Pain management in spinal cord injury

Pain following spinal cord injury (SCI) is common and includes a spectrum of pain types, which can affectfunction across the physical, psychological, and social domains. Chronic neuropathic pain is a complicatedcondition after a SCI that often has a lifelong and significant negative impact on life after the injury. The majorityof individuals with SCI (۷۵%) have pain and experience at least two different distinct types of pain with manyreporting three or more.Neuropathic pain (NP) is classified into 'at-level' and 'below-level' NP. 'at-level' NP has an early onset while'below-level' NP develops months to years after the SCI. It is usually difficult to distinguish between the twosubcategories of 'at-level' SCI pain, spinal cord pain and radicular pain, because both are typically involved inany traumatic SCI and may have the exact same clinical presentation. There are some specific clinicalmanifestations 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 painreduction. Pharmacological treatment consists of antiepileptics, tricyclic antidepressants, serotoninnorepinephrinereuptake inhibitors, opioids, ketamine, baclofen, tizanidine, dantrolene, botulinum toxin, andlidocaine infusions. Interventional treatments are neuromodulation, spinal cord stimulation, deep brainstimulation, 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 AmericanSpinal Injury Association Impairment Scale. Usually patients with incomplete injury and 'at-level' neuropathicpain (if pain mechanism would not be central) may benefit from interventional treatments.