Can People with Spinal Cord Injury Develop Complex Regional Pain Syndrome?
Yes, individuals with spinal cord injury (SCI) can develop complex regional pain syndrome (CRPS), and spinal cord stimulation—a primary treatment for CRPS—is specifically recommended for use in SCI patients with persistent pain. 1
Evidence Supporting CRPS Development in SCI Patients
The American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine (ASRA) explicitly recognize spinal cord injury as a condition for which spinal cord stimulation should be used, listing it alongside CRPS as distinct but related pain conditions that respond to the same neuromodulation therapy. 1 This guideline acknowledgment indicates that:
SCI patients can develop pain syndromes requiring the same interventional treatments used for CRPS, including spinal cord stimulation for persistent radicular pain, neuropathic pain, and other chronic pain manifestations. 1
The overlap in treatment recommendations suggests shared pathophysiological mechanisms between CRPS and SCI-related pain, both involving peripheral and central sensitization, neurogenic inflammation, and maladaptive neuroplasticity. 2
Pathophysiological Mechanisms Linking SCI and CRPS
Both conditions share common pain mechanisms that explain why CRPS can develop following spinal cord injury:
Peripheral and central sensitization occurs in both CRPS and SCI, leading to hyperexcitability in affected nerve pathways and spontaneous firing of damaged nerves. 2
Neurogenic inflammation and autonomic dysfunction are hallmark features of CRPS that can also manifest in SCI patients, particularly those with cervical and high thoracic injuries who experience loss of cardiovascular sympathetic innervation. 1
Maladaptive brain plasticity develops in both conditions, contributing to chronic pain persistence beyond the initial injury. 2
Clinical Recognition in SCI Populations
The recognition that SCI patients may develop CRPS-like pain is reflected in treatment guidelines:
Spinal cord stimulation trials should be performed before permanent implantation in both CRPS and SCI patients, indicating similar diagnostic and therapeutic approaches. 1
Sympathetic nerve blocks may be considered for both conditions when sympathetically maintained pain is present, though they should demonstrate progressive improvement with increasing duration of relief. 1, 3
Physical therapy remains the cornerstone of treatment for both CRPS and SCI-related pain, with all other interventions serving to facilitate participation in rehabilitation. 4
Important Clinical Considerations
When evaluating SCI patients for possible CRPS development:
Look for disproportionate pain that exceeds what would be expected from the initial SCI, characterized as excruciating, burning pain that worsens with touch or stimulation. 4, 3
Assess for sensory abnormalities including allodynia and hyperalgesia, which are hallmark features distinguishing CRPS from other SCI-related pain syndromes. 4
Monitor for autonomic dysfunction such as temperature dysregulation, skin color changes, and abnormal sweating patterns in affected limbs. 4
Document motor impairment and trophic changes including functional limb weakness, decreased active range of motion, hair loss, and skin discoloration. 4
Treatment Approach for SCI Patients with CRPS Features
The management strategy mirrors standard CRPS treatment:
Initiate physical and occupational therapy immediately as the cornerstone of treatment, with gentle stretching, active range of motion exercises, and sensorimotor integration training. 4, 3
Use analgesics (NSAIDs, acetaminophen) to enable therapy participation rather than as primary treatment. 4, 3
Consider sympathetic nerve blocks (stellate ganglion or lumbar sympathetic blocks) for moderate to severe cases with documented sympathetic dysfunction, ensuring consistent improvement with each successive block. 3
Proceed to spinal cord stimulation for refractory cases that have not responded to conservative management, with mandatory trial before permanent implantation. 1, 3
Critical Pitfall to Avoid
Do not delay physical therapy while waiting for pain to resolve, as this worsens outcomes through disuse and pain upregulation in both CRPS and SCI populations. 4 The pain will not resolve without active rehabilitation, and early aggressive management is critical for improving long-term outcomes. 5