Spinal Cord Injury Pain: Types, Causes, and Interventional Treatment

Understanding Pain After Spinal Cord Injury

Not all pain after a spinal cord injury (SCI) is the same. Understanding the type of pain is essential for choosing the right treatment.

Neuropathic pain at and below the injury level is the most common type. It is caused by damage to the spinal cord itself. The nervous system generates abnormal signals and interprets them as burning, stabbing, or electric pain, even in areas where sensation is otherwise reduced or absent. This is one of the most difficult types of pain to treat with medications alone.

Musculoskeletal pain above the injury level is very common in wheelchair users. The shoulders, neck, and upper back take on enormous strain during transfers and manual wheelchair propulsion. Over time, this causes rotator cuff damage, cervical joint degeneration, and significant chronic pain.

Spasticity-related pain occurs when abnormal spinal cord signalling causes involuntary muscle spasms. These spasms can be extremely painful. They may also cause joint contractures over time, which adds further musculoskeletal pain to the picture.

Visceral pain felt in the abdomen or pelvis is less common but deeply unpleasant. It is caused by disrupted autonomic nerve supply to the internal organs.

Symptoms of SCI Pain

The symptoms vary depending on the type of pain and the level of the injury.

1. Burning, stabbing, or electric-shock like pain in or below the level of injury
2. Constant aching or pressure pain in the trunk or limbs
3. Painful muscle spasms that wake the patient from sleep
4. Sharp shoulder, neck, or upper back pain from overuse
5. Allodynia, which is pain triggered by a light touch or change in temperature in areas of reduced sensation
6. Abdominal cramping or pelvic pain with no clear cause
7. Pain that worsens with bladder or bowel issues, pressure sores, or infections

Pain that is worsening or changing in character should always be assessed promptly. New or escalating pain after SCI can sometimes indicate a correctable cause such as a pressure ulcer, urinary tract infection, or autonomic dysreflexia.

Why is SCI Pain So Difficult to Treat?

Several reasons make SCI pain particularly challenging.

1. Central Sensitisation: The injured spinal cord itself becomes hyperexcitable. Neurons fire spontaneously and amplify incoming signals. This is driven by structural and chemical changes in the cord that persist long after the original injury.
2. Loss of Inhibitory Control: The brain normally sends descending signals that moderate pain processing in the spinal cord. After SCI, these inhibitory signals can no longer reach below the injury level. Pain is processed without its normal brakes.
3. Neuroplasticity: The nervous system rewires itself after injury. Some of this rewiring is helpful for recovery. Other changes unfortunately create new pain circuits that were not present before the injury.
4. Multiple Overlapping Pain Types: Most SCI patients have neuropathic pain, musculoskeletal pain, and spasticity all at once. Each type needs a different approach, which makes treatment more complex.
5. Undertreatment: Healthcare providers sometimes focus entirely on rehabilitation and mobility and overlook the significant pain burden. This delays effective pain management and allows central sensitisation to become more entrenched.

What Conditions Worsen SCI Pain?

Certain factors can trigger or amplify pain in SCI patients. These are sometimes called nociceptive triggers.

1. Urinary tract infections or bladder distension
2. Constipation and bowel distension
3. Pressure ulcers or skin breakdown
4. Deep vein thrombosis
5. Autonomic dysreflexia (a sudden dangerous rise in blood pressure triggered by a stimulus below the injury)
6. Poor posture, ill-fitting wheelchair, or prosthetic equipment
7. Anxiety, depression, and poor sleep

Identifying and correcting these triggers is always the first step. It can significantly reduce pain without any invasive treatment.

How is SCI Pain Assessed?

A thorough, systematic assessment is essential before treatment is planned.

1. Full neurological assessment including the level and completeness of the SCI using standard classification tools
2. Pain mapping to identify which areas are affected and what type of pain is present in each area
3. MRI of the spine to check for syrinx (fluid-filled cavities in the cord), tethering, or hardware complications in surgical patients
4. Assessment of spasticity severity using clinical scales
5. Urodynamic studies and bowel function assessment to rule out visceral triggers
6. Psychological assessment, since depression and anxiety are common after SCI and significantly amplify pain perception