Pain management in spinal cord injury

Chronic neuropathic pain is a complicated condition after a spinal cord injury (SCI) that often has a lifelong and significant negative impact on life after the injury; therefore, improved pain management is considered a significant and unmet need. Longitudinal studies indicate that ‘at-level’ pain has an early onset while ‘below-level’ pain develops months to years after the spinal injury. There are some specific clinical manifestations in SCI, which are paradoxical hypoalgesia, mitempfndung, and alloesthesia. The primary goal of treatment would be improvement in quality of life and the secondary goal would be pain reduction. Pharmacological treatment is very similar to the other types of neuropathic pain, which consists of the antiepileptics, tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, opioids, ketamine and lidocaine infusions. Interventional treatments are neuromodulation, spinal cord stimulation, deep brain stimulation, intrathecal delivery pumps (baclofen, morphine, clonidine, ziconotide) and ablative therapy. It is important to be able to classify the SCI into complete and incomplete injury according to the American Spinal Injury Association (ASIA) Impairment Scale. In addition, the neuropathic pain of SCI should be classified as ‘at-level’ and ‘below-level’ neuropathic pain. Usually patients with incomplete injury and ‘at-level’ neuropathic pain (if pain mechanism would not be central) may benefit from interventional treatments.