Ketamine for Complex Regional Pain Syndrome Secondary to Spinal Cord Injury

Initial Management Approach

The American College of Physicians recommends initiating first-line treatment with gabapentinoids or tricyclic antidepressants for neuropathic pain following spinal cord injury, reserving ketamine infusion therapy as a second-line or rescue option for refractory cases 1
The guideline suggests starting with gabapentinoids, such as pregabalin or gabapentin, titrated to 2400 mg daily in divided doses, as the primary treatment for neuropathic pain following spinal cord injury 1
Alternatively, initiate tricyclic antidepressants, such as amitriptyline, starting at 10-25 mg/day, particularly in patients over 40 years with baseline ECG screening due to cardiac risks 1

The evidence suggests that ketamine may be beneficial for CRPS, particularly in patients with central sensitization and "clinical wind-up", although it does not support routine use of ketamine for neuropathic pain 2
The guideline recommends using a 5-day inpatient ketamine infusion protocol at subanesthetic doses of 0.1-0.35 mg/kg/h, administered over 6 hours daily, as this provides the best balance between pain control and side effects 1

The American Academy of Physical Medicine and Rehabilitation suggests using extreme caution in elderly patients due to significant risk of postoperative confusion and delirium 3
The guideline recommends closely monitoring respiratory parameters, including respiratory rate and pulse oximetry, as concomitant use with opioids, benzodiazepines, or other CNS depressants may result in profound sedation and respiratory depression 3
Ketamine treatment should not delay or interrupt the comprehensive rehabilitation protocol that must begin immediately upon medical stability, and multimodal analgesia should be continued as part of the overall pain management strategy 4