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SCI – Refractory Neuropathic Pain — SCE Neurology MCQ

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ModerateNeurorehabilitationSCI – Refractory Neuropathic PainSCE Neurology

A 45-year-old man with complete T6 paraplegia from a spinal cord injury presents with severe neuropathic pain below the level of injury. He describes burning, shooting pain in both legs. He has tried gabapentin 900 mg TDS, amitriptyline 50 mg nocte, and duloxetine 60 mg daily without adequate pain control. What should be considered next?

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Correct answer: C — Refer to a specialist pain service for consideration of intrathecal drug delivery or neuromodulation

Neuropathic pain below the level of spinal cord injury that is refractory to adequate trials of first-line (gabapentin/pregabalin, amitriptyline/duloxetine) and second-line agents requires referral to a specialist pain service. Options include combination pharmacotherapy, intrathecal drug delivery (baclofen, clonidine, ziconotide), transcutaneous electrical nerve stimulation (TENS), or spinal cord stimulation. A: The gabapentin dose is already adequate; further increase may cause side effects without benefit. B: Switching within the same class may not add benefit. D: Opioids have limited efficacy for neuropathic pain and significant risks. E: Topical capsaicin requires intact sensation, which is absent below the injury level.

Reference: NICE CG173 Neuropathic Pain (2013); NICE NG62 Spinal Cord Injury (2016)