Attending Faculty Memorial Healthcare System Hollywood, Florida, United States
Case Diagnosis: Traumatic Incomplete Asia C Quadriplegia
Case Description: 33 y/o opioid naive female who sustained a MVA resulting in C6 vertebral fracture and acute cord compression requiring emergent cervical decompression and fusion. Postoperative course was complicated by intractable pain managed within 5 days with maximum dose of pregabalin (200mg three times a day), 50mg of amitriptyline at bedtime, methadone 5mg twice a day, cyclobenzaprine 10mg three times a day, and 15mg of immediate release morphine sulfate every 4 hours as needed which patient was using around the clock. On admission to our acute inpatient rehabilitation facility (IRF) patient presented with uncontrolled pain, hyperalgesia, irritable, impulsive, irrational, and with labile mood. On her 2nd night at the IRF patient left against medical advice without any medications. Patient was readmitted to the hospital 3 days later, presenting much more coherent, cooperative, and rational. Pain was then successfully treated with low dose of gabapentin and tramadol.
Discussions: Patients with spinal cord injuries (SCI) will experience pain, which can be severe. Pain is usually multifactorial, including nociceptive and neuropathic components. Neuropathic pain (NP) can be complex and therefore difficult to treat. Opioids are commonly used for pain management in this population, however their use for NP is controversial. We present a case of an opioid naïve patient with an acute traumatic SCI, aggressively treated with opioids, tricyclics antidepressants and maximum dose of antiepileptics in a short period of time and how this impacted acute IRF stay.
Conclusions: Pain is a common complication in patients with SCI and can impair quality of life. It is imperative for physicians to not only understand the type of pain, but also the timing and the context in order to prescribe an appropriate pain management regimen including pharmacological and non-pharmacological approaches keeping in mind the ethical principles of beneficence and first do no harm.