Pain management in spinal cord

injury

Kazuko L. Shem, M.D.

Physical Medicine & Rehabilitation
Santa Clara Valley Medical Center
www.scvmed.org
SCVMC
 Incidence of pain

 65 - 95% of SCI individuals experience pain

 50% musculoskeletal
 30% neurogenic

 5-45% experience severe disabling pain

 Incidence of pain

 More common in patients with:

 Injuries due to gunshot wounds and violence
 Lower level of injury
 Incomplete SCI?
 Spasticity
 Psychosocial factors

 Depression / Sadness
 Adjustment disorders
 Anger
 Anxiety
 Stress
 Patient evaluation

 Detailed history
 quality of pain
 distribution of pain
 relieving factors
 aggravating factors
 Physical examination
 Diagnostic tests
 Pain syndrome classification

 Musculoskeletal

 Neuropathic

 Visceral
 Pain classification

 Above the level

 At the level

 Below the level

 Musculoskeletal pain syndrome

 Bone, joint, muscle trauma

 Tendon inflammation
 Muscle spasm
 Overuse syndrome
 Instability of spine
 Vertebral column pain

 Neck, middle back, low back pain

 Spine deformities
 Arthritis
 X-rays
 evaluate instrumentation placement
 evaluate degenerative changes
 Mechanical instability of spine

 Most common after cervical spine injury

 Due to injury to ligaments, fx of spine
 Pain around the spine
 Treatment for mechanical
instability of spine

 Relieved by immobilization
 Rest, bracing
 Medications
 Anti-inflammatory medication
 Opiates
 Surgical fusion
Trigger points
 Muscle spasm pain

 Pain with visible and palpable spasms

 Anti-inflammatory medications
 Anti-spasticity medications
 Baclofen
 Zanaflex
 Anti-spasm medications
 Flexeril, Robaxin, Skelexin
 Secondary overuse syndromes

 More common in paraplegics

 Pain in intact areas
 Delayed onset
 Shoulder pain: arthritis, tendinitis
 Pain from CTS, ulnar nerve entrapment
 Other arthritis
 Shoulder pain

 50-95% prevalence
 Secondary to:
 Weight bearing
 Overuse
 Muscle imbalance
Shoulder pain: Differential diagnoses

 Rotator cuff tendinitis and tear

 Muscle pain
 Radiculopathy
 Arthritis
 Elbow / Hand pain

 Elbow pain (32%)

 Hand pain (48%)
 Differential diagnosis
 Epicondylitis / tendinitis
 Olecranon bursitis
 Arthritis
 CTS, Ulnar nerve entrapment
 Diagnostic tests

 Physical examination

 Plain x-ray

 MRI

 EMG
 Treatment options

 Rest
 Therapeutic exercises
 Modalities
 Changes in positioning, ergonomics
 Changes in equipment
 Splints
 Weight reduction
 Treatment options

 Anti-inflammatory medication
 Opioids
 Injections
 Acupuncture
 Surgical release for CTS
 Neuropathic pain

 Nerve root entrapment

 Syringomyelia

 Transitional zone pain

 Central dysesthesia syndrome
 Nerve entrapment syndrome
 Nerve root pain / radicular

 Unilateral pain in the single nerve root

distribution
 At the level of spinal trauma
 Pain since the time of injury
 Lancinating, burning, stabbing, shooting,
paroxysmal, allodynia, hyperesthesia
 Case study
 49 YO male with C4-5 quadriplegia x 20 years
 Numbness and pain on the right side of his face
and neck when turning his head to the right
while driving and looking at a computer monitor
 Physical Examination:
 Trigger point in the right upper cervical PSM
 Symptom reproduction with head turning to the R
 Case study

 MRI:
 C2-3 posterior osteophytes causing right-sided
foraminal narrowing
 Treatment
 NSAIDs
 Trigger point injection
 Instructed patient to reposition the computer
monitor to midline
 Transitional zone pain

 At the border of normal sensation and numb

skin
 Bilateral
 Burning, aching, allodynia, tingling
 Pain within first few months of injury
 Injury to the gray matter of dorsal horn
 Central pain syndrome

 Pain below the level of injury

 Constant

 Fluctuates with mood or activity

 Responds poorly to medications or other
treatment
 Pathophysiology of neuropathic pain

 “Imbalance hypothesis”
 Imbalance between dorsal column and
spinothalamic tracts
 “Pattern-generating mechanism” and “loss of
spinal inhibitory mechanisms”
 Loss of inhibitory control
 Focal hyperactivity in the spinal cord and
thalamus
 Pain description
 Tingling
 Shooting
 Stabbing
 Squeezing
 Pressure
 Cold
 Numbness
 Muscle cramp
 Exacerbating factors

 Noxious stimuli below the level of injury

 Fatigue
 Lack of distraction
 Smoking
 Psychological stress
 Overexertion
 Weather changes
 Nerve entrapment syndrome

 Carpal tunnel syndrome

 Ulnar nerve entrapment
 at the wrist
 across the elbow
 Radial nerve entrapment
 Nerve entrapment syndrome:
risk factors

 Use of assistive devices

 Routine pressure relief
 Weight shifts
 Transfers

 Wheelchair mobility
 Syringomyelia (Syrinx)

 Delayed onset, years

 New neurological deficits
 Constant, burning pain
 Pain to touch
 Diagnosed with MRI
 Treatment: shunt
 Treatment

 Pharmacological
 Nerve blocks
 Physical
 Surgical
 Stimulation techniques
 Psychological
 Acupuncture
 Pharmacological treatment

 Anticonvulsants

 Antidepressants

 Alpha-adrenergic agonists
 Opioids

 Anti-spasticity medication
 Anti-seizure medications

 Carbamazepine (Tegretol)
 Valproate
 Gabapentin (Neurontin)
 Trileptal
 Topamax
 Antidepressants

 Tricylic antidepressants: amitriptyline (Elavil),

nortriptyline, imipramine, desipramine
 Effective in neuropathic pain
 Increase pain inhibitory mechanisms
 May be used in combination with anti-seizure
medication
 Anti-spasticity medication

 Relief of muscle spasms

 Baclofen

 Clonazepam

 Dantrium
 Alpha adrenergic agonists

 Relief of neuropathic pain

 Clonidine

 Zanaflex
 Capsacin

 Topical

 Applied to skin overlying the painful area

 Deplete peptides that cause pain from
nerve ending
 Opioids

 May be used in neuropathic pain

 Side effects
 Physical dependency
 Severe constipation
 Mild cognitive impairment
 Risk for addiction
 Therapy

 Positioning

 Modify transfer techniques

 Splinting

 Padded gloves / elbow pads

 Exercise routines
 Other interventions

 Acupuncture

 TENS unit
 Spinal cord stimulator
 Dorsal rhizotomy
 TENS unit

 Electrical stimulation on skin

 More effective at the level of injury?
 Requires a therapist for set-up
 Spinal cord stimulator

 Not generally helpful with SCI pain

 More effective with transitional zone or
radicular pain
 Initial improvement in 20-75% of patients
 Long term efficacy in 10-40%
 Surgical intervention

 Spine stabilization
 Removal of instrumentation
 Decompression of impinged nerve roots
 Decompression surgery for syrinx
 Dorsal root rhizotomy

 May be more effective in radicular pain

or neuropathic pain at the level of injury
 Risks of cerebrospinal fluid leaks,
sensory or motor level changes
 Psychological treatment

 Psychological assessment
 Cognitive behavioral therapy
 Relaxation techniques
 Biofeedback

 Peer support
 Visceral pain

 Above, at or below the level of injury

 Poorly localized if at or below the LOI
 Non-specific symptoms:
 Nausea, vomiting, anorexia
 Autonomic dysreflexia
 Fever
 Visceral pain etiologies

 Kidney stones
 Bowel dysfunction (constipation)
 Appendicitis

 Gallbladder stones
 Gynecological
 Contact Information

Kazuko Shem, MD
Nancy Jorgensen, NP
Santa Clara Valley Medical Center
Physical Medicine & Rehabilitation
2400 Moorpark Avenue, Suite 100
San Jose, CA 95128
(408)885-5920, (800)314-4611