1030 Melatonin use for insomnia in post-traumatic spinal cord injury

Introduction Spinal cord injury, in particular cervical spinal cord injuries with tetraplegia, often leads to decreased sleep efficiency. Reasons for this might include pain, sleep disordered breathing or diminished melatonin secretion. Report of Case Here we present a case of melatonin use for insomnia following a spinal cord injury. The patient is a 43-year-old male with a history of cervical spinal cord injury after a vehicle accident and onset of insomnia immediately after the time of injury. Nineteen years after his accident, he was seen in Insomnia Clinic. At this time, he has recovered function of hands and arms and can walk. He has persistent dysautonomia and orthostasis. During his evaluation, he was found to have an insomnia severity index score of 25. He was treated with CBT-I, sleep hygiene, and increased mindfulness. A consultation with Sleep Medicine was requested. Polysomnography demonstrated no underlying sleep disordered breathing. Melatonin was recommended after reviewing the literature and finding that diminished melatonin secretion can be a secondary effect of cervical spinal cord injuries. He was started on 3 mg of melatonin one hour prior to sleep. At a follow up visit, the patient endorsed improved sleep time and quality. Support The pathway for melatonin release is a complicated one. Light signals are relayed from the retina through the suprachiasmatic nucleus of the hypothalamus. From there they are sent to the cervical spinal cord and superior cervical ganglion. From there the post ganglionic neurons ascend to the pineal gland, the organ producing melatonin. The fact that part of the pathway is in the cervical spinal ganglia lends credence to the theory that injuries in this area lead to decreased melatonin surge at night. Conclusion A case-controlled study performed in 2006 demonstrated that cervical spinal cord injury resulted in lower sleep efficiency with an absence of nocturnal melatonin surge. Other studies have revealed that patients with spinal cord injuries (SCI) experience greater amounts of excessive daytime fatigue and sleepiness, regardless of the presence of sleep disordered breathing. Based on this, it was extrapolated that the physiologic melatonin surge could be mimicked with exogenous melatonin be