Pain management in spinal cord injury

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Pain management in spinal cord injury

• Kazuko L. Shem, M.D.
• Physical Medicine Rehabilitation
• Santa Clara Valley Medical Center
• www.scvmed.org

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SCVMC
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Incidence of pain

• 65 - 95 of SCI individuals experience pain
• 50 musculoskeletal
• 30 neurogenic
• 5-45 experience severe disabling pain

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Incidence of pain

• More common in patients with
• Injuries due to gunshot wounds and violence
• Lower level of injury
• Incomplete SCI?
• Spasticity

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Psychosocial factors

• Depression / Sadness
• Adjustment disorders
• Anger
• Anxiety
• Stress

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Patient evaluation

• Detailed history
• quality of pain
• distribution of pain
• relieving factors
• aggravating factors
• Physical examination
• Diagnostic tests

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Pain syndrome classification

• Musculoskeletal
• Neuropathic
• Visceral

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Pain classification

• Above the level
• At the level
• Below the level

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Musculoskeletal pain syndrome

• Bone, joint, muscle trauma
• Tendon inflammation
• Muscle spasm
• Overuse syndrome
• Instability of spine

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Vertebral column pain

• Neck, middle back, low back pain
• Spine deformities
• Arthritis
• X-rays
• evaluate instrumentation placement
• evaluate degenerative changes

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Mechanical instability of spine

• Most common after cervical spine injury
• Due to injury to ligaments, fx of spine
• Pain around the spine

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Treatment for mechanical instability of spine

• Relieved by immobilization
• Rest, bracing
• Medications
• Anti-inflammatory medication
• Opiates
• Surgical fusion

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Trigger points
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Muscle spasm pain

• Pain with visible and palpable spasms
• Anti-inflammatory medications
• Anti-spasticity medications
• Baclofen
• Zanaflex
• Anti-spasm medications
• Flexeril, Robaxin, Skelexin

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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

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Shoulder pain

• 50-95 prevalence
• Secondary to
• Weight bearing
• Overuse
• Muscle imbalance

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Shoulder pain Differential diagnoses

• Rotator cuff tendinitis and tear
• Muscle pain
• Radiculopathy
• Arthritis

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Elbow / Hand pain

• Elbow pain (32)
• Hand pain (48)
• Differential diagnosis
• Epicondylitis / tendinitis
• Olecranon bursitis
• Arthritis
• CTS, Ulnar nerve entrapment

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Diagnostic tests

• Physical examination
• Plain x-ray
• MRI
• EMG

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Treatment options

• Rest
• Therapeutic exercises
• Modalities
• Changes in positioning, ergonomics
• Changes in equipment
• Splints
• Weight reduction

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Treatment options

• Anti-inflammatory medication
• Opioids
• Injections
• Acupuncture
• Surgical release for CTS

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Neuropathic pain

• Nerve root entrapment
• Syringomyelia
• Transitional zone pain
• Central dysesthesia syndrome
• Nerve entrapment syndrome

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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

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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

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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

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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

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Central pain syndrome

• Pain below the level of injury
• Constant
• Fluctuates with mood or activity
• Responds poorly to medications or other treatment

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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

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Pain description

• Tingling
• Shooting
• Stabbing
• Squeezing
• Pressure
• Cold
• Numbness
• Muscle cramp

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Exacerbating factors

• Noxious stimuli below the level of injury
• Fatigue
• Lack of distraction
• Smoking
• Psychological stress
• Overexertion
• Weather changes

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Nerve entrapment syndrome

• Carpal tunnel syndrome
• Ulnar nerve entrapment
• at the wrist
• across the elbow
• Radial nerve entrapment

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Nerve entrapment syndromerisk factors

• Use of assistive devices
• Routine pressure relief
• Weight shifts
• Transfers
• Wheelchair mobility

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Syringomyelia (Syrinx)

• Delayed onset, years
• New neurological deficits
• Constant, burning pain
• Pain to touch
• Diagnosed with MRI
• Treatment shunt

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Treatment

• Pharmacological
• Nerve blocks
• Physical
• Surgical
• Stimulation techniques
• Psychological
• Acupuncture

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Pharmacological treatment

• Anticonvulsants
• Antidepressants
• Alpha-adrenergic agonists
• Opioids
• Anti-spasticity medication

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Anti-seizure medications

• Carbamazepine (Tegretol)
• Valproate
• Gabapentin (Neurontin)
• Trileptal
• Topamax

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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

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Anti-spasticity medication

• Relief of muscle spasms
• Baclofen
• Clonazepam
• Dantrium

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Alpha adrenergic agonists

• Relief of neuropathic pain
• Clonidine
• Zanaflex

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Capsacin

• Topical
• Applied to skin overlying the painful area
• Deplete peptides that cause pain from nerve ending

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Opioids

• May be used in neuropathic pain
• Side effects
• Physical dependency
• Severe constipation
• Mild cognitive impairment
• Risk for addiction

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Therapy

• Positioning
• Modify transfer techniques
• Splinting
• Padded gloves / elbow pads
• Exercise routines

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Other interventions

• Acupuncture
• TENS unit
• Spinal cord stimulator
• Dorsal rhizotomy

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TENS unit

• Electrical stimulation on skin
• More effective at the level of injury?
• Requires a therapist for set-up

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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

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Surgical intervention

• Spine stabilization
• Removal of instrumentation
• Decompression of impinged nerve roots
• Decompression surgery for syrinx

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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

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Psychological treatment

• Psychological assessment
• Cognitive behavioral therapy
• Relaxation techniques
• Biofeedback
• Peer support

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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

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Visceral pain etiologies

• Kidney stones
• Bowel dysfunction (constipation)
• Appendicitis
• Gallbladder stones
• Gynecological

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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
• [phone], [phone]