1235 - Hands On Fire: Managing Severe Refractory Neuropathic Pain With Topical Capsaicin

Case Diagnosis: Refractory neuropathic pain due to C4 AIS C SCI

Case Description:

79-year-old male (C6 AIS C) admitted to the SCI program at the East Orange VA Medical Center. SCI was sustained 12 months prior after mechanical fall that resulted in a cervical fracture and spinal cord compression. Following decompression he was discharged to inpatient rehabilitation and later home.

 

Initially, neuropathic pain was well-managed with gabapentin. However, his pain worsened in a stocking-and-glove distribution, despite maximal dosing of gabapentin. This rendered him unable to tolerate basic care, including bowel program, pressure offloading, and physical therapy. This resulted in diffuse musculoskeletal rigidity, dependent level assistance, a pressure injury, diverting colostomy, and significant psychological distress.

 

Discussions:

Upon admission, the veteran reported 10/10 neuropathic pain with severe allodynia. Pregabalin resulted in severe sedation, and trials of TCAs and SNRIs offered only mildly reduced pain to 8/10, without improving allodynia or ability to participate in PT/OT, or effective wound care. 

 

He was subsequently started on topical capsaicin therapy, initially applied to his hands, the location of his most severe pain and care barrier. After 7 days, his pain reduced to 6/10, and at 14 days, to 4/10. After 4 weeks of treatment with increased dosing, his baseline pain score decreased to 0/10.

Conclusions:

In addition to a significant reduction in pain, the patient showed improved tolerance for wound care and therapy. His mood also improved, according to psychological evaluations. Neuropathic pain affects up to 80% of SCI patients, creating barriers to care and increasing secondary complications. In cases where neuropathic pain continues to be refractory to standardized treatments, alternative topical therapies such as capsaicin can be an effective treatment means to improve quality of life.