Page 201 Guide to Pain Management in Low-Resource Settings

Chapter 25

Central Neuropathic Pain

Maija Haanpää and Aki Hietaharju

Case report 1 penetrate the spinal canal. Cord contusion was prob-
ably the result of the kinetic energy transmitted by the
Abdul Shamsuddin, a 35-year-old shopkeeper from bullet. Th e patient’s pain medication included amitrip-
oor tyline and gabapentin. Within 4 years, the neuropathic flGulshan, Dhaka, was found by his wife lying on the
of his apartment. He was brought into the hospital on a pain started gradually to resolve, and gabapentin was
. ffmakeshift stretcher carried by four relatives, all saying successfully tapered o
erent things about what had happened. In the emer- ffdi
gency room, he was conscious but not able to move his
Case report 2
legs or left arm. He was complaining of severe burning
pain in his right hand and deep aching pain in both of Shabana, an Afghan housewife from Jalalabad in her
his upper extremities. Th e man explained, incoherently, late thirties, came to a psychiatric outpatient clinic es-
ered for more than ffthat his house had been entered by a gang of robbers, corted by her husband. She had su
and the last thing he remembered was a loud gunshot. A 2 years from continuous burning pain in her left hand
lacerated wound 1 cm in diameter was revealed on ex- and the right side of her face. She had been referred to
amination of his neck. Neurological examination showed the psychiatrist by a general practitioner who, due to
total loss of sensation below T2. Th ere was severe hyper- Shabana’s infertility, had assumed a psychogenic basis
esthesia, hyperalgesia, and dynamic allodynia as well as as the cause of her pain. History taking revealed that she
ngers and had had a sudden attack of vertigo, slurred speech, and fiimpaired cold sensation in the 4th and 5th
on the ulnar side of his right hand. In the left hand, there motor weakness in her left extremities 3 years earlier.
was mild dynamic allodynia, and hyperalgesia was no- She had not consulted her doctor at that time. Most of
ex his her symptoms had subsided within 2 days, but the mo- flnger. Th e patient was able to fiticed in the 3rd
right arm and lift his hand up against gravity. A radio- tor weakness had persisted for weeks. She reported that
graph of the cervical spine showed a posterior arch frac- the painful symptoms had appeared about 2 months
ture of C7 and a 9-mm bullet lying close to the scapula after this attack. Neurological examination revealed
on the right side. MRI of the cervical spine showed spinal slight clumsiness and ataxia in her left arm, but muscle
cord contusion extending from the C4 to T2 level. Th e strength was regarded as normal. A conspicuous de-
continuity of the spinal cord was intact, and no signs of crease in cold and pain sensibility was noticed on her
hematoma were present. right cheek, and in the lower two-thirds of her left arm as
Th is case shows that neurological injury and compared to the contralateral side. Cardiac auscultation
spinal cord pain can occur even if a projectile does not did not reveal a pathological rhythm or sounds. Due to
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. No responsibility is assumed by IASP 189
for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or
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