Disclosures: Benjamin T. Buterbaugh, DO: No financial relationships or conflicts of interest

Case Diagnosis: 28-year-old male with unresolved neuropathic pain in a spinal cord injury

Case Description or Program Description: The patient presented to the ED with a gunshot wound with loss of motor and sensation in bilateral lower extremities, fecal incontinence, and loss of rectal tone. Patient was found to have a spinal cord injury at level of the conus medullaris along with pneumoperitoneum and a descending colonic injury requiring exploratory laparotomy. Patient was placed on hydromorphone, acetaminophen, cyclobenzaprine, gabapentin, and duloxetine for neuropathic pain that radiated down his back, into his sacrum and right lower extremity. He was transferred to the spinal cord unit for further management.

Setting: Academic Inpatient Rehabilitation Facility

Assessment/Results: ASIA examination revealed a T12 ASIA A injury with zone of partial preservation of L1-L4 on right side. Hydromorphone was weaned off, but his neuropathic pain was unable to be controlled with patient using as needed oxycodone every four hours along with his scheduled medications. Amitriptyline was added for neuropathic pain but removed after increasing his urinary retention. Patient was switched to methadone hydrochloride reporting no further neuropathic pain and requiring no more as needed pain medication

Discussion (relevance): Pharmacologic treatment of spinal cord pain is challenging with few guidelines in place. First line treatment for neuropathic pain includes tricyclic antidepressants, gabapentin, pregabalin, and serotonin-noradrenaline reuptake inhibitors (SNRIs). Failure of these interventions leads to second line agents such as opioids. Methadone hydrochloride, an N-methyl-D-aspartate antagonist, may also be effective choice for neuropathic pain as it blocks the same receptors as SNRI’s. Methadone hydrochloride is not without risks, as it has a long half-life and causes QTc prolongation leading to fatal overdose and cardiac arrhythmias

Conclusions: Patients should be started on first line agents for neuropathic pain, and if failure, then should consider methadone hydrochloride as a potential option for providing pain relief.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/use-of-methadone-for-unresolved-neuropathic-pain-in-setting-of-acute-paraplegia-a-case-report/