Chapter 22
Paid After Spinal Cord Injury
Pain is common after spinal cord injury (SCI). As many as 40 percent of individuals with SCI report pain that is severe enough to interfere with their daily activities. All SCI patients will experience some pain at some time in their life, though in many this is temporary and mild.
KINDS OF PAIN
There are several different kinds of pain after SCI. A person with SCI usually has one kind of severe pain but may have two kinds of pain at the same time. The different kinds of pain can be described by location and by duration.
Location of Pain
Muscle, Bone, or Tendon Pain
This kind of pain often results from injury to muscles, bones, or tendons that might occur from overuse, overstretching, or falls. Such pain can last for weeks or months if your body reacts to the injury with inflammation or muscle spasm. Common sites for this pain are shoulder, low back, neck, and hands, but other sites may show this pain as well. This pain often feels like aching, grinding, or gnawing; it is often worse with activity but relieved by rest. Technical names for this kind of pain and its causes include myofascial pain, heterotopicossification (bone formation in soft tissues), arthritis, and shoulder impingement.
Nerve Pain
Pressure, irritation, or stretching to a nerve can cause pain. This can occur at the neck or back where the nerves exit the spine, such as with a slipped disk. Nerves may also be compressed at the elbow or at the wrist causing pain; one type of wrist pain due to nerve compression is carpal tunnel syndrome. This nerve pain can feel like aching, heaviness, tingling, or numbness in the fingers or hand.
Spinal Cord Pain
This is a mysterious kind of pain. Cutting the spinal cord does not cause immediate pain, but SCI can, over days to weeks, lead to pain. This kind of pain that originates in the spinal cord or brain is often called central pain or neuropathic pain. It may be felt at the level of the spinal cord injury as a band around the body--this band may be hypersensitive to touch or may tingle or burn. Another type of central pain is a burning, tingling, or freezing sensation below the level of the injury--this may be felt in the feet or around the anus. Another type of central pain is a brief shock or jolt or a series of quick shocks, often in the legs. This spinal cord pain can develop days to weeks after a spinal cord injury or it can develop years later if there is additional damage to the spinal cord--for example, if an expanding fluid-filled cyst develops in the spinal cord (called a syrinx or syringomyelia). Those with incomplete SCI or with cauda equina injuries (low level SCI at L1 or below) often have the most severe spinal cord pain, though even those with complete SCI may experience this pain.
Internal Organ Pain
Your internal organs, such as your stomach, intestines, or bladder, develop pain if they are overstretched. Thus, if you have constipation and your intestine overstretches or if your bladder overfills, then you will feel internal abdominal pain. Internal organs may also develop pain if they lose their blood flow; for example, a heart attack causes chest pain when blood flow is interrupted to the heart. Internal organ pain (also called visceral pain) may be difficult to distinguish from spinal cord injury pain. If pain suddenly worsens, it is important to identify new internal organ pain and distinguish it from a worsening spinal cord problem or from a new muscle, bone, tendon pain. Bladder overfilling, constipation, inflammation of the gallbladder, and heart attack are medical emergencies that require prompt treatment. After spinal cord injury in the neck (cervical) or upper back (thoracic at T6 or higher), sensation from the heart, stomach, intestines, and bladder may be dulled and difficult to pinpoint but it is not usually absent.
Headache Pain of Autonomic Dysreflexia
People with SCI above a T6 level can develop autonomic dysreflexia, where blood pressure rises rapidly to high levels in response to bladder overdistension or some other pain stimulus below the SCI. Blood pressure may rise to dangerously high levels (i.e., greater than 180 mm Hg) making this a medical emergency. See the chapter on Autonomic Dysreflexia. Such high blood pressures often cause headache. This is a kind of pain unique to spinal cord injury.
Duration of Pain
Acute or Short-Duration Pain
Sudden onset, severe pain is worrisome since it may indicate a medical emergency (for example, autonomic dysreflexia, heart attack, bleeding ulcer, or appendicitis); get prompt medical advice or go to an emergency room. Mild to moderate pain lasting days to weeks is often muscle, bone, or tendon pain. It will usually resolve on its own and can benefit from treatment with rest and mild pain medications.
Chronic or Long-Duration Pain
Long-duration, severe pain lasting months to years with a burning, tingling, shock-like, or shooting quality is often spinal cord pain. Long-duration, mild to moderate pain that is aching in quality and that is aggravated by activity is usually muscle, bone, or tendon pain; occasionally, this muscle, bone, tendon pain can be severe.
DIAGNOSIS
Diagnosis is identifying the cause of a patient’s kind of pain or pains. To diagnose pain, a doctor listens to your symptoms, examines you, may obtain blood and urine tests, may take X-rays or other imaging studies, and may order electrical tests of your nerve and muscle (EMG). If the cause of the pain can be identified, then treatment can be targeted against that kind of pain. Sometimes the cause of the pain cannot be definitely identified. Then treatments are undertaken on a trial-and-error basis.
TREATMENT
Muscle, Bone, or Tendon Pain
Muscle, bone, and tendon pain can often be improved or cured. Treatments include short-term rest (less than 3 days), cold or heat, stretching, massage, mild analgesics (e.g., acetaminophen), anti-inflammatory medications (e.g., aspirin, ibuprofen). Other treatments for persisting pain may include improving posture, modifying mobility techniques, injections into muscle or joint, and electrical stimulation to skin (TENS or transcutaneous electrical nerve stimulation).
Nerve Pain
Nerve pain may be improved by avoiding pressure or stretching, e.g., a wrist splint can relieve night pain due to carpal tunnel syndrome or an elbow pad may relieve pain due to pressure on the ulnar nerve. Splints, pads, alternate wheelchair armrests, positioning aids for computer use, a neck collar, and TENS may help. Occasionally surgery can help relieve pressure on nerves and thus relieve pain. Medications that have been used for this nerve pain include antidepressants, antiseizure medications, mild pain medications (such as acetaminophen, aspirin, ibuprofen) and strong pain medications (such as oxycodone and methadone).
Spinal Cord Pain
This spinal cord pain is often not fully relieved by current treatment. Various treatments can lessen the pain. Stretching, active exercise, electrical stimulation of the skin, relaxation exercises can help.
Certain medications can lessen this spinal cord pain: antidepressants such as amitriptyline and desipramine and antiseizure medications such as carbamazepine (Tegretol ®) and gabapentin (Neurontin ®). Topical pain medications (such as capsaicin or analgesic balm) may also help. At times, narcotic medications are used, such as codeine and methadone. Disadvantages to narcotics are that they cause constipation and some tolerance to the pain relief develops.
Various surgeries have been tried to relieve this spinal cord pain, but none with consistent success; these include cutting pain pathways in the spinal cord and implanting an electrical stimulator to interrupt the flow of pain signals to the brain.
Expanding vocational, social, and recreational activities may help distract you from the pain. Sometimes other factors such as depression or muscle, bone, joint pain or visceral pain can add to spinal cord pain; by treating these other factors, the spinal cord pain will be less. Other treatments exist such as herbal medicine, chiropractic manipulation, and acupuncture, but their effectiveness in spinal cord pain has not been demonstrated.
WHAT SHOULD YOU DO, IF YOU HAVE PAIN?
- New Severe Pain, No Clear Cause: Seek medical advice promptly. If you experience associated shortness of breath, light-headedness, dizziness, sweating, or passing out then consider ambulance transport to an emergency room. If there is associated high blood pressure, then seek treatment for autonomic dysreflexia (see Chapter 11).
- New Muscle, Bone or Tendon Pain: Apply cold for 15 minutes, take acetaminophen, rest for 3 days. Seek medical advice if there is no improvement after 5 days.
- New Mild to Moderate Pain, No Clear Cause: If you have any constipation that might be aggravating pain, then treat as needed. If you have any new loss of sensation or new weakness, then seek medical advice promptly. Try acetaminophen with or without ibuprofen (avoid ibuprofen if you have a history of stomach ulcer, kidney disease, or allergy to ibuprofen or aspirin) and rest for 3 days; if there is no improvement or there is worsening then seek medical advice.
- Long-Standing Pain, No Clear Cause: Try daily gentle stretching. Try acetaminophen with or without ibuprofen (avoid ibuprofen if you have a history of stomach ulcer, kidney disease, or allergy to ibuprofen or aspirin). Try a hot water bottle. (Use only warm water; do not use very hot water that will cause burns on skin with poor sensation. Do not use a heating pad on skin with poor sensation). Seek medical advice if pain persists and it interferes with sleep or daily activities.
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Pain after Spinal Cord Injury