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| Introduction |
- Central Post Stoke Pain
(CPSP) or Thalamic Pain Syndrome is a type of nerve pain that starts when part of
the central nervous system has been injured.
- It is commonly seen after a stroke or cerebrovascular
accident (CVA). A stroke implies there has been an injury
(infarction, cell death) in part of the central
nervous system, caused by either lack of blood flow
(thrombosis) or lack of oxygen (ischaemia).
- As well as the usual stroke features caused by
infarction in the cerebral hemispheres (weakness,
numbness, paralysis, speech difficulties, confusion), up
to 10% of people develop CPSP when the infarction also
involves the thalamus (brain stem sensory processing
area).
- Some authorities have suggested that minor CPSP
symptoms are reported by 50% of stroke victims.
Thankfully the full blown syndrome is less common.
- CPSP occurs more commonly when the right side of the
brain is infarcted causing left sided symptoms. The
onset time for symptoms to develop is variable, ranging
from days to years. Pain can be felt in the face, arm,
leg, trunk on the stroke side. The unfortunate may have
symptoms affecting the whole of one side of the
body.
- The pain has been described as burning, aching, or
pricking in nature, although the character of the pain
can be widely variable. It is usually constant and
unrelenting, with a tendency to increase in intensity
over time. Movement, changes in temperature, or other
unrelated stimuli may aggravate the symptoms. It is often
accompanied by abnormal sensation in the affected body
part.
- It is very important to differentiate between CPSP
and other forms of musculoskeletal pain that commonly
occur in stroke victims e.g. frozen shoulder, tight
muscles. These musculoskeletal problems often resolve
with physical therapy and injections, whereas CPSP
usually responds to oral medications.
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| Treatment |
-
Oral
Medications
- CPSP is a difficult condition to treat. Clinical
experience would suggest that the combination of low
dose amitripyline (10 - 50 mg at night) plus
gabapentin (between 300 - 1800 mg per day) produces
the best pain relief with the lowest incidence of
side effects.
- For other oral medication options / see Anti/convulsants, Anti/depressants, Anti/arrhythmics.
- Intravenous Lidocaine Infusions are
useful for some patients.
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Surgery
- Deep Brain
Stimulation
 has been shown to
provide some measure of pain relief for at least 50%
of patients, with some achieving excellent relief of
pain.
- Motor cortex stimulation is a
newer procedure which is now being used in the
treatment of post-stroke pain. The results appear to
be comparable to deep brain stimulation, with about
50% of patients achieving good pain relief and a
smaller percentage achieving excellent or complete
relief.
- The selection of deep brain
stimulation versus motor cortex stimulation depends
on the character and distribution of the pain, as
well as the extent of the stroke and other
factors.
- As with all chronic pain
syndromes, psychological factors play a major role in
the intensity of the pain. It is recommended that all
patients with post-stroke pain consult with a
psychologist specializing in the evaluation and
treatment of chronic pain. although post-stroke pain
is a challenging problem, surgical procedures offer
some hope for relief.
- Surgical and anaesthetic risk
assessment is required before undertaking any
surgical procedure. Detailed counselling is essential
before proceeding.
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