Chronic neuropathic pain in spinal cord injured patients: what is the effectiveness of surgical treatments excluding central neurostimulations?

OBJECTIVE

Analyzing the literature and elaborating recommendations on the following topics: relevance of dorsal root entry zone (DREZ) lesions, surgical treatment for posttraumatic syringomyelia, other therapeutic approaches (peripheral nerve root pain, nerve trunk pain and Sign Posterior Cord [SCI] pain).

METHODS

The methodology used, proposed by the French Society of Physical Medicine and Rehabilitation (SOFMER), includes a systematic review of the literature, the gathering of information regarding current clinical practices and a validation by a multidisciplinary panel of experts.

RESULTS

Ninety-two articles were selected, 10 with a level of evidence at 2, 82 with a level of evidence at 4. Some articles lacked information on the type of injury, the pain characteristics and the symptoms' evolution over time. DREZ: This type of procedure has been validated for its effectiveness on pain at the level of injury (transitional zone pain), but is inefficient for pain located below the level of injury. Posttraumatic syringomyelia (PTS): suspected when there is an increased neurological impairment, changes below the level of injury (mainly bladder dysfunctions) or a sudden onset of pain. The surgery associates arachnoid grafting, cyst drainage, expansile dural plasty (same treatment for posttraumatic tethered spinal cord and posttraumatic myelomalacia). PERIPHERAL NERVE ROOT, NERVE TRUNK OR TRANSITIONAL ZONE PAIN: Surgical implants (screws or clips) can generate radicular pain caused by inflammation and they can even move around with time. The material-induced constraints can also trigger pain. Surgical removal of osteosynthesis material (with an eventual saddle block) remains a simple procedure yielding good results. Correcting surgeries can also be performed (malunion and nonunion). Finally, compressive neuropathies (carpal tunnel syndrome, ulnar nerve entrapment) already have a well-defined treatment.

CONCLUSIONS

The literature review can define the relevance of surgical treatments on some types of SCI pain. However, the results of many articles are difficult to analyze, as they do not report clinical or follow-up data.