一例难治性脊髓损伤痛患者的处理：病例报道及文献综述

慢性疼痛是脊髓损伤众多后遗症之一，它会妨碍患者的基本活动、功能恢复及生活质量。脊髓损伤患者的疼痛常常难以治疗。有限的治疗选择，包括药物治疗和非药物治疗使疼痛的治疗更加困难。我们用检索词“脊髓损伤”或“脊髓损伤和疼痛”或“僵直”或“肌僵直”从Medline数据库查阅1975～2005年的关于脊髓损伤后疼痛的相关文章。我们也手工查阅了国际疼痛研究协会最近出版的关于脊髓损伤痛的书籍以及综述，同时检出参考文献中的相关文章。文中我们报道了一例难治性脊髓损伤痛患者，该患者通过采用综合性治疗措施成功治愈。同时对治疗方式的循证医学证据也进行了回顾。     

Non-opioid pharmacologic treatment of chronic spinal cord injury-related pain

Purpose: Spinal cord injury-related pain is often a severe debilitating condition that adversely affects the patient’s physical health, psychological wellbeing and quality of life. Opioid medications have historically been prescribed to this population with great frequency. As opioid abuse disorder becomes an ever-worsening public health issue, more attention must be placed upon non-opioid options. This paper reviews non-opioid medications to be considered when treating spinal cord injury-related pain. The pertinent literature is reviewed, and the advantages and pitfalls of various medication options are discussed in the complicated context of the individual with a spinal cord injury.Methods: Peer-reviewed journal articles and medication package insert data are reviewed.Results:. The non-opioid medications with the greatest evidence for efficacy in the treatment of chronic spinal cord injury-related pain are drawn from the antiepileptic drug and antidepressant categories though the specific selection must be nuanced to the particular individual patient. More research is required to understand the role of calcitonin, lithium, and marijuana in treating spinal cord injury-related pain.Conclusions: The complex clinical situation of each individual patient must be weighed against the risks and benefits of each medication, as reviewed in this paper, to determine the ideal treatment strategy for chronic spinal cord injury-related pain.     

Management of Pain in Persons With Spinal Cord Injury

Abstract

Pain is a common complaint following spinal cord injury (SCI). While nociceptive pain can often be effectively managed by traditional therapies, neurogenic pain is more refractory to treatment. Several categories of pain are recognized in persons with SCI and an accurate diagnosis will improve the therapeutic response. Nociceptive pain is usually perceived to be above or at the level of the cord lesion and is most commonly related to musculoskeletal pathology. 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, depending on its hypothetical origin and the clinical presentation. Management requires recognition of all factors that may influence pain perception and knowledge of the entire range of therapeutic options. (J Spinal Cord Med 1997; 20:186-199)     

Pain management after traumatic spinal cord injury

Pain is experienced by people suffering from spinal cord injury leading to disability and affecting the person's functional ability, independence, psychological well - being, ability to return to work and quality of life. Pain management in these patients is notoriously difficult due to multiple factors and varied mechanism leading to pain. Only few treatments have been assessed in randomized, controlled trials and management is based on different case reports. We are reporting our experience of managing 2 patients with neuropathic pain following traumatic spinal cord injury. Both the patients were refractory to conventional pain medications but there was significant reduction in pain following lignocaine infusion in the first patient and with ketamine in the second patient.     

Virtual reality for the treatment of neuropathic pain in people with spinal cord injuries: A scoping review

Context: Virtual and augmented imagery are emerging technologies with potential to reduce the severity and impact of neuropathic pain in people with spinal cord injury (SCI).Objective: We aimed to identify and discuss studies using virtual and augmented reality applications for the management of neuropathic pain in people with spinal cord injury.Methods (data sources, data extraction): A systematic literature search was conducted using PRISMA scoping review guidelines. Articles were searched in PubMed, Embase and Web of Science databases using search terms relating to SCI, virtual and augmented reality and neuropathic pain. With no strong evidence for visual imagery in the treatment of pain in SCI patients, we selected exploratory, feasibility and more rigorous methodologies such as randomized controlled trials and case-control studies. We only selected studies evaluating the effects of visual imagery on neuropathic pain at or below the spinal cord injury level.Results: Of 60 articles located, we included nine articles involving 207 participants. All studies were exploratory using head-mounted devices or 3D and 2D screens with virtual walking or limb movement imagery. Outcomes included pain sensitivity, motor function and body ownership. Eight of the nine studies reported significant reductions in neuropathic pain intensity. However, given small sample sizes in all studies, results may be unreliable.Conclusion: Although the number of studies and individual sample sizes are small, these initial findings are promising. Given the limited options available for the effective treatment of neuropathic SCI pain and early evidence of efficacy, they provide valuable incentive for further research.     

Complex regional pain syndrome type I after myocardial infarction treated with spinal cord stimulation

OBJECTIVE: A rare case of Complex Regional Pain Syndrome (CRPS) type I after myocardial infarction (MI) and significant comorbid illness with few treatment options for pain control was successfully managed with the placement of a spinal cord stimulator (SCS). CASE REPORT: A 44-year-old man presented with left upper extremity burning pain after MI. His past medical history included insulin-dependent diabetes mellitus, oxygen-dependent idiopathic pulmonary fibrosis, and recent coronary revascularization surgery. His pain was presumed to be related to his MI and a clinical diagnosis of CRPS type I (or reflex sympathetic dystrophy) was made. Facing limited medical and less invasive options for his pain relief, he underwent a spinal cord stimulation trial with excellent response. He had more than 70% pain relief from the spinal cord stimulation at the last follow-up, 2 years later. CONCLUSION: CRPS type I after MI can be difficult to treat because of other comorbid illnesses. SCS can be a safe and effective mode of therapy for patients facing limited treatment options.     

Pain in patients with spinal cord injury: An A to Z approach

Spinal cord injury is a devastating occurence, an event that alters patients' lives and their families. Individuals with spinal cord injury often have chronic pain. The aim is to present a course with management measures that should be taken at the time of appearance of pain, acute, chronic or both, a multimodal management approach according to pathophysiology, taking into account that its treatment remains unsatisfactory. Also consider involving cognitive, emotional, and social issues for a comprehensive approach to patient with spinal cord injury.     

Clinical and objective data on spinal cord stimulation for the treatment of severe Raynaud's phenomenon.

Ischemic vascular disease of the upper extremity represents a difficult therapeutic problem wherein medical treatment often fails. Epidural spinal cord stimulation has been shown to be an effective alternative in severe peripheral arterial disease. Although this method has been used for nearly two decades only limited experience exists in Raynaud's phenomenon of the upper limbs. In addition objective parameters to prove therapeutic success are not well defined. Herein we describe a patient with severe primary Raynaud's phenomenon over several years who had significant pain relief and complete healing of ischemic digital ulcerations after spinal cord stimulation. Pain level was evaluated using a visual rating scale before and after surgery. Microcirculatory parameters were assessed before and after spinal cord stimulation by capillary microscopy and laser Doppler anemometry. Significant improvement of red blood cell velocity, capillary density, and capillary permeability was demonstrated. At follow-up 18 months after surgery the patient had no complaints and all ulcerations of her fingertips had healed. Spinal cord stimulation appears to be an effective treatment in severe cases of Raynaud's phenomenon and we recommend its use in the case of failed medical therapy. Pain rating and capillary microscopy enable one to assess and visualize the effects of spinal cord stimulation.     

Calcitonin for acute neuropathic pain associated with spinal cord injury

Neuropathic pain associated with spinal cord injury is caused by complex neural mechanisms and is often refractory to standard therapy. Salmon calcitonin was an effective treatment for neuropathic symptoms in this case series of three patients with recent spinal cord injury. Salmon calcitonin is already used to help manage pain after limb amputation and also after vertebral fractures and it is perhaps surprising that it has not been trialled previously for spinal cord injury pain. Calcitonin is thought to exert its effect by modulation of the serotonergic system and is generally well tolerated and convenient to administer. This underutilised drug may be a very useful adjuvant for neuropathic pain associated with spinal cord injury.     

Management of acute spinal cord injury: A summary of the evidence pertaining to the acute management,operative and non-operative management

Acute traumatic spinal cord injury is often a lifechanging and devastating event with considerable mortality and morbidity. Over half a million people suffer from traumatic spinal cord injury annually with the majority resulting from road traffic accidents or falls. The Individual, societal and economic costs are enormous. Initial recognition and treatment of acute traumatic spinal cord injury are crucial to limit secondary injury to the spinal cord and to provide patients with the best chance of some functional recovery. This article is an overview of the management of the acute traumatic spinal cord injury patient presenting to the emergency department. We review the initial assessment, criteria for imaging and clearing the spine, and evaluate the literature to determine the optimum timing of surgery and the role of non-surgical treatment in patients presenting with acute spinal cord injury.     

Pain and dysesthesia in patients with spinal cord injury: A postal survey.

STUDY DESIGN: A postal survey. OBJECTIVES: To assess the prevalence and characteristics of pain and dysesthesia in a community based sample of patients with spinal cord injury (SCI) with special focus on neuropathic pain. SETTING: Community. Western half of Denmark. METHODS: We mailed a questionnaire to all outpatients (n = 436) of the Viborg rehabilitation centre for spinal cord injury. The questionnaire contained questions regarding cause and level of spinal injury and amount of sensory and motor function below this level. The words pain and unpleasant sensations were used to describe pain (P) and dysesthesia (D) respectively. Questions included location and intensity of chronic pain or dysesthesia, degree of interference with daily activity and sleep, presence of paroxysms and evoked pain or dysesthesia, temporal aspects, alleviating and aggravating factors, McGill Pain Questionnaire (MPQ) and treatment. RESULTS: Seventy-six per cent of the patients returned the questionnaire, (230 males and 100 females). The ages ranged from 19 to 80 years (median 42.6 years) and time since spinal injury ranged from 0.5 to 39 years (median 9.3 years). The majority (> 75%) of patients had traumatic spinal cord injury. Of the respondents, 77% reported having pain or unpleasant sensations, and 67% had chronic pain or unpleasant sensations at or below lesion. Forty-eight per cent reported that P/D could be evoked by non-noxious stimulation of the skin indicating that allodynia is present in almost half of the patients. Forty-three per cent of respondents took analgesics, 7% received antidepressants or anticonvulsants. CONCLUSION: This survey suggests that pain and dysesthesia are common and serious complaints in SCI patients. Unexpectedly, only 7% of the patients were treated with drugs considered to be most effective in neuropathic pain. This emphasizes the need for a continued research and education on P/D in SCI.     

Intrinsic spinal cord catheter placement: implications of new intractable pain in a patient with a spinal cord injury

We present a case of new intractable flank pain after intrathecal infusion system placement in a 45-yr-old man with a history of a T12 spinal cord injury with dysesthetic leg pain. Pain after intrathecal infusion system placement was evaluated by magnetic resonance imaging and the catheter was found to be intraparenchymal. The patient was treated by cessation of infusion and surgical removal of the system. Before surgical removal, the pump was turned off and the patient's flank pain resolved. Increased vigilance is warranted when caring for paraplegic patients. When new pain persists, intrathecal medication tapering should be considered.     

Surgical management of posttraumatic thoracolumbar kyphosis

BACKGROUND CONTEXT: Spine trauma is relatively common, and each year approximately 10,000 to 17,000 people in the United States will sustain a spinal cord injury and approximately 150,000 to 160,000 will fracture their spinal column. Posttraumatic spinal deformity is a common potential complication of spinal injury and poses one of the greatest challenges in spinal surgery. PURPOSE: To provide a comprehensive and current review of posttraumatic deformity focusing on the epidemiology, clinical and radiographical presentation, treatment options, and prognosis. STUDY DESIGN/SETTING: A thorough review of the English literature on the management of posttraumatic deformity was performed. Pertinent articles were identified by using PubMed and a review of publications by the American Academy of Orthopaedic Surgeons. METHODS: Each article was reviewed, and findings were analyzed to formulate a concise review of current treatment methods for posttraumatic deformity. RESULTS: Successful treatment of posttraumatic deformity is dependent on careful patient selection and appropriate surgical intervention, which should be considered in the presence of significant or increasing deformity, increasing back and/or leg pain, "breakdown" at levels above or below the deformity, pseudarthrosis or malunion, and increasing neurological deficit. The goals of surgery should be to decompress the neural elements if neurological claudication or a neurological deficit is present, to recreate normal sagittal contours and balance, and to optimize the chances for successful fusion; these goals can be achieved through an all-anterior, all-posterior, or a combined anterior/posterior approach assuming that close attention is paid to using the appropriate bone-grafting techniques, selecting technically sound segmental instrumentation, and providing appropriate biomechanical environment for maintenance of correction and successful fusion. CONCLUSIONS: Posttraumatic spinal deformity is a common complication of spinal injury, and it is therefore essential for patients with vertebral column injuries to have a careful initial evaluation, close follow-up, and early intervention when needed. Once posttraumatic deformity is present, successful outcome is achievable assuming a thorough, systematic, and technically well-executed surgical intervention is performed.     

The analgesic effect of intravenous ketamine and lidocaine on pain after spinal cord injury

BACKGROUND: Pain following spinal cord injury (SCI) is a therapeutic challenge. Only a few treatments have been assessed in randomized, controlled trials. The primary objective of the present study was to examine the analgesic effect of ketamine and lidocaine in a group of patients with neuropathic pain below the level of spinal cord injury. We also wanted to assess sensory abnormalities to see if this could help us to identify responders and if treatments resulted in changes of sensibility. METHODS: Ten patients with spinal cord injury and neuropathic pain below the level of injury were included. The analgesic effect of ketamine 0.4 mg kg(-1) and lidocaine 2.5 mg kg(-1) was investigated. Saline was used as placebo. The drugs were infused over 40 min. A randomized, double-blind, three-period, three-treatment, cross-over design was used. Systemic plasma concentrations of ketamine and lidocaine were assessed. Pain rating was performed using a visual analogue scale (VAS). Sensory function was assessed with a combination of traditional sensory tests and quantitative measurement of temperature thresholds. RESULTS: Response to treatment, defined as 50% reduction in VAS-score during infusion, was recorded in 5/10 in the ketamine, 1/10 in the lidocaine and 0/10 in the placebo groups. Neither ketamine nor lidocaine changed temperature thresholds or assessments of mechanical; dynamic and static sensibility. Nor could these sensory assessments predict response to treatment in this setting. Lidocaine and particularly ketamine were associated with frequent side-effects. CONCLUSION: Ketamine but not lidocaine showed a significant analgesic effect in patients with neuropathic pain after spinal cord injury. The pain relief was not associated with altered temperature thresholds or other changes of sensory function.     

Treatment of chronic pain by epidural spinal cord stimulation: a 10-year experience

Epidural spinal cord stimulation by means of chronically implanted electrodes was carried out on 121 patients with pain of varied benign organic etiology. In 116 patients, the pain was confined to the back and lower extremities and, of these, 56 exhibited the failed-back syndrome. Most patients were referred by a pain management service because of failure of conventional pain treatment modalities. Electrodes were implanted at varying sites, dictated by the location of pain. A total of 140 epidural implants were used: 76 unipolar, 46 Resume electrodes, 12 bipolar, and six quadripolar. Patients were followed for periods ranging from 6 months to 10 years, with a mean follow-up period of 40 months. Forty-eight patients (40%) were able to control their pain by neurostimulation alone. A further 14 patients (12%), in addition to following a regular stimulation program, needed occasional analgesic supplements to achieve 50% or more relief of the prestimulation pain. Pain secondary to arachnoiditis or perineural fibrosis following multiple intervertebral disc operations, when predominantly confined to one lower extremity, seemed to respond favorably to this treatment. Uniformly good results were also obtained in lower-extremity pain secondary to multiple sclerosis. Pain due to advanced peripheral vascular disease of the lower limbs was well controlled, and amputation below the knee was delayed for up to 2 years in some patients. Pain due to cauda equina injury, paraplegic pain, phantom-limb pain, pure midline back pain without radiculopathy, or pain due to primary bone or joint disease seemed to respond less well. Patients who responded to preliminary transcutaneous electrical nerve stimulation generally did well with electrode implants. Notable complications included wound infection, electrode displacement or fracturing, and fibrosis at the stimulating tip of the electrode. Three patients in this series died due to unrelated causes. Epidural spinal cord stimulation has proven to be an effective and safe means of controlling pain on a long-term basis in selected groups of patients. The mechanism of action of stimulation-produced analgesia remains unclear; further studies to elucidate it might allow spinal cord stimulation to be exploited more effectively in disorders that are currently refractory to this treatment modality.     

Metastatic spine disease: epidemiology, pathophysiology, and evaluation of patients

Spinal metastasis is the most commonly en-countered tumor of the spine and represents an ominous extension of neoplastic disease. Symptomatic spinal metastases produce a characteristic clinical syndrome beginning with local back or neck pain. All too often, the significance of presenting pain is not appreciated and correct diagnosis is delayed until more blatant manifestations of spinal cord or nerve root dysfunction are manifest. Pain is followed by weakness,numbness, and sphincter dysfunction. The natural history is one of relentless progression to complete and irreversible paralysis unless timely treatment is undertaken.Plain radiographs provide a simple and useful screening test. MRI is, however, the imaging method of choice, providing information concern-ing the level, location, and geometry of the spinal tumor as well as details concerning the bony integrity of the spine, particularly adjacent to a culpable tumor, all of which is essential to determine the management options and treatment strategies. Percutaneous image-guided biopsy is a useful test to establish a tissue diagnosis.     

Spinal cord stimulation does not change peripheral skin blood flow in patients with neuropathic pain

BACKGROUND AND OBJECTIVE: Spinal cord stimulation has been used successfully for many years in the management of neuropathic pain. Nociceptive pathways are closely integrated into many autonomic reflexes. The aim was to test the hypothesis that pain relief caused by spinal cord stimulation is related to changes in peripheral skin blood flow. METHODS: Twelve patients with spinal cord stimulators implanted as a treatment for neuropathic pain were entered into the study. Laser Doppler perfusion scanning was used as a direct method for selective measurement of changes in skin (peripheral) blood flow. Measurements were taken before and after the onset of spinal cord stimulation over the site of its sensory projection. The degree of pain relief due to spinal cord stimulation and the skin temperature of each patient were also recorded. RESULTS: Apart from one patient, spinal cord stimulation did not change skin blood flow in a statistically significant manner. CONCLUSIONS: Pain relief due to spinal cord stimulation is not related to changes of skin blood flow.     

Neurogenic Detrusor Overactivity in Patients With Spinal Cord Injury: Evaluation and Management

Lower urinary tract dysfunction can have a significant impact on patients with spinal cord injury. Over the years, many treatment options have become available. This article reviews the assessment and management of neurogenic detrusor overactivity, with a particular focus on articles from the recent literature. Recent guidelines on the subject will be discussed. Management options include antimuscarinics and bladder emptying measures, botulinum toxin A, and neuromodulation in refractory cases and surgery for intractable cases. Recent and relevant publications in these areas will be summarized and discussed.