Treatment of Complex Regional Pain Syndrome in Patients with Spinal Cord Injury

First-Line Pharmacological Management

The American College of Physicians recommends gabapentinoids as first-line treatment for neuropathic pain following spinal cord injury, with gabapentin titrated to 2400 mg daily in divided doses, or use pregabalin as an alternative 1, 3
The American College of Physicians also recommends tricyclic antidepressants, such as amitriptyline, as first-line treatment, starting at 10-25 mg/day, particularly in patients over 40 years 1, 3
Baseline ECG screening is recommended before starting amitriptyline in patients over 40 due to cardiac risks 1, 3
The French medical society recommends introducing oral gabapentinoid treatment for more than 6 months in association with tricyclic antidepressants or serotonin reuptake inhibitors when monotherapy is inefficient 4

The American Society of Anesthesiologists recommends combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids to prevent prolonged pain during the acute phase 4
This approach is recommended during the acute phase to reduce the occurrence of chronic neuropathic pain 4

Physical therapy is the cornerstone and first-line treatment for CRPS and must begin immediately upon medical stability, with gentle stretching, mobilization techniques.Ptr techniques, and active range of motion exercises specifically targeting the affected limb 2, 4, 5
Early, vigorous, and consistent rehabilitation practices maximize neurological recovery 5

Topical compounded creams containing amitriptyline can be used for neuropathic pain management 3
A combination of topical baclofen, amitriptyline, and ketamine gel has shown effectiveness after 4 weeks 3
Topical treatments have minimal systemic effects, making them suitable for patients who cannot tolerate oral medications 3

The American Society of Anesthesiologists recommends spinal cord stimulation for CRPS patients who have not responded to other therapies 2, 6, 7
A temporary spinal cord stimulation trial must be performed before permanent implantation, demonstrating adequate pain relief (typically >50% reduction) and measurable functional improvement 2, 6, 7

Ketamine infusion can be used as second-line or rescue therapy, with a 5-day inpatient protocol at subanesthetic doses of 0.1-0.35 mg/kg/h, administered over 6 hours daily 1
Ketamine is particularly beneficial for CRPS patients with central sensitization and "clinical wind-up" 1
Use extreme caution in elderly patients due to significant risk of postoperative confusion and delirium 1
Monitor respiratory parameters closely, as concomitant use with opioids, benzodiazepines, or other CNS depressants may result in profound sedation and respiratory depression 1

Medical cannabis may be considered for appropriate patients, with cannabis oil potentially effective for neuropathic pain, though evidence quality is moderate 3
Start with low doses and titrate slowly, monitoring for neuropsychiatric effects 3
Benefits must be balanced against potential risks including neuropsychiatric adverse effects, lung damage from smoked forms, and addiction risk 3