Abstract:

This case report describes a patient with chronic spastic myelopathy, under rehabilitation for over a year without significant clinical improvement, who developed persistent neuropathic pain in the lower limbs, particularly worsening at night. The pain followed a dermatomal pattern consistent with L1–L4, accompanied by intermittent paresthesias in the upper limbs.
MRI showed vertebral misalignment, muscle contractures, and signal changes at L5–S1. Electromyography revealed focal neuropathic changes in the posterior tibial nerves and evidence of bilateral median nerve involvement. The findings point toward coexisting central and peripheral components of pain, with chronic lumbar radiculopathy and suspected carpal tunnel syndrome.

The clinical picture aligns with central sensitization superimposed on longstanding pyramidal tract dysfunction. The patient presented with signs of pyramidal release, including spasticity and sustained reflexes, though without motor ataxia or paresis. Pain followed the trajectory of the saphenous and tibial nerves, extending from the pubic region to the dorsum of the foot.

Management recommendations included escalation of neuromodulatory therapy with gabapentinoids or SNRIs, intensified motor rehabilitation targeting spasticity and proprioception, functional electrostimulation, and orthopedic consultation for possible peripheral nerve blocks. This case highlights the complexity of mixed pain syndromes in chronic spinal cord dysfunction and the importance of a multidisciplinary neurofunctional approach.