The treatment of central pain syndrome in spinal cord injury with a combination of a tricyclic antidepressant and carbamazepine: A case series

Central pain syndrome (CPS) is a common acid disabling sequela in many patients with spinal cord injury. Such pain frequently impedes functional recovery and leads to significant physical and psychological disability. While the treatment of CPS with antidepressant or anticonvulsant medication has been investigated, the treatment with a combination of these two classes of medications has not been studied. We report four separate cases of patients with paralysis and associated burning dysesthesias who had substantial improvement following a short course of treatment with a combination of a tricyclic antidepressant (TCA) and carbamazepine. Each patient suffered significant discomfort resulting in loss of sleep or interference with functional abilities. These patients were treated with a therapeutic dose of a TCA alone without subjective improvement in pain. Subsequently, carbamazepine was added without changing the TCA dose. Each patient responded favorably to this combination of medications and reported a minimum of 50% reduction in pain within two to three days of adding the carbamazepine. Two patients had complete resolution of pain. When the antidepressant was later discontinued in two patients, the dysesthesias significantly increased in both patients. The combination of a TCA and carbamazepine may improve the functional status and quality of life for patients with CPS unresponsive to either medication alone.