Management of Neuropathic Pain Following Spinal Cord Injury

First-Line Oral Medications

The American College of Physicians recommends gabapentinoids (pregabalin, gabapentin) as first-line oral treatments for neuropathic pain following spinal cord injury, with typical dosing of gabapentin titrated to 2400 mg daily in divided doses 1, 2
The French medical society recommends tricyclic antidepressants such as amitriptyline (Elavil) as first-line treatments for neuropathic pain in spinal cord injury patients, typically starting at 10-25 mg/day 3, 4
Amitriptyline has shown small improvement in neuropathic pain with a trend for improvement in quality of life in clinical trials, though evidence quality is modest 3, 4

Topical compounded creams containing amitriptyline have demonstrated efficacy for neuropathic pain management 8
A combination of topical baclofen, amitriptyline, and ketamine gel has shown effect after 4 weeks on motor function in chemotherapy-induced peripheral neuropathy, which may be applicable to spinal cord injury neuropathic pain 3, 4
Topical treatments are particularly beneficial for localized peripheral neuropathic pain and have minimal systemic effects, making them suitable for patients who cannot tolerate oral medications 2

Medical cannabis may be an effective treatment option for neuropathic pain in appropriate patients, though evidence quality is moderate 1
Current evidence suggests medical cannabis may be more effective for patients with a history of prior cannabis use, but benefits must be balanced against potential risks of neuropsychiatric adverse effects, lung damage from smoked forms, and addiction risk 1, 2

The treatment algorithm for neuropathic pain in spinal cord injury recommends starting with gabapentinoids (pregabalin or gabapentin) or amitriptyline, and adding topical treatments (compounded creams with amitriptyline) for localized pain 2, 5, 6, 7
For inadequate response to monotherapy, combining gabapentinoid with tricyclic antidepressant (amitriptyline) or adding topical treatments is recommended 2, 5, 6, 7
For refractory pain, considering adding cannabis oil as adjunctive therapy or serotonin-norepinephrine reuptake inhibitors (SNRIs) like duloxetine is recommended 1, 2

When using amitriptyline, starting at low doses (10-25 mg/day) and titrating slowly, particularly in older adults, is recommended 3, 4, 2
Obtaining ECG screening for patients over 40 years before starting amitriptyline due to potential cardiac risks is recommended 2
Monitoring for anticholinergic side effects with amitriptyline, including dry mouth, orthostatic hypotension, constipation, and urinary retention, is necessary 2
For cannabis oil, starting with low doses and titrating slowly, monitoring for neuropsychiatric effects, particularly in patients with no prior cannabis use, is recommended 1