6. Pharmacological Management of Neuropathic Pain

Use a step-wise evidence-based protocol for the management of neuropathic pain in SCI, and review pain management annually.

The Problem

It is estimated that neuropathic pain affects 40% to 75% of individuals with spinal cord injury (SCI). Neuropathic pain in SCI can result from nerve root damage, spinal cord damage or syringomyelia. Pain can manifest at or below the level of lesion. Pharmacological management of pain in SCI must take into account: polypharmacy for other SCI-related complications; altered pharmacokinetics due to SCI; effect of pharmacological interventions on function and fatigue; effect of inadequately treated pain on functioning and quality of life

Evidence-based Best Practice

Stepwise management of neuropathic pain is as follows:

  1. First-line agents –> pregabalin, gabapentin, amitriptyline (particularly if depression is also present)
  2. Second-line agents –> tramadol, lamotrigine
  3. Third-line agents –> transcranial direct current stimulation
  4. Fourth-line agents –> transcutaneous electrical nerve stimulation oxycodone, dorsal root entry zone procedure

There is mixed evidence for cannabinoids, botulinum toxin and baclofen.
There is no evidence in favour of clonidine (alone), mexiletine, levetiracetam, valproic acid, trazadone, duloxetine.

Neuropathic pain has been shown to be generally poorly treated in the community, and many individuals with SCI experience pain that is refractory to pharmacological agents. For those with refractory pain, referral to a tertiary pain clinic may be advised, for multidimensional pain management including cognitive/psychological therapies and alternative/complementary modalities

Key Reference

Loh, E., Guy, S. D., Mehta, S., Moulin, D. E., Bryce, T. N., Middleton, J. W., … & Kras-Dupuis, A. (2016). The CanPain SCI clinical practice guidelines for rehabilitation management of neuropathic pain after spinal cord: introduction, methodology and recommendation overview. Spinal Cord, 54(S1), S1.

Mehta, S., Guy, S. D., Bryce, T. N., Craven, B. C., Finnerup, N. B., Hitzig, S. L., … & Côté, I. (2016). The CanPain SCI clinical practice guidelines for rehabilitation management of neuropathic pain after spinal cord: screening and diagnosis recommendations. Spinal Cord, 54(S1), S7.

Actionable Nuggets (4th ed., 2019)

Additional References (since 2016)

Mehta, S., McIntyre, A., Janzen, S., Loh, E., Teasell, R., & Spinal Cord Injury Rehabilitation Evidence Team. (2016). Systematic review of pharmacologic treatments of pain after spinal cord injury: An update.Archives of Physical Medicine and Rehabilitation, 97(8), 1381-1391.e1. doi:10.1016/j.apmr.2015.12.023

Gwak, Y. S., Kim, H. Y., Lee, B. H., & Yang, C. H. (2016). Combined approaches for the relief of spinal cord injury-induced neuropathic pain.Complementary Therapies in Medicine, 25, 27-33. doi:10.1016/j.ctim.2015.12.021

Ogawa, S., Arakawa, A., Hayakawa, K., & Yoshiyama, T. (2016). Pregabalin for neuropathic pain: Why benefits could be expected for multiple pain conditions.Clinical Drug Investigation, 36(11), 877-888. doi:10.1007/s40261-016-0423-x

Kramer, J. L. K., Minhas, N. K., Jutzeler, C. R., Erskine, E. L. K. S., Liu, L. J. W., & Ramer, M. S. (2017). Neuropathic pain following traumatic spinal cord injury: Models, measurement, and mechanisms.Journal of Neuroscience Research, 95(6), 1295-1306. doi:10.1002/jnr.23881

Chen, F., Shao, H., & Han, F. (2018). A pilot study of neuromuscular electrical stimulation for neuropathic pain caused by spinal cord injury.Medicine, 97(31), e11658. doi:10.1097/MD.0000000000011658

Agarwal, N., & Joshi, M. (2017). Effectiveness of amitriptyline and lamotrigine in traumatic spinal cord injury-induced neuropathic pain: A randomized longitudinal comparative study.Spinal Cord, 55(2), 126-130. doi:10.1038/sc.2016.123

Han, Z., Song, D. H., Oh, H., & Chung, M. E. (2016). Botulinum toxin type A for neuropathic pain in patients with spinal cord injury.Annals of Neurology, 79(4), 569-578. doi:10.1002/ana.24605

Nagoshi, N., Kaneko, S., Fujiyoshi, K., Takemitsu, M., Yagi, M., Iizuka, S., . . . Nakamura, M. (2016). Characteristics of neuropathic pain and its relationship with quality of life in 72 patients with spinal cord injury.Spinal Cord, 54(9), 656-661. doi:10.1038/sc.2015.210

Widerström-Noga, E., Felix, E. R., Adcock, J. P., Escalona, M., & Tibbett, J. (2016). Multidimensional neuropathic pain phenotypes after spinal cord injury.Journal of Neurotrauma, 33(5), 482-492. doi:10.1089/neu.2015.4040