Spinal Cord Stim Eases Post-Stroke Shoulder Pain

Spinal cord stimulation led to half the level of post-stroke shoulder pain in one patient, a researcher reported here.

Within 5 days of undergoing spinal cord stimulation of the dorsal root ganglion, the woman, age 45, reported a 50% reduction in pain with improved range of motion and improved upper extremity function, along with full resolution of hyperesthesia, allodynia, and upper arm edema, said Varun Channagiri, MD, of Rutgers New Jersey Medical School in Newark.

The patient underwent implantation in August and continues to report maintained pain relief, he told MedPage Today at the American Society for Interventional Pain Physicians (ASIPP) virtual meeting.

In an ASIPP poster on this case study, Channagiri's group reported that the patient experienced a left middle cerebral artery stroke, which left her with hemi-body pain, most frequently felt in the right upper extremity. The pain was first treated with gabapentin, which offered some relief. The patient was then transitioned to pregabalin.

A subsequent physical examination revealed hyperesthesia, allodynia and edema, accompanied by tenderness in the acromioclavicular and glenohumeral joints. She was administered two corticosteroid injections. When the pain returned, she underwent nerve blocks as the pain was limiting her rehabilitation therapy, according to the authors.

The patient then experienced shoulder pain 2 months later that limited her ability to raise her arm greater than 90°. She underwent stellate ganglion nerve blocks. "She tolerated the procedure, performed with ultrasound guidance, and said she felt she had good pain relief, and was discharged to her home," according to the authors.

The patient reported a 60% decrease in pain level following the procedure for 2-3 days, but the pain returned by day 4. The pain was at baseline by day 12, the authors noted, although the patient did report that the hyperesthesia and allodynia was better. A second stellate ganglion nerve block was done with similar duration of effect, Channagiri reported.

"We did expect that these stellate ganglion nerve blocks would be effective for a short period of time," he said. "Given that the stellate ganglion block treated the patient's pain for a brief period does not indicate that central regional pain syndrome is the sole diagnosis."

He added that her clinicians believed the sympathetic nerve system might also be involved so they moved forward with spinal cord stimulation. After a 2-week trial period, the stimulator was implanted at the C2 vertebrae. Channagiri reported that, to date, the patient has reported decreased pain for at least 3 weeks.

Yili Huang, DO, of the Pain Management Center at Northwell Health's Phelps Hospital in Sleepy Hollow, New York, commented that "Shoulder pain is a frequent complaint of patients who had strokes that affect the upper extremities. As many as 80% of stroke survivors complain of shoulder pain."

"Spinal cord stimulation is most effective in patients who have nerve-related pain," he told MedPage Today. "In this case, the patient's pain is likely nerve related because of the history and response to stellate ganglion. Therefore, it is reasonable to consider a spinal cord stimulation trial as a treatment. This may be useful in patients who have shoulder pain after strokes secondary to neuropathic pain."

But "Like [with] all treatments, it is important to discuss all potential benefits, risks, and alternatives with the patient and to encourage shared decision-making," Huang advised.

Channagiri's group concluded that "Ultimately, prevention is the key management of post-stroke shoulder pain and should begin as soon as the patient is medically stable."