6. Pharmacological Management of Neuropathic Pain

Actionable Nuggets for SCI (2nd ed., 2013)

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

The Problem:

Evidence-based Best Practice:

Stepwise pharmacological management of neuropathic pain is as follows:

• First-line agents –> Gabapentin, Pregabalin
• Second-line agents –> Serotonin noradrenalin re-uptake inhibitors, topical lidocaine
• Third-line agents –> Controlled-release opioid analgesics, tramodol
• Fourth-line agents –> Lamotrigine, topiramate, valproic acid, cannabinoids, methadone

Randomized controlled trials (RCTs) have shown that the anti-convulsants Gabapentin and Pregabalin are effective in the management of neuropathic pain in most individuals with SCI . Trials of serotonin noradrenalin reuptake inhibitors (SNRIs) have reduced neuropathic pain, although there is no direct evidence in individuals with SCI. Topical lidocaine has been shown to be effective in the management of localized neuropathic pain. Tramadol and other opioids have been shown to offer pain relief for some individuals with post-SCI neuropathic pain. The fourth line agents have produced mixed results in neuropathic pain trials although there are no studies in individuals with SCI. Tricyclic antidepressants ( eg., amitriptyline, nortriptyline) have shown mixed results for pain management in this population.

Pain in many individuals with SCI is refractory to pharmacological agents. Neuropathic pain has been shown to be generally poorly treated in the community, and a case is made in the literature for referral to tertiary pain clinics for those with refractory pain, and multidimensional pain management including alternative and complementary therapies.

Key reference:

    Teasell, R.W., Mehta, S., Loh, E., Wolfe, D.L., Hsieh, J.T.C., & Short, C. (2012). Pain following spinal cord injury. In Eng., J.J., Teasell, R.W., Miller, W.C., Wolfe, D.L., Townson, A.F., Hsieh, J.T.C., Connolly, S.J., et al. editors. Spinal Cord Injury Rehabilitation Evidence. Version 4.0.

Additional references:

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    Ahn, S.H., et al. (2003). Gabapentin effect on neuropathic pain compared among patients with spinal cord injury and different durations of symptoms. Spine, 28(4): 341-346.
http://dx.doi.org/10.1097/00007632-200302150-00005
    Amr, Y. M. (2010). Multi-day low dose ketamine infusion as adjuvant to oral gabapentin in spinal cord injury related chronic pain: A prospective, randomized, double blind trial. Pain Physician, 13(13): 245-249.
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http://dx.doi.org/10.1097/01.BRS.0000112068.16108.3A
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http://dx.doi.org/10.1097/AJP.0b013e31818a744d
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    Perrouin-Verbe, B., Ventura, M., Albert, T., Souan, P., Fattal, C., & Revel, M. (2009). Clinical practice guidelines for chronic neuropathic pain in the spinal cord injury patient: introduction and methodology. Annals of Physical & Rehabilitation Medicine, 52(2): 77-82.
    Previnaire, J. G., Nguyen, J. P., Perrouin-Verbe, B., & Fattal, C. (2009). Chronic neuropathic pain in spinal cord injury: efficiency of deep brain and motor cortex stimulation therapies for neuropathic pain in spinal cord injury patients. Annals of Physical & Rehabilitation Medicine, 52(2): 188-193.
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