We present a 36-year old female with a history of leukemia on chemotherapy that developed aphasia, and right hemiparesis and hemisensory loss. MRI revealed a large ischemic infarction in the left MCA distribution. Two months post-stroke, she developed right leg burning pain. Despite significant motor recovery, pain prevented independence with daily activities. Diagnostic imaging of the spine and extremity did not reveal contributory abnormalities.

Treatment with pregabalin and hydrocodone resulted in minimal relief. Trial with lamotrigine was complicated by rash and discontinued. Methadone provided partial relief but was sedating. Finally, a spinal cord stimulator (SCS) trial resulted in greater than 50% decrease in pain score. Dual octrode percutaneous leads were implanted with lead tips at the T10 vertebral body. Pre-implantation pain intensity was 10/10. Post implantation intensity was 2/10 at 1 month and maintained thru 4 months. The patient also reported improved ambulation and was successfully weaned off methadone.

Discussion

Central Post-Stroke Pain (CPSP) is seen in 8-11% of patients after stroke⁴. Although usually described as burning pain within the first months after the event⁴, CPSP presentation is variable and frequently misdiagnosed. Treatment options for post-stroke pain are limited. Amitriptyline, gabapentin, lamotrigine, and IV lidocaine and opioids have shown effectiveness in a subset of patients^2,5. Less commonly, mexilitine and ketamine have been used. Interventional options include stimulation of the motor cortex (MCS), thalamus (DBS), and SCS. One study showed relief in 7% of patients treated with SCS, and 25% and 48% with DBS and MCS, respectively³.

Conclusion

Currently, SCS is used to effectively treat failed back surgery syndrome, complex regional pain syndrome, angina, and ischemic limb¹. The excellent response to SCS achieved in our patient is promising. Further studies on the use of spinal cord stimulation for CPSP are warranted.