Current IASP diagnostic criteria for CRPS have low specificity, potentially leading to overdiagnosis. This validation study compared current IASP diagnostic criteria for CRPS to proposed new diagnostic criteria (the “Budapest Criteria”) regarding diagnostic accuracy. Structured evaluations of CRPS-related signs and symptoms were conducted in 113 CRPS-I and 47 non-CRPS neuropathic pain patients. Discriminating between diagnostic groups based on presence of signs or symptoms meeting IASP criteria showed high diagnostic sensitivity (1.00), but poor specificity (0.41), replicating prior work. In comparison, the Budapest clinical criteria retained the exceptional sensitivity of the IASP criteria (0.99), but greatly improved upon the specificity (0.68). As designed, the Budapest research criteria resulted in the highest specificity (0.79), again replicating prior work. Analyses indicated that inclusion of four distinct CRPS components in the Budapest Criteria contributed to enhanced specificity. Overall, results corroborate the validity of the Budapest Criteria and suggest they improve upon existing IASP diagnostic criteria for CRPS.

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The goal of treatment in patients with complex regional pain syndrome (CRPS) is to improve function, relieve pain, and achieve remission. Current guidelines recommend interdisciplinary management, emphasizing 3 core treatment elements: pain management, rehabilitation, and psychological therapy. Although the best therapeutic regimen or the ideal progression through these modalities has not yet been established, increasing evidence suggests that some cases are refractory to conservative measures and require flexible application of the various treatments as well as earlier consideration of interventions such as spinal cord stimulation (SCS). While existing treatment guidelines have attempted to address the comprehensive management of CRPS, all fail to provide guidance for contingent management in response to a sudden change in the patient's medical status. This paper reviews the current pathophysiology as it is known, reviews the purported treatments, and provides a modified clinical pathway (guideline) that attempts to expand the scope of previous guidelines.

OSTOPERATIVE PAIN AFFECTS A variety of physiological functions and can adversely influence surgical outcome. 1 Efficient management of acute postoperative pain has been demonstrated to improve clinical outcome 2 and effective postoperative analgesia is part of a major initiative for US hospitals, with the introduction of pain as the fifth monitored vital sign. 3 Surgical trauma induces cyclooxygenase 2 (COX-2) and subsequent synthesis of prostaglandins that sensitize peripheral nociceptors and mediate central sensitization. 4 In addition to analgesic synergism with opioids, 5 nonsteroidal anti-inflammatory drugs (NSAIDs) decrease this inflammatory response associated with surgery. 6 There is evidence that prostaglandin synthesis plays a role in postoperative orthopedic pain. 7 Inadequate control of postoperative pain has been associated with poor functional recovery after total knee arthroplasty (TKA). 8 Preoperative administration of NSAIDs may be effective by establishing a sufficient tissue NSAID concentration to Author Affiliations are listed at the end of this article.

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