Central pain following spinal cord injury is poorly understood, and is often resistant to conventional pain therapy regimens. We describe an individual with paraplegia who for many years experienced rapidly fluctuating, severe, unilateral pain below the level of his lesion. Prior to the initiation of pharmacological treatment, regional cerebral blood flow (rCBF) was measured during PAIN and NON-PAIN states using single photon emission computed tomography (SPECT). When experiencing pain, the subject had increased anterior cingulate gyrus blood flow, increased thalamic blood flow bilaterally and increased somatosensory cortex blood flow contralaterally but decreased caudate blood flow bilaterally. The subject's subsequent clinical course included a trial of gabapentin which produced a substantial reduction in frequency and average intensity of his episodic pain and which has been maintained for almost 2 years. This case demonstrates the correspondence between rCBF and pain associated with spinal cord injury and also suggests the potential utility of gabapentin for treatment of this central pain state. Copyright (C) 1998 International Association for the Study of Pain. Published by Elsevier Science B.V.