Pain Management in Spinal Cord Injury: A Narrative Review

  • Zahid Hussain Khan Department of Anesthesiology and Critical Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
  • Hossein Majedi Department of Anesthesiology and Critical Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
  • Tahseen Asaad Hassan Department of Anesthesia, School of Allied Medical Sciences, International Campus, Tehran University of Medical Sciences, Tehran, Iran
Spinal cord injury, Pain mechanism, Pain management


Spinal cord injury (SCI) occurs due to any damage to the spinal cord and cauda equina. Most of the patients after spinal cord injury develop chronic pain, irrespective to the site and type of pain. This pain is severe in most of the cases and severely impairs the quality of life. The mechanisms responsible for the pain after spinal cord injury is poorly understood. The pain of SCI is basically classified in two main types: nociceptive or neuropathic. The objectives of this paper are to review the different treatment options for the SCI pain. The pain management after SCI includes pharmacological therapy and non-pharmacological therapy.


1. Yılmaz T, Turan Y, Keleş A. Pathophysiology of the spinal cord injury. J Clin Exp Invest/Klinik ve Deneysel Arastirmalar Dergisi. 2014; 5(1):131-6.
2. Æsøy MS, Solvang SEH, Grønning M, Rekand T. Epidemiology of persistent iatrogenic spinal cord injuries in Western Norway. Brain Behav. 2016; 6(10):1-6.
3. Benzon HT, Rathmell JP, Wu CL, Argoff CE, Turk DC. Practical management of pain: Elsevier Health Sciences; 2014; (5):384-391.
4. Kvarnström A, Karlsten R, Quiding H, Gordh T. The analgesic effect of intravenous ketamine and lidocaine on pain after spinal cord injury. Acta Anaesthesiol Scand. 2004; 48(4):498-506.
5. Sadosky A, Parsons B, Emir B, Nieshoff EC. Pain relief and functional improvement in patients with neuropathic pain associated with spinal cord injury: An exploratory analysis of pregabalin clinical trials. J Pain Res. 2016; 9:405-16.
6. Sezer N, Akkuş S, Uğurlu FG. Chronic complications of spinal cord injury. World J Orthop. 2015; 6(1):24-33.
7. Widerström-Noga E, Turk D. Types and effectiveness of treatments used by people with chronic pain associated with spinal cord injuries: Influence of pain and psychosocial characteristics. Spinal Cord. 2003; 41(11):600-9.
8. Rekand T, Hagen EM, Grønning M. Chronic pain following spinal cord injury. Tidsskr Nor Laegeforen. 2012; 132(8):974-9.
9. Wilson MW, Richards JS, Klapow JC, DeVivo MJ, Greene P. Cluster analysis and chronic pain: An empirical classification of pain subgroups in a spinal cord injury sample. Rehabil Psychol. 2005; 50(4):381-388.
10. Kennedy P, Frankel H, Gardner B, Nuseibeh I. Factors associated with acute and chronic pain following traumatic spinal cord injuries. Spinal Cord. 1997; 35(12):814-7.
11. Gorp S, Kessels A, Joosten E, Kleef M, Patijn J. Pain prevalence and its determinants after spinal cord injury: a systematic review. Eur J Pain. 2015; 19(1):5-14.
12. Siddall P, Middleton J. A proposed algorithm for the management of pain following spinal cord injury. Spinal Cord. 2006; 44(2):67-77.
13. Westgren N, Levi R. Quality of life and traumatic spinal cord injury. Arch Phys Med Rehabil. 1998; 79(11):1433-9.
14. Ditor D, Latimer A, Ginis KM, Arbour K, McCartney N, Hicks A. Maintenance of exercise participation in individuals with spinal cord injury: Effects on quality of life, stress and pain. Spinal Cord. 2003;41(8):446-450
15. New P, Lim T, Hill S, Brown D. A survey of pain during rehabilitation after acute spinal cord injury. Spinal Cord. 1997; 35(10):658-63.
16. Finnerup N, Jensen MP, Norrbrink C, Trok K, Johannesen IL, Jensen T, et al. A prospective study of pain and psychological functioning following traumatic spinal cord injury. Spinal Cord. 2016; 54(10):816-21.
17. Amr YM. Multi-day low dose ketamine infusion as adjuvant to oral gabapentin in spinal cord injury related chronic pain: A prospective, randomized, double blind trial. Pain Physician. 2010; 13(3):245-9.
18. Finnerup NB, Biering-Sørensen F, Johannesen IL, Terkelsen AJ, Juhl GI, Kristensen AD, et al. Intravenous Lidocaine Relieves Spinal Cord Injury PainA Randomized Controlled Trial. Anesthesiology. 2005; 102(5):1023-30.
19. Maizels M, McCarberg B. Antidepressants and Antiepileptic Drugs for Chronic Non-Cancer Pain. South African Family Practice. 2006; 48(3):483-490.
20. Attal N, Cruccu G, Baron Ra, Haanpää M, Hansson P, Jensen TS, et al. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur J Neurol. 2010; 17(9):1113-1123.
21. Adams MM, Hicks AL. Spasticity after spinal cord injury. Spinal Cord. 2005; 43(10):577-585
22. Richards JS, Bombardier CH, Wilson CS, Chiodo AE, Brooks L, Tate DG, et al. Efficacy of venlafaxine XR for the treatment of pain in patients with spinal cord injury and major depression: A randomized, controlled trial. Arch Phys Med Rehabil. 2015; 96(4):680-9.
23. Hagen EM, Rekand T. Management of neuropathic pain associated with spinal cord injury. Pain Ther. 2015; 4(1):51-65.
24. Benzon H, Raja SN, Fishman SE, Liu SS, Cohen SP. Essentials of Pain Medicine E-book: Elsevier Health Sciences; 2011;8:370-377.
25. Drewes A, Andreasen A, Poulsen L. Valproate for treatment of chronic central pain after spinal cord injury. A double-blind cross-over study. Spinal Cord. 1994;32(8):565-9.
26. Teasell RW, Mehta S, Aubut J-AL, Foulon B, Wolfe DL, Hsieh JT, et al. A systematic review of pharmacologic treatments of pain after spinal cord injury. Arch Phys Med Rehabilitation. 2010; 91(5):816-31.
27. Norrbrink C, Lundeberg T. Tramadol in neuropathic pain after spinal cord injury: A randomized, double-blind, placebo-controlled trial. Clin J Pain. 2009; 25(3):177-84.
28. Woller SA, Hook MA. Opioid administration following spinal cord injury: Implications for pain and locomotor recovery. Exp Neurol. 2013; 247:328-41.
29. Siddall PJ, Molloy AR, Walker S, Mather LE, Rutkowski SB, Cousins MJ. The efficacy of intrathecal morphine and clonidine in the treatment of pain after spinal cord injury. Anesth Analg. 2000; 91(6):1493-8.
30. Cohen S, DeJesus M. Ketamine patient-controlled analgesia for dysesthetic central pain. Spinal Cord. 2004; 42(7):425-8.
31. Souza MFd, Kraychete DC. The analgesic effect of intravenous lidocaine in the treatment of chronic pain: A literature review. Rev Bras Reumatol. 2014; 54(5):386-92.
32. Finnerup N, Jensen T. Spinal cord injury pain–mechanisms and treatment. Eur J Neurol. 2004; 11(2):73-82.
33. Chiodo AC. Pain Management With lnterventional Spine Therapy in Patients With Spinal Cord Injury: A Case Series. J Spinal Cord Med. 2005; 28(4):338-42.
34. Li G, Lv C-a, Tian L, Jin L-j, Sun P, Zhao W. A randomized controlled trial of botulinum toxin A for treating neuropathic pain in patients with spinal cord injury. Medicine. 2017; 96(20):1-3.
35. G H adjipavlou AMC, B Ramaswamy. Spinal cord injury and chronic pain. Br J Anaesth. 2016; 16 (8):264–8.
36. Zuniga RE, Schlicht CR, Abram SE. Intrathecal baclofen is analgesic in patients with chronic pain. Anesthesiology. 2000; 92(3):876-80.
37. Hagenbach U, Luz S, Ghafoor N, Berger J, Grotenhermen F, Brenneisen R, et al. The treatment of spasticity with [Delta] 9-tetrahydrocannabinol in persons with spinal cord injury. Spinal cord. 2007; 45(8):551-562.
38. Pooyania S, Ethans K, Szturm T, Casey A, Perry D. A randomized, double-blinded, crossover pilot study assessing the effect of nabilone on spasticity in persons with spinal cord injury. Arch Phyl Med Rehabil. 2010; 91(5):703-7.
39. Elbasiouny SM, Moroz D, Bakr MM, Mushahwar VK. Management of spasticity after spinal cord injury: Current techniques and future directions. Neurorehabil Neural Repair. 2010; 24(1):23-33.
40. Hama A, Sagen J. Combination drug therapy for pain following chronic spinal cord injury. Pain Res Treat. 2012; 2012:1-7.
41. Friedly JL, Comstock BA, Turner JA, Heagerty PJ, Deyo RA, Sullivan SD, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. 2014; 371(1):11-21.
42. Gilron I, Bailey JM, Tu D, Holden RR, Weaver DF, Houlden RL. Morphine, gabapentin, or their combination for neuropathic pain. N Engl J Med. 2005; 352(13):1324-34.
43. Celik E, Erhan B, Gunduz B, Lakse E. The effect of low-frequency TENS in the treatment of neuropathic pain in patients with spinal cord injury. Spinal Cord. 2013;51(4):334-7.
44. Norrbrink C. Transcutaneous electrical nerve stimulation for treatment of spinal cord injury neuropathic pain. J Rehabil Res Dev. 2009; 46(1):85-94.
45. Norrbrink C, Lindberg T, Wahman K, Bjerkefors A. Effects of an exercise programme on musculoskeletal and neuropathic pain after spinal cord injury;Results from a seated double-poling ergometer study. Spinal Cord. 2012; 50(6):457-461.
46. Norrbrink C, Lundeberg T. Acupuncture and massage therapy for neuropathic pain following spinal cord injury: an exploratory study. Acupunct Med. 2011; 29(2):108-15.
47. Kenney JD. Acupuncture and Pain Management. American Association of Equine Practitioners. 2011; 57:121-37.
48. Choi DC, Lee JY, Lim EJ, Baik HH, Oh TH, Yune TY. Inhibition of ROS-induced p38MAPK and ERK activation in microglia by acupuncture relieves neuropathic pain after spinal cord injury in rats. Exp Neurol. 2012;236(2):268-82.
49. Chari A, Hentall ID, Papadopoulos MC, Pereira EA. Surgical Neurostimulation for Spinal Cord Injury. Brain Sci. 2017; 7(2):1-18.
50. Spaić M, Petković S, Tadić R, Minić L. DREZ surgery on conus medullaris (after failed implantation of vascular omental graft) for treating chronic pain due to spine (gunshot) injuries. Acta Neurochirurgica. 1999; 141(12):1309-12.
51. Bohlman HH, Kirkpatrick JS, Delamarter RB, Leventhal M. Anterior decompression for late pain and paralysis after fractures of the thoracolumbar spine. Clin Orthop Relat Res. 1994; 300:24-9.
52. Bang H, Chun SM, Park HW, Bang MS, Kim K. Lumbar Epidural Steroid Injection for Painful Spasticity in Cervical Spinal Cord Injury: A Case Report. Annal Rehabil Med. 2015;39(4):649-53.
53. Santamato A, Panza F, Ranieri M, Amoruso MT, Amoruso L, Frisardi V, et al. Effect of intrathecal baclofen, botulinum toxin type A and a rehabilitation programme on locomotor function after spinal cord injury: A case report. J Rehabil Med. 2010; 42(9):891-4.
54. Saulino M. Successful reduction of neuropathic pain associated with spinal cord injury via of a combination of intrathecal hydromorphone and ziconotide: A case report. Spinal Cord. 2007;45(11):749-752.
How to Cite
Khan Z, Majedi H, Hassan T. Pain Management in Spinal Cord Injury: A Narrative Review. Arch Anesth & Crit Care. 5(2):62-8.
Review Article(s)