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lthough pain is a prominent symptom in patients suffering from syringomyelia,and this central neuropathic pain is very difficult to treat. However, more than half of all patients with syringomyelia suffer from symptoms related to central neuropathic pain.
Patients often present with complaints of radicular pain and/or central cord pain. Furthermore, nearly half of all patients with syringomyelia experience neuropathic dysesthetic pain, like burning sensation and/or pins and needles.
But only small series of patients are available as a base for these figures. In patients suffering from this type of central neuropathic pain, it is often an overwhelming and disabling symptom that over-shadows many of the other complaints, such as decrease in temperature sensation and numbness. Similar central neuropathic pain can be found in other spinal cord pathological conditions such as intramedullary tumors, multiple sclerosis and infarctions.
Surgical treatment of syringomyelia resulted in improvement of dysesthetic pain in nearly half of a small series of patients (37), but a significant number of patients (41%) reported no improvement or an intensification of pain despite the operation. Improvement in pain status following operation seems difficult to predict. Postoperative neuropathic pain is disabling and responds poorly to treatment with analgesics, sedatives and antiepileptics. To date, there is no consensus as to the best pharmacological treatment for pain in syringomyelia. No clinical trials have been conducted yet.

In our centre we follow the normal steps for treating central neuropathic pain, and mostly prescribe two or more analgesics, such as low dose amitriptyline (10 – 50 mg per day) combined with either gabapentin (1800 – 2400 mg per day) or pregabalin (150 – 600 mg per day)and/or tramadol. However, there are patients non responding to these drugs. One of our patients did not respond to the drugs mentioned above, but did respond favourable to a topcial cream we developed in our centre, based isosorbidedinitrate(ISDN)0.4%, capsaicin 0.075%, and lidocaine 3%.
A challenge-rechallenge paradigm was followed. The pain decreased by using this topical cream from score 8 to 5 (11 points Likert scale) and after stopping the cream, the pain was rebouding to score 8 in a few weeks. Starting again using this cream reduced the painscore again, and in a preriod of several weeks the pain decreased for more than 30% compared to baseline. Presented by Jan M. Keppel Hesselink, MD, PhD of www.neuropathy.nl and neuropathie.nu