Page 292 Acute Pain Management

Table 9.1 Taxonomy of acute pain associated with spinal cord injury
Pain type Location relative Description, structures and pathology
to level of injury
Neuropathic Above level pain located in an area of sensory preservation
pain peripheral nerve or plexus injury
At level ‘segmental pain’ at level of the injury
spinal cord lesion (central pain)
nerve root lesion (cauda equina)
combined cord and root lesions
syringomyelia
Below level pain below the level of injury
spinal cord lesion (eg central dysaesthesia syndrome)
phantom pain
Other complex regional pain syndrome
Nociceptive Somatic musculoskeletal pain (eg vertebral fracture, muscle spasms,
pain overuse syndromes)
procedure‐related pain (eg pressure sore dressings)
Visceral urinary tract (eg calculi)
gastrointestinal tract
Other dysreflexic headache

The taxonomy of acute pain associated with spinal cord injury in Table 9.1 is based on Siddall
(Siddall et al, 2002).
Treatment of acute neuropathic pain after spinal cord injury
There are no studies specifically examining the treatment of acute neuropathic pain following
SCI. Treatment must therefore be based on evidence from studies of chronic central pain and
other neuropathic pain syndromes. An algorithm for the treatment of pain in patients with SCI
has been promulgated (Siddall & Middleton, 2006).
CHAPTER 9 Under experimental conditions, IV alfentanil decreased central pain following SCI compared
Opioids and tramadol

with placebo and ketamine (Eide et al, 1995 Level II). IV morphine decreased tactile allodynia but
had no effect on other neuropathic pain components in SCI and poststroke patients (Attal et al,
2002 Level II). Tramadol was effective for the treatment of neuropathic pain after spinal cord
injury but the incidence of side effects was high (Norrbrink & Lundeberg, 2009 Level II).
Ketamine
Ketamine infusion decreased neuropathic pain in SCI patients (Eide et al, 1995 Level II;
Kvarnstrom et al, 2004 Level II).
Membrane stabilisers
Under experimental conditions, IV lignocaine reduced neuropathic pain in SCI (Finnerup, Biering‐
Sorensen et al, 2005 Level II) and reduced spontaneous pain and brush allodynia in central pain
(Attal et al, 2000 Level II). Other trials have found that lignocaine reduced pain in only one of ten
SCI patients (Kvarnstrom et al, 2004 Level II) and that mexiletine was ineffective (Chiou‐Tan et al,
1996 Level II). Lignocaine was most effective in the treatment of neuropathic pain due to
peripheral nerve lesions (Kalso et al, 1998 Level I).

244 Acute Pain Management: Scientific Evidence