Complex regional pain syndrome Assiut 2012

Complex Regional Pain

Syndrome

Dr. H. MetwallyBScAPh, MBChB, MDA, FFARCSI, MRCA, MSc Pain Management

Diana Princess of Wales Hospital

Pain Medicine, Anaesthesia and Critical CareLincs Pain Clinic

Assiut Anaesthesia Conference 2012 Dr.

Metwally, Diana, Princess of Wales Hospital

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What is CRPS?

A chronic painful progressive disease

Characterized by severe pain, swelling and changes in the skin (colour, temp hair and nails).

There is no cure.



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Is it one type?

The International Association for the Study of

Pain has divided CRPS into two types based

on the presence of nerve lesion following the

injury.



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CRPS Type I

Formerly known as:

Reflex sympathetic

dystrophy (RSD),

Sudeck's atrophy

Reflex neurovascular

dystrophy (RND)

Algoneurodystrophy

It does not have

demonstrable nerve

lesions.



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CRPS Type II

Formerly known

as causalgia

It has evidence

of obvious

nerve damage.



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CRPS

The cause: unknown.

Precipitating factors

Injury

Surgery

There are documented cases that have no demonstrable injury to the original site.

These problem was certainly major by the importance of the vasomotor and sudomotor symptoms, but stemmed from minor neurological lesions.



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History

Pathophysiology

Susceptibility

Contributing factors

Genetic theory

(hidden slides)



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Symptoms

Usually manifest near the site of an injury, either major or minor.

The most common symptoms overall are Burning, electrical sensations, shooting pain

May also experience muscle spasms

Local swelling

Abnormally increased sweating

Changes in skin temperature and color

Softening and thinning of bones

Joint tenderness or stiffness, restricted or painful movement.



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Symptoms

The pain is continuous

May be heightened by emotional or physical

stress

Moving or touching the limb is often

intolerable.

The symptoms of CRPS vary in severity and

duration.



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Diagnosis, The IASP criteria for CRPS

CRPS types I and II share the common diagnostic criteria Spontaneous pain or allodynia is not limited to the

territory of a single peripheral nerve, and is disproportionate to the inciting event.

There is a history of oedema, skin blood flow abnormality, or abnormal sweating in the region of the pain since the inciting event.

No other conditions can account for the degree of pain and dysfunction.

The two types differ only in the nature of the inciting event. Type I CRPS develops following an initiating noxious

event that may or may not have been traumatic

Type II CRPS (causalgia) develops after a nerve injury.



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Thermography

Measuring blood flow by determining the variations in heat emitted from the body.

An altered blood supply to the painful area, appearing as a different shade (abnormally pale or violet) than the surrounding areas of the corresponding part on the other side of the body.

A difference of 1.0°C between two symmetrical body parts is considered significant

The affected limb may be warmer or cooler than the unaffected limb



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Sweat testing

Abnormal sweating can be

detected by several tests.

A powder that changes color

when exposed to sweat can be

applied to the limbs; however,

this method does not allow for

quantification of sweating.

Two quantitative tests that may

be used are the resting sweat

output test and the quantitative

sudomotor axon reflex test.

These quantitative sweat tests

have been shown to correlate

with clinical signs of CRPS.



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Radiography

Patchy osteoporosis, which may be due to disuse of the affected extremity, can be detected through X-ray imagery as early as two weeks after the onset of CRPS.

A bone scan of the affected limb may detect these changes even sooner.

Bone densitometry can also be used to detect changes in bone mineral density. It can also be used to monitor the results of treatment, as bone densitometry parameters improve with treatment.



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Electrodiagnostic testingElectromyography

Known as Nerve

conduction study

Detect the nerve injury

that characterizes type

II CRPS.

The symptoms of type

II CRPS extend beyond

the distribution of the

affected peripheral

nerve (In contrast to

peripheral

mononeuropathy)



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Management

Prevention

Treatment



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Prevention

Treat post traumatic pain and inflammation without

dealy.

Vitamin C has been shown to reduce the prevalence

of complex regional pain syndrome after wrist

fractures. A daily dose of 500 mg for fifty days is

recommended

These studies are difficult to interpret because the

incidence of CRPS in those who took the Vitamin C

in this study are similar to the incidence without

taking anything in other studies



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Treatment

The general strategy in CRPS treatment is

often multi-disciplinary, with the use of

different types of medications combined with

distinct physical therapies.



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Drugs

Variety of drugs including:

Antidepressants

anti-inflammatories such as corticosteroids and COX-inhibitorssuch as piroxicam

Vasodilators

GABA analogs such as gabapentin and pregabalin

Alpha- or beta-adrenergic-blocking compounds

The entire pharmacy of opioids.

Bisphosphonates: treat osteoporosis in cancer patients (Pamidronate)

Ketamine?????

Although many different drugs are used, there is not much supportive evidence for most of them. This doesn't necessarily reflect evidence that they don't work, just a lack of evidence that they do.



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How to use each of these drug groups?

(Leave it for the discussion)



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Pamidronate in complex regional

pain syndrome type I

30-60 mg as a single dose IVI over one hour

Good response so far

. 80-276):3(5Sep;2004 Pain Med.

http://www.ncbi.nlm.nih.gov/pubmed/15367305



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Bier’s Block

Guanethidine (Ismelin) (30 mg for U.L or 40 mg for L.L): antihypertensive drug that reduces the release of catecholamines

Bretylium: (100 mg) antiarrhythmic agent. It blocks the release of noradrenaline from nerve terminals

+ Clonidine 75mcg +Ketorolac 40 mg + Prolocaine 40 mls (U.L) or 60 mls (L.L)



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Ketamine

Ketamine is the only potent

NMDA-blocking drug currently

available for clinical use

Ketamine is being used as

an experimental and

controversial treatment for

CRPS.

May have more than one

mechanism of action

Can be taken oral or

infusion



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Local anaesthetic

Blocks, Regional injections or Topical

Often the first step in treatment

Repeated as needed

Early intervention with non-invasive management may be preferred to repeated nerve blockade.

The use of topical lidocaine patches has been shown to be useful



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Spinal cord stimulators

Directly stimulating the spinal cord

Place electrodes either in the epidural or directly over nerves located outside the central nervous system

A systematic review concluded: Spinal cord stimulation appears to be an effective therapy in the management of patients with CRPS type I (Level A evidence) and type II (Level D evidence)

Moreover, there is evidence

to demonstrate that SCS is

a cost-effective treatment

for CRPS type I.



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Implantable drug pumpsImplantable drug

pumps may also be

used to deliver pain

medication directly to

the cerebrospinal fluid

which allows powerful

opioids to be used in a

much smaller dose

than when taken orally

Other treatments with

encouraging published

results (e.g., neural

stimulators) are not

used often enough."



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Sympathectomy

Surgical, chemical, or radiofrequency

Interruption of the affected portion of the sympathetic nervous system

Can be used as a last resort in patients with impending tissue loss, edema, recurrent infection, or ischemic necrosis

There is little evidence that these permanent interventions alter the pain symptoms of the affected patients.



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Chemical Sympathectomy

Non destructive:

Local anesthetic

Botulinum toxinType A in addition to Local anesthetic

Clonidine

Destructive:

Alcohol 100%

Phenol



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Physical and occupational therapy

Primarily by desensitizing the affected body part

Restoring motion

Improving function.

Some people at certain stages of the disease are incapable of participating in physical therapy due to touch intoleranceGraded Motor Imagery

Mirror Therapy



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Physical and occupational

therapy Mirror box therapy

Tactile discrimination training

Graded exposure to fearful activities

EEG Biofeedback



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Prognosis of CRPS

Good progress can be made in treating

CRPS if treatment is begun early,

ideally within 3 months of the first

symptoms.

If treatment is delayed, >> spread to the

entire limb >> changes in bone, nerve

and muscle may become irreversible.



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Prognosis of CRPS

Is not always good.

The limb, or limbs, can experience

muscle atrophy, loss of use and

functionally useless >> require

amputation.



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Conclusion

CRPS will not "burn itself out" but, if

treated early, it is likely to go into

remission.



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Thank You

Documents

Complex regional pain syndrome Assiut 2012