What is the best medication for spinal cord girdle sensation (neuropathic pain)?

Treatment of Spinal Cord Injury-Related Neuropathic Pain (Girdle Sensation)

Pregabalin is the best first-line medication for spinal cord injury-related neuropathic pain, including girdle sensation, with FDA approval and the strongest evidence for efficacy at doses of 150-600 mg/day. 1

First-Line Treatment: Pregabalin

Pregabalin should be initiated at 75 mg twice daily (150 mg/day) and titrated to 150 mg twice daily (300 mg/day) within one week based on tolerability. 1 For patients without sufficient pain relief after 2-3 weeks at 300 mg/day, the dose can be increased to 300 mg twice daily (600 mg/day). 1

Evidence Supporting Pregabalin

• Pregabalin has FDA approval specifically for neuropathic pain associated with spinal cord injury, distinguishing it from other medications. 1
• In two large controlled trials, pregabalin 150-600 mg/day significantly improved pain scores and increased the proportion of patients achieving at least 30% and 50% pain reduction (p<0.001). 1
• Pain relief was observed as early as week 1 and persisted throughout the study duration. 1
• The American College of Physicians and American Geriatrics Society recommend pregabalin as a first-line treatment for neuropathic pain. 2

Alternative First-Line Option: Gabapentin

If pregabalin is not tolerated or available, gabapentin is an acceptable alternative, starting at 100-300 mg at bedtime and titrating to 900-3600 mg/day in 2-3 divided doses. 2, 3

Evidence Supporting Gabapentin

• Gabapentin reduced both intensity and frequency of neuropathic pain in spinal cord injury patients in prospective, randomized, double-blind trials. 3
• A maximum dose of 3600 mg/day was required for significant pain reduction (p=0.000), whereas lower doses of 1200 mg/day failed to show benefit. 4
• Gabapentin is considered a first-line medication for spinal cord injury-related neuropathic pain with Grade A evidence. 3
• The medication improved quality of life and relieved most neuropathic pain descriptors. 3

Comparison: Pregabalin vs Gabapentin

Pregabalin appears more efficacious than gabapentin for spinal cord injury pain, though it causes more side effects. 4 Pregabalin reduced pain scores at lower equivalent doses compared to gabapentin, and gabapentin required maximum dosing (3600 mg/day) to achieve significant benefit. 4

Second-Line Treatment: Tricyclic Antidepressants

If gabapentinoids fail or provide only partial relief, add or switch to a tricyclic antidepressant (TCA), preferably nortriptyline or desipramine, starting at 10 mg/day in older adults and titrating slowly to a maximum of 75 mg/day. 2

• Secondary amine TCAs (nortriptyline, desipramine) are preferred over tertiary amines due to fewer anticholinergic side effects. 2
• TCAs have Grade B evidence for spinal cord injury pain and Grade A evidence for other neuropathic pain conditions. 5
• Obtain a screening ECG for patients over 40 years before starting TCAs, and use with caution in patients with cardiac disease. 2

Alternative: SNRIs (Duloxetine)

Duloxetine 60 mg once daily can be used as an alternative to TCAs, with fewer anticholinergic effects and no ECG monitoring requirement. 2 The dose can be increased to 60-120 mg/day if needed. 2

Combination Therapy

If monotherapy provides only partial relief, combine gabapentin (or pregabalin) with an antidepressant (nortriptyline or duloxetine). 6

• The combination of gabapentin and extended-release morphine required lower doses of both medications and resulted in better pain relief than either alone. 6
• The combination of nortriptyline and gabapentin was superior to either medication administered alone. 6
• Allow at least 2 weeks at adequate dosage before evaluating efficacy of any medication. 2

Third-Line Treatment: Opioids

If first-line and combination therapies fail, consider tramadol (200-400 mg/day in divided doses) or strong opioids as a reserve option. 5, 2

• Tramadol has dual mechanism (weak μ-opioid agonist and inhibits serotonin/norepinephrine reuptake) with lower abuse potential than strong opioids. 2, 5
• Strong opioids should be used at the smallest effective dose and only after other treatments have failed. 5
• Neuropathic pain is generally less responsive to opioids than other pain types. 2

Special Considerations and Refractory Cases

For patients with incomplete spinal cord injury and allodynia who fail standard treatments, consider lamotrigine (Grade B evidence). 5

• In refractory central pain, cannabinoids may be considered based on positive results in other central pain conditions like multiple sclerosis. 5
• Patients with failed back surgery syndrome may respond to spinal cord stimulation when medications are ineffective. 6
• Intravenous ketamine and lidocaine can only be proposed in specialized centers for refractory cases. 5

Important Caveats

• Spinal cord injury-related neuropathic pain may be relatively refractory to existing first-line treatments compared to other neuropathic pain conditions. 6
• Adverse event withdrawals are more common with gabapentin (11%) than placebo (8.2%), with dizziness (19%), somnolence (14%), peripheral edema (7%), and gait disturbance (14%) being the most common side effects. 7
• Dose adjustment is required for pregabalin and gabapentin in patients with renal impairment. 1, 2
• Physical therapy and functional training should be added to medication to reduce symptoms. 2