Abstract
Objectives: Assess the occurrence of neuropathic pain in spinal cord injured persons (SCIP) and define the relationship between neuropathic pain with demographic and clinical characteristics in SCIPs.
Methods: This Analytical cross-sectional study was conducted on 104 SCIPs treated at our tertiary care hospital. Initial clinical evaluation was done according to the American Spinal Injury Association (ASIA) impairment scale. A clinical evaluation was done. All subjects were screened with the Leeds Assessment of Neuropathic Symptoms, Signs (LANSS) and DN4 questionnaire for neuropathic pain. The Visual Analogue Scale (VAS) was used to measure the severity of neuropathic pain. Later two groups were created based on the presence and absence of neuropathic pain.
Results: The mean age was 35.04 ± 13 years. Fifty-eight patients (55.8%) had a complete injury (ASIA grade A), 41 (39.4%) patients had an incomplete kind of injury (ASIA grade B-D) and 5(4.8%) patients had no deficits (ASIA grade E). Neuropathic pain was present in 77(74.0%) and absent in 27(26.0%) patients. Seventy-one patients (92.2%) experience neuropathic pain in the first year after traumatic SCI. Medicines were a common pain-relieving factor 64(83.1%).
Conclusion: 74% of patients complained of neuropathic pain, indicating a significant complication. A comprehensive evaluation and treatment are necessary to address it while including variables like the completeness of injury, duration and timing.
Keywords: Neuropathic pain, Rehabilitation, Spinal cord injury
Introduction
Spinal cord injury (SCI) causes loss of motor and sensory functions, among other complex co-morbidities. About two-thirds of patients with SCI report some form of pain, and nearly one-third rate their pain as severe (2). The prevalence of neuropathic pain varies between 18 to 96%, and a third of it is neuropathic pain making it a common debilitating complication (1).
The International Association for the Study of Pain broadly classifies pain as nociceptive and neuropathic. Neuropathic pain is caused by a lesion or disease of the somatosensory nervous system (2). It results from peripheral or central nervous system dysfunction without peripheral nociceptive stimulation (3). SCI-specific neuropathic pain is spontaneous and described as an abnormal sensation experienced as burning, tingling, stabbing, shooting and aching (1). Neuropathic pain directly contributes to disability by reducing the patient's ability to participate in rehabilitation, compromising the quality of life and activities of daily living (3).
This study explores the occurrence of neuropathic pain in post-traumatic SCI patients who presented for rehabilitation and follow-up at our tertiary care hospital. We also assess a possible relationship between neuropathic pain and socio-demographic and clinical characteristics.
Methods and materials
This cross-sectional study included one hundred four post-traumatic SCI patients. Patients with age less than 18 years of age, time since injury less than one month, peripheral nerve injury, urinary tract infection, diabetes mellitus, heterotrophic ossification formation, pressure ulcer (grade 3 or more) and severe spasticity (Ashworth 3 or more) or any other co-morbidity affecting the neuraxial or peripheral nervous system are not included in the study.
American Spinal Injury Association (ASIA) impairment scale & clinical evaluation, including sensory and motor examination, was done (4). Age, sex, marital status, education, pre-morbid employment status, demographics and socioeconomic status were recorded. Kuppuswamy scale was used to classify socioeconomic status (5). The patients were divided by age at the time of injury into six groups: 18–30, 31–40, 41–50, 51–60, 61–70, and 71–80 years. Patients were divided into cervical, thoracic, and lumbar groups according to injured segment and further divided into upper and lower segments groups for ease of statistical assessment. Screening for neuropathic pain was performed with the Leeds assessment of neuropathic symptoms and signs (LANSS) (6), and further evaluation was done with the DN4 questionnaire (7,8). The time interval between trauma and neuropathic pain onset was also recorded. The severity of neuropathic pain was assessed using 10 points Visual Analogue Scale (VAS). Hamilton depression scale was used to evaluate depression in patients (9).
The hospital's ethics committee approved the study, which was carried out according to the institutional guidelines. All study participants gave informed consent before inclusion.
Statistical analysis: The data were recorded in Microsoft Excel software. The qualitative data were expressed as rates and proportions, while quantitative data were expressed as mean and standard deviation. The chi-square and Fisher Exact tests were applied to explore whether the association value <0.05 was significant.
Results
Eighty-seven males (83.7%) and seventeen females (16.3%) are included in this study, and on screening, neuropathic pain was present in 77(74.0%) and absent in 27(26.0%) patients.
The occurrence of neuropathic pain according to each group is shown in Table 1.The mean age of patients included in the study was 35.04 ± 13.00 years; notably, the occurrence of neuropathic pain was higher in the elder age group.
Table 1.
Occurrence of neuropathic pain according to each socio-demographic variable.
| Parameters | N | Neuropathic Pain | Occurrence of Neuropathic pain | P-value | |
|---|---|---|---|---|---|
| Yes(n = 77) | No(n = 27) | ||||
| Age (Years) | 36.10 ± 12.48 | 32.00 ± 14.20 | 0.055 | ||
| Age groups | |||||
| 18–30 Years | 48 (46.2%) | 33 (42.9%) | 15 (55.6%) | 33 (68.8%) | 0.246 |
| 31–40 Years | 29 (27.9%) | 23 (29.9%) | 6 (22.2%) | 23 (79.3%) | |
| 41–50 Years | 13 (12.5%) | 9 (11.7%) | 4 (14.8%) | 9 (69.2%) | |
| 51–60 Years | 9 (8.7%) | 9 (11.7%) | 0 (0.0%) | 9 (100.0%) | |
| 61–70 Years | 4 (3.8%) | 2 (2.6%) | 2 (7.4%) | 2 (50.0%) | |
| 71–80 Years | 1 (1.0%) | 1 (1.3%) | 0 (0.0%) | 1 (100.0%) | |
| Sex | |||||
| Male | 87 (83.7%) | 65 (84.4%) | 22 (81.5%) | 65 (74.7%) | 0.765 |
| Female | 17 (16.3%) | 12 (15.6%) | 5 (18.5%) | 12 (70.6%) | |
| Marital Status | |||||
| Married | 79 (76.0%) | 61 (79.2%) | 18 (66.7%) | 61 (77.2%) | 0.189 |
| Unmarried | 25 (24.0%) | 16 (20.8%) | 9 (33.3%) | 16 (64.0%) | |
| Education | |||||
| Illiterate | 17 (16.3%) | 13 (16.9%) | 4 (14.8%) | 13 (76.5%) | 0.704 |
| Primary School Certificate | 15 (14.4%) | 10 (13.0%) | 5 (18.5%) | 10 (66.7%) | |
| Middle School Certificate | 26 (25.0%) | 21 (27.3%) | 5 (18.5%) | 21 (80.8%) | |
| High School Certificate | 15 (14.4%) | 9 (11.7%) | 6 (22.2%) | 9 (60.0%) | |
| Intermediate Or Diploma | 17 (16.3%) | 12 (15.6%) | 5 (18.5%) | 12 (70.6%) | |
| Graduate | 10 (9.6%) | 8 (10.4%) | 2 (7.4%) | 8 (80.0%) | |
| Professional Or Honours | 4 (3.8%) | 4 (5.2%) | 0 (0.0%) | 4 (100.0%) | |
| Occupation | |||||
| Unemployed | 21 (20.2%) | 13 (16.9%) | 8 (29.6%) | 13 (61.90%) | 0.117 |
| Employed | 75 (72.1%) | 59 (76.62%) | 16 (59.26%) | 59 (78.67%) | |
| Homemaker | 8 (7.7%) | 5 (6.5%) | 3 (11.1%) | 5 (62.5%) | |
| Kuppuswamy SES Score | |||||
| Upper Middle | 1 (1.0%) | 0 (0.0%) | 1 (3.7%) | 0 (0.0%) | 0.088 |
| Lower Middle | 14 (13.5%) | 13 (16.9%) | 1 (3.7%) | 13 (92.9%) | |
| Upper Lower | 82 (78.8%) | 58 (75.3%) | 24 (88.9%) | 58 (70.7%) | |
| Lower | 7 (6.7%) | 6 (7.8%) | 1 (3.7%) | 6 (85.7%) | |
Forty-eight (46.2%) patients were of the 18–30 years age group, 29(27.9%), 13(12.5), 9(8.7%), 4(3.8%) and 1(1.0%) patients were in the age group of 31–40 years, age group 41–50 years, 51–60 years age group, 61–70 years age group and 1(1.0%) of 71–80 years age group respectively.
The pain occurrence among males (74.7%) was slightly higher than the females (70.6%), but this sex difference was not statistically significant (P = 0.765).
Most of the patients were educated, and only seventeen (16.3%) patients were Illiterate, but the educational background did not correlate with the occurrence of neuropathic pain (P = 0.704). Only a tiny group was unemployed, 21(20.2%) (Table 1).
According to the Kuppuswamy scale, 82 (78.8%) patients are from the upper–lower class and 7(6.7%) patients to the lower socioeconomic class. There was no association between the prevalence of neuropathic pain and socioeconomic variables (P-value >0.05) (Table 1).
The occurrence of neuropathic pain among the groups classified according to the ASIA Impairment Scale (AIS) classification is shown in Table 2. Occurrence of neuropathic pain was 79.3% in patients with a complete type of injury (ASIA grade A), which is higher than the incomplete kind of injury group (73.2%) (ASIA grade B-D). A significant relationship between neuropathic pain and completeness of injury (P = 0.022) was observed.
Table 2.
Occurrence of neuropathic pain according to each clinical variable.
| Parameters | N | Neuropathic Pain | Occurrence of Neuropathic pain | P-value | |
|---|---|---|---|---|---|
| Yes(n = 77) | No(n = 27) | ||||
| Trauma-Pain Interval (Days) | 132.10 ± 217.66 | - | - | ||
| Segment Involved (Vertebral Level) | |||||
| Upper Cervical | 12 (11.5%) | 9 (11.7%) | 3 (11.1%) | 9 (75.0%) | 0.457 |
| Lower Cervical | 38 (36.5%) | 29 (37.7%) | 9 (33.3%) | 29 (76.3%) | |
| Upper Dorsal | 9 (8.7%) | 5 (6.5%) | 4 (14.8%) | 5 (55.6%) | |
| Lower Dorsal | 33 (31.7%) | 26 (33.8%) | 7 (25.9%) | 26 (78.8%) | |
| Upper Lumbar | 11 (10.6%) | 8 (10.4%) | 3 (11.1%) | 8 (72.7%) | |
| Lower Lumbar | 1 (1.0%) | 0 (0.0%) | 1 (3.7%) | 0 (0.0%) | |
| Neurological Level | |||||
| Upper Cervical | 12 (12.2%) | 10 (13.2%) | 2 (9.1%) | 10 (83.3%) | 0.203 |
| Lower Cervical | 33 (33.7%) | 25 (32.9%) | 8 (36.4%) | 25 (75.8%) | |
| Upper Dorsal | 10 (10.2%) | 6 (7.9%) | 4 (18.2%) | 6 (60.0%) | |
| Lower Dorsal | 29 (29.6%) | 23 (30.3%) | 6 (27.3%) | 23 (79.3%) | |
| Upper Lumbar | 10 (10.2%) | 10 (13.2%) | 0 (0.0%) | 10 (100.0%) | |
| Lower Lumbar | 4 (4.1%) | 2 (2.6%) | 2 (9.1%) | 2 (50.0%) | |
| Sensory Score | |||||
| Light Touch | 66.73 ± 30.86 | 77.11 ± 36.69 | 0.114 | ||
| Pin Prick | 65.61 ± 29.87 | 77.11 ± 36.69 | 0.079 | ||
| Motor Score | |||||
| Upper Limb | 36.32 ± 16.72 | 41.04 ± 15.42 | 0.264 | ||
| Lower Limb | 9.86 ± 15.40 | 17.30 ± 20.33 | 0.069 | ||
| Type of Injury | |||||
| Complete | 58 (55.8%) | 46 (59.7%) | 12 (44.4%) | 46 (79.3%) | 0.022 |
| Incomplete | 41 (39.4%) | 30 (39.0%) | 11 (40.7%) | 30 (73.2%) | |
| Normal | 5 (4.8%) | 1 (1.3%) | 4 (14.8%) | 1 (20.0%) | |
| Asia Grade | |||||
| A | 58 (55.8%) | 46 (59.7%) | 12 (44.4%) | 46 (79.3%) | 0.073 |
| B | 5 (4.8%) | 4 (5.2%) | 1 (3.7%) | 4 (80.0%) | |
| C | 18 (17.3%) | 14 (18.2%) | 4 (14.8%) | 14 (77.8%) | |
| D | 18 (17.3%) | 12 (15.6%) | 6 (22.2%) | 12 (66.7%) | |
| E | 5 (4.8%) | 1 (1.3%) | 4 (14.8%) | 1 (20.0%) | |
| Spasticity | 37 (35.6%) | 30 (39.0%) | 7 (25.9%) | 30 (81.08%) | 0.223 |
| Pressure sore | 22 (21.2%) | 16 (20.8%) | 6 (22.2%) | 16 (72.73%) | 0.874 |
The average time interval between spinal cord injury and the onset of neuropathic pain was 132.10 ± 217.66 days in our study group (Table 3).
Table 3.
Trauma and pain-onset interval.
| Trauma-Pain onset Interval | Neuropathic Pain | |
|---|---|---|
| N | % | |
| ≤30 Days | 16 | 20.8% |
| 31–90 Days | 38 | 49.4% |
| 91–180 Days | 10 | 13.0% |
| 181–365 Days | 7 | 9.1% |
| >365 Days | 6 | 7.8% |
| Total | 77 | 100.0% |
As mentioned, each spinal segment (cervical, thoracic & lumbar) was further divided into upper and lower segments. 11.5% of patients had upper cervical part (C1–C4) involvement, and 36.5%, 8.7%, 31.7%, 10.6% in lower cervical part (C5–C7), upper dorsal segment (D1–D6), lower dorsal segment (D7–D12), upper lumbar segment (L1–L2) and lower lumbar part (L3–L5) respectively.
The occurrence of neuropathic pain varies from 6.5% to 37.5% based on different spinal segments but was higher in patients with cervical spine injury at lower cervical segment involvement (C5–C7 Level). In comparison, no neuropathic pain was found in patients with lower lumbar segment involvement.
The correlation of neuropathic pain was neither observed with spasticity nor pressure ulcers.
Table 4 shows that out of 77 patients with neuropathic pain, 34(44.2%) patients had a gradual onset of pain. Whereas 43(55.8%) patients had sudden onset of pain. According to the Visual Analogue Scale (VAS), most patients had mild to moderate pain severity, and only eight (10.4%) reported severe pain. In contrast, 34(44.2%) patients had mild pain, and 35(45.5%) patients had moderate pain severity.
Table 4.
Neuropathic pain details.
| Pain Details | Frequency (%) |
|---|---|
| Neuropathic Pain | 77 (74.0%) |
| Onset of Pain | |
| Gradual | 34 (44.2%) |
| Sudden | 43 (55.8%) |
| Pain Severity | |
| Mild | 34 (44.2%) |
| Moderate | 35 (45.5%) |
| Severe | 8 (10.4%) |
Aggravating factors for neuropathic pain were wearing orthosis 28(36.4%) and tight clothes 2(2.6%), sitting 5(6.5%) and standing 1(1.3%) position, range of motion exercises 10(13.0%), hot 6(7.8%) and cold 2(2.6%) climate, walking 2(2.6%), night 37(48.1%), evening 7(9.1%) and afternoon 7(9.1%) a day (Table 5). Night time was most challenging for patients with neuropathic pain.
Table 5.
Aggravating factors of neuropathic pain.
| Aggravating Factors | Yes | No |
|---|---|---|
| Orthosis | 28 (36.4%) | 49 (63.6%) |
| Sitting | 5 (6.5%) | 72 (93.5%) |
| Standing | 1 (1.3%) | 76 (98.7%) |
| Rom Exercises | 10 (13.0%) | 67 (87.0%) |
| Summers / Hot | 6 (7.8%) | 71 (92.2%) |
| Walking | 2 (2.6%) | 75 (97.4%) |
| Tight Clothes | 2 (2.6%) | 75 (97.4%) |
| Winters / Cold | 2 (2.6%) | 75 (97.4%) |
| Evening | 7 (9.1%) | 70 (90.9%) |
| Night | 37 (48.1%) | 40 (51.9%) |
| Afternoon | 7 (9.1%) | 70 (90.9%) |
The most common pain-relieving factor was medicine intake 64(83.1%) (Table 6).
Table 6.
Relieving factors of neuropathic pain.
| Relieving Factors | Yes | No |
|---|---|---|
| Medicines | 64 (83.1%) | 13 (16.9%) |
| Orthosis | 8 (10.4%) | 69 (89.6%) |
| Bending Knees | 1 (1.3%) | 76 (98.7%) |
| Sitting | 1 (1.3%) | 76 (98.7%) |
| Straight Legs Position | 1 (1.3%) | 76 (98.7%) |
| ROM Exercises | 2 (2.6%) | 75 (97.4%) |
| Rest | 1 (1.3%) | 76 (98.7%) |
Out of 77 neuropathic pain patients, 9(11.7%) patients had no depression and 65(84.4%) patients suffered from mild depression. Three patients (3.9%) suffer from moderate depression. No patient had severe depression (Table 7).
Table 7.
Depression in neuropathic pain patients.
| Depression | Number of patients (out of 77) | Percentage |
|---|---|---|
| Normal | 9 | 11.7% |
| Mild | 65 | 84.4% |
| Moderate | 3 | 3.9% |
| Severe | 0 | 0% |
The variable Hamilton depression score was not normally distributed in the three subgroups of the variable Pain Severity. Thus, non-parametric tests (Kruskal Wallis Test) were used to make group comparisons, and we observed a significant difference between the three groups in terms of Hamilton Depression Score (P = <0.001). The median Hamilton Depression Score was higher in the moderate and severe pain severity groups (Table 8).
Table 8.
Comparison of the 3 Subgroups of the variable pain severity in terms of Hamilton depression score (n = 77).
| Hamilton Depression Score | Pain Severity | Kruskal Wallis Test | |||
|---|---|---|---|---|---|
| Mild | Moderate | Severe | χ2 | P-value | |
| Mean (SD) | 9.56 (2.93) | 12.57 (3.08) | 12.25 (3.69) | 15.813 | <0.001 |
| Median (IQR) | 9.5 (9–11) | 13 (11–15) | 12 (11.75–13.5) | ||
| Range | 3–16 | 6–21 | 5–18 | ||
| Pair-wise comparison of subcategories of pain severity | Adjusted P Value | ||||
| Mild – Moderate | <0.001 | ||||
| Mild – Severe | 0.067 | ||||
| Moderate – Severe | 1.000 | ||||
Post-Hoc pairwise tests for the Kruskal-Wallis test were performed using the Dunn Test method with Sidak correction.
We used non-parametric tests (Kruskal Wallis Test) and found that the median Hamilton Depression Score was higher in the ASIA Grade A and B groups. There was a statistically significant difference in Hamilton Depression Score between the five groups (P = 0.004) (Fig. 1).
Figure 1.
Association between ASIA grade and Hamilton Depression Score.
Discussion
In various studies, the prevalence of neuropathic pain in patients with SCI varies from 30% to 90% (1-2, 10–20). The occurrence of neuropathic pain is higher (77(74%))in this study than in the study of Afsar et al. (1), Werhagen et al. (10) & Margot-Duclot et al. (11) where its 53%, 40%& 40% respectively. The higher observation can be due to not distinguishing between at- or below-level neuropathic pain. Burke et al. (12) conducted a systematic review and meta-analysis to consider the pooled point prevalence of neuropathic pain post-SCI; prevalence rates for neuropathic pain were reported to be 53%. Siddall et al. (13) conducted a longitudinal cohort study among 100 traumatic SCI patients and observed that the prevalence of at-level neuropathic pain was 41% and below-level neuropathic pain was 34%. Budh et al. (14) conducted a study on pain in 456 Swedish spinal cord injury patients and found that 291 out of 456 SCI patients (63.7%) suffered from pain, and out of these, 45.7% suffered from neuropathic pain. Singh et al. (15) surveyed fifty persons with SCI, a follow-up assessment was performed in northern India and reported a 42% prevalence of neuropathic pain in SCI patients. Kalirathinam et al. (16) conducted a cross-sectional study on hundred patients with traumatic spinal cord injury at six months following SCI, and they reported a 36% prevalence of neuropathic pain. Verma et al. (17) surveyed a hundred patients with SCI and noted that out of 100, 90 patients suffered from pain, with neuropathic pain being the most prevalent. Kim et al. (2) showed the prevalence of neuropathic pain in SCI patients to be 69.1%. Andresen et al. (18) presented that 73% of traumatic SCI patients reported chronic pain, and 60% used descriptors suggestive of neuropathic pain. Adriaansen et al. (19) conducted a multicentre longitudinal study among 139 wheelchair-dependent persons with SCI and reported a one to five-year prevalence of neuropathic pain after discharge from initial inpatient rehabilitation. They found neuropathic pain prevalence at one year was 92.1%; at two years was 83.7%; and at five years was 87.1%. This change of plurality with time might be explained by the number of participants included in their study at one, two and five years. They had 224 persons with SCI at the start of the study, but 156 persons participated one year after discharge from the rehabilitation centre, 99 persons at two years and 146 persons five years after discharge. One hundred thirty-nine persons completed at least two measurements and were included in the analysis. Vall et al. (20) conducted a descriptive cross-sectional study on 109 patients with SCI living in Curitiba, Brazil and found an 18.3% prevalence of neuropathic pain. Ataoglu et al. (21) conducted a cross-sectional study among 140 SCI patients during inpatient rehabilitation treatment at Ankara Physical Medicine and Rehabilitation Education and Research Hospital, Turkey. They found neuropathic pain was the most common type (80 patients, 73.4%). All 80 patients had below-level neuropathic pain, and 11(13.8%) patients also had at-level neuropathic pain.
Studies on the relationship between SCI-related pain and age have not provided a precise conclusion (22–24). We found no association between neuropathic pain presence and age (P = 0.246). Afsar et al. (1) also reported no correlation between neuropathic pain presence and age. Werhagen et al. (10) submitted that the prevalence of neuropathic pain has a positive correlation with age. Aquarone et al. (25) described a high prevalence of neuropathic pain in SCI patients between 30 and 39 years. On the other end study by Vall et al. (19) indicated higher neuropathic pain prevalence in patients younger than 40 years.
We found no relationship between neuropathic pain presence and educational level (P = 0.704) and ASIA grade (P = 0.073), similar to Afsar et al. (1) and Kim et al. (2). However, Aquarone et al. (25) reported a greater prevalence of neuropathic pain in SCI patients with primary education.
We found no significant relationship between neuropathic pain presence and sex (P = 0.765) analogous to Werhagen et al. (10). Conversely, Aquarone et al. (25) and Vall et al. (20) described higher prevalence in males.
Budh et al. (14, 26) and Afsar et al. (1) reported a significant relationship between neuropathic pain presence and sex. Their study showed that neuropathic pain was statistically significantly more common in females.
No significant relationship is witnessed between neuropathic pain presence and marital status (P = 0.189) in this study, whereas Kim et al. (2) and Aquarone et al. (25) discerned more among the married.
We observe no substantial relationship between neuropathic pain and occupation (P = 0.117), similar to the study by Kim et al. (2).
An insignificant relationship between neuropathic pain presence and socioeconomic status (Kuppuswamy score) (P = 0.088) is observed by us. Goossens et al. (27) conducted a literature review including 34 articles to assess the impact of socioenvironmental factors on the onset of pain and found that low socioeconomic status and unemployment were considered potential triggering factors for the start of chronic pain in spinal cord injury patients.
A sizable relationship between neuropathic pain appearance and type of injury (P = 0.022) is noted here. Budh et al. (14, 26) found neuropathic pain more common in patients with incomplete lesions, although Werhagen et al. (10) couldn't show a statistically significant difference between neuropathic pain prevalence and type of injury. Aquarone et al. (25) and Vall et al. (20) also reported that neuropathic pain is most common in incomplete injury. Summers et al. (28) conducted a study on psychosocial factors in chronic spinal cord injury pain in Kansas City, U.S.A. and found that completeness of injury was not associated with pain severity.
No expressive relationship between the presence of neuropathic pain and neurological level of injury (P = 0.203), pain severity (P = 1.000) and vertebral level (P = 0.4572) is observed by us. Afsar et al. (1) compared groups with or without pain and found no meaningful difference in lesion level or severity (P = 0.686,P = 0.340, respectively). Werhagen et al. (10) noted a trivial difference between neuropathic pain prevalence and neurological level of injury. Siddall et al. (13) reported no relationship between pain and lesion level and severity, as by Turner & Cardenas (24) and Summers et al. (28) noted that the level of the lesion was not associated with pain severity.
We didn’t find any connection between neuropathic pain and Spasticity (P = 0.2233) even though Spasticity exists in 37(35.6%) out of 104 traumatic SCI patients. We found no link between spasticity and neurological level, type of injury, ASIA grade or pain severity. Singh et al. (15) surveyed fifty SCI follow-up patients and found a 60% prevalence of Spasticity. Andresen et al. (18) reported that the majority of Spasticity in traumatic SCI patients was 71%. They suggested that participants with pain and a DN4 score ≥3 had a higher spasm frequency.
In our study, there are pressure ulcers in 22(21.2%) patients but no corresponding association between the presence of neuropathic pain and pressure sore (P = 0.874).
Neuropathic pain, a significant complication of SCI, has been reported to happen usually within the first year, mainly during the first six months. We find here that 92.2% of our patients experienced neuropathic pain in the first year after traumatic SCI, consistent with the existing literature. Budh et al. (26) reported that most SCI patients experienced neuropathic pain within three months after SCI, whereas Henwood and Ellis (29) showed appearance within the first six months of injury. Aquarone et al. (25) substantiated stemming up neuropathic pain between one and five years post-injury. Stormer et al. (30) too noted the onset of pain/dysesthesia in 58% of SCI patients within the first year. Some patients experienced pain/dysesthesia soon after the spinal injury in 34% of cases. Notably, Celik et al. (3) shared that 70% of it begins within the first six months of injury. Siddall et al. (13) reported that 46% of traumatic SCI patients with at-level neuropathic pain presented for the first time within the first three months following injury, and 51% of traumatic SCI patients with below-level neuropathic pain experienced it for the first time two or more years post-injury. Adriaansen et al. (19) similarly found a high neuropathic pain prevalence one year after discharge from inpatient rehabilitation.
The present study found that wearing orthosis, sitting and standing positions, ROM exercises, hot climate, walking, tight clothes, cold weather, afternoon, evening, and night aggravate pain. Neuropathic pain was described as occurring during the night time (48.1%) in most patients.
The most common relieving factor of SCI patients is medicines (83.1%), while other relieving factors are orthosis, bending knees, sitting, straight/long legs position, ROM exercises and rest. Similarly, Budh et al. (25) found that 40.8% of SCI patients used pain-relieving drugs. Whereas Finnerup et al. (31) showed that rest, physical activity and alcohol were better pain (and dysesthesia) alleviating factors. However, Celik et al. (3) depicted no change in pain severity.
Conclusion
Neuropathic pain after traumatic SCI is common. A high occurrence of neuropathic pain is noted in patients with a complete type of injury (ASIA grade A). Neuropathic pain commonly develops within the first year after trauma, and the most disabling phase is at night. Treatment strategies for patients with traumatic SCI and neuropathic pain should consider the above-stated factors, like addressing the pain issue earlier and prescribing the medications when the peak concentration happens at night. These new insights need further research on neuropathic pain triggers in traumatic SCI.
Disclosure statement
No potential conflict of interest was reported by the author(s).
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