Neuropathic pain: Hidden in plain sight

On this Spinal Injury Awareness Day, Sami Palmer-Latif, Senior Associate in our Serious Injury team, is reflecting on current observations and trends, both in the clinical field and in serious injury legal practice, regarding neuropathic pain.

What is neuropathic pain?

Neuropathic pain occurs when an individual’s nervous system generates and perpetuates pain without any instigating and ongoing noxious stimuli from injury. Put simply, it is a chronic pain condition that results from a problem with nerve signals. An analogy is to think of a mobile phone with unreliable signal strength, such that some communications get through and some are disturbed, overall making for a disorganised and malfunctioning status.

To the uninitiated, neuropathic pain may be thought to sit a considerable way down the list of concerns in relation to secondary complications that may arise for individuals with a spinal cord injury. However, for those within this demographic who live with paraplegia or tetraplegia, it can be one of the most unforgiving, relentless and debilitating aspects of their lives. It is variously described as a burning, shooting, stabbing, tingling or electric shock type sensation and therefore usually very different in nature to musculoskeletal pain.

Who does neuropathic pain affect?

The intrusiveness and pervasiveness of neuropathic pain is such that many affected individuals cannot remember a life without being in pain. Published statistics estimate that somewhere between 40-50% of individuals with paraplegia or tetraplegia report experiencing neuropathic pain. It transcends the cognitive, sensory and emotional domains, and therefore is at the heart of everyday functioning and wellbeing.

For family and friends of neuropathic pain sufferers, it can be very distressing to see its manifestation in a loved one. Its occurrence produces a shared experience that activates the part of the brain responsible for processing the emotional component of pain. There is also at least anecdotal evidence that sensory areas can also be activated in others. It therefore has a ‘contagious’ emotional and potentially somatic aspect, which all too often goes undetected and unsupported.

I see first-hand with my clients the fatiguing impact this has on them as well as their loved ones. Conversely, seeing people in a happy mood has the capacity to produce shared positive biochemical changes in the brain, releasing endorphins and other hormones like dopamine and serotonin.

Understanding the complex nature of pain after spinal cord injury

A frequently used trope in litigation is that each case turns on its specific facts. Similarly, pain mechanisms, pain experiences and pain management cannot be reduced to common denominators, because they are person specific. Specialist professionals may be the best placed to know what is happening from a physiological perspective, but it is not their body and brain, and they never actually feel the subjective pain.

It can be experienced at, above or below the level of injury. Indeed, a cruel paradox that exists with neuropathic pain is that whilst a spinal cord injury deprives you of sensation and movement in a part of your body, you may still experience pain in areas that otherwise have no sensation.

Generally speaking, the majority of the time there is no clearly identifiable trigger so it can have a truly blindsiding effect.

There is always the concern that what cannot be clinically seen and easily categorised will receive less clinical attention than that which is more easily discernible and measurable.

How can this pain be managed?

Neuropathic pain management is multimodal. An individual’s function, engagement in rehabilitation and quality of life can be severely limited by pain the and the side effects of medication.

The standard initial form of treatment that is offered to individuals with a spinal cord injury who are experiencing neuropathic pain is physiotherapy and pharmacological intervention (this could be antiepileptics, antidepressants or opioids). However, such treatments alone usually prove insufficient and are undesirable. Many clients are understandably concerned about developing a physiological dependence on pain relieving medication as the body becomes accustomed to it and the potential side effects.

Major surgery is rarely an attractive proposition either due to the perceived risks. As alluded to above, neuropathic pain affects cognitive, sensory and emotional domains and so it follows that to optimally address it, a multi-disciplinary approach should be taken. This in itself requires careful commissioning, monitoring and evaluation on a holistic basis.

A client of mine recently participated in a university research study which focused on transcutaneous i.e. non-invasive spinal stimulation. Not only has their involvement given them a number of symptomatic benefits, but a renewed sense of purpose through the engagement as well.

A modality which has a tendency to be underplayed in conventional medical circles is hydrotherapy. Unfortunately, there is a real dearth of community-based hydrotherapy pools which can facilitate safe and regular access. The covid-19 pandemic only compounded this issue with the temporary, and even permanent in some cases, closure of what already represents a very finite resource.

The Chartered Society of Physiotherapists have been actively campaigning on this issue because they realise that land-based physiotherapy is not interchangeable. Hydrotherapy has distinct physiological and psychological benefits.

Stoke Mandeville Spinal Research

We are a Gold Corporate Partner of Stoke Mandeville Spinal Research, a charity which since its inception in 2008 has been dedicated to promoting quality of life in people with spinal cord injury through research. One of its current active projects in conjunction with St George’s Hospital, London has the specific objective of attempting to reduce the debilitating effects of neuropathic pain by providing patients with a safe and effective surgical form of relief. The minimally invasive procedure called cingulotomy involves trying to locate and target a specific part of the brain responsible for overactive nerve pathways so as to disrupt the transmission of chronic pain signals.

Cingulotomy is a non-reversible procedure and so is reserved for patients who have exhausted other non-conservative and pharmacological treatment options. The neurosurgical procedure was first developed in the 1960’s and over the subsequent decades technological advances have made it minimally invasive. It is imperative that charities and institutions receive support to enable them to continue invaluable research.

I have discovered from recent visits to regional spinal injury units that there has been a change in the patient cohort. There is an increasing incidence of elderly patients who have sustained a spinal cord injury due to falls being admitted. The rate of neuropathic pain is generally higher amongst the elderly due to the greater likelihood of co-morbidities and refractory reactions to medication. This coupled with an aging population as a whole only makes it even more essential that innovative research on neuropathic pain and alternative therapies receive the necessary investment, so that alongside conventional medicine, maximal effort is being made on all fronts to enable people to experience minimal pain in their lives.