16. Complex Regional Pain Syndrome

Abstract

Complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy is a pain syndrome with an unclear pathophysiology and unpredictable clinical course. The disease is often therapy resistant, the natural course not always favorable. The diagnosis of CRPS is based on signs and symptoms derived from medical history and physical examination. Pharmacological pain management and physical rehabilitation of limb function are the main pillars of therapy and should be started as early as possible. If, however, there is no improvement of limb function and persistent severe pain, interventional pain management techniques may be considered. Intravenous regional blocks with guanethidine did not prove superior to placebo but frequent side effects occurred.Therefore this technique receives a negative recommendation (2 A–). Sympathetic block is the interventional treatment of first choice and has a 2 B+ rating. Ganglion stellatum (stellate ganglion) block with repeated local anesthetic injections or by radiofrequency denervation after positive diagnostic block is documented in prospective and retrospective trials in patients suffering from upper limb CRPS. Lumbar sympathetic blocks can be performed with repeated local anesthetic injections. For a more prolonged lumbar sympathetic block radiofrequency treatment is preferred over phenol neurolysis because effects are comparable whereas the risk for side effects is lower (2 B+). For patients suffering from CRPS refractory to conventional treatment and sympathetic blocks, plexus brachialis block or continuous epidural infusion analgesia coupled with exercise therapy may be tried (2 C+). Spinal cord stimulation is recommended if other treatments fail to improve pain and dysfunction (2 B+). Alternatively peripheral nerve stimulation can be considered, preferentially in study conditions (2 C+).

Interventional management of neuropathic pain: NeuPSIG recommendations

“…Following literature searches, all participants were provided with copies of existing treatment guidelines, systematic reviews, meta-analyses, and clinical trials prior to an in-person meeting, and similar materials published subsequent to the meeting were circulated by e-mail and reviewed [20,25,28,29,34,60,93,100,107,123,129,130,133,137,140,143]. Targeted reviews of the literature on the treatment of NP with nerve blocks (S. Raja), spinal cord stimulation (SCS) (B. Stacey), implantable treatments (S. Mackey), and neurosurgical interventions (R. Levy) were presented during the meeting.…”

Challenging Case in Clinical Practice: Acupuncture and Autonomically Mediated Pain

“…10 In sympathetically mediated pain, the treatment objective is to decrease and deplete noradrenaline at the postganglionic sympathetic axon. 11 In studies of acupuncture and chronic pain, ANS-mediated reductions in heart rate and blood pressure are demonstrated, suggesting shifts in sympatho-vagal balance toward vagal predominance. 12 Acupuncture needling at points in the periphery, which have a neural relationship to autonomic outflow, such as LI4, LR3, SP6, and SI3 (Figs.…”

Radiofrequency ablation of stellate ganglion in a patient with complex regional pain syndrome

“…International association of study of pain has defined CRPS as a collection of locally appearing painful conditions following a trauma, which chiefly occur distally and exceed in intensity and duration of the expected clinical course of the original trauma, often resulting in considerably restricted motor function. [1] Clinically, CRPS is characterized by a combination of sensory, motor, vasomotor and pseudomotor dysfunctions, along with trophic signs. Despite the disagreement in the literature regarding the exact pathophysiology, the current understanding underlines the involvement of central, peripheral, afferent and efferent mechanisms.…”

“…Afterward, a third type was added i.e., CRPS not otherwise specified (NOS), describing a syndrome only partially compling with the diagnostic criteria, in such a situation, where no other diagnosis is probable. [1] There is no proven and universally acceptable treatment protocol for managing such patients. Pharmacotherapy with a wide array of drugs[456] and physical therapy in the form of graded motor imagery therapy remains two major arms in the conservative management.…”