A case of neuropathic pain and electroconvulsive therapy

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A case of neuropathic pain and electroconvulsive therapy

A 32-year old male had a 10-year history of chronic right arm and shoulder pain. His pain started spontaneously as an aching, burning pain in the right shoulder, which then spread down the arm to the hand, and proximally to the lateral portion of the right side of the neck. He also complained of pain radiating into the scapular area and toward the thoracic spinal column. He described the pain as burning, sharp and crushing in nature.

Which one of the following condition is the possible diagnosis of this presentation?

  • Fibromyalgia
  • Neuropathic Pain
  • Spinal Stenosis
  • Arthritis

Introduction

Neuropathic pain is defined as pain that results from damage or abnormal function of the central or peripheral ner­vous system. Neuropathic pain can be dif­ficult to manage using conventional treat­ment modalities. The usual treatments include opioids, anticonvulsants, antide­pressants, antiarrhythmics and interven­tional procedures (e.g., spinal cord stim­ulators, nerve blocks, and neurosurgical ablation). Unfortunately, many patients fail these treatment modalities. Though not well studied, a few case reports illus­trate the benefit of electroconvulsive ther­apy (ECT) in the management of chronic pain syndromes.

The exact origin of ECT is unknown. It probably dates back to the medical us­age of eels by the Romans to treat head­ache and later the experiments of Ital­ian naturalists with electricity1. Fur­ther, the physician Galen employed elec­tricity in the treatment of gout and other illnesses. Later, a Hungarian psychiatrist, Laszlo Meduna, was credited with the first modern use of convulsive therapy. He was intrigued by the studies of Nyiro and Jablonski2 in the 1920s, which demon­strated that patients with schizophrenia seemed to have a lower incidence of ep­ilepsy than the general population. They postulated that dementia praecox (the old term for schizophrenia) had a curative ef­fect on epilepsy, and Meduna wondered if the reverse might be true. He found that convulsions induced with intrave­nous Metrazol or intramuscular camphor could treat psychosis. Though Meduna is credited as the father of convulsive thera­py, it was not until the late 1930s that Drs. Bini and Cerletti in Italy were successful in using electric currents to induce thera­peutic seizures3.

Medical History

His past medical history included hypertension, seizure disorder and de­pression. He was treated as an inpatient and outpatient multiple times for depres­sion.

Examination and Laboratory Investigations

Physical examination: His right arm was noted to have decreased sensa­tion to light touch and cold along the pos­terior aspect of the arm. There was hy­peresthesia to pinprick in the right pos­terior shoulder area, right posterior arm, and the distal lateral wrist, encompassing an area of approximately 5 cm by 7 cm. There was obvious atrophy of the pectora­lis muscle. He was able to demonstrate at least 3/5-muscle strength in the shoulder.

 

Imaging studies: MRI of his brachial plexus showed no anatomical abnormality, and MRI of the cervical spine showed no cord or nerve compression. An EMG showed chronic changes consistent with brachial plexopathy with involvement of the infra­spinatus and supraspinatus muscles.

Management

Treatment included continuous in­fusions of local anesthetics via an inter­pleural catheter, an intravenous lidocaine test, stellate ganglion blocks, TENS and interscalene brachial plexus blocks, all of which resulted in temporary mild pain re­lief, but no long-lasting relief. Medica­tions included methadone 100 mg a day in divided doses, hydromorphone 2 mg orally every 8 hours as needed, gabapen­tin 1200 mg 3 times a day, clonidine 0.1 mg daily, clonazepam 1 mg four times a day and ibuprofen 800 mg 3 times a day.

 

Polypharmacy, interventional pro­cedures, and behavioral pain manage­ment were unsatisfactory. He developed recurrent severe depression and attempt­ed suicide. He was admitted to a psychi­atric hospital for depression and suicidal ideation. While hospitalized, he under­went five right unilateral electroconvul­sive treatments under methohexital (80 mg) and succinylcholine (100 mg) anes­thesia, with average seizure duration of 62 seconds. He experienced relief of both the chronic pain and depression.

 

The patient spent approximately 2 weeks in the psychiatric hospital and then was discharged home. Subsequently, he did relatively well and began to taper his medications, including the opioids. Dur­ing the recovery phase, he rated his pain as 3/10 on a visual analog scale. He was happy with the response and increased his activity level significantly. Unfortunately, eight weeks later, the pain recurred. Al­though it is tempting to attribute the en­tire pain syndrome to a psychiatric disor­der, this patient had bona fide evidence of brachial plexopathy and appeared to be in pain. The ECT treatments correlated with the 8-week period of pain relief.

Discussion

It is widely observed and acknowl­edged that there is an association between chronic pain and depression. Conse­quently, many physicians initially believed that antidepressants and psychotropic drugs might relieve chronic pain by im­proving depression. Although ECT may be considered a non-pharmacologic method of treating depression, there are undoubtedly signifi­cant pharmacologic effects of ECT on the brain. ECT is often the only known effec­tive treatment for severe depression resis­tant to medications. ECT may also be an effective and relatively safe treatment for psychosis and mania.  Not surprisingly, ECT is rarely con­sidered for chronic intractable pain syn­dromes today, although there is an old, but rather sparse literature on the therapeutic use of ECT for pain.

 

Mandel4 report­ed that ECT alleviated symptoms for four of six patients suffering from chronic pain and depression. Bloomstein et al5 reported that out of twenty-one patients who received ECT for concurrent affective symptoms, twenty experienced improvement in their pain levels, and concluded that ECT could be an effective treatment modality for patients who have chronic pain com­plicated by affective symptoms. Further, King et al6 described a patient with depression who developed RSD and was helped by ECT. The patient had total res­olution of pain for several hours after the first treatment. On the other hand, McCance et al7 reported that ECT was not effective in the treatment of post-stroke thalam­ic pain. The authors performed a pilot study in 3 patients who received six bilat­eral ECT treatments over a period of two weeks and observed no improvement in thalamic pain or mood. Furthermore, Salmon et al8 could not verify a pos­itive response to unilateral ECT treat­ment for thalamic pain.

 

Even though ECT was used for vari­ous types of intractable chronic pain dur­ing the 1940s and 1950s, it is not now of­ten used for pain, for obvious reasons. Nonetheless, concerns about such factors as amnesia and injury from ECT make the option rather unpopular, despite the fact that more recent evidence, again from case reports, suggests that ECT may ben­efit subsets of patients with chronic pain.

Learning

Although ECT is widely accepted as a treatment for severe depression, it is seldom used in the treatment of chronic pain, despite the fact that chronic pain and depression frequently occur together. The case report rekindles a discussion about the possible use of ECT in depressed patients presenting with intractable pain syndromes. Although prospective randomized studies are needed, such studies most likely will never be done. Nonetheless, there is anecdotal evidence that ECT may alleviate symptoms of depression and pain in some patients who have failed conventional treatment.

References

  1. Harms E. The origin and early history of electrotherapy and electroshock. Am J Psychiatry 1956; 111:933-934.
  2. Nyiro J, Jablonsky A. Einige daten zur prognose der Epilepsie, mit besonderer rucksicht auf die konstitution. Psychiatr Neurol Wochenschr 1929; 31:547-549.
  3. Cerletti U, Bini L. Unnuevo metodo di shockterapie “L’elettroshock.” Bollettino Accademia Medica Roma 1938; 64:136-138.
  4. Mandel MR. Electroconvulsive therapy for chronic pain associated with depression. Am J Psychiatry 1975; 132:632-636.
  5. Bloomstein JR, Rummans TA, Maruta T et al. The use of electroconvulsive therapy in pain patients. Psychosomatics 1996; 37:374-379.
  6. King JH, Nuss S. Reflex sympathetic dys­trophy treated by electroconvulsive ther­apy: Intractable pain, depression, and bi­lateral electrode ECT. Pain 1993; 55:393-396.
  7. McCance S, Hawton K, Brighouse D et al. Does electroconvulsive therapy (ECT) have any role in the management of in­tractable thalamic pain? Pain 1996; 68:129-131.
  8. Salmon JB, Hanna MH, Williams M et al. Thalamic pain-the effect of electroconvul­sive therapy (ECT). Pain 1988; 33:67-71.

 

 

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