Interventional Pain Medicine in Spine Cord Injury Patients: contributions to the field
Macrinici G, Alkhudari A, Torres M, Rahman A, Penmetcha T, Subieta G, Clar S
John H. Stroger Jr Hospital of Cook County, Naperville, IL, United states
Introduction: Pain is a well-known and problematic consequence after SCI and is known to have association with spasticity. Pain in SCI patients can occur above, below and at the level of the injury. We present a case of a patient with tetraplegia who developed debilitating pain and spasticity below the neurological level of his injury 2 years after the GSW to the neck.
Timeline: The patient is a 43 years old male with a 2-year history of tetraplegia who was admitted to the hospital through the ED due to new onset of severe pain in the buttock area “feeling like tearing of the bones” and muscle spasticity. On examination he was found to have C3 AIS A tetraplegia with severe gluteal allodynia and diffuse pelvic and lower extremity spasticity. The spasticity at the knees was graded MAS 3 and the Penn Spasm Frequency scale > 20/hr.
Diagnostic: Interventional pain procedures were done both under fluoroscopy and ultrasound guidance for diagnostic and therapeutic goals. Patient had extensive work up of the spine, sacroiliac joints that included CT scans, X-ray and prior MRI, that showed multiple bullets fragments at C3-C4 spine level, some degenerative disk disease of the spine, no spinal canal or neuroforaminal stenosis, mild multilevel facet arthropathy. The sacroiliac joints did not show any abnormalities.
Therapeutic: PM&R, Pain Medicine service, and Neurology was consulted for management. Due to excruciating pain, the patient was initially started on Morphine, Percocet and Hydromorphone and Gabapentin with little relive of pain or spasticity. Patient had following time lined procedures: repeated bilateral sacroiliac joint infections, bilateral piriformis muscle injection, Lidocaine infusion and Ketamine infusion with little relieve of the pain. It was felt the patient had some component of pain related to his muscle spasticity and following an intrathecal baclofen trial he obtained good relieve of muscle spasticity and some relieve of pain.
Results: Following an intrathecal baclofen pump implantation the patient received good relieve of the spasms, spasticity and partial relieve of the pain. Neuropathic pain continued to be treated with multimodal pain management approach and physical therapies.
Discussion: Sixty percent of patients with posttraumatic para- or tetraplegia suffer from severe, continuous burning and/or lancinating pain. Neurogenic pain is usually felt by the patient at or below the neurological level and may be classified as radicular, segmental or deafferentation central pain. Management requires recognition of all factors and knowledge of the entire range of therapeutic options.
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