Pain Management in Spinal Cord Injury

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Pain

According to the International Association for the study of Pain (IASP), pain can be defined as "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage,”

The prevalence of chronic pain after spinal cord injury varies from 34-90 % and among them 2/3rd of the patient suffer from chronic pain.

Classification of pain

According to the International Spinal Cord Injury Pain Classification (ISCIPC), pain in Spinal Cord Injury (SCI) can be systematically classified into three tiers:

• The first tier (Tier 1) is classifying pain as nociceptive pain, neuropathic pain, other pain, and unknown pain.
• The second tier (Tier 2) classifies various subtypes of pain under the category neuropathic and nociceptive pain.
• The third tier (Tier 3) specifies the primary pain source at the organ level as well as the pathology if either is known. This tier also includes the pain or syndromes which do not fulfill the criteria for nociceptive or neuropathic pain.

Nociceptive pain

Nociceptive pain is those arriving from a noxious stimulus through nociceptors (peripheral nerve endings or sensory receptors). Nociceptive pain can be further classified as musculoskeletal pain, visceral pain, and other types of pain.

Musculoskeletal pain can be defined as pain occurring in parts of the body with preserved sensation and that is due to nociceptors within musculoskeletal structures(muscles, tensors, lig, joints, bones). Musculoskeletal pain can occur below the Neurological Level of Injury (NLI). Musculoskeletal pain can be characterized by one or more of the following features:

• Pain intensity is affected by the movement or change in position
• On palpation, the musculoskeletal structures affected are tender
• Pain presentation matches with the imaging findings
• Endorsement of pain descriptors "dull" or "aching"
• Improvement in pain intensity from the use of anti-inflammatory or opioid medications

Note: If the pain is located below the neurological level and there is the failure of pain response to treatment and evidence shows no musculoskeletal pathology, it can be indicative of neuropathic pain.

Example of musculoskeletal pain includes pain occurring from joint arthritis, fracture pain,muscle and tendon injury, muscle spasms.

Visceral pain is pain generated in visceral structures located usually in the thorax, abdomen, and pelvis. The presence of visceral pain can be characterized by one or more of the following features:

• Temporal relationship of food intake or visceral functions (for example constipation)
• Tenderness present over the visceral organ during palpation
• Pain presentation matches with the imaging findings
• Endorsement of one or more of the following pain descriptors"cramping", "dull", or "tender"
• Associated nausea and vomiting

An example includes pain resulting from constipation, urinary tract infection, ureteral calculus, bowel impaction, cholecystitis and myocardial infarction.

Other pain (nociceptive pain)refers to nociceptive pain other than the musculoskeletal or visceral type of pain. These pains may be indirectly linked with the SCI or may be unrelated to SCI. Example of the pain includes pain from pressure sores, autonomic dysreflexia, migraine.

Neuropathic pain

The neuropathic type of pain is the pain initiated or caused by the primary lesion/ dysfunction of the nervous system. It can be classified as below level SCI pain, at-level SCI pain,and other neuropathic pain.

At-level SCI (neuropathic) pain is experienced in a segmental pattern anywhere within the dermatome of the NLI and/or within three dermatomes below this level and not in any lower dermatomes. If the pain is found to extend one dermatome above the NLI, it still can be classified as at-level neuropathic pain. At-level SCI pain may arise from pathology in two different sites 1) the spinal cord, where the trauma is to the central somatosensory system and 2) the nerve roots where the trauma is to the peripheral somatosensory system.The at-level SCI pain can be characterized as:

• Sensory deficits within the pain distribution
• Allodynia or hyperalgesia within pain distribution
• Endorsement of one or more of the following pain descriptors: hot burning, tingling, pricking, pins and needles, sharp, shooting, squeezing, painful cold, and electric shock-like

Below-level SCI (neuropathic) pain is experienced in more than three dermatomes below the dermatome of NLI. The most important character of below-level SCI pain is that the pain must be because of a lesion/disease affecting the spinal cord. Below-level SCI pain can be characterized by the presence of the following features:

• Sensory deficits within the pain distribution
• Allodynia or hyperalgesia within the pain distribution (for persons with incomplete injury)
• Endorsement of one or more of the following pain descriptors: ‘hot-burning’, ‘tingling’, ‘pricking’, ‘pins and needles’, ‘sharp’, ‘shooting’, ‘squeezing’, ‘painful cold’ and ‘electric shock-like’

Other (neuropathic) pain is defined as pain that is experienced above, at, or below the NLI but pathologically is not related to SCI. Some example includes postherpetic neuralgia, pain associated with diabetic neuropathy, or a compressive mononeuropathy, central stroke pain, pain from multiple sclerosis. Pain that occurs at or below the NLI but is clearly attributable to nerve root avulsion should also be classified as other (neuropathic) pain.

Other pain

Other pain or dysfunctional pain is defined as pain that occurs when there is no identifiable noxious stimulus nor any detectable inflammation or damage to the nervous. Pain should be categorized in this category if the pain is unrelated to the underlying SCI both temporally and mechanistically. Pain should not be classified in this category if pain appears soon after SCI with neuropathic and nociceptive qualities and associated profound autonomic changes localized to the level of injury. Examples of Other pain include Complex Regional Pain Syndrome type I, interstitial cystitis pain, irritable bowel syndrome pain, and fibromyalgia.

Unknown

Unknown pain is the type of pain that cannot be assigned with any degree of certainty to the category: nociceptive, neuropathic, and other. For pains that seem to have both nociceptive and neuropathic qualities, the two components should be classified separately using the appropriate nociceptive, neuropathic, or other subtypes. Defined pain syndromes of unknown etiology (for example, fibromyalgia) should be coded as ‘Other pain and not Unknown pain’.

Diagnosing and assesing the pain

A multidimensional approach is required for the proper diagnosis and assessment of the condition. While assessing the patient, a full review and detailed knowledge about his/her life in the past 12 months will be helpful. Clinical assessment includes the following process :

1. History taking
2. Examination
3. Psychological assessment

Management of pain

There are various pharmacological and non-pharmacological treatment strategies for pain management in SCI. Successful management of pain in SCI depends on proper identification of factors contributing to or modifying pain perception. The management team should be multidisciplinary and while setting the goal, it should be developed collaboratively with the individual prior to making management strategies for an effective multimodal approach.

Pharmacological management

Nociceptive pain

For the management of nociceptive pain, simple analgesics like NSAIDs and opioids are more likely to be effective. For visceral pain, proper investigation for pathology must be done prior to starting the analgesics. Opioids have a major side effect as constipation in SCI patients so, one should be careful before using opioids. As a general principle, short acting and injectable opioids should be avoided. If long-term treatment is being considered patients should be placed on a slow-release formulation to reduce dose escalation and to provide more stable analgesia.The first step while prescribing analgesics in nociceptive pain(especially musculoskeletal) would be paracetamol and NSAIDs followed by tramadol and then by Buprenorphine, morphine, oxycodone, fentanyl.

Neuropathic pain

Neuropathic pain management

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