Update to Canadian Clinical Practice Guidelines for Neuropathic Pain in Spinal Cord Injury

The 2016 Canadian clinical practice guidelines for the management of neuropathic pain among patients with spinal cord injury (CanPainSCI) have been updated. A summary of the updates was published in Spinal Cord.

On the basis of new data, the panel formulated 3 new screening and diagnosis recommendations and 8 new treatment recommendations.

Screening and Diagnosis

The screening and diagnosis recommendations are that the Spinal Cord Injury (SCI) Pain Instrument (SCPI) and Neuropathic Pain Symptom Pain Inventory (NPSI) can be used to supplement a diagnosis of neuropathic pain (NP) among patients with SCI; NPSI can be used to supplement the assessment and documentation of NP; and NPSI can be used to supplement the evaluation of treatment response.

These 3 recommendations were based on 3 studies that found sufficient diagnostic accuracy for these instruments. The evidence supporting these recommendations, however, was not strong enough to change or replace current screening and diagnosis tools.

Treatment

The key guiding principles of caring for patients with NP after SCI are:

·   Patients should be encouraged to employ self-management strategies to help cope with NP after SCI.

·   A comprehensive management strategy should include aspects of pain associated with activity, sleep, and mood interference.

·   Clinicians should consider referring their patients to a SCI rehabilitation expert to help improve affected areas of their life.

·   An interdisciplinary pain management program can consist of education and/or cognitive therapy.

·   Cognitive behavioral therapy has been associated with improved coping skills and reducing pain interference.

For specific treatments, there were no updated recommendations for first-line treatments. The existing recommendations are that pregabalin or gabapentin should be used to reduce NP intensity and amitriptyline can be an alternative option.

For second-line treatments, now reclassified as “B” options, the panel recommends that oxcarbazepine can be used to reduce NP intensity following SCI. The existing recommendations are that tramadol can also be used as B options for reducing NP intensity. For patients with incomplete SCI, lamotrigine can be considered.

For C options, or third-line treatments, the new recommendation is that botulinum toxin A may be considered for the management of below-level NP after SCI. The botulinum toxin A injection should be given in the area of maximal pain. The existing recommendations are for transcranial direct current stimulation, or combined visual illusion can be considered.

For D options, cannabinoids can be considered to manage NP after SCI. The recommendation authors caution, however, that this recommendation is weak, as the quality of the evidence is moderate and there is a large adverse effect profile associated with cannabinoids. Existing recommendations are for transcutaneous electrical nerve stimulation or oxycodone to be considered.

Future Directions

The recommendation authors identified 14 treatment options that were not evaluated in the 2016 CanPainSCI recommendations but that require further research. Some of these options include ketamine, transcranial magnetic stimulation, hypnotic suggestion, diet, ultramicronized palmitoylethanolamide, and acupuncture, among others. There were also 10 treatments that were previously evaluated but deemed to require more study. As of the review for this update, no new studies were identified. These options include exercise, massage, lidocaine, and morphine, among others.

The CanPainSCI were designed to be living guidelines with an update every 4 to 5 years. The next steps should be for clinicians to review these recommendations and update existing clinical algorithms.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.

Reference

Loh E, Mirkowski M, Agudelo AR, et al. The CanPain SCI clinical practice guidelines for rehabilitation management of neuropathic pain after spinal cord injury: 2021 update. Spinal Cord. Published online February 5, 2022. doi:10.1038/s41393-021-00744-z