Spinal cord injury pain is one of the most important factors for a decreased quality of life. It's reported in between 34% to 94% of the population, and somewhere between 27% to 71% report severe pain, and the severe pain interferes with their quality of life, often through depression and social isolation. The pain assessment starts with a good history and physical. The medical evaluation for spinal cord injury pain needs to start by looking for non-SCI causes of somatic pain, musculoskeletal injury, disc disease, peripheral vascular disease, trauma, any of those things that may be non-SCI related. But then there also may be reversible causes of spinal cord injury pain, such as a syringomyelia or a compression mononeuropathy. Medical problems that make the spinal cord injury pain worse include urinary tract infections, bladder stones, pressure injuries, constipation. Any of those can exacerbate the neuropathic pain that is present at a low roar until one of these occurs, and then it turns into a screaming nightmare of pain. The SCI pain classification is typically divided into neuropathic and nociceptive, and each of those then is divided above level of injury, at level of injury, and below level of injury, and based on this classification, we're able to identify the most likely cause of the pain and can address it most effectively. Bumping all of spinal cord injury pain together results in confusion and inadequate treatment. So when you begin a treatment for spinal cord injury pain, you have to identify the pain generator because your management depends on the pain generator. Likewise, you need to maintain good health, good nutrition, maintain activity, maintain good sleep, and minimize exacerbating factors like we talked about, the pressure sores, infections, and stones. So for nociceptive, which is typically musculoskeletal in nature, we recommend the use of a sports medicine approach, an understanding that muscles are not overused but undertrained, and that when we can retrain muscles that are painful, and in spinal cord injury we're talking oftentimes shoulder musculature, if we can train the muscles and the shoulder complex, we can allow the person with spinal cord injury to improve their nociceptive muscular pain. If there's a nociceptive musculoskeletal problem below the level of injury or at the level of injury, these two can be treated with a physiatric muscular and musculoskeletal approach. It's a neuropathic pain that we typically think of as spinal cord pain, but needs to be differentiated from the nociceptive problems as well. For neuropathic pain, we have a myriad of medications and interventions. Antidepressants, typically, historically, amitriptyline, nortriptyline, and duloxetine have been used and have been effective in not only improving neuropathic pain, but also improving sleep and improving mood. Anticonvulsants, including gabapentin, pregabalin, and the carbamazepine and oxycarbazepine and lamotrigine, all of these have been used in various doses and in various settings. Antirhythmics, topical lidocaine, mixilatine has been tried. As you can see, there are a long list of different medications that have been tried. And as any time when you've got a long list of medications that can be tried, it means that none of them are really successful. At least none of them are successful in every case. And so a combination of these is often used in the atypical medications, the antidepressants, anticonvulsants, and antirhythmics, before or in addition to the standard pain medications, including opiates, NSAIDs, and acetaminophen. The effort of minimizing the use of opiates is critical because opiates do not seem to be as effective in neuropathic pain as once was thought. Interventions including transcutaneous electrical neurostimulation and computer-assisted dorsal root entry zone ablation have been demonstrated in many cases to be effective. The key with the DRESS procedure is you need to have a surgeon who believes in this and is able to do this. Neuropathic pain that cannot be treated with the typical and atypical pain medications is often an ongoing challenge, and the emotional and psychological component of pain and suffering needs to also be fully addressed. I want to talk about pulmonary complications because the loss of expiratory muscle strength, the loss of an effective cough, is the number one cause of respiratory complications. People who have high level of injury and have ventilatory insufficiency, we can manage that with support, but if we can't get rid of those secretions, then re-hospitalization, death due to pneumonia and atelectasis are very common, and again, the consortium clinical practice guideline is very beneficial. Sputum clearance is essential because in the supine position, the lungs don't clear well, and this image on the screen shows the left lower lobe consolidation in this individual. The left lower lobe is very difficult to drain, and without a combination of assisted cough, insufflation, exsufflation, and possibly electrical stimulation to recreate a good cough, suctioning will not in itself clear most of the secretions on the left and definitely not clear the left lower lobe. Stroke and cessation is critical and yet is not very successful in these patients as well. Sleep apnea is more common in people with tetraplegia and should be investigated, and immunizations are vital because influenza and pneumococcal pneumonia are treatable and preventable but can be life-threatening in cases of spinal cord injury, especially tetraplegia. I want to also just emphasize that for those people on ventilators, tidal volume makes a difference. This is an individual who has, on the left, who has a tidal volume set at 600, which is approximately 6 cc per kilogram of body weight, not an uncommon level of ventilation to prevent barotrauma for ICU-type patients, but a neuromuscular weakness. This just leads to atelectasis and potential pneumonia. When we increased his tidal volume to 10 cc per kilogram or 1,000 cc, we were able to clear these airways significantly in a period of a month. So the challenge is often balancing the pulmonary specialist's approach to the polio specialist's approach. Neuromuscular weakness versus intrinsic lung disease requires a different approach to managing ventilator tidal volumes. Sexuality and sexual function after spinal cord injury are very important to our patients and are becoming more and more successful in management. The Clinical Practice Guideline on Sexuality and Reproductive Health was published a number of years ago and has provided significant advances in this area. When assessing for sexual function, we want to look not just at the sacral roots, which are both parasympathetic innervation and somatic innervation, but also the preservation of the T11 to L2 sympathetic innervation through the hypogastric nerve. These two areas of nerve innervation are important in understanding what type of sexual function may be available. Likewise, the presence of voluntary anal contraction and the presence or absence of anal reflexes is essential. So for men, we're talking initially about erections. For those who have preservation of the T11 to L2 dermatomes, they often will have psychogenic erections. Those with complete spinal cord injury above T10 with ongoing reflex activity below the level of injury can have reflex erections, and some men can have the combination. 46% of men in one report reported ejaculating after spinal cord injury, and a similar number reporting orgasm following spinal cord injury. Much of this really depends on degree of completeness and the level of injury. 29% reported symptoms of autonomic dysreflexia during sexual activity, but only 16% said it interfered with their quality of sexual activity. Ejaculation consists of seminal emission mediated through the T10 to L2 segments, pelvic ejaculation of the pelvic nerve and parasympathetic, which is coming both through pelvic contraction and autonomic innervation. Men with incomplete lower motor neuron injuries are more likely to be able to ejaculate with routine and private sexual practices, but those with complete upper motor neuron lesions, no matter what the level, are least likely. Therefore, efforts at sperm retrieval are necessary in this population. Vibration can be effective for men with upper motor neuron lesions who have an intact T10 to S4 spinal cord. Therefore they have reflexes and the vibro-stimulation can trigger a reflex ejaculation. Electro-ejaculation directly stimulates the peripheral nerves intrarectally to elicit a seminal emission and is independent of the spinal reflexes. The sperm quality will be improved with repeated ejaculation, and if good quality sperm cannot be achieved using these methods, then more surgical methods may be employed as well. For erectile dysfunction, oral phosphodiesterase inhibitors are now commonly used in people with spinal cord injury. If a person is using a nitrate, either for blood pressure or for autonomic dysreflexia, the timing of the use of the nitrate needs to be aware because the combination of the PDE5 inhibitors and nitrates can be fatal due to irreversible hypotension. Likewise, effective erections can be obtained through intracavernosal injections through prostaglandins or a combination of the classic trimix of alprostadil, papavirin, and fentolamine. For example, vacuum erection devices and constriction bands can be valuable, and then surgical prostheses and even sacral root stimulators have been used to treat erectile dysfunction. For women, sexual function requires a combination of vaginal engorgement and lubrication, and again like psychogenic erections in men, preservation of the low thoracic and upper lumbar nerves allows psychogenic engorgement and lubrication, but reflex vaginal engorgement and lubrication is available with complete spinal cord injury above T10, as long as the reflexes are intact parallel to men. Nearly half of women report the ability to achieve an orgasm with manual stimulation. More commonly in women with incomplete spinal cord injury, and specifically 17% with complete lower motor neuron injuries versus 59% of women with levels not affecting that sacral root. So the injury to the S2 through 5 roots makes orgasm much more unlikely in women. Women retain their fertility once their menstrual cycle resumes following injury, and birth control methods should resume then with sexual activity if she doesn't want to become pregnant. The most common use of birth control, 39% using a condom by the partner, permanent sterilization, a little over a quarter percent in oral contraceptives at 22%. Oral contraceptives are effective but do have an increased risk of thromboembolic disease. For a woman with spinal cord injury who gets pregnant, there are a number of things to be considered, including the increased risk of urinary tract infection, decreased respiratory capacity because of the growing uterus, worsening edema in the lower extremities, a change of weight in the center of gravity will affect their posture in their wheelchair and their ability to do transfers. There may also be a change in their bowel function. They may develop autonomic dysreflexia, either because of bowel, bladder, or uterine pain. Spasticity can worsen, and there may need to be a modification of their medication regimen to get them off of medications that can have fetal side effects. Delivery for a woman with spinal cord injury is always considered high risk because they're at a high risk for unrecognized labor, especially if they've got a higher level T10 and above. So frequent checks for early labor after 28 weeks is recommended. They also may experience atypical symptoms of labor initiating. Spasticity changes, dysreflexia, bladder spasm, or pain of their shoulder or upper back may be their symptom of labor starting. And for those with a T6 and above spinal cord injury, autonomic dysreflexia can occur with the onset of labor, and this may be mistaken for preeclampsia, high blood pressure in women who are pregnant. The use of epidural anesthesia is recommended for women who have a spinal cord injury above T6 and are at risk for dysreflexia, or for women who are incomplete and have sensory pain in the area. A vaginal delivery is possible and is often successful, although forceps vacuum may be helpful or necessary, and with failure to progress, a C-section may be necessary. Functional deteriorations following spinal cord injury can occur due to a number of factors. There may be neurologic changes, musculoskeletal changes, social and psychological changes, behavioral complications, aging. All of these things can contribute to changes in function over time, and it's important to identify and treat the underlying cause of that deteriorating function. And for many, a repeat round of rehabilitation, focusing on exercises, education, equipment, and environmental modification, and reemphasizing the role of empowerment and self-control may be necessary to allow these people to regain some of their independence. Late neurologic deterioration can be seen due to syringomyelia. Interestingly, pain is the most common presenting sign, and so pain above the level of injury should be investigated with MRI for the evidence of expanding syrinx. There can also be adjacent segment-bind degeneration above and below a spinal fusion. There can be excess mechanical forces, which leads to increased degenerative changes and canal stenosis, resulting in myelopathy at a higher level, and extending the decompression may be necessary. Likewise, peripheral nerve compression can be seen due to either positioning or particular use of their hands during transfers or wheelchair propulsion. Doing an annual neurologic exam is necessary to document and identify changes early. Once you identify that there is a change, identifying the underlying cause, including an HNP to look for treatable and reversible causes, an MRI at the level of injury and maybe extending above and below, and usually EMG to look for evidence of peripheral nerve involvement, radicular nerve involvement, or anterior horn cell involvement can be helpful. Whether or not there is a recovery of this depends on early detection and aggressive neurosurgical treatment, because once the neurological deficit has been present, there is little likelihood of a significant recovery unless it has been identified early. Spinal cord injury, as I mentioned earlier, used to be a cause, the most common cause of death was infection and renal failure. Now the most common cause of death are diseases of the respiratory system, infectious disease continued to be high, but neoplasm, hypertensive and ischemic heart disease, and other heart disease, those diseases of an advanced civilization are creeping into the causes of death of people with spinal cord injury. Unintentional injuries are also important to consider because they may be preventable with seatbelt use and proper transportation, safety measures, diseases of the GI system, cerebrovascular disease, and interestingly, suicide is also in the top 10 causes of death in SCI. The top 10 rounds out the pulmonary circulation, so pulmonary embolism makes up number 10 for the top 10 causes of death. Most of these are preventable with good quality care and rehabilitation.

spinal cord injury pain

quality of life

medical evaluation

neuropathic pain

antidepressants

respiratory health