Chapter 38

Central pain, defined as “pain associated with lesions of the central nervous system,”1 is a type of neuropathic pain whose features are summarized in Table 38-1, as discussed by many authors.2–9 Central pain of spinal cord origin is essentially a young man’s disease, usually resulting from trauma, whereas central pain of brain origin is usually the result of stroke.

Table 38-1 Characteristics of Neuropathic and Central Pain

One of the amazing things about central pain is that the clinical picture is similar in a patient with a cord lesion so slight it produces no clinically detectable sensory loss to that seen after complete cord transection.10–13 Furthermore, stroke pain after a lesion so massive that it essentially produces a hemispherectomy is similar to that after a stroke with no persisting sensory loss. Furthermore, only a certain percentage of patients with apparently identical lesions develop central pain.

A chief problem is that the mechanism of this pain is poorly understood, making attempts at treatment difficult to rationalize. It must be remembered that the most common feature is the steady, constant, burning, dysesthetic or aching element for which there is no laboratory model. Patients must serve as models, because only they can tell us what they feel.

As has been mentioned, not every patient who suffers cord damage develops central pain; the reported incidence ranges from 6% to 94%. The etiology is usually trauma. In a personal series of 127 patients,25 65% were victims of trauma, 12% suffered from iatrogenic lesions, 9% from inflammatory lesions, 6% from neoplastic lesions, 4% from congenital lesions, 2% from vascular lesions, and 2% from skeletal pathology. The location of lesions in these patients was as follows: cervical, 42%; T1 to T9, 21%; and T10 to L2, 37%. Thirty-two percent of lesions were clinically complete, 64% were incomplete, and 4% of patients had no clinically detectable sensory loss. Etiology and level or completeness of lesion did not correlate with presence, severity, or quality of pain, except as discussed subsequently.

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