Intractable Abdominal Pain in a Patient With Spinal Cord Injury: A Case Report
A 37-year-old male patient was admitted to the department of rehabilitation medicine at our hospital with a major complaint for severe abdominal pains. He was affected by flaccid paraplegia in July 2011 due to a SCI at the T10 level in a traffic accident which led to compression fracture of vertebral body T10 with dislocation. After a long hospitalization in the intensive care unit, he developed a stage IV sacral pressure ulcer (length 10 cm, width 10 cm, depth 5 cm) which was steadily worsened due to fecal incontinences despite the intensive dressings three times a day. Plastic surgeons, therefore, recommended a colostomy to provide a clean environment for healing the pressure ulcer. He also suffered from intermittent abdominal pain 1 month after the injury. The pain was mainly localized in the periumbilical area and did not appear in a radiating pattern. The initial pain scale was 60 mm on visual analog scale (VAS). Physical examination demonstrated no tenderness or distension to palpation of the abdomen. Peripheral blood tests showed elevated erythrocyte sedimentation rates with 69 mm/hr and C-reactive protein was elevated to 3.77 mg/dL. His past medical history included antibiotics therapy for acute cholecystitis a month ago. Computerized tomography (CT) on abdomen showed mild nonspecific gallbladder wall thickening (). Chronic cholecystitis was diagnosed and the patient was referred to the general surgery department for a colostomy and cholecystectomy. Laparoscopic cholecystectomy and sigmoid colon loop colostomy were performed on November 2011, but the abdominal pain around umbilicus persisted and became even more severe. The pain intensity scored 80 mm on VAS. The pain was not associated with food intakes or defecations. No other possible causes of visceral pain such as constipation, paralytic ileus or abdominal distension were identified. Laboratory findings on the peripheral blood tests were nonspecific and follow-up CT images of abdomen showed no abnormalities. The pain was not aggravated by positions, activities, movement and not associated with somatic tenderness, thus, we can rule out the possibility of musculoskeletal origin, such as mechanical instability, muscle spasm, overused syndromes. A magnetic resonance imaging scan of the thoracolumbar spine revealed no evidence for compression of the nerve root in the foramen by bone or disc that are correlated with the location of the pain. The nature of pain was either burning, pricking, electric shock-like, painful cold, tingling or an itching pain, which would fit the diagnostic criteria for neuropathic pain based on the Douleur Neuropathique 4 (DN4) questionnaire [] and had a correlation with the dermatomal pattern within the level of injury. Thus, we concluded the pain as neuropathic at 5 months after the injury and exercised a medication according to guidelines []. We administrated amitriptyline 10 mg twice a day, pregabalin 150 mg four times a day, and oxycodone 5 mg twice a day, after which the pain slightly subsided from 80 to 65 mm on VAS. However, he still suffered from insomnia and could not tolerate rehabilitation programs. He was then referred to the department of anesthesiology for intrathecal injections, with 12 mL of 0.4% lidocaine and 3 mL of 10 mg/mL triamcinolone. The pain level was reduced from 80 to 40 mm on VAS. The effect was not long-term and intrathecal lidocaine injection was scheduled more frequently, once a week for 3 consecutive weeks, keeping the oral medications. A repeated injection resulted in a remarkable decrease in pain level up to 30 mm on VAS for at least 2 months.