Brief Overview: Chronic pain is a common and complex complication of spinal cord injury, often involving multiple mechanisms. Pain can be neuropathic (nerve-related), musculoskeletal, or visceral and may persist for years after the injury. It significantly impacts function, mental health, and quality of life in patients with SCI.
Prevalence: According to UpToDate, “Reported prevalences vary considerably. On average, two-thirds of patients suffer chronic pain and approximately one-quarter to one-third of patients have severe pain that significantly affects quality of life.”
Etiology:
- Neuropathic pain: damaged spinal cord pathways, abnormal nerve signaling.
- Musculoskeletal pain: overuse of shoulders/arms with wheelchair use or transfers, posture issues.
- Visceral pain: bowel, bladder, or abdominal complications.
- Secondary complications: pressure sores, infections, spasticity.
Risk Factors:
- Higher level or more severe SCI.
- Complete vs. incomplete spinal cord injuries.
- Older age at time of injury.
- Prolonged immobility.
- Poor posture, wheelchair dependence.
- Depression and anxiety.
Commonly Associated Conditions:
- Depression, anxiety, PTSD.
- Sleep disturbance, fatigue.
- Spasticity and contractures.
- Pressure ulcers, urinary tract infections, constipation.
- Autonomic dysreflexia in high-level SCI.
Common Medications:
- NSAIDs, Tylenol
- Anti-seizure medications like gabapentin
- Muscle relaxers
- Antidepressants
- Topicals like lidocaine
- Opioids
- Intrathecal morphine, clonidine, baclofen
Common Labs, Imaging, and Tests:
- Diagnosis is typically made clinically
- Imaging (X-ray, MRI) if new/worsening musculoskeletal pain or hardware complication.
- Labs (CBC, metabolic panel) if systemic infection suspected.
- Pain questionnaires (Neuropathic Pain Scale, Numeric Pain Rating).
Common Symptoms:
- Neuropathic: burning, shooting, tingling, electric shock-like pain below level of injury.
- Musculoskeletal: dull, aching pain in overused joints (shoulders, neck, back).
- Visceral: abdominal cramps, bladder pain, constipation-related pain.
- Pain may be constant or triggered by activity.
- Associated with sleep problems, mood changes, reduced mobility.
Common Treatments:
- Physical therapy
- Changing your activity or equipment
- TENS
- Acupuncture
- Relaxation techniques
- CBT
- Spinal cord stimulation may be indicated, or an option, for some
Physical Findings:
- May be normal despite severe reported pain.
- Neuropathic: sensory changes (allodynia, hyperalgesia, numbness).
- Musculoskeletal: joint/muscle tenderness, limited ROM, abnormal posture.
- Spasticity, contractures, muscle atrophy.
- Pressure ulcers or skin breakdown may be present.
Potential Complications and Contraindications:
- Complications:
- Severe disability, reduced independence.
- Depression, anxiety, substance misuse.
- Pressure ulcers, infections due to immobility.
- Falls or injuries from spasticity or weakness.
- Contraindications:
- NSAIDs: avoid in renal disease, GI bleed risk.
- TCAs: caution in older adults (cardiac risk, anticholinergic side effects).
- Muscle relaxants: risk of sedation, falls in seniors.
- Chronic opioid therapy: high risk of dependence, limited long-term benefit.
General Health and Lifestyle Guidance:
- Encourage daily stretching and gentle activity as tolerated.
- Maintain skin care and pressure relief routines to prevent ulcers.
- Ensure wheelchair fit and posture are optimized.
- Prioritize sleep hygiene and stress management.
- Balanced diet with adequate hydration and bowel regimen.
- Support mental health with counseling or peer groups.
- Encourage regular follow-up with rehabilitation and pain specialists.
Suggested Questions to Ask Patients:
- Where is your pain located, and how would you describe it?
- How long have you had this pain, and what makes it better or worse?
- Does the pain interfere with sleep, mood, or daily activities?
- Do you use a wheelchair or assistive devices — do they cause discomfort?
- What medications or treatments are you currently using for pain? Do they help?
- Do you have muscle spasms, stiffness, or skin sores?
- How does pain affect your independence and quality of life?
Suggested Talking Points:
- Chronic pain after a spinal cord injury is very common and can come from nerves, muscles, or even posture.
- You will likely use a combination of treatments — not just medications — to help manage your pain.
- Neuropathic pain medicines like gabapentin or duloxetine may help with nerve-related pain.
- Physical therapy, proper wheelchair support, and gentle activity can reduce muscle strain.
- Pain can affect mood and sleep — treating both physical and emotional health is important.
Sources:
- https://www.upmc.com/services/rehab/rehab-institute/conditions/spinal-cord-injury/education-spinal-injury/pain-management
- https://stanfordhealthcare.org/medical-conditions/brain-and-nerves/chronic-pain/types/spinal-cord-injury-pain.html
- https://sci.washington.edu/info/pamphlets/msktc-pain.asp
- https://www.uptodate.com/contents/chronic-complications-of-spinal-cord-injury-and-disease?search=chronic%20pain%20after%20spinal%20cord%20injury&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H26
This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner