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# Management of Chronic Central Neuropathic Pain Following Traumatic Spinal Cord Injury

*Evidence Reports/Technology Assessments, No. 45*

Investigators: Alex Jadad, MD, Principal Investigator, Mary Ann O'Brien, MSc, Dean Wingerchuk, MD, Pam Angle, MD, Heather Biagi, BHSc, Matt Denkers, BHSc, Carmen Tamayo, MD, and Mary Gauld, BA.

Agency for Healthcare Research and Quality (US)2001 Sep
Report No.: 01-E0631-58763-108-3

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## Structured Abstract

#### Objectives:

           To evaluate (a) the measurement of central neuropathic pain (CNP) after traumatic spinal cord injury (TSCI), (b) the prevalence of acute and chronic CNP, (c) predictive factors for chronic CNP, and (d) the effectiveness and safety of various interventions for CNP.

#### Search Strategy:

            Studies were identified by searching MEDLINE, EMBASE, and PsycINFO (to May 2000); CINAHL, HEALTHStar, and Sociological Abstracts (to November 1999); the Cochrane Library (issue 4, 1999); reference lists of eligible articles found in the searches; and personal files of advisory panel members.

#### Selection Criteria:

            Studies about the cause, management, or measurement of CNP were included. Exclusion criteria were participants without TSCI or CNP, children younger than 13 years, or inability to determine whether chronic pain was central and neuropathic.

#### Data Collection and Analysis:

            Two reviewers independently extracted data for all studies except case reports. One reviewer extracted case report data, which was checked by another. Disagreements were resolved by consensus. The quality of data was assessed. Data were not pooled because clinical heterogeneity existed across studies, outcome measurements were inconsistent, studies had low methodological quality, and data reporting was incomplete.

#### Main Results:

            132 unique studies (6 randomized controlled trials and 126 observational studies, including 47 case series and at least 56 single or multiple case reports) met the selection criteria. Few studies evaluated the management of CNP following TSCI in women; and no studies evaluated adolescents only, the role of treatment algorithms, or multidisciplinary approaches. Only two studies evaluated self-management strategies in cases of CNP following TSCI. *Diagnosis, assessment and natural history:* No discriminative or evaluative measurement instruments have been adequately investigated with respect to psychometric measurement properties in this setting. *Pharmacological interventions:* Little research has been done. The few studies available have such poor methods that it was not possible to evaluate interventions. It appears that local anesthetics, opioids, and clonidine given spinally may be effective in relieving CNP following TSCI, but better research is needed. *Spinal cord and deep brain stimulation techniques:* The studies had similar deficiencies to those described above. The limited evidence available suggests that spinal cord stimulation has a variable rate of early success and a low rate of long-term effectiveness. Deep brain stimulation has a low rate of early success and an even lower long-term success rate, coupled with significant adverse events. *Dorsal root entry zone (DREZ) lesions and other surgical interventions:* All studies on DREZ showed high rates of success but had poorly defined or no eligibility criteria, included no control groups, and did not report adequately the severity of adverse effects.

#### Conclusions:

            This report describes rigorous systematic reviews on the measurement and management of CNP after TSCI in adults and adolescents. The research on this topic is in its infancy. This report describes the limitations of the available evidence and provides recommendations for future research.

## Contents

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                        - Preface
                        - Summary
                        - 1. Pain as a Problem Following Traumatic Spinal Cord Injury                           - Introduction
                          - Classification of Pain After SCI
                          - The Role of Systematic Reviews in the Study of Neuropathic Pain After Traumatic Spinal Cord Injury
                          - Commissioning of This Report
                          - Review Questions
                          - Anticipated Challenges for This Task Order
                          - The Collaborative Team
                        - 2. Methodology                           - Introduction
                          - Technical Expert Panel
                          - Consultations With the Task Order Officer and Partners
                          - Peer Reviewers
                          - Screening Process
                          - Data Extraction Process
                          - Data Synthesis
                        - 3. General Results                           - Results of the Literature Search
                          - Results of the Screening Process
                          - General Characteristics of All Included Studies
                        - 4. Diagnosis, Assessment and Natural History of Pain After Traumatic Spinal Cord Injury                           - Background
                          - Methods
                          - Results
                          - Discussion
                        - 5. Pharmacological Interventions                           - Background
                          - Results
                          - Implications for Practice
                        - 6. Spinal Cord and Deep Brain Stimulation Techniques                           - Introduction
                          - Types of Stimulation
                          - Methods
                          - Results
                          - Discussion
                        - 7. Dorsal Root Entry Zone Lesions and Other Surgical Interventions                           - Introduction
                          - Methods
                          - Results
                        - 8. Conclusions and Implications for Future Research                           - General Implications for Research
                          - Limitations of This Task Order Report
                          - Closing Remarks
                        - Evidence Tables
                        - Appendixes                           - Appendix A. Consortium for Spinal Cord Medicine Member Organizations
                          - Appendix B. Personnel
                          - Appendix C. Peer Reviewers for the Management of Chronic Central Neuropathic Pain Following Traumatic Spinal Cord Injury
                          - Appendix D. Final Search Strategy for Primary Studies
                          - Appendix E. Assessment and Natural History Study Form
                          - Appendix F. Acronyms and Abbreviations
                        - References
                        - Bibliography

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Prepared for: Agency for Healthcare Research and                            Quality, U.S. Department of Health and Human Services.1             Contract No. 290-97-0017. Prepared by: McMaster University Evidence-based Practice Center.

#### Suggested citation:

Jadad A, O'Brien MA, Wingerchuk D, et al. Management of Chronic Central Neuropathic Pain Following Traumatic Spinal Cord Injury. Evidence Report/Technology Assessment Number 45. (Prepared by McMaster University Evidence-based Practice Center under Contract No. 290-97-0017.) AHRQ Publication No. 01-E063. Rockville, MD: Agency for Healthcare Research and Quality. September 2001.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. Endorsement by the Agency for Healthcare Research and Quality (AHRQ) or the U.S. Department of Health and Human Services (DHHS) of such derivative products may not be stated or implied.

AHRQ is the lead Federal agency charged with supporting research designed to improve the quality of health care, reduce its cost, address patient safety and medical errors, and broaden access to essential services. AHRQ sponsors and conducts research that provides evidence-based information on health care outcomes; quality; and cost, use, and access. The information helps heath care decisionmakers -- patients and clinicians, health system leaders, and policymakers -- make more informed decisions and improve the quality of health care services.

The authors of this report are responsible for its content. Statements                        in the report should not be construed as endorsement by the Agency for                        Healthcare Research and Quality or the U.S. Department of Health and                        Human Services of a particular drug, device, test, treatment, or other                        clinical service.

                        - 1
                        - 
2101 East Jefferson Street, Rockville, MD 20852. www​.ahrq.gov

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Bookshelf ID: NBK33834

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                    - Cite this Page Jadad A, O'Brien MA, Wingerchuk D, et al. Management of Chronic Central Neuropathic Pain Following Traumatic Spinal Cord Injury. Rockville (MD): Agency for Healthcare Research and Quality (US); 2001 Sep. (Evidence Reports/Technology Assessments, No. 45.)

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