Nigerian Journal of Clinical Practice

CASE REPORT
Year
: 2019  |  Volume : 22  |  Issue : 9  |  Page : 1301--1303

Management of neuropathic pain following traumatic brachial plexus injury with neurolysis and oral gabapentin: A case report


AO Adetoye1, OI Aaron1, EA Orimolade2, KA P Adetifa3,  
1 Department of Anaesthesia and Intensive Care, Obafemi Awolowo University, Ile-Ife, Nigeria
2 Department of Orthopaedics and Traumatology, Obafemi Awolowo Universty, Ile-Ife, Nigeria
3 Department of Anaesthesia and Intensive Care, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria

Correspondence Address:
Dr. A O Adetoye
Department of Anaesthesia and Critical Care, Obafemi Awolowo University, Ile-Ife
Nigeria

Abstract

Neuropathic pain responds poorly to common analgesics that effectively control nociceptive pain because its pathophysiology is different and it is usually associated with co-morbidities such as sleep disturbance, depression and anxiety. Patients with this chronic pain are sometimes left with neurolysis as the last resort. A 65-year-old male multiply-injured retiree presented with disabling pain following traumatic brachial plexus injury sustained from road traffic accident 5 years earlier. Other injuries resolved with therapy except the chronic severe burning and electrifying pain (VAS score 9) in the paralyzed left upper limb associated with allodynia and insomnia which was unresponsive to conventional analgesics. PainDETECT score was 29. A test supraclavicular block with 0.25% Bupivacaine was done, followed by chemical neurolysis one month later. He was placed on oral Gabapentin. The pain score a week post injection was 3 and has remained same 18 months post injection. Patient's level of satisfaction on 5 point Likert scale was 5. Chronic neuropathic pain following traumatic brachial plexus injury could be successfully managed by chemical neurolysis and oral gabapentin.



How to cite this article:
Adetoye A O, Aaron O I, Orimolade E A, P Adetifa K A. Management of neuropathic pain following traumatic brachial plexus injury with neurolysis and oral gabapentin: A case report.Niger J Clin Pract 2019;22:1301-1303


How to cite this URL:
Adetoye A O, Aaron O I, Orimolade E A, P Adetifa K A. Management of neuropathic pain following traumatic brachial plexus injury with neurolysis and oral gabapentin: A case report. Niger J Clin Pract [serial online] 2019 [cited 2019 Oct 22 ];22:1301-1303
Available from: http://www.njcponline.com/text.asp?2019/22/9/1301/266166


Full Text



 Background



Access to pain treatment is a human right.[1] The neuropathic pain has been defined as “pain caused by a lesion or disease of the somatosensory system”. It constitutes a major health burden.[2] It is difficult to manage with conventional analgesics.[3] Evidence based pharmacologic treatment recommendations have been published.[4],[5] Commonly used drugs are NSAIDs, antidepressants and anticonvulsants.[6] Many patients have pain that is refractory to these drugs.[7]

The efficacy and role of non-pharmacologic non-interventional treatments such as TENS are not clear. Patients live with this chronic pain when other treatment options have failed, leaving neurolysis as the last resort.[8]

Neurolysis could be done using chemical injection (phenol or alcohol), radiofrequency ablation, cryoablation or through surgical procedure.[9]

There is no universal protocol for chemical neurolysis.[10] Ethanol is commonly used for chemical neurolysis.[11] It was first used as a neurolytic agent in 1902 in order to treat trigeminal neuralgia.[12]

The efficacy of chemical neurolysis using dilute alcohol has been proven.[10],[13]

The aim of this report is to highlight the successful management of neuropathic pain secondary to traumatic brachial plexus injury with chemical neurolysis and oral gabapentin.

 Procedure



A 65-year old man, who was multiply-injured from road traffic accident presented 5 years later with features of neuropathic pain secondary to traumatic injury to the left brachial plexus including severe disabling burning and electrifying pain which was changing in character over time despite the resolution of all other injuries following appropriate treatment. The pain was resistant to NSAIDs [Arthrotec 75 mg bd], Tramadol [50 mg bd], Amitriptyline [25 mg nocte], pregabaline [300 mg bd] and morphine [up to 7.5 mg 4 hourly] as sole agents and combination of two or three of them at some periods. Herbal medications and physiotherapy, including the use of TENS caused no improvement. The left upper limb pain worsened over time and was associated with muscular atrophy, insomnia and weight loss. The intractable pain made the patient to contemplate suicide and requested a disarticulation of the limb.

Physical examination revealed an anxious patient in obvious painful distress hanging the left upper limb with Neck sling. Patient was diaphoretic. The left upper limb was limpy, with gross muscle atrophy, hypotonic, hyporeflexic, with no sensation over the forearm and a tender swelling over the supraclavicular region. Shoulder joint dislocation was noted and muscle power was grade 0. There was hyperpathia. Pain score on VAS was 9. PainDETECT score was 29.

He was counselled on the available treatment options other than the medications already tried. A detailed explanation of chemical neurolysis procedure and possible complications were given. An informed consent was taken in the presence of relations under video coverage in the light of the irreversibility of the outcome of the procedure.

A test supraclavicular block was carried out using 20 mls of 0.25% bupivacaine with the aid of EZstim II peripheral nerve locator and stimulator Model ES400. The onset time was 7 minutes and there was pain relieve for 6 hours 45 minutes. Pain score declined from 9 to 3 on VAS.

Neurolysis was planned for a month later to allow the patient enough time to give an informed consent. Meanwhile, he was placed on Tab Gabapentin 300 mg bd which was increased up to 600 mg tds within two weeks. He had best pain score of 7 for two to three hours after ingestion of oral Gabapentin.

Pre-procedural baseline vital signs were taken and documented. A peripheral intravenous line was established and normal saline administered at maintenance rate.

Neurolysis was done with supraclavicular injection of 15 mls of 70% alcohol in a sterile fashion with the aid of EZstim II peripheral nerve locator and stimulator Model ES400 and B-Ultrasound scanner Teknova Model TH-80. There was moderate to severe pain on injection which subsided after about five minutes. Patient was monitored for 2 hours before discharge home. He continued with oral Gabapentine 300 mg bd which was reduced to 300 mg nocte after 3 months. He was seen at the clinic every 2 weeks for the first month, monthly for 6 months and quarterly thereafter.

The pain score declined to 3 from 9 on VAS after 3 days, and has remained so 18 months afterwards. However, muscle atrophy over the left shoulder and arm worsened.

 Discussion



Chronic pain is usually difficult to manage. It is worse with neuropathic pain. Though there are guidelines for pharmacological management when drug combinations are not achieving the desired pain control at maximum tolerable doses, practitioners usually result to interventional therapies. Specific guidelines are yet to be developed and adopted in this line of management.

Our patient showed significant improvement in symptoms of neuropathic pain secondary to traumatic brachial plexus injury when chemical neurolysis was undertaken and patient was placed on oral gabapentin. The pain became mild (pain score of 3 on VAS); Hyperpathia and allodynia resolved completely. This is similar to the outcome in the report by Mozena et al.[13] Gabapentin was useful as an adjunct to the chemical neurolysis in this report. Howard et al.[14] had proved that addition of incremental doses of gabapentin to other drugs including opioid for management of neuropathic pain provided analgesic activity with low side effect profile, while opioid doses were reduced. It was observed that the symptoms of neuropathic pain could be distressing which could tilt patient into life-threatening depression. This was alluded to by the quest of our patient for a disarticulation of the limb and contemplation of suicide.

The commonly used analgesics and adjuvants either as sole agents or in combinations were ineffective in resolving symptoms of neuropathic pain in our patient. This is consistent with the outcome of the review done by Sakellariou et al.[15] which observed that pain in patients with complete palsy was difficult to manage which in turn prevents rehabilitation. NSAIDs and opioids did not help with neuropathic pain but antidepressants and anticonvulsants did. Physical therapy did not achieve any improvement in symptoms in the index case. Baseline hyperpathia and allodynia in the patient may account for the worsening of symptom recorded each time physiotherapy was done.

 Conclusion



Chemical neurolysis using 70% alcohol followed by oral gabapentin could be helpful in the management of chronic neuropathic pain following traumatic injury to the brachial plexus.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgements

Dr A.T. Adenekan.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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