well as in the periphery, thalamus and cortex.
Treatment of SCI pain
Management of musculoskeletal pain involves pharmacological treatment to provide symptomatic relief of pain and inflammation as well as correction of the underlying mechanical factors. Management of visceral pain is primarily based on finding and treating the underlying cause. First-line agents for the management of neuropathic pain include the anticonvulsants, pregabalin or gabapentin alone or in combination with a tricyclic antidepressant such as amitriptyline. Second-line agents include adding a weak opioid medication or substituting an serotonin noradrenaline reuptake inhibitor for a tricyclic antidepressant. Strong opioid medications are controversial and used as third-line agents. The role of other invasive treatments is limited to a subset of patients, where evidence is poor and efficacy tends to decrease over time when initially successful. A delayed onset of at-level neuropathic pain may be associated with syrinx formation and a red flag, particularly in presence of an ascending sensory level with or without loss of motor function, which requires prompt investigation with a MRI scan. As with chronic pain in other contexts, the management of chronic intractable pain after SCI requires a multidisciplinary team approach incorporating medical, physical, educational and cognitive-behavioral components to enable self-management.
Conclusion
We still have a long way to go in our understanding of pain following SCI and providing effective treatment. There are advances in the pipeline that offer promise for the future.
Pain is a common problem for people following a spinal cord injury (SCI). Not only does it occur frequently, but often is severe impacting negatively on physical function, mood, social participation and quality of life (QoL). Several well-defined types of...
