What is the best course of treatment for a patient experiencing episodes of lightheadedness, full-body tremors, anxiety, insomnia, fatigue, and chest pain, with a history of neck injury (cervical spine injury), whiplash, and frequent plasma donation (plasmapheresis), despite normal cardio workup, brain Magnetic Resonance Imaging (MRI), Electroencephalogram (EEG), and Electromyogram (EMG) results, and partial resolution with gabapentin (Neurontin)?

Management of Full-Body Tremors and Neurological Symptoms Following Cervical Spine Injury

Continue gabapentin therapy and escalate the dose systematically to 1800-2400 mg/day in divided doses, as this is the established first-line treatment for neuropathic pain and tremor following spinal cord injury, with proven efficacy in reducing both pain and associated neurological symptoms. 1, 2

Primary Treatment Strategy

Gabapentin Optimization

• Increase gabapentin dosing to therapeutic levels of 1800-2400 mg/day in divided doses (typically 600-800 mg three times daily), as studies demonstrate optimal efficacy at these higher doses for spinal cord injury-related neuropathic symptoms 1, 3
• The current partial response indicates you are undertreated; effective doses for neuropathic pain in spinal cord injury range from 1800-3600 mg/day, with mean effective doses around 2400 mg/day 1, 4
• Titrate gradually over 2-4 weeks to minimize side effects while achieving therapeutic benefit 1
• Monitor for gabapentin toxicity symptoms (myokymia, myoclonus, excessive tremor) particularly if renal function is impaired, though therapeutic levels are 2.0-20.0 μg/mL 5

Cervical Spine Management

• Discontinue prolonged cervical immobilization immediately if still in use, as rigid collars beyond 48-72 hours cause significant morbidity including increased intracranial pressure, airway problems, and neurological complications without providing stability 6
• The C5-C6 bulging disc with whiplash history places you at risk for delayed neurological deterioration if cervical spine instability was missed 6
• Refer urgently to neurosurgery or spine specialist for reassessment of cervical spine stability, as your progressive symptoms (tremor, throat tightness, extremity tingling) may indicate evolving cervical myelopathy or nerve root compression 6

Secondary Considerations

Metabolic and Nutritional Assessment

• Evaluate for protein depletion and electrolyte abnormalities from chronic plasma donation (twice weekly for one year represents significant protein loss) 6
• Check comprehensive metabolic panel, albumin, calcium, magnesium, and phosphate levels, as electrolyte disturbances can cause tremor, muscle fasciculations, and neurological symptoms 6
• Discontinue plasma donation immediately until symptoms resolve and nutritional status is optimized 6

Multimodal Pain and Symptom Management

• Add tricyclic antidepressants (amitriptyline 25-75 mg nightly) or serotonin reuptake inhibitors if gabapentin monotherapy remains insufficient after dose optimization 6
• This combination is recommended for neuropathic pain in spinal cord injury when monotherapy fails 6
• Consider adding low-dose clonazepam (0.5-1 mg at bedtime) specifically for tremor control if gabapentin optimization alone is inadequate 2

Physical Rehabilitation

• Refer to rehabilitation specialist immediately for comprehensive neuromuscular assessment and management of cervical spine injury sequelae 6
• Physical therapy should focus on cervical range of motion, shoulder function assessment, and prevention of secondary complications from neck injury 6
• Stretching techniques for at least 20 minutes per affected zone to prevent contractures and maintain joint mobility 6

Critical Red Flags Requiring Urgent Evaluation

Progressive Myelopathy Warning Signs

• Your constellation of symptoms—progressive throat tightness, full-body tremor, extremity tingling/numbness, and muscle jerks—raises concern for evolving cervical myelopathy from the C5-C6 injury 6
• Throat and upper chest heaviness may indicate anterior cervical soft tissue involvement or autonomic dysfunction from spinal cord compression 6
• Obtain urgent cervical spine MRI with flexion-extension views if not already done, as static MRI may miss dynamic instability 6

Exclusion of Alternative Diagnoses

• While your EEG and EMG are normal, the sudden onset full-body tremor with tongue and eyelid involvement warrants consideration of non-convulsive status epilepticus if symptoms worsen, though this is less likely given normal EEG 6
• The normal brain MRI effectively excludes structural lesions but does not rule out functional neurological disorders secondary to trauma 7

Common Pitfalls to Avoid

• Do not accept "partial resolution" with gabapentin as adequate treatment—this indicates subtherapeutic dosing that should be escalated 1, 4
• Do not attribute all symptoms to anxiety/insomnia without fully addressing the underlying cervical spine pathology and neuropathic pain 6, 1
• Do not continue plasma donation while symptomatic, as this may be contributing to metabolic derangements and preventing recovery 6
• Do not delay cervical spine reassessment given progressive symptoms over months, as delayed diagnosis of cervical spine injury leads to permanent neurological deficits in 29.4% of cases 6

Expected Timeline and Monitoring

• With optimized gabapentin dosing, expect 60-80% symptom improvement within 1-3 months 1, 2, 4
• Pain scores should decrease from baseline by approximately 50% at 1 month and continue improving through 6 months 1, 4
• If no improvement after 4-6 weeks at therapeutic gabapentin doses, add adjunctive therapy rather than abandoning gabapentin 6, 1